Critically ill patients with high predicted mortality: Incidence and outcome / Pacientes en cuidados intensivos con alta mortalidad prevista: Incidencia y evolución

Objective As calculated by the severity scores, an unknown number of patients are admitted to the Intensive Care Unit (ICU) with a very high risk of death. Clinical studies have poorly addressed this population, and their prognosis is largely unknown. Design Post hoc analysis of a multicenter, cohort, longitudinal, observational, retrospective study (CIMbA). Setting Sixteen Portuguese multipurpose ICUs. Patients Patients with a Simplified Acute Physiology Score II (SAPS II) predicted hospital mortality above 80% on admission to the ICU (high-risk group); A comparison with the remaining patients was obtained. Interventions None. Main Variables of Interest Hospital, 30 days, 1 year mortality. Results We identified 4546 patients (59.9% male), 12.2% of the whole population. Their SAPS II predicted hospital mortality was 89.0±5.8%, whilst the observed mortality was lower, 61.0%. This group had higher mortality, both during the first 30 days (aHR 3.52 [95% CI 3.34–3.71]) and from day 31 to day 365 after ICU admission (aHR 1.14 [95%CI 1.04–1.26]), respectively. However, their hospital standardized mortality ratio was similar to the other patients (0.69 vs. 0.69, P=.92). At one year of follow-up, 30% of patients in the high-risk group were alive. Conclusions Roughly 12% of patients admitted to the ICU for more than 24h had a SAPS II score predicted mortality above 80%. Their hospital standardized mortality was similar to the less severe population and 30% were alive after one year of follow-up. (AU)

Objetivo Según las escalas de gravedad, un número indeterminado de pacientes ingresan en la Unidad de Cuidados Intensivos (UCI) con riesgo de muerte muy elevado. Este grupo ha sido poco abordado en los estudios clínicos y se desconoce en gran medida su pronóstico. Diseño Análisis post-hoc de estudio multicéntrico, de cohortes, longitudinal, observacional y retrospectivo (CIMbA). Âmbito Dieciséis UCI polivalentes portuguesas. Pacientes Pacientes con mortalidad hospitalaria prevista en el Simplified Acute Physiology Score II (SAPS II) superior al 80% nel ingreso en la UCI (grupo de alto riesgo); se compararon con los restantes. Intervenciones Ninguna. Variables de interés principals Mortalidad hospitalaria, a 30 días y 1 año. Resultados Se identificaron 4546 pacientes (59.9% hombres), 12.2% da población. La mortalidad hospitalaria estimada por lo SAPS II fue de 89.0±5.8%, aunque la observada fue inferior, 61.0%. Este grupo presentó mayor mortalidad, tanto durante los primeros 30 días (aHR 3.52 [IC 95%: 3.34–3.71]) y desde el día 31 hasta el día 365 después del ingreso en UCI (aHR 1.14 [IC 95%: 1.04–1.26]). Sin embargo, su índice de mortalidad hospitalaria estandarizada fue similar a los otros pacientes (0.69 vs. 0.69; P=.92). Al primer año de seguimiento, 30% de los pacientes de alto riesgo estaban vivos. ConclusionesAproximadamente 12% de los pacientes ingresados en la UCI durante más de 24 horas tenían una mortalidad prevista por SAPS II superior al 80%. Su mortalidad hospitalaria estandarizada fue similar a la de la población menos grave y el 30% estaban vivos después de un año de seguimiento. (AU)

Pneumococcal Septic Shock Syndrome: A Deadly Condition Despite Vaccination.

Invasive pneumococcal disease is a serious infection with an elevated case-fatality rate that can be even higher among patients with asplenia. Its impact has been blunted by the widespread use of vaccines; even recently, in 2021, two new pneumococcal conjugate vaccines emerged. The authors present a case of a 58-year-old male, splenectomised with the immunisation schedule complete, who died of invasive pneumococcal disease with a fulminant course. It is highlighted that fever in a patient with impaired splenic function is an emergency, and despite the success of immunisation in reducing pneumococcal carriage and invasive disease, serotypes continue to change. Also, the local epidemiology may help guide situations where the immunisation recommendations are dubious regarding the implementation of the new vaccines.

Critically ill patients with high predicted mortality: Incidence and outcome.

OBJECTIVE: As calculated by the severity scores, an unknown number of patients are admitted to the Intensive Care Unit (ICU) with a very high risk of death. Clinical studies have poorly addressed this population, and their prognosis is largely unknown. DESIGN: Post hoc analysis of a multicenter, cohort, longitudinal, observational, retrospective study (CIMbA). SETTING: Sixteen Portuguese multipurpose ICUs. PATIENTS: Patients with a Simplified Acute Physiology Score II (SAPS II) predicted hospital mortality above 80% on admission to the ICU (high-risk group); A comparison with the remaining patients was obtained. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Hospital, 30 days, 1 year mortality. RESULTS: We identified 4546 patients (59.9% male), 12.2% of the whole population. Their SAPS II predicted hospital mortality was 89.0±5.8%, whilst the observed mortality was lower, 61.0%. This group had higher mortality, both during the first 30 days (aHR 3.52 [95% CI 3.34-3.71]) and from day 31 to day 365 after ICU admission (aHR 1.14 [95%CI 1.04-1.26]), respectively. However, their hospital standardized mortality ratio was similar to the other patients (0.69 vs. 0.69, P=.92). At one year of follow-up, 30% of patients in the high-risk group were alive. CONCLUSIONS: Roughly 12% of patients admitted to the ICU for more than 24h had a SAPS II score predicted mortality above 80%. Their hospital standardized mortality was similar to the less severe population and 30% were alive after one year of follow-up.

Family Satisfaction With Critical Care: Before and After the COVID-19 Outbreak.

Introduction Family satisfaction with intensive care units (ICU) is recognized as a key component of the quality of care. As a result, family members are now more involved in the care process, and their needs are recognized throughout the ICU stay. The coronavirus disease 2019 (COVID-19) changed healthcare worldwide, due to the several restrictions imposed; the communication patterns changed drastically, and institutions were forced to adapt to create a balance between security and the needs of relatives. The aim of this study was to assess family members' satisfaction with the ICU and determine if the COVID-19 restructuring affected family satisfaction. Methods A prospective observational study was performed among the designated family members (DFM) of ICU patients over two time periods, a pre-pandemic period from December 2019 to February 2020 and a pandemic period from May 2020 to February 2021. The Family Satisfaction in the Intensive Care Unit 24 (FS-ICU 24) questionnaire, which was given to the DFM, was the instrument used to determine family satisfaction. Results The study involved 290 DFM, 175 during the pre-pandemic phase and 115 during the pandemic period. The overall and domain-specific family satisfaction scores were high (score > 80) in both the pre-pandemic and pandemic periods. The greatest satisfaction levels were related with symptom management and how nurses and doctors cared for the patient. No statistical differences were found between the two time periods. Lastly, a positive association between the two domains explored by FS-ICU 24, satisfaction with care and satisfaction with decision-making process, was verified in both time frames. Conclusion The data obtained revealed very good outcomes on the different FS-ICU 24 domains, in line with other studies in literature. No significant differences were found between the pre-pandemic and pandemic periods, suggesting that the measures implemented during the COVID-19 were successful. The importance of involving families in the decision-making process, providing them with accurate information, and active listening, as well as using better communication skills, is emphasized throughout all these results. The relevance of measuring family satisfaction should be brought to the attention of family members and healthcare professionals so that additional research may be conducted.

Treatment of Cerebral Vasospasm With Continuous Intra-Arterial Nimodipine: A Case Report.

Aneurysmal subarachnoid hemorrhage (aSAH) is an important cause of death and disability, not just due to the initial event, but also because of the delayed complications. Cerebral vasospasm (CV) stands out as a serious complication, with high prevalence and association with permanent neurologic impairment. The treatment of CV includes non-invasive measures, like oral nimodipine and induced hypertension, but also invasive measures. Endovascular rescue treatment (ERT), with intra-arterial approaches, is linked with improvement of cerebral perfusion and thus associated with a better outcome. There are several, widely studied substances used in intra-arterial approaches, none showing clear superiority over the others. The main issues with these substances are the adverse systemic effects and the recurrence of CV, due to the short duration of action. Recent studies suggest that the use of continuous infusion of nimodipine, instead of bolus injection, may be related to better outcomes. The authors present a case of severe refractory vasospasm successfully treated with continuous intra-arterial nimodipine infusion. A 23-year-old female was admitted with aSAH, Fischer IV, and Hunt Hess 5. A brain CT scan showed an extensive and diffuse subarachnoid hemorrhage causing ill-defined hypodensity of the brainstem, bilateral hemispheric hypodensities, and alterations compatible with diffuse cerebral edema. The cerebral angiography revealed an aneurysm in the emergence of the left posterior communicating artery. Coil target detachment was performed with partial occlusion of the aneurysm. On the fifth day of hospitalization, transcranial Doppler (TCD) ultrasonography revealed hemodynamic signs suggestive of vasospasm. Cerebral angiography performed later showed vasospasm of the terminal segment of the left internal carotid artery (ICA) and the A1 and M1 segments. Intra-arterial verapamil was instilled, with angiographic control showing a slight increase in the caliber of these segments. On the 13th day of hospitalization, the patient maintained sonographic evidence of vasospasm in the left ICA and middle cerebral artery (MCA). Selective catheterization of the left ICA was performed with a microcatheter at the level of the petrous segment and continuous infusion of 1 mg/h intra-arterial nimodipine was started. A progressive improvement was documented after the beginning of the continuous infusion of intra-arterial nimodipine, which was maintained for five days, and angiographic control revealed improvement of vasospasm in the terminal portion of the ICA as well as in the A1 and M1 segments. Long-term continuous intra-arterial nimodipine infusion is a promising technique for the treatment of refractory CV and may be considered in selected cases.

Long-term efficacy and safety profiles following small incision lenticule extraction in eyes with ≥ 5-year follow-up.

PURPOSE: To evaluate long-term efficacy, safety, predictability and stability (refractive and keratometric) of myopic and myopic astigmatism correction with Small Incision Lenticule Extraction (SMILE). METHODS: Single center retrospective review of eyes undergoing SMILE from 2012-2015. Forty-two eyes (23 patients) with ≥ 5-year follow-up. Variables analyzed were preoperative, 3-month, 1-year and last follow-up uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest refraction, spherical equivalent (SE) and mean keratometry. Descriptive statistics were performed and results reported following the Standard for Reporting Astigmatism Outcomes. RESULTS: Mean follow-up of 5.98 ± 0.90 years. Mean preoperative SE was -5.26 ± 1.22D (range -2.50 to -8.12D). Mean preoperative cylinder was -0.66 ± 0.61D (range 0.00 to -2.25D). Efficacy and safety indices were 0.86 and 0.98, respectively. In total, 81% of operated eyes achieved an UDVA of ≥ 0.09 logMar (20/25 Snellen). At the last follow-up, ≥1 line of CDVA was gained in 14% of eyes. Five percent lost 1 line of CDVA, and no eye loss ≥2 lines of CDVA. Sixty-nine percent of eyes were within ± 0.50D and 86% within ± 1.00D of the attempted SE correction. Ninety-one percent of eyes had ≤0.50D of postoperative astigmatism and 71% were within ± 15° from the intended correction axis. At the final follow-up, a statistically significant myopic regression of 0.19 ± 0.50D was observed (p = 0.01). CONCLUSIONS: Long-term results demonstrate that SMILE is effective, predictable and safe. SMILE has good stability, low regression compared to LASIK, and no signs of corneal ectasia staging within our standard criteria.

Tracheal Rupture After Trauma: A Successful Conservative Management.

Tracheobronchial injury (TBI) is a rare life-threatening injury that can result from either penetrating or blunt trauma. Treatment may be surgical or conservative, but the evidence regarding which is the best approach is still very scarce. This case report describes the successful conservative management of a 32-year-old male with a traumatic tracheal laceration. The alarming signs and symptoms, the imaging modalities of choice, the rationale behind the treatment strategy, and the most common complications are detailed here. Through this case, the authors wish to highlight the features that should lead to the suspicion of this potentially fatal traumatic injury, as well as raise awareness on how to adequately manage these patients.