Ascorbic Acid, Thiamine, and Steroids in Septic Shock: Propensity Matched Analysis.

INTRODUCTION: We aimed to study the use of ascorbic acid, thiamine, and steroids (ATS) in patients with septic shock (SS). METHODS: Data on 62 patients with SS were collected from Acute Physiologic and Chronic Health Evaluation (APACHE) Outcome database and medical records. The ATS group received full doses of intravenous (IV) ATS (ascorbic acid [1.5 g every 6 hours for 4 days], hydrocortisone [50 mg every 6 hours for 7 days], and thiamine [200 mg every 12 hours for 4 days]). Data included age, gender, APACHE III, acute physiologic score (APS), mechanical ventilation (MV), lactic acid (LA), serum creatinine (Cr), duration of vasopressors (VP, days, median: interquartile ranges [IQR]: [Q1, Q3]), MV-free days (median: IQR [Q1-Q3]), percentage of patients requiring renal replacement therapy (RRT) for acute kidney injury (AKI), and mortality. Propensity analysis was used to match patients on age, gender, MV, APACHE III, APS, LA, and Cr. RESULTS: The ATS group had longer duration of VP (4.5: 4.0-6.0 vs 2.0: 1.0-2.0, P = .001), similar RRT for AKI (26% vs 29%, P = .8), similar MV-free days (10.2: 5.0-15.0 vs 10.2: 1.6-18.0, P > .9), lower intensive care unit mortality (9.6% vs 42%, P = .004), and a trend toward lower hospital mortality (29% vs 45%, P = .2) compared to the NO ATS group. CONCLUSIONS: The use of IV ascorbic acid, thiamine, and hydrocortisone might be beneficial in patients with SS.

Is it possible to recover from traumatic brain injury and a Glasgow coma scale score of 3 at emergency department presentation?

INTRODUCTION: A Glasgow Coma Scale (GCS) score of 3 on presentation in patients with traumatic brain injury (TBI) portends a poor prognosis. Consequently, there is often a tendency to treat these patients less aggressively because of low expectations for a good outcome. METHODS AND RESULTS: We performed a retrospective review of patients with TBI and a GCS score of 3. Patients were divided into 2 groups based on Glasgow Outcome Scale (GOS): Group 1 (GOS=1-3) and Group 2 (GOS=4-5). A total of 62 patients were included. The overall mortality rate was 80.6%. At 6-month, 9 patients (14.5%) achieved a GOS 4-5. Compared to Group 2 (n=9), Group 1 (n=53) had higher average APACHE IV score (104±19 vs 89±27, p=0.04), more patients with bilateral fixed pupils (59% vs 22%, p=0.04), and higher ICP burden (50±34 vs 0±0, p=0.0001). Using the CRASH calculator, the estimated mortality at 14days was 66% compared to actual mortality of 81%; difference of 15%, (p=0.05), and the estimated GOS 1-3 was 85.5% compared to actual of 85.5%, (p=1.0). CONCLUSIONS: 14.5% of patients with TBI and a GCS of 3 at presentation achieved a good outcome at 6months, and 6.9% of patients with GCS of 3 and bilateral fixed pupils on presentation to the ED achieved a good outcome at 6months.

Do All Acute Stroke Patients Receiving tPA Require ICU Admission?

BACKGROUND: Limited resources warrant investigating models for predicting which stroke tissue-type plasminogen activator (tPA) patients benefit from admission to neurologic intensive care unit (neuroICU). METHODS: This model classifies patients who on day 1 of their ICU admission are predicted to receive one or more of 30 subsequent active life supporting treatments. Two groups of patients were compared: low risk monitor (LRM) (patients who did not receive active treatment (AT) on the first day and whose risk of ever receiving active treatment was ≤ 10%) and AT (patients who received at least one treatment on any day of their ICU admission). RESULTS: Compared to LRM group (21 patients), AT group (59 patients) had similar age (75 ± 13 vs. 72 ± 17, P = 0.4), similar gender (male: 56% vs. 52%, P = 0.8), similar National Institutes of Health stroke scale (NIHSS, 16 ± 9 vs. 14 ± 8, P = 0.4), and higher Acute Physiologic and Chronic Health Evaluation (APACHE) III scores (62 ± 26 vs. 41 ± 15, P = 0.0008). Compared to LRM group, AT group had longer ICU length of stay (4.5 ± 4.4 vs. 2.5 ± 1.3, P = 0.04), higher ICU mortality (22% vs. 4.7% (one patient DNR/hospice); OR: 5.6; 95% CI: 0.7 - 46.0; P = 0.1), and higher hospital mortality (36% vs. 4.7%; OR: 11; 95% CI: 1.4 - 88.0; P = 0.02). CONCLUSION: The outcome of LRM patients with stroke post-tPA suggests that they may not require admission to a formal neuroICU, improving resource use and reducing costs.

Does Red Cell Distribution Width Predict Outcome in Traumatic Brain Injury: Comparison to Corticosteroid Randomization After Significant Head Injury.

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of death and disability. The role of red cell distribution width (RDW) as a prognostic biomarker for outcome in TBI patients is unknown. Based on the corticosteroid randomization after significant head injury (CRASH) trial database, a prognosis calculator (CRASH) has been developed for outcome prediction in TBI. The objectives of this study are to investigate the association between RDW on day 1 of TBI and outcome, and to compare outcome prediction from RDW to that from CRASH. METHODS: We performed a retrospective review of patients with TBI and a Glasgow coma scale (GCS) score of 14 or less. Day 1 RDW and CRASH data were extracted. CRASH was calculated for each patient. Outcome was defined as mortality at 14 days and GOS at 6 months, with poor outcome defined as GOS of 1 - 3. Patients were stratified according to RDW values into six groups, and according to CRASH values into six groups. RESULTS: A total of 416 patients with TBI were included, with 339 survivors (S) and 77 non-survivors (NS). Compared to survivors, non-survivors were of similar age in years (58 ± 23 vs. 58 ± 23, P = 1.0), had lower GCS scores (5 ± 3 vs. 12 ± 3, P = 0.0001), similar RDW (14.0 ± 1.2 vs. 13.9 ± 1.5, P = 0.6), and higher CRASH values (68 ± 26 vs. 24 ± 22, P = 0.0001). Estimating the receiver-operating characteristic (ROC) area under the curve (AUC) showed that CRASH was a significantly better predictor of mortality compared to RDW (AUC = 0.91 ± 0.01 for CRASH compared to 0.66 ± 0.03 for RDW; P < 0.0001). In addition, CRASH was a better predictor of neurologic outcome compared to RDW (AUC = 0.85 ± 0.02 for CRASH compared to 0.76 ± 0.03 for RDW; P = 0.005). CONCLUSIONS: CRASH calculator was a strong predictor of mortality in patients with TBI. RDW on day 1 did not differ between survivors and non-survivors, and was a poor predictor of mortality. Both RDW on day 1 and CRASH calculator are good predictors of 6-month outcome in TBI patients, although CRASH calculator remains a better predictor.

Predicting Mortality of Patients With Sepsis: A Comparison of APACHE II and APACHE III Scoring Systems.

BACKGROUND: Acute Physiology, Age and Chronic Health Evaluation (APACHE) II and III scores were developed in 1985 and 1991, respectively, and are used mainly for critically ill patients of all disease categories admitted to the intensive care unit (ICU). They differ in how chronic health status is assessed, in the number of physiologic variables included (12 vs. 17), and in the total score. These two scoring systems have not been compared in predicting hospital mortality in patients with sepsis. METHODS: We retrospectively identified all septic patients admitted to our 54-bed medical-surgical ICU between June 2009 and February 2014 using the APACHE outcomes database. We calculated correlation coefficients for APACHE II and APACHE III scores in predicting hospital mortality. Receiver-operating characteristic (ROC) curves were also used to assess the mortality predictions. RESULTS: We identified a total of 2,054 septic patients. Average APACHE II score was 19 ± 7, and average APACHE III score was 68 ± 28. ICU mortality was 11.8% and hospital mortality was 18.3%. Both APACHE II (r = 0.41) and APACHE III scores (r = 0.44) had good correlations with hospital mortality. There was no statistically significant difference between the two correlations (P = 0.1). ROC area under the curve (AUC) was 0.80 (95% confidence interval (CI): 0.78 - 0.82) for APACHE II, and 0.83 (95% CI: 0.81 - 0.85) for APACHE III, suggesting that both scores have very good discriminative powers for predicting hospital mortality. CONCLUSIONS: This study shows that both APACHE II and APACHE III scores in septic patients were very strong predictors of hospital mortality. APACHE II was as good as APACHE III in predicting hospital mortality in septic patients.

A Model for Identifying Patients Who May Not Need Neurologic Intensive Care Unit Admission: Resource Utilization Study.

PURPOSE: Limited resources, neurointensivists, and neurologic intensive care unit (neuro-ICU) beds warrant investigating models for predicting who will benefit from admission to neuro-ICU. This study presents a possible model for identifying patients who might be too well to benefit from admission to a neuro-ICU. METHODS: We retrospectively identified all patients admitted to our 16-bed neuro-ICU between November 2009 and February 2013. We used the Acute Physiology and Chronic Health Evaluation (APACHE) outcomes database to identify patients who on day 1 of neuro-ICU admission received 1 or more of 30 subsequent active life-supporting treatments. We compared 2 groups of patients: low-risk monitor (LRM; patients who did not receive active treatment [AT] on the first day and whose risk of ever receiving AT was ≤ 10%) and AT (patients who received at least 1 of the 30 ICU treatments on any day of their ICU admission). RESULTS: There were 873 (46%) admissions in the LRM group and 1006 (54%) admissions in the AT group. The ICU length of stay in days was 1.7 (± 1.9) for the LRM group versus 4.5 (± 5.5) for the AT group. The ICU mortality was 0.8% for the LRM group compared to 14% for the AT group (odds ratio [OR] = 17.6; 95% confidence interval [CI], 8.2-37.8, P < .0001). Hospital mortality was 1.9% for the LRM group compared to 19% for the AT group (OR = 9.7; 95% CI, 5.8-16.1, P < .0001). CONCLUSION: The outcome for LRM patients in our neuro-ICU suggests they may not require admission to neurologic intensive care. This may provide a measure of neuro-ICU resource use. Improved resource use and reduced costs might be achieved by strategies to provide care for these patients on floors or intermediate care units. This model will need to be validated in other neuro-ICUs and prospectively studied before it can be adopted for triaging admissions to neuro-ICUs.

Sepsis in the neurologic intensive care unit: epidemiology and outcome.

BACKGROUND: Sepsis is a major contributor to mortality in patients admitted to a general intensive care unit (ICU). Early recognition and treatment of sepsis is key in improving outcomes. The epidemiology and outcome of sepsis in neurologic ICU (NeuroICU) has not been evaluated. METHODS: We retrospectively identified all patients admitted to our 16-bed NeuroICU between June 2009 and December 2013 using the acute physiologic and chronic health evaluation (APACHE) outcomes database. We excluded patients admitted with an infection, such as meningitis, encephalitis, brain or spinal abscess, or with any other infection. We compared NeuroICU patients who did to NeuroICU patients who did not develop sepsis after ICU admission. The diagnosis of sepsis was based on the SCCM/ACCP consensus conference definition. RESULTS: There were a total of 2,025 patients, out of which 29 patients (1.4%) developed sepsis. Patients who developed sepsis had a trend towards older age (67 ± 13 vs. 61 ± 11 years, P = 0.07), a trend towards more male gender (69.0% vs. 51.5%, P = 0.07), significantly higher APACHE III scores (58 ± 17 vs. 43 ± 21, P = 0.0001), and significantly higher acute physiologic scores (APS) (43 ± 16 vs. 32 ± 18, P = 0.001) than patients who did not develop sepsis. Patients who developed sepsis had higher ICU mortality (41.4% vs. 5.1%, odds ratio (OR) = 13.1; 95% confidence interval (CI), 6.1 - 28.2, P < 0.0001), and higher hospital mortality (44.8% vs. 8.2%, OR = 9.0; 95% CI, 4.3 - 19.0, P < 0.0001). CONCLUSIONS: Sepsis developed in 1.4% of patients admitted to a NeuroICU. Predictors of sepsis development were comorbidities and worsening acute physiologic variables. Patients who developed sepsis had significantly higher mortality. Vigilance to development of sepsis in NeuroICU is paramount, especially in this era when early recognition and intervention of sepsis significantly improves outcomes.

Comparison of the Full Outline of UnResponsiveness score and the Glasgow Coma Scale in predicting mortality in critically ill patients*.

OBJECTIVE: Impaired consciousness has been incorporated in prediction models that are used in the ICU. The Glasgow Coma Scale has value but is incomplete and cannot be assessed in intubated patients accurately. The Full Outline of UnResponsiveness score may be a better predictor of mortality in critically ill patients. SETTING: Thirteen ICUs at five U.S. hospitals. SUBJECTS: One thousand six hundred ninety-five consecutive unselected ICU admissions during a six-month period in 2012. DESIGN: Glasgow Coma Scale and Full Outline of UnResponsiveness score were recorded within 1 hour of admission. Baseline characteristics and physiologic components of the Acute Physiology and Chronic Health Evaluation system, as well as mortality were linked to Glasgow Coma Scale/Full Outline of UnResponsiveness score information. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: We recruited 1,695 critically ill patients, of which 1,645 with complete data could be linked to data in the Acute Physiology and Chronic Health Evaluation system. The area under the receiver operating characteristic curve of predicting ICU mortality using the Glasgow Coma Scale was 0.715 (95% CI, 0.663-0.768) and using the Full Outline of UnResponsiveness score was 0.742 (95% CI, 0.694-0.790), statistically different (p = 0.001). A similar but nonsignificant difference was found for predicting hospital mortality (p = 0.078). The respiratory and brainstem reflex components of the Full Outline of UnResponsiveness score showed a much wider range of mortality than the verbal component of Glasgow Coma Scale. In multivariable models, the Full Outline of UnResponsiveness score was more useful than the Glasgow Coma Scale for predicting mortality. CONCLUSIONS: The Full Outline of UnResponsiveness score might be a better prognostic tool of ICU mortality than the Glasgow Coma Scale in critically ill patients, most likely a result of incorporating brainstem reflexes and respiration into the Full Outline of UnResponsiveness score.

Transfusion of red blood cells is associated with improved central venous oxygen saturation but not mortality in septic shock patients.

BACKGROUND: Although the optimum hemoglobin (H) concentration for patients with septic shock (SS) has not been specifically investigated, current guidelines suggest that H of 7 - 9 g/dL, compared with 10 - 12 g/dL, was not associated with increased mortality in critically ill adults. This contrasts with early goal-directed resuscitation protocols that use a target hematocrit of 30% in patients with low central venous oxygen saturation (ScvO2) during the first 6 hours of resuscitation of SS. METHODS: Data elements were prospectively collected on all patients with SS patients (lactic acid (LA) > 4 mmol/L, or hypotension). Out of a total of 396 SS patients, 46 patients received red blood cell (RBC) transfusion for ScvO2 < 70% (RBC group). We then matched 71 SS patients that did not receive RBC transfusion (NRBC group) on the following goals (G): LA obtained within 6 hours (G1), antibiotics given within 3 hours (G2), 20 mL/kg fluid bolus followed by vasopressors (VP) if needed to keep mean arterial pressure > 65 mm Hg (G3), central venous pressure > 8 mm Hg within 6 hours (G4) and ScvO2 > 70% within 6 hours (G5). RESULTS: In the RBC group, after one unit of RBC transfusion, ScvO2 improved from average of 63% (± 12%) to 68% (± 10%) (P = 0.02). Sixteen patients required another unit of RBC, and this resulted in increase of ScvO2 to 78% (± 11%) (P < 0.01). The RBC and NRBC groups were matched on sequential organ failure assessment (SOFA) scores and all five goals. There was no difference in mortality between the two groups: 41% vs. 39.4% (OR: 0.8, 95% CI: 0.4 - 1.7, P = 0.6). CONCLUSIONS: In our study, transfusion of RBC was not associated with decreased mortality in SS patients.

Fluid resuscitation in septic shock: the effect of increasing fluid balance on mortality.

PURPOSE: To determine whether progressively increasing fluid balance after initial fluid resuscitation for septic shock is associated with increased mortality. METHODS: A retrospective review of the use of intravenous fluids in patients with septic shock in a large university affiliated hospital with 56 medical-surgical intensive care unit beds. We analyzed the data of 350 patients with septic shock who were managed according to the Surviving Sepsis Campaign guidelines. Based on net fluid balance at 24 hours, we examined the results of increase in positive fluid balance on the risk of in-hospital mortality. Patients were divided into 4 groups based on the amount of fluid balance by 24 hours, based on 6-L aliquots. RESULTS: At 24 hours, the average fluid balance was +6.5 L. After correcting for age and sequential organ failure assessment score, a more positive fluid balance at 24 hours significantly increased the risk of in-hospital mortality. Using Cox proportional hazard analysis, excess 12-, 18-, and 24-L positive fluid balance had higher risk of mortality than those patients with a neutral to positive 6-L fluid balance (reference group). Adjusted hazard ratios, 1.519 (95% confidence interval [CI], 1.353-1.685), 1.740 (95% CI, 1.467-2.013), and 1.620 (95% CI, 1.197-2.043), respectively, P < .05. CONCLUSION: In patients with septic shock resuscitated according to current guidelines, a more positive fluid balance at 24 hours is associated with an increase in the risk of mortality. Optimal survival occurred at neutral fluid balance and up to 6-L positive fluid balance at 24 hours after the development of septic shock.

Red cell distribution width and outcome in patients with septic shock.

INTRODUCTION: Red cell distribution width (RDW) is reflective of systemic inflammation. The objective of this study was to investigate the association between RDW (on day 1 of development of septic shock) and mortality. METHODS: A total of 279 patients with septic shock were included. We categorized the patients into quintiles based on RDW as follows: <13.5%, 13.5% to 15.5%, 15.6% to 17.5%, 17.5% to 19.4%, and >19.4%. RESULTS: Red cell distribution width was a strong predictor of hospital mortality with a significant risk gradient across RDW quintiles after multivariable adjustment: RDW 13.5% to 15.5% (odds ratio [OR], 4.6; 95% confidence interval [CI], 1.0-23.4; P = .06); RDW 15.6% to 17.5% (OR, 8.0; 95% CI, 1.5-41.6; P = .01); RDW 17.6% to 19.4% (OR, 25.3; 95% CI, 4.3-149.2; P < .001); and RDW >19.4% (OR, 12.3; 95% CI, 2.1-73.3; P = .006), all relative to patients with RDW <13.5%. Similar significant robust associations were present for intensive care unit mortality. Estimating the receiver-operating characteristic area under the curve (AUC) showed that RDW has very good discriminative power for hospital mortality (AUC = 0.74). The AUC was 0.69 for Acute Physiologic and Chronic Health Evaluation II (APACHE II) and 0.69 for sequential organ failure assessment (SOFA). When adding RDW to APACHE II, the AUC increased from 0.69 to 0.77. CONCLUSIONS: Red cell distribution width on day 1 of septic shock is a robust predictor of mortality. The RDW is inexpensive and commonly measured. The RDW fared better than either APACHE II or SOFA, and the sum of RDW and APACHE II was a stronger predictor of mortality than either one alone.

The effect of red blood cell transfusion on tissue oxygenation and microcirculation in severe septic patients.

BACKGROUND: Microcirculation plays a vital role in the development of multiple organ failure in severe sepsis. The effects of red blood cell (RBC) transfusions on these tissue oxygenation and microcirculation variables in early severe sepsis are not well defined. METHODS: This is a prospective, observational study of patients with severe sepsis requiring RBC transfusions of one to two units of non-leukoreduced RBCs for a hemoglobin < 7.0, or for a hemoglobin between 7.0 and 9.0 with lactic acidosis or central venous oxygen saturation < 70%. This study took place in a 54-bed, medical-surgical intensive care unit of a university-affiliated hospital. Thenar tissue oxygen saturation was measured by using a tissue spectrometer on 21 patients, and a vaso-occlusive test was performed before and 1 hour after transfusion. The sublingual microcirculation was assessed with a Sidestream Dark Field device concomitantly on 11 of them. RESULTS: RBC transfusion resulted in increase in hemoglobin (7.23 (± 0.87) to 8.75 (± 1.06) g/dl; p < 0.001). RBC transfusion did not globally affect near-infrared spectrometry (NIRS)-derived variables. However, percent change in muscle oxygen consumption was negatively correlated with baseline (r = - 0.679, p = 0.001). There was no statistically significant correlation between percent change in vascular reactivity and baseline (p = 0.275). There was a positive correlation between percent change in oxygen consumption and percent change in vascular reactivity (r = 0.442, p = 0.045). In the 11 patients, RBC transfusion did not globally affect NIRS-derived variables or SDF-derived variables. There was no statistically significant correlation between percent change in small vessel perfusion and baseline perfusion (r = -0.474, p = 0.141), between percent change in small vessel flow and baseline flow (r = -0.418, p = 0.201), or between percent change in small vessel perfusion and percent change in small vessel flow (r = 0.435, p = 0.182). CONCLUSIONS: In a small sample population, muscle tissue oxygen consumption, microvascular reactivity and sublingual microcirculation were globally unaltered by RBC transfusion in severe septic patients. However, muscle oxygen consumption improved in patients with low baseline and deteriorated in patients with preserved baseline. Future research with larger samples is needed to further examine the association between RBC transfusion and outcomes of patients resuscitated early in severe sepsis, with an emphasis on elucidating the potential contribution of microvascular factors.

Activated protein C in septic shock: a propensity-matched analysis.

INTRODUCTION: The use of human recombinant activated protein C (rhAPC) for the treatment of severe sepsis remains controversial despite multiple reported trials. The efficacy of rhAPC remains a matter of dispute. We hypothesized that patients with septic shock who were treated with rhAPC had an improved in-hospital mortality compared to patients with septic shock with similar acuity who did not receive rhAPC. METHODS: This retrospective cohort study was completed at a large university-affiliated hospital. All patients with septic shock admitted to a 50-bed ICU between July 2003 and February 2009 were included. Patients were treated according to sepsis management guidelines. RESULTS: A total of 563 septic shock patients were included (110 received rhAPC and 453 did not). Treated and untreated groups were matched in patient characteristics, comorbidities, and physiologic variables in a 1:1 propensity-matched analysis (108 received rhAPC, 108 did not). Mean Acute Physiology And Chronic Health Evaluation II (APACHE II) scores were 24.5 for the matched treated and 23.9 for the matched untreated group (P = 0.54). Receipt of rhAPC was associated with reduced in-hospital mortality (35.2% vs. 53.8%, P = 0.005), similar mean days on vasopressors (2 vs. 2, P = 0.90), similar mean days on mechanical ventilation (9 vs. 8.7, P = 0.80), similar mean length of ICU stay in days (11.0 vs. 11.3, P = 0.90), and similar mean length of hospital stay in days (19.5 vs 27, P = 0.11). No patients in either group had intracranial bleeding; differences in gastrointestinal bleeding and transfusion requirements were not statistically significant. CONCLUSIONS: Patients in our institution with septic shock who were treated with rhAPC had a reduced in-hospital mortality compared with patients with septic shock with similar acuity who were not treated with rhAPC. In addition, time on mechanical ventilation, time on vasopressors, lengths of stay and bleeding complications did not differ between the groups.

Outcomes of etomidate in severe sepsis and septic shock.

BACKGROUND: The use of single-dose etomidate to facilitate intubation in critically ill patients has recently been debated given its suppression of steroidogenesis with possible resultant adverse outcomes. Our objective was to assess the effects of single-dose etomidate used during rapid-sequence intubation (RSI) on various measures of outcome, such as mortality, vasopressor use, corticosteroid use, ICU length of stay (ICU-LOS), and number of ventilator days. METHODS: A retrospective 18-month cohort study was performed in a multidisciplinary ICU of an academic tertiary care institution. Consecutive patients with severe sepsis or septic shock who were intubated and mechanically ventilated were identified and grouped as having received single-dose etomidate during intubation or not. Hospital mortality, ICU length of stay, number of ventilator days, corticosteroid use, vasopressor use, and demographic and clinical variables were recorded. RESULTS: Two hundred twenty-four patients were identified; 113 had received etomidate. The mean Acute Physiology and Chronic Health Evaluation II scores in the etomidate and nonetomidate groups were 21.3 ± 8.1 and 21.9 ± 8.3, respectively (P = .62). The relative risks for mortality and vasopressor use were 0.92 (CI, 0.74-1.14; P = 0.51) and 1.16 (CI, 0.9-1.51; P = .31), respectively, in the etomidate group. There were no significant differences in ICU-LOS (mean, 14 vs 12 days; P = .31) or number of ventilator days (mean, 11 vs 8 days; P = .13) between the etomidate and nonetomidate groups, respectively. The relative risk for corticosteroid use in the etomidate group was 1.34 (CI, 1.11-1.61; P = .003). Multivariate analysis using logistic regression demonstrated no significant association of etomidate with mortality (OR, 0.9; CI, 0.45-1.83; P = .78). CONCLUSION: Single-dose etomidate used during RSI in critically ill patients with severe sepsis and septic shock was not associated with increased mortality, vasopressor use, ICU-LOS, or number of ventilator days. Patients intubated with etomidate had an increased incidence of subsequent corticosteroid use, with no difference in outcomes.

Red blood cell transfusions and nosocomial infections in critically ill patients.

OBJECTIVE: A previous retrospective evaluation of Project Impact data demonstrated an association between red blood cell transfusions, nosocomial infections, and poorer outcomes in critically ill patients, independent of survival probability or patient age. The objective of this study was to determine whether transfused patients, independent of survival probability based on Mortality Prediction Model scores, have higher nosocomial infection rates, longer intensive care unit and hospital lengths of stay, and higher mortality rates than nontransfused patients. DESIGN: Prospective, observational, cohort study. SETTING: A single-center, mixed medical/surgical, closed intensive care unit. PATIENTS: : Adults admitted to St. John's Mercy Medical Center between August 2001 and June 2003 (n = 2,085) were enrolled using Project Impact software. Both nonoperative and postoperative populations were represented, and transfusion decisions were made independently of patient study inclusion. Patients whose nosocomial infection was diagnosed before transfusion were counted as nontransfused. INTERVENTIONS: : None. MEASUREMENTS AND MAIN RESULTS: Nosocomial infections, mortality rates, and intensive care unit and hospital length of stay were the main outcome measures. Of the 2,085 patients enrolled, 21.5% received red blood cell transfusions. The posttransfusion nosocomial infection rate was 14.3% in 428 evaluable patients, significantly higher than that observed in nontransfused patients (5.8%; p < .0001, chi-square). In a multivariate analysis controlling for patient age, maximum storage age of red blood cells, and number of red blood cell transfusions, only the number of transfusions was independently associated with nosocomial infection (odds ratio 1.097; 95% confidence interval 1.028-1.171; p = .005). When corrected for survival probability, the risk of nosocomial infection associated with red blood cell transfusions remained statistically significant (p < .0001). Leukoreduction tended to reduce the nosocomial infection rate but not significantly. Mortality and length of stay (intensive care unit and hospital) were significantly higher in transfused patients, even when corrected for illness severity. CONCLUSIONS: Red blood cell transfusions should be used sparingly, bearing in mind the potential risks of infection and poor outcomes in critically ill patients.

Impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient.

OBJECTIVE: To determine whether critically ill patients who receive allogenic packed red blood cell transfusions are at increased risk of developing nosocomial infections during hospitalization. DESIGN: Retrospective database study utilizing Project IMPACT. SETTING: A 40-bed medical-surgical-trauma intensive care unit in an 825-bed tertiary referral teaching hospital. PATIENTS: One thousand seven hundred and seventeen patients admitted to the medical-surgical-trauma intensive care unit. MEASUREMENTS AND MAIN RESULTS: Data were collected by using the Project IMPACT database. Nosocomial infection rates were compared among three groups: the entire cohort, the transfusion group, and the nontransfusion group. We determined the nosocomial infection rates in these groups while adjusting for probability of survival by using Mortality Prediction Model (MPM-0) scores, age, gender, and number of units of packed red blood cells transfused. The average number of units transfused per patient was 4.0. The nosocomial infection rate for the entire cohort was 5.94%. The nosocomial infection rates for the transfusion group (n = 416) and the nontransfusion group (n = 1301) were 15.38% and 2.92%, respectively (p <.005 chi-square). Transfusion of packed red blood cells was related to the occurrence of nosocomial infection, and there was a dose-response pattern (the more units of packed red blood cells transfused, the greater the chance of nosocomial infection; p< 0.0001 chi-square). The transfusion group was six times more likely to develop nosocomial infection compared with the nontransfusion group. In addition, for each unit of packed red blood cells transfused, the odds of developing nosocomial infection were increased by a factor of 1.5. A subgroup analysis of nosocomial infection rates adjusted for probability of survival by using MPM-0 scores showed nosocomial infection to occur at consistently higher rates in transfused patients vs. nontransfused patients. A second subgroup analysis adjusted for patient age showed a statistically significant increase in rates of nosocomial infection for transfused patients regardless of age. CONCLUSIONS: Transfusion of packed red blood cells is associated with nosocomial infection. This association continues to exist when adjusted for probability of survival and age. In addition, mortality rates and length of intensive care unit and hospital stay are significantly increased in transfused patients.