Hypotension Prediction Score for Endotracheal Intubation in Critically Ill Patients: A Post Hoc Analysis of the HEMAIR Study.

BACKGROUND: Hypotension with endotracheal intubation (ETI) is common and associated with adverse outcomes. We sought to evaluate whether a previously described hypotension prediction score (HYPS) for ETI is associated with worse patient outcomes and/or clinical conditions. METHODS: This study is a post hoc analysis of a prospective observational multicenter study involving adult (age ≥18 years) intensive care unit (ICU) patients undergoing ETI in which the HYPS was derived and validated on the entire cohort and a stable subset (ie, patients in stable condition). We evaluated the association between increasing HYPSs in both subsets and several patient-centered outcomes and clinical conditions. RESULTS: Complete data for HYPS calculations were available for 783 of 934 patients (84%). Logistic regression analysis showed increasing odds ratios (ORs) for the highest risk category for new-onset acute kidney injury (OR, 7.37; 95% CI, 2.58-21.08); new dialysis need (OR, 8.13; 95% CI, 1.74-37.91); ICU mortality (OR, 16.39; 95% CI, 5.99-44.87); and hospital mortality (OR, 18.65; 95% CI, 6.81-51.11). Although not increasing progressively, the OR for the highest risk group was significantly associated with new-onset hypovolemic shock (OR, 6.06; 95% CI, 1.47-25.00). With increasing HYPSs, median values (interquartile ranges) decreased progressively (lowest risk vs. highest risk) for ventilator-free days (23 [18-26] vs. 1 [0-21], P < .001) and ICU-free days (20 [11-24] vs. 0 [0-13], P < .001). Of the 729 patients in the stable subset, 598 (82%) had complete data for HYPS calculations. Logistic regression analysis showed significantly increasing ORs for the highest risk category for new-onset hypovolemic shock (OR, 7.41; 95% CI, 2.06-26.62); ICU mortality (OR, 5.08; 95% CI, 1.87-13.85); and hospital mortality (OR, 7.08; 95% CI, 2.63-19.07). CONCLUSIONS: As the risk for peri-intubation hypotension increases, according to a validated hypotension prediction tool, so does the risk for adverse clinical events and certain clinical conditions. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (NCT02508948).

Intensive Care Unit and Hospital Outcomes of Patients Admitted with Blastomycosis: A 14-Year Retrospective Study.

INTRODUCTION: Blastomycosis is an uncommon; potentially life-threatening granulomatous fungal infection. The aim of this study is to report hospital and intensive care unit (ICU) outcomes of patients admitted with blastomycosis. METHODS: All patients admitted for treatment of blastomycosis at the Mayo Clinic-Rochester, Minnesota between 01/01/2006 and 09/30/2019 were included. Demographics, comorbidities, clinical presentation, ICU admission, and outcomes were reviewed. RESULTS: A total of 84 Patients were identified with 90 unique hospitalizations primarily for blastomycosis. The median age at diagnosis was 49 (IQR 28.1-65, range: 6-85) years and 56 (66.7%) were male. The most frequent comorbidities included hypertension (n = 28, 33.3%); immunosuppressed state (n = 25, 29.8%), and diabetes mellitus (n = 21, 25%). The lungs were the only organ involved in 56 (66.7%) cases and the infection was disseminated in 19 (22.6%) cases. A total of 29 patients (34.5%) underwent ICU admission due to complications of blastomycosis. ICU related events included mechanical ventilation (n = 20, 23.8%), acute respiratory distress syndrome (ARDS) (n = 13, 15.5%), tracheostomy (n = 9, 10.7%), renal replacement therapy (n = 8, 9.5%), and extracorporeal membrane oxygenation (ECMO) (n = 4, 4.8%). A total of 12 patients (14.3%) died in the hospital; all of whom had undergone ICU admission. In-hospital mortality was associated with renal replacement therapy (RRT) (P = 0.0255). CONCLUSION: Blastomycosis is a serious, potentially life-threatening infection that results in significant morbidity and mortality with a 34.5% ICU admission rate. RRT was associated with in-hospital mortality.

Ensuring trust in COVID-19 data: A retrospective cohort study.

ABSTRACT: There are no standardized methods for collecting and reporting coronavirus disease-2019 (COVID-19) data. We aimed to compare the proportion of patients admitted for COVID-19-related symptoms and those admitted for other reasons who incidentally tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).Retrospective cohort studyData were sampled twice weekly between March 26 and June 6, 2020 from a "COVID-19 dashboard," a system-wide administrative database that includes the number of hospitalized patients with a positive SARS-CoV-2 polymerase chain reaction test. Patient charts were subsequently reviewed and the principal reason for hospitalization abstracted.Data collected during a statewide lockdown revealed that 92 hospitalized patients had positive SARS-CoV-2 test results. Among these individuals, 4.3% were hospitalized for reasons other than COVID-19-related symptoms but were incidentally found to be SARS-CoV-2-positive. After the lockdown was suspended, the total inpatient census of SARS-CoV-2-positive patients increased to 128, 20.3% of whom were hospitalized for non-COVID-19-related complaints.In the absence of a statewide lockdown, there was a significant increase in the proportion of patients admitted for non-COVID-19-related complaints who were incidentally found to be SARS-CoV-2-positive. In order to ensure data integrity, coding should distinguish between patients with COVID-19-related symptoms and asymptomatic patients carrying the SARS-CoV-2 virus.

Risk factors for and prediction of post-intubation hypotension in critically ill adults: A multicenter prospective cohort study.

OBJECTIVE: Hypotension following endotracheal intubation in the ICU is associated with poor outcomes. There is no formal prediction tool to help estimate the onset of this hemodynamic compromise. Our objective was to derive and validate a prediction model for immediate hypotension following endotracheal intubation. METHODS: A multicenter, prospective, cohort study enrolling 934 adults who underwent endotracheal intubation across 16 medical/surgical ICUs in the United States from July 2015-January 2017 was conducted to derive and validate a prediction model for immediate hypotension following endotracheal intubation. We defined hypotension as: 1) mean arterial pressure <65 mmHg; 2) systolic blood pressure <80 mmHg and/or decrease in systolic blood pressure of 40% from baseline; 3) or the initiation or increase in any vasopressor in the 30 minutes following endotracheal intubation. RESULTS: Post-intubation hypotension developed in 344 (36.8%) patients. In the full cohort, 11 variables were independently associated with hypotension: increasing illness severity; increasing age; sepsis diagnosis; endotracheal intubation in the setting of cardiac arrest, mean arterial pressure <65 mmHg, and acute respiratory failure; diuretic use 24 hours preceding endotracheal intubation; decreasing systolic blood pressure from 130 mmHg; catecholamine and phenylephrine use immediately prior to endotracheal intubation; and use of etomidate during endotracheal intubation. A model excluding unstable patients' pre-intubation (those receiving catecholamine vasopressors and/or who were intubated in the setting of cardiac arrest) was also developed and included the above variables with the exception of sepsis and etomidate. In the full cohort, the 11 variable model had a C-statistic of 0.75 (95% CI 0.72, 0.78). In the stable cohort, the 7 variable model C-statistic was 0.71 (95% CI 0.67, 0.75). In both cohorts, a clinical risk score was developed stratifying patients' risk of hypotension. CONCLUSIONS: A novel multivariable risk score predicted post-intubation hypotension with accuracy in both unstable and stable critically ill patients. STUDY REGISTRATION: Clinicaltrials.gov identifier: NCT02508948 and Registered Report Identifier: RR2-10.2196/11101.

Catheter-Associated Urinary Tract Infections in Intensive Care Unit Patients.

OBJECTIVE: To delineate the epidemiology of catheter-associated urinary tract infections (CAUTIs) and to better understand the value of urine cultures for evaluation of fever in the intensive care unit (ICU) setting DESIGN: Two-year retrospective review (2012-2013) SETTING: A single tertiary center with 1,200 hospital beds and 158 adult ICU beds PATIENTS: ICU patients with a CAUTI event METHODS: The cohort was identified from a prospective infection prevention database. Charts were reviewed to characterize the patients. CAUTI rates and device utilization ratio (DUR) were calculated. Clinical outcomes were recorded. RESULTS: A total of 105 CAUTIs were identified using the National Health and Safety Network (NHSN) definition. Fever was the primary indication for obtaining urine culture in 102 patients (97%). Of these 105 patients, 51 (51%) had an alternative infection to explain the fever, with pneumonia (55%) being the most common followed by bloodstream infection (22%). A total of 18 patients (18%) had fever due to noninfectious cause, and 32 patients (32%) had no alternative explanation. Of these, 66% received appropriate empiric antimicrobial therapy, but no targeted therapy changes were made based on urine culture results. The other 34% did not receive antimicrobial therapy at all. Only 6% of all CAUTIs resulted in blood cultures positive for the same organism within 2 days. The urinary tract was not definitely established as the source of bloodstream infection. CONCLUSIONS: Urine cultures obtained for evaluation of fever form the basis for identification of CAUTIs in the ICU. However, most patients with CAUTIs are eventually found to have alternative explanations for fever. CAUTI is associated with a low complication rate.

Ketamine/propofol admixture (ketofol) at induction in the critically ill against etomidate (KEEP PACE trial): study protocol for a randomized controlled trial.

BACKGROUND: Endotracheal intubation (ETI) is commonly performed as a life-saving procedure in the intensive care unit (ICU). It is often associated with significant hemodynamic perturbations and can severely impact the outcome of ICU patients. Etomidate is often chosen by many critical care providers for the patients who are hypotensive because of its superior hemodynamic profile compared to other induction medications. However, recent evidence has raised concerns about the increased incidence of adrenal insufficiency and mortality associated with etomidate use. A combination of ketamine and propofol (known as ketofol) has been studied in various settings as an alternative induction agent. In recent years, studies have shown that this combination may provide adequate sedation while maintaining hemodynamic stability, based on the balancing of the hemodynamic effects of these two individual agents. We hypothesized that ketofol may offer a valuable alternative to etomidate in critically ill patients with or without hemodynamic instability. METHODS/DESIGN: A randomized controlled parallel-group clinical trial of adult critically ill patients admitted to either a medical or surgical ICU at Mayo Clinic in Rochester, MN will be conducted. As part of planned emergency research, informed consent will be waived after appropriate community consultation and notification. Patients undergoing urgent or emergent ETI will receive either etomidate or a 1:1 admixture of ketamine and propofol (ketofol). The primary outcome will be hemodynamic instability during the first 15 minutes following drug administration. Secondary outcomes will include ICU length of stay, mortality, adrenal function, ventilator-free days and vasoactive medication use, among others. The planned sample size is 160 total patients. DISCUSSION: The overall goal of this trial is to assess the hemodynamic consequences of a ketamine-propofol combination used in critically ill patients undergoing urgent or emergent ETI compared to etomidate, a medication with an established hemodynamic profile. The trial will address a crucial gap in the literature regarding the optimal induction agent for ETI in patients that may have potential or established hemodynamic instability. Greater experience with planned emergency research will, hopefully, pave the way for future prospective randomized clinical trials in the critically ill population. TRIAL REGISTRATION: Clinicaltrials.gov: NCT02105415. 31 March 2014.

Ketamine and propofol combination ("ketofol") for endotracheal intubations in critically ill patients: a case series.

BACKGROUND: Endotracheal intubation is a common procedure performed for critically ill patients that can have immediate life-threatening complications. Induction medications are routinely given to facilitate the procedure, but most of these medications are associated with hypotension. While etomidate is known for its neutral hemodynamic profile, it has been linked with increased mortality in septic patients and increased morbidity in trauma patients. Ketamine and propofol are effective anesthetics with counteracting cardiovascular profiles. No data are available about the use of this combination in critically ill patients undergoing endotracheal intubation. CASE REPORT: We describe 6 cases in which the combination of ketamine and propofol ("ketofol") was used as an induction agent for endotracheal intubation in critically ill patients with a focus on hemodynamic outcomes. All patients received a neuromuscular blocker and fentanyl, while 5 patients received midazolam. We recorded mean arterial pressure (MAP) 1 minute before induction and 15 minutes after intubation with the combination. Of the 6 patients, 5 maintained a MAP ≥ 65 mmHg 15 minutes after intubation. One patient was on norepinephrine infusion with a MAP of 64 mmHg, and did not require an increase in the dose of the vasopressor 15 minutes after intubation. No hemodynamic complications were reported after any of the intubations. CONCLUSIONS: This case series describes the use of the "ketofol" combination as an induction agent for intubation in critically ill patients when hemodynamic stability is desired. Further research is needed to establish the safety of this combination and how it compares to other induction medications.

The impact of multidrug resistance on outcomes in ventilator-associated pneumonia.

Multidrug-resistant (MDR) organisms in ventilator-associated pneumonia were found in 49 of 107 patients and were associated with home antibiotics, pre-ventilator-associated pneumonia hospital stay, and health care exposure. Overall, MDR organisms were associated with increased mortality (P = .006). On multivariate analysis, MDR status was modulated by organism class. In nonfermenting gram-negative rods, no association between MDR and mortality was found, but, in all other organisms, MDR was associated with increased mortality risk (hazard ratio, 6.15; 95% confidence interval: 1.80-21.05, P = .004).

The descriptive epidemiology of central line-associated bloodstream infection among patients in non-intensive care unit settings.

OBJECTIVE: To review and describe device utilization and central line-associated bloodstream (CLABSI) events among patients in a non-intensive care unit (ICU) setting and to examine the morbidity and mortality associated with these events. DESIGN: One-year descriptive review. SETTING: A single tertiary center with a 1,200-bed hospital and 209 adult ICU beds. PATIENTS: Hospitalized patients identified as having a CLABSI event attributed to a non-ICU setting. METHODS: The cohort was identified from a prospective infection prevention database. Charts and administrative data sets were reviewed to further characterize the patients. Device utilization ratios (DURs) and CLABSI rates were calculated using National Health and Safety Network (NHSN) CLABSI definitions. Need for ICU stay and crude mortality rates were recorded. RESULTS: A total of 136 patients with 156 CLABSIs were identified, of whom 78 (57%) were being treated for a hematological malignancy (HM). The overall DUR was 0.27. A tunneled line was in place for 118 (76%) of the CLABSI events, and a peripherally inserted central catheter was in place for 32 (21%) of the CLABSI events. The non-ICU CLABSI rate was significantly higher than the concurrent ICU rate (2.1 CLABSIs per 1,000 catheter-days vs 1.5 CLABSIs per 1,000 catheter-days; [Formula: see text]). Hospital mortality was 23% in the affected group and was significantly higher in patients with HM. CONCLUSIONS: CLABSI rates over a 1-year period were higher in patients outside the ICU at our hospital and were associated with significant mortality.