Real-world use of procalcitonin and other biomarkers among sepsis hospitalizations in the United States: A retrospective, observational study.

BACKGROUND: Sepsis management guidelines endorse use of biomarkers to support clinical assessment and treatment decisions in septic patients. The impact of biomarkers on improving patient outcomes remains uncertain. METHODS: Retrospective observational study of adult sepsis discharges between January 1, 2012, and December 31, 2015, from Premier Healthcare Database hospitals. Sepsis was defined by an All Patients Refined Diagnosis-Related Group code of 720 (septicemia and disseminated infections). Use of four biomarker strategies was evaluated based on hospital records: (i) >1 procalcitonin (PCT), (ii) 1 PCT, (iii) no PCT but ≥1 C-reactive protein (CRP) and/or lactate and (iv) no sepsis biomarkers. Associations between biomarker use and clinical and cost outcomes were examined. The primary outcome was impact of biomarker strategy on hospital costs per day. RESULTS: Among 933,591 adult sepsis discharges during the study period, 731,392 (78%) had biomarker tests ordered. In multivariable analyses, discharges with >1 PCT had higher hospital costs per day ($1,904; 95% confidence interval [CI] $1,896-$1,911) compared with discharges with no sepsis biomarkers ($1,606; 95% CI $1,658-$1,664). Discharges with >1 PCT also had greater illness severity and antimicrobial exposure compared with other biomarker-use groups. The adjusted odds of dying during hospital stay compared with being discharged were significantly lower for sepsis discharges with >1 PCT (0.64; 95% CI 0.61-0.67) and 1 PCT (0.88; 95% CI 0.85-0.91) compared with no sepsis biomarker use. The proportion of discharges with ≥1 PCT increased almost six-fold during the study; use of other biomarkers remained constant. CONCLUSIONS: Between 2012 and 2015, PCT use among sepsis discharges increased six-fold while lactate and CRP use remained unchanged. PCT use was associated with decreased odds of in-hospital mortality but increased hospital costs per day. Serial biomarker monitoring may be associated with improved patient outcomes in the most critically ill septic patients.

Multicenter evaluation of noninvasive cardiac output measurement by bioreactance technique.

OBJECTIVES: Bioreactance, the analysis of intrabeat variations in phase of a transthoracic voltage in response to an applied high frequency transthoracic current, was recently introduced for noninvasive cardiac output measurement (NICOM). We evaluated NICOM compared to thermo- dilution (TD) in several clinical settings. METHODS: 111 patients with a clinical indication for TD cardiac output (CO) measurement were recruited at five centers, including patients in cardiac catheterization laboratories, cardiac care units and intensive care units. CO measurements were made simulta- neously with TD and the bioreactance method and compared by regression analysis. RESULTS: For studies in the intensive care units, TD-based CO and NICOM were highly correlated (r = 0.78, P < 0.0001) and did not differ significantly from each other (P = 0.55). Results in the cardiac catheterization laboratory were similar (r = 0.71, P < 0.001; P = 0.28 NICOM versus TD). In subsets of patients, NICOM was shown to be better corre- lated with TD-CO than CO obtained with the Fick method or with standard bioimpedance-based measurements of CO. CONCLUSIONS: On average, compared to TD, bioreactance- based NICOM has acceptable accuracy in challenging clinical environments. Availability of such a tool may allow clinicians to have information about CO in patients where this information is not currently available to help diagnosis and guide therapy.

Pectus excavatum with inspiratory inferior vena cava compression: a new presentation of pulsus paradoxus.

A 29-year-old man with pectus excavatum presented with exercise intolerance, pulsus paradoxus, and paradoxically split S2. Chest computed tomography (CT) showed the heart shifted leftward and a pectus severity index of 7.18. Cardiopulmonary exercise study showed reduced VO2max, anaerobic threshold, and oxygen pulse. Echocardiography revealed a decline in mitral and tricuspid valve inflow, and stroke volume during inspiration. Cardiac extrinsic compression and anatomic cardiac abnormalities were not present. Dynamic magnetic resonance imaging (MRI) demonstrated inspiratory inferior vena cava (IVC) compression at the diaphragm. We discuss IVC compression by the diaphragm as a source of patient symptoms and as a mechanism for pulsus paradoxus associated with pectus excavatum.