National ICU Registries as Enablers of Clinical Research and Quality Improvement.

OBJECTIVES: Clinical quality registries (CQRs) have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. This narrative review describes the challenges, proposed solutions, and evidence generated by National ICU registries as facilitators for research and quality improvement. DATA SOURCES: English language articles were identified in PubMed using phrases related to ICU registries, CQRs, outcomes, and case-mix. STUDY SELECTION: Original research, review articles, letters, and commentaries, were considered. DATA EXTRACTION: Data from relevant literature were identified, reviewed, and integrated into a concise narrative review. DATA SYNTHESIS: CQRs have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. The initial experience in European countries and in Oceania ensured that through locally generated data, ICUs could assess their performances by using risk-adjusted measures and compare their results through fair and validated benchmarking metrics with other ICUs contributing to the CQR. The accomplishment of these initiatives, coupled with the increasing adoption of information technology, resulted in a broad geographic expansion of CQRs as well as their use in quality improvement studies, clinical trials as well as international comparisons, and benchmarking for ICUs. CONCLUSIONS: ICU registries have provided increased knowledge of case-mix and outcomes of ICU patients based on real-world data and contributed to improve care delivery through quality improvement initiatives and trials. Recent increases in adoption of new technologies (i.e., cloud-based structures, artificial intelligence, machine learning) will ensure a broader and better use of data for epidemiology, healthcare policies, quality improvement, and clinical trials.

Epidemiology of Renal Replacement Therapy for Critically Ill Patients across Seven Health Jurisdictions.

INTRODUCTION: Acute kidney injury (AKI) requiring treatment with renal replacement therapy (RRT) is a common complication after admission to an intensive care unit (ICU) and is associated with significant morbidity and mortality. However, the prevalence of RRT use and the associated outcomes in critically patients across the globe are not well described. Therefore, we describe the epidemiology and outcomes of patients receiving RRT for AKI in ICUs across several large health system jurisdictions. METHODS: Retrospective cohort analysis using nationally representative and comparable databases from seven health jurisdictions in Australia, Brazil, Canada, Denmark, New Zealand, Scotland, and the USA between 2006 and 2023, depending on data availability of each dataset. Patients with a history of end-stage kidney disease receiving chronic RRT and patients with a history of renal transplant were excluded. RESULTS: A total of 4,104,480 patients in the ICU cohort and 3,520,516 patients in the mechanical ventilation cohort were included. Overall, 156,403 (3.8%) patients in the ICU cohort and 240,824 (6.8%) patients in the mechanical ventilation cohort were treated with RRT for AKI. In the ICU cohort, the proportion of patients treated with RRT was lowest in Australia and Brazil (3.3%) and highest in Scotland (9.2%). The in-hospital mortality for critically ill patients treated with RRT was almost fourfold higher (57.1%) than those not receiving RRT (16.8%). The mortality of patients treated with RRT varied across the health jurisdictions from 37 to 65%. CONCLUSION: The outcomes of patients who receive RRT in ICUs throughout the world vary widely. Our research suggests that differences in access to and provision of this therapy are contributing factors.

Biomarkers: Are They Useful in Severe Community-Acquired Pneumonia?

Community acquired pneumonia (CAP) is a prevalent infectious disease often requiring hospitalization, although its diagnosis remains challenging as there is no gold standard test. In severe CAP, clinical and radiologic criteria have poor sensitivity and specificity, and microbiologic documentation is usually delayed and obtained in less than half of sCAP patients. Biomarkers could be an alternative for diagnosis, treatment monitoring and establish resolution. Beyond the existing evidence about biomarkers as an adjunct diagnostic tool, most evidence comes from studies including CAP patients in primary care or emergency departments, and not only sCAP patients. Ideally, biomarkers used in combination with signs, symptoms, and radiological findings can improve clinical judgment to confirm or rule out CAP diagnosis, and may be valuable adjunctive tools for risk stratification, differentiate viral pneumonia and monitoring the course of CAP. While no single biomarker has emerged as an ideal one, CRP and PCT have gathered the most evidence. Overall, biomarkers offer valuable information and can enhance clinical decision-making in the management of CAP, but further research and validation are needed to establish their optimal use and clinical utility.

ICU registries: From tracking to fostering better outcomes.

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Comparing causal random forest and linear regression to estimate the independent association of organisational factors with ICU efficiency.

PURPOSE: Parametric regression models have been the main statistical method for identifying average treatment effects. Causal machine learning models showed promising results in estimating heterogeneous treatment effects in causal inference. Here we aimed to compare the application of causal random forest (CRF) and linear regression modelling (LRM) to estimate the effects of organisational factors on ICU efficiency. METHODS: A retrospective analysis of 277,459 patients admitted to 128 Brazilian and Uruguayan ICUs over three years. ICU efficiency was assessed using the average standardised efficiency ratio (ASER), measured as the average of the standardised mortality ratio (SMR) and the standardised resource use (SRU) according to the SAPS-3 score. Using a causal inference framework, we estimated and compared the conditional average treatment effect (CATE) of seven common structural and organisational factors on ICU efficiency using LRM with interaction terms and CRF. RESULTS: The hospital mortality was 14 %; median ICU and hospital lengths of stay were 2 and 7 days, respectively. Overall median SMR was 0.97 [IQR: 0.76,1.21], median SRU was 1.06 [IQR: 0.79,1.30] and median ASER was 0.99 [IQR: 0.82,1.21]. Both CRF and LRM showed that the average number of nurses per ten beds was independently associated with ICU efficiency (CATE [95 %CI]: -0.13 [-0.24, -0.01] and -0.09 [-0.17,-0.01], respectively). Finally, CRF identified some specific ICUs with a significant CATE in exposures that did not present a significant average effect. CONCLUSION: In general, both methods were comparable to identify organisational factors significantly associated with CATE on ICU efficiency. CRF however identified specific ICUs with significant effects, even when the average effect was nonsignificant. This can assist healthcare managers in further in-dept evaluation of process interventions to improve ICU efficiency.

Challenges for a broad international implementation of the current severe community-acquired pneumonia guidelines.

Severe community-acquired pneumonia (sCAP) remains one of the leading causes of admission to the intensive care unit, thus consuming a large share of resources and is associated with high mortality rates worldwide. The evidence generated by clinical studies in the last decade was translated into recommendations according to the first published guidelines focusing on severe community-acquired pneumonia. Despite the advances proposed by the present guidelines, several challenges preclude the prompt implementation of these diagnostic and therapeutic measures. The present article discusses the challenges for the broad implementation of the sCAP guidelines and proposes solutions when applicable.

Impact of systemic corticosteroids on the clinical course and outcomes of patients with severe community-acquired pneumonia: a cohort study

Introduction: Our aim was to evaluate the impact of corticosteroids on clinical course and outcomes ofpatients with severe community-acquired pneumonia (CAP) requiring invasive mechanical ventilation.Methods: This was a cohort study of patients with severe CAP from 2 intensive care units in tertiaryhospitals in Brazil and Portugal.Results: A total of 111 patients were included (median age, 69 years; 56% men; 34% hospitalmortality). Corticosteroids were prescribed in 61 (55%) patients. Main indications for their use werebronchospasm (52.5%) and septic shock (36%). Mortality rate of patients treated with and withoutcorticosteroids was comparable (29.5% vs 32%, P = .837). No significant differences were observed onclinical course from day 1 to day 7 as assessed by the Sequential Organ Failure Assessment score (P =.95). Furthermore, C-reactive protein declined similarly in both groups (P = .147). In a multivariateanalysis, mortality was associated with older age and higher Acute Physiology and Chronic Health Evaluation II score.(AU)

Hemophagocytic syndrome associated with cytomegalovirus infection in a severely immunocompromised AIDS patient: case report

Hemophagocytic syndrome is a clinical condition characterized by the infiltration of the bone marrow and reticuloendothelial system by macrophages and activated histiocytes, leading to uncontrolled phagocytosis of platelets, erythrocytes, lymphocytes and precursor cells. It is a severe inflammatory and aggressive condition, characterized by high fever, hepatosplenomegaly, lymphadenopathy and cytopenia, and it may lead to organ dysfunction. This syndrome is classified as familial or acquired; the latter is more frequent and is associated with diverse conditions, such as infections, malignancies and rheumatic diseases. We report a case of HLH associated with cytomegalovirus infection in a patient with acquired-immunodeficiency syndrome and Burkitt's lymphoma.(AU)

Short- and Long-term Outcomes ofCritically Ill Patients With Cancer andProlonged ICU Length of Stay

Background: Data on patients with cancer who have a prolonged length of stay (LOS) in the ICUare scarce. The aim of the present study was to evaluate the characteristics and the outcomes ofcancer patients with life-threatening complications with an ICU stay > 21 days.Methods: A cohort study performed at a 10-bed oncology medical-surgical ICU from May 2000 toDecember 2005. Prolonged ICU LOS was defined as an ICU stay > 21 days.Results: During the period, 1,090 patients were admitted to the ICU and 163 patients (15%) hada prolonged ICU LOS. These patients, however, accounted for 48% (5,828/12,224) of the total ICUbed-days. The hospital and 6-month mortality rates were 50% and 60%, respectively, and similar topatients with ICU LOS < 21 days (51% and 61%, respectively). ICU-acquired events and complicationswere common, and the most frequent were infections (90%), mechanical ventilation (99%), andneed for vasopressors (88%). The number of organ failures, older age, and poor performance statuswere the main outcome predictors. The median long-term follow-up after hospital discharge was 537days (range, 193 to 1,119 days), and 29 patients (18%) were alive.Conclusions: Fifteen percent of critically ill patients with cancer had a prolonged ICU LOS. Shortandlong-term survival rates were reasonable, and the prognosis was better than expected a priori. Inour opinion, the length of ICU admission per se should not be used in the clinical decisions regardingthe continuation of treatment in these patients.

Adrenal Response in SevereCommunity-Acquired Pneumonia*Impact on Outcomes and Disease Severity

Background: High cortisol levels are frequent in patients with severe infections. However, thepredictive value of total cortisol and of the presence of critical illness-related corticosteroidinsufficiency (CIRCI) in severe community-acquired pneumonia (CAP) remains to be thoroughlyevaluated. The aim of this study was to investigate the predictive value of adrenal response inpatients with severe CAP admitted to the ICU.Methods: Baseline and postcorticotropin cortisol levels C-reactive protein (CRP), d-dimer, clinicalvariables, sequential organ failure assessment (SOFA), APACHE (acute physiology and chronichealth evaluation) II, and CURB-65 (confusion, urea nitrogen, respiratory rate, BP, age > 65years) scores were measured in the first 24 h. Results are shown as median (interquartile range[IQR]). The major outcome measure was hospital mortality.Results: Seventy-two patients with severe CAP admitted to the ICU were evaluated. Baselinecortisol levels were 18.1 g/dL (IQR, 14.4 to 26.7 g/dL), and the difference between baselineand postcorticotropin cortisol after 250 g of corticotropin was 19 g/dL (IQR, 12.8 to 27 g/dL).Baseline cortisol levels presented positive correlations with scores of disease severity, includingCURB-65, APACHE II, and SOFA (p < 0.05). Cortisol levels in nonsurvivors were higher than insurvivors. CIRCI was diagnosed in 29 patients (40.8%). In univariate analysis, baseline cortisol,CURB-65, and APACHE II were predictors of death. The discriminative ability of baselinecortisol (area under receiver operating characteristic curve, 0.77; 95% confidence interval, 0.65to 0.90; best cutoff for cortisol, 25.7 g/dL) for in-hospital mortality was better than APACHE II,CURB-65, SOFA, d-dimer, or CRP.Conclusions: Baseline cortisol levels are better predictors of severity and outcome in severe CAPthan postcorticotropin cortisol or routinely measured laboratory parameters or scores asAPACHE II, SOFA, and CURB-65.

Prognosis of Lung Cancer Patients WithLife-Threatening Complications

Background: The management of patients with lung cancer has improved recently, and many ofthem will require admission to the ICU. The aims of this study were to determine hospitalmortality and to identify risk factors for death in a large cohort of critically ill patients.Methods: Cohort study in two ICUs specialized in the management of patients with cancer, inFrance and Brazil.Results: Of the 143 patients (mean age, 61.6 9.9 years [ SD]), 25 patients (17%) had small celllung cancer and 118 patients (83%) had non-small cell lung cancer. The main reasons for ICUadmission were sepsis (44%) and acute respiratory failure (31%). Mechanical ventilation (MV) wasused in 100 patients (70%), including 38 patients in whom lung cancer was considered a reasonfor MV. Hospital mortality was 59% overall and 69% in patients receiving MV. By multivariatelogistic regression, airway infiltration or obstruction by cancer, number of organ failures, cancerrecurrence or progression, and severity of comorbidities were associated with increased mortality.Conclusions: The improved survival previously reported in patients with cancer admitted to theICU seems to extend to patients with lung cancer, including those who need MV. Mortalityincreased with the number of organ failures, severity of comorbidities, and presence ofrespiratory failure due to cancer progression. The type of the cancer per se was not associatedwith mortality and, therefore, should not be factored into ICU triage decisions.(AU)

Prognosis of lung Cancer Patients withLife-Threatening complications

them will require admission to the ICU. The aims of this study were to determine hospital mortality and to identify risk factors for death in a large cohort of critically ill patients.Methods: Cohort study in two ICUs specialized in the management of patients with cancer, in France and Brazil. Results: Of the 143 patients (mean age, 61.6 + - 9.9 years [+ - SD]), 25 patients (17%) had small celllung cancer and 118 patients (83%) had non-small cell lung cancer. The main reasons for ICU admission were sepsis (44%) and acute respiratory failure (31%). Mechanical ventilation (MV) was used in 100 patients (70%), including 38 patients in whom lung cancer was considered a reasonfor MV. Hospital mortality was 59% overall and 69% in patients receiving MV. By multivariate logistic regression, airway infiltration or obstruction by cancer, number of organ failures, cancer recurrence or progression, and severity of comorbidities were associated with increased mortality. Conclusions: The improved survival previously reported in patients with cancer admitted to theICU seems to extend to patients with lung cancer, including those who need MV. Mortality increased with the number of organ failures, severity of comorbidities, and presence ofrespiratory failure due to cancer progression. The type of the cancer per se was not associated with mortality and, therefore, should not be factored into ICU triage decisions.(AU)

C-reactive protein in critically ill cancer patients with sepsis: influence of neutropenia

Introduction: Several biomarkers have been studied in febrile neutropenia. Our aim was to assess C-reactiveprotein (CRP) concentration in septic critically ill cancer patients and to compare those with and withoutneutropenia.Methods: A secondary analysis of a matched case-control study conducted at an oncologic medical-surgicalintensive care unit (ICU) was performed, segregating patients with severe sepsis/septic shock. The impact ofneutropenia on CRP concentrations at admission and during the first week of ICU stay was assessed.Results: A total of 154 critically ill septic cancer patients, 86 with neutropenia and 68 without, were included in thepresent study. At ICU admission, the CRP concentration of neutropenic patients was significantly higher than innon-neutropenic patients, 25.9 ­· 11.2 mg/dL vs. 19.7 ­· 11.4 mg/dL (P = 0.009). Among neutropenic patients, CRPconcentrations at ICU admission were not influenced by the severity of neutropenia (< 100/mm3 vs. ­í 100/mm3neutrophils), 25.1 ­· 11.6 mg/dL vs. 26.9 ­· 10.9 mg/dL (P = 0.527). Time dependent analysis of CRP from Day 1 toDay 7 of antibiotic therapy showed an almost parallel decrease in both groups (P = 0.335), though CRP ofneutropenic patients was, on average, always higher in comparison to that of non-neutropenic patients.Conclusions: In septic critically ill cancer patients CRP concentrations are more elevated in those with neutropenia.However, the CRP course seems to be independent from the presence or absence of neutropenia.(AU)

Critically ill patients with cancer and sepsis: Clinical course and prognostic factors

AbstractPurpose: The purposes of this study were to evaluate the clinical course and to identify independentpredictors of mortality in patients with cancer with sepsis.Materials and Methods: This is a secondary analysis of a prospective cohort study conducted at anoncological medical-surgical intensive care unit. Logistic regression was used to identify predictors ofhospital mortality.Results: A total of 563 patients (77%solid tumor, 23% hematologic malignancies) were included over a 55-month period. The most frequent sites of infection were the lung, abdomen, and urinary tract; 91% patientshad severe sepsis/septic shock. Gram-negative bacteria were responsible for more than half of the episodes ofinfection; 38% of patients had polymicrobial infections. Intensive care unit, hospital, and 6-month mortalityrates were 51%, 65%, and 72%, respectively. In multivariate analyses, sepsis in the context of medicalcomplications; active disease; compromised performance status; presence of 3 to 4 systemic inflammatoryresponse syndrome criteria; and the presence of respiratory, renal, and cardiovascular failures wereassociated with increased mortality. Adjusting for other covariates, patients with non–urinary tractinfections, mostly represented by patients with pneumonia and abdominal infections, had worse outcomes.Conclusions: Sepsis remains a frequent complication in patients with cancer and associated with highmortality. Our results can be of help to assist intensivists in clinical decisions and to improve characterizationand risk stratification in these patients.(AU)

The impact of coagulation parameters on the outcomes of patients with severe community-acquired pneumoniarequiring intensive care unit admission

Introduction: Coagulation abnormalities are frequent in patients with severe infections. However, thepredictive value of D-dimer and of the presence of associated coagulation derangements in severecommunity-acquired pneumonia (CAP) remains to be thoroughly evaluated. The aim of this study wasto investigate the predictive value of coagulation parameters in patients with severe CAP admitted to theintensive care unit.Methods: D-Dimer, antithrombin, International Society of Thrombosis and Hemostasis score, clinicalvariables, Sequential Organ Failure Assessment (SOFA), The Acute Physiology and Chronic HealthEvaluation II (APACHE II) and the CURB-65 score were measured in the first 24 hours. Results areshown as median (25%-75% interquartile range). The main outcome measure was hospital mortality.(AU)