Procalcitonin kinetics in the first 48 hours of ICU admission is associated with higher mortality in critically ill patients with community-acquired pneumonia in a setting of high HIV prevalence

Background: Severe community acquired pneumonia (CAP) commonly results in ICU admission and is associated with significant morbidity and mortality. Procalcitonin (PCT) may assist risk stratification and prediction of aetiology but is not well studied in critically ill patients with a high HIV prevalence.Methods: A retrospective observational study of patients admitted to ICU with a clinical diagnosis of CAP was undertaken. PCT on admission and at 48 hours was evaluated as a predictor of ICU outcome and pneumonia aetiology.Results: A total of 100 patients were included; 62% were HIV positive. Overall ICU mortality was 61%. PCT at admission and 48 hours was not associated with any outcome variables. A significant association was found between mortality and patients whose PCT levels increased or remained >10 ng/ml at 48 hours, compared with those that remained unchanged or decreased (67% vs. 41% p = 0.018). The commonest aetiology identified was Mycobacterium tuberculosis (n = 18, 21.4%). Patients with admission PCT levels >10 ng/ml were more likely to have positive bacterial cultures (OR = 3.14; 95% CI 1.11–9.73).Conclusions: Increasing or persistently elevated PCT predicts a higher mortality in critically ill patients with CAP. This suggests PCT kinetics may be useful in risk stratifying patients with CAP at 48 hours. While positive bacterial cultures are more likely in patients with high admission PCT, this assay does not allow for decisions to be made on antimicrobial management and is of limited clinical utility in critically ill patients with a high HIV prevalence and CAP.Keywords: critical care, procalcitonin, intensive care, prognosis, severe community acquired pneumoni

The utility of hyperlactataemia in the definition of septic shock: Evaluating the Sepsis-3 definitions in a sub-Saharan African intensive care unit

Background. Sepsis-3 definitions were published in 2016 and included hyperlactataemia (serum lactate >2.0 mmol/L) as a mandatory component of the new definition of septic shock. These data were collected mainly from high-income countries and lack adequate validation in scenarios outside these countries.Objectives. To evaluate admission serum lactate as a predictor of intensive care unit (ICU) mortality in patients with infection and hypotension requiring inotropic support.Methods. This was a retrospective observational study of 170 patients with infection and hypotension requiring inotropic support admitted to the ICU at King Edward VIII Hospital in Durban, South Africa. Admission serum lactate was evaluated as a predictor of ICU mortality in this cohort.Results. The study population had a median age of only 42 years. The ICU mortality rate for the cohort was 49.4%. Most patients were surgical (71.8%), with the most common source of sepsis being abdominal (55.9%). The ICU mortality rate was 40.9% in patients with a lactate level ≤2.0 mmol/L and 52.4% in those with a level >2.0 mmol/L; this did not reach statistical significance. The optimal cut-off was 4.5 mmol/L, at which there was a clear, statistically significant difference in mortality between patients without (39.3%) and with hyperlactataemia (59.3%) (p=0.009).Conclusions. Hyperlactataemia was associated with increased mortality. However, a lactate level >2.0 mmol/l, as proposed in Sepsis-3, did not reach statistical significance, and a higher cut-off of >4.5 mmol/L was more appropriate

Hypoxaemia on arrival in a multidisciplinary intensive care unit

Background. Transport of the critically ill patient poses the risk of numerous complications. Hypoxaemia is one such serious adverse event and is associated with potential morbidity and mortality. It is, however, potentially preventable.Objective. To determine the incidence of hypoxaemia on arrival in a tertiary multidisciplinary intensive care unit (ICU) and to identify risk factors for this complication.Method. A retrospective observational study was conducted at King Edward VIII Hospital, Durban, South Africa, from May 2013 to February 2014.Results. Hypoxaemia occurred in 15.5% of admissions sampled. Statistically significant risk factors for hypoxaemia on univariate analysis (p<0.05) included lack of peripheral capillary oxygen saturation (SpO2) monitoring, transfer by an intern as opposed to other medical/ paramedical staff, and transfer from internal medicine. Use of neuromuscular blockers and transfer from theatre were protective. Binary logistic regression analysis revealed lack of SpO2 monitoring to be the only significant independent predictor of hypoxaemia (odds ratio 6.1; 95% confidence interval 1.5 - 24.5; p=0.02).Conclusion. Hypoxaemia is common on admission to the ICU and may be prevented by simple interventions such as appropriate transport monitoring

Early catecholamine dose as a predictor of outcome among patients in a multidisciplinary intensive care unit

Background. Vasoactive and/or inotropic agents are used in the management of patients with circulatory shock. It is a clinical perception that mortality in critically ill patients increases with increasing doses of inotropes and/or vasopressors; however, the clinical significance of catecholamine doses early in the management of critically ill patients has not been investigated well, especially in the South African (SA) context. Arbitrary ‘maximum’ doses of catecholamine therapy are used that are not evidence based. This study will help clinicians by either showing that there is no clear cut-off beyond which survival is unlikely or by identifying a dose of inotropic support above which survival is unlikely. This article provides clinicians with an evidence base against which to direct their therapy.Objectives. To describe the inotropic prescribing practices in a heterogeneous population of shocked critically ill patients in a tertiary intensive care unit (ICU) in SA, establish an association between inotropic dose and outcome and ascertain the nature of this association.Methods. This was a retrospective observational study of 189 patients admitted to a multidisciplinary academic ICU. The admission, 24-hour and maximum inotrope doses were collected and analysed, and these and other biochemical and clinical parameters were evaluated as predictors of mortality.Results. A total of 189 patients met the study inclusion criteria. The overwhelming majority of patients (99%) received adrenaline, with only 7% of those requiring inotropes receiving noradrenaline. Median inotrope dose at admission, 24-hour dose and maximum dose in the first 24 hours were all significantly higher in non-survivors than survivors. ICU mortality increased with increasing inotrope dose, and an inotrope dose ≥60 μg/min on admission was associated with an ICU mortality of 89%, with the same cut-off at 24 hours being associated with a mortality of 89%. Survivors at doses >80 μg/min were only noted among trauma patients.Conclusions. High early inotrope doses are associated with increasing ICU mortality. The findings highlight the need for further research on the clinical use of inotrope dose in risk stratification in the critical care environment. The current results call into question the routine provision of high-dose inotropic support in non-trauma patients

An analysis of referrals to a level 3 intensive care unit in a resource-limited setting in South Africa

Background. With a shortage of intensive care unit (ICU) beds and rising healthcare costs in resource-limited settings, clinicians need to appropriately triage admissions into ICU to avoid wasteful expenditure and unnecessary bed utilisation. Objective. To assess the nature, appropriateness and outcome of referrals to a tertiary centre ICU. Methods. A retrospective review of ICU consults from September 2016 to February 2017 at King Edward VIII Hospital was performed. The study was approved by the University of KwaZulu-Natal Biomedical Research Ethics Committee (BE291/17). Data pertaining to patients’ demographics, referring doctor, diagnosis, comorbidities as well as biochemical and haemodynamic parameters were extracted. This information was then cross- referenced to the outcome of the ICU consultation. Data were descriptively analysed. Results. Five hundred consultations were reviewed over a 6-month period; 52.2% of patients were male and the mean age was 44 years. Junior medical officers referred 164 (32.8%) of the consultations. Although specialist supervision was available in 459 cases, it was only utilised in 339 (73.9%) of these cases. Most referrals were from tertiary (46.8%) or regional (30.4%) hospitals; however, direct referrals from district hospitals and clinics accounted for 20.4% and 1.4% of consultations, respectively. The appropriate referral pathway was not followed in 81 (16.2%) consultations. Forty-five percent of consults were accepted; however, 9.3% of these patients died before arrival in ICU. A total of 151 (30.2%) patients were refused ICU admission, with the majority (57%) of these owing to futility. Patients were unstable at the time of consult in 53.2% of referrals and 34.4% of consults had missing data. Conclusion. Critically ill patients are often referred by junior doctors without senior consultation, and directly from low-level healthcare facilities. A large proportion of ICU referrals are deemed futile and, of the patients accepted for admission, almost 1 in 10 dies prior to ICU admission. More emphasis needs to be placed on the training of doctors to appropriately triage and manage critically ill patients and ensure appropriate ICU referral and optimising of patient outcomes