Thyroid hormones as potential prognostic factors in sepsis

Background: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host reaction to infection. There is an upward trend in sepsis prevalence and mortality worldwide. Sepsis causes hypoxia, which reduces the ability of cells to produce ATP. This process is also influenced by thyroid hormones. Some of the previous studies revealed association between the mortality rate in sepsis and thyroid hormone levels. We aimed to evaluate thyroid hormones’ predictive value in septic patients. Methods: Forty-nine adult patients with sepsis admitted to the Intensive Care Unit of Allergy and Immunology Department at the University Hospital in Krakow, Poland, between 2015 and 2017 were enrolled in the study. Blood samples were obtained from septic patients immediately after establishing the diagnosis, in order to measure free triiodothyronine (fT3), free thyroxine (fT4), and thyroid-stimulating hormone (TSH) levels. The primary endpoint was 30-day survival rate. The secondary endpoint was death anytime during intensive care unit (ICU) stay. Results: Patients who died within 30 days had significantly lower level of fT4 than survivors (9.8 vs. 12.7 pmol L-1; P = 0.033). There was no statistically significant difference between the groups in TSH and fT3 levels. As for the secondary endpoint, both fT3 (1.6 vs. 1.8 pmol L-1; P = 0.021) and fT4 (9.8 vs. 12.7 μIU mL-1; P = 0.019) levels were significantly lower among non-survivors compared to survivors, which was not the case for TSH. Conclusions: Thyroid hormone levels were significantly lower among patients who died during ICU stay. The results of the presented study suggest that fT3 and fT4 levels may be taken into consideration as potential new prognostic factors in sepsis

Impact of arterial procedures on coagulation and fibrinolysis : a pilot study

Abstract Objective: The main goal of our study was to assess the impact of vascular procedures on the activity of hemostatic and fibrinolytic pathways. Methods: We enrolled 38 patients with ≥ 45 years old undergoing surgery for abdominal aortic aneurysm or peripheral artery disease under general or regional anesthesia and who were hospitalized at least one night after the procedure. Patients undergoing carotid artery surgery and those who had acute bypass graft thrombosis, cancer, renal failure defined as estimated glomerular filtration rate < 30 ml/min/1.73m2, venous thromboembolism three months prior to surgery, or acute infection were excluded from the study. We measured levels of markers of hemostasis (factor VIII, von Willebrand factor:ristocetin cofactor [vWF:CoR], antithrombin), fibrinolysis (D-dimer, tissue plasminogen activator [tPA], plasmin-antiplasmin complexes), and soluble cluster of differentiation 40 ligand (sCD40L) before and 6-12h after vascular procedure. Results: Significant differences between preoperative and postoperative levels of factor VIII (158.0 vs. 103.3, P<0.001), antithrombin (92.1 vs. 74.8, P<0.001), D-dimer (938.0 vs. 2406.0, P=0.005), tPA (10.1 vs. 12.8, P=0.002), and sCD40L (9092.9 vs. 1249.6, P<0.001) were observed. There were no significant differences between pre- and postoperative levels of vWF:CoR (140.6 vs. 162.8, P=0.17) and plasmin-antiplasmin complexes (749.6 vs. 863.7, P=0.21). Conclusion: Vascular surgery leads to significant alterations in hemostatic and fibrinolytic systems. However, the direction of these changes in both pathways remains unclear and seems to be different depending on the type of surgery. A study utilizing dynamic methods of coagulation and fibrinolysis assessment performed on a larger population is warranted

Concentration of meropenem in patients with sepsis and acute kidney injury before and after initiation of continuous renal replacement therapy : a prospective observational trial

Background The effect of renal replacement therapy on drug concentrations in patients with sepsis has not been fully elucidated because the pharmacokinetic properties of many antimicrobials are influenced by both pathophysiological and treatment-related factors. The aim of this study was to determine meropenem concentrations in patients with sepsis before and after the initiation of continuous venovenous hemodialysis with regional citrate anticoagulation (RCA-CVVHD). Methods The study included 15 critically ill patients undergoing RCA-CVVHD due to sepsis-induced acute kidney injury. All participants received 2 g of meropenem every 8 h in a prolonged infusion lasting 3 h. Meropenem concentrations were measured in blood plasma using high-performance liquid chromatography coupled with tandem mass spectrometry. Blood samples were obtained at six-time points prior to and at six-time points after introducing RCA-CVVHD. Results The median APACHE IV and SOFA scores on admission were 118 points (interquartile range [IQR] 97-134 points) and 19.5 points (IQR 18-21 points), respectively. There were no significant differences in the plasma concentrations of meropenem measured directly before RCA-CVVHD and during the first 450 min of the procedure. The drug concentration reached its peak 2 h after initiating the infusion and then steadily declined. Conclusions The concentration of high-dose meropenem (2 g every 8 h) administered in a prolonged infusion was similar before and after the introduction of RCA-CVVHD in patients with sepsis who developed acute kidney injury

Time from admission to surgery in Polish patients with hip fractures : temporal trends in the last decade and association with duration of hospitalization and in-hospital mortality

Introduction: Hip fracture is an important cause of morbidity and mortality among elderly patients worldwide. It poses a particular challenge for healthcare systems with limited financial and human resources. Objectives: The aim of the study was to assess factors associated with the length of hospital stay and in-hospital mortality, focusing on the time from admission to surgery. The secondary goal was to assess temporal trends in the intervals of admission to surgery between 2010 and 2011 and in 2019. Patients and methods: This was a cross-sectional study enrolling patients aged 65 years or older who underwent surgery for hip fracture between January 2010 and October 2011 in 12 Polish hospitals. Demographic and clinical data, dates of hospital admission and surgery as well as information about in-hospital death were gathered. We additionally searched the databases of the same 12 hospitals for patients hospitalized due to hip fracture between January and June 2019 and recorded the dates of admission and surgery. Results: We included 381 patients who underwent surgery in 2010 and 2011 and 761 patients hospitalized in 2019. In a multivariable analysis, including age, sex, and diagnosis of dementia, we observed association between time from admission to surgery and higher in-hospital mortality and longer hospital stay. There was a decrease in proportion of patients undergoing surgery within 2 days from admission (52.8% vs 44.3%; P = 0.007) between 2010 to 2011 and in 2019. Conclusions: In-hospital mortality and length of hospitalization were associated with time from admission to surgery in patients undergoing surgery for hip fracture. We observed an alarming trend towards an increase in the admission–surgery interval

Validity of the total SOFA score in patients ≥ 80 years old acutely admitted to intensive care units: a post-hoc analysis of the VIP2 prospective, international cohort study

BACKGROUND: Little is known about the performance of the Sequential Organ Failure Assessment (SOFA) score in older critically ill adults. We aimed to evaluate the prognostic impact of physiological disturbances in the six organ systems included in the SOFA score. METHODS: We analysed previously collected data from a prospective cohort study conducted between 2018 and 2019 in 22 countries. Consecutive patients ≥ 80 years old acutely admitted to intensive care units (ICUs) were eligible for inclusion. Patients were followed up for 30 days after admission to the ICU. We used logistic regression to study the association between increasing severity of organ dysfunction and mortality. RESULTS: The median SOFA score among 3882 analysed patients was equal to 6 (IQR: 4-9). Mortality was equal to 26.1% (95% CI 24.7-27.5%) in the ICU and 38.7% (95% CI 37.1-40.2%) at day 30. Organ failure defined as a SOFA score ≥ 3 was associated with variable adjusted odds ratios (aORs) for ICU mortality dependant on the organ system affected: respiratory, 1.53 (95% CI 1.29-1.81); cardiovascular 1.69 (95% CI 1.43-2.01); hepatic, 1.74 (95% CI 0.97-3.15); renal, 1.87 (95% CI 1.48-2.35); central nervous system, 2.79 (95% CI 2.34-3.33); coagulation, 2.72 (95% CI 1.66-4.48). Modelling consecutive levels of organ dysfunction resulted in aORs equal to 0.57 (95% CI 0.33-1.00) when patients scored 2 points in the cardiovascular system and 1.01 (0.79-1.30) when the cardiovascular SOFA equalled 3. CONCLUSIONS: Different components of the SOFA score have different prognostic implications for older critically ill adults. The cardiovascular component of the SOFA score requires revision

Prognosticating the outcome of intensive care in older patients—a narrative review

Prognosis determines major decisions regarding treatment for critically ill patients. Statistical models have been developed to predict the probability of survival and other outcomes of intensive care. Although they were trained on the characteristics of large patient cohorts, they often do not represent very old patients (age ≥ 80 years) appropriately. Moreover, the heterogeneity within this particular group impairs the utility of statistical predictions for informing decision-making in very old individuals. In addition to these methodological problems, the diversity of cultural attitudes, available resources as well as variations of legal and professional norms limit the generalisability of prediction models, especially in patients with complex multi-morbidity and pre-existing functional impairments. Thus, current approaches to prognosticating outcomes in very old patients are imperfect and can generate substantial uncertainty about optimal trajectories of critical care in the individual. This article presents the state of the art and new approaches to predicting outcomes of intensive care for these patients. Special emphasis has been given to the integration of predictions into the decision-making for individual patients. This requires quantification of prognostic uncertainty and a careful alignment of decisions with the preferences of patients, who might prioritise functional outcomes over survival. Since the performance of outcome predictions for the individual patient may improve over time, time-limited trials in intensive care may be an appropriate way to increase the confidence in decisions about life-sustaining treatment

Noninvasive ventilation in COVID-19 patients aged ≥ 70 years—a prospective multicentre cohort study

Funding Information: COVIP study did not have any funding. Publication of this article was funded by the Priority Research Area qLife under the program “Excellence Initiative – Research University” at the Jagiellonian University in Krakow (06/IDUB/2019/94). Publisher Copyright: © 2022, The Author(s).Background: Noninvasive ventilation (NIV) is a promising alternative to invasive mechanical ventilation (IMV) with a particular importance amidst the shortage of intensive care unit (ICU) beds during the COVID-19 pandemic. We aimed to evaluate the use of NIV in Europe and factors associated with outcomes of patients treated with NIV. Methods: This is a substudy of COVIP study—an international prospective observational study enrolling patients aged ≥ 70 years with confirmed COVID-19 treated in ICU. We enrolled patients in 156 ICUs across 15 European countries between March 2020 and April 2021.The primary endpoint was 30-day mortality. Results: Cohort included 3074 patients, most of whom were male (2197/3074, 71.4%) at the mean age of 75.7 years (SD 4.6). NIV frequency was 25.7% and varied from 1.1 to 62.0% between participating countries. Primary NIV failure, defined as need for endotracheal intubation or death within 30 days since ICU admission, occurred in 470/629 (74.7%) of patients. Factors associated with increased NIV failure risk were higher Sequential Organ Failure Assessment (SOFA) score (OR 3.73, 95% CI 2.36–5.90) and Clinical Frailty Scale (CFS) on admission (OR 1.46, 95% CI 1.06–2.00). Patients initially treated with NIV (n = 630) lived for 1.36 fewer days (95% CI − 2.27 to − 0.46 days) compared to primary IMV group (n = 1876). Conclusions: Frequency of NIV use varies across European countries. Higher severity of illness and more severe frailty were associated with a risk of NIV failure among critically ill older adults with COVID-19. Primary IMV was associated with better outcomes than primary NIV. Clinical Trial RegistrationNCT04321265, registered 19 March 2020, https://clinicaltrials.gov.publishersversionpublishe