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Estimated effects of early diuretic use in critical illness.

ABSTRACT: Objective:To estimate the effects of diuretic use during the first 24 hours of an intensive care unit stay on in-hospital mortality and other clinical outcomes including acute kidney injury and duration of mechanical ventilation. Design:Retrospective cohort study. Setting:Urban, academic medical center. Patients:Adult patients admitted to medical or cardiac ICUs between 2001 and 2012, excluding those on maintenance dialysis or with ICU length of stay < 24 hours. Interventions:None. Measurements and Main Results:We included 13,589 patients: 2,606 with and 10,983 without early diuretic use (loop diuretic exposure during the first 24 hours of an ICU stay). Propensity score matching generated 2523 pairs with well-balanced baseline characteristics. Early diuretic use was unassociated with in-hospital mortality (risk ratio 1.01, 99.5% confidence interval 0.83-1.22). We found no evidence of associations with ICU or hospital length of stay, or duration or provision of mechanical ventilation. Early diuretic use was associated with higher rates of subsequent acute kidney injury (risk ratio 1.41, 99.5% confidence interval 1.25 to 1.59) and electrolyte abnormalities. Results were not materially different in subgroups of patients with heart failure, chronic kidney disease, or acute lung injury. Conclusions:Early diuretic use in critical illness was unassociated with in-hospital mortality, ICU or hospital length of stay, or duration of mechanical ventilation, but risks of acute kidney injury and electrolyte abnormalities were higher.

SUBMITTER: McCoy IE

PROVIDER: S-EPMC6705600 | biostudies-literature | 2019 Jul

REPOSITORIES: biostudies-literature

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Estimated effects of early diuretic use in critical illness.

McCoy Ian E IE Montez-Rath Maria E ME Chertow Glenn M GM Chang Tara I TI

Critical care explorations 20190701 7

<h4>Objective</h4>To estimate the effects of diuretic use during the first 24 hours of an intensive care unit stay on in-hospital mortality and other clinical outcomes including acute kidney injury and duration of mechanical ventilation.<h4>Design</h4>Retrospective cohort study.<h4>Setting</h4>Urban, academic medical center.<h4>Patients</h4>Adult patients admitted to medical or cardiac ICUs between 2001 and 2012, excluding those on maintenance dialysis or with ICU length of stay < 24 hours.<h4>I ...[more]

PMID: 31440746

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Project description:Preventing rehospitalizations for patients with serious chronic illnesses is a focus of national quality initiatives. Although 8 million people are admitted yearly to an ICU, the frequency of rehospitalizations (readmissions to the hospital after discharge) is unknown. We sought to determine the frequency of rehospitalization after an ICU stay, outcomes for rehospitalized patients, and factors associated with rehospitalization.Retrospective cohort study using the New York Statewide Planning and Research Cooperative System, an administrative database of all hospital discharges in New York State.ICUs in New York State.ICU patients who survived to hospital discharge in 2008-2010.None.Primary outcome was the cumulative incidence of first early rehospitalization (within 30 days of discharge), and secondary outcome was the cumulative incidence of late rehospitalization (between 31 and 180 d). Factors associated with rehospitalization within both time periods were identified using competing risk regression models. Of 492,653 ICU patients, 79,960 had a first early rehospitalization (cumulative incidence, 16.2%) and an additional 73,250 late rehospitalizations (cumulative incidence, 18.9%). Over one quarter of all rehospitalizations (28.6% for early; 26.7% for late) involved ICU admission. Overall hospital mortality for rehospitalized patients was 7.6% for early and 4.6% for late rehospitalizations. Longer index hospitalization (adjusted hazard ratio, 1.61; 95% CI, 1.57-1.66 for 7-13 d vs < 3 d), discharge to a skilled nursing facility versus home (adjusted hazard ratio, 1.54; 95% CI, 1.51-1.58), and having metastatic cancer (adjusted hazard ratio, 1.46; 95% CI, 1.41-1.51) were associated with the greatest hazard of early rehospitalization.Approximately 16% of ICU survivors were rehospitalized within 30 days of hospital discharge; rehospitalized patients had high rates of ICU admission and hospital mortality. Few characteristics were strongly associated with rehospitalization, suggesting that identifying high-risk individuals for intervention may require additional predictors beyond what is available in administrative databases.

Project description:IntroductionGuidelines recommend follow-up for patients after an intensive care unit (ICU) stay. Methods for identifying patients with psychological problems after intensive care would be of value, to optimize treatment and to improve adequate resource allocation in ICU follow-up of ICU survivors. The aim of the study was to develop a predictive screening instrument, for use at ICU discharge, to identify patients at risk for post-traumatic stress, anxiety or depression.MethodsTwenty-one potential risk factors for psychological problems - patient characteristics and ICU-related variables - were prospectively collected at ICU discharge. Two months after ICU discharge 252 ICU survivors received the questionnaires Post-Traumatic Stress Symptom scale -10 (PTSS-10) and Hospital Anxiety and Depression Scale (HADS) to estimate the degree of post-traumatic stress, anxiety and depression.ResultsOf the 150 responders, 46 patients (31%) had adverse psychological outcome, defined as PTSS-10 >35 and/or HADS subscales ?8. After analysis, six predictors were included in the screening instrument: major pre-existing disease, being a parent to children younger than 18 years of age, previous psychological problems, in-ICU agitation, being unemployed or on sick-leave at ICU admission and appearing depressed in the ICU. The total risk score was related to the probability for adverse psychological outcome in the individual patient. The predictive accuracy of the screening instrument, as assessed with area under the receiver operating characteristic curve, was 0.77. When categorizing patients in three risk probability groups - low (0 to 29%), moderate (30 to 59%) high risk (60 to 100%), the actual prevalence of adverse psychological outcome in respective groups was 12%, 50% and 63%.ConclusionThe screening instrument developed in this study may aid ICU clinicians in identifying patients at risk for adverse psychological outcome two months after critical illness. Prior to wider clinical use, external validation is needed.

Project description:IntroductionMuscle ultrasound is emerging as a promising tool in the diagnosis of neuromuscular diseases. The current observational study evaluates the usefulness of muscle ultrasound in patients with severe sepsis for assessment of critical illness polyneuropathy and myopathy (CINM) in the intensive care unit.Methods28 patients with either septic shock or severe sepsis underwent clinical neurological examinations, muscle ultrasound, and nerve conduction studies on days 4 and 14 after onset of sepsis. 26 healthy controls of comparable age underwent clinical neurological evaluation and muscle ultrasound only.Results26 of the 28 patients exhibited classic electrophysiological characteristics of CINM, and all showed typical clinical signs. Ultrasonic echogenicity of muscles was graded semiquantitatively and fasciculations were evaluated in muscles of proximal and distal arms and legs. 75% of patients showed a mean echotexture greater than 1.5, which was the maximal value found in the control group. A significant difference in mean muscle echotexture between patients and controls was found at day 4 and day 14 (both p < 0.001). In addition, from day 4 to day 14, the mean grades of muscle echotexture increased in the patient group, although the values did not reach significance levels (p = 0.085). Controls revealed the lowest number of fasciculations. In the patients group, fasciculations were detected in more muscular regions (lower and upper arm and leg) in comparison to controls (p = 0.08 at day 4 and p = 0.002 at day 14).ConclusionsMuscle ultrasound represents an easily applicable, non-invasive diagnostic tool which adds to neurophysiological testing information regarding morphological changes of muscles early in the course of sepsis. Muscle ultrasound could be useful for screening purposes prior to subjecting patients to more invasive techniques such as electromyography and/or muscle biopsy.Trial registrationGerman Clinical Trials Register, DRKS-ID: DRKS00000642.

Project description:BackgroundChildren who have suffered from critical illnesses that required treatment in a paediatric intensive care unit (PICU) have long-term physical and neurodevelopmental impairments. The mechanisms underlying this legacy remain largely unknown. In patients suffering from chronic diseases hallmarked by inflammation and oxidative stress, poor long-term outcome has been associated with shorter telomeres. Shortened telomeres have also been reported to result from excessive food consumption and/or unhealthy nutrition. We investigated whether critically ill children admitted to the PICU have shorter-than-normal telomeres, and whether early parenteral nutrition (PN) independently affects telomere length when adjusting for known determinants of telomere length.MethodsTelomere length was quantified in leukocyte DNA from 342 healthy children and from 1148 patients who had been enrolled in the multicenter, randomised controlled trial (RCT), PEPaNIC. These patients were randomly allocated to initiation of PN within 24 h (early PN) or to withholding PN for one week in PICU (late PN). The impact of early PN versus late PN on the change in telomere length from the first to last PICU-day was investigated with multivariable linear regression analyses.ResultsLeukocyte telomeres were 6% shorter than normal upon PICU admission (median 1.625 (IQR 1.446-1.825) telomere/single-copy-gene ratio (T/S) units vs. 1.727 (1.547-1.915) T/S-units in healthy children (P < 0.0001)). Adjusted for potential baseline determinants and leukocyte composition, early PN was associated with telomere shortening during PICU stay as compared with late PN (estimate early versus late PN -0.021 T/S-units, 95% CI -0.038; 0.004, P = 0.01). Other independent determinants of telomere length identified in this model were age, gender, baseline telomere length and fraction of neutrophils in the sample from which the DNA was extracted. Telomere shortening with early PN was independent of post-randomisation factors affected by early PN, including longer length of PICU stay, larger amounts of insulin and higher risk of infection.ConclusionsShorter than normal leukocyte telomeres are present in critically ill children admitted to the PICU. Early initiation of PN further shortened telomeres, an effect that was independent of other determinants. Whether such telomere-shortening predisposes to long-term consequences of paediatric critical illness should be further investigated in a prospective follow-up study.Trial registrationClinicalTrials.gov, NCT01536275 . Registered on 16 February 2012.

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Estimated effects of early diuretic use in critical illness.

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Estimated effects of early diuretic use in critical illness.

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