Objective To determine the clinical features and outcomes of patients readmitted to the intensive care unit (ICU) during the same hospital stay and the causes for these readmissions. Design Multicenter, cohort study. Setting Three ICUs from two teaching hospitals and four ICUs from four community hospitals. Patients All ICU admissions were collected prospectively for a registry database in the seven ICUs. We retrospectively analyzed ICU admissions between January 1, 1995 and February 29, 1996. Interventions None. Measurements and Main Results During the study period, 236 (4.6%) of the patients discharged alive from the ICU were readmitted to the unit. Patients with gastrointestinal (GI) and neurologic diagnoses had the highest readmission rate. Of the readmissions, 45% had recurrence of the initial disease, 39% experienced new complications, and 14% required further planned operation. Among patients readmitted for the same illness, cardiovascular and respiratory problems were the most frequent diagnoses. Of patients readmitted with a new diagnosis, 30% initially had GI diseases, while respiratory diseases accounted for 58% of the new complications. Readmissions within 24 hrs occurred in 27% of all readmissions. Patients requiring readmission had a higher hospital mortality rate (31.4%) compared with those not requiring readmission (4.3%, p < .001), even after adjustment for disease severity score (odds ratio = 5.93, p < .001). Conclusions Patients with GI and neurologic diseases are at greatest risk of requiring ICU readmission. Respiratory diseases are the major reason for readmission due to new complications. Readmitted patients have a high risk of hospital death that may be underestimated by the usual physiologic indicators on either initial admission or readmission. Further studies are required to determine if patients at risk for readmission can be identified early to improve the outcome. (Crit Care Med 1998; 26:1834-1841)
Sepsis is characterized by a severe systemic inflammatory response to infection that is associated with high morbidity and mortality despite optimal care. Invariant natural killer T (iNK T) cells are potent regulatory lymphocytes that can produce pro- and/or anti-inflammatory cytokines, thus shaping the course and nature of immune responses; however, little is known about their role in sepsis. We demonstrate here that patients with sepsis/severe sepsis have significantly elevated proportions of iNK T cells in their peripheral blood (as a percentage of their circulating T cells) compared to non-septic patients. We therefore investigated the role of iNK T cells in a mouse model of intra-abdominal sepsis (IAS). Our data show that iNK T cells are pathogenic in IAS, and that T helper type 2 (Th2) polarization of iNK T cells using the synthetic glycolipid OCH significantly reduces mortality from IAS. This reduction in mortality is associated with the systemic elevation of the anti-inflammatory cytokine interleukin (IL)-13 and reduction of several proinflammatory cytokines within the spleen, notably interleukin (IL)-17. Finally, we show that treatment of sepsis with OCH in mice is accompanied by significantly reduced apoptosis of splenic T and B lymphocytes and macrophages, but not natural killer cells. We propose that modulation of iNK T cell responses towards a Th2 phenotype may be an effective therapeutic strategy in early sepsis.
• The hyperviscosity syndrome is most commonly seen in association with monoclonal gammopathies and has only rarely been described in association with polyclonal hypergammaglobulinemia. We have recently seen a patient with known acquired immunodeficiency syndrome who presented with the hyperviscosity syndrome in the setting of polyclonal hypergammaglobulinemia. To our knowledge, this is the first reported case of a patient with the acquired immunodeficiency syndrome and the hyperviscosity syndrome. The case is presented and the pathogenesis and implications of this diagnosis are discussed. (Arch Intern Med. 1989;149:1435-1436)
This study was undertaken to describe the metabolic O2 reserve of the coronary circulation in an awake sheep model of hyperdynamic sepsis. Forty-eight hours after sheep were randomized to either a SHAM group (n = 8) or a cecal ligation and perforation (CLP) group (n = 8), we measured hemodynamics, organ blood flows, and systemic and myocardial O2 metabolism variables at baseline and through four stages of progressive hypoxia. A significant elevation in arterial lactate levels occurred at a higher O2 delivery in the CLP group (527 +/- 55 ml/min/m2) than in the SHAM group (357 +/- 29 ml/min/m2, p < 0.05). The heart's metabolic O2 reserve (difference in circulatory determinants of O2 availability between baseline and where O2 uptake could not be sustained) was exhausted at an O2 content of 56.9 +/- 4.2 ml O2/L in SHAM sheep and 79.6 +/- 7.2 ml O2/L (p < 0.05) in CLP sheep. An increase in coronary blood flow was three times greater in SHAM than in CLP animals. Myocardial O2 extraction increased in hypoxia in SHAM sheep (0.78 +/- 0.03 to 0.88 +/- 0.02, p < 0.05), but not in CLP sheep (0.79 +/- 0.02 to 0.80 +/- 0.04). We conclude that the metabolic O2 reserve of the coronary circulation is depressed in this model of hyperdynamic sepsis as the ability to increase both coronary blood flows and myocardial O2 extraction was significantly limited.
Rationale: Understanding the magnitude of moral distress and its associations may point to solutions. Objectives: To understand the magnitude of moral distress and other measures of wellness in Canadian critical care physicians, to determine any associations among these measures, and to identify potentially modifiable factors. Methods: This was an online survey of Canadian critical care physicians whose e-mail addresses were registered with either the Canadian Critical Care Society or the Canadian Critical Care Trials Group. We used validated measures of moral distress, burnout, compassion fatigue, compassion satisfaction, and resilience. We also measured selected individual, practice, and workload characteristics. Results: Of the 499 physicians surveyed, 239 (48%) responded and there were 225 usable surveys. Respondents reported moderate scores of moral distress (107 ± 59; mean ± standard deviation, maximum 432), one-third of respondents had considered leaving or had previously left a position because of moral distress, about one-third met criteria for burnout syndrome, and a similar proportion reported medium-high scores of compassion fatigue. In contrast, about one-half of respondents reported a high score of compassion satisfaction, and overall, respondents reported a moderate score of resilience. Each of the "negative" wellness measures (moral distress, burnout, and compassion fatigue) were associated directly with each of the other "negative" wellness measures, and inversely with each of the "positive" wellness measures (compassion satisfaction and resilience), but moral distress was not associated with resilience. Moral distress was lower in respondents who were married or partnered compared with those who were not, and the prevalence of burnout was lower in respondents who had been in practice for longer. There were no differences in any of the wellness measures between adult and pediatric critical care physicians. Conclusions: Canadian critical care physicians report moderate scores of moral distress, burnout, and compassionate fatigue, and moderate-high scores of compassion satisfaction and resilience. We found no modifiable factors associated with any wellness measures. Further quantitative and qualitative studies are needed to identify interventions to reduce moral distress, burnout, and compassion fatigue.
The optimal method for monitoring intensive care unit (ICU) performance is unknown. We sought to compare process control charts using standardized mortality ratio (SMR), p-charts, and cumulative sum (CUSUM) charts for detecting increases in risk-adjusted mortality within ICUs.
Sepsis is a continuing problem in modern healthcare, with a relatively high prevalence, and a significant mortality rate worldwide. Currently, no specific anti-sepsis treatment exists despite decades of research on developing potential therapies. Annexins are molecules that show efficacy in preclinical models of sepsis but have not been investigated as a potential therapy in patients with sepsis. Human annexins play important roles in cell membrane dynamics, as well as mediation of systemic effects. Most notably, annexins are highly involved in anti-inflammatory processes, adaptive immunity, modulation of coagulation and fibrinolysis, as well as protective shielding of cells from phagocytosis. These discoveries led to the development of analogous peptides which mimic their physiological function, and investigation into the potential of using the annexins and their analogous peptides as therapeutic agents in conditions where inflammation and coagulation play a large role in the pathophysiology. In numerous studies, treatment with recombinant human annexins and annexin analogue peptides have consistently found positive outcomes in animal models of sepsis, myocardial infarction, and ischemia reperfusion injury. Annexins A1 and A5 improve organ function and reduce mortality in animal sepsis models, inhibit inflammatory processes, reduce inflammatory mediator release, and protect against ischemic injury. The mechanisms of action and demonstrated efficacy of annexins in animal models support development of annexins and their analogues for the treatment of sepsis. The effects of annexin A5 on inflammation and platelet activation may be particularly beneficial in disease caused by SARS-CoV-2 infection. Safety and efficacy of recombinant human annexin A5 are currently being studied in clinical trials in sepsis and severe COVID-19 patients.
