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Red blood cell transfusion within the first 24 hours of admission is associated with increased mortality in the pediatric trauma population: a retrospective cohort study
Taylor J Stone, Paul J Riesenman, Anthony G Charles
Journal of Trauma Management & Outcomes , 2008, DOI: 10.1186/1752-2897-2-9
Abstract: Age, race, and mechanism of injury did not differ between transfused and non-transfused groups, although there were significantly more female patients in the transfusion group (51 vs. 37%; p < 0.01). Shock index (pulse/systolic blood pressure), injury severity score, and new injury severity score were all significantly higher in the transfused group (1.21 vs. 0.96, 26 vs. 10, and 33 vs. 13 respectively; all p ≤ 0.01). Patients who received a red blood cell transfusion experienced a higher mortality compared to the non-transfused group (29% vs. 3%; p < 0.001). When attempting to control for injury severity, goodness-of-fit analysis revealed a poor fit for the statistical model preventing reliable conclusions about the contribution of red blood cell transfusion as an independent predictor of mortality.Red blood cell transfusion within the first 24 hours following admission is associated with an increase in mortality in pediatric trauma patients. The potential contribution of red blood cell transfusion as an independent predictor of hospital mortality could not be assessed from our single-institution trauma registry. A review of state-wide or national trauma databases may be necessary to obtain adequate statistical confidence.Nonoperative management of blunt traumatic injury is now a widely accepted practice in hemodynamically stable patients[1,2]. The transfusion of allogeneic packed red blood cells (PRBCs) is employed to attenuate reductions in hemoglobin. An increase in serum hemoglobin will increase the oxygen-carrying capacity of the blood, which theoretically provides more oxygen to vital tissues malperfused in the shock state. However, recent studies have associated adverse hospital outcomes with therapeutic blood transfusions in adult patients. Allogeneic blood transfusion has been reported to be an independent predictor of hospital mortality in adult trauma patients [1-4]. Additionally, PRBC transfusion is associated with an increased risk of infection [5], mu
Index Blood Tests and National Early Warning Scores within 24 Hours of Emergency Admission Can Predict the Risk of In-Hospital Mortality: A Model Development and Validation Study  [PDF]
Mohammed A. Mohammed, Gavin Rudge, Duncan Watson, Gordon Wood, Gary B. Smith, David R. Prytherch, Alan Girling, Andrew Stevens
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0064340
Abstract: Background We explored the use of routine blood tests and national early warning scores (NEWS) reported within ±24 hours of admission to predict in-hospital mortality in emergency admissions, using empirical decision Tree models because they are intuitive and may ultimately be used to support clinical decision making. Methodology A retrospective analysis of adult emergency admissions to a large acute hospital during April 2009 to March 2010 in the West Midlands, England, with a full set of index blood tests results (albumin, creatinine, haemoglobin, potassium, sodium, urea, white cell count and an index NEWS undertaken within ±24 hours of admission). We developed a Tree model by randomly splitting the admissions into a training (50%) and validation dataset (50%) and assessed its accuracy using the concordance (c-) statistic. Emergency admissions (about 30%) did not have a full set of index blood tests and/or NEWS and so were not included in our analysis. Results There were 23248 emergency admissions with a full set of blood tests and NEWS with an in-hospital mortality of 5.69%. The Tree model identified age, NEWS, albumin, sodium, white cell count and urea as significant (p<0.001) predictors of death, which described 17 homogeneous subgroups of admissions with mortality ranging from 0.2% to 60%. The c-statistic for the training model was 0.864 (95%CI 0.852 to 0.87) and when applied to the testing data set this was 0.853 (95%CI 0.840 to 0.866). Conclusions An easy to interpret validated risk adjustment Tree model using blood test and NEWS taken within ±24 hours of admission provides good discrimination and offers a novel approach to risk adjustment which may potentially support clinical decision making. Given the nature of the clinical data, the results are likely to be generalisable but further research is required to investigate this promising approach.
Assessment of risk factors related to healthcare-associated methicillin-resistant Staphylococcus aureus infection at patient admission to an intensive care unit in Japan
Kazuma Yamakawa, Osamu Tasaki, Miyuki Fukuyama, Junichi Kitayama, Hiroki Matsuda, Yasushi Nakamori, Satoshi Fujimi, Hiroshi Ogura, Yasuyuki Kuwagata, Toshimitsu Hamasaki, Takeshi Shimazu
BMC Infectious Diseases , 2011, DOI: 10.1186/1471-2334-11-303
Abstract: We prospectively studied HA-MRSA infection in 474 consecutive patients admitted for more than 2 days to our medical, surgical, and trauma ICU in a tertiary referral hospital in Japan. Data obtained from patients within 24 hours of ICU admission on 11 prognostic variables possibly related to outcome were evaluated to predict infection risk in the early phase of ICU stay. Stepwise multivariate logistic regression analysis was used to identify independent risk factors for HA-MRSA infection.Thirty patients (6.3%) had MRSA infection, and 444 patients (93.7%) were infection-free. Intubation, existence of open wound, treatment with antibiotics, and steroid administration, all occurring within 24 hours of ICU admission, were detected as independent prognostic indicators. Patients with intubation or open wound comprised 96.7% of MRSA-infected patients but only 57.4% of all patients admitted.Four prognostic variables were found to be risk factors for HA-MRSA infection in ICU: intubation, open wound, treatment with antibiotics, and steroid administration, all occurring within 24 hours of ICU admission. Preemptive infection control in patients with these risk factors might effectively decrease HA-MRSA infection.Healthcare-associated methicillin-resistant Staphylococcus aureus (HA-MRSA) infection in critically ill patients is associated with prolonged intensive care unit (ICU) stay, increased medical cost, and high mortality [1,2]. Furthermore, patients in the ICU have an increased susceptibility to HA-MRSA infections [3,4]. Special risk factors make such patients temporarily immunocompromised: normal host defense mechanisms are often disrupted by multiple invasive devices, impaired by underlying disease, and reduced by medical interventions and medications. Overall, intrinsic together with extrinsic risk factors make the ICU patient extremely vulnerable to HA-MRSA infections. Therefore, control of HA-MRSA transmission and infection in the ICU is a serious concern.Although most
Case mix, outcome and activity for patients with severe acute kidney injury during the first 24 hours after admission to an adult, general critical care unit: application of predictive models from a secondary analysis of the ICNARC Case Mix Programme Database
Nitin V Kolhe, Paul E Stevens, Alex V Crowe, Graham W Lipkin, David A Harrison
Critical Care , 2008, DOI: 10.1186/cc7003
Abstract: Severe AKI admissions (defined as serum creatinine ≥300 μmol/l and/or urea ≥40 mmol/l during the first 24 hours) were extracted from the ICNARC CMP database of 276,326 admissions to UK ICUs from 1995 to 2004. Subgroups of oliguric and nonoliguric AKI were identified by daily urine output. Data on surgical status, survival and length of stay were also collected. Severity of illness scores and mortality prediction models were compared (UK Acute Physiology and Chronic Health Evaluation [APACHE] II, Stuivenberg Hospital Acute Renal Failure [SHARF] T0, SHARF II0 and the Mehta model).Severe AKI occurred in 17,326 out of 276,731 admissions (6.3%). The source of admission was nonsurgical in 83.7%. Sepsis was present in 47.3% and AKI was nonoliguric in 63.9% of cases. Admission to ICU with severe AKI accounted for 9.3% of all ICU bed-days. Oliguric AKI was associated with longer length of stay for survivors and shorter length of stay for nonsurvivors compared with nonoliguric AKI. Oliguric AKI was associated with significantly greater ICU and hospital mortality (55.8% and 77.3%, respectively) compared with nonoliguric AKI (33.4% and 49.3%, respectively). Surgery during the 1 week before admission or during the first week in the CMP unit was associated with decreased odds of mortality. UK APACHE II and the Mehta scores under-predicted the number of deaths, whereas SHARF T0 and SHARF II0 over-predicted the number of deaths.Severe AKI accounts for over 9% of all bed-days in adult, general ICUs, representing a considerable drain on resources. Although nonoliguric AKI continues to confer a survival benefit, overall survival from AKI in the ICU and survival to leave hospital remains poor. The use of APACHE II score measured during the first 24 hours of ICU stay performs well as compared with SHARF T0, SHARF II0 and the Mehta score, but it lacks perfect calibration.Acute kidney injury (AKI) is relatively common in the intensive care setting and has an associated mortality of 50% to
Can generic paediatric mortality scores calculated 4 hours after admission be used as inclusion criteria for clinical trials?
Stéphane Leteurtre, Francis Leclerc, Jessica Wirth, Odile Noizet, Eric Magnenant, Ahmed Sadik, Catherine Fourier, Robin Cremer
Critical Care , 2004, DOI: 10.1186/cc2869
Abstract: All children admitted from June 1998 to May 2000 in one tertiary PICU were prospectively included. Data were collected to generate scores and predictions using PRISM, PRISM III and PIM.There were 802 consecutive admissions with 80 deaths. For the time points for which the scores were developed, observed and predicted mortality rates were significantly different for the three scores (P < 0.01) whereas all exhibited good discrimination (area under the receiver operating characteristic curve ≥0.83). At 4 hours after admission only the PIM had good calibration (P = 0.44), but all three scores exhibited good discrimination (area under the receiver operating characteristic curve ≥0.82).Among the three scores calculated at 4 hours after admission, all had good discriminatory capacity but only the PIM score was well calibrated. Further studies are required before the PIM score at 4 hours can be used as an inclusion criterion in clinical trials.Adjustment to severity is considered important in clinical trials for ensuring comparability between groups. Generic mortality scoring systems for children admitted to intensive care units (ICUs) have been developed for use at specific time points in the ICU stay. Two systems have been validated in paediatric ICUs (PICUs): the Paediatric RISk of Mortality (PRISM) and the Paediatric Index of Mortality (PIM). The PRISM, which is used in PICUs worldwide, requires an observation period of 24 hours [1], and the updated PRISM III score [2] measures severity at two time points (12 and 24 hours) during the PICU stay. The PIM and the recently updated PIM2 scores are calculated 1 hour after admission [3,4]. The 12–24 hour period of observation has been a criticism levelled at the PRISM scoring system, and it has been speculated that it may diagnose rather than predict death [4,5]. With the PIM and PIM2 scores, the single measurement of values shortly after admission is susceptible to random variation [6] or may reflect a transient state resulti
Severe lactic acidosis reversed by thiamine within 24 hours
Karin Amrein, Werner Ribitsch, Ronald Otto, Harald C Worm, Rudolf E Stauber
Critical Care , 2011, DOI: 10.1186/cc10495
Abstract: We report the case of a 56-year-old man with profound lactic acidosis that resolved rapidly after thiamine infusion. He was admitted because of a decreased level of consciousness (Glasgow Coma Scale score of 6). Vital signs, including blood pressure, heart rate, and oxygen saturation, were normal. Besides reporting regular alcohol consumption, relatives reported recent progressive weakness and 5-kg weight loss. Laboratory findings on admission were remarkable for moderate hypoglycemia and metabolic acidosis - pH of 6.87, base excess of -29.5, partial pressure of carbon dioxide (pCO2) of 14 mm Hg - with a high anion gap (37 mmol/L) that was attributed to severe hyperlactatemia (21 mmol/L). After intravenous glucose administration, the patient was transferred to the intensive care unit, where he received sodium bicarbonate and 1,500 mL of lactate-free isotonic crystalloids. Within the next few hours, lactate levels increased further while pH slowly improved. Clinically, thiamine deficiency was suspected after other causes of hyperlactatemia, such as hypoxia and hepatic failure, were excluded. After administration of 300 mg of intravenous thiamine, hyperlactatemia normalized rapidly (Figure 1). Unfortunately, the patient suffered persistent neurocognitive deficits.Thiamine deficiency may cause unspecific neurologic symptoms. Glucose administration or feeding may aggravate depletion. Thiamine deficiency is an underdiagnosed cause of lactic acidosis, although treatment is safe, inexpensive, and readily available. Current guidelines on parenteral nutrition recommend a daily intravenous dose of 100 to 300 mg of thiamine during the first 3 days in the intensive care unit when deficiency is a possibility (grade B) [5]. In conclusion, although its clinical significance has been known for decades, thiamine deficiency remains an under-recognized condition. Intensivists should have an increased awareness of this problem and a low threshold to infuse high-dose thiamine. Future pr
Evaluation and Comparison of Admission and Discharge Criteria in Admitted Patients’ of Pediatric Intensive Care Unit of Bahrami Children’s Hospital with the Criteria of American Academy of Pediatrics
A Eghbalkhah,P Salamati,K Sotoudeh,P Khashayar
Iranian Journal of Pediatrics , 2006,
Abstract: Background: During the past few years several pediatric intensive care units (PICU) are opened across the country. The effective use of PICU beds is an important issue because they are expensive and have limited resources. The aim of this study was to evaluate the PICU bed utilization in a new established general PICU in a university children’s hospital. Methods: In a three-month period after opening PICU, the criteria of admission and discharge of all admitted and discharged patients were reviewed and compared with the standard criteria of admission and discharge of American Academy of Pediatrics. Findings: Fifty six patients (34 males and 22 females) with median age of 2.8 years were admitted in this period and totally stayed 254 days. Wrong admission rate was 20%, these patients consumed about 10% of the days of care. Early (wrong) discharge was found in 6% of patients. The average and median duration of stay was 4.5 and 2 days, respectively. Only 9% of patients stayed for 14 or more days. Conclusion: Adherence to standard guidelines of admission and discharge improves the utilization of PICU beds.
Newly Admitted Psychiatric Inpatients after the 3.11 Disaster in Fukushima, Japan  [PDF]
Masaki Hisamura, Arinobu Hori, Akira Wada, Itaru Miura, Hiroshi Hoshino, Shuntaro Itagaki, Yasuto Kunii, Junya Matsumoto, Hirobumi Mashiko, Craig Katz, Shin-Ichi Niwa
Open Journal of Psychiatry (OJPsych) , 2017, DOI: 10.4236/ojpsych.2017.73013
Abstract: Background: After the March 2011 “triple” disaster in Japan, the residents of Fukushima Prefecture suffered from serious psychological stress. Aims: This study aimed to elucidate the influence of stressful conditions on psychiatric disorders, as reflected in new psychiatric admissions. Methods: Diagnoses and background conditions among new psychiatric admissions during the 3 months immediately after the disaster in 2011 and the corresponding time periods of 2010 and 2012 were surveyed. Results: In 2011, more patients were admitted in confusional, manic, neurasthenic, and delirious states, whereas there were fewer admissions for depression. In 2012, more admissions pertained to depression. Twenty-four percent of the new admissions in 2011 were associated with concerns about radiation contamination and hospitalization, which declined to 4% in 2012. Conclusions: The diagnoses and background conditions among new psychiatric admissions were affected by the disaster; with the influence differing according to the time elapsed after the disaster.
Mortality Pattern within Twenty-Four Hours of Emergency Paediatric Admission in a Resource-Poor Nation Health Facility
MAN Adeboye, A Ojuawo, SK Ernest, A Fadeyi, OT Salisu
West African Journal of Medicine , 2010,
Abstract: BACKGROUND: Mortality among emergency paediatric admissions within the first 24 hours is high in resource- poor nations. Measures to reduce the childhood mortality rate can only be effectively planned and implemented when the causes and magnitude of this problem are well defined. OBJECTIVE: To determine the mortality pattern among emergency paediatric admissions within the first 24 hours in a health facility in Nigeria. METHODS: The clinical state and progress of post-neonatal patients who presented alive and were admitted into the emergency paediatric room of the University of Ilorin Teaching Hospital, Ilorin, Nigeria were monitored over a period of six months. The monitoring included records of diagnosis and outcome of management. RESULTS: A total of 606 children were admitted during the period of study out of which 51(8.4%) died. Twenty-nine (57%) of the deaths occurred within the first 24 hours of admission comprising 15 (51.7%) males and 14 (48.3%) females giving M:F ratio of about of 1:1. Majority of the deaths were among patients who reported late to the hospital. Loss of consciousness was a strong risk factor for mortality within 24 hours of admission. The highest mortality within the first 24 hours of admission was recorded among patients with malaria (89.0%) followed by protein energy malnutrition. CONCLUSION: Majority of deaths among emergency paediatric admission occur within the first 24 hours of admission and are associated with clinical conditions such as malaria and protein-energy malnutrition for which sustained intervention strategies must be developed.
Nurses and Physicians in a Medical Admission Unit Can Accurately Predict Mortality of Acutely Admitted Patients: A Prospective Cohort Study  [PDF]
Mikkel Brabrand, Jesper Hallas, Torben Knudsen
PLOS ONE , 2014, DOI: 10.1371/journal.pone.0101739
Abstract: Background There exist several risk stratification systems for predicting mortality of emergency patients. However, some are complex in clinical use and others have been developed using suboptimal methodology. The objective was to evaluate the capability of the staff at a medical admission unit (MAU) to use clinical intuition to predict in-hospital mortality of acutely admitted patients. Methods This is an observational prospective cohort study of adult patients (15 years or older) admitted to a MAU at a regional teaching hospital. The nursing staff and physicians predicted in-hospital mortality upon the patients' arrival. We calculated discriminatory power as the area under the receiver-operating-characteristic curve (AUROC) and accuracy of prediction (calibration) by Hosmer-Lemeshow goodness-of-fit test. Results We had a total of 2,848 admissions (2,463 patients). 89 (3.1%) died while admitted. The nursing staff assessed 2,404 admissions and predicted mortality in 1,820 (63.9%). AUROC was 0.823 (95% CI: 0.762–0.884) and calibration poor. Physicians assessed 738 admissions and predicted mortality in 734 (25.8% of all admissions). AUROC was 0.761 (95% CI: 0.657–0.864) and calibration poor. AUROC and calibration increased with experience. When nursing staff and physicians were in agreement (±5%), discriminatory power was very high, 0.898 (95% CI: 0.773–1.000), and calibration almost perfect. Combining an objective risk prediction score with staff predictions added very little. Conclusions Using only clinical intuition, staff in a medical admission unit has a good ability to identify patients at increased risk of dying while admitted. When nursing staff and physicians agreed on their prediction, discriminatory power and calibration were excellent.
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