Herein, we evaluated the optimal timing for implementing the BioFire® FilmArray® Pneumonia Panel (FA-PP) in the medical intensive care unit (MICU). Respiratory samples from 135 MICU-admitted patients with acute respiratory failure and severe pneumonia were examined using FA-PP. The cohort had an average age of 67.1 years, and 69.6% were male. Notably, 38.5% were smokers, and the mean acute physiology and chronic health evaluation-II (APACHE-II) score at initial MICU admission was 30.62, and the mean sequential organ failure assessment score (SOFA) was 11.23, indicating sever illness. Furthermore, 28.9, 52.6, and 43% of patients had a history of malignancy, hypertension, and diabetes mellitus, respectively. Community-acquired pneumonia accounted for 42.2% of cases, whereas hospital-acquired pneumonia accounted for 37%. The average time interval between pneumonia diagnosis and FA-PP implementation was 1.9 days, and the mean MICU length of stay was 19.42 days. The mortality rate was 50.4%. Multivariate logistic regression analysis identified two variables as significant independent predictors of mortality: APACHE-II score (p = 0.033, OR = 1.06, 95% CI 1.00-1.11), history of malignancy (OR = 3.89, 95% CI 1.64-9.26). The Kaplan-Meier survival analysis indicated that early FA-PP testing did not provide a survival benefit. The study suggested that the FA-PP test did not significantly impact the mortality rate of patients with severe pneumonia with acute respiratory failure. However, a history of cancer and a higher APACHE-II score remain important independent risk factors for mortality.

BACKGROUND: Data about de-escalation in sepsis associated to bloodstream caused by Enterobacterales are scarce. The objectives of this study are to identify factors associated to early de-escalation and to analyse the impact of de-escalation in mortality of patients with Enterobacterales BSI with a SOFA score ≥ 2.
METHODS: A prospective, multicenter cohort study including episodes of BSI due to Enterobacterales and SOFA score ≥2 receiving an active antipseudomonal beta-lactam was performed; the isolate should be susceptible to at least one narrower-spectrum antibiotic. Variables associated to de-escalation were identified using logistic binary regression. The association of de-escalation with 30-day mortality was investigated; confounding was controlled by calculating a propensity score used as covariate, as matching variable and for inverse probability treatment weighting (IPTW).
RESULTS: Of 582 cases included, de-escalation was performed in 311 (53.4%). Neutropenia (adjusted OR: 0.37; 95%CI 0.18-0.75), central venous catheter (aOR: 0.52; 95%CI 0.32-0.83) and ESBL-producing isolate (aOR: 0.28; 95%CI 0.17-0.48) were negatively associated to de-escalation, and urinary tract source was positively associated (aOR: 2.27; 95%CI 1.56-3.33). Thirty-day mortality was 6.8% (21 patients) in de-escalated patients and 14.4% (39) in not de-escalated (relative risk, 0.63; 95%CI 0.44-0.89). In multivariate analysis including the propensity score, de-escalation was not associated with mortality (aOR: 0.98; 95% CI 0.39-2.47) and was protective in urinary or biliary tract source (aOR: 0.31 95%CI: 0.09-1.06). Matched and IPWT analysis showed similar results.
CONCLUSIONS: These results suggest that early de-escalation from antipseudomonal beta-lactams is safe in patients with Enterobacterales bacteremia and SOFA ≥2.

Background Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection, often resulting in severe outcomes such as septic shock and death. Globally, sepsis ranks among the most common causes of illness and death. The Sequential Organ Failure Assessment (SOFA) score is an established marker used to assess and predict the extent of organ failure in septic patients. The introduction of novel markers, such as the lactate/albumin (L/A) ratio, serves as a prognostic indicator in critical care settings, particularly for patients with sepsis. In this context, a higher L/A ratio upon admission aids in assessing disease severity and improving clinical decision-making to reduce mortality and adverse outcomes, which we aim to correlate through our study. Materials and methods This was an observational cross-sectional analysis conducted on 100 patients aged over 18 years who met the \"Sepsis-3\" guidelines and were admitted to the medical intensive care unit of Dr. D. Y. Patil Hospital, Pune, Maharashtra, India, between October 2022 and May 2024. Patients with chronic liver disease classified as Child-Pugh class C were excluded, as were those with chronic kidney disease (CKD). Written informed consent was obtained from each participant before the study. Data were collected through physical examination, routine laboratory investigations, and radiological assessments. Statistical analysis was performed using IBM SPSS version 20 (IBM Corp., Armonk, NY). Descriptive statistical analyses were conducted using the SPSS data editor. Statistical significance was considered at a p-value of less than 0.05 for all analyses. Results In the study population, 78 patients survived, while 22 patients died. The L/A ratio and SOFA score were significantly higher in non-survivors compared to survivors, both upon admission and thereafter, with statistical significance (p < 0.05). The correlation between the L/A ratio and the SOFA score was examined upon admission at 24 hours, 48 hours, day 7, and day 28. Pearson correlation analysis revealed statistically significant results (p < 0.05) throughout the entire study period. Conclusion A high L/A ratio, along with the SOFA score at ICU admission, was associated with a grave prognosis and poor outcomes, serving as independent risk factors for ICU admission. Therefore, patients with a high L/A ratio and SOFA score should be identified early and managed aggressively to avoid poor outcomes. Our study demonstrates that combining serum lactate and serum albumin levels into the L/A ratio significantly enhances prognostic accuracy compared to using serum lactate alone.

BACKGROUND: This study aimed to develop prognostic models for predicting the need for invasive mechanical ventilation (IMV) in intensive care unit (ICU) patients with COVID-19 and compare their performance with the Respiratory rate-OXygenation (ROX) index.
METHODS: A retrospective cohort study was conducted using data collected between March 2020 and August 2021 at three hospitals in Rio de Janeiro, Brazil. ICU patients aged 18 years and older with a diagnosis of COVID-19 were screened. The exclusion criteria were patients who received IMV within the first 24 h of ICU admission, pregnancy, clinical decision for minimal end-of-life care and missing primary outcome data. Clinical and laboratory variables were collected. Multiple logistic regression analysis was performed to select predictor variables. Models were based on the lowest Akaike Information Criteria (AIC) and lowest AIC with significant p values. Assessment of predictive performance was done for discrimination and calibration. Areas under the curves (AUC)s were compared using DeLong\'s algorithm. Models were validated externally using an international database.
RESULTS: Of 656 patients screened, 346 patients were included; 155 required IMV (44.8%), 191 did not (55.2%), and 207 patients were male (59.8%). According to the lowest AIC, arterial hypertension, diabetes mellitus, obesity, Sequential Organ Failure Assessment (SOFA) score, heart rate, respiratory rate, peripheral oxygen saturation (SpO2), temperature, respiratory effort signals, and leukocytes were identified as predictors of IMV at hospital admission. According to AIC with significant p values, SOFA score, SpO2, and respiratory effort signals were the best predictors of IMV; odds ratios (95% confidence interval): 1.46 (1.07-2.05), 0.81 (0.72-0.90), 9.13 (3.29-28.67), respectively. The ROX index at admission was lower in the IMV group than in the non-IMV group (7.3 [5.2-9.8] versus 9.6 [6.8-12.9], p < 0.001, respectively). In the external validation population, the area under the curve (AUC) of the ROX index was 0.683 (accuracy 63%), the AIC model showed an AUC of 0.703 (accuracy 69%), and the lowest AIC model with significant p values had an AUC of 0.725 (accuracy 79%).
CONCLUSIONS: In the development population of ICU patients with COVID-19, SOFA score, SpO2, and respiratory effort signals predicted the need for IMV better than the ROX index. In the external validation population, although the AUCs did not differ significantly, the accuracy was higher when using SOFA score, SpO2, and respiratory effort signals compared to the ROX index. This suggests that these variables may be more useful in predicting the need for IMV in ICU patients with COVID-19.
RESULTS:
UNASSIGNED: NCT05663528.

OBJECTIVE: We aimed to study the etiologies and clinical profile and to describe the factors associated with mortality in acute-on-chronic liver failure (ACLF) patients at our center.
METHODS: Patients meeting the Asian Pacific Association for the Study of the Liver (APASL) definition of ACLF were included. We studied etiologies and clinical profile and analyzed the factors associated with mortality in patients with ACLF. We also analyzed the mortality rates based on the number of organ failures and the grade of ACLF.
RESULTS: 114 patients were included. Alcohol (82, 71.9%), drugs (22, 19.3%), and viral hepatitis (17, 14.9%) were the commonest precipitating factors of ACLF. The commonest cause of chronic disease was alcohol (83, 72.8%). Fifty-three (46.5%), 60 (52.6%), 44 (38.6%), 32 (28.1%), and 24 (21.1%) experienced renal, coagulation, cerebral, respiratory, and circulation failures, respectively. Overall, the in-hospital mortality rate stood at 54 (48.6%), with a median stay of eight days. Advanced hepatic encephalopathy and ventilator support independently predicted mortality. The Sequential Organ Failure Assessment (SOFA) score outperformed all other prognostic scores in predicting mortality in ACLF.
CONCLUSIONS: Alcohol was the most common precipitating factor for ACLF. The in-hospital mortality rate was 48.6%. Advanced hepatic encephalopathy and ventilator support independently predicted mortality. The SOFA score is a more accurate predictor of mortality in ACLF when compared to other prognostic scores.

UNASSIGNED: Sepsis is a major global health affecting millions worldwide, hence understanding its contributing factors becomes paramount. This cross-sectional study at a tertiary care center explores the relationship between iron profile, vitamin D levels, and outcomes in sepsis and septic shock patients. The primary objective was to explore the prevalence of iron profile and vitamin D parameters during early intensive care unit (ICU) admission and their association with 28-day mortality.
UNASSIGNED: Spanning 18 months, the study enrolled adult patients meeting sepsis or septic shock criteria at the ICU. Data collection included demographic information, clinical characteristics, and blood samples for iron profile and vitamin D levels at admission. Disease severity was assessed using sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation II (APACHE II) scores, and treatment was administered as per surviving sepsis-3 guidelines.
UNASSIGNED: The research involved 142 participants, uncovering prevalent organisms such as Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae. Noteworthy connections to mortality were identified for factors including vasopressor support, ICU stay duration, SOFA score, and APACHE-II score. Interestingly, age, gender, and vitamin D levels showed no significant associations. However, the study did reveal a significant association between iron, ferritin, and transferrin saturation levels with increased 28-day mortality.
UNASSIGNED: Our study concluded that low Iron, elevated ferritin, and decreased transferrin saturation levels maintained associations with the outcome of interest. While no such relationship was established with vitamin D levels. These results suggest potential implications for patient management and prognosis, warranting further exploration in future research.
UNASSIGNED: Bairwa M, Jatteppanavar B, Kant R, Singh M, Choudhury A. Impact of Iron Profile and Vitamin D Levels on Clinical Outcomes in Patients with Sepsis and Septic Shock: A Cross-sectional Analysis at a Tertiary Care Center. Indian J Crit Care Med 2024;28(6):569-574.

Clinical studies investigating the benefits of beta-lactam therapeutic drug monitoring (TDM) among critically ill patients are hindered by small patient groups, variability between studies, patient heterogeneity, and inadequate use of TDM. Accordingly, definitive conclusions regarding the efficacy of TDM remain elusive. To address these challenges, we propose an innovative approach that leverages data-driven methods to unveil the concealed connections between therapy effectiveness and patient data, collected through a randomized controlled trial (DRKS00011159; 10th October 2016). Our findings reveal that machine learning algorithms can successfully identify informative features that distinguish between healthy and sick states. These hold promise as potential markers for disease classification and severity stratification, as well as offering a continuous and data-driven \"multidimensional\" Sequential Organ Failure Assessment (SOFA) score. The positive impact of TDM on patient recovery rates is demonstrated by unraveling the intricate connections between therapy effectiveness and clinically relevant data via machine learning.

Due to the high mortality rate of TS, effective guidance for its diagnosis and treatment is essential. The diagnostic criteria introduced by the JTA in 2012, along with the Burch-Wartofsky Point Scale, constitute valuable tools for the diagnosis of TS. In 2016, Guidelines on the management of TS were produced by the JTA and the JES. Recently, a prospective multicenter register-based study compared the prognosis and outcome of 110 new-onset TS patients with the results of previous comparable studies and evaluated the efficacy of the Guidelines. The study revealed higher APACHE II scores and significant correlations between lower BMI, post-resuscitation shock, and fever with outcomes and, overall, improved TS prognosis. Most patients in the study received methimazole and potassium iodide, the timely administration of which was linked to lower fatality rates. Adherence to treatment guidelines correlates with lower mortality rates, emphasizing the importance of experienced multidisciplinary teams in ICU settings and the necessity for periodic review of the guidelines to enhance therapeutic approaches and reduce mortality.

UNASSIGNED: Recent studies suggest that erythropoietin has an anti-inflammatory effect on the central nervous system. The authors aimed to investigate the effect of erythropoietin on Glasgow Coma Scale (GCS), Sequential Organ Failure Assessment (SOFA) scores, and the mortality rate of traumatic brain injury (TBI) patients.
UNASSIGNED: Sixty-eight patients with available inclusion criteria were randomly allocated to the control or intervention groups. In the intervention group, erythropoietin (4000 units) was administrated on days 1, 3, and 5. In the control group, normal saline on the same days was used. The primary outcomes were the GCS and SOFA score changes during the intervention. The secondary outcomes were the ventilation period during the first 2 weeks and the 3-month mortality rate.
UNASSIGNED: Erythropoietin administration significantly affected SOFA score over time (P=0.008), but no significant effect on the GCS, and duration of ventilation between the two groups was observed. Finally, erythropoietin had no significant effect on the three-month mortality (23.5% vs. 38.2% in the erythropoietin and control group, respectively). However, the mortality rate in the intervention group was lower than in the control group.
UNASSIGNED: Our finding showed that erythropoietin administration in TBI may improve SOFA score. Therefore, erythropoietin may have beneficial effects on early morbidity and clinical improvement in TBI patients.

OBJECTIVE: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a life-saving procedure for supporting patients with cardiogenic shock after cardiac surgery. This work aimed to analyse the impact of changes in blood lactate levels on the survival of patients on post-cardiotomy ECMO (PC-ECMO) and whether lactate clearance (LC) performs better than absolute lactate levels.
RESULTS: We retrospectively analysed the data of adult patients who received PC-ECMO at our centre between 2016 and 2022. The primary outcome was the in-hospital mortality rate. Arterial lactate levels were measured at ECMO initiation, peak and 12 and 24 h after VA-ECMO support. LC was calculated at 12 and 24 h. Out of 2368 patients who received cardiac surgeries, 152 (median age, 48 years; 57.9% of them were men) received PC-ECMO. Of them, 48 (31.6%) survived and were discharged, while 104 (68.4%) died during the index hospitalization. Non-survivors had higher frequencies of atrial fibrillation (41.35% vs. 12.5%, P < 0.001), chronic kidney disease (26.9% vs. 6.3%, P = 0.004), prolonged cardiopulmonary bypass (237 vs. 192 min, P = 0.016) and aortic cross-clamping times (160 vs. 124 min, P = 0.04) than survivors. Non-survivors had a significantly higher median Sequential Organ Failure Assessment (SOFA) score at ECMO initiation (13.5 vs. 9, P < 0.001) and a lower median Survival After Veno-arterial ECMO (SAVE) score (-3 vs. 3, P < 0.001) with higher SAVE classes (P < 0.001) than survivors. After 12 h of VA-ECMO support, the blood lactate level was negatively correlated with LC in survivors (r = -0.755, P < 0.001) and non-survivors (r = -0.601, P < 0.001). After 24 h, the same negative correlation was identified between survivors (r = -0.764, P < 0.001) and non-survivors (r = -0.847, P < 0.001). Blood lactate levels measured at 12 h to determine hospital mortality [>8.2 mmol/L, area under the receiver operating characteristic curve (AUROC): 0.868] and 24 h (>2.6 mmol/L, AUROC: 0.896) had the best performance, followed by LC-T12 (<21.94%, AUROC: 0.807), LC-T24 (<40.3%, AUROC: 0.839) and peak blood lactate (>14.35 mmol/L, AUROC: 0.828). The initial pre-ECMO blood lactate (>6.25 mmol/L, AUROC: 0.731) had an acceptable ability to discriminate mortality but was less than the following measurements and clearance. Kaplan-Meier curves demonstrated that LC of <21.94% at T12 h and <40.3% at T24 h was associated with decreased survival (log-rank P < 0.001). Cox proportional hazards regression analysis for mortality revealed that LC of <21.94% at T12 h had an adjusted hazard ratio (HR) of 2.73 [95% confidence interval (CI): 1.64-5.762, P < 0.001] and LC of <40.3% at T24 h had an adjusted HR of 1.98 (95% CI: 1.46-4.173, P < 0.001). The predictors of hospital mortality after PC-ECMO were the lactate level at 12 h [odds ratio (OR): 1.67, 95% CI: 1.121-2.181, P = 0.001], initial SOFA score (OR: 1.593, 95% CI: 1.15-2.73, P < 0.001), initial blood lactate (OR: 1.21, 95% CI: 1.016-1.721, P = 0.032) and atrial fibrillation (OR: 6.17, 95% CI: 2.37-57.214, P = 0.003). Bivariate models using lactate levels and clearance at the same points revealed that blood lactate levels performed better than the clearance percentage.
CONCLUSIONS: Serial measurements of arterial blood lactate and LC help in obtaining early prognostic guidance in adult patients supported by VA-ECMO after cardiac surgery. Absolute lactate levels, compared with LC at the same time points, demonstrated better performance in differentiating mortality.