IntroductionWe recently presented a prediction score providing decision support with the often-ch... more IntroductionWe recently presented a prediction score providing decision support with the often-challenging early differential diagnosis of acute lung injury (ALI) vs cardiogenic pulmonary edema (CPE). To facilitate clinical adoption, our objective was to prospectively validate its performance in an independent cohort.MethodsOver 9 months, adult patients consecutively admitted to any intensive care unit of a tertiary-care center developing acute pulmonary edema were identified in real-time using validated electronic surveillance. For eligible patients, predictors were abstracted from medical records within 48h of the alert. Post-hoc expert review blinded to the prediction score established gold standard diagnosis.ResultsOf 1,516 patients identified by electronic surveillance, data were abstracted for 249 patients (93% within 48h of disease onset), of which expert review (kappa 0.93) classified 72 as ALI, 73 as CPE and excluded 104 as ¿other¿. With an area under the curve (AUC) of 0.8...
Background: Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory ... more Background: Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) commonly complicate transfusion in critically ill patients. Prior outcome studies of TACO and TRALI have focused on short-term morbidity and mortality, but the longterm survival and quality of life (QOL) of these patients remain unknown. Methods: In a nested case-control study, we compared survival and QOL between critically ill medical patients who developed pulmonary edema after transfusion (TRALI or TACO) and medical critically ill transfused controls, matched by age, gender, and admission diagnostic group. QOL in survivors was assessed with a 36-item short form health survey 1 year after initial hospitalization. Results: Hospital, 1-year, and 2-year mortality among the 74 TRALI cases and 74 matched controls were 43.2% vs 24.3% (P 5 .020), 63.8% vs 46.4% (P 5 .037) and 74.3% vs 54.3% (P 5 .031), whereas among the 51 TACO cases and 51 matched controls these values were 7.8% vs 11.8% (P 5 .727), 38.0% vs 28.0% (P 5 .371), and 44.9% vs 38.8% (P 5 .512). When adjusted for age and baseline severity of illness in a Cox proportional hazard analysis, the development of TRALI remained associated with decreased survival (hazard ratio 1.86; 95% CI, 1.19-2.93; P 5 .006). Both TRALI (P 5 .006, P 5 .03) and TACO (P 5 .03, P 5 .049) were associated with prolonged ICU and hospital lengths of stay. Conclusions: In critically ill medical patients, development of TRALI, but not TACO, is independently associated with decreased long-term survival.
Introduction: Acute respiratory failure (ARF) is associated with substantial morbidity and short ... more Introduction: Acute respiratory failure (ARF) is associated with substantial morbidity and short and long-term mortality. We propose to evaluate the long-term survival and the predictors of mortality in patients requiring mechanical ventilation (MV) during the years of 2005 to 2009 in a defined community.Hypothesis: We hypothesize that age, comorbidities, severity of illness and ARF due to medical etiologies are associated with worse long-term survival. Methods:This is a population-based retrospective cohort study, where we evaluated a sample of adults from Olmsted County admitted to the all the Mayo Clinic Rochester ICUs with ARF requiring invasive MV during the years of 2005 to 2009. We excluded post-operative patients on MV for less than 12 hours. Predictors included patients' demographics, Charlson index, Apache III and etiology of ARF. The primary outcome was long-term survival. Cox regression model was used to identify predictors of survival. Results: Of 701 patients who m...
Background: Sepsis is a major risk factor for the development of thrombocytopenia, but few studie... more Background: Sepsis is a major risk factor for the development of thrombocytopenia, but few studies have specifically evaluated prognostic importance of thrombocytopenia in patients with sepsis. We investigated the incidence, risk factors, and prognostic importance of thrombocytopenia in adult patients admitted to the intensive care unit (ICU) with sepsis. Methods: A retrospective analysis of patients admitted with severe sepsis/septic shock from December 2007 to January 2009 to a 24-bed medical ICU was done. Results: A total of 304 patients were included in the study. The patients' mean (±SD) age was 68.8 (±15.8) years. The majority (93.7%) had septic shock, and pneumonia was the most common infection (38.8%). Thrombocytopenia developed in 145 patients (47.6%): 77 (25.3%) at ICU admission and 68 (22.3%) during their hospital course. The median (IQR) duration of thrombocytopenia was 4.4 (1.9-6.9) days. Patients who developed thrombocytopenia had more episodes of major bleeding (14.4% vs. 3.7%, P < 0.01) and received more transfusions. Patients with thrombocytopenia had a higher incidence of acute kidney injury (44.1% vs. 29.5%, P < 0.01), prolonged vasopressor support (median (IQR): 37 (17-76) vs. 23 (13-46) h, P < 0.01), and longer ICU stay (median (IQR): 3.1 (1.6-7.8) vs. 2.1 (1.2-4.4) days, P < 0.01). The 28-day mortality was similar between patients with and without thrombocytopenia (32.4% vs. 24.5%, P = 0.12). However, while 15 of 86 patients (17.4%) who resolved their thrombocytopenia died, 32 of 59 patients (54.2%) whose thrombocytopenia did not resolve died (P < 0.01). The association between non-resolution of thrombocytopenia and mortality remained significant after adjusting for age, APACHE III score and compliance with a sepsis resuscitation bundle (P < 0.01). Conclusions: Thrombocytopenia is common in patients who are admitted to the ICU with severe sepsis and septic shock. Patients with thrombocytopenia had more episodes of major bleeding, increased incidence of acute kidney injury, and prolonged ICU stay. Non-resolution of thrombocytopenia, but not thrombocytopenia itself, was associated with increased 28-day mortality.
Journal of Bronchology & Interventional Pulmonology, 2013
Background: Malignant pleural effusions are common complications of advanced malignancies and are... more Background: Malignant pleural effusions are common complications of advanced malignancies and are associated with significant morbidity and reduced survival. Tunnelled indwelling pleural catheters (TIPCs) are implantable devices used for palliation of symptomatic malignant pleural effusions. Although complication rates are overall low, their use in the setting of concurrent chemotherapy has not been carefully reviewed. We report our experience with infectious complications directly attributable to TIPCs (pleural or local soft tissue infections) in those patients receiving concurrent chemotherapy. Methods: We conducted a retrospective analysis of patients who underwent TIPC placement for malignant pleural effusion in a 6-year period from November 2005 to March 2011. We reviewed the incidence of infection in these patients receiving catheter placement and attempted to determine whether chemotherapy was associated with an increased infectious risk. Results: A total of 262 TIPC procedures, performed in 243 patients, were included in the study. Out of 262, 173 (66%) TIPC were in the chemotherapy group and 89 TIPC were in the nonchemotherapy group. Infections developed in 16 of the 262 TIPC placements (6.1%). The rate of complications in the chemotherapy group was 9 of the 173 TIPCs (5.2%) compared with 7 of the 89 TIPCs (7.9%) in the other group, a difference that was not statistically different (P = 0.4). Conclusions: The overall risk of infection in TIPC is low. Patients undergoing chemotherapy while the TIPC is in place do not seem to have an increased risk of infection, and therefore chemotherapy should not necessarily be viewed as a contraindication to TIPC insertion.
Objective Full Outline of Unresponsiveness (FOUR) score has previously been validated scale in th... more Objective Full Outline of Unresponsiveness (FOUR) score has previously been validated scale in the Neurosciences Intensive Care Unit. In this study, we sought to validate the use of FOUR score in the emergency department (ED) using non-neurology staff. We also compared its performance to the Glasgow Coma Scale (GCS) and correlated it to functional outcome at hospital discharge and overall survival. Methods We prospectively rated 69 patients with initial neurologic symptoms presenting to the ED. Three types of examiners performed the FOUR score: ED physician, ED resident, and ED nurse. Patients were followed through hospital discharge; functional outcome was measured using modified Rankin Score (mRS). Results Interrater reliability for FOUR score and GCS was excellent (respectively, j w = 0.88 and 0.86). Both FOUR score and GCS predicted functional outcome, and overall survival with and without adjustment for age, sex, and alertness group. Conclusion The FOUR score can be reliably used in the ED by non-neurology staff. Both FOUR score and GCS performed equally well, but the neurologic detail incorporated in the FOUR score makes it more useful in management and triage of patients.
Preintubation shock index (SI) and modified shock index (MSI) have demonstrated predictive capabi... more Preintubation shock index (SI) and modified shock index (MSI) have demonstrated predictive capability for postintubation hypotension in emergency department. The primary aim was to explore this relationship in the critical care environment. The secondary aims were to evaluate the relationship of shock indices with other short-term outcomes like mortality and length of stay in intensive care unit. Materials and methods: This is a nonconcurrent cohort study, conducted in eligible 140 adult intensive care unit (ICU) patients of a tertiary care medical center. Eligibility criterion was emergent endotracheal intubation in apparently hemodynamically stable patients. Results: Preintubation SI ≥ 0.90 had a significant association with postintubation hypotension as defined by systolic blood pressure b 90 mm Hg in the univariate (P = .03; odds ratio [OR], 2.13; 95% confidence interval [CI], 1.07-4.35) and multivariate analyses (P = .01; OR, 3.17; 95% CI, 1.36-7.73) after adjusting for confounders. It was also associated with higher ICU mortality in both the univariate (P = .01; OR, 4.00; 95% CI, 1.26-12.67) and multivariate analyses (P = .01; OR, 5.75; 95% CI, 1.58-26.48). There was no association of preintubation MSI with postintubation hemodynamic instability and ICU mortality. No association was found between preintubation SI and MSI, with ICU length of stay and 30-day mortality. Conclusions: Our findings indicate that preintubation SI greater than or equal to 0.90 is a predictor of postintubation hypotension (systolic blood pressure b90 mm Hg) and ICU mortality in emergently intubated adult patients in intensive care units.
IntroductionWe recently presented a prediction score providing decision support with the often-ch... more IntroductionWe recently presented a prediction score providing decision support with the often-challenging early differential diagnosis of acute lung injury (ALI) vs cardiogenic pulmonary edema (CPE). To facilitate clinical adoption, our objective was to prospectively validate its performance in an independent cohort.MethodsOver 9 months, adult patients consecutively admitted to any intensive care unit of a tertiary-care center developing acute pulmonary edema were identified in real-time using validated electronic surveillance. For eligible patients, predictors were abstracted from medical records within 48h of the alert. Post-hoc expert review blinded to the prediction score established gold standard diagnosis.ResultsOf 1,516 patients identified by electronic surveillance, data were abstracted for 249 patients (93% within 48h of disease onset), of which expert review (kappa 0.93) classified 72 as ALI, 73 as CPE and excluded 104 as ¿other¿. With an area under the curve (AUC) of 0.8...
Background: Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory ... more Background: Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) commonly complicate transfusion in critically ill patients. Prior outcome studies of TACO and TRALI have focused on short-term morbidity and mortality, but the longterm survival and quality of life (QOL) of these patients remain unknown. Methods: In a nested case-control study, we compared survival and QOL between critically ill medical patients who developed pulmonary edema after transfusion (TRALI or TACO) and medical critically ill transfused controls, matched by age, gender, and admission diagnostic group. QOL in survivors was assessed with a 36-item short form health survey 1 year after initial hospitalization. Results: Hospital, 1-year, and 2-year mortality among the 74 TRALI cases and 74 matched controls were 43.2% vs 24.3% (P 5 .020), 63.8% vs 46.4% (P 5 .037) and 74.3% vs 54.3% (P 5 .031), whereas among the 51 TACO cases and 51 matched controls these values were 7.8% vs 11.8% (P 5 .727), 38.0% vs 28.0% (P 5 .371), and 44.9% vs 38.8% (P 5 .512). When adjusted for age and baseline severity of illness in a Cox proportional hazard analysis, the development of TRALI remained associated with decreased survival (hazard ratio 1.86; 95% CI, 1.19-2.93; P 5 .006). Both TRALI (P 5 .006, P 5 .03) and TACO (P 5 .03, P 5 .049) were associated with prolonged ICU and hospital lengths of stay. Conclusions: In critically ill medical patients, development of TRALI, but not TACO, is independently associated with decreased long-term survival.
Introduction: Acute respiratory failure (ARF) is associated with substantial morbidity and short ... more Introduction: Acute respiratory failure (ARF) is associated with substantial morbidity and short and long-term mortality. We propose to evaluate the long-term survival and the predictors of mortality in patients requiring mechanical ventilation (MV) during the years of 2005 to 2009 in a defined community.Hypothesis: We hypothesize that age, comorbidities, severity of illness and ARF due to medical etiologies are associated with worse long-term survival. Methods:This is a population-based retrospective cohort study, where we evaluated a sample of adults from Olmsted County admitted to the all the Mayo Clinic Rochester ICUs with ARF requiring invasive MV during the years of 2005 to 2009. We excluded post-operative patients on MV for less than 12 hours. Predictors included patients' demographics, Charlson index, Apache III and etiology of ARF. The primary outcome was long-term survival. Cox regression model was used to identify predictors of survival. Results: Of 701 patients who m...
Background: Sepsis is a major risk factor for the development of thrombocytopenia, but few studie... more Background: Sepsis is a major risk factor for the development of thrombocytopenia, but few studies have specifically evaluated prognostic importance of thrombocytopenia in patients with sepsis. We investigated the incidence, risk factors, and prognostic importance of thrombocytopenia in adult patients admitted to the intensive care unit (ICU) with sepsis. Methods: A retrospective analysis of patients admitted with severe sepsis/septic shock from December 2007 to January 2009 to a 24-bed medical ICU was done. Results: A total of 304 patients were included in the study. The patients' mean (±SD) age was 68.8 (±15.8) years. The majority (93.7%) had septic shock, and pneumonia was the most common infection (38.8%). Thrombocytopenia developed in 145 patients (47.6%): 77 (25.3%) at ICU admission and 68 (22.3%) during their hospital course. The median (IQR) duration of thrombocytopenia was 4.4 (1.9-6.9) days. Patients who developed thrombocytopenia had more episodes of major bleeding (14.4% vs. 3.7%, P < 0.01) and received more transfusions. Patients with thrombocytopenia had a higher incidence of acute kidney injury (44.1% vs. 29.5%, P < 0.01), prolonged vasopressor support (median (IQR): 37 (17-76) vs. 23 (13-46) h, P < 0.01), and longer ICU stay (median (IQR): 3.1 (1.6-7.8) vs. 2.1 (1.2-4.4) days, P < 0.01). The 28-day mortality was similar between patients with and without thrombocytopenia (32.4% vs. 24.5%, P = 0.12). However, while 15 of 86 patients (17.4%) who resolved their thrombocytopenia died, 32 of 59 patients (54.2%) whose thrombocytopenia did not resolve died (P < 0.01). The association between non-resolution of thrombocytopenia and mortality remained significant after adjusting for age, APACHE III score and compliance with a sepsis resuscitation bundle (P < 0.01). Conclusions: Thrombocytopenia is common in patients who are admitted to the ICU with severe sepsis and septic shock. Patients with thrombocytopenia had more episodes of major bleeding, increased incidence of acute kidney injury, and prolonged ICU stay. Non-resolution of thrombocytopenia, but not thrombocytopenia itself, was associated with increased 28-day mortality.
Journal of Bronchology & Interventional Pulmonology, 2013
Background: Malignant pleural effusions are common complications of advanced malignancies and are... more Background: Malignant pleural effusions are common complications of advanced malignancies and are associated with significant morbidity and reduced survival. Tunnelled indwelling pleural catheters (TIPCs) are implantable devices used for palliation of symptomatic malignant pleural effusions. Although complication rates are overall low, their use in the setting of concurrent chemotherapy has not been carefully reviewed. We report our experience with infectious complications directly attributable to TIPCs (pleural or local soft tissue infections) in those patients receiving concurrent chemotherapy. Methods: We conducted a retrospective analysis of patients who underwent TIPC placement for malignant pleural effusion in a 6-year period from November 2005 to March 2011. We reviewed the incidence of infection in these patients receiving catheter placement and attempted to determine whether chemotherapy was associated with an increased infectious risk. Results: A total of 262 TIPC procedures, performed in 243 patients, were included in the study. Out of 262, 173 (66%) TIPC were in the chemotherapy group and 89 TIPC were in the nonchemotherapy group. Infections developed in 16 of the 262 TIPC placements (6.1%). The rate of complications in the chemotherapy group was 9 of the 173 TIPCs (5.2%) compared with 7 of the 89 TIPCs (7.9%) in the other group, a difference that was not statistically different (P = 0.4). Conclusions: The overall risk of infection in TIPC is low. Patients undergoing chemotherapy while the TIPC is in place do not seem to have an increased risk of infection, and therefore chemotherapy should not necessarily be viewed as a contraindication to TIPC insertion.
Objective Full Outline of Unresponsiveness (FOUR) score has previously been validated scale in th... more Objective Full Outline of Unresponsiveness (FOUR) score has previously been validated scale in the Neurosciences Intensive Care Unit. In this study, we sought to validate the use of FOUR score in the emergency department (ED) using non-neurology staff. We also compared its performance to the Glasgow Coma Scale (GCS) and correlated it to functional outcome at hospital discharge and overall survival. Methods We prospectively rated 69 patients with initial neurologic symptoms presenting to the ED. Three types of examiners performed the FOUR score: ED physician, ED resident, and ED nurse. Patients were followed through hospital discharge; functional outcome was measured using modified Rankin Score (mRS). Results Interrater reliability for FOUR score and GCS was excellent (respectively, j w = 0.88 and 0.86). Both FOUR score and GCS predicted functional outcome, and overall survival with and without adjustment for age, sex, and alertness group. Conclusion The FOUR score can be reliably used in the ED by non-neurology staff. Both FOUR score and GCS performed equally well, but the neurologic detail incorporated in the FOUR score makes it more useful in management and triage of patients.
Preintubation shock index (SI) and modified shock index (MSI) have demonstrated predictive capabi... more Preintubation shock index (SI) and modified shock index (MSI) have demonstrated predictive capability for postintubation hypotension in emergency department. The primary aim was to explore this relationship in the critical care environment. The secondary aims were to evaluate the relationship of shock indices with other short-term outcomes like mortality and length of stay in intensive care unit. Materials and methods: This is a nonconcurrent cohort study, conducted in eligible 140 adult intensive care unit (ICU) patients of a tertiary care medical center. Eligibility criterion was emergent endotracheal intubation in apparently hemodynamically stable patients. Results: Preintubation SI ≥ 0.90 had a significant association with postintubation hypotension as defined by systolic blood pressure b 90 mm Hg in the univariate (P = .03; odds ratio [OR], 2.13; 95% confidence interval [CI], 1.07-4.35) and multivariate analyses (P = .01; OR, 3.17; 95% CI, 1.36-7.73) after adjusting for confounders. It was also associated with higher ICU mortality in both the univariate (P = .01; OR, 4.00; 95% CI, 1.26-12.67) and multivariate analyses (P = .01; OR, 5.75; 95% CI, 1.58-26.48). There was no association of preintubation MSI with postintubation hemodynamic instability and ICU mortality. No association was found between preintubation SI and MSI, with ICU length of stay and 30-day mortality. Conclusions: Our findings indicate that preintubation SI greater than or equal to 0.90 is a predictor of postintubation hypotension (systolic blood pressure b90 mm Hg) and ICU mortality in emergently intubated adult patients in intensive care units.
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Papers by rahul kashyap