Mortality Rates in Early versus Late Intensive Care Unit Readmission.

Background: ICU readmission is associated with poor outcomes. Few studies have directly compared the outcomes of early versus late readmissions, especially in Saudi Arabia. Objective: To compare the outcomes between early and late ICU readmissions, mainly with regards to hospital mortality. Methods: This retrospective study included unique patients who, within the same hospitalization, were admitted to the ICU, discharged to the general wards, and then readmitted to the ICU of King Saud Medical City, Riyadh, Saudi Arabia, between January 01, 2015, and June 30, 2022. Patients readmitted within 2 calendar days were grouped into the Early readmission group, while those readmitted after 2 calendar days were in the Late readmission group. Results: A total of 997 patients were included, of which 753 (75.5%) belonged to the Late group. The mortality rate in the Late group was significantly higher than that in the Early group (37.6% vs. 29.5%, respectively; 95% CI: 1%-14.8%; P = 0.03). The readmission length of stay (LOS) and severity score of both groups were similar. The odds ratio of mortality for the Early group was 0.71 (95% CI: 0.51-0.98, P = 0.04); other significant risk factors were age (OR = 1.023, 95% CI: 1.016-1.03; P < 0.001) and readmission LOS (OR = 1.017, 95% CI: 1.009-1.026; P < 0.001). The most common reason for readmission in the Early group was high Modified Early Warning Score, while in the Late group, it was respiratory failure followed by sepsis or septic shock. Conclusion: Compared with late readmission, early readmission was associated with lower mortality, but not with lower LOS or severity score.

Tele-Rapid Response Team (Tele-RRT): The effect of implementing patient safety network system on outcomes of medical patients-A before and after cohort study.

BACKGROUND: Rapid Response Teams were developed to provide interventions for deteriorating patients. Their activation depends on timely detection of deterioration. Automated calculation of warning scores may lead to early recognition, and improvement of RRT effectiveness. METHOD: This was a "Before" and "After" study, in the "Before" period ward nurses activated RRT after manually recording vital signs and calculating warning scores. In the "After" period, vital signs and warning calculations were automatically relayed to RRT through a wireless monitoring network. RESULTS: When compared to the before group, the after group had significantly lower incidence and rate of cardiopulmonary resuscitation (CPR) (2.3 / 1000 inpatient days versus 3.8 / 1000 inpatient days respectively, p = 0.01), significantly shorter length of hospital stay and lower hospital mortality, but significantly higher number of RRT activations. In multivariable logistic regression model, being in the "After" group decreases odds of CPR by 33% (OR = 0.67 [95% CI: 0.46-0.99]; p = 0.04). There was no difference between groups in ICU admission. CONCLUSION: Automated activation of the RRT significantly reduced CPR events and rates, improved CPR success rate, reduced hospital length of stay and mortality, but increased the number of RRT activations. There were no differences in unplanned ICU admission or readmission.

Reverse takotsubo cardiomyopathy in fulminant COVID-19 associated with cytokine release syndrome and resolution following therapeutic plasma exchange: a case-report.

BACKGROUND: Fulminant (life-threatening) COVID-19 can be associated with acute respiratory failure (ARF), multi-system organ failure and cytokine release syndrome (CRS). We present a rare case of fulminant COVID-19 associated with reverse-takotsubo-cardiomyopathy (RTCC) that improved with therapeutic plasma exchange (TPE). CASE PRESENTATION: A 40 year old previous healthy male presented in the emergency room with 4 days of dry cough, chest pain, myalgias and fatigue. He progressed to ARF requiring high-flow-nasal-cannula (flow: 60 L/minute, fraction of inspired oxygen: 40%). Real-Time-Polymerase-Chain-Reaction (RT-PCR) assay confirmed COVID-19 and chest X-ray showed interstitial infiltrates. Biochemistry suggested CRS: increased C-reactive protein, lactate dehydrogenase, ferritin and interleukin-6. Renal function was normal but lactate levels were elevated. Electrocardiogram demonstrated non-specific changes and troponin-I levels were slightly elevated. Echocardiography revealed left ventricular (LV) basal and midventricular akinesia with apex sparing (LV ejection fraction: 30%) and depressed cardiac output (2.8 L/min) consistent with a rare variant of stress-related cardiomyopathy: RTCC. His ratio of partial arterial pressure of oxygen to fractional inspired concentration of oxygen was < 120. He was admitted to the intensive care unit (ICU) for mechanical ventilation and vasopressors, plus antivirals (lopinavir/ritonavir), and prophylactic anticoagulation. Infusion of milrinone failed to improve his cardiogenic shock (day-1). Thus, rescue TPE was performed using the Spectra Optia™ Apheresis System equipped with the Depuro D2000 Adsorption Cartridge (Terumo BCT Inc., USA) without protective antibodies. Over 5 days he received daily TPE (each lasting 4 hours). His lactate levels, oxygenation, and LV function normalized and he was weaned off vasopressors. His inflammation markers improved, and he was extubated on day-7. RT-PCR was negative on day-17. He was discharged to home isolation in good condition. CONCLUSION: Stress-cardiomyopathy may complicate the course of fulminant COVID-19 with associated CRS. If inotropic therapy fails, TPE without protective antibodies may help rescue the critically ill patient.

Insidious development of pulmonary embolism in asymptomatic patients with COVID-19: Two rare case-reports.

Scarce data exist regarding the clinical sequelae of COVID-19 and/or the prevalence of thromboembolic disease in asymptomatic patients. Surely, there is increased prevalence of thromboembolic disease and pulmonary embolism (PE) in critically ill patients with COVID-19; hence the administration of even enhanced thromboprophylaxis was suggested. However, the administration of regular thromboprophylaxis in asymptomatic outpatients is an entirely different matter. Herein, we present the clinical story of insidious PE development in two asymptomatic COVID-19 female patients. Issues regarding the pathogenesis of thromboembolism in COVID-19 and the clinical management are equally discussed.