Factors influencing diagnostic accuracy among intensive care unit clinicians - an observational study.

OBJECTIVES: Diagnostic errors are a source of morbidity and mortality in intensive care unit (ICU) patients. However, contextual factors influencing clinicians' diagnostic performance have not been studied in authentic ICU settings. We sought to determine the accuracy of ICU clinicians' diagnostic impressions and to characterize how various contextual factors, including self-reported stress levels and perceptions about the patient's prognosis and complexity, impact diagnostic accuracy. We also explored diagnostic calibration, i.e. the balance of accuracy and confidence, among ICU clinicians. METHODS: We conducted an observational cohort study in an academic medical ICU. Between June and August 2019, we interviewed ICU clinicians during routine care about their patients' diagnoses, their confidence, and other contextual factors. Subsequently, using adjudicated final diagnoses as the reference standard, two investigators independently rated clinicians' diagnostic accuracy and on each patient on a given day ("patient-day") using 5-point Likert scales. We conducted analyses using both restrictive and conservative definitions of clinicians' accuracy based on the two reviewers' ratings of accuracy. RESULTS: We reviewed clinicians' responses for 464 unique patient-days, which included 255 total patients. Attending physicians had the greatest diagnostic accuracy (77-90 %, rated as three or higher on 5-point Likert scale) followed by the team's primary fellow (73-88 %). Attending physician and fellows were also least affected by contextual factors. Diagnostic calibration was greatest among ICU fellows. CONCLUSIONS: Additional studies are needed to better understand how contextual factors influence different clinicians' diagnostic reasoning in the ICU.

Characteristics and Outcomes of Individuals With Pre-existing Kidney Disease and COVID-19 Admitted to Intensive Care Units in the United States.

RATIONALE & OBJECTIVE: Underlying kidney disease is an emerging risk factor for more severe coronavirus disease 2019 (COVID-19) illness. We examined the clinical courses of critically ill COVID-19 patients with and without pre-existing chronic kidney disease (CKD) and investigated the association between the degree of underlying kidney disease and in-hospital outcomes. STUDY DESIGN: Retrospective cohort study. SETTINGS & PARTICIPANTS: 4,264 critically ill patients with COVID-19 (143 patients with pre-existing kidney failure receiving maintenance dialysis; 521 patients with pre-existing non-dialysis-dependent CKD; and 3,600 patients without pre-existing CKD) admitted to intensive care units (ICUs) at 68 hospitals across the United States. PREDICTOR(S): Presence (vs absence) of pre-existing kidney disease. OUTCOME(S): In-hospital mortality (primary); respiratory failure, shock, ventricular arrhythmia/cardiac arrest, thromboembolic events, major bleeds, and acute liver injury (secondary). ANALYTICAL APPROACH: We used standardized differences to compare patient characteristics (values>0.10 indicate a meaningful difference between groups) and multivariable-adjusted Fine and Gray survival models to examine outcome associations. RESULTS: Dialysis patients had a shorter time from symptom onset to ICU admission compared to other groups (median of 4 [IQR, 2-9] days for maintenance dialysis patients; 7 [IQR, 3-10] days for non-dialysis-dependent CKD patients; and 7 [IQR, 4-10] days for patients without pre-existing CKD). More dialysis patients (25%) reported altered mental status than those with non-dialysis-dependent CKD (20%; standardized difference=0.12) and those without pre-existing CKD (12%; standardized difference=0.36). Half of dialysis and non-dialysis-dependent CKD patients died within 28 days of ICU admission versus 35% of patients without pre-existing CKD. Compared to patients without pre-existing CKD, dialysis patients had higher risk for 28-day in-hospital death (adjusted HR, 1.41 [95% CI, 1.09-1.81]), while patients with non-dialysis-dependent CKD had an intermediate risk (adjusted HR, 1.25 [95% CI, 1.08-1.44]). LIMITATIONS: Potential residual confounding. CONCLUSIONS: Findings highlight the high mortality of individuals with underlying kidney disease and severe COVID-19, underscoring the importance of identifying safe and effective COVID-19 therapies in this vulnerable population.

Anticoagulation in Cardiobacterium hominis Prosthetic Valve Endocarditis in a Patient with Hypercoagulability: A Clinical Dilemma.

Cardiobacterium hominis is an uncommon cause of prosthetic valve endocarditis (PVE) and often presents insidiously. In comparison, prosthetic valve thrombosis (PVT) is a rare, but life-threatening condition that commonly occurs due to inadequate anticoagulation. Anticoagulation is relatively contraindicated in patients with endocarditis as it may prove to be lethal due to increased risk of cerebral hemorrhage. However, anticoagulation is required in patients with PVT, or for its prevention. We present a case of a 35-year-old male with a history of hypercoagulability and St. Jude's aortic valve on warfarin, who presented with chest pain andwas found to have a mass on the aorticvalve, with blood cultures revealing C. hominis.The patient was treated with appropriate antibiotics and anticoagulation was continued. No neurological complications were noted during the treatment period. This case demonstrates that carefully weighing the risks and benefits of continuing anticoagulation is essential in preventing poor outcomes.

Venous and arterial air embolism: a rare phenomenon with fatal consequences.

Air embolism is often an iatrogenic complication which may occur in venous or arterial circulation depending on the port of entry. We present two cases in which air embolism occurred in venous and arterial circulation after contrast medium injection (CMI) and coronary artery bypass graft (CABG) surgery, respectively. In one case, accumulation of air bubbles was observed in the pulmonary artery after CMI. This was attributed to inadvertent injection of air owing to improper connection of the injector and the catheter. The patient was managed with 100% oxygen in the Trendelenburg and left lateral decubitus position. Repeat imaging demonstrated resorption of the emboli. In another case, air was introduced during CABG in the left atrium and ventricle. Immediate suction of air was attempted however, the patient developed cardiogenic shock requiring vasopressors, and subsequently seizures and coma due to diffuse ischaemic stroke. The patient eventually expired.