The need for ICU admission in intoxicated patients: a prediction model.

CONTEXT: Intoxicated patients are frequently admitted from the emergency room to the ICU for observational reasons. The question is whether these admissions are indeed necessary. OBJECTIVE: The aim of this study was to develop a model that predicts the need of ICU treatment (receiving mechanical ventilation and/or vasopressors <24 h of the ICU admission and/or in-hospital mortality). MATERIALS AND METHODS: We performed a retrospective cohort study from a national ICU-registry, including 86 Dutch ICUs. We aimed to include only observational admissions and therefore excluded admissions with treatment, at the start of the admission that can only be applied on the ICU (mechanical ventilation or CPR before admission). First, a generalized linear mixed-effects model with binominal link function and a random intercept per hospital was developed, based on covariates available in the first hour of ICU admission. Second, the selected covariates were used to develop a prediction model based on a practical point system. To determine the performance of the prediction model, the sensitivity, specificity, positive, and negative predictive value of several cut-off points based on the assigned number of points were assessed. RESULTS: 9679 admissions between January 2010 until January 2015 were included for analysis. In total, 632 (6.5%) of the patients admitted to the ICU eventually turned out to actually need ICU treatment. The strongest predictors for ICU treatment were respiratory insufficiency, age >55 and a GCS <6. Alcohol and "other poisonings" (e.g., carbonmonoxide, arsenic, cyanide) as intoxication type and a systolic blood pressure ≥130 mmHg were indicators that ICU treatment was likely unnecessary. The prediction model had high sensitivity (93.4%) and a high negative predictive value (98.7%). DISCUSSION AND CONCLUSION: Clinical use of the prediction model, with a high negative predictive value (98.7%), would result in 34.3% less observational admissions.

In-hospital mortality and long-term survival of patients with acute intoxication admitted to the ICU.

OBJECTIVE: To assess in-hospital and long-term mortality of Dutch ICU patients admitted with an acute intoxication. DESIGN: Cohort of ICU admissions from a national ICU registry linked to records from an insurance claims database. SETTING: Eighty-one ICUs (85% of all Dutch ICUs). PATIENTS: Seven thousand three hundred thirty-one admissions between January 1, 2008, and October 1, 2011. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Kaplan-Meier curves were used to compare the unadjusted mortality of the total intoxicated population and for specific intoxication subgroups based on the Acute Physiology and Chronic Health Evaluation IV reasons for admission: 1) alcohol(s), 2) analgesics, 3) antidepressants, 4) street drugs, 5) sedatives, 6) poisoning (carbon monoxide, arsenic, or cyanide), 7) other toxins, and 8) combinations. The case-mix adjusted mortality was assessed by the odds ratio adjusted for age, gender, severity of illness, intubation status, recurrent intoxication, and several comorbidities. The ICU mortality was 1.2%, and the in-hospital mortality was 2.1%. The mortality 1, 3, 6, 12, and 24 months after ICU admission was 2.8%, 4.1%, 5.2%, 6.5%, and 9.3%, respectively. Street drugs had the highest mortality 2 years after ICU admission (12.3%); a combination of different intoxications had the lowest (6.3%). The adjusted observed mortality showed that intoxications with street drugs and "other toxins" have a significant higher mortality 1 month after ICU admission (odds ratioadj = 1.63 and odds ratioadj= 1.73, respectively). Intoxications with alcohol or antidepressants have a significant lower mortality 1 month after ICU admission (odds ratioadj = 0.50 and odds ratioadj = 0.46, respectively). These differences were not found in the adjusted mortality 3 months upward of ICU admission. CONCLUSIONS: Overall, the mortality 2 years after ICU admission is relatively low compared with other ICU admissions. The first 3 months after ICU admission there is a difference in mortality between the subgroups, not thereafter. Still, the difference between the in-hospital mortality and the mortality after 2 years is substantial.

Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity, country, and time period: a systematic review and meta-analysis.

BACKGROUND: Unruptured intracranial aneurysms (UIAs) are increasingly detected and are an important health-care burden. We aimed to assess the prevalence of UIAs according to family history, comorbidity, sex, age, country, and time period. METHODS: Through searches of PubMed, Embase, and Web of Science we updated our 1998 systematic review up to March, 2011. We calculated prevalences and prevalence ratios (PRs) with random-effects binomial meta-analysis. We assessed time trends with year of study as a continuous variable. FINDINGS: We included 68 studies, which reported on 83 study populations and 1450 UIAs in 94 912 patients from 21 countries. The overall prevalence was estimated as 3·2% (95% CI 1·9-5·2) in a population without comorbidity, with a mean age of 50 years, and consisting of 50% men. Compared with populations without the comorbidity, PRs were 6·9 (95% CI 3·5-14) for autosomal dominant polycystic kidney disease (ADPKD), 3·4 (1·9-5·9) for a positive family history of intracranial aneurysm of subarachnoid haemorrhage, 3·6 (0·4-30) for brain tumour, 2·0 (0·9-4·6) for pituitary adenoma, and 1·7 (0·9-3·0) for atherosclerosis. The PR for women compared with men was 1·61 (1·02-2·54), with a ratio of 2·2 (1·3-3·6) in study populations with a mean age of more than 50 years. Compared with patients older than 80 years, we found no differences by age, except for patients younger than 30 years (0·01, 0·00-0·12). Compared with the USA, PRs were similar for other countries, including Japan (0·8, 0·4-1·7) and Finland (1·0, 0·4-2·4). There was no statistically significant time trend. INTERPRETATION: The prevalence of UIAs is higher in patients with ADPKD or a positive family history of intracranial aneurysm of subarachnoid haemorrhage than in people without comorbidity. In Finland and Japan, the higher incidence of subarachnoid haemorrhage is not explained by a higher prevalence of UIAs, implicating higher risks of rupture. FUNDING: Julius Centre for Health Sciences and Primary Care and Department of Neurology and Neurosurgery, University Medical Centre, Utrecht.