Comparison of COVID-19 with influenza A in the ICU: a territory-wide, retrospective, propensity matched cohort on mortality and length of stay.

OBJECTIVES: Direct comparisons between COVID-19 and influenza A in the critical care setting are limited. The objective of this study was to compare their outcomes and identify risk factors for hospital mortality. DESIGN AND SETTING: This was a territory-wide, retrospective study on all adult (≥18 years old) patients admitted to public hospital intensive care units in Hong Kong. We compared COVID-19 patients admitted between 27 January 2020 and 26 January 2021 with a propensity-matched historical cohort of influenza A patients admitted between 27 January 2015 and 26 January 2020. We reported outcomes of hospital mortality and time to death or discharge. Multivariate analysis using Poisson regression and relative risk (RR) was used to identify risk factors for hospital mortality. RESULTS: After propensity matching, 373 COVID-19 and 373 influenza A patients were evenly matched for baseline characteristics. COVID-19 patients had higher unadjusted hospital mortality than influenza A patients (17.5% vs 7.5%, p<0.001). The Acute Physiology and Chronic Health Evaluation IV (APACHE IV) adjusted standardised mortality ratio was also higher for COVID-19 than influenza A patients ((0.79 (95% CI 0.61 to 1.00) vs 0.42 (95% CI 0.28 to 0.60)), p<0.001). Adjusting for age, PaO2/FiO2, Charlson Comorbidity Index and APACHE IV, COVID-19 (adjusted RR 2.26 (95% CI 1.52 to 3.36)) and early bacterial-viral coinfection (adjusted RR 1.66 (95% CI 1.17 to 2.37)) were directly associated with hospital mortality. CONCLUSIONS: Critically ill patients with COVID-19 had substantially higher hospital mortality when compared with propensity-matched patients with influenza A.

Restrictive and liberal transfusion strategies in extracorporeal membrane oxygenation: A retrospective observational study.

BACKGROUND: To compare the outcomes of patients requiring extracorporeal membrane oxygenation (ECMO) support who had a restrictive transfusion strategy with those who had a liberal strategy. STUDY DESIGN AND METHODS: We retrospectively reviewed all adult patients from 2010 to 2019 who received a minimum of one packed red blood cell (pRBC) during ECMO. Hemoglobin values before each transfusion were retrieved. Restrictive transfusion strategy was defined as a transfusion threshold ≤8.5 g/dl in all transfusion episodes for a single patient, while liberal transfusion strategy was defined as a transfusion threshold >8.5 g/dl in any transfusion episode. RESULTS: The analysis included 763 patients, with 138 (18.1%) patients in the restrictive and 625 (81.9%) in the liberal transfusion strategy group. The median hemoglobin level, taking into account all measured hemoglobin values, during ECMO support was 8.3 and 9.9 g/dl, and the average units of pRBC received per day were 0.7 (0.3-1.8) and 1.2 (0.6-2.3), respectively. There were no significant differences in intensive care unit (ICU) mortality (adjusted odds ratio (OR), 0.86; 95% CI 0.56-1.30; p = .47), hospital mortality (adjusted OR, 0.79; 95% CI 0.52-1.21; p = .28), and 90-day mortality (adjusted OR, 0.84; 95% CI 0.55-1.28; p = .42) between the two groups. Among subgroup analyses, a restrictive transfusion strategy was associated with decreased risk of ICU mortality in patients on veno-venous ECMO (adjusted OR, 0.36; 95% CI 0.17-0.73; p = .005). There was no heterogeneity on outcomes across patients stratified by age, APACHE IV score, or need for large volume transfusion. DISCUSSION: Our data suggested it may be safe to adopt a restrictive red cell transfusion threshold of 8.5 g/dl in patients on ECMO, and highlighted the need for prospective trials in this heavily-transfused population.

Effect of hospital case volume on clinical outcomes of patients requiring extracorporeal membrane oxygenation: a territory-wide longitudinal observational study.

Background: The utilization of extracorporeal membrane oxygenation (ECMO) has increased rapidly around the world. Being an overall low-volume high-cost form of therapy, the effectiveness of having care delivered in segregated units across a geographical locality is debatable. Methods: All adult extracorporeal membrane oxygenation cases admitted to public hospitals in Hong Kong between 2010 and 2019 were included. "High-volume" centers were defined as those with >20 extracorporeal membrane oxygenation cases in the respective calendar year, while "low-volume" centers were those with ≤20. Clinical outcomes of patients who received extracorporeal membrane oxygenation care in high-volume centers were compared with those in low-volume centers. Results: A total of 911 patients received extracorporeal membrane oxygenation-297 (32.6%) veno-arterial extracorporeal membrane oxygenation, 450 (49.4%) veno-venous extracorporeal membrane oxygenation, and 164 (18.0%) extracorporeal membrane oxygenation-cardiopulmonary resuscitation. The overall hospital mortality was 456 (50.1%). The annual number of extracorporeal membrane oxygenation cases in high- and low-volume centers were 29 and 11, respectively. Management in a high-volume center was not significantly associated with hospital mortality (adjusted odds ratio (OR) 0.86, 95% confidence interval (CI): 0.61-1.21, P=0.38), or with intensive care unit mortality (adjusted OR 0.76, 95% CI: 0.54-1.06, P=0.10) compared with a low-volume center. Over the 10-year period, the overall observed mortality was similar to the Acute Physiology And Chronic Health Evaluation IV-predicted mortality, with no significant difference in the standardized mortality ratios between high- and low-volume centers (P=0.46). Conclusions: In a territory-wide observational study, we observed that case volumes in extracorporeal membrane oxygenation centers were not associated with hospital mortality. Maintaining standards of care in low-volume centers is important and improves preparedness for surges in demand.

Correction of severe hyponatremia by continuous veno-venous hemodialysis with regional citrate anticoagulation: A case series.

INTRODUCTION: Hyponatremia is a common electrolyte disturbance in critically ill patients. Management of intensive care unit patients with concurrent hyponatremia and renal failure requiring dialysis is challenging especially with regional citrate anticoagulation, which may cause excessive rise of serum [Na+ ]. We described the first and successful modified continuous veno-venous hemodialysis (CVVHD) regimen using regional citrate anticoagulation. METHOD: A mathematical model was developed to predict serum [Na+ ] change during CVVHD. Our in-house CVVHD regimen using regional citrate anticoagulation was modified to slow down the rise of serum [Na+ ] by both modifying the dialysate solution and modifying the circuit. RESULT: Five out of six patients had gradual serum [Na+ ] correction not exceeding the daily limit. None of them developed osmotic demyelination syndrome. CONCLUSION: We concluded that regional citrate anticoagulation, with proper modification, is safe and effective for patients with concomitant renal failure requiring hemodialysis.

Characteristics and outcomes of patients admitted to adult intensive care units in Hong Kong: a population retrospective cohort study from 2008 to 2018.

BACKGROUND: Globally, mortality rates of patients admitted to the intensive care unit (ICU) have decreased over the last two decades. However, evaluations of the temporal trends in the characteristics and outcomes of ICU patients in Asia are limited. The objective of this study was to describe the characteristics and risk adjusted outcomes of all patients admitted to publicly funded ICUs in Hong Kong over a 11-year period. The secondary objective was to validate the predictive performance of Acute Physiology And Chronic Health Evaluation (APACHE) IV for ICU patients in Hong Kong. METHODS: This was an 11-year population-based retrospective study of all patients admitted to adult general (mixed medical-surgical) intensive care units in Hong Kong public hospitals. ICU patients were identified from a population electronic health record database. Prospectively collected APACHE IV data and clinical outcomes were analysed. RESULTS: From 1 April 2008 to 31 March 2019, there were a total of 133,858 adult ICU admissions in Hong Kong public hospitals. During this time, annual ICU admissions increased from 11,267 to 14,068, whilst hospital mortality decreased from 19.7 to 14.3%. The APACHE IV standard mortality ratio (SMR) decreased from 0.81 to 0.65 during the same period. Linear regression demonstrated that APACHE IV SMR changed by - 0.15 (95% CI - 0.18 to - 0.11) per year (Pearson's R = - 0.951, p < 0.001). Observed median ICU length of stay was shorter than that predicted by APACHE IV (1.98 vs. 4.77, p < 0.001). C-statistic for APACHE IV to predict hospital mortality was 0.889 (95% CI 0.887 to 0.891) whilst calibration was limited (Hosmer-Lemeshow test p < 0.001). CONCLUSIONS: Despite relatively modest per capita health expenditure, and a small number of ICU beds per population, Hong Kong consistently provides a high-quality and efficient ICU service. Number of adult ICU admissions has increased, whilst adjusted mortality has decreased over the last decade. Although APACHE IV had good discrimination for hospital mortality, it overestimated hospital mortality of critically ill patients in Hong Kong.

Impact of renal replacement therapy on survival in patients with KDIGO stage 3 acute kidney injury: A propensity score matched analysis.

AIM: To investigate the impact of renal replacement therapy (RRT) on 90-day mortality in critically ill patients suffering from KDIGO stage 3 acute kidney injury (AKI) with or without life-threatening complications using propensity score matching analysis. METHODS: We conducted a retrospective analysis of critically ill adult patients with KDIGO Stage 3 AKI with or without RRT during ICU stay between 1/1/2011-31/12/2013. Cox regression analysis and propensity score matching methods were used to determine predictors for 90-day mortality. RESULTS: Among 661 patients, 50.5% received RRT. The unadjusted 90-day mortality rate was 42.5% and 54.1% in patients who had or had not received RRT, respectively. After adjustment with propensity score based on the probability of receiving RRT, the cox regression analysis showed that RRT was associated with a lower 90-day mortality (p<0.001). Among 322 propensity-matched pairs, RRT was associated with lower ICU (23.6% vs. 39.8%, p=0.002), hospital (33.5% vs. 55.9%, p<0.001) and 90-day mortality (34.2% vs. 58.4%, p<0.001), and a higher 90-day renal recovery rate (57.8% vs. 45.3% full recovery, p=0.026) compared with no RRT. When an alternate propensity model was used, the benefits associated with RRT were very similar, except 90-day renal recovery became insignificant. CONCLUSION: Our observational study found that in critically ill patients with KDIGO Stage 3 AKI, RRT may be associated with lower 90-day mortality. The benefit of RRT on renal recovery was less prominent. Medical futility and practice variations may complicate study interpretation. To avoid these limitations, large-scale multicenter, non-observational study is recommended.

Treatment of Acute Kidney Injury Complicating Septic Shock with EMiC2 High-cutoff Hemofilter: Case Series.

INTRODUCTION: Extracorporeal blood purification therapies have been proposed to improve outcomes of patients with severe sepsis, with or without accompanying acute kidney injury (AKI), by removal of excessive inflammatory mediators. MATERIALS AND METHODS: We report our experience with EMiC2 high-cutoff continuous venovenous hemofiltration/hemodialysis (HCO-CVVH/HD) in seven patients with AKI complicating septic shock. RESULTS: The median treatment duration was 71 h, and the procedure was well tolerated. Trough serum albumin level of 20 g/L was observed after 2 h of treatment and none of the patients required albumin supplement. The hospital mortality rate was 29%, which appeared more favorable than the predicted mortality of 60%-78% based on disease severity scores. Circulating levels of interleukin-6 (IL-6), IL-10, and tumor necrosis factor-alpha improved over time. CONCLUSION: This case series shows that HCO-CVVH/CVVHD using EMiC2 hemofilter may provide good cytokine modulation, when used along with good quality standard sepsis therapy. A further large-scale prospective randomized controlled trial is recommended.

Preoperative red cell distribution width: Not a useful prognostic indicator for 30-day mortality in patients who undergo major- or ultra-major noncardiac surgery.

BACKGROUND: Red cell distribution width (RDW) has been shown to be associated with mortality in cardiac surgical patients. This study investigates the association of RDW with the 30-day mortality for those patients who undergo major- or ultra-major noncardiac surgery. METHODS: Patients who received major- or ultra-major noncardiac surgery between July 2012 and May 2013 were included in the study and patients those with preoperative hemoglobin <10 g/day were excluded from the study. Patients were followed till day 30 from the date of surgery or death, whichever occurred earlier. RESULTS: The overall 30-day mortality for major- and ultra-major surgery was 11.4%. The mean RDW of the 30-day survivors was 13.6 ± 1.6 and that of nonsurvivors was 14.2 ± 2.1 (P < 0.001). Other factors that were significantly different (P < 0.05) between survivors and nonsurvivors included age, sex, preoperative pulse rate, current or ex-alcoholic, the American Society of Anesthesiologists score, diabetes mellitus, use of antihypertensives, sepsis with 48 h before surgery, preoperative hemoglobin, white cell count, sodium, urea, creatinine, albumin, international normalized ratio (INR), pH, base excess, estimated blood loss, and emergency surgery. Logistic regression revealed that preoperative RDW > 13.35% (P = 0.025, odds ratio [OR]: 1.52), INR (P = 0.008, OR: 4.49), albumin level (P < 0.001, OR: 1.10), use of antihypertensives (P = 0.001, OR: 1.82), and preoperative pulse rate (P = 0.006, OR: 1.02) independently predicted the 30-day mortality. However, the area under receiver operating characteristic curve for the prediction of 30-day mortality using RDW was only 0.614. CONCLUSIONS: Although preoperative RDW independently predicted 30-day mortality in patients who underwent major- or ultra-major noncardiac surgery, it may not serve as an influential prognostic indicator in view of its low sensitivity and specificity.

Septic acute kidney injury in critically ill patients - a single-center study on its incidence, clinical characteristics, and outcome predictors.

Purpose The objective of this study is to examine the incidence, clinical characteristics, and outcome (90-day mortality) of critically ill Chinese patients with septic AKI. Methods Patients admitted to the ICU of a regional hospital from 1 January 2011 to 31 December 2013 were included, excluding those on chronic renal replacement therapy. AKI was defined using KDIGO criteria. Patients were followed till 90 days from ICU admission or death, whichever occurred earlier. Demographics, diagnosis, clinical characteristics, and outcome were analyzed. Results In total, 3687 patients were included and 54.7% patients developed AKI. Sepsis was the most common cause of AKI (49.2%). Compared to those without AKI, AKI patients had higher disease severity, more physiological and biochemical disturbance, and carried significant co-morbidities. Ninety-day mortality increased with severity of AKI (16.7, 27.5, and 48.3% for KDIGO stage 1, 2, and 3 AKI, p < 0.001). Full renal recovery was achieved in 71.6% of AKI patients. Compared with non-septic AKI, septic AKI was associated with higher disease severity and required more aggressive support. Non-recovery of renal function occurred in 2.5% of patients with septic AKI, compared with 6.4% in non-septic AKI (p < 0.001). Cox regression analysis showed that age, emergency ICU admission, post-operative cases, admission diagnosis, etiology of AKI, disease severity score, mechanical ventilation, vasopressor support, and blood parameters (like albumin, potassium and pH) independently predicted 90-day mortality. Conclusions AKI, especially septic AKI is common in critically ill Chinese patients and is associated with poor patient outcome. Etiology of AKI has a significant impact on 90-day mortality and may affect renal outcome.

Predictive value of plasma neutrophil gelatinase-associated lipocalin for acute kidney injury in intensive care unit patients after major non-cardiac surgery.

AIM: The performance of plasma neutrophil gelatinase-associated lipocalin (pNGAL) for prediction of acute kidney injury (AKI) in non-cardiac surgical patients has not been well described. This study investigates the use of pNGAL for early detection of AKI in patients admitted to an intensive care unit (ICU) after major or ultra-major non-cardiac surgery. METHODS: A total of 151 patients were recruited. Blood samples at 0 h and 6 h post-ICU admission were collected. Primary outcome was occurrence of AKI within 48 h of ICU admission defined using Acute Kidney Injury Network (AKIN) classification. RESULTS: Forty-five (29.8%) patients developed AKI within 48 h of ICU admission. Among them, 22, 14, and nine were classified as AKIN Stage 1, 2, and 3 respectively. pNGAL levels at 0 h and 6 h were significantly related to AKI severity. The AUROC for pNGAL at 0 h and 6 h increased with AKI severity (AKIN stage ≥1 0.671 ± 0.048 and 0.691 ± 0.047; stage ≥2 0.737 ± 0.055 and 0.796 ± 0.048; stage 3 0.829 ± 0.072 and 0.860 ± 0.065, respectively) and requirement of renal replacement therapy (0.880 ± 0.059 & 0.837 ± 0.088). Change of pNGAL from 0 h to 6 h showed no advantage in predictive power compared with pNGAL level at 0 h or 6 h alone. The addition of pNGAL into clinical AKI prediction model could only provide marginal benefit. CONCLUSION: pNGAL correlated with severity of AKI and requirement of renal replacement therapy in ICU patients who received major or ultra-major non-cardiac surgery. However, the benefit of adding pNGAL into clinical AKI prediction model is marginal.

Alteco endotoxin hemoadsorption in Gram-negative septic shock patients.

BACKGROUND AND AIMS: Severe sepsis and septic shock are common causes of mortality and morbidity in an intensive care unit setting. Endotoxin, derived from the outer membranes of Gram-negative bacteria, is considered a major factor in the pathogenesis of sepsis. This study investigated the effect of Alteco endotoxin hemoadsorption device on Gram-negative septic shock patients. MATERIALS AND METHODS: An open, controlled, prospective, randomized, single-center trial was conducted between February 2010 and June 2012. Patients with septic shock due to intra-abdominal sepsis were randomized to either conventional therapy (n = 8) or conventional therapy plus two 2-hourly sessions of Alteco endotoxin hemoadsorption (n = 7). Primary endpoint was the Sequential Organ Failure Assessment (SOFA) score changes from 0 to 72 h. Secondary end points included vasopressor requirement, PaO2/FiO2 ratio (PFR), length of stay (LOS), and 28-day mortality. RESULTS: This study was terminated early as interim analysis showed a low probability of significant findings. No significant difference was noted between the two groups with respect to change in SOFA score, vasopressor score, PFR, LOS, and 28-day mortality. Side-effect was minimal. CONCLUSIONS: We could not identify any clinical benefit on the addition of Alteco endotoxin hemoadsorption to conventional therapy in patients who suffered from intra-abdominal sepsis with shock. The side effect profile of this novel device was acceptable.

The use of regional citrate anticoagulation continuous venovenous hemofiltration in extracorporeal membrane oxygenation.

Patients on extracorporeal membrane oxygenation (ECMO) frequently requires continuous renal replacement therapy (CRRT). Additional anticoagulation for the CRRT circuit is usually not employed, but this may increases the risk of clot embolization, which shortens oxygenator lifespan and increases patient's risk. We report our experience on the use of regional citrate anticoagulation continuous venovenous hemofiltration (RCA-CVVH) connected to an ECMO circuit, which could be useful during low heparin or heparin-free ECMO situations. Regional citrate anticoagulation continuous venovenous hemofiltration was performed using AK200US machine with a blood flow of 150 ml/min, Acid Citrate Dextrose Solution prefilter infusion at 240 ml/hr, ultrafiltration rate of 2,040 ml/hr, and postdilutional online generated replacement fluid infused as appropriate. The circuit was aimed to run for 30 hrs. From May 2009 to May 2013, 63 patients received ECMO and 29 received RCA-CVVH. The median total CVVH time was 131 hrs (interquartile range [IQR]: 61-224 hrs), and hemofilter life was 27.2 hrs (IQR: 25.7-28.5 hrs). No hemofilter or oxygenator was changed because of clotting. Their hospital mortality was 27.6%. There were eight patients, who were judged to be too sick for anticoagulation, received predilution CRRT during the same period. Their hospital mortality was 75%. In conclusion, online postdilutional RCA-CVVH connected to an ECMO circuit is a feasible, safe, and effective CRRT technique.

Timing for initiation of continuous renal replacement therapy in patients with septic shock and acute kidney injury.

The optimal timing for renal replacement therapy initiation in septic acute kidney injury (AKI) remains controversial. This study investigates the impact of early versus late initiation of continuous renal replacement therapy (CRRT) on organ dysfunction among patients with septic shock and AKI. Patients were dichotomized into "early" (simplified RIFLE Risk) or "late" (simplified RIFLE Injury or Failure) CRRT initiation. Patients with chronic kidney disease stage 5 or those on long-term dialysis were excluded. Organ dysfunction was quantified by Sequential Organ Failure Assessment (SOFA) score. From January 2008 to June 2011, 120 patients fulfilled the inclusion criteria. Thirty-one (26%) underwent "early" while 89 (74%) had "late" CRRT. No significant difference was noted between groups on improvement of total SOFA/non-renal SOFA score or noradrenaline equivalent in the first 24 and 48 h after CRRT initiation. Dialysis requirement and mortality (at 28 days, 3 months and 6 months) did not differ. In conclusion, improvement of non-renal SOFA score 48 h after CRRT correlated with SOFA score on CRRT initiation (P = 0.040) and APACHE IV risk of death (P = 0.000), but not estimated glomerular filtration rate on CRRT initiation (P = 0.377). Improvement of non-renal SOFA score correlated with SOFA score on CRRT initiation and APACHE IV risk of death. However, this retrospective review cannot identify any significant clinical benefit of early CRRT initiation in patients presenting with septic shock and AKI.

A retrospective review of the use of regional citrate anticoagulation in continuous venovenous hemofiltration for critically ill patients.

Background. The emergence of a commercially prepared citrate solution has revolutionized the use of RCA in the intensive care unit (ICU). The aim of this study was to evaluate the safety profile of a commercially prepared citrate solution. Method. Predilution continuous venovenous hemofiltration (CVVH) was performed using Prismocitrate 10/2 at 2500 mL/h and a blood flow rate of 150 mL/min. Calcium chloride solution was infused to maintain ionized calcium within 1.0-1.2 mmol/L. An 8.4% sodium bicarbonate solution was infused separately. Treatment was stopped when the predefined clinical target was reached or the filter clotted. Result. 58 sessions of citrate RCA were analyzed. The median circuit lifetime was 26.0 h (interquartile range IQR 21.2-44.3). The percentage of circuits lasting more than 12 h, 24 h, and 48 h was 94.6%, 58.9%, and 16.1%, respectively. There was no incidence of hypernatremia and median pH was <7.5. Hypomagnesemia and hypophosphatemia were detected in 41.6% and 17.6% of blood samples taken, respectively. Although 16 episodes had a total calcium/ionized calcium (total Ca/iCa) >2.5, only four patients had evidence of citrate accumulation. Conclusion. The commercially prepared citrate solution could be used safely in critically ill patients who required CVVH with no major adverse events.

Regional citrate anticoagulation in predilution continuous venovenous hemofiltration using prismocitrate 10/2 solution.

Regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) is associated with a longer filter life and fewer bleeding events. Complexity of the regimen is the major hurdle preventing widespread application. This study describes a simple predilution continuous venovenous hemofiltration (CVVH) protocol utilizing a commercially prepared replacement solution containing citrate (Prismocitrate 10/2). Ten patients with acute renal failure were evaluated. The Prismaflex system was used for predilution CVVH, with Prismocitrate 10/2 running at 2500 mL/h as the main predilution replacement. An 8.4% sodium bicarbonate solution was infused at 50 mL/h in the first 2 h followed by 30 mL/h; 10% calcium gluconate was given to achieve an ionized calcium (iCa) level of 1-1.2 mmol/L. The circuit was run for 72 h unless there was filter clotting, transportation was required, or the patient did not require further CRRT. Total treatment duration was 504.5 h. The post-dilution equivalent ultrafiltration rate was 32.9 mL/kg/h (interquartile range [IQR] 31.6-38.2) and the median circuit life was 50.3 h (IQR 25.5-72.0). None of the circuit was changed due to circuit clotting. The median systemic iCa was 0.98 mmol/L (IQR 0.91-1.08). The total calcium-to-iCa ratio was 2.33 (IQR 2.21-2.45). None of the patients developed hypernatremia (Na ≥ 150 mmol/L) or citrate toxicity (total Ca-to-iCa ratio > 2.5 plus increasing metabolic acidosis), and metabolic alkalosis (pH ≥ 7.5) occurred in one patient. This simple RCA CVVH protocol using commercially-prepared solution could be a feasible, relatively safe, and effective alternative to the conventional regimen for patients with a body weight up to 80 kg.

Interaction between fluid balance and disease severity on patient outcome in the critically ill.

PURPOSE: There is evidence in literature regarding the benefits of immediate aggressive fluid resuscitation together with conservative fluid management approach after initial stabilization. This retrospective study assesses the relationship between fluid balance during intensive care unit (ICU) stay and outcomes among general critically ill patients. In addition, we also aim to see the effect of fluid gain among patients with different disease severity. METHODS: A total of 639 patients admitted into ICU who stayed for 3 days or more were evaluated. Fluid balances during ICU stay were recorded. A logistic regression analysis was performed to identify significant factors associated with hospital mortality. RESULTS: Acute Physiology and Chronic Health Evaluation IV predicted risk of death, fluid balance on the second plus third ICU days, and total fluid balance during ICU stay were positively associated with hospital death. Significant positive fluid balance on first ICU day, in contrast, was negatively associated with hospital mortality. The positive correlation between standardized mortality ratio (Acute Physiology and Chronic Health Evaluation IV) and fluid gain on the second plus third ICU days increases with disease severity. CONCLUSION: Early adequate fluid resuscitation together with conservative late fluid management may provide better patient outcomes. The effect of fluid management strategy on patient outcome may depend on the underlying disease severity.

Triage decisions and outcomes for patients with Triage Priority 3 on the Society of Critical Care Medicine scale.

OBJECTIVE: To identify factors associated with the triage decision for patients classified as Society of Critical Care Medicine (SCCM) Triage Priority 3, and their outcomes. DESIGN: Single-centre, prospective, observational cohort study. SETTING: General intensive care unit in a tertiary regional hospital, over the 9 months January to September 2007. PATIENTS: SCCM Triage Priority 3 patients. RESULTS: All patients were followed up for at least 6 months. Among the 1346 triaged patients, 250 were classified as SCCM Triage Priority 3. Fewer than a third of these (76, 30.4%) were admitted to the ICU. Medical patients were more likely to be rejected than surgical or neurosurgical patients. Those with a poorer physicianpredicted chance of long-term survival were more likely to be rejected than those with a better predicted prognosis. The MPMII0-predicted mortality was higher for those denied ICU admission. Non-postoperative status (odds ratio [OR], 26.3) and physician-predicted risk > 50% of death within 1 month (OR, 11.8) were independently correlated with denial of ICU admission in a multiple logistic regression analysis. Cox regression analysis showed that independent risk factors for mortality were denial of ICU admission (hazard ratio [HR], 2.80), higher MPMII0-predicted mortality (HR, 1.12 for every 10% increment) and the presence of renal disease as an admission diagnosis (HR, 2.28). CONCLUSIONS: For SCCM Triage Priority 3 patients, postoperative status and better physician-predicted prognosis correlated with ICU admission. Patients had lower medium-term survival if they were denied ICU admission, or had higher MPMII0-predicted mortality, or renal disease as the admission diagnosis.