Abstract Background Severity stratification scores developed in intensive care units (ICUs) are used in interventional studies to identify the most critically ill. Studies that evaluate accuracy of these scores in ICU patients admitted with pneumonia are lacking. This study aims to determine performance of severity scores as predictors of mortality in critically ill patients admitted with pneumonia. Methods Prospective cohort study in a general ICU in Brazil. ICU severity scores (Simplified Acute Physiology Score 3 [SAPS 3] and Sepsis-Related Organ Failure Assessment [qSOFA]), prognostic scores of pneumonia (CURB-65 [confusion, urea, respiratory rate, blood pressure, age] and CRB-65 [confusion, respiratory rate, blood pressure, age]), and clinical and epidemiological variables in the first 6 hours of hospitalization were analyzed. Results Two hundred patients were included between 2015 and 2018, with a median age of 81 years (interquartile range, 67–90 years) and female predominance (52%), primarily admitted from the emergency department (65%) with community-acquired pneumonia (CAP, 80.5%). SAPS 3, CURB-65, CRB-65,and qSOFA all exhibited poor performance in predicting mortality. Multivariate regression identified variables independently associated with mortality that were used to develop a novel pneumonia-specific ICU severity score (Pneumonia Shock score) that outperformed SAPS 3, CURB-65, and CRB-65. The Shock score was validated in an external multicenter cohort of critically ill patients admitted with CAP. Conclusions We created a parsimonious score that accurately identifies patients with pneumonia at highest risk of ICU death. These findings are critical to accurately stratify patients with severe pneumonia in therapeutic trials that aim to reduce mortality.

Objective ICU severity scores such as the Sequential Organ Failure Assessment (SOFA) determine neurologic dysfunction based on the Glasgow Coma Scale, a tool that may be limited in a critically ill population. It remains unknown whether alternative methods to assess for neurologic dysfunction, such as FOUR and RASS, are superior. This study aimed to determine the predictive performance of a modified SOFA tool in a large Brazilian ICU cohort. Design Prospective cohort single center study.

Evaluate host and pathogen factors associated with mortality in those with hospital acquired infections (HAI) in a tertiary intensive care unit in Brazil. Methods: Observational and analytical cohort single center study in a general intensive care unit (ICU) in Northeastern Brazil between January 2016 and August 2018, including those over 18 years of age admitted to the ICU found to have a HAI. Results: A total of 165 patients were included, with a mean age of 72 years and male predominance (53.3%) and observed mortality of 46%. Mortality in those with HAI was significantly associated with older age, increased ICU length of stay and readmission to the ICU in univariate analysis. Multivariate analysis revealed that development of septic shock and obtundation during ICU admission was significantly associated with an increased risk of death (OR: 6.94, 95% CI 1.23-39.27, OR: 2.48, 95% CI 1.17-5.29, respectively). A trend towards mortality risk was noted in those with increased age and prior cardiovascular disease. Surprisingly, mortality risk was independent of site of infection, type of pathogen and antibiotic resistance. Furthermore, having more than one HAI over the course of the ICU admission did not impact mortality. Conclusion: Risk of death in those with HAI is associated with obtundation and septic shock, in addition to vasopressor use. Host factors, rather than pathogen-specific characteristics or infecting site, impact risk of death related to HAI in the ICU.

Objective: To investigate the prevalence of complicating and concurrent morbidities in older diabetic patients and to evaluate to what extent their occurrence affects the burden of disease and use of medical healthcare. Study design: Cross-sectional analysis of retrospectively obtained data on comorbidities and use of medical healthcare. Healthcare registration systems were used to retrieve data on 300 patients with diabetes aged >60 years who, according to the severity of their disease and intensity of care required, were treated in a regional general practitioner (GP), diabetes nurse specialist (DNS) or medical specialist (MS) practice. Results: Complicating and concurrent morbidities were often found irrespective of the type of practice involved. After adjustments for differences in sex, age and glycosylated haemoglobin (HbA1c), the extent of complicating comorbidities showed sequential increases in patients managed by GP, DNS and MS (mean number of 3.6, 4.7 and 6.7, respectively; p trend ,0.001). However, the mean number of concurrent comorbidities was similar across all three settings (2.1, 1.8 and 2.0, respectively). Both complicating and concurrent comorbidities were similarly associated with the extent of drug use (b = 0.49 (95% CI 0.40 to 0.58) and b = 0.57 (95% CI 0.52 to 0.72), respectively) and the number of consultations with specialists other than the main care giver (b = 1.19 (95% CI 1.15 to 1.24) and b = 1.21 (95% CI 1.14 to 1.28), respectively). However, the mean number of different specialists involved in a patient's care per additional concurrent comorbidity was twice as high as per any additional complicating comorbidity (b = 0.60 (95% CI 0.48 to 0.71) vs b = 0.31 (95% CI 0.24 to 0.39)). Conclusions: The use of healthcare facilities by older patients with diabetes is substantial, irrespective of the complexity of the disease and the kind of practice involved. The common manifestation of complicating and concurrent comorbidities and their varying complexity in individual patients requires a patient-oriented rather than a disease-oriented approach and vocational training programmes for care givers that are tailored to the complexity of multiple chronic diseases.

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Objective This study aimed to assess the performance of a commonly used ICU severity score (SAPS3) and determine whether an alternative scoring system may be more accurate across all age strata. Methods Retrospective cohort study in a general ICU in Brazil. A secondary analysis was performed with clinical and epidemiological data, present in the first 24 hours of unit admission. Then, a binary logistic regression, followed by cross-validation, was made to develop a novel prognostic tool. ICU mortality was the primary outcome evaluated. Results A total of 3042 patients were included over the study period between August 2015 and July 2018 with a median age of 67 ± 18.4 years. SAPS3 performed fairly in prediction of ICU mortality, particularly in the 80 years or older subset. Multivariable regression identified variables independently associated with mortality that were used to develop the Age Calibrated ICU Score (ACIS) tool that performed similarly to SAPS3 across age categories, being slightly superior in the very elderly population (AUC 0.80 vs 0.72). Conclusions The ACIS offers a robust and simple tool to predict ICU mortality, particularly in an increasingly elderly critical care population.

BackgroundPrognostic tools developed to stratify critically ill patients in Intensive Care Units (ICUs), are critical to predict those with higher risk of mortality in the first hours of admission. This study aims to evaluate the performance of the pShock score in critically ill patients admitted to the ICU with SARS-CoV-2 infection.MethodsProspective observational analytical cohort study conducted between January 2020 and March 2021 in four general ICUs in Salvador, Brazil. Descriptive statistics were used to characterize the cohort and a logistic regression, followed by cross-validation, were performed to calibrate the score. A ROC curve analysis was used to assess accuracy of the models analyzed.ResultsSix hundred five adult ICU patients were included in the study. The median age was 63 (IQR: 49–74) years with a mortality rate of 33.2% (201 patients). The calibrated pShock-CoV score performed well in prediction of ICU mortality (AUC of 0.80 [95% Confidence Interval (CI): 0.77–0.83; p-value < 0.0001]).ConclusionsThe pShock-CoV score demonstrated robust discriminatory capacity and may assist in targeting scarce ICU resources during the COVID-19 pandemic to those critically ill patients most likely to benefit.

Obesity has emerged as a significant global health problem, and its association with increased morbidity and mortality is well established. An obesity paradox has been extensively documented in the critically ill, appearing as a protective factor. Whether body mass index (BMI) impacts critical care severity scores has not been extensively studied previously, particularly in developing countries. This study aimed to evaluate the performance of severity scores across different BMI categories in a tertiary intensive care unit in Brazil. Observational and analytical cohort study in a general ICU in Northeastern Brazil between August 2015 and July 2018 that included all patients over 18 years of age admitted to the ICU. A total of 2,179 patients were included, with a mean age of 67.9 years and female predominance (53.1%). Similar to previous findings, those with overweight and obesity of any grade were not significantly associated with mortality, though for each additional 1kg/m2 there was a decrease of 0.04% in odds of death. The Simplified Acute Physiology Score III (SAPS3) accurately predicted mortality in all groups except in those underweight. Low weight appeared as an independent risk factor for mortality in the ICU. Furthermore, this is the first study to identify poor prognostic performance of a common ICU severity score in those with low weight, highlighting the need for alternative more precise metrics.