Vijay Krishnamoorthy

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BACKGROUND: Improved understanding of intensive care unit (ICU) utilization among obstetric patients is essential for optimizing outcomes, managing severe maternal morbidity (SMM), and guiding resource allocation. Despite the clinical importance of ICU care in obstetrics, large-scale data examining utilization patterns and differences by mode of delivery remain limited. To address this gap, our objectives were to determine the proportion of delivery hospitalizations involving ICU admission, to describe the indications for ICU admissions, and to assess factors associated with ICU admission. METHODS: We conducted a retrospective cohort study using delivery hospitalizations in the Premier Database (October 1, 2015–December 31, 2020). ICU admission indications were characterized using Centers for Disease Control and Prevention (CDC)-defined SMM events. Mode of delivery was stratified as vaginal birth, intended cesarean birth (cesarean without trial of labor), and intrapartum cesarean birth (cesarean after trial of labor). Multivariable logistic regression was used to evaluate factors associated with ICU admission. We also performed a secondary analysis to determine the rate of ICU admission in non-SMM and SMM patients with and without comorbidities. RESULTS: We analyzed 4.7 million delivery hospitalizations; 3261,071/4789,673 (68.1%) were vaginal births, 539,670/4,789,673 (11.3%) intrapartum cesarean births, 988,932/4789,673 (20.6%) intended cesarean births. Overall, 35,837/4789,673 (0.75%) patients required ICU admission, including 16,490/3261,071 (0.51%) vaginal births, 8243/539,670 (1.53%) intrapartum cesarean births, and 11,104/988,932 (1.12%) intended cesarean births. Non-transfusion SMM occurred in 18,552/4789,673 (0.39%) of patients. Among ICU patients, 6574/35,837 (18.4%) experienced non-transfusion SMM events, while 27,329/35,837 (76.3%) patients did not meet criteria for a SMM event. The most common SMM events in the ICU were acute respiratory distress syndrome (2509/35,837; 7.0%), ventilation (2401/35,837; 6.7%), shock (2186/35,837; 6.1%), hysterectomy (2150/35,837; 6.0%), and disseminated intravascular coagulopathy (1433/35,837; 4.0%). In multivariable analysis, both intrapartum cesarean and intended cesarean births were associated with increased odds of ICU admission compared with vaginal birth—adjusted odds ratio (aOR) 1.87 (95% CI, 1.81–1.94) and 1.46 (1.41–1.52), respectively. Additional factors associated with ICU admission included transfusion of ≥4 units of packed red blood cells (aOR 116.3; 95% CI, 110.3–122.7); cardiomyopathy (18.5; 16.7–20.4); preeclampsia with severe features (6.72; 6.48–6.97); pulmonary hypertension (6.53; 5.17–8.25); arrhythmia (3.99; 3.60–4.43); placenta accreta spectrum (3.90; 3.46–4.39); preterm birth (3.55; 3.45–3.66); and chronic renal disease (2.48; 2.24–2.75). In a secondary analysis, SMM occurred in 24,358/2,831,900 (0.9%) patients with comorbidities compared with 4128/1957,773 (0.2%) of patients with no comorbidity present. Additionally, patients with comorbidities without SMM had higher rates of ICU admission across modes of delivery when compared to patients without comorbidities. CONCLUSIONS: There is approximately one ICU admission per 135 delivery hospitalizations in this US database. Intrapartum and intended cesarean births confer higher risks of ICU admission compared with vaginal birth. Among all investigated factors, significant transfusion requirements were most strongly associated with ICU admission. These findings highlight the importance of early recognition and preparation for potential morbidity associated with intrapartum cesarean birth and underscore the need for proactive obstetric critical care planning.

Introduction: Traumatic brain injury (TBI) is a complex condition that may lead to alterations in cerebral hemodynamics. Impairment of cerebral autoregulatory mechanisms, as well as autonomic dysfunction, has been associated with worse patient outcomes after TBI. Aims: The purpose of this narrative review is to synthesize current evidence on impaired cerebral autoregulation, autonomic dysfunction, and their relationship with intracranial pressure in TBI. Findings: Initial studies examining waveform data have found that impaired cerebral autoregulation and autonomic dysfunction are present in a high proportion of patients after TBI. These are distinct but closely related phenomena, with current evidence suggesting a bidirectional relationship. Conclusions: Impaired cerebral autoregulation and autonomic dysfunction are closely associated. The intersection of these mechanisms is a potential target for intervention to improve patient outcomes after TBI. Additional research is needed to further characterize this relationship.

Introduction: Patients with an intracerebral hemorrhage (ICH) have been shown to have a high incidence of acute respiratory distress syndrome (ARDS). We aimed to determine the incidence of ARDS following ICH in the era of lung-protective ventilation. We also examined risk factors associated with ARDS following ICH. Materials and Methods: A retrospective cohort study of adults admitted to a single health system’s intensive care units with acute, spontaneous ICH from 1 March 2015 to 28 February 2018, using univariate and multivariable logistic regression models to evaluate the associations of patient characteristics with the diagnosis of ARDS. Results: In total, 269 patients were included, with 155 patients requiring invasive mechanical ventilation. The overall incidence of ARDS was 6.7% (18/269), and the incidence in intubated patients was 10% (16/155), as the median time of ventilation with >8 cc/mL of ideal body weight was low. For the entire ICH population, severity of hypoxemia on initial arterial blood gas (ABG; Odds Ratio [OR] per 10 mmHg 0.855 [95% Confidence Interval [CI] 0.74–0.987]) and total minutes of mechanical ventilation (OR per 60 min 1.018 [95% CI 1.007–1.029]) were both associated with the diagnosis of ARDS. In intubated patients, ventilation, younger age (OR per 10 years 0.655 [95% CI 0.431–0.997]), and total minutes of mechanical ventilation (OR per 60 min 1.028 [95% CI 1.006–1.049] increased the odds of developing ARDS. Conclusions: ARDS was found to be significantly lower in the present cohort of ICH patients when compared to prior studies, with younger age and hypoxemia associated with an increasing risk.

Intracerebral hemorrhage (ICH) remains the least treatable form of stroke, with inflammation implicated as a major pathophysiological feature. Hence, this study sought to associate serum proteins and hormones associated with inflammation and ICH outcomes. Patients presenting to Duke University Hospital with computed tomography-verified spontaneous, supratentorial, non-traumatic ICH within 24 h of symptom onset were prospectively recruited. In this pilot study, equal numbers of men and women and Black and White individuals were included and matched by a 6-month modified Rankin Score (mRS). The primary analyses were the correlation of L-ratios (LR; Log2(Day 2/Day 1 concentrations)) of serum gonadal hormones and neuroinflammatory proteins with mRS > 3 at 6 months. A total of 40 participants were included in this pilot study. LRs were significantly higher for C-reactive protein (CRP; p = 0.013) and lower for interleukin-6 (IL-6; p = 0.026) and surfactant protein-D (p = 0.036) in participants with unfavorable outcomes at 6 months after ICH. Further, higher CRP (p = 0.02) and lower IL-6 (p = 0.035) and surfactant protein-D (p = 0.041) LRs were associated with mRS > 3 at 6 months after ICH in multiple logistic regression analyses, adjusted for race and sex. The relationship amongst gonadal hormones, neuroinflammatory proteins, and ICH outcome is complex. In this pilot study, unfavorable outcomes after ICH may have been associated with selected inflammatory biomarkers. A larger scale study is warranted to define interactions between hormones, proteins, and their effects on ICH outcomes.

Objective: To evaluate the implementation of a blood culture algorithm in a mixed medical-surgical ICU at a community hospital, and examine the association with blood culture utilization rate and patient outcomes. Design: A quasi-experimental study examining pre- and post-implementation periods. Setting: A 22-bed mixed medical-surgical ICU at a community hospital. Patients: Adult ICU patients were admitted between February 2022 and October 2024, excluding those with neutropenia (Intervention: Introduction of a multidisciplinary-developed blood culture algorithm designed to standardize ordering practices for new clinical events and clearance of bacteremia. Measurements and Main Results: Primary outcomes included blood culture event rates. Secondary outcomes were antibiotic days of therapy, mortality, and readmissions. Interrupted time series analysis using Poisson regression models were used to examine associations between the intervention and clinical outcomes. The intervention reduced blood culture event rates by 39% (IRR 0.61, 95% 0.49, 0.75) without significantly decreasing adverse events such as 90-day death incidence (5.7% vs 7.2%, p-value 0.44) and 30-day hospital readmission (11.0% vs 8.0%, p-value 0.11). Inappropriate blood culture rates also decreased. Conclusions: Implementation of a blood culture algorithm in a community ICU setting was associated with reduced blood culture utilization without compromising patient safety. The intervention may substantially reduce unnecessary blood cultures, addressing a key gap in diagnostic stewardship in non-academic settings.

IMPORTANCE: The influence of disease-causing pathogen on acute kidney injury (AKI) in septic patients is poorly understood. OBJECTIVES: We examined the association of microbial pathogen with AKI among patients with community-onset sepsis. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study. Patient data were acquired from the nationwide multicenter PINC AI Healthcare Database (2016–2020). Participants included adult patients with Centers for Disease Control and Prevention-defined community-onset sepsis. MAIN OUTCOMES AND MEASURES: The primary exposure was pathogen type identified by culture growth. Microbial cultures from any site were included. The primary endpoint was development of AKI within 7 days of admission using the Kidney Disease: Improving Global Outcomes serum creatinine criteria. We used multilevel logistic regression to examine the association between pathogen type and AKI. Escherichia coli-positive cultures were used as the reference category. RESULTS: We included 119,733 patients with community-onset sepsis. The median age was 67 years, 33.3% were mechanically ventilated, 36.1% received vasopressors, and hospital mortality was 13.1%. Forty-two thousand twenty-seven patients (35.1%) developed stage 1 AKI, 22,979 (19.2%) developed stage 2 AKI, and 25,073 (20.9%) developed stage 3 AKI. Relative to patients with E. coli infection (odds ratio [OR], 1.0), Proteus species (OR, 1.26; 95% CI, 1.06–1.50), and Streptococcus species (OR, 1.24; 95% CI, 1.10–1.41) were associated with increased odds of AKI. Meanwhile, Pseudomonas aeruginosa (OR, 0.56; 95% CI, 0.49–0.64) and Serratia species (OR, 0.70; 95% CI, 0.52–0.94) were associated with decreased odds of AKI. CONCLUSIONS AND RELEVANCE: The causative pathogen in patients with sepsis may influence the development of AKI. Further mechanistic and clinical research is needed to confirm these findings and to explore how different pathogens may affect AKI risk in critically ill patients.

Background/Objectives: Traumatic brain injury (TBI) is a complex condition and a leading cause of injury-related disability and death, with significant impacts on patient outcomes. Extracranial organ involvement plays a critical role in the outcome of patients following TBI. Method: This review aims to provide a comprehensive overview of the pathophysiology, clinical presentation, and challenges in diagnosing patients with autonomic dysfunction after TBI. The databases used in this review include PubMed/MEDLINE, Cochrane Central Register, and Scopus. Results: Of 172 articles identified for screening, 98 were ultimately included in the review. Conclusion: This review summarized the current evidence on the pathophysiology, clinical presentation, and diagnosis of early autonomic dysfunction. It also emphasizes the effects of autonomic dysfunction on end-organ damage. These insights aim to guide clinicians and researchers toward improving the care for and understanding of autonomic dysfunction in TBI patients, while underscoring the need for further research in this area.

Background: Various social determinants of health have been established as significant risk factors for COVID-19 transmission, prevalence, incidence, and mortality. Area deprivation index (ADI, a composite score made up of educational, housing, and poverty markers) is an accepted multidimensional social determinants of health measure. Little is known about how structural social determinants of health before hospitalization, including ADI, may affect mortality related to COVID-19 in critically ill patients. Objectives: To examine the association of ADI with intensive care unit (ICU) mortality in patients with COVID-19 and compare its predictive power with that of clinical factors. Methods: This was a retrospective cohort study of critically ill adults with COVID-19 in 3 hospitals within a single health system. Multivariable logistic regression models (adjusted for demographic and clinical variables) were used to examine the association of ADI with ICU mortality. Results: Data from 1784 patients hospitalized from 2020 to 2022 were analyzed. In multivariable models, no association was found between national ADI and ICU mortality. Notable factors associated with ICU mortality included treatment year, age, van Walraven weighted score, invasive mechanical ventilation, and body mass index. Conclusion: In this study, clinical factors were more predictive of mortality than ADI and other social determinants of health. The influence of ADI may be most relevant before hospital admission. These findings could serve as a foundation for shaping targeted public health strategies and hospital interventions, enhancing care delivery, and potentially contributing to better outcomes in future pandemics.