Systemic rheumatic diseases (SRD) affect multiple organs and are, by their very nature, heterogeneous disorders. Patients diagnosed with SRD often present for critical care management. The most common causes of intensive care unit (ICU) admission in this patient population are SRD exacerbation, treatment-related infections or toxicities.
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Guillaume Dumas, MD, a critical care physician at the Saint-Louis Teaching Hospital in Paris, France, and colleagues designed a study to characterize the use of intensive care by patients with SRD. In May, they published the results of their retrospective observational study online in the journal Chest. The study’s primary endpoint was mortality, and the secondary outcome was SRD exacerbation. The investigators examined a large cohort of 363 critically ill patients with SRD who were admitted 381 times to 10 centers between Jan. 1, 2009, and Jan. 1, 2013. Data collected from the patients’ charts showed their median age to be 59 years (range = 42–70 years), and a median of three (range = 1–4) organs involved in disease. The most common SRD was systemic lupus erythematosus. SRD was newly diagnosed in approximately 10% of the cases. Patients were considered to have been admitted directly to the ICU if they were admitted from the emergency department or emergency ambulance service.
At ICU discharge, patients were retrospectively classified by the ICU physician for the cause of ICU admittance. Approximately one-third of patients were admitted to the ICU because of infection and one-third because of SRD exacerbation. In both cases, the lung was the chief target of disease. Moreover, the researchers found that acute respiratory failure was one of the most prevalent symptoms in patients admitted to the ICU, followed by shock, acute kidney injury and sepsis. Community-acquired infections and non-opportunistic infections were more common than hospital-acquired or opportunistic infections. Patients who were newly diagnosed with SRD during their ICU stay were most often placed in the ICU as a result of SRD exacerbation. The most common causes of readmissions were infection and SRD exacerbation.
Upon ICU admittance, patients had a mean Sequential Organ Failure Assessment (SOFA) score of 5. Approximately half the patients required mechanical ventilators, one-third required vasopressors, and one-third required renal replacement therapy. In 7.4% of the cases, urgent surgery (e.g., cardiac, gastrointestinal or neurological/soft tissue) was required. Approximately one-third of patients had immunosuppressive treatment initiated in the ICU. The median length of stay in the ICU was six days (range = 3–12 days).
The cohort had an overall crude mortality rate of 21%. Factors associated with mortality included shock, SOFA score on Day 1 and direct admission. Comorbidities and specific SRD characteristics were not associated with survival. The investigators found that direct admission to the ICU was, however, associated with significantly reduced mortality, and the authors concluded their paper by suggesting that patients with SRD may have improved outcomes if they are admitted directly to the ICU.
Lara C. Pullen, PhD, is a medical writer based in the Chicago area.
- Dumas G, Géri G, Montlahuc C, et al. Outcomes in critically ill patients with systemic rheumatic disease: A multicenter study. Chest. 21 May 2015. doi:10.1378/chest.14-3098