Adith Sekaran, MD

Background: Fevers (like other vital sign abnormalities) often trigger interventions from providers. However, hypothermia (temperature under 36° C) may also be associated with higher mortality.

Study design: Retrospective subanalysis of a previous study (Focused Outcome Research on Emergency Care for Acute respiratory distress syndrome, Sepsis and Trauma [FORECAST]).

Setting: Adult patients with severe sepsis based on Sepsis-2 in 59 ICUs in Japan.

Synopsis: The study involved 1,143 patients admitted to ICUs with severe sepsis (62.6% with septic shock). The median age was 73 years with a median APACHE II and SOFA scores of 22 and 9, respectively. Core temperatures were measured on admission to ICU with patients categorized into three arms: temperature under 36° C (hypothermic), temperature 36°-38° C, and febrile patients with temperature greater than 38° C. Of studied patients, 11.1% were hypothermic on presentation. These patients were older, sicker (higher APACHE/SOFA scores), had lower body mass indexes, and had higher prevalence of septic shock than did the febrile patients. Hypothermic patients fared worse in every clinical outcome measured – in-hospital mortality, 28-day mortality, ventilator-free days, ICU-free days, length of hospital stay, and likelihood of discharge home. The odds ratio of in-hospital mortality for hypothermic patients, compared with reference febrile patients, was 1.76 (95% CI, 1.14-2.73). Patients with hypothermia were also significantly less likely to receive the entire 3-hour resuscitation bundle, including broad-spectrum antibiotics (56.3%) versus 60.8% of patients with temperature 36-38° C and 71.1% for febrile group (P = .003).

Bottom line: Hypothermia in patients with severe sepsis is associated with a significantly higher disease severity, mortality risk, and lower implementation of sepsis bundles. More emphasis on earlier identification and treatment of this specific patient population appears needed.

Citation: Kushimoto S et al. Impact of body temperature abnormalities on the implementation of sepsis bundles and outcomes in patients with severe sepsis: A retrospective sub-analysis of the focused outcome of research of emergency care for acute respiratory distress syndrome, sepsis and trauma study. Crit Care Med. 2019 May;47(5):691-9.

Dr. Sekaran is a hospitalist at Massachusetts General Hospital.

Background: Fevers (like other vital sign abnormalities) often trigger interventions from providers. However, hypothermia (temperature under 36° C) may also be associated with higher mortality.

Study design: Retrospective subanalysis of a previous study (Focused Outcome Research on Emergency Care for Acute respiratory distress syndrome, Sepsis and Trauma [FORECAST]).

Setting: Adult patients with severe sepsis based on Sepsis-2 in 59 ICUs in Japan.

Synopsis: The study involved 1,143 patients admitted to ICUs with severe sepsis (62.6% with septic shock). The median age was 73 years with a median APACHE II and SOFA scores of 22 and 9, respectively. Core temperatures were measured on admission to ICU with patients categorized into three arms: temperature under 36° C (hypothermic), temperature 36°-38° C, and febrile patients with temperature greater than 38° C. Of studied patients, 11.1% were hypothermic on presentation. These patients were older, sicker (higher APACHE/SOFA scores), had lower body mass indexes, and had higher prevalence of septic shock than did the febrile patients. Hypothermic patients fared worse in every clinical outcome measured – in-hospital mortality, 28-day mortality, ventilator-free days, ICU-free days, length of hospital stay, and likelihood of discharge home. The odds ratio of in-hospital mortality for hypothermic patients, compared with reference febrile patients, was 1.76 (95% CI, 1.14-2.73). Patients with hypothermia were also significantly less likely to receive the entire 3-hour resuscitation bundle, including broad-spectrum antibiotics (56.3%) versus 60.8% of patients with temperature 36-38° C and 71.1% for febrile group (P = .003).

Bottom line: Hypothermia in patients with severe sepsis is associated with a significantly higher disease severity, mortality risk, and lower implementation of sepsis bundles. More emphasis on earlier identification and treatment of this specific patient population appears needed.

Citation: Kushimoto S et al. Impact of body temperature abnormalities on the implementation of sepsis bundles and outcomes in patients with severe sepsis: A retrospective sub-analysis of the focused outcome of research of emergency care for acute respiratory distress syndrome, sepsis and trauma study. Crit Care Med. 2019 May;47(5):691-9.

Dr. Sekaran is a hospitalist at Massachusetts General Hospital.

Background: Fevers (like other vital sign abnormalities) often trigger interventions from providers. However, hypothermia (temperature under 36° C) may also be associated with higher mortality.

Study design: Retrospective subanalysis of a previous study (Focused Outcome Research on Emergency Care for Acute respiratory distress syndrome, Sepsis and Trauma [FORECAST]).

Setting: Adult patients with severe sepsis based on Sepsis-2 in 59 ICUs in Japan.

Synopsis: The study involved 1,143 patients admitted to ICUs with severe sepsis (62.6% with septic shock). The median age was 73 years with a median APACHE II and SOFA scores of 22 and 9, respectively. Core temperatures were measured on admission to ICU with patients categorized into three arms: temperature under 36° C (hypothermic), temperature 36°-38° C, and febrile patients with temperature greater than 38° C. Of studied patients, 11.1% were hypothermic on presentation. These patients were older, sicker (higher APACHE/SOFA scores), had lower body mass indexes, and had higher prevalence of septic shock than did the febrile patients. Hypothermic patients fared worse in every clinical outcome measured – in-hospital mortality, 28-day mortality, ventilator-free days, ICU-free days, length of hospital stay, and likelihood of discharge home. The odds ratio of in-hospital mortality for hypothermic patients, compared with reference febrile patients, was 1.76 (95% CI, 1.14-2.73). Patients with hypothermia were also significantly less likely to receive the entire 3-hour resuscitation bundle, including broad-spectrum antibiotics (56.3%) versus 60.8% of patients with temperature 36-38° C and 71.1% for febrile group (P = .003).

Bottom line: Hypothermia in patients with severe sepsis is associated with a significantly higher disease severity, mortality risk, and lower implementation of sepsis bundles. More emphasis on earlier identification and treatment of this specific patient population appears needed.

Citation: Kushimoto S et al. Impact of body temperature abnormalities on the implementation of sepsis bundles and outcomes in patients with severe sepsis: A retrospective sub-analysis of the focused outcome of research of emergency care for acute respiratory distress syndrome, sepsis and trauma study. Crit Care Med. 2019 May;47(5):691-9.

Dr. Sekaran is a hospitalist at Massachusetts General Hospital.

Background: Critically ill patients have a high risk of venous thromboembolism (VTE) during their hospitalizations, and it is standard of care to prophylax against this complication by either pharmacological or mechanical means.

Study design: Prospective, randomized, controlled trial (Pneumatic Compression for Preventing Venous Thromboembolism [PREVENT]).

Setting: Multicenter study involving 20 ICUs in Saudi Arabia, Canada, Australia, and India.

Synopsis: The study monitored 2,003 medical and surgical ICU patients on pharmacological thromboprophylaxis (unfractionated or low-molecular-weight heparin) after receiving either adjunctive pneumatic compression or pharmacological thromboprophylaxis alone. The primary outcome was incident (newly diagnosed) proximal lower-limb DVT detected by twice-weekly venous ultrasonography until ICU discharge, death, attainment of full mobility, or trial day 28, whichever occurred first. Key secondary outcomes included the occurrence of any lower-limb DVTs and pulmonary embolism. Intermittent pneumatic compression was used a median of 22 hours daily. The incidence of proximal lower limb DVT did not differ in the two groups and was relatively low (4%) in the control group. There were also no differences in the groups in the composite VTE, death at 28 days, or any other secondary outcomes studied.

The main limitation of the study was the low incidence of primary outcomes in the control group, which reduced the power of the study.

Bottom line: Based on the PREVENT trial, adjunctive intermittent pneumatic compression provided no additional benefit to pharmacological prophylaxis in the prevention of incident proximal lower-limb DVT.

Citation: Arabi Y et al. Adjunctive intermittent pneumatic compression for venous thromboprophylaxis. N Eng J Med. 2019 Feb 18. doi: 10.1056/NEJMoa1816150.

Dr. Sekaran is a hospitalist at Massachusetts General Hospital.

Background: Critically ill patients have a high risk of venous thromboembolism (VTE) during their hospitalizations, and it is standard of care to prophylax against this complication by either pharmacological or mechanical means.

Study design: Prospective, randomized, controlled trial (Pneumatic Compression for Preventing Venous Thromboembolism [PREVENT]).

Setting: Multicenter study involving 20 ICUs in Saudi Arabia, Canada, Australia, and India.

Synopsis: The study monitored 2,003 medical and surgical ICU patients on pharmacological thromboprophylaxis (unfractionated or low-molecular-weight heparin) after receiving either adjunctive pneumatic compression or pharmacological thromboprophylaxis alone. The primary outcome was incident (newly diagnosed) proximal lower-limb DVT detected by twice-weekly venous ultrasonography until ICU discharge, death, attainment of full mobility, or trial day 28, whichever occurred first. Key secondary outcomes included the occurrence of any lower-limb DVTs and pulmonary embolism. Intermittent pneumatic compression was used a median of 22 hours daily. The incidence of proximal lower limb DVT did not differ in the two groups and was relatively low (4%) in the control group. There were also no differences in the groups in the composite VTE, death at 28 days, or any other secondary outcomes studied.

The main limitation of the study was the low incidence of primary outcomes in the control group, which reduced the power of the study.

Bottom line: Based on the PREVENT trial, adjunctive intermittent pneumatic compression provided no additional benefit to pharmacological prophylaxis in the prevention of incident proximal lower-limb DVT.

Citation: Arabi Y et al. Adjunctive intermittent pneumatic compression for venous thromboprophylaxis. N Eng J Med. 2019 Feb 18. doi: 10.1056/NEJMoa1816150.

Dr. Sekaran is a hospitalist at Massachusetts General Hospital.

Background: Critically ill patients have a high risk of venous thromboembolism (VTE) during their hospitalizations, and it is standard of care to prophylax against this complication by either pharmacological or mechanical means.

Study design: Prospective, randomized, controlled trial (Pneumatic Compression for Preventing Venous Thromboembolism [PREVENT]).

Setting: Multicenter study involving 20 ICUs in Saudi Arabia, Canada, Australia, and India.

Synopsis: The study monitored 2,003 medical and surgical ICU patients on pharmacological thromboprophylaxis (unfractionated or low-molecular-weight heparin) after receiving either adjunctive pneumatic compression or pharmacological thromboprophylaxis alone. The primary outcome was incident (newly diagnosed) proximal lower-limb DVT detected by twice-weekly venous ultrasonography until ICU discharge, death, attainment of full mobility, or trial day 28, whichever occurred first. Key secondary outcomes included the occurrence of any lower-limb DVTs and pulmonary embolism. Intermittent pneumatic compression was used a median of 22 hours daily. The incidence of proximal lower limb DVT did not differ in the two groups and was relatively low (4%) in the control group. There were also no differences in the groups in the composite VTE, death at 28 days, or any other secondary outcomes studied.

The main limitation of the study was the low incidence of primary outcomes in the control group, which reduced the power of the study.

Bottom line: Based on the PREVENT trial, adjunctive intermittent pneumatic compression provided no additional benefit to pharmacological prophylaxis in the prevention of incident proximal lower-limb DVT.

Citation: Arabi Y et al. Adjunctive intermittent pneumatic compression for venous thromboprophylaxis. N Eng J Med. 2019 Feb 18. doi: 10.1056/NEJMoa1816150.

Dr. Sekaran is a hospitalist at Massachusetts General Hospital.