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KEY POINTS

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KEY POINTS

  1. ICU mortality can be as high as 55% and can reach 79% in the systemic lupus erythematous (SLE) population.

  2. Severe sepsis and septic shock represent in fact the primary reason for ICU admission in about half of the rheumatologic patients.

  3. The clinical manifestations of autoimmune diseases itself can be very heterogeneous and virtually all organ systems can be affected.

  4. Most common adult rheumatologic disease encountered by the intensivist are in order of frequency, according to the most recent literature, SLE, rheumatoid arthritis (RA), systemic vasculitis, and systemic sclerosis (SS).

  5. Conditions associated with airway involvement include RA, granulomatosis with polyangiitis (GPA, former Wegener granulomatosis), relapsing polychondritis and SLE.

  6. Among all the rheumatologic diseases SS seems to have the highest prevalence (80%) of pulmonary involvement.

  7. Rheumatologic patients are at high risk of acute coronary syndromes due to premature atherosclerosis compared to age-match population.

  8. Renal involvement occurs in roughly 30% of the overall rheumatologic patients.

  9. Chronic steroids therapy used in the treatment of numerous rheumatologic conditions increase the risk of adrenal insufficiency in acutely critically ill patients.

  10. No clear prognosticator of in-ICU mortality has been identified as applicable to single patient yet, but intuitively high Apache score, multiorgan failure, comorbidities, advanced age and pancytopenia were all associated with worse outcome.

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INTRODUCTION

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According to the most recent literature, about a third of rheumatologic patients admitted to the hospital will require admission in an intensive care unit (ICU). Their in-ICU mortality can be as high as 55% and can reach 79% in the systemic lupus erythematous (SLE) population. Such a severe life threatening decompensation may be caused by multiorgan system failure related to disease flare or by the complications of immunosuppressive state or therapy, such as infection.1,2,3,4,5,6,7,8,9,10,11,12,13,14

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Severe sepsis and septic shock represent in fact the primary reason for ICU admission in about half of the rheumatologic patients. It is the first cause of mortality in SLE patients, therefore, it is crucial to recognize and aggressively treat any infectious process before attempting to achieve diseases control with immunosuppressive therapy.

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An increasing number of patients will be recognized ex novo to have a rheumatologic condition during their ICU stay. Such diagnosis can be quite challenging for the intensivist and usually require a multidisciplinary approach.

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Few diagnostic tests, that is, autoantibodies, are confirmatory and when negative do not rule out the disease if clinical criteria are met. On the other end of the spectrum, positive autoantibodies can be found in healthy individuals and in extrarheumatologic conditions (Table 46–1). The clinical manifestations of autoimmune diseases itself can be very heterogeneous and virtually all organ systems can be affected.

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Table Graphic Jump Location
Table 46–1Autoantibodies and associated disorders.

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