Journal of Critical Care

Editor's introduction: Patient care and safety

Philip D. Lumb — 2010-06-01

In this issue of the Journal of Critical Care (JCC), Peter Brindley argues that medical “crashes” deserve more rigorous attention, analysis, and strategies for prevention than have been provided previously. Analysis of error presupposes an understanding of its morphology, provenance, and psychology, areas in which the medical profession is, regrettably, lacking. It is apparent that medicine is the ultimate team sport, requiring ever-increasing performance from disparate individuals involved in an intricate and complex series of actions that increasingly are interdependent and require flawless execution to ensure desired outcomes. System failure in a small area may result in an inappropriate or failed administration of a scheduled medication or treatment that has negative consequence. The concept of the “Swiss cheese” alignment permitting adverse outcomes has been discussed for many years, and the importance of interpersonal and communication skills resonates in the form of a “core competence” in graduate medical education. Yet the inability of medical professionals to reintroduce themselves to one another before embarking on a complex procedure is the norm rather than the exception, despite administrative exhortation and checklist preparation to the contrary. There is little doubt that the individual practitioner cannot survive in isolation; and recent GE advertising during the Olympic Games suggests that an individual patient's care becomes synonymous with an integrated and team-focused effort that does not eliminate the final physician transfer and responsibility, “Thank you, I've got it now.”

Discordance in interpretation of chest radiographs between pediatric intensivists and a radiologist: Impact on patient management

2009-08-17

Abstract: Purpose: When radiologists are not available, chest radiographs (CXRs) of pediatric intensive care unit (PICU) patients are commonly interpreted by pediatric intensivists. We prospectively investigated the frequency of errors in CXR interpretation by pediatric intensivists and their impact on patient management.Materials and Methods: Chest radiographs of PICU patients were evaluated by 5 pediatric intensivists then by a pediatric radiologist (the “gold standard”). If the interpretation of the radiologist and intensivist differed, an independent intensivist determined whether a management change took place. A pediatric pulmonologist determined how many intensivist interpretations were different from the radiologist's interpretations.Results: Seven hundred twenty-eight radiographic findings were identified by the radiologist in 460 CXRs. There were 33 interpretation errors by the intensivists (4.5% of the findings in 7.1% of the CXRs). Only 3/33 error corrections (0.45% of the findings in 0.7% of the CXRs) resulted in change in patient management.Conclusions: Errors in interpretation of CXRs by pediatric intensivists were common but less than that in other series, probably because of education of the pediatric intensivists through daily rounds with the radiologist. Although interpretation errors that affected patient management were rare, their clinical importance supports the growing practice of 24/7 remote radiograph reading by radiologists.

Hospitalist bed management effecting throughput from the emergency department to the intensive care unit

Eric Howell, Edward Bessman, Robert Marshall, Scott Wright — 2009-10-14

Abstract: Rationale: Emergency department (ED) patients in need of an intensive care unit (ICU) admission are very sick. Reducing the length of time to get these patients into ICU beds is associated with improved outcomes.Objective: To reduce the ED length of stay for patients requiring admission to the medical ICU or coronary care unit through the implementation of the “active bed management” (ABM) intervention.Methods: A pre-post study design compared data from November 2006 to February 2007 with those from those same months in the prior year at Johns Hopkins Bayview Medical Center in Baltimore. The ABM intervention was carried out by hospitalist physicians and involved: (i) making triage decisions for patients to be admitted and facilitating their transfer from ED to the appropriate care setting and (ii) having proactive management of Department of Medicine resources, which included twice-daily ICU bed management rounds and regular visits to the ED to assess flow.Measurement: Throughput time for patients presenting to the ED requiring ICU admission was analyzed.Main Results: The ED census was higher during the intervention period as compared with the control period, 17 573 versus 16 148 patients. Throughput from ED to coronary care unit and medical ICU beds was reduced by 99 (±14) minutes (from 353 minutes in the control period to 254 minutes in the 4 months after the initiation of ABM, P < .0001). Staffing, length of stay, case mix index, ICU transfer rates, and ICU death rates were stable across the 2 periods, all P = not significant.Conclusion: Conscientious management of hospital beds, in this case by hospitalist physicians providing ABM, can have a positive and substantial impact on the ED throughput of critically ill patients admitted to ICU beds. This efficiency is likely to positively have impacted on patient satisfaction and safety.

Mortality reduction after implementing a clinical practice guidelines–based management protocol for severe traumatic brain injury

2009-07-10

Abstract: Introduction: The objective of this study was to examine the effect of implementing a clinical practice guidelines–based management protocol on the outcome of patients with severe traumatic brain injury (TBI).Methods: We carried out a pre-post guideline implementation study using previously collected data in the Intensive Care Unit (ICU). All patients older than 12 years with severe TBI, defined as a Glasgow Coma Scale score of 8 or less, from March 1999 to January 2001 (control group) and from February 2001 to December 2006 (protocol group) were identified and included in this study. Patients in the protocol group were managed using a clinical practice guidelines–based management protocol, derived from the guidelines published by the Brain Trauma Foundation. Primary outcome was hospital mortality, whereas the secondary outcome was ICU mortality. To assess whether the ICU protocol might have led to an increase in the number of surviving patients with severe disability, we examined the association of the protocol use and the need for tracheostomies, mechanical ventilation duration, and ICU and hospital length of stay (LOS) among survivors.Results: During the study period, a total of 434 patients met the inclusion criteria. After adjustment for several prognostic factors, the use of protocol was independently associated with a significant reduction in hospital and ICU mortality (odds ratio, 0.45; 95% confidence interval, 0.24-0.86; and odds ratio, 0.47; 95% confidence interval, 0.23-0.96, respectively). The use of the protocol was not associated with an increase in the need for tracheostomies, mechanical ventilation duration, ICU LOS, and hospital LOS.Conclusion: The protocol implementation was associated with a reduction in hospital and ICU mortality. This improvement was not associated with an increase in the frequency of tracheostomies and in ICU or hospital LOS, suggesting that the improved survival was not associated with the increased number of surviving patients with severe disability and that the functional status might have also improved.

The effects of critical care outreach services before and after critical care: A matched-cohort analysis

David A. Harrison, Haiyan Gao, Catherine A. Welch, Kathryn M. Rowan — 2010-06-01

Abstract: Purpose: The purpose of the study was to evaluate the effect of visits from critical care outreach services (CCOS) before admission to and following discharge from critical care.Materials and Methods: A cohort study was performed in 52 acute hospitals in England. A total of 23 234 patients received CCOS visits; 10 404 (45%) were admitted to a critical care unit, and 7078 (68%) were included in the analysis. Patients receiving CCOS visits before (n = 2203) and after (n = 5924) critical care were matched 1:1 to 3 control pools: historical admissions to the same unit before introduction of CCOS, admissions to a unit in a hospital with no CCOS, and contemporary admissions to the same unit not receiving CCOS visits. Matching was based on individual factors and on propensity.Results: The CCOS visits preadmission were not associated with differences in severity of illness, but were associated with lower rates of cardiopulmonary resuscitation, longer prior hospital stay, and longer unit stay. The CCOS visits postdischarge were associated with lower hospital mortality and shorter hospital stay in 2 matches, but not when compared with contemporary admissions to the same unit.Conclusions: Our results suggest a benefit to scheduled follow-up visits of patients discharged from critical care. Results for CCOS before critical care are inconclusive.

A model for identifying patients who may not need intensive care unit admission

Jack E. Zimmerman, Andrew A. Kramer — 2009-08-17

Abstract: Purpose: This study presents a new model for identifying patients who might be too well to benefit from intensive care unit (ICU) care.Patients and Methods: Intensive care unit admissions in 2002 to 2003 were used to develop a model to predict whether patients monitored on day one would receive one or more of 33 subsequent active life-supporting treatments. Accuracy was assessed by testing the model in a subsequent cohort of admissions in 2004 to 2006. We then assessed the frequency of active treatment among monitor patients at a low (<10%) risk for active life-supporting therapy on ICU day 1.Results: Among 28 847 ICU monitor admissions in 2004 to 2006, 3153 patients (11.0%) were predicted to receive active treatment; 3296 (11.5%) actually did. There were 17 720 admissions with a low (<10%) risk for receiving subsequent active life-supporting treatment; 1238 (7.0%) received subsequent active treatment. Hospital mortality (2.5%) and mean ICU stay (1.8 days) suggests that most of these patients did not require ICU care.Conclusions: The outcome for low-risk monitor patients suggest they may be too well to benefit from intensive care. The frequency of low-risk monitor admissions provides a measure of ICU resource use. Improved resource use and reduced costs might be achieved by strategies to provide care for these patients on floors or intermediate care units.

Overuse of stress ulcer prophylaxis in the critical care setting and beyond

Christopher P. Farrell, Giancarlo Mercogliano, Catherine L. Kuntz — 2009-08-17

Abstract: Background: Patients admitted to the intensive care unit (ICU) are susceptible to stress ulcers. We hypothesize that despite recommendations, stress ulcer prophylaxis (SUP) is still overused in the ICU and often continued after resolution of risk factors for bleeding.Methods: We retrospectively studied all ICU admissions for 4 months. Risk factors for stress ulcer bleeding were collected. Patients were categorized into 4 groups: (1) ≥1 major risk factor; (2) ≥1 minor risk factors; (3) no risk factors; (4) preadmission use of acid-suppressive medication. The rate of SUP was calculated by group during ICU stay, on transfer from the ICU, and at hospital discharge.Results: Two hundred ten patients were studied. Of all the ICU admissions, 87.1% received SUP. Among patients with no risk factors, 68.1% were placed on prophylaxis on ICU admission; 60.4% continued on treatment upon transfer from the ICU; 31.0% were discharged home on an agent without a new indication.Conclusions: Although judicious use of SUP in high-risk patients can decrease the incidence of gastrointestinal bleeding, inappropriate use may increase drug reactions, unnecessary hospital costs, and personal monetary burden. Our findings argue for improvement measures to reduce initial inpatient overuse of SUP and to prompt discontinuation before hospital discharge.

Relevant risk factors affecting time of ventilation during early postoperative period after orthotopic liver transplantation

Qiang Li, Gaiqi Yao, Qinggang Ge, Min Yi, Jing Gao, Zhu Xi — 2009-09-25

Abstract: Purpose: The aim of this study is to examine the relevant factors affecting the duration of mechanical ventilation after orthotopic liver transplantation.Materials and Methods: The 96 patients who underwent liver transplantation were divided into 2 groups according to whether or not the duration of mechanical ventilation after operation was longer than 24 hours. Nineteen variables, including clinical and experimental variables, were analyzed by t test for continuous variables and χ2 test for discrete variables. The variables with significance (P < .05) were then analyzed with stepwise logistic regression.Results: Nine continuous preoperative clinical and experimental variables, including preoperative Child-Pugh stage, time of operation, volume of intraoperative liquid transfusion, volume of intraoperative blood loss, volume of intraoperative blood transfusion, volume of intraoperative urine, time of intraoperative hypotension, postoperative renal failure, and postoperative pulmonary edema revealed significant differences between the 2 groups. Stepwise logistic regression analysis for 9 variables indicated that volume of intraoperative blood loss, volume of intraoperative urine, and postoperative renal failure are relevant independent risk factors.Conclusion: The relevant risks affecting the time of ventilation in patients after orthotopic liver transplantation are multiple. The volume of intraoperative blood loss, volume of intraoperative urine, and postoperative renal failure are independent risk factors.

Risk factors and outcome of acute renal failure in patients with severe acute pancreatitis

Hao Li, Zhaoxin Qian, Zhiling Liu, Xiaoliang Liu, Xiaotong Han, Hong Kang — 2009-09-25

Abstract: Objective: Acute renal failure (ARF) is one of the most common causes of death in patients with severe acute pancreatitis (SAP). Here, we aimed to investigate the risk factors of ARF in patients with SAP, assess the prognosis of patients with SAP and ARF, and seek potential measures to prevent ARF.Method: A cross-sectional study was performed to analyze the data from patients with SAP. Both univariate and multivariate logistic regression analyses were performed, including 15 indices such as age, history of renal disease, Acute Physiology and Chronic Health Evaluation II scores, hypoxemia, abdominal compartment syndrome (ACS), and others. Univariate analysis was also used to compare the prognosis between the groups of patients with SAP with and without ARF.Results: There was a significant difference in age, history of renal disease, Acute Physiology and Chronic Health Evaluation II scores, hypoxemia, and ACS between the groups with and without ARF. Patients with SAP and ARF had significantly longer average length of stay and intensive care unit length of stay and higher infection rate of the pancreas and mortality rate.Conclusion: The significant risk factors for ARF in patients with SAP include history of renal disease, hypoxemia, and ACS. Measures that can prevent ARF include homeostasis maintenance, adequate perfusion of the kidneys, adequate oxygenation, and abdominal decompression to avoid ACS.

Severe respiratory failure due to diffuse alveolar hemorrhage: Clinical characteristics and outcome of intensive care

2009-07-10

Abstract: Background: The aim of this study was to characterize patients and report outcome of diffuse alveolar hemorrhage (DAH) requiring intensive care unit support.Patients and Methods: Thirty-seven patients were identified. Clinical characteristics and outcome were determined by chart review.Results: Eighty-nine percent of patients presented with shortness of breath, 23% with cough, and 3% with hemoptysis. In 9% of patients, a diagnosis of DAH was suspected on admission. Diagnosis was confirmed by finding a progressively hemorrhagic bronchoalveolar lavage fluid in 89% and by a positive iron stain in 11% of patients. Vasculitis was causative in 19%, drug toxicity in 11%, thrombocytopenia in 27%, stem-cell transplantation in 5%, sepsis-associated lung injury in 22%, and unknown mechanisms in 16%. Thirty-two patients were mechanically ventilated, 4 received noninvasive ventilation, and 1 received supplemental oxygen therapy. Overall, 18 (49%) of 37 patients survived the intensive care unit stay. Survival was markedly different between patients with an immunologic/unknown etiology (82%) and patients with thrombocytopenia and/or sepsis (22%).Discussion: Diffuse alveolar hemorrhage should be considered in all patients with persistent pulmonary infiltrates. Both bronchoalveolar lavage fluid and iron stain are mandatory diagnostic means. Patients with an immunologic/idiopathic pathogenetic mechanism have a relatively good prognosis, whereas the outcome in individuals with DAH secondary to cancer therapy or sepsis is poor.

Risk factors and treatment outcome in scuba divers with spinal cord decompression sickness

Emmanuel Gempp, Jean-Eric Blatteau — 2009-08-17

Abstract: Purpose: This study was designed to determine the recompression strategy and the potential risk factors associated with the development of severe diving-related spinal cord decompression sickness (DCS).Material and Methods: Sixty-three injured recreational divers (52 men and 11 women; 46 ± 12 years) presenting with symptoms of spinal involvement were retrospectively included. Diving information, symptom latency after dive completion, and time interval between symptom onset and hyperbaric treatment were studied. The severity of spinal cord DCS was rated numerically for both the acute event and 1-month later. Initial recompression treatment at 2.8 atmosphere absolute (ATA) with 100% oxygen breathing or deeper recompression at 4 atmosphere absolute with nitrogen-oxygen or helium-oxygen breathing mixture was also noted.Results: Twenty-one divers (33%) had incomplete resolution after 1 month. The clinical severity at presentation was the only independent predictor of poor outcome (odd ratio, 2.68; P < .033). Time to treatment did not influence the recovery with a similar median delay (3 hours) between the divers with or without long-term sequelae. Choice of recompression procedure was not also a determinant factor for treatment outcome.Conclusion: The initial clinical course before treatment is a major prognostic factor of spinal cord DCS. Delay to recompression less than 3 hours and use of deep treatment tables did not improve outcome in DCS divers.

High concentrations of resistin in the peripheral blood of patients with acute basal ganglia hemorrhage are associated with poor outcome

Xiao-Qiao Dong, Yue-Yu Hu, Wen-Hua Yu, Zu-Yong Zhang — 2009-11-11

Abstract: Purpose: Resistin increases in peripheral blood of patients with intracerebral hemorrhage (ICH). We sought to evaluate its relation with disease outcome.Materials and Methods: Thirty healthy controls and 86 patients with acute ICH were included. Plasma samples were obtained on admission. Its concentration was measured by enzyme-linked immunosorbent assay.Results: Thirty-two patients (37.2%) died from ICH in a week. The plasma resistin level (24.2 ± 9.7 ng/mL) in patients was significantly higher than that (8.8 ± 2.4 ng/mL) in healthy controls after adjustment by age, sex, hypertension, diabetes mellitus, hyperlipidemia, and body mass index using analysis of covariate (F = 9.507, P = .003).A univariate correlation analysis found Glasgow Coma Scale (GCS) score and ICH volume, but a multivariate linear regression only selected GCS score (t = −4.587, P < .001) to be related to plasma resistin level. On a multivariate logistic regression, plasma resistin level (odds ratio = 1.257, 95% confidence interval = 1.058-1.492, P = .009) was an independent variable predicting 1-week mortality. A receiver operating characteristic curve identified that a plasma resistin level greater than 26.3 ng/mL predicted 1-week mortality of patients with 81.2% sensitivity and 81.5% specificity (P < .001). Areas under curves of GCS score and ICH volume were not statistically significantly larger than that of plasma resistin level (P > .05).Conclusions: Increased resistin level is found after ICH, in association with a poor clinical outcome.

Outcome of patients with injection drug use–associated endocarditis admitted to an intensive care unit

Ghulam Saydain, Jatinder Singh, Bhavinkumar Dalal, Wonsuk Yoo, Donald P. Levine — 2009-11-12

Abstract: Purpose: The purpose of this study was to study the outcome of patients with injection drug use–associated infective endocarditis (IDU-IE) admitted to an intensive care unit (ICU).Material and Methods: A retrospective review of medical records of 33 consecutive patients with IDU-IE admitted to ICU was conducted.Results: Main indications for admission to ICU were as follows: severe sepsis or septic shock (36%), respiratory failure (33%), and neurologic deterioration (18%). Staphylococcus aureus was found in 94% of patients, and 15% had polymicrobial infection. Fifteen (45%) patients had septic emboli to 1 or more organs, including 12 (36%) to lungs and 7 (21%) to central nervous system. In-hospital mortality was 27%, and in univariate analysis, previous history of endocarditis (odds ratio [OR], 11.2; P = .03), respiratory failure (OR, 7; P = .03), neurologic failure (OR, 6.25; P = .03), and high Acute Physiology and Chronic Health Evaluation II (OR, 1.21; P = .016) and Sequential Organ Failure Assessment scores (OR, 1.25; P = .01) increased risk of death. By multivariate logistic regression analysis, previous history of endocarditis and high Acute Physiology and Chronic Health Evaluation II score were independently associated with poor survival.Conclusions: Complicated IDU-IE necessitating admission to ICU is associated with high mortality. In addition to consequences of sepsis, septic embolization to central nervous system and lungs contributes to development of organ failure. Increased severity of illness and prior history of endocarditis are associated with poor outcome.

Rehabilitation therapy and outcomes in acute respiratory failure: An observational pilot project

2009-11-30

Abstract: Purpose: The aim of this study was to describe the frequency, physiologic effects, safety, and patient outcomes associated with traditional rehabilitation therapy in patients who require mechanical ventilation.Materials and Methods: Prospective observational report of consecutive patients ventilated 4 or more days and eligible for rehabilitation in a single medical intensive care unit (ICU) during a 13-week period was conducted.Results: Of the 32 patients who met the inclusion criteria, only 21 (66%) received physician orders for evaluation by rehabilitation services (physical and/or occupational therapy). Fifty rehabilitation treatments were provided to 19 patients on a median of 12% of medical ICU days per patient, with deep sedation and unavailability of rehabilitation staff representing major barriers to treatment. Physiologic changes during rehabilitation therapy were minimal. Joint contractures were frequent in the lower extremities and did not improve during hospitalization. In 53% and 79% of initial ICU assessments, muscle weakness was present in upper and lower extremities, respectively, with a decreased prevalence of 19% and 43% at hospital discharge, respectively. New impairments in physical function were common at hospital discharge.Conclusions: This pilot project illustrated important barriers to providing rehabilitation to mechanically ventilated patients in an ICU and impairments in strength, range of motion, and functional outcomes at hospital discharge.

Hyperglycemia in sepsis is a risk factor for development of type II diabetes

Ivan Gornik, Ana Vujaklija, Edita Lukić, Goran Madžarac, Vladimir Gašparović — 2009-11-16

Abstract: Background: Hyperglycemia is frequent in sepsis, even in patients without diabetes or impaired glucose metabolism. It is a consequence of inflammatory response and stress, so its occurrence is related to severity of illness. However, not all severely ill develop hyperglycemia and some do even in mild disease. We hypothesized the existence of latent disturbance of glucose metabolism that contributes to development of hyperglycemia and that those patients might have increased risk for diabetes.Methods: Patients admitted with sepsis and no history of impaired glucose metabolism were included and divided in the hyperglycemia group (glucose ≥7.8 mmol/L) and normoglycemia group. Severity of sepsis was assessed. Surviving patients without diabetes at discharge were followed-up for 5 years to investigate risk for development of diabetes.Results: Hyperglycemia was related to severity of sepsis. Follow-up was finished for 55 patients with hyperglycemia, of which 8 (15.7%) developed diabetes, and 118 patients with normoglycemia, of which 5 (4.2%) developed diabetes (P = .002). Relative risk for developing type 2 diabetes was 4.29 (95% CI, 1.35-13.64).Conclusion: Patients with hyperglycemia in sepsis who are not diagnosed with diabetes before or during the hospitalization should be considered a population at increased risk for developing diabetes.

Troponin-I as a prognosticator of mortality in severe sepsis patients

2010-02-11

Abstract: Purpose: The purpose of this retrospective study was to evaluate cardiac troponin-I (cTnI) as a 28-day mortality prognosticator and predictor for a drotrecogin alfa (activated) (DrotAA) survival benefit in recombinant human activated Protein C Worldwide Evaluation in Severe Sepsis patients.Methods: Cardiac troponin-I was measured using the Access AccuTnI Troponin I assay (Beckman Coulter, Fullerton, CA). There were 598 patients (305 DrotAA, 293 placebo) with baseline cTnI data (cTnI negative [<0.06 ng/mL], n = 147; cTnI positive [≥0.06 ng/mL], n = 451).Results: Cardiac troponin-I–positive patients were older (mean age, 61 vs 56 years; P = .002), were sicker (mean Acute Physiology and Chronic Health Evaluation II, 26.1 vs 22.3; P < .001), had lower baseline protein C levels (mean level, 49% vs 56%; P = .017), and had higher 28-day mortality (32% vs 14%, P < .0001) than cTnI-negative patients. Elevated cTnI was an independent prognosticator of mortality (odds ratio, 2.020; 95% confidence interval, 1.153-3.541) after adjusting for other significant variables. Breslow-Day interaction test between cTnI levels and treatment was not significant (P = .65).Conclusion: This is the largest severe sepsis study reporting an association between elevated cTnI and higher mortality. Cardiac troponin-I elevation was not predictive of a survival benefit with DrotAA treatment.

Prognostic factors of mortality in patients with community-acquired bloodstream infection with severe sepsis and septic shock

2010-02-11

Abstract: Purpose: The purpose of the study was to determine the independent risk factors on mortality in patients with community-acquired severe sepsis and septic shock.Methods: A single-site prospective cohort study was carried out in a medical-surgical intensive care unit in an academic tertiary care center. One hundred twelve patients with community-acquired bloodstream infection with severe sepsis and septic shock were identified. Clinical, microbiologic, and laboratory parameters were compared between hospital survivors and hospital deaths.Results: One-hundred twelve patients were included. The global mortality rate was 41.9%, 44.5% in septic shock and 34.4% in severe sepsis. One or more comorbidities were present in 66% of patients. The most commonly identified bloodstream pathogens were Escherichia coli (25%) and Staphylococcus aureus (21.4%). The proportion of patients receiving inadequate antimicrobial treatment was 8.9%. By univariate analysis, age, Acute Physiology and Chronic Health Evaluation II score, at least 3 organ dysfunctions, and albumin, but neither microbiologic characteristics nor site of infection, differed significantly between survivors and nonsurvivors. Acute Physiology and Chronic Health Evaluation II (odds ratio, 1.13; 95% confidence interval, 1.06-1.21) and albumin (odds ratio, 0.34; 95% confidence interval, 0.15-0.76) were independent risk factors associated with global mortality in logistic regression analysis.Conclusion: In addition to the severity of illness, hypoalbuminemia was identified as the most important prognostic factor in community-acquired bloodstream infection with severe sepsis and septic shock.

Investigation of critical care unit utilization and mortality in patients infected with Clostridium difficile

James Gasperino, Maya Garala, Hillel W. Cohen, Vladimir Kvetan, Brian Currie — 2009-07-10

Abstract: Background: A nationwide increase in the rate and severity of Clostridium difficile–associated disease may reflect infection with a virulent strain characterized by polymerase chain reaction as ribotype 027 (NAP1/B1).Hypothesis: The high prevalence of ribotype 027 at our institution would allow investigation of the risk of mortality and admission to the intensive care unit (ICU) associated with C difficile infection.Methods: In a retrospective cohort study, we identified 108 patients with positive enzyme-linked immunosorbant assay tests for C difficile toxins over a 6-month period and compared them to 108 patients who were suspected to have C difficile but with negative toxin assays. Proportions of all-cause mortality and ICU admission were compared using χ2, and odds ratios (ORs) were estimated using logistic regression to adjust for potential confounders. Mean log lengths of stay were compared using t test.Results: Comparing patients with C difficile to those without, mortality (20% vs 8%) and ICU admission (32% vs 17%) were significantly higher (P = .02 for both), whereas log length of stay was not (P = .29). Adjusting for potential confounders, the OR for mortality was 6.8 (95% confidence interval, 1.8-25.4; P = .01), whereas for ICU admission, the association was no longer observed (OR, 1.0; 95% confidence interval, 0.4-2.5; P = .97).Conclusion: C difficile infection was associated with increased all-cause mortality. An observed association with ICU admission and C difficile infection was identified through univariate analysis but was not significant in multivariate analysis. Although we did not strain-type isolates for patients infected with C difficile, the institutional prevalence of ribotype 027 C difficile infection was known to be high. These results document a strong association between ribotype 027 C difficile infection and mortality and underscore the need to identify effective C difficile preventive strategies.

The 4Ts scoring system for heparin-induced thrombocytopenia in medical-surgical intensive care unit patients

2010-02-11

Abstract: Background: Heparin-induced thrombocytopenia (HIT) is commonly considered but rarely confirmed in critically ill patients. The 4Ts score (Thrombocytopenia, Timing of thrombocytopenia, Thrombosis, and oTher reason) might identify individual patients at risk of having this disorder.Objective: The aim of the study was to evaluate the value of the 4Ts HIT score in comparison with the serotonin-release assay (SRA) in critically ill patients.Methods: This study describes the combined results of 3 prospective studies enrolling critically ill patients who were investigated for HIT if platelets fell to less than 50 × 109/L or if platelet counts decreased to less than 50% of the value upon intensive care unit admission. We confirmed HIT by a positive platelet SRA. We assigned a 4Ts score blinded to SRA results to all 50 patients investigated for HIT; those with positive SRA results were scored in duplicate.Results: Of 528 patients, 50 (9.5%) were investigated for HIT; 39 (78%) of 50 (64%-88%) of these patients were scored as “low probability” by 4Ts score and none had a positive SRA. Of 49 patients who underwent SRA testing because of thrombocytopenia, only 2 (4.1%; 0.5-14.0) had a positive SRA (1 with a moderate 4Ts score and 1 with a high 4Ts score). Therefore, the overall incidence of HIT confirmed by SRA was 2 (0.4%) of 528 (0.04%-1.4%).Conclusions: Significant thrombocytopenia during heparin administration occurred in 9.5% of critically ill patients, but HIT was confirmed in only 4.1% of those undergoing testing, for an overall incidence of 0.4%. A low 4Ts score occurred in 78% of patients investigated for HIT; none of these patients had a positive SRA. We conclude that HIT is uncommon in critically ill patients and that the 4Ts score is worthy of further evaluation in this patient population.

Revised Acute Physiology and Chronic Health Evaluation score as a predictor of neurosurgery intensive care unit readmission: A case-controlled study

Huan Fang Lee, Shu-Ching Lin, Chin-Li Lu, Chiao Fang Chen, Miaofen Yen — 2010-03-02

Abstract: Purpose: Patients with neurologic system problems are among the most common patients readmitted to the intensive care unit (ICU). Readmission predictors for neurologic ICU patients have not been established. Previous research suggests that the Revised Acute Physiology and Chronic Health Evaluation (APACHE II) score is one indication of the critical status of ICU-admitted patients; however, the ability of the discharge APACHE II to predict readmission to the ICU requires further study. The purpose of this study was to investigate the ability of the APACHE II scoring system to predict ICU readmission of neurosurgical and ICU patients.Materials and Methods: A retrospective case-controlled comparison study and a review of patient records for all patients admitted to 8 ICUs from January 2003 to June 2005 (N = 753) were conducted. Readmitted neurosurgery ICU patients were matched with 58 randomly selected nonreadmitted patients.Results: Nine variables were significantly different between the readmission and case-controlled group. The APACHE II discharge score was the only significant predictor and was able to predict 18.6% of neurologic ICU readmissions. The risk of ICU readmission increased when the APACHE II score at the time of discharge exceeded 8.5 points.Conclusions: The risk of ICU readmission of neurologic ICU patients can be predicted by determining APACHE II score upon ICU discharge.

Electroencephalogram for prognosis after cardiac arrest

2009-09-25

Abstract: Background: In assessing neurologic prognosis after cardiac arrest (CA), electroencephalogram (EEG) reactivity has not been specifically included with EEG classifications. Most studies have divided recordings into benign and malignant; however, some patterns within these groups may have greater prognostic significance than such broad classifications. We sought to explore reactivity, with broad classifications and subclassifications for their prognostic significance.Methods: All consecutive adults in coma who had an EEG recording performed at least 1 day after CA or during normothermia after a 24-hour mild hypothermia protocol. Outcomes were dichotomous: recovery of awareness or no recovery of awareness during hospitalization.Results: Twenty-nine patients met the inclusion criteria. Of the 18 patients with no reactivity, only 1 recovered awareness; of the 11 patients who demonstrated reactivity, 10 recovered awareness (sensitivity of 90% [95% confidence interval, or CI, 0.57-1] and specificity of 94% [95% CI, 0.7-1]). Of those with benign patterns, 7 recovered awareness and 1 did not; however, those patients demonstrating malignant patterns, 4 recovered and 17 did not (sensitivity of 94% [95% CI, 0.7-1] and a specificity of 63% [95% CI, 0.32-0.88]). None of the 15 patients with suppression or generalized spikes recovered consciousness, and none of these patients demonstrated reactivity.Conclusions: Electroencephalogram reactivity after CA is a relatively favorable EEG feature; generalized suppression or generalized epileptiform activity, without reactivity, is associated with lack of recovery of awareness.

Reduced expression of systemic proinflammatory and myocardial biomarkers after off-pump versus on-pump coronary artery bypass surgery: A prospective randomized study

2009-09-25

Abstract: Background: The effects of off-pump (OffPCABG) and on-pump (OnPCABG) coronary artery bypass grafting (CABG) on myocardium and inflammation are unclear.Objective: Compare the inflammatory response and myocardial injury from patients (pts) submitted to OffPCABG with those that undergo OnPCABG.Methods: Patients with normal left ventricular function were assigned to OffPCABG (n = 40) and OnPCABG (n = 41). Blood samples were collected before and 24 hours after surgery for determination of creatine kinase (CK)–MB (CK-MB), troponin I (cTnI), interleukin (IL)–6, IL-8, P-selectin, intercellular adhesion molecule (ICAM)-1 and C-reactive protein (CRP). Mortalities were registered at 12 months.Results: Preoperative CK-MB and cTnI levels were 3.1 ± 0.6 IU and 1.2 ± 0.5 ng/mL for OffPCABG and 3.0 ± 0.5 IU and 1.0 ± 0.2 ng/mL for OnPCABG pts. Postoperative CK-MB and cTnI levels were 13.9 ± 6.5 IU and 19.0 ± 9.0 ng/mL for OffPCABG vs 29.5 ± 11.0 IU and 31.5 ± 10.1 ng/mL for OnPCABG (P < .01). OffPCABG and OnPCABG pts had similar preoperative IL-6 (10 ± 7 and 9 ± 13 pg/mL), IL-8 (19 ± 7 and 17 ± 7 pg/mL), soluble P-selectin (70 ± 21 and 76 ± 23 pg/mL), soluble ICAM–1 (117 ± 50 and 127 ± 52 ng/mL), and CRP (0.09 ± 0.05 and 0.11 ± 0.07 mg/L). At 24 hours, for OffPCABG and OnPCABG: IL-6 was 37 ± 38* and 42 ± 41*,† g/mL; IL-8, 33 ± 31* and 60 ± 15*,† pg/mL; soluble P-selectin, 99 ± 26 and 172 ± 30*,† pg/mL; soluble ICAM-1, 227 ± 47 and 236 ± 87*,† ng/mL; and CRP, 10 ± 11* and 14 ± 13*,† mg/L (*P < .01 vs preoperation; †P < .01 vs OffPCABG). Increased 24-hour postoperative CRP levels was the only marker to have significant positive correlations with events and occurred just for the OnPCABG pts. In-hospital and 1-year mortalities for the OnPCABG and OffPCABG pts were 2.0% and 2.2% (P = .1) and 2.7% and 4.7% (P = .06), respectively.Conclusions: Thus, the absence of CPB during CABG preserves better the myocardium and attenuates inflammation—however, without improving survival.

Real-time monitoring of heart rate variability in critically ill patients

2009-09-25

Abstract: Purpose: Heart rate variability (HRV) is widely used to evaluate autonomic nervous function; however, real-time monitoring of HRV has rarely been attempted in the intensive care unit (ICU). We report our experience in performing real-time monitoring of HRV in our ICU.Methods: We investigated 10 critically ill patients on total ventilatory support. Heart rate variability analysis was performed using the MemCalc system, which is a noninvasive, real-time analysis system. The low-frequency (LF) component of HRV reflects sympathetic and parasympathetic modulation, whereas the high-frequency (HF) component mainly reflects parasympathetic modulation. The LF/HF ratio represents a measure of sympathetic/parasympathetic balance.Results: The HRV parameters for patients breathing spontaneously after extubation were significantly higher than those for patients on total ventilatory support. These findings suggest that mechanical ventilation under sedation may reduce autonomic nervous function in critically ill patients. In a representative case with septic shock, systolic blood pressure and LF/HF ratio showed a significant increase after intravenous infusion of epinephrine and then the HF component showed a significant increase due to vagal reflex.Conclusions: The MemCalc system is practicable for real-time monitoring of HRV in the ICU. Heart rate variability parameters may offer useful information in the management of critically ill patients.

Role of amplitude-integrated electroencephalography in neonates with cardiovascular compromise

Walid I. El-Naggar, Matthew Keyzers, Patrick J. McNamara — 2009-02-13

Abstract: Background: Neonates with congenital heart disease (CHD) and persistent pulmonary hypertension of the newborn (PPHN) represent conditions with increased risk of abnormal neurologic outcome. The role of aEEG in disorders where cerebral perfusion/oxygenation is affected by cardiac or pulmonary disease is unknown.Objective: The aim of the study was to characterize amplitude-integrated electroencephalography (aEEG) traces in nonasphyxiated neonates with cardiorespiratory compromise secondary to PPHN or CHD.Design/Methods: Three hundred sixty-three aEEG records (June 2004-November 2006) were reviewed to identify neonates with a diagnosis of isolated CHD or PPHN. Clinical course, critical interventions, and neurodiagnostic investigation data were collected. The aEEG traces were reviewed by a single blinded expert and classified according to background activity (normal, moderate, or severely abnormal) and presence of seizures. The frequency of abnormal aEEG in both groups and its relationship to recognized markers of abnormal neurologic outcome (electrophysiology [EP] testing and neuroimaging [ultrasound (USS), computerized tomography, and magnetic resonance imaging] was studied.Results: Thirty neonates (PPHN [n = 20], CHD [n = 10]) were reviewed at a mean gestation of 39.2 ± 1.1 weeks and weight of 3375 ± 565g. Neonates with PPHN had lower Apgar scores at 1-minute (P = .02) and were significantly more likely to require inotropic support (P < .001), inhaled nitric oxide (P = .001), or surfactant (P = .01). An abnormal aEEG was found in 15 (50%) babies, but rates did not differ between CHD (n = 6) and PPHN (n = 9). The rates of abnormal composite neurologic outcome (2/3 of abnormal EP, neuroimaging, or neurologic examination) were significantly higher in neonates with abnormal aEEG. An abnormal magnetic resonance imaging was seen in 4 of 5 neonates with abnormal aEEG.Conclusions: The risk of abnormal aEEG is high in sick neonates with PPHN or complex CHD. Prospective evaluation of the relationship between aEEG recordings in these disorders and acute cardiorespiratory physiology, comprehensive neuroimaging, and long-term patient outcomes is needed.

Etiology of troponin elevation in critically ill patients

2009-09-25

Abstract: Purpose: The aim of this study was to assess the etiology of cardiac troponin elevation among patients admitted to the intensive care unit (ICU) and to examine whether etiology affects mortality and length of stay.Methods: All patients admitted over 2 months underwent screening with troponin measurements and were included if 1 or more measurements were elevated. Two adjudicators retrospectively reviewed patient charts to determine the likely cause of troponin elevation.Results: Of 103 patient admissions, 52 (50.5%) had 1 or more elevated troponin measurements, and 49 (94.2%) had medical charts available for review. Troponin elevation was adjudicated as myocardial infarction (MI) in 53.1% of patients, sepsis in 18.4%, renal failure in 12.2%, and other causes in 16.3%. Overall ICU mortality was 16.0%; 2.0% for patients with no troponin elevation, 23.1% in patients with MI, and 39.1% in patients with troponin elevation not due to MI. Having an elevated troponin level not due to MI was significantly associated with increased hospital mortality compared with having no troponin elevation.Conclusions: The most common cause of troponin elevation among critically ill patients was MI. Patients with elevated troponin had worse outcomes compared with patients without troponin elevation, and troponin elevation not due to MI was predictive of increased hospital mortality.

Clinical characteristics, and laboratory and echocardiographic findings in takotsubo cardiomyopathy presenting as cardiogenic shock

2010-06-01

Abstract: Purpose: Although takotsubo cardiomyopathy (TTC) has been reported to have an excellent clinical recovery, there are few data regarding clinical, laboratory, and echocardiographic findings in TTC presenting as cardiogenic shock. We aimed to assess the differences in these parameters between TTC presenting with and without cardiogenic shock.Methods: Fifty patients were enrolled from the TTC registry database and divided according to the presence of cardiogenic shock. Sixteen patients presented with cardiogenic shock as initial presentation (S group), and 34 did not (NS group).Results: The S group had a higher prevalence of dyspnea (81% vs 38%, P = .005), pulmonary edema (69% vs 29%, P = .009), and significant reversible mitral regurgitation (44% vs 15%, P = .025) than the NS group. In addition, the S group had significantly higher troponin-I (median, 8.2 vs 1.4 pg/mL; P = .043) and N-terminal prohormone brain natriuretic peptide levels (median, 8831 vs 2348 pg/mL; P = .046). During follow-up (median, 3.1 years), cardiac deaths associated with TTC itself and recurrences of TTC were not noted in both groups.Conclusions: The S group has a higher prevalence of heart failure symptoms, significant reversible mitral regurgitation, and troponin-I and N-terminal prohormone brain natriuretic peptide levels. However, with meticulous therapeutic strategies, prognosis of this syndrome may be excellent irrespective of hemodynamic instability.

Vena caval thromboses

2009-11-16

Abstract: Background: Patients with vena caval (VC) thrombosis have been reported with a variety of clinical presentations, which may create a diagnostic challenge for physicians.Objective: The objective of the study was to evaluate the clinical characteristics of patients with VC thrombosis.Patients and Methods: Files and all imaging methods of consecutive patients with superior or inferior VC thrombosis with or without pulmonary embolism (PE) between January 26, 2001, and May 12, 2006, were retrospectively studied in detail.Results: In our series, VC thromboses within the inferior and superior VC were detected in 28 patients, mostly by combined computed tomographic venography and spiral computed tomographic pulmonary angiography. Nine of these 28 patients (32.1%) had VC thromboses without PE (7 patients with isolated and 2 patients with nonisolated VC thrombosis). Key symptoms and findings in the 9 patients without PE were unexplained dyspnea and tachypnea, respectively.Conclusions: Many patients with VC thrombosis do not have peripheral vein thrombosis. Moreover, nearly one third of patients with VC thrombosis have negative pulmonary angiograms but do have dyspnea and tachypnea.

Hemodynamic effects of recombinant human activated protein C in patients with septic shock

2009-09-25

Abstract: Purpose: The aim of this study is to examine the effects of recombinant human activated protein C (rhAPC) on hemodynamic parameters in patients with septic shock.Methods: This is a retrospective study of 2 university-hospital critical care units. Patients with septic shock with pulmonary artery catheterization or transthoracic thermodilution monitoring were studied. We matched patients with septic shock with at least 2 organ failures (18 treated with rhAPC and 18 controls) on sex, age, sequential organ failure assessment (SOFA), Acute Physiology and Chronic Health Evaluation (APACHE) II, and sepsis etiology. We recorded norepinephrine dose and hemodynamic parameters at baseline and 24, 36, and 48 hours after the real or theoretical start of rhAPC treatment.Results: Mean arterial pressure remained stable in both groups. In rhAPC patients, norepinephrine requirements, initially higher than in controls, were significantly lower at 48 hours, and stroke volume at 24 and 48 hours improved (P < .05).Conclusion: Recombinant human activated protein C use correlated with improved hemodynamic parameters and decreased norepinephrine requirements. The retrospective nature of the study limits the strength of these findings.

Epoetin alfa reduces blood transfusion requirements in patients with intertrochanteric fracture

2009-07-10

Abstract: Purpose: The purpose of this study is to identify the potential benefits or complications from the use of epoetin alfa in patients with intertrochanteric fracture.Materials and Methods: Seventy-nine patients who sustained an intertrochanteric fracture were divided into 2 groups. One group received 10 daily doses of 20 000 IU of epoetin alfa beginning from the day of trauma, whereas the control group received placebo.Results: We found a statistically significant difference in the required units of allogenic blood used between the 2 groups (P = .034). The group that received epoetin alfa also showed an elevation of hematocrit and hemoglobin values, which was statistically significant at the seventh postoperative day (P = .019 and .015, respectively) compared to the control group. No complications were evident during our study.Conclusions: Patients with intertrochanteric fractures seem to benefit from the use of epoetin alfa because it is safe and reduces the need for blood transfusions.

Variables affecting outcomes in critical care trials: Is prone positioning research exempt from these factors?

Carlos L. Alviar, Juan P. Cordova, Aleksandr Korniyenko, Ethan D. Fried — 2010-04-09

An interesting paper that was published by Dr Dellinger and colleagues on December 2008 in the Journal of Critical Care described several factors that influence the design and the interpretation of outcomes in clinical trials intended to test hypothesis in critical care medicine. Accordingly, a recent study comparing the outcomes of intubated patients placed in prone positioning is a good example of the different challenges faced by critical care researchers who have to deal with multiple variables that characterize intensive care settings. Among these, the complexity of the conditions affecting these patients and the variability of the population admitted to the intensive care units (ICUs) play a major role. These authors published a randomized clinical trial studying the use of prone position for 20 hours per day in intubated patients in the intensive care unit . They described how the use of prone position did not result in differences in patient mortality as the primary end point, when compared to supine position. Also, secondary end points such as decrease in the ventilatory requirements and respiratory mechanics improvement were not different, while complication rates were higher in the prone group. The authors based this trial on 2 prior studies supporting the use of prone position. One of them is a post hoc analysis from a prior trial in which patients with respiratory failure were placed in prone position for 6 hours daily . The other was a prospective study that showed a trend toward an increased survival when used for 20 hours per day .

Preventing medical “crashes”: Psychology matters

Peter G. Brindley — 2010-06-01

The commonest reason for commercial aviation to crash is human error . The same is true regarding patient errors in critical care medicine . Comprehensive efforts to reduce errors should therefore incorporate more than just factual or procedural know-how. Physicians, like pilots, should also appreciate the basics of error psychology occur if we are ever to substantially mitigate them.

The effects of methylene blue infusion on gastric tonometry and intestinal fatty acid binding protein levels in septic shock patients

2010-04-09

Abstract: Objective: We prospectively studied the effect of methylene blue (MB) infusion on gastric mucosal metabolism perfusion ratio, assessed by gastric tonometry, and on mucosal cell damage, assessed by urinary levels of intestinal fatty acid binding protein, in septic shock patients.Methods: Methylene blue (MB) infusion (1 mg/kg per hour) during 4 hours in 10 consecutive patients with a proven or suspected bacterial infection and with severe vasodilatory shock, defined as a mean arterial pressure 70 mm Hg or lower for at least 1 hour despite adequate volume resuscitation and norepinephrine infusion at a rate ≥0.2 μg/kg per minute.Results: Methylene blue infusion did not significantly change the P(g-a)CO2 gradient (P = .16). Post hoc analysis of the subgroup of patients with an elevated baseline P(g-a)CO2 gradient, defined as ≥20 mm Hg, showed that the median P(g-a)CO2 gradient (interquartile range [IQR]) decreased from 45 (41-56) mm Hg before infusion to 41 (28-52) at the end of the 4-hour infusion and decreased further to 32 (26-36) mm Hg 2 hours after cessation of MB infusion (P = .012). The median urinary intestinal fatty acid binding protein concentration at baseline was elevated (210 [79-437] pg/μmol creatinine) and did not change significantly after 24 hours (116 [53-601] pg/μmol creatinine, P = .15). The median mean arterial blood pressure (IQR) increased from 70 (69-71) mm Hg at baseline to 77 (67-83) mm Hg after 1 hour (P = .04), the norepinephrine dose did not change significantly. The median (IQR) cardiac index decreased from 4.4 (3.2-5.5) L min-1 m-2 at baseline to 3.6 (3.3-4.7) L min-1 m-2 after 2 h, returning back to baseline values after cessation of MB infusion P = .02).Conclusion: Although MB infusion in patients with septic shock and advanced multi-organ failure increases mean arterial blood pressure and decreases cardiac index, it does not compromise the gastric mucosal perfusion metabolism ratio as indicated by tonometry, and by the release of a mucosal cellular injury marker.

Scoring systems in acute pancreatitis: Which one to use in intensive care units?

Deven Juneja, Palepu B. Gopal, Murthy Ravula — 2010-02-11

Abstract: Purpose: The aim of the study was to assess and compare the efficacy of various scoring systems in predicting the severity and outcome of patients with acute pancreatitis (AP) admitted in intensive care unit (ICU).Methods: Prospective, single institution review of 55 consecutive AP patients admitted in ICU during a 2-year period. Disease severity scores and mortality predictions were calculated using the collected data in the first 48 hours of ICU admission for Ranson and Glasgow scores and in the first 24 hours for other scores.Results: Forty-two patients (76.4%) developed severe pancreatitis. Intensive care unit and 30-day mortality was 18.2% and 27.3%, respectively. Use of mechanical ventilation (MV) was an independent predictor of outcome on multivariate analysis with lack of MV being protective (adjusted odds ratio, 0.003; 95% confidence interval [CI], 0.00001-0.67; P = .04). All scoring systems had comparable accuracy in predicting severity and 30-day mortality, but sequential organ failure assessment (SOFA) score had greater efficacy with its area under curve for predicting severity and 30-day mortality being 0.81 (95% CI, 0.69-0.92) and 0.93 (95% CI, 0.85-0.99), respectively. Sensitivity and specificity (SOFA score, >4) was 76.2% and 69.2%, respectively, for predicting severity, and sensitivity and specificity (SOFA score, >8) was 86.7% and 90%, respectively, for predicting 30-day mortality.Conclusions: Use of MV is an independent predictor of outcome in AP patients admitted to ICU. Although all scoring systems had reliable accuracy in predicting severity and outcome, SOFA score performed better with additional advantages of easy applicability and timely assessment.

Triggers for emergency team activation: A multicenter assessment

2010-03-02

Abstract: Purpose: The purpose of the study was to examine triggers for emergency team activation in hospitals with or without a medical emergency team (MET) system.Materials and Methods: Within a cluster randomized controlled trial examining the effect of introducing a MET system, we recorded the triggers for emergency team activation. We compared the proportion and rate of such triggers in hospitals with or without a MET system and in relation to type of hospital, type of patient ward, and time of day.Results: In control hospitals, the most common trigger for emergency team activation was a decrease in Glasgow Coma Score by 2 or more points (45.6%), whereas in MET hospitals, it was the fact that staff members were “worried” or the call occurred despite the lack of a “specified reason” (39.3%). In particular, MET hospitals were 35 times more likely to make a call because of staff being “worried” about the patient (14.1% vs 0.4%, P < .001). Control hospitals were also significantly more likely to call an emergency team because of a deteriorating respiratory (P = .003) or pulse (P < .001) rate, more calls had at least 3 triggers for activation (20.8% vs 10.2%, P = .036), and the average number of triggers per call was significantly higher (P = .013). Nonmetropolitan hospitals were more likely to call an emergency team because of respiratory rate abnormalities (33.6% vs 23.2%, P = .015). Coronary care unit calls were more likely to be triggered by abnormalities in pulse rate and systolic blood pressure, and more calls occurred during the period from 6:00 am to noon.Conclusions: In MET hospitals, more emergency team calls are triggered because staff members are worried about the patient; and fewer calls have multiple triggers. Type of hospital, type of ward, and time of day also affect the nature and frequency of triggers for emergency team activation.

Managing intensive care units: Make LOVE, not war!

2010-03-02

Abstract: Objective: Describe a program set up in a French intensive care unit (ICU) aimed at improving communication inside the team and communication information given to patients and their relatives; explain how those actions can improve communication inside the ICU and ultimately why it could improve patient's outcome.Design and Methods: Position paper.Intervention: Progressive implementation of multifaceted quality improvement program.Results: The program Leadership, Ownership, Values, and Evaluation (LOVE) was developed over 10 years. It was usually well accepted by the members of the team, patients, and relatives, in particular the 24-hour visiting program that was prospectively evaluated. Information and decisions were shared with the patients or more often with the relatives, who became for some of them really “part of the team.” Additional actions such as participation to some of the simplest cares by the families are under investigation. A prospective evaluation of such programs, although difficult to perform, remains probably necessary.Conclusion: Quality of life within the ICU is based on many factors including a strong and positive leadership, an absolute respect of individuals, and a rigorous evaluation of quality of care, which could influence heavily the quality of life in the ICU for patients, relatives, and health care professionals and facilitate team work. Whether this could really influence outcome remains to be demonstrated.

Extubation versus tracheostomy in withdrawal of treatment—ethical, clinical, and legal perspectives

2009-10-22

Abstract: The provision of life-sustaining ventilation, such as tracheostomy to critically ill patients, is commonly performed. However, the utilization of tracheostomy or extubation after a withdrawal of treatment decision is debated. There is a dearth of practical information available to aid clinical decision making because withdrawal of treatment is a challenging scenario for all concerned. This is further complicated by medicolegal and ethical considerations. Care of the “hopelessly ill” patient should be based on daily evaluation and comfort making it impossible to fit into general algorithms. Although respect for autonomy is important in healthcare, it is limited for patients in an unconscious state. Beneficence remains the basis for withdrawing treatment in futile cases and underpins the “doctrine of double effect.” This article presents a relevant clinical case of hypoxic brain injury where a question of withdrawal of treatment arose and examines the ethical, clinical, and medicolegal considerations inherent in such cases, including beneficence, nonmaleficence, and the “sanctity of life doctrine.” In addition, the considerations of prognosis for recovery, patient autonomy, patient quality of life, and patient family involvement, which are central to decision making, are addressed. The varying legal frameworks that exist internationally regarding treatment withdrawal are also described. Good ethics needs sound facts, and despite the lack of legal foundation in several countries, withdrawal of treatment remains practiced, and the principles described within this article aim to aid clinician decision making during such complex and multifaceted end-of-life decisions.

Effect of head rotation on overlap and relative position of internal jugular vein to carotid artery in infants and children: A study of the anatomy using ultrasonography

Jeong-Yeon Hong, Bon Nyeo Koo, Won Ok Kim, Eunkyeong Choi, Hae Keum Kil — 2010-02-11

Abstract: Purpose: The aim of this study was to evaluate the influence of head rotation on the relative anatomy of internal jugular vein (IJV) and carotid artery (CA) in infants and children.Materials and Methods: Two hundred pediatric patients (26.5 ± 23.3 months old) who were undergoing elective surgery were eligible for this consecutive and prospective study. Using 2-dimensional ultrasound, the amount of overlap and the relative position of the 2 vessels were compared between heads in the neutral position and in 90° of rotation.Results: The mean percentage overlap of CA by IJV in the neutral position increased significantly as the head was rotated to the right (23.3% vs 39.2%) and left (35.3% vs 52.8%). The incidence of lateral positioning of IJV to CA decreased significantly when the head was rotated (40% vs 21% in right, 26.5% vs 10.5% in left). The right IJV is associated with less overlap of the CA than the left, regardless of head position.Conclusions: The head should be kept in as near a neutral position as possible because the overlap increased by head rotation in both sides. In addition, the right IJV should be preferred because of less CA overlap and more lateral positioning than the left.

Effects of polygeline and hydroxyethyl starch solutions on liver functions assessed with LIMON in hypovolemic patients

Mehmet Turan Inal, Dilek Memiş, Beyhan Karamanlıoglu, Necdet Sut — 2009-08-17

Abstract: Background: Hypovolemia is a common clinical entity in critical patients, and adequate volume replacement therapy seems to be essential for maintaining tissue perfusion. However, it is still uncertain which solution is most appropriate for fluid resuscitation.Objective: The aim of this study was to investigate the effects of fluid resuscitation with 3.5% polygeline versus 6% hydroxyethyl starch solutions on hemodynamic functions and liver functions assessed with a noninvasive liver function monitoring system (LIMON) in hypovolemic patients.Design: This study is a prospective randomized clinical trial.Measurements and Results: Thirty hypovolemic patients (intrathoracic blood volume index, <850 mL/m2) were randomized into hydroxyethyl starch (mean molecular weight, 130 000 Da) and polygeline (mean molecular weight, 30 000 Da) groups (15 patients each). Indocyanine green plasma disappearance elimination (ICG-PDR) were conducted concurrently using LIMON. A dose of 0.3 mg/kg ICG was given through a cubital fossa vein as a bolus. For fluid resuscitation, 500 mL of colloid was given to the patients. Repeated hemodynamic and ICG-PDR measurements were done at baseline, after infusion, and then at 30 minutes after infusion.Results: Intrathoracic blood volume index and systolic, diastolic, and mean blood pressures increased significantly after infusion and remained elevated for 30 minutes after infusion, but there was no significant difference between the 2 groups. Indocyanine green plasma disappearance elimination values were similar in both groups with no significant difference between the two.Conclusion: Increasing intrathoracic blood volume index and hemodynamic variables by fluid loading is not associated with a significant change in ICG-PDR.

Severe hypocholesterolemia in surgical patients, sepsis, and critical illness

2009-10-14

Abstract: After surgery, in sepsis and various critical illnesses, factors such as severity of the acute phase response, liver dysfunction, and hemodilution from blood loss have cumulative impacts in decreasing cholesterol; therefore, degree of hypocholesterolemia often reflects severity of illness. The direct correlation between cholesterol and several plasma proteins is mediated by the parallel impact of commonly shared determinants. Cholestasis is associated with a moderation of the degree of hypocholesterolemia. In human sepsis, the poor implications of hypocholesterolemia seem to be aggravated by the simultaneous development of hypertriglyceridemia. Cholesterol and triglyceride levels reflect altered lipoprotein patterns, and the issue is too complex and too poorly understood to be reduced to simple concepts; nevertheless, these simple measurements often represent helpful adjunctive clinical tools.

Soluble triggering receptor expressed on myeloid cells 1 and the diagnosis of sepsis

2009-11-16

Abstract: Purpose: Early diagnosis and assessment of the systemic inflammatory response to infection are difficult with usual markers (fever, leukocytosis, C-reactive protein [CRP]). Triggering receptor expressed on myeloid cells-1 (TREM-1) expression on phagocytes is up-regulated by microbial products. We studied the ability of soluble TREM-1 (sTREM-1) to identify patients with sepsis.Materials and Methods: Plasma samples were obtained on intensive care unit admission from patients with systemic inflammatory response syndrome for sTREM-1 measurement.Results: Soluble TREM-1, CRP concentrations and erythrocyte sedimentation rate (ESR) were higher in the sepsis group (n = 52) than in the non-infectious systemic inflammatory response syndrome group (n = 43; P = .00, .02, and .001, respectively). Soluble TREM-1, CRP concentrations, white blood cell count and ESR were higher in the sepsis group than in the non SIRS group (n = 37; P = .04, .00, .01, and .00, respectively).In a receiver-operating characteristic curve analysis, ESR, CRP and sTREM-1 had an area under the curve larger than 0.65 (P = .00), in distinguishing between septic and non-infectious SIRS patients. CRP, ESR, sTREM-1 had a sensitivity of 60%, 70% and 70% and a specificity of 60%, 69% and, 60% respectively in diagnosing infection in SIRS.Conclusion: C-reactive protein and ESR performed better than sTREM-1 and white blood cell count in diagnosing infection.

Discontinuation of vasopressin before norepinephrine increases the incidence of hypotension in patients recovering from septic shock: A retrospective cohort study

2009-11-20

Abstract: Purpose: There are little data regarding the discontinuation of vasoactive medications in patients recovering from septic shock. We designed this retrospective cohort study to evaluate the incidence of hypotension based on the order of removal of norepinephrine (NE) and vasopressin (AVP) in patients receiving concomitant NE and AVP infusions for the treatment of septic shock.Materials and Methods: Consecutive patients receiving concomitant NE and AVP infusions for septic shock admitted to the intensive care units of a tertiary care academic medical center were evaluated.Results: Of 50 included patients, the first vasoactive medication discontinued was NE in 32 patients and AVP in 18 patients. The groups had similar Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores at shock onset and at the time of discontinuation of the first agent. Five patients who had NE discontinued first (16%) versus 10 patients who had AVP discontinued first (56%) developed hypotension within 24 hours (unadjusted relative risk, 3.6; 95% confidence interval, 1.5-4.5; P = .008). In a multivariate analysis, only discontinuation of AVP first was independently associated with hypotension (adjusted relative risk, 5.9; 95% confidence interval, 1.7-21.0; P = .006).Conclusions: Discontinuation of AVP before NE may lead to a higher incidence of hypotension in patients recovering from septic shock receiving concomitant AVP and NE.

Acetaminophen has limited antipyretic activity in critically ill patients

Rachel S. Greenberg, Hegang Chen, Jeffrey D. Hasday — 2009-09-25

Abstract: Purpose: Fever occurs commonly in the critically ill patients and may adversely affect outcome. Acetaminophen is one of the most commonly used antipyretic agents in the intensive care unit; however, there is little evidence that it is effective in this population. The objective of this study was to analyze the antipyretic activity of acetaminophen in critically ill patients.Materials and Methods: We performed a retrospective study of medical intensive care unit and surgical intensive care unit patients with systemic inflammatory response syndrome and compared the resolution of fever in the presence and absence of acetaminophen treatment by comparing the absolute reduction in body temperature and the rate of cooling over comparable time frames in fevers that were untreated and those treated with acetaminophen.Results: We analyzed 166 febrile episodes (body temperature, >38°C) in 59 patients with systemic inflammatory response syndrome without cancer, neurologic disease, or liver disease. Acetaminophen was administered for 88 of 166 fevers. Febrile episodes in which other antipyretic drugs or external cooling were administered were excluded. The response to acetaminophen was variable, but the absolute temperature reduction was slightly higher (mean, 0.86 versus 0.56°C; P = .0362), and the cooling rate was slightly more rapid (mean, 0.20 versus 0.13°C per hour; P = .0152) in acetaminophen-treated versus untreated fevers. There were no obvious differences between the most and least responsive patients.Conclusions: We conclude that acetaminophen has significant albeit modest antipyretic activity in critically ill patients.

Practice variability in the assessment and treatment of critical illness-related corticosteroid insufficiency

2009-09-25

Abstract: Purpose: Little is known about how published evidence regarding use of steroids in septic shock has been incorporated into clinical practice.Materials and methods: All patients admitted to an intensive care unit at a single, tertiary-care, academic medical center from November 1, 2004, through February 28, 2005, were screened using the hospital's computerized pharmacy database to determine if they had received at least 1 qualifying medication: cosyntropin, fludrocortisone, hydrocortisone, or dopamine, epinephrine, or norepinephrine as a vasopressor infusion.Results: Only 58% (95% confidence interval, 47%-69%) of the 81 patients who met criteria for vasopressor-dependent septic shock (VDSS) were evaluated for critical illness-related corticosteroid insufficiency. Forty-seven percent of the 81 patients who met the criteria for VDSS and 49% of the 47 patients who did not meet the criteria for VDSS were treated with corticosteroids. Nearly all (85%; 95% confidence interval, 72%-94%) patients who did not meet the criteria for VDSS received an adrenocorticotropic hormone test.Conclusions: Treatment and evaluation of critical illness-related corticosteroid insufficiency in critically ill patients at our institution are inconsistent. Many patients with VDSS do not receive either treatment or evaluation for critical illness-related corticosteroid insufficiency, and patients who do not meet the current criteria are being evaluated and/or treated for critical illness-related corticosteroid insufficiency.

Systematized Nomenclature of Medicine–Clinical Terms direction and its implications on critical care

Reza Shahpori, Christopher Doig — 2009-10-16

Abstract: Purpose: The aim of this study was to describe the new advancements in Systematized Nomenclature of Medicine–Clinical Terms (SNOMED-CT) terminology and its applicability to critical care documentation.Materials and Methods: Narrative review of existing literature published in indexed medical and health informatics journals and of gray literature available on the Internet and personal communication with authors and researchers engaged in SNOMED-CT projects related to critical care are conducted.Results: Systematized Nomenclature of Medicine–Clinical Terms is a system of comprehensive health and clinical terminology that covers most of the needs of health care documentation. It will potentially become the terminology of clinical enterprise and administrative information systems. Despite a ground swell of international support from health information management experts, the terminology remains unknown to most clinicians. We discuss the reasons why clinical familiarity with SNOMED-CT is an important prerequisite to proceeding with local or national electronic health records or clinical information systems.Conclusions: We propose that SNOMED-CT is suitable for use in critical care; however, work is urgently required to validate the completeness of terminology and to determine clinicians' perceptions on the utility of such a standardized terminology for use in critical care clinical information systems.

Depression among white and nonwhite caregivers of the chronically critically ill

Sara L. Douglas, Barabara J. Daly, Elizabeth O'Toole, Ronald L. Hickman — 2009-10-19

Abstract: Purpose: The study aimed to describe characteristics of caregivers of chronically critically ill (CCI) patients, describe key outcomes (depression, employment, physical health), and examine race as one of several predictors of post-hospital depressive symptoms.Materials and Methods: This was a prospective study of caregivers of hospital survivors of prolonged (>72 hours) mechanical ventilation. Caregivers were interviewed at admission to the intensive care unit (ICU) and 2 months post-discharge.Results: Patients discharged to an institution had a high risk of post-hospital mortality (odds ratio, 8.61; P = .01). Caregivers of patients residing in an institution 2 months post-discharge had greater odds of being depressed than caregivers of patients residing at home (odds ratio, 2.75; P = .001). Nonwhite caregivers of patients residing in an institution had the least improvement in depression over time. Predictors of depression 2 months post-discharge were depression during hospitalization (P = .001), sex (P = .019), health status (P = .009), and residence of the patient (P = .001), with no change based on race. Almost 50% of employed caregivers had a reduction in paid work. There was a significant reduction in physical health status over time (P = .001) with no difference based on race.Conclusions: Caregivers of CCI patients are at risk for depression post-hospital discharge. Nonwhite caregivers of patients residing in an institution 2 months post-discharge are at highest risk for depression.

2010-06-01

Editorial Board

2010-06-01

Journal of Critical Care

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Depression among white and nonwhite caregivers of the chronically critically ill

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