Rates and risk factors associated with hospitalization for pneumonia with ICU admission among adults.

PubMed

Storms, Aaron D; Chen, Jufu; Jackson, Lisa A; Nordin, James D; Naleway, Allison L; Glanz, Jason M; Jacobsen, Steven J; Weintraub, Eric S; Klein, Nicola P; Gargiullo, Paul M; Fry, Alicia M

2017-12-16

Pneumonia poses a significant burden to the U.S. health-care system. However, there are few data focusing on severe pneumonia, particularly cases of pneumonia associated with specialized care in intensive care units (ICU). We used administrative and electronic medical record data from six integrated health care systems to estimate rates of pneumonia hospitalizations with ICU admissions among adults during 2006 through 2010. Pneumonia hospitalization was defined as either a primary discharge diagnosis of pneumonia or a primary discharge diagnosis of sepsis or respiratory failure with a secondary diagnosis of pneumonia in administrative data. ICU admissions were collected from internal electronic medical records from each system. Comorbidities were identified by ICD-9-CM codes coded during the current pneumonia hospitalization, as well as during medical visits that occurred during the year prior to the date of admission. We identified 119,537 adult hospitalizations meeting our definition for pneumonia. Approximately 19% of adult pneumonia hospitalizations had an ICU admission. The rate of pneumonia hospitalizations requiring ICU admission during the study period was 76 per 100,000 population/year; rates increased for each age-group with the highest rates among adults aged ≥85 years. Having a co-morbidity approximately doubled the risk of ICU admission in all age-groups. Our study indicates a significant burden of pneumonia hospitalizations with an ICU admission among adults in our cohort during 2006 through 2010, especially older age-groups and persons with underlying medical conditions. These findings reinforce current strategies aimed to prevent pneumonia among adults.

Acute Physiologic Stress and Subsequent Anxiety Among Family Members of ICU Patients.

PubMed

Beesley, Sarah J; Hopkins, Ramona O; Holt-Lunstad, Julianne; Wilson, Emily L; Butler, Jorie; Kuttler, Kathryn G; Orme, James; Brown, Samuel M; Hirshberg, Eliotte L

2018-02-01

The ICU is a complex and stressful environment and is associated with significant psychologic morbidity for patients and their families. We sought to determine whether salivary cortisol, a physiologic measure of acute stress, was associated with subsequent psychologic distress among family members of ICU patients. This is a prospective, observational study of family members of adult ICU patients. Adult medical and surgical ICU in a tertiary care center. Family members of ICU patients. Participants provided five salivary cortisol samples over 24 hours at the time of the patient ICU admission. The primary measure of cortisol was the area under the curve from ground; the secondary measure was the cortisol awakening response. Outcomes were obtained during a 3-month follow-up telephone call. The primary outcome was anxiety, measured by the Hospital Anxiety and Depression Scale-Anxiety. Secondary outcomes included depression and posttraumatic stress disorder. Among 100 participants, 92 completed follow-up. Twenty-nine participants (32%) reported symptoms of anxiety at 3 months, 15 participants (16%) reported depression symptoms, and 14 participants (15%) reported posttraumatic stress symptoms. In our primary analysis, cortisol level as measured by area under the curve from ground was not significantly associated with anxiety (odds ratio, 0.94; p = 0.70). In our secondary analysis, however, cortisol awakening response was significantly associated with anxiety (odds ratio, 1.08; p = 0.02). Roughly one third of family members experience anxiety after an ICU admission for their loved one, and many family members also experience depression and posttraumatic stress. Cortisol awakening response is associated with anxiety in family members of ICU patients 3 months following the ICU admission. Physiologic measurements of stress among ICU family members may help identify individuals at particular risk of adverse psychologic outcomes.

Intensive care unit admission in chronic obstructive pulmonary disease: patient information and the physician's decision-making process.

PubMed

Schmidt, Matthieu; Demoule, Alexandre; Deslandes-Boutmy, Emmanuelle; Chaize, Marine; de Miranda, Sandra; Bèle, Nicolas; Roche, Nicolas; Azoulay, Elie; Similowski, Thomas

2014-06-04

ICU admission is required in more than 25% of patients with chronic obstructive pulmonary disease (COPD) at some time during the course of the disease. However, only limited information is available on how physicians communicate with COPD patients about ICU admission. COPD patients and relatives from 19 French ICUs were interviewed at ICU discharge about their knowledge of COPD. French pulmonologists self-reported their practices for informing and discussing intensive care treatment preferences with COPD patients. Finally, pulmonologists and ICU physicians reported barriers and facilitators for transfer of COPD patients to the ICU and to propose invasive mechanical ventilation. Self-report questionnaires were filled in by 126 COPD patients and 102 relatives, and 173 pulmonologists and 135 ICU physicians were interviewed. For 41% (n = 39) of patients and 54% (n = 51) of relatives, ICU admission had never been expected prior to admission. One half of patients were not routinely informed by their pulmonologist about possible ICU admission at some time during the course of COPD. Moreover, treatment options (that is, non-invasive ventilation, intubation and mechanical ventilation or tracheotomy) were not explained to COPD patients during regular pulmonologist visits. Pulmonologists and ICU physician have different perceptions of the decision-making process pertaining to ICU admission and intubation. The information provided by pulmonologists to patients and families concerning the prognosis of COPD, the risks of ICU admission and specific care could be improved in order to deliver ICU care in accordance with the patient's personal values and preferences. Given the discrepancies in the decision-making process between pulmonologists and intensivists, a more collaborative approach should probably be discussed.

A comparison of pre ICU admission SIRS, EWS and q SOFA scores for predicting mortality and length of stay in ICU.

PubMed

Siddiqui, Shahla; Chua, Maureen; Kumaresh, Venkatesan; Choo, Robin

2017-10-01

The 2015 sepsis definitions suggest using the quick SOFA score for risk stratification of sepsis patients among other changes in sepsis definition. Our aim was to validate the q sofa score for diagnosing sepsis and comparing it to traditional scores of pre ICU admission sepsis outcome prediction such as EWS and SIRS in our setting in order to predict mortality and length of stay. This was a retrospective cohort study. We retrospectively calculated the q sofa, SIRS and EWS scores of all ICU patients admitted with the diagnosis of sepsis at our center in 2015. This was analysed using STATA 12. Logistic regression and ROC curves were used for analysis in addition to descriptive analysis. 58 patients were included in the study. Based on our one year results we have shown that although q SOFA is more sensitive in predicting LOS in ICU of sepsis patients, the EWS score is more sensitive and specific in predicting mortality in the ICU of such patients when compared to q SOFA and SIRS scores. In conclusion, we find that in our setting, EWS is better than SIRS and q SOFA for predicting mortality and perhaps length of stay as well. The q Sofa score remains validated for diagnosis of sepsis. Copyright © 2017 Elsevier Inc. All rights reserved.

Intensive care unit admission in chronic obstructive pulmonary disease: patient information and the physician’s decision-making process

PubMed Central

2014-01-01

Introduction ICU admission is required in more than 25% of patients with chronic obstructive pulmonary disease (COPD) at some time during the course of the disease. However, only limited information is available on how physicians communicate with COPD patients about ICU admission. Methods COPD patients and relatives from 19 French ICUs were interviewed at ICU discharge about their knowledge of COPD. French pulmonologists self-reported their practices for informing and discussing intensive care treatment preferences with COPD patients. Finally, pulmonologists and ICU physicians reported barriers and facilitators for transfer of COPD patients to the ICU and to propose invasive mechanical ventilation. Results Self-report questionnaires were filled in by 126 COPD patients and 102 relatives, and 173 pulmonologists and 135 ICU physicians were interviewed. For 41% (n = 39) of patients and 54% (n = 51) of relatives, ICU admission had never been expected prior to admission. One half of patients were not routinely informed by their pulmonologist about possible ICU admission at some time during the course of COPD. Moreover, treatment options (that is, non-invasive ventilation, intubation and mechanical ventilation or tracheotomy) were not explained to COPD patients during regular pulmonologist visits. Pulmonologists and ICU physician have different perceptions of the decision-making process pertaining to ICU admission and intubation. Conclusions The information provided by pulmonologists to patients and families concerning the prognosis of COPD, the risks of ICU admission and specific care could be improved in order to deliver ICU care in accordance with the patient’s personal values and preferences. Given the discrepancies in the decision-making process between pulmonologists and intensivists, a more collaborative approach should probably be discussed. PMID:24898342

Patient-related factors and circumstances surrounding decisions to forego life-sustaining treatment, including intensive care unit admission refusal.

PubMed

Reignier, Jean; Dumont, Romain; Katsahian, Sandrine; Martin-Lefevre, Laurent; Renard, Benoit; Fiancette, Maud; Lebert, Christine; Clementi, Eva; Bontemps, Frederic

2008-07-01

To assess decisions to forego life-sustaining treatment (LST) in patients too sick for intensive care unit (ICU) admission, comparatively to patients admitted to the ICU. Prospective observational cohort study. A medical-surgical ICU. Consecutive patients referred to the ICU during a one-yr period. None. Of 898 triaged patients, 147 were deemed too well to benefit from ICU admission. Decisions to forego LST were made in 148 of 666 (22.2%) admitted patients and in all 85 patients deemed too sick for ICU admission. Independent predictors of decisions to forego LST at ICU refusal rather than after ICU admission were: age; underlying disease; living in an institution; preexisting cognitive impairment; admission for medical reasons; and acute cardiac failure, acute central neurologic illness, or sepsis. Hospital mortality after decisions to forego LST was not significantly different in refused and admitted patients (77.5% vs. 86.5%; p = .1). Decisions to forego LST were made via telephone in 58.8% of refused patients and none of the admitted patients. Nurses caring for the patient had no direct contact with the ICU physicians for 62.3% of the decisions in refused patients, whereas meetings between nurses and physicians occurred in 70.3% of decisions to forego LST in the ICU. Patients or relatives were involved in 28.2% of decisions to forego LST at ICU refusal compared with 78.4% of decisions to forego LST in ICU patients (p < .001). All patients deemed too sick for ICU admission had decisions to forego LST. These decisions were made without direct patient examination in two-thirds of refused patients (vs. none of admitted patients) and were associated with less involvement of nurses and relatives compared with decisions in admitted patients. Further work is needed to improve decisions to forego LST made under the distinctive circumstances of triage.

Selective digestive and oropharyngeal decontamination in medical and surgical ICU patients: individual patient data meta-analysis.

PubMed

Plantinga, N L; de Smet, A M G A; Oostdijk, E A N; de Jonge, E; Camus, C; Krueger, W A; Bergmans, D; Reitsma, J B; Bonten, M J M

2018-05-01

Selective digestive decontamination (SDD) and selective oropharyngeal decontamination (SOD) improved intensive care unit (ICU), hospital and 28-day survival in ICUs with low levels of antibiotic resistance. Yet it is unclear whether the effect differs between medical and surgical ICU patients. In an individual patient data meta-analysis, we systematically searched PubMed and included all randomized controlled studies published since 2000. We performed a two-stage meta-analysis with separate logistic regression models per study and per outcome (hospital survival and ICU survival) and subsequent pooling of main and interaction effects. Six studies, all performed in countries with low levels of antibiotic resistance, yielded 16 528 hospital admissions and 17 884 ICU admissions for complete case analysis. Compared to standard care or placebo, the pooled adjusted odds ratios for hospital mortality was 0.82 (95% confidence interval (CI) 0.72-0.93) for SDD and 0.84 (95% CI 0.73-0.97) for SOD. Compared to SOD, the adjusted odds ratio for hospital mortality was 0.90 (95% CI 0.82-0.97) for SDD. The effects on hospital mortality were not modified by type of ICU admission (p values for interaction terms were 0.66 for SDD and control, 0.87 for SOD and control and 0.47 for SDD and SOD). Similar results were found for ICU mortality. In ICUs with low levels of antibiotic resistance, the effectiveness of SDD and SOD was not modified by type of ICU admission. SDD and SOD improved hospital and ICU survival compared to standard care in both patient populations, with SDD being more effective than SOD. Copyright © 2017 The Author(s). Published by Elsevier Ltd.. All rights reserved.

Satisfaction in the Intensive Care Unit (ICU). Patient opinion as a cornerstone.

PubMed

Holanda Peña, M S; Talledo, N Marina; Ots Ruiz, E; Lanza Gómez, J M; Ruiz Ruiz, A; García Miguelez, A; Gómez Marcos, V; Domínguez Artiga, M J; Hernández Hernández, M Á; Wallmann, R; Llorca Díaz, J

2017-03-01

To study the agreement between the level of satisfaction of patients and their families referred to the care and attention received during admission to the ICU. A prospective, 5-month observational and descriptive study was carried out. ICU of Marqués de Valdecilla University Hospital, Santander (Spain). Adult patients with an ICU stay longer than 24h, who were discharged to the ward during the period of the study, and their relatives. Instrument: FS-ICU 34 for assessing family satisfaction, and an adaptation of the FS-ICU 34 for patients. The Cohen kappa index was calculated to assess agreement between answers. An analysis was made of the questionnaires from one same family unit, obtaining 148 pairs of surveys (296 questionnaires). The kappa index ranged between 0.278-0.558, which is indicative of mild to moderate agreement. The families of patients admitted to the ICU cannot be regarded as good proxies, at least for competent patients. In such cases, we must refer to these patients in order to obtain first hand information on their feelings, perceptions and experiences during admission to the ICU. Only when patients are unable to actively participate in the care process should their relatives be consulted. Copyright © 2016 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

qSOFA, SIRS and NEWS for predicting inhospital mortality and ICU admission in emergency admissions treated as sepsis.

PubMed

Goulden, Robert; Hoyle, Marie-Claire; Monis, Jessie; Railton, Darran; Riley, Victoria; Martin, Paul; Martina, Reynaldo; Nsutebu, Emmanuel

2018-06-01

The third international consensus definition for sepsis recommended use of a new prognostic tool, the quick Sequential Organ Failure Assessment (qSOFA), based on its ability to predict inhospital mortality and prolonged intensive care unit (ICU) stay in patients with suspected infection. While several studies have compared the prognostic accuracy of qSOFA to the Systemic Inflammatory Response Syndrome (SIRS) criteria in suspected sepsis, few have compared qSOFA and SIRS to the widely used National Early Warning Score (NEWS). This was a retrospective cohort study carried out in a UK tertiary centre. The study population comprised emergency admissions in whom sepsis was suspected and treated. The accuracy for predicting inhospital mortality and ICU admission was calculated and compared for qSOFA, SIRS and NEWS. Among 1818 patients, 53 were admitted to ICU (3%) and 265 died in hospital (15%). For predicting inhospital mortality, the area under the receiver operating characteristics curve for NEWS (0.65, 95% CI 0.61 to 0.68) was similar to qSOFA (0.62, 95% CI 0.59 to 0.66) (test for difference, P=0.18) and superior to SIRS (P<0.001), which was not predictive. The sensitivity of NEWS≥5 (74%, 95% CI 68% to 79%) was similar to SIRS≥2 (80%, 95% CI 74% to 84%) and higher than qSOFA≥2 (37%, 95% CI 31% to 43%). The specificity of NEWS≥5 (43%, 95% CI 41% to 46%) was higher than SIRS≥2 (21%, 95% CI 19% to 23%) and lower than qSOFA≥2 (79%, 95% CI 77% to 81%). The negative predictive value was 88% (86%-90%) for qSOFA, 86% (82%-89%) for SIRS and 91% (88%-93%) for NEWS. Results were similar for the secondary outcome of ICU admission. NEWS has equivalent or superior value for most test characteristics relative to SIRS and qSOFA, calling into question the rationale of adopting qSOFA in institutions where NEWS is already in use. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No

Embedding measurement within existing computerized data systems: scaling clinical laboratory and medical records heart failure data to predict ICU admission.

PubMed

Fisher, William P; Burton, Elizabeth C

2010-01-01

This study employs existing data sources to develop a new measure of intensive care unit (ICU) admission risk for heart failure patients. Outcome measures were constructed from laboratory, accounting, and medical record data for 973 adult inpatients with primary or secondary heart failure. Several scoring interpretations of the laboratory indicators were evaluated relative to their measurement and predictive properties. Cases were restricted to tests within first lab draw that included at least 15 indicators. After optimizing the original clinical observations, a satisfactory heart failure severity scale was calibrated on a 0-1000 continuum. Patients with unadjusted CHF severity measures of 550 or less were 2.7 times more likely to be admitted to the ICU than those with higher measures. Patients with low HF severity measures (550 or less) adjusted for demographic and diagnostic risk factors are about six times more likely to be admitted to the ICU than those with higher adjusted measures. A nomogram facilitates routine clinical application. Existing computerized data systems could be programmed to automatically structure clinical laboratory reports using the results of studies like this one to reduce data volume with no loss of information, make laboratory results more meaningful to clinical end users, improve the quality of care, reduce errors and unneeded tests, prevent unnecessary ICU admissions, lower costs, and improve patient satisfaction. Existing data typically examined piecemeal form a coherent scale measuring heart failure severity sensitive to increased likelihood of ICU admission. Marked improvements in ROC curves were found for the aggregate measures relative to individual clinical indicators.

Determining delayed admission to intensive care unit for mechanically ventilated patients in the emergency department.

PubMed

Hung, Shih-Chiang; Kung, Chia-Te; Hung, Chih-Wei; Liu, Ber-Ming; Liu, Jien-Wei; Chew, Ghee; Chuang, Hung-Yi; Lee, Wen-Huei; Lee, Tzu-Chi

2014-08-23

The adverse effects of delayed admission to the intensive care unit (ICU) have been recognized in previous studies. However, the definitions of delayed admission varies across studies. This study proposed a model to define "delayed admission", and explored the effect of ICU-waiting time on patients' outcome. This retrospective cohort study included non-traumatic adult patients on mechanical ventilation in the emergency department (ED), from July 2009 to June 2010. The primary outcomes measures were 21-ventilator-day mortality and prolonged hospital stays (over 30 days). Models of Cox regression and logistic regression were used for multivariate analysis. The non-delayed ICU-waiting was defined as a period in which the time effect on mortality was not statistically significant in a Cox regression model. To identify a suitable cut-off point between "delayed" and "non-delayed", subsets from the overall data were made based on ICU-waiting time and the hazard ratio of ICU-waiting hour in each subset was iteratively calculated. The cut-off time was then used to evaluate the impact of delayed ICU admission on mortality and prolonged length of hospital stay. The final analysis included 1,242 patients. The time effect on mortality emerged after 4 hours, thus we deduced ICU-waiting time in ED > 4 hours as delayed. By logistic regression analysis, delayed ICU admission affected the outcomes of 21 ventilator-days mortality and prolonged hospital stay, with odds ratio of 1.41 (95% confidence interval, 1.05 to 1.89) and 1.56 (95% confidence interval, 1.07 to 2.27) respectively. For patients on mechanical ventilation at the ED, delayed ICU admission is associated with higher probability of mortality and additional resource expenditure. A benchmark waiting time of no more than 4 hours for ICU admission is recommended.

Variation in ICU Utilization and Mortality After Blunt Splenic Injury

PubMed Central

Kaufman, Elinore J.; Wiebe, Douglas J.; Martin, Niels D.; Pascual, Jose L.; Reilly, Patrick M.; Holena, Daniel N.

2016-01-01

Background While trauma patients are frequently cared for in the ICU, admission triage criteria are unclear and may vary among providers and institutions. The benefits of close monitoring must be weighed against the economic and opportunity costs of an ICU admission. Materials and Methods We conducted a retrospective cohort study of patients treated for blunt splenic injuries at 30 level I and II Pennsylvania trauma centers, 2011–2014. We used multivariable logistic regression to assess the relationship between ICU admission and mortality, adjusting for patient characteristics, injury characteristics, and physiology. We calculated center-level observed-to-expected ratios for ICU utilization and mortality and evaluated correlations with Spearman’s rho. We compared the proportion of patients receiving critical care procedures, such as mechanical ventilation or central line placement, between high- and low-ICU-utilization centers. Results Of 2,587 patients with blunt splenic injuries, 63.9% (1,654) were admitted to the ICU. Median injury severity score (ISS) was 17 overall, 13 for non-ICU patients and 17 for ICU patients (p < 0.001). In multivariable logistic regression, ICU admission was not significantly associated with mortality. Center-level risk-adjusted ICU admission rates ranged from 17.9% to 87.3%. Risk-adjusted mortality rates ranged from 1.2% to 9.6%. There was no correlation between O:E ratios for ICU utilization and mortality (rs = −0.2595, p=0.2103). Proportionately fewer ICU patients at high-utilization centers received critical care procedures than at low-utilization centers. Conclusions Risk-adjusted ICU utilization rates for splenic trauma varied widely among trauma centers, with no clear relationship to mortality. Standardizing ICU admission criteria could improve resource utilization without increasing mortality. PMID:27363642

Prognosis of patients presenting extreme acidosis (pH <7) on admission to intensive care unit.

PubMed

Allyn, Jérôme; Vandroux, David; Jabot, Julien; Brulliard, Caroline; Galliot, Richard; Tabatchnik, Xavier; Combe, Patrice; Martinet, Olivier; Allou, Nicolas

2016-02-01

The purpose was to determine prognosis of patients presenting extreme acidosis (pH <7) on admission to the intensive care unit (ICU) and to identify mortality risk factors. We retrospectively analyzed all patients who presented with extreme acidosis within 24 hours of admission to a polyvalent ICU in a university hospital between January 2011 and July 2013. Multivariate analysis and survival analysis were used. Among the 2156 patients admitted, 77 patients (3.6%) presented extreme acidosis. Thirty (39%) patients suffered cardiac arrest before admission. Although the mortality rate predicted by severity score was 93.6%, death occurred in 52 cases (67.5%) in a median delay of 13 (5-27) hours. Mortality rate depended on reason for admission, varying between 22% for cases linked to diabetes mellitus and 100% for cases of mesenteric infarction (P = .002), cardiac arrest before admission (P < .001), type of lactic acidosis (P = .007), high Simplified Acute Physiology Score II (P = .008), and low serum creatinine (P = .012). Patients with extreme acidosis on admission to ICU have a less severe than expected prognosis. Whereas mortality is almost 100% in cases of cardiac arrest before admission, mortality is much lower in the absence of cardiac arrest before admission, which justifies aggressive ICU therapies. Copyright © 2015 Elsevier Inc. All rights reserved.

Early hemodynamic assessment and treatment of elderly patients in the medical ICU.

PubMed

Voga, Gorazd; Gabršček-Parežnik, Lucija

2016-12-01

The aim of this retrospective study was to analyze differences in the initial hemodynamic assessment and its impact on the treatment in patients aged 80 years or older compared to younger patients during the first 6 h after admission to the medical intensive care unit (ICU). We analyzed 615 consecutive patients admitted to the medical ICU of which 124 (20%) were aged 80 years or more. The older group had a significantly higher acute physiology and chronic health evaluation (APACHE II) score, an overall mortality in the ICU and a presence of pre-existing cardiac disease. Both groups did not differ in the presence of shock and shock types on admission. In 57% of older and in 56% of younger patients, transthoracic echocardiography was performed with a higher therapeutic impact in the older patients. Transesophageal echocardiography was performed in 3% of the patients in both groups for specific diagnostic problems. Early reassessment with transthoracic echocardiography was necessary in 5% of the older and in 6% of the younger patients and resulted in a change of the treatment in one third of the patients. Continuous invasive hemodynamic monitoring was used in 11% of the older and in 10% of the younger patients and resulted in a therapeutic change in 71% of the older and in 64% of the younger patients. Patients aged 80 years or older represent 20% of all admissions to the medical ICU. Once admitted the older patients were similarly hemodynamically assessed as the younger ones with a similar impact on the treatment.

Limitation of life-sustaining treatment in patients with prolonged admission to the ICU. Current situation in Spain as seen from the EPIPUSE Study.

PubMed

Hernández-Tejedor, A; Martín Delgado, M C; Cabré Pericas, L; Algora Weber, A

2015-10-01

Limitation of life-sustaining treatment (LLST) is a recommended practice in certain circumstances. Limitation practices are varied, and their application differs from one center to another. The present study evaluates the current situation of LLST practices in patients with prolonged admission to the ICU who suffer worsening of their condition. A prospective, observational cohort study was carried out. Seventy-five Spanish ICUs. A total of 589 patients suffering 777 complications or adverse events with organ function impairment after day 7 of admission, during a three-month recruitment period. The timing of limitation, the subject proposing LLST, the degree of agreement within the team, the influence of LLST upon the doctor-patient-family relationship, and the way in which LLST is implemented. LLST was proposed in 34.3% of the patients presenting prolonged admission to the ICU with severe complications. The incidence was higher in patients with moderate to severe lung disease, cancer, immunosuppressive treatment or dependence for basic activities of daily living. LLST was finally implemented in 97% of the cases in which it was proposed. The decision within the medical team was unanimous in 87.9% of the cases. The doctor-patient-family relationship usually does not change or even improves in this situation. LLST in ICUs is usually carried out under unanimous decision of the medical team, is performed more frequently in patients with severe comorbidity, and usually does not have a negative impact upon the relationship with the patients and their families. Copyright © 2013 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.

Implications of ICU triage decisions on patient mortality: a cost-effectiveness analysis

PubMed Central

2011-01-01

Introduction Intensive care is generally regarded as expensive, and as a result beds are limited. This has raised serious questions about rationing when there are insufficient beds for all those referred. However, the evidence for the cost effectiveness of intensive care is weak and the work that does exist usually assumes that those who are not admitted do not survive, which is not always the case. Randomised studies of the effectiveness of intensive care are difficult to justify on ethical grounds; therefore, this observational study examined the cost effectiveness of ICU admission by comparing patients who were accepted into ICU after ICU triage to those who were not accepted, while attempting to adjust such comparison for confounding factors. Methods This multi-centre observational cohort study involved 11 hospitals in 7 EU countries and was designed to assess the cost effectiveness of admission to intensive care after ICU triage. A total of 7,659 consecutive patients referred to the intensive care unit (ICU) were divided into those accepted for admission and those not accepted. The two groups were compared in terms of cost and mortality using multilevel regression models to account for differences across centres, and after adjusting for age, Karnofsky score and indication for ICU admission. The analyses were also stratified by categories of Simplified Acute Physiology Score (SAPS) II predicted mortality (< 5%, 5% to 40% and >40%). Cost effectiveness was evaluated as cost per life saved and cost per life-year saved. Results Admission to ICU produced a relative reduction in mortality risk, expressed as odds ratio, of 0.70 (0.52 to 0.94) at 28 days. When stratified by predicted mortality, the odds ratio was 1.49 (0.79 to 2.81), 0.7 (0.51 to 0.97) and 0.55 (0.37 to 0.83) for <5%, 5% to 40% and >40% predicted mortality, respectively. Average cost per life saved for all patients was $103,771 (€82,358) and cost per life-year saved was $7,065 (€5,607). These

Measurement of Dead Space Fraction Upon ICU Admission Predicts Length of Stay and Clinical Outcomes Following Bidirectional Cavopulmonary Anastomosis.

PubMed

Cigarroa, Claire L; van den Bosch, Sarah J; Tang, Xiaoqi; Gauvreau, Kimberlee; Baird, Christopher W; DiNardo, James A; Kheir, John Nagi

2018-01-01

Increased alveolar dead space fraction has been associated with prolonged mechanical ventilation and increased mortality in pediatric patients with respiratory failure. The association of alveolar dead space fraction with clinical outcomes in patients undergoing bidirectional cavopulmonary anastomosis for single ventricle congenital heart disease has not been reported. We describe an association of alveolar dead space fraction with postoperative outcomes in patients undergoing bidirectional cavopulmonary anastomosis. In a retrospective case-control study, we examined for associations between alveolar dead space fraction ([PaCO2 - end-tidal CO2]/PaCO2), arterial oxyhemoglobin saturation, and transpulmonary gradient upon postoperative ICU admission with a composite primary outcome (requirement for surgical or catheter-based intervention, death, or transplant prior to hospital discharge, defining cases) and several secondary endpoints in infants following bidirectional cavopulmonary anastomosis. Cardiac ICU in a tertiary care pediatric hospital. Patients undergoing bidirectional cavopulmonary anastomosis at our institution between 2011 and 2016. None. Of 191 patients undergoing bidirectional cavopulmonary anastomosis, 28 patients were cases and 163 were controls. Alveolar dead space fraction was significantly higher in the case (0.26 ± 0.09) versus control group (0.17 ± 0.09; p < 0.001); alveolar dead space fraction at admission was less than 0.12 in 0% of cases and was greater than 0.28 in 35% of cases. Admission arterial oxyhemoglobin saturation was significantly lower in the case (77% ± 12%) versus control group (83% ± 9%; p < 0.05). Sensitivity and specificity for future case versus control assignment was best when prebidirectional cavopulmonary anastomosis risk factors, admission alveolar dead space fraction (AUC, 0.74), and arterial oxyhemoglobin saturation (AUC, 0.65) were combined in a summarial model (AUC, 0.83). For a given arterial oxyhemoglobin

A critical analysis of unplanned ICU transfer within 48 hours from ED admission as a quality measure.

PubMed

Dahn, Cassidy M; Manasco, A Travis; Breaud, Alan H; Kim, Samuel; Rumas, Natalia; Moin, Omer; Mitchell, Patricia M; Nelson, Kerrie P; Baker, William; Feldman, James A

2016-08-01

Unplanned intensive care unit (ICU) transfer (UIT) within 48 hours of emergency department (ED) admission increases morbidity and mortality. We hypothesized that a majority of UITs do not have critical interventions (CrIs) and that CrI is associated with worse outcomes. The objective of the study is to characterize all UITs (including patients who died before ICU transfer), the proportion with CrI, and the effect of having CrI on mortality. This is a single-center, retrospective cohort study of UITs within 48 hours from 2008 to 2013 at an urban academic medical center and included patients 18 years or older without advanced directives (ADs). Critical intervention was defined by modified Delphi process. Data included demographics, comorbidities, reasons for UIT, length of stay, CrIs, and mortality. We calculated descriptive statistics with 95% confidence intervals (CIs). A total of 837 (0.76%) of 108 732 floor admissions from the ED had a UIT within 48 hours; 86 admitted patients died before ICU. We excluded 23 ADs, 117 postoperative transfers, 177 planned ICU transfers, and 4 with missing data. Of the 516 remaining, 65% (95% CI, 61%-69%) received a CrI. Unplanned ICU transfer reasons are as follows: 33 medical errors, 90 disease processes not present on arrival, and 393 clinical deteriorations. Mortality was 10.5% (95% CI, 8%-14%), and mean length of stay was 258 hours (95% CI, 233-283) for those with CrI, whereas the mortality was 2.8% (95% CI, 1%-6%) and mean length of stay was 177 hours (95% CI, 157-197) for those without CrI. Unplanned ICU transfer is rare, and only 65% had a CrI. Those with CrI had increased morbidity and mortality. Copyright © 2016 Elsevier Inc. All rights reserved.

The Utility of Routine Intensive Care Admission for Patients Undergoing Intracranial Neurosurgical Procedures: A Systematic Review.

PubMed

de Almeida, Cesar Cimonari; Boone, M Dustin; Laviv, Yosef; Kasper, Burkhard S; Chen, Clark C; Kasper, Ekkehard M

2018-02-01

Patients who have undergone intracranial neurosurgical procedures have traditionally been admitted to an intensive care unit (ICU) for close postoperative neurological observation. The purpose of this study was to systematically review the evidence for routine ICU admission in patients undergoing intracranial neurosurgical procedures and to evaluate the safety of alternative postoperative pathways. We were interested in identifying studies that examined selected patients who presented for elective, non-emergent intracranial surgery whose postoperative outcomes were compared as a function of ICU versus non-ICU admission. A systematic review was performed in July 2016 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist of the Medline database. The search strategy was created based on the following key words: "craniotomy," "neurosurgical procedure," and "intensive care unit." The nine articles that satisfied the inclusion criteria yielded a total of 2227 patients. Of these patients, 879 were observed in a non-ICU setting. The most frequent diagnoses were supratentorial brain tumors, followed by patients with cerebrovascular diseases and infratentorial brain tumors. Three percent (30/879) of the patients originally assigned to floor or intermediate care status were transferred to the ICU. The most frequently observed neurological complications leading to ICU transfer were delayed postoperative neurological recovery, seizures, worsening of neurological deficits, hemiparesis, and cranial nerves deficits. Our systematic review demonstrates that routine postoperative ICU admission may not benefit carefully selected patients who have undergone elective intracranial neurosurgical procedures. In addition, limiting routine ICU admission may result in significant cost savings.

The surgical Apgar score is strongly associated with ICU admission after high-risk intra-abdominal surgery

PubMed Central

Sobol, Julia B.; Gershengorn, ayley B.; Wunsch, Hannah; Li, Guohua

2014-01-01

Background Understanding intensive care unit (ICU) triage decisions for high-risk surgical patients may ultimately facilitate resource allocation and improve outcomes. The surgical Apgar score (SAS) is a simple score that uses intraoperative information on hemodynamics and blood loss to predict postoperative morbidity and mortality, with lower scores associated with worse outcomes. We hypothesized that the SAS would be associated with the decision to admit a patient to the ICU postoperatively. Methods Retrospective cohort study of adults undergoing major intra-abdominal surgery from 2003 to 2010 at an academic medical center. We calculated the SAS (0 – 10) for each patient based on intraoperative heart rate, mean arterial pressure, and estimated blood loss. Using logistic regression, we assessed the association of the SAS with the decision to admit a patient directly to the ICU after surgery. Results The cohort consisted of 8,501 patients, with 72.7% having a SAS of 7-10 and less than 5% a SAS of 0-4. A total of 8.7% of patients were transferred immediately to the ICU postoperatively. After multivariate adjustment, there was a strong association between the SAS and the decision to admit a patient to the ICU (adjusted odds ratio 14.41 [95% CI 6.88 – 30.19, P < 0.001] for SAS 0-2, 4.42 [95% CI 3.19 – 6.13, P <0.001] for SAS 3-4, and 2.60 [95% CI 2.08 – 3.24, P < 0.001] for SAS 5-6 compared with SAS 7-8). Conclusions The SAS is strongly associated with clinical decisions regarding immediate ICU admission after high-risk intra-abdominal surgery. These results provide an initial step towards understanding whether intraoperative hemodynamics and blood loss influence ICU triage for post-surgical patients. PMID:23744956

Secondary Prevention in the Intensive Care Unit: Does ICU Admission Represent a “Teachable Moment?”

PubMed Central

Clark, Brendan J.; Moss, Marc

2011-01-01

Objective Cigarette smoking and unhealthy alcohol use are common causes of preventable morbidity and mortality that frequently result in admission to an intensive care unit. Understanding how to identify and intervene in these conditions is important because critical illness may provide a “teachable moment.” Furthermore, the Joint Commission recently proposed screening and receipt of an intervention for tobacco use and unhealthy alcohol use as candidate performance measures for all hospitalized patients. Understanding the efficacy of these interventions may help drive evidence-based institution of programs, if deemed appropriate. Data Sources A summary of the published medical literature on interventions for unhealthy alcohol use and smoking obtained through a PubMed search. Summary Interventions focusing on behavioral counseling for cigarette smoking in hospitalized patients have been extensively studied. Several studies include or focus on critically ill patients. The evidence demonstrates that behavioral counseling leads to increased rates of smoking cessation but the effect depends on the intensity of the intervention. The identification of unhealthy alcohol use can lead to brief interventions. These interventions are particularly effective in trauma patients with unhealthy alcohol use. However, the current literature would not support routine delivery of brief interventions for unhealthy alcohol use in the medical ICU population. Conclusion ICU admission represents a “teachable moment” for smokers and some patients with unhealthy alcohol use. Future studies should assess the efficacy of brief interventions for unhealthy alcohol use in medical ICU patients. In addition, identification of the timing and optimal individual to conduct the intervention will be necessary. PMID:21494113

Emotional reactions and needs of family members of ICU patients.

PubMed

Płaszewska-Żywko, Lucyna; Gazda, Dorota

2012-01-01

The aim of the study was to determine emotional reactions and needs of families of ICU patients. The study group included 60 relatives of ICU patients, aged 18-80 years. The diagnostic questionnaire-based survey was conducted. The questionnaire contained questions regarding demographic data, emotions and needs as well as the Courtauld Emotional Control Scale (CECS). The major emotions of patients' families on ICU admission were anxiety, uncertainty, fear, depression, and nervousness (particularly among parents and adult offsprings). On second-third day of hospitalisation, the emotions became less severe (P < 0.001). The anxiety-related emotional reactions were better controlled by men (P < 0.01); most women experienced stronger negative emotions (P < 0.05) and their needs to receive information and to be involved in patient care were expressed more. Negative emotions of ICU patients' relatives were highly intense, especially amongst parents and adult children. Women were characterised by higher levels of emotions and needs compared to men.

The pharmacokinetics of propofol in ICU patients undergoing long-term sedation.

PubMed

Smuszkiewicz, Piotr; Wiczling, Paweł; Przybyłowski, Krzysztof; Borsuk, Agnieszka; Trojanowska, Iwona; Paterska, Marta; Matysiak, Jan; Kokot, Zenon; Grześkowiak, Edmund; Bienert, Agnieszka

2016-11-01

The aim of this study was to characterize the pharmacokinetics (PK) of propofol in ICU patients undergoing long-term sedation and to assess the influence of routinely collected covariates on the PK parameters. Propofol concentration-time profiles were collected from 29 patients. Non-linear mixed-effects modelling in NONMEM 7.2 was used to analyse the observed data. The propofol pharmacokinetics was best described with a three-compartment disposition model. Non-parametric bootstrap and a visual predictive check were used to evaluate the adequacy of the developed model to describe the observations. The typical value of the propofol clearance (1.46 l/min) approximated the hepatic blood flow. The volume of distribution at steady state was high and was equal to 955.1 l, which is consistent with other studies involving propofol in ICU patients. There was no statistically significant covariate relationship between PK parameters and opioid type, SOFA score on the day of admission, APACHE II, predicted death rate, reason for ICU admission (sepsis, trauma or surgery), gender, body weight, age, infusion duration and C-reactive protein concentration. The population PK model was developed successfully to describe the time-course of propofol concentration in ICU patients undergoing prolonged sedation. Despite a very heterogeneous group of patients, consistent PK profiles were observed. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

Reasons for refusal of admission to intensive care and impact on mortality.

PubMed

Iapichino, Gaetano; Corbella, Davide; Minelli, Cosetta; Mills, Gary H; Artigas, Antonio; Edbooke, David L; Pezzi, Angelo; Kesecioglu, Jozef; Patroniti, Nicolò; Baras, Mario; Sprung, Charles L

2010-10-01

To identify factors influencing triage decisions and investigate whether admission to the intensive care unit (ICU) could reduce mortality compared with treatment on the ward. A multicentre cohort study in 11 university hospitals from seven countries, evaluating triage decisions and outcomes of patients referred for admission to ICU who were either accepted, or refused and treated on the ward. Confounding in the estimation of the effect of ICU admission on mortality was controlled by use of a propensity score approach, which adjusted for the probability of being admitted. Variability across centres was accounted for in both analyses of factors influencing ICU admission and effect of ICU admission on mortality. Eligible were 8,616 triages in 7,877 patients referred for ICU admission. Variables positively associated with probability of being admitted to ICU included: ventilators in ward; bed availability; Karnofsky score; absence of comorbidity; presence of haematological malignancy; emergency surgery and elective surgery (versus medical treatment); trauma, vascular involvement, liver involvement; acute physiologic score II; ICU treatment (versus ICU observation). Multiple triages during patient's hospital stay and age were negatively associated with ICU admission. The area under the receiver operating characteristic (ROC) curve of the model was 0.83 [95% confidence interval (CI): 0.81-0.84], with Hosmer-Lemeshow test P = 0.300. ICU admission was associated with a statistically significant reduction of both 28-day mortality [odds ratio (OR): 0.73; 95% CI: 0.62-0.87] and 90-day mortality (0.79; 0.66-0.93). The benefit of ICU admission increased substantially in patients with greater severity of illness. We suggest that intensivists take great care to avoid ICU admission of patients judged not severe enough for ICU or with low performance status, and they tend to admit surgical patients more readily than medical patients. Interestingly, they do not judge age per se as

ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research.

PubMed

Nates, Joseph L; Nunnally, Mark; Kleinpell, Ruth; Blosser, Sandralee; Goldner, Jonathan; Birriel, Barbara; Fowler, Clara S; Byrum, Diane; Miles, William Scherer; Bailey, Heatherlee; Sprung, Charles L

2016-08-01

To update the Society of Critical Care Medicine's guidelines for ICU admission, discharge, and triage, providing a framework for clinical practice, the development of institutional policies, and further research. An appointed Task Force followed a standard, systematic, and evidence-based approach in reviewing the literature to develop these guidelines. The assessment of the evidence and recommendations was based on the principles of the Grading of Recommendations Assessment, Development and Evaluation system. The general subject was addressed in sections: admission criteria and benefits of different levels of care, triage, discharge timing and strategies, use of outreach programs to supplement ICU care, quality assurance/improvement and metrics, nonbeneficial treatment in the ICU, and rationing considerations. The literature searches yielded 2,404 articles published from January 1998 to October 2013 for review. Following the appraisal of the literature, discussion, and consensus, recommendations were written. Although these are administrative guidelines, the subjects addressed encompass complex ethical and medico-legal aspects of patient care that affect daily clinical practice. A limited amount of high-quality evidence made it difficult to answer all the questions asked related to ICU admission, discharge, and triage. Despite these limitations, the members of the Task Force believe that these recommendations provide a comprehensive framework to guide practitioners in making informed decisions during the admission, discharge, and triage process as well as in resolving issues of nonbeneficial treatment and rationing. We need to further develop preventive strategies to reduce the burden of critical illness, educate our noncritical care colleagues about these interventions, and improve our outreach, developing early identification and intervention systems.

Hospitalized children with 2009 pandemic influenza A (H1N1): comparison to seasonal influenza and risk factors for admission to the ICU.

PubMed

Bagdure, Dayanand; Curtis, Donna J; Dobyns, Emily; Glodé, Mary P; Dominguez, Samuel R

2010-12-15

Limited data are available describing the clinical presentation and risk factors for admission to the intensive care unit for children with 2009 H1N1 infection. We conducted a retrospective chart review of all hospitalized children with 2009 influenza A (H1N1) and 2008-09 seasonal influenza at The Children's Hospital, Denver, Colorado. Of the 307 children identified with 2009 H1N1 infections, the median age was 6 years, 61% were male, and 66% had underlying medical conditions. Eighty children (26%) were admitted to the ICU. Thirty-two (40%) of the ICU patients required intubation and 17 (53%) of the intubated patients developed acute respiratory distress syndrome (ARDS). Four patients required extracorporeal membrane oxygenation. Eight (3%) of the hospitalized children died. Admission to the ICU was significantly associated with older age and underlying neurological condition. Compared to the 90 children admitted during the 2008-09 season, children admitted with 2009 H1N1 influenza were significantly older, had a shorter length of hospitalization, more use of antivirals, and a higher incidence of ARDS. Compared to the 2008-09 season, hospitalized children with 2009 H1N1 influenza were much older and had more severe respiratory disease. Among children hospitalized with 2009 H1N1 influenza, risk factors for admission to the ICU included older age and having an underlying neurological condition. Children under the age of 2 hospitalized with 2009 H1N1 influenza were significantly less likely to require ICU care compared to older hospitalized children.

Use of early corticosteroid therapy on ICU admission in patients affected by severe pandemic (H1N1)v influenza A infection.

PubMed

Martin-Loeches, I; Lisboa, T; Rhodes, A; Moreno, R P; Silva, E; Sprung, C; Chiche, J D; Barahona, D; Villabon, M; Balasini, C; Pearse, R M; Matos, R; Rello, J

2011-02-01

Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza A infection, although relatively common, remains controversial. Prospective, observational, multicenter study from 23 June 2009 through 11 February 2010, reported in the European Society of Intensive Care Medicine (ESICM) H1N1 registry. Two hundred twenty patients admitted to an intensive care unit (ICU) with completed outcome data were analyzed. Invasive mechanical ventilation was used in 155 (70.5%). Sixty-seven (30.5%) of the patients died in ICU and 75 (34.1%) whilst in hospital. One hundred twenty-six (57.3%) patients received corticosteroid therapy on admission to ICU. Patients who received corticosteroids were significantly older and were more likely to have coexisting asthma, chronic obstructive pulmonary disease (COPD), and chronic steroid use. These patients receiving corticosteroids had increased likelihood of developing hospital-acquired pneumonia (HAP) [26.2% versus 13.8%, p < 0.05; odds ratio (OR) 2.2, confidence interval (CI) 1.1-4.5]. Patients who received corticosteroids had significantly higher ICU mortality than patients who did not (46.0% versus 18.1%, p < 0.01; OR 3.8, CI 2.1-7.2). Cox regression analysis adjusted for severity and potential confounding factors identified that early use of corticosteroids was not significantly associated with mortality [hazard ratio (HR) 1.3, 95% CI 0.7-2.4, p = 0.4] but was still associated with an increased rate of HAP (OR 2.2, 95% CI 1.0-4.8, p < 0.05). When only patients developing acute respiratory distress syndrome (ARDS) were analyzed, similar results were observed. Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza A infection did not result in better outcomes and was associated with increased risk of superinfections.

To develop a regional ICU mortality prediction model during the first 24 h of ICU admission utilizing MODS and NEMS with six other independent variables from the Critical Care Information System (CCIS) Ontario, Canada.

PubMed

Kao, Raymond; Priestap, Fran; Donner, Allan

2016-01-01

Intensive care unit (ICU) scoring systems or prediction models evolved to meet the desire of clinical and administrative leaders to assess the quality of care provided by their ICUs. The Critical Care Information System (CCIS) is province-wide data information for all Ontario, Canada level 3 and level 2 ICUs collected for this purpose. With the dataset, we developed a multivariable logistic regression ICU mortality prediction model during the first 24 h of ICU admission utilizing the explanatory variables including the two validated scores, Multiple Organs Dysfunctional Score (MODS) and Nine Equivalents Nursing Manpower Use Score (NEMS) followed by the variables age, sex, readmission to the ICU during the same hospital stay, admission diagnosis, source of admission, and the modified Charlson Co-morbidity Index (CCI) collected through the hospital health records. This study is a single-center retrospective cohort review of 8822 records from the Critical Care Trauma Centre (CCTC) and Medical-Surgical Intensive Care Unit (MSICU) of London Health Sciences Centre (LHSC), Ontario, Canada between 1 Jan 2009 to 30 Nov 2012. Multivariable logistic regression on training dataset (n = 4321) was used to develop the model and validate by bootstrapping method on the testing dataset (n = 4501). Discrimination, calibration, and overall model performance were also assessed. The predictors significantly associated with ICU mortality included: age (p < 0.001), source of admission (p < 0.0001), ICU admitting diagnosis (p < 0.0001), MODS (p < 0.0001), and NEMS (p < 0.0001). The variables sex and modified CCI were not significantly associated with ICU mortality. The training dataset for the developed model has good discriminating ability between patients with high risk and those with low risk of mortality (c-statistic 0.787). The Hosmer and Lemeshow goodness-of-fit test has a strong correlation between the observed and expected ICU mortality (χ (2) = 5

Late HIV diagnosis is a major risk factor for intensive care unit admission in HIV-positive patients: a single centre observational cohort study

PubMed Central

2013-01-01

Background HIV positive patients are at risk of infectious and non-infectious complications that may necessitate intensive care unit (ICU) admission. While the characteristics of patients requiring ICU admission have been described previously, these studies did not include information on the denominator population from which these cases arose. Methods We conducted an observational cohort study of ICU admissions among 2751 HIV positive patients attending King’s College Hospital, South London, UK. Poisson regression models were used to identify factors associated with ICU admission. Results The overall incidence rate of ICU admission was 1.0 [95% CI 0.8, 1.2] per 100 person-years of follow up, and particularly high early (during the first 3 months) following HIV diagnosis (12.4 [8.7, 17.3] per 100 person-years compared to 0.37 [0.27, 0.50] per 100 person-years thereafter; incidence rate ratio 33.5 [23.4, 48.1], p < 0.001). In time-updated analyses, AIDS and current CD4 cell counts of less than 200 cells/mm3 were associated with an increased incidence of ICU admission while receipt of combination antiretroviral therapy (cART) was associated with a reduced incidence of ICU admission. Late HIV diagnosis (initial CD4 cell count <350 or AIDS within 3 months of HIV diagnosis) applied to 81% of patients who were first diagnosed HIV positive during the study period and who required ICU admission. Late HIV diagnosis was significantly associated with ICU admission in the first 3 months following HIV diagnosis (adjusted incidence rate ratio 8.72, 95% CI 2.76, 27.5). Conclusions Late HIV diagnosis was a major risk factor for early ICU admission in our cohort. Earlier HIV diagnosis allowing cART initiation at CD4 cell counts of 350 cells/mm3 is likely to have a significant impact on the need for ICU care. PMID:23331544

Characteristics and outcomes of patients admitted to ICU following activation of the medical emergency team: impact of introducing a two-tier response system.

PubMed

Aneman, Anders; Frost, Steven A; Parr, Michael J; Hillman, Ken M

2015-04-01

To determine the impact of introducing a two-tier system for responding to deteriorating ward patients on ICU admissions after medical emergency team review. Retrospective database review before (2006-2009) and after (2011-2013) the introduction of a two-tier system. Tertiary, university-affiliated hospital. A total of 1,564 ICU admissions. Two-tier rapid response system. The median number of medical emergency team activations/1,000 hospitalizations increased from 22 to 31 (difference [95% CI], 9 [5-10]; p<0.0001) with a decreased rate of medical emergency team activations leading to ICU admission (from median 11 to 8; difference [95% CI], 3 [3-4]; p=0.03). The median proportion of medical emergency team reviews leading to ICU admission increased for those triggered by tachypnoea (from 11% to 15%; difference [95% CI], 4 [3-5]; p<0.0001) and by hypotension (from 27% to 43%; difference [95% CI], 15 [12-19]; p<0.0001) and decreased for those triggered by reduced level of consciousness (from 20% to 17%; difference [95% CI], 3 [2-4]; p<0.0001) and by clinical concern (from 18% to 9%; difference [95% CI], 10 [9-13]; p<0.0001). The proportions of ICU admissions following medical emergency team review did not change significantly for tachycardia, seizure, or cardiorespiratory arrest. The overall ICU mortality for admissions following medical emergency team review for tachypnoea, tachycardia, and clinical concern decreased (from 29% to 9%: difference [95% CI], 20 [11-29]; p<0.0001) but did not change for the other triggers. The Acute Physiology and Chronic Health Evaluation predicted and observed ICU mortality and the proportion of patients dying with a not-for-resuscitation order decreased. The introduction of a two-tier response to clinical deterioration increased ICU admissions triggered by cardiorespiratory criteria, whereas admissions triggered by more subjective criteria decreased. The overall ICU mortality for patients admitted following medical emergency team review

The Association Between Visiting Intensivists and ICU Outcomes.

PubMed

Whitehouse, Tony; Hodson, James; Pemberton, Philip; Veenith, Tonny; Snelson, Catherine; Bion, Julian; Rubenfeld, Gordon D

2017-06-01

We hypothesized that intensivists unfamiliar with an ICU team and the context of that ICU would affect patient outcomes. We examined differences in mortality when ICU patients were admitted under intensivists routinely working in that ICU and compared with those admitted by intensivists familiar with an ICU elsewhere in the same hospital. A 5-year natural experimental crossover study involving patients admitted to four ICUs in a large U.K. teaching hospital. During a period of service reconfiguration, intensivists routinely rostered to work in one ICU worked in another of the hospital's four ICUs. "Home" intensivists were those who continued to work in their usual ICU; "visitor" intensivists were those who delivered care in an unfamiliar ICU. Patient data were obtained from electronic patient records to provide analysis on sex, age, admission Sequential Organ Failure Assessment score, date and time of admission, and admission type (elective, transfer, or unplanned). We analyzed 9,981 admissions to four separate ICUs over a 5-year period. In total, 34.5% of patients were admitted by intensivists working in nonfamiliar surroundings. Visitor intensivists admitted patients with similar age and gender distributions but with greater physiologic derangement (mean Sequential Organ Failure Assessment score, 4.1 ± 2.8 vs 3.9 ± 2.8; p < 0.001) than home intensivists. Overall ICU mortality rates were higher in visitor intensivists, albeit not significantly so (11.5% vs 10.2%; p = 0.052). However, when the ICUs were analyzed separately, visitor mortality rates were found to be significantly higher than for home intensivists in two of the four ICUs (p = 0.017, 0.006). A multivariable analysis adjusting for confounding factors and the clustering of consultants revealed that the overall mortality rate was significantly higher for visitors (odds ratio, 1.18; 95% CI, 1.02-1.37; p = 0.024). A significant interaction between the ICU and visitor status was also detected (p

First influenza season after the 2009 pandemic influenza: report of the first 300 ICU admissions in Spain.

PubMed

Rodríguez, A; Martin-Loeches, I; Bonastre, J; Olaechea, P; Alvarez-Lerma, F; Zaragoza, R; Guerrero, J; Blanco, J; Gordo, F; Pozo, F; Lorente, J; Carratalá, J; Cordero, M; Rello, J; Esteban, A; León, C

2011-05-01

During the 2009 influenza pandemic, several reports were published, nevertheless, data on the clinical profiles of critically ill patients with the new virus infection during this second outbreak are still lacking. Prospective, observational, multi-center study conducted in 148 Spanish intensive care units (ICU) during epidemiological weeks 50-52 of 2010 and weeks 1 - 4 of 2011. Three hundred patients admitted to an intensive care unit (ICU) with confirmed An/H1N1 infection were analyzed. The median age was 49 years [IQR=38-58] and 62% were male. The mean APACHE II score was 16.9 ± 7.5 and the mean SOFA score was 6.3 ± 3.5 on admission. Comorbidities were present in 76% (n=228) of cases and 111 (37.4%) patients were reportedly obese and 59 (20%) were COPD. The main presentation was viral pneumonia with severe hypoxemia in 65.7% (n=197) of the patients whereas co-infection was identified in 54 (18%) patients. All patients received antiviral treatment and initiated empirically in 194 patients (65.3%), however only 53 patients (17.6%) received early antiviral treatment. Vaccination was only administered in 22 (7.3%) patients. Sixty-seven of 200 patients with ICU discharge died. Haematological disease, severity of illness, infiltrates in chest X-ray and need for mechanical ventilation were variables independently associated with ICU mortality. In patients admitted to the ICU in the post-pandemic seasonal influenza outbreak vaccination was poorly implemented and appear to have higher frequency of severe comorbidities, severity of illness, incidence of primary viral pneumonia and increased mortality when compared with those observed in the 2009 pandemic outbreak. Copyright © 2011 Elsevier España, S.L. y SEMICYUC. All rights reserved.

Subjects hospitalized with the 2009 pandemic influenza A (H1N1) virus in a respiratory infection unit: clinical factors correlating with ICU admission.

PubMed

Rovina, Nikoletta; Erifaki, Magdalini; Katsaounou, Paraskevi; Lyxi, Georgia; Koutsoukou, Antonia; Koulouris, Nikolaos G; Alchanatis, Manos

2014-10-01

The 2009 pandemic influenza A (H1N1) virus was accompanied by high morbidity and mortality. The aim of this study was to describe the clinical characteristics of patients with documented 2009 influenza A (H1N1) virus admitted to a reference chest hospital, the disease outcome, and risk factors associated with ICU admission. We assessed 109 subjects admitted to the respiratory infection unit of a hospital for chest disease with signs and symptoms of the 2009 influenza A (H1N1) virus between April 2009 and December 2010. Demographic data, comorbidities, clinical signs and symptoms, laboratory tests, radiographic findings, treatment, and final outcomes were all recorded. Factors associated with severe disease requiring ICU admission were determined. Ninety subjects (82.5%) had laboratory-confirmed 2009 influenza A (H1N1). Sixty-four percent of these subjects had pneumonia on admission, 26% had respiratory failure, and 11% required care in the ICU. Dyspnea and the presence of infiltrates on chest x-rays were the most common signs among the subjects with H1N1. All subjects were treated with antiviral therapy, and 75% received antibiotic treatment based on their clinical and laboratory findings. The predictive factors of ICU admission were severe hypoxemia and lymphocytosis. The outcome of subjects with influenza A (H1N1) virus infection was influenced by the severity of the disease on admission, the subjects' underlying conditions, and complications during hospitalization. Copyright © 2014 by Daedalus Enterprises.

Prognostic value of admission serum lactate concentrations in intensive care unit patients.

PubMed

Soliman, H M; Vincent, J-L

2010-01-01

Although blood lactate concentrations have an established prognostic value in circulatory shock or after cardiac arrest, their relationship with morbidity and length of stay in general intensive care unit (ICU) populations has not been well defined. This study included all 433 patients (246 surgical and 187 medical) consecutively admitted to the Department of medico-surgical intensive care. Hyperlactataemia was defined as a serum lactate concentration > or = 2 mEq/l. On admission, 195 patients (45%) had hyperlactataemia. Hyperlactataemic patients had higher Acute Physiology and Chronic Health Evaluation (APACHE) II (13.3 +/- 6.9 vs 10.0 +/- 5.2) and Sequential Organ Failure Assessment (SOFA) (5.3 +/- 3.3 vs 3.3 +/- 2.3) scores than patients with normal lactate concentrations (both p < 0.01). There was no overall difference in length of ICU stay (LOS) between the two groups but survivors in the hyperlactataemic group had a longer LOS than survivors in the normal lactate group, whereas hyperlactataemic non-survivors had a shorter LOS than normal lactate non-survivors. Mortality was 9% in patients with normal lactate concentrations and 23% in hyperlactataemic patients. The mortality rate increased with increasing lactate concentrations, from 17% in patients with lactate concentrations from 2-4 mEq/l to 64% in those with concentrations more than 8 mEq/l. Non-survivors had higher lactate concentrations than survivors on admission, and after 24 and 48 hours. Risk factors for developing hyperlactataemia that were present on admission were SOFA score > 5, mean arterial blood pressure less than 70 mmHg, blood sugar greater than 110 mg/dl, and current use of vasopressors. Our study documents a direct relationship between the serum lactate level on ICU admission and not only the risk of death in ICU but also the length of ICU stay. Hyperlactataemic survivors have a longer LOS and non-survivors a shorter LOS than normal lactate survivors and non-survivors, respectively.

Clinical impact of sepsis at admission to the ICU of a private hospital in Salvador, Brazil.

PubMed

Juncal, Verena Ribeiro; Britto Neto, Lelivaldo Antonio de; Camelier, Aquiles Assunção; Messeder, Octavio Henrique Coelho; Farias, Augusto Manoel de Carvalho

2011-01-01

To describe the clinical characteristics, laboratory data, and clinical outcomes of patients with and without sepsis admitted to the ICU of a private hospital in the city of Salvador, Brazil, and to identify clinical variables related to a worse prognosis in those with sepsis. This was a longitudinal study including all patients admitted to the general ICU of the Hospital Português, in the city of Salvador, Brazil, between June of 2008 and March of 2009. At ICU admission, two groups of patients were identified: with sepsis and without sepsis. Epidemiological, clinical and laboratory data were collected, and the Acute Physiology and Chronic Health Evaluation II (APACHE II) score was calculated. Of the 144 patients in the study, 29 (20.1%) had sepsis. Among the patients with sepsis, males accounted for 55.2%, the mean age was 73.1 ± 14.6 years, and the mean APACHE II score was 23.8 ± 9.1, compared with 36.3%, 68.7 ± 17.7 years, and 18.4 ± 9.5, respectively, among those without sepsis. There were significant associations between a diagnosis of sepsis and the following variables: APACHE II score; in-hospital mortality; ICU mortality; HR; mean arterial pressure; hematocrit level; white blood cell count; and antibiotic use. The use of life support measures and lower hematocrit levels were associated with a worse prognosis in the patients with sepsis. The patients diagnosed with sepsis presented worse clinical outcomes, probably due to their greater severity. Hematocrit level was the only variable that was a predictor of mortality risk in the patients with sepsis.

Effect of methylphenidate on ICU and hospital length of stay in patients with severe and moderate traumatic brain injury.

PubMed

Moein, Houshang; Khalili, Hossein A; Keramatian, Kamyar

2006-09-01

Traumatic brain injury is one of the major causes of death and disability among young people. Methylphenidate, a neural stimulant and protective drug, which has been mainly used for childhood attention deficit/hyperactivity disorder, has shown some benefits in late psychosocial problems in patients with traumatic brain injury. Its effect on arousal and consciousness has been also revealed in the sub-acute phase of traumatic brain injury. We studied its effect on the acute phase of moderate and severe traumatic brain injury (TBI) in relation to the length of ICU and hospital admission. Severely and moderately TBI patients (according to inclusion and exclusion criteria) were randomized to treatment and control groups. The treatment group received methylphenidate 0.3mg/kg per dose PO BID by the second day of admission until the time of discharge, and the control group received a placebo. Admission information and daily Glasgow Coma Scale (GCS) were recorded. Medical, surgical, and discharge plans for patients were determined by the attending physician, blinded to the study. Forty patients with severe TBI (GCS = 5-8) and 40 moderately TBI patients (GCS = 9-12) were randomly divided into treatment and control groups on the day of admission. In the severely TBI patients, both hospital and ICU length of stay, on average, were shorter in the treatment group compared with the control group. In the moderately TBI patients while ICU stay was shorter in the treatment group, there was no significant reduction of the period of hospitalization. There were no significant differences between the treatment and control groups in terms of age, sex, post resuscitation GCS, or brain CT scan findings, in either severely or moderately TBI patients. Methylphenidate was associated with reductions in ICU and hospital length of stay by 23% in severely TBI patients (P = 0.06 for ICU and P = 0.029 for hospital stay time). However, in the moderately TBI patients who received methylphenidate

Epidemiological profile of ICU patients at Faculdade de Medicina de Marília.

PubMed

El-Fakhouri, Silene; Carrasco, Hugo Victor Cocca Gimenez; Araújo, Guilherme Campos; Frini, Inara Cristina Marciano

2016-01-01

To characterize the epidemiological profile of the hospitalized population in the ICU of Hospital das Clínicas de Marília (Famema). A retrospective, descriptive and quantitative study. Data regarding patients admitted to the ICU Famema was obtained from the Technical Information Center (Núcleo Técnico de Informações, NTI, Famema). For data analysis, we used the distribution of absolute and relative frequencies with simple statistical treatment. 2,022 ICU admissions were recorded from June 2010 to July 2012 with 1,936 being coded according to the ICD-10. The epidemiological profile comprised mostly males (57.91%), predominantly seniors ≥ 60 years (48.89%), at an average age of 56.64 years (±19.18), with limited formal education (63.3% complete primary school), mostly white (77.10%), Catholic (75.12%), from the city of Marília, state of São Paulo, Brazil (53.81%). The average occupancy rate was 94.42%. The predominant cause of morbidity was diseases of the circulatory system with 494 admissions (25.5%), followed by traumas and external causes with 446 admissions (23.03%) and neoplasms with 213 admissions (11.00%). The average stay was 8.09 days (±10.73). The longest average stay was due to skin and subcutaneous tissue diseases, with average stay of 12.77 days (±17.07). There were 471 deaths (24.32%), mainly caused by diseases of the circulatory system (30.99%). The age group with the highest mortality was the range from 70 to 79 years with 102 deaths (21.65%). The ICU Famema presents an epidemiological profile similar to other intensive care units in Brazil and worldwide, despite the few studies available in the literature. Thus, we feel in tune with the treatment of critical care patients.

Antibiotic Prescription, Organisms and its Resistance Pattern in Patients Admitted to Respiratory ICU with Respiratory Infection in Mysuru.

PubMed

Mahendra, M; Jayaraj, B S; Lokesh, K S; Chaya, S K; Veerapaneni, Vivek Vardhan; Limaye, Sneha; Dhar, Raja; Swarnakar, Rajesh; Ambalkar, Shrikant; Mahesh, P A

2018-04-01

Respiratory infections account for significant morbidity, mortality and expenses to patients getting admitted to ICU. Antibiotic resistance is a major worldwide concern in ICU, including India. It is important to know the antibiotic prescribing pattern in ICU, organisms and its resistance pattern as there is sparse data on Indian ICUs. We conducted a prospective study from August 2015 to February 2016. All patients getting admitted to RICU with respiratory infection who were treated with antibiotics were included into study. Demographic details, comorbidities, Clinco-pathological score (CPI) on day1 and 2 of admission, duration of ICU admission, number of antibiotics used, antibiotic prescription, antimicrobial resistance pattern of patients were collected using APRISE questionnaire. During study period 352 patients were screened and 303 patients were included into study. Mean age was 56.05±16.37 and 190 (62.70%) were men. Most common diagnosis was Pneumonia (66%). Piperacillin-tazobactam was most common empirical antibiotic used. We found 60% resistance to piperacillin-tazobactam. Acinetobacter baumanii was the most common organism isolated (29.2%) and was highly resistant to Carbapenem (60%). Klebsiella pneumoniae was resistant to Amikacin (45%), piperacillin (55%) and Ceftazidime (50%). Piperacillin-tazobactam was the most common antibiotic prescribed to patients with respiratory infection admitted to ICU. More than half of patients (60%) had resistance to the empirical antibiotic used in our ICU, highlighting the need for antibiogram for each ICU. Thirty six percent of patient had prior antibiotic use and had mainly gram negative organisms with high resistance to commonly used antibiotics.

Antibiotic Prescription, Organisms and its Resistance Pattern in Patients Admitted to Respiratory ICU with Respiratory Infection in Mysuru

PubMed Central

Mahendra, M; Jayaraj, BS; Lokesh, KS; Chaya, SK; Veerapaneni, Vivek Vardhan; Limaye, Sneha; Dhar, Raja; Swarnakar, Rajesh; Ambalkar, Shrikant; Mahesh, PA

2018-01-01

Aim of Study: Respiratory infections account for significant morbidity, mortality and expenses to patients getting admitted to ICU. Antibiotic resistance is a major worldwide concern in ICU, including India. It is important to know the antibiotic prescribing pattern in ICU, organisms and its resistance pattern as there is sparse data on Indian ICUs. Materials and Methods: We conducted a prospective study from August 2015 to February 2016. All patients getting admitted to RICU with respiratory infection who were treated with antibiotics were included into study. Demographic details, comorbidities, Clinco-pathological score (CPI) on day1 and 2 of admission, duration of ICU admission, number of antibiotics used, antibiotic prescription, antimicrobial resistance pattern of patients were collected using APRISE questionnaire. Results: During study period 352 patients were screened and 303 patients were included into study. Mean age was 56.05±16.37 and 190 (62.70%) were men. Most common diagnosis was Pneumonia (66%). Piperacillin-tazobactam was most common empirical antibiotic used. We found 60% resistance to piperacillin-tazobactam. Acinetobacter baumanii was the most common organism isolated (29.2%) and was highly resistant to Carbapenem (60%). Klebsiella pneumoniae was resistant to Amikacin (45%), piperacillin (55%) and Ceftazidime (50%). Conclusion: Piperacillin-tazobactam was the most common antibiotic prescribed to patients with respiratory infection admitted to ICU. More than half of patients (60%) had resistance to the empirical antibiotic used in our ICU, highlighting the need for antibiogram for each ICU. Thirty six percent of patient had prior antibiotic use and had mainly gram negative organisms with high resistance to commonly used antibiotics. PMID:29743760

The ICU-Diary study: prospective, multicenter comparative study of the impact of an ICU diary on the wellbeing of patients and families in French ICUs.

PubMed

Garrouste-Orgeas, Maïté; Flahault, Cécile; Fasse, Léonor; Ruckly, Stéphane; Amdjar-Badidi, Nora; Argaud, Laurent; Badie, Julio; Bazire, Amélie; Bige, Naike; Boulet, Eric; Bouadma, Lila; Bretonnière, Cédric; Floccard, Bernard; Gaffinel, Alain; de Forceville, Xavier; Grand, Hubert; Halidfar, Rebecca; Hamzaoui, Olfa; Jourdain, Mercé; Jost, Paul-Henri; Kipnis, Eric; Large, Audrey; Lautrette, Alexandre; Lesieur, Olivier; Maxime, Virginie; Mercier, Emmanuelle; Mira, Jean Paul; Monseau, Yannick; Parmentier-Decrucq, Erika; Rigaud, Jean-Philippe; Rouget, Antoine; Santoli, François; Simon, Georges; Tamion, Fabienne; Thieulot-Rolin, Nathalie; Thirion, Marina; Valade, Sandrine; Vinatier, Isabelle; Vioulac, Christel; Bailly, Sebastien; Timsit, Jean-François

2017-11-15

Post-intensive care syndrome includes the multiple consequences of an intensive care unit (ICU) stay for patients and families. It has become a new challenge for intensivists. Prevention programs have been disappointing, except for ICU diaries, which report the patient's story in the ICU. However, the effectiveness of ICU diaries for patients and families is still controversial, as the interpretation of the results of previous studies was open to criticism hampering an expanded use of the diary. The primary objective of the study is to evaluate the post-traumatic stress syndrome in patients. The secondary objectives are to evaluate the post-traumatic stress syndrome in families, anxiety and depression symptoms in patients and families, and the recollected memories of patients. Endpoints will be evaluated 3 months after ICU discharge or death. A prospective, multicenter, randomized, assessor-blind comparative study of the effect of an ICU diary on patients and families. We will compare two groups: one group with an ICU diary written by staff and family and given to the patient at ICU discharge or to the family in case of death, and a control group without any ICU diary. Each of the 35 participating centers will include 20 patients having at least one family member who will likely visit the patient during their ICU stay. Patients must be ventilated within 48 h after ICU admission and not have any previous chronic neurologic or acute condition responsible for cognitive impairments that would hamper their participation in a phone interview. Three months after ICU discharge or death of the patient, a psychologist will contact the patient and family by phone. Post-traumatic stress syndrome will be evaluated using the Impact of Events Scale-Revised questionnaire, anxiety and depression symptoms using the Hospital Anxiety and Depression Scale questionnaire, both in patients and families, and memory recollection using the ICU Memory Tool Questionnaire in patients. The

Severity assessment tools in ICU patients with 2009 influenza A (H1N1) pneumonia.

PubMed

Pereira, J M; Moreno, R P; Matos, R; Rhodes, A; Martin-Loeches, I; Cecconi, M; Lisboa, T; Rello, J

2012-10-01

The aim of this study was to determine if severity assessment tools (general severity of illness and community-acquired pneumonia specific scores) can be used to guide decisions for patients admitted to the intensive care unit (ICU) due to pandemic influenza A pneumonia. A prospective, observational, multicentre study included 265 patients with a mean age of 42 (±16.1) years and an ICU mortality of 31.7%. On admission to the ICU, the mean pneumonia severity index (PSI) score was 103.2 ± 43.2 points, the CURB-65 score was 1.7 ± 1.1 points and the PIRO-CAP score was 3.2 ± 1.5 points. None of the scores had a good predictive ability: area under the ROC for PSI, 0.72 (95% CI, 0.65-0.78); CURB-65, 0.67 (95% CI, 0.59-0.74); and PIRO-CAP, 0.64 (95% CI, 0.56-0.71). The PSI score (OR, 1.022 (1.009-1.034), p 0.001) was independently associated with ICU mortality; however, none of the three scores, when used at ICU admission, were able to reliably detect a low-risk group of patients. Low risk for mortality was identified in 27.5% of patients using PIRO-CAP, but above 40% when using PSI (I-III) or CURB65 (<2). Observed mortality was 13.7%, 13.5% and 19.4%, respectively. Pneumonia-specific scores undervalued severity and should not be used as instruments to guide decisions in the ICU. © 2011 The Authors. Clinical Microbiology and Infection © 2011 European Society of Clinical Microbiology and Infectious Diseases.

Blood Urea Nitrogen (BUN) is independently associated with mortality in critically ill patients admitted to ICU.

PubMed

Arihan, Okan; Wernly, Bernhard; Lichtenauer, Michael; Franz, Marcus; Kabisch, Bjoern; Muessig, Johanna; Masyuk, Maryna; Lauten, Alexander; Schulze, Paul Christian; Hoppe, Uta C; Kelm, Malte; Jung, Christian

2018-01-01

Blood urea nitrogen (BUN) was reported to be associated with mortality in heart failure patients. We aimed to evaluate admission BUN concentration in a heterogeneous critically ill patient collective admitted to an intensive care unit (ICU) for prognostic relevance. A total of 4176 medical patients (67±13 years) admitted to a German ICU between 2004 and 2009 were included. Follow-up of patients was performed retrospectively between May 2013 and November 2013. Association of admission BUN and both intra-hospital and long-term mortality were investigated by Cox regression. An optimal cut-off was calculated by means of the Youden-Index. Patients with higher admission BUN concentration were older, clinically sicker and had more pronounced laboratory signs of multi-organ failure including kidney failure. Admission BUN was associated with adverse long-term mortality (HR 1.013; 95%CI 1.012-1.014; p<0.001). An optimal cut-off was calculated at 28 mg/dL which was associated with adverse outcome even after correction for APACHE2 (HR 1.89; 95%CI 1.59-2.26; p<0.001), SAPS2 (HR 1.85; 95%CI 1.55-2.21; p<0.001) and several parameters including creatinine in an integrative model (HR 3.34; 95%CI 2.89-3.86; p<0.001). We matched 614 patients with admission BUN >28 mg/dL to case-controls ≤ 28mg/dL corrected for APACHE2 scores: BUN above 28 mg/dL remained associated with adverse outcome in a paired analysis with the difference being 5.85% (95%CI 1.23-10.47%; p = 0.02). High BUN concentration at admission was robustly associated with adverse outcome in critically ill patients admitted to an ICU, even after correction for co-founders including renal failure. BUN might constitute an independent, easily available and important parameter for risk stratification in the critically ill.

Blood Urea Nitrogen (BUN) is independently associated with mortality in critically ill patients admitted to ICU

PubMed Central

Lichtenauer, Michael; Franz, Marcus; Kabisch, Bjoern; Muessig, Johanna; Masyuk, Maryna; Lauten, Alexander; Schulze, Paul Christian; Hoppe, Uta C.; Kelm, Malte; Jung, Christian

2018-01-01

Purpose Blood urea nitrogen (BUN) was reported to be associated with mortality in heart failure patients. We aimed to evaluate admission BUN concentration in a heterogeneous critically ill patient collective admitted to an intensive care unit (ICU) for prognostic relevance. Methods A total of 4176 medical patients (67±13 years) admitted to a German ICU between 2004 and 2009 were included. Follow-up of patients was performed retrospectively between May 2013 and November 2013. Association of admission BUN and both intra-hospital and long-term mortality were investigated by Cox regression. An optimal cut-off was calculated by means of the Youden-Index. Results Patients with higher admission BUN concentration were older, clinically sicker and had more pronounced laboratory signs of multi-organ failure including kidney failure. Admission BUN was associated with adverse long-term mortality (HR 1.013; 95%CI 1.012–1.014; p<0.001). An optimal cut-off was calculated at 28 mg/dL which was associated with adverse outcome even after correction for APACHE2 (HR 1.89; 95%CI 1.59–2.26; p<0.001), SAPS2 (HR 1.85; 95%CI 1.55–2.21; p<0.001) and several parameters including creatinine in an integrative model (HR 3.34; 95%CI 2.89–3.86; p<0.001). We matched 614 patients with admission BUN >28 mg/dL to case-controls ≤ 28mg/dL corrected for APACHE2 scores: BUN above 28 mg/dL remained associated with adverse outcome in a paired analysis with the difference being 5.85% (95%CI 1.23–10.47%; p = 0.02). Conclusions High BUN concentration at admission was robustly associated with adverse outcome in critically ill patients admitted to an ICU, even after correction for co-founders including renal failure. BUN might constitute an independent, easily available and important parameter for risk stratification in the critically ill. PMID:29370259

Anemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU length of stay: a cohort study

PubMed Central

Chant, Clarence; Wilson, Gail; Friedrich, Jan O

2006-01-01

Introduction Anemia among the critically ill has been described in patients with short to medium length of stay (LOS) in the intensive care unit (ICU), but it has not been described in long-stay ICU patients. This study was performed to characterize anemia, transfusion, and phlebotomy practices in patients with prolonged ICU LOS. Methods We conducted a retrospective chart review of consecutive patients admitted to a medical-surgical ICU in a tertiary care university hospital over three years; patients included had a continuous LOS in the ICU of 30 days or longer. Information on transfusion, phlebotomy, and outcomes were collected daily from days 22 to 112 of the ICU stay. Results A total of 155 patients were enrolled. The mean age, admission Acute Physiology and Chronic Health Evaluation II score, and median ICU LOS were 62.3 ± 16.3 years, 23 ± 8, and 49 days (interquartile range 36–70 days), respectively. Mean hemoglobin remained stable at 9.4 ± 1.4 g/dl from day 7 onward. Mean daily phlebotomy volume was 13.3 ± 7.3 ml, and 62% of patients received a mean of 3.4 ± 5.3 units of packed red blood cells at a mean hemoglobin trigger of 7.7 ± 0.9 g/dl after day 21. Transfused patients had significantly greater acuity of illness, phlebotomy volumes, ICU LOS and mortality, and had a lower hemoglobin than did those who were not transfused. Multivariate logistic regression analysis identified the following as independently associated with the likelihood of requiring transfusion in nonbleeding patients: baseline hemoglobin, daily phlebotomy volume, ICU LOS, and erythropoietin therapy (used almost exclusively in dialysis dependent renal failure in this cohort of patients). Small increases in average phlebotomy (3.5 ml/day, 95% confidence interval 2.4–6.8 ml/day) were associated with a doubling in the odds of being transfused after day 21. Conclusion Anemia, phlebotomy, and transfusions, despite low hemoglobin triggers, are common in ICU patients long after admission

Long-term outcome of elderly patients requiring intensive care admission for abdominal pathologies: survival and quality of life.

PubMed

Merlani, P; Chenaud, C; Mariotti, N; Ricou, B

2007-05-01

Medical developments have allowed the management of patients aged over 70 years with severe abdominal pathologies requiring intensive care unit (ICU) admission. These patients require enhanced life support and present a high ICU mortality. We investigated the outcome and quality of life (QOL) of elderly patients 2 years after their ICU stay for abdominal pathologies. Patients aged 70 years or over with abdominal pathologies, admitted to our ICU over a period of 2 years, were included. Two years following their ICU stay, a letter informed the patients about the present study. Consent to participate was obtained by telephone. QOL was assessed by the Euro-QOL and Short Form-36 questionnaires. Other patient-centered outcomes were evaluated. Overall, 2780 patients were admitted to the ICU during the study period; 141 (5%) patients were eligible; 112 of the 141 (79%) survived their ICU stay, 95 (67%) survived their hospital stay and 52 (37%) were alive 2 years after their ICU stay; 36 of the 52 survivors (69%) answered the questionnaire. Their QOL 2 years after their ICU stay was decreased in comparison with an age-matched population. Eighty-one per cent of patients lived at home and 57% were totally independent. They perceived their ICU stay as positive and 75% stated that they would agree to go through intensive care again. Factors associated with 2-year survival were the absence of co-morbidity, absence of malignancy and a lower Simplified Acute Physiology II score on ICU admission. A high mortality rate and a decrease in QOL were observed in elderly patients with severe abdominal pathologies. Nonetheless, these patients were able to adapt well to their physical disabilities.

Fluid balance and chloride load in the first 24h of ICU admission and its relation with renal replacement therapies through a multicentre, retrospective, case-control study paired by APACHE-II.

PubMed

González-Castro, A; Ortiz-Lasa, M; Leizaola, O; Salgado, E; Irriguible, T; Sánchez-Satorra, M; Lomas-Fernández, C; Barral-Segade, P; Cordero-Vallejo, M; Rodrigo-Calabia, E; Dierssen-Sotos, T

2017-05-01

To analyse the association between water balance during the first 24h of admission to ICU and the variables related to chloride levels (chloride loading, type of fluid administered, hyperchloraemia), with the development of acute kidney injury renal replacement therapy (AKI-RRT) during patients' admission to ICU. Multicentre case-control study. Hospital-based, national, carried out in 6 ICUs. Cases were patients older than 18 years who developed an AKI-RRT. Controls were patients older than 18 years admitted to the same institutions during the study period, who did not develop AKI-RRT during ICU admission. Pairing was done by APACHE-II. An analysis of unconditional logistic regression adjusted for age, sex, APACHE-II and water balance (in evaluating the type of fluid). We analysed the variables of 430 patients: 215 cases and 215 controls. An increase of 10% of the possibility of developing AKI-RRT per 500ml of positive water balance was evident (OR: 1.09 [95% CI: 1.05 to 1.14]; P<.001). The study of mean values of chloride load administered did not show differences between the group of cases and controls (299.35±254.91 vs. 301.67±234.63; P=.92). The water balance in the first 24h of ICU admission relates to the development of IRA-TRR, regardless of chloraemia. Copyright © 2017 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

Spontaneous hypothermia on intensive care unit admission is a predictor of unfavorable neurological outcome in patients after resuscitation: an observational cohort study.

PubMed

den Hartog, Alexander W; de Pont, Anne-Cornélie J M; Robillard, Laure B M; Binnekade, Jan M; Schultz, Marcus J; Horn, Janneke

2010-01-01

A large number of patients resuscitated for primary cardiac arrest arrive in the intensive care unit (ICU) with a body temperature < 35.0 degrees C. The aim of this observational cohort study was to determine the association between ICU admission temperature and neurological outcome in this patient group. Demographics and parameters influencing neurological outcome were retrieved from the charts of all patients resuscitated for primary cardiac arrest and treated with induced mild hypothermia in our ICU from January 2006 until January 2008. Patients were divided into two groups according to their body temperature on ICU admission: a hypothermia group (< 35.0 degrees C) and a non-hypothermia group (>or=35.0 degrees C). Neurological outcome after six months was assessed by means of the Glasgow Outcome Score (GOS), with GOS 1 to 3 defined as unfavorable and GOS 4 to 5 as favorable. A logistic regression model was used to analyze the influence of the different parameters on neurological outcome. The data of 105 consecutive patients resuscitated for primary cardiac arrest and treated with induced mild hypothermia were analyzed. Median ICU admission temperature was 35.1 degrees C (interquartile range (IQR) 34.3 to 35.7). After six months, 61% of the patients had an unfavorable outcome (59% died and 2% were severely disabled), whereas 39% had a favorable outcome (moderate disability or good recovery). Among patients with spontaneous hypothermia on ICU admission, the percentage with unfavorable outcome was higher (69% versus 50%, P = 0.05). Logistic regression showed that age, acute physiology and chronic health evaluation (APACHE) II and sequential organ failure assessment (SOFA) scores and spontaneous hypothermia on ICU admission all had an increased odds ratio (OR) for an unfavorable outcome after six months. Spontaneous hypothermia had the strongest association with unfavorable outcome (OR 2.6, 95% CI (confidence interval) 1.1 to 5.9), which became even stronger after

Severe vitamin D deficiency upon admission in critically ill patients is related to acute kidney injury and a poor prognosis.

PubMed

Zapatero, A; Dot, I; Diaz, Y; Gracia, M P; Pérez-Terán, P; Climent, C; Masclans, J R; Nolla, J

2018-05-01

To evaluate the prevalence of vitamin D deficiency in critically ill patients upon admission to an Intensive Care Unit (ICU) and its prognostic implications. A single-center, prospective observational study was carried out from January to November 2015. Patients were followed-up on until death or hospital discharge. The department of Critical Care Medicine of a university hospital. All adults admitted to the ICU during the study period, without known factors capable of altering serum 25(OH)D concentration. Determination of serum 25(OH)D levels within the first 24h following admission to the ICU. Prevalence and mortality at 28 days. The study included 135 patients, of which 74% presented deficient serum 25(OH)D levels upon admission to the ICU. Non-survivors showed significantly lower levels than survivors (8.14ng/ml [6.17-11.53] vs. 12ng/ml [7.1-20.30]; P=.04], and the serum 25(OH)D levels were independently associated to mortality (OR 2.86; 95% CI 1.05-7.86; P=.04]. The area under the ROC curve was 0.61 (95% CI 0.51-0.75), and the best cut-off point for predicting mortality was 10.9ng/ml. Patients with serum 25(OH)D<10.9ng/ml also showed higher acute kidney injury rates (13 vs. 29%; P=.02). Vitamin D deficiency is highly prevalent upon admission to the ICU. Severe Vitamin D deficiency (25[OH]D<10.9ng/ml) upon admission to the ICU is associated to acute kidney injury and mortality. Copyright © 2017 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

Cumulative lactate and hospital mortality in ICU patients

PubMed Central

2013-01-01

Background Both hyperlactatemia and persistence of hyperlactatemia have been associated with bad outcome. We compared lactate and lactate-derived variables in outcome prediction. Methods Retrospective observational study. Case records from 2,251 consecutive intensive care unit (ICU) patients admitted between 2001 and 2007 were analyzed. Baseline characteristics, all lactate measurements, and in-hospital mortality were recorded. The time integral of arterial blood lactate levels above the upper normal threshold of 2.2 mmol/L (lactate-time-integral), maximum lactate (max-lactate), and time-to-first-normalization were calculated. Survivors and nonsurvivors were compared and receiver operating characteristic (ROC) analysis were applied. Results A total of 20,755 lactate measurements were analyzed. Data are srpehown as median [interquartile range]. In nonsurvivors (n = 405) lactate-time-integral (192 [0–1881] min·mmol/L) and time-to-first normalization (44.0 [0–427] min) were higher than in hospital survivors (n = 1846; 0 [0–134] min·mmol/L and 0 [0–75] min, respectively; all p < 0.001). Normalization of lactate <6 hours after ICU admission revealed better survival compared with normalization of lactate >6 hours (mortality 16.6% vs. 24.4%; p < 0.001). AUC of ROC curves to predict in-hospital mortality was the largest for max-lactate, whereas it was not different among all other lactate derived variables (all p > 0.05). The area under the ROC curves for admission lactate and lactate-time-integral was not different (p = 0.36). Conclusions Hyperlactatemia is associated with in-hospital mortality in a heterogeneous ICU population. In our patients, lactate peak values predicted in-hospital mortality equally well as lactate-time-integral of arterial blood lactate levels above the upper normal threshold. PMID:23446002

Risk of Death Influences Regional Variation in Intensive Care Unit Admission Rates among the Elderly in the United States.

PubMed

Cooke, Colin R

2016-01-01

The extent to which geographic variability in ICU admission across the United States is driven by patients with lower risk of death is unknown. To determine whether patients at low to moderate risk of death contribute to geographic variation in ICU admission. Retrospective cohort of hospitalizations among Medicare beneficiaries (age > 64 years) admitted for ten common medical and surgical diagnoses (2004 to 2009). We examined population-adjusted rates of ICU admission per 100 hospitalizations in 304 health referral regions (HRR), and estimated the relative risk of ICU admission across strata of regional ICU and risk of death, adjusted for patient and regional characteristics. ICU admission rates varied nearly two-fold across HRR quartiles (quartile 1 to 4: 13.6, 17.3, 20.0, and 25.2 per 100 hospitalizations, respectively). Observed mortality for patients in regions (quartile 4) with the greatest ICU use was 17% compared to 21% in regions with lowest ICU use (quartile 1) (p<0.001). After adjusting for patient and regional characteristics, including regional differences in ICU, skilled nursing, and long-term acute care bed capacity, individuals' risk of death modified the relationship between regional ICU use and an individual's risk of ICU admission (p for interaction<0.001). Region was least important in predicting ICU admission among patients with high (quartile 4) risk of death (RR 1.27, 95% CI 1.22-1.31, for high versus low ICU use regions), and most important for patients with moderate (quartile 2; RR 1.63, 95% CI 1.53-1.72, quartile 3; RR 1.56 95% CI 1.47-1.65) and low (quartile 1) risk of death (RR 1.50, 95% CI 1.41-1.59). There is wide variation in in ICU use by geography, independent of ICU beds and physician supply, for patients with low and moderate risks of death.

Predictors of intensive care unit admission and mortality in patients with ischemic stroke: investigating the effects of a pulmonary rehabilitation program.

PubMed

Güngen, Belma Doğan; Tunç, Abdulkadir; Aras, Yeşim Güzey; Gündoğdu, Aslı Aksoy; Güngen, Adil Can; Bal, Serdar

2017-07-11

The aim of this study was to investigate the predictors of intensive care unit (ICU) admission and mortality among stroke patients and the effects of a pulmonary rehabilitation program on stroke patients. This prospective study enrolled 181 acute ischemic stroke patients aged between 40 and 90 years. Demographical characteristics, laboratory tests, diffusion-weighed magnetic resonance imaging (DWI-MRI) time, nutritional status, vascular risk factors, National Institute of Health Stroke Scale (NIHSS) scores and modified Rankin scale (MRS) scores were recorded for all patients. One-hundred patients participated in the pulmonary rehabilitation program, 81 of whom served as a control group. Statistically, one- and three-month mortality was associated with NIHSS and MRS scores at admission and three months (p<0.001; r=0.440, r=0.432, r=0.339 and r=0.410, respectively). One and three months mortality- ICU admission had a statistically significant relationship with parenteral nutrition (p<0.001; r=0.346, r=0.300, respectively; r=0.294 and r=0.294, respectively). Similarly, there was also a statistically significant relationship between pneumonia onset and one- and three-month mortality- ICU admission (p<0.05; r=0.217, r=0.127, r=0.185 and r=0.185, respectively). A regression analysis showed that parenteral nutrition (odds ratio [OR] =13.434, 95% confidence interval [CI] =1.148-157.265, p=0.038) was a significant predictor of ICU admission. The relationship between pulmonary physiotherapy (PPT) and ICU admission- pneumonia onset at the end of three months was statistically significant (p=0.04 and p=0.043, respectively). This study showed that PPT improved the prognosis of ischemic stroke patients. We believe that a pulmonary rehabilitation program, in addition to general stroke rehabilitation programs, can play a critical role in improving survival and functional outcomes. NCT03195907 . Trial registration date: 21.06.2017 'Retrospectively registered'.

Pressure ulcers in ICU patients: Incidence and clinical and epidemiological features: A multicenter study in southern Brazil.

PubMed

Becker, Delmiro; Tozo, Tatiane Cristiana; Batista, Saionara Savaris; Mattos, Andréa Luciana; Silva, Mirian Carla Bortolamedi; Rigon, Sabrina; Laynes, Rosane Lucia; Salomão, Edilaine C; Hubner, Karina Drielli Gonçalves; Sorbara, Silvia Garcia Barros; Duarte, Péricles A D

2017-10-01

To evaluate the incidence and risk factors of pressure ulcers (PU) in adult patients admitted to intensive care units (ICUs), as well as the outcome (including ICU and hospital mortality) of these patients. Epidemiological cohort multicenter prospective study, evaluating patients admitted for a period of 31days (June 01 to July 01, 2015) until hospital discharge. Epidemiological and clinical data were collected daily until ICU discharge, as was the incidence of PU, either new or present on admission. 10 general adult ICUs. We evaluated 332 patients, 52.1% male, mean age 63.1 years. The most common cause of admission was medical diseases (50.3%), and the mean APACHE II score was 14.9. A total of 45 patients (13.6%) had PU; the most common sites were sacral, calcaneal, ears, and trochanter. The incidence of PU was related to predictive factors, such as the Braden Scale and length of lack of nutrition. The presence of PU was strongly related to unfavorable outcomes, such as Mechanical Ventilation (MV) duration and ICU and hospital mortality. PU incidence is related to severity of the patient's condition and predicted by Braden Scale score. The presence of PU is also related to adverse outcomes, such as MV duration and ICU and hospital mortality. It was also shown that patients with PU have a higher incidence of medical complications, such as acute renal failure, pneumonia, and the need for vasoactive drugs. Copyright © 2017 Elsevier Ltd. All rights reserved.

Problematic Dichotomization of Risk for Intensive Care Unit (ICU)-Acquired Invasive Candidiasis: Results Using a Risk-Predictive Model to Categorize 3 Levels of Risk From a Multicenter Prospective Cohort of Australian ICU Patients.

PubMed

Playford, E Geoffrey; Lipman, Jeffrey; Jones, Michael; Lau, Anna F; Kabir, Masrura; Chen, Sharon C-A; Marriott, Deborah J; Seppelt, Ian; Gottlieb, Thomas; Cheung, Winston; Iredell, Jonathan R; McBryde, Emma S; Sorrell, Tania C

2016-12-01

 Delayed antifungal therapy for invasive candidiasis (IC) contributes to poor outcomes. Predictive risk models may allow targeted antifungal prophylaxis to those at greatest risk.  A prospective cohort study of 6685 consecutive nonneutropenic patients admitted to 7 Australian intensive care units (ICUs) for ≥72 hours was performed. Clinical risk factors for IC occurring prior to and following ICU admission, colonization with Candida species on surveillance cultures from 3 sites assessed twice weekly, and the occurrence of IC ≥72 hours following ICU admission or ≤72 hours following ICU discharge were measured. From these parameters, a risk-predictive model for the development of ICU-acquired IC was then derived.  Ninety-six patients (1.43%) developed ICU-acquired IC. A simple summation risk-predictive model using the 10 independently significant variables associated with IC demonstrated overall moderate accuracy (area under the receiver operating characteristic curve = 0.82). No single threshold score could categorize patients into clinically useful high- and low-risk groups. However, using 2 threshold scores, 3 patient cohorts could be identified: those at high risk (score ≥6, 4.8% of total cohort, positive predictive value [PPV] 11.7%), those at low risk (score ≤2, 43.1% of total cohort, PPV 0.24%), and those at intermediate risk (score 3-5, 52.1% of total cohort, PPV 1.46%).  Dichotomization of ICU patients into high- and low-risk groups for IC risk is problematic. Categorizing patients into high-, intermediate-, and low-risk groups may more efficiently target early antifungal strategies and utilization of newer diagnostic tests. © The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.

Neuro-, Trauma -, or Med/Surg-ICU: Does it matter where polytrauma patients with TBI are admitted? Secondary analysis of AAST-MITC decompressive craniectomy study

PubMed Central

Scalea, Tom; Sperry, Jason; Coimbra, Raul; Vercruysse, Gary; Jurkovich, Gregory J; Nirula, Ram

2016-01-01

Introduction Patients with non-traumatic acute intracranial pathology benefit from neurointensivist care. Similarly, trauma patients with and without TBI fare better when treated by a dedicated trauma team. No study has yet evaluated the role of specialized neurocritical (NICU) and trauma intensive care units (TICU) in the management of TBI patients, and it remains unclear which TBI patients are best served in NICU, TICU, or general (Med/Surg) ICU. Methods This study is a secondary analysis of The American Association for the Surgery of Trauma Multi-Institutional Trials Committee (AAST-MITC) decompressive craniectomy study. Twelve Level 1 trauma centers provided clinical data and head CT scans of patients with Glasgow Coma Scale (GCS) ≤13 and CT evidence of TBI. Non-ICU admissions were excluded. Multivariate logistic regression was performed to measure the association between ICU-type and survival and calculate the probability of death for increasing ISS. Polytrauma patients (ISS > 15) with TBI and isolated TBI patients (other AIS < 3) were analyzed separately. Results There were 3641 patients with CT evidence of TBI with 2951 admitted to an ICU. Prior to adjustment, patient demographics, injury severity, and survival differed significantly by unit type. After adjustment, unit-type, age and ISS remained independent predictors of death. Unit-type modified the effect of ISS on mortality. TBI-polytrauma patients admitted to a TICU had improved survival across increasing ISS (Fig1). Survival for isolated TBI patients was similar between TICU and NICU. Med/Surg ICU carried the greatest probability of death. Conclusion Polytrauma patients with TBI have lower mortality risk when admitted to a Trauma ICU. This survival benefit increases with increasing injury severity. Isolated TBI patients have similar mortality risk when admitted to a Neuro ICU compared to a Trauma ICU. Med/Surg ICU admission carries the highest mortality risk. PMID:28225527

Out-of-office hours' elective surgical intensive care admissions and their associated complications.

PubMed

Morgan, David J R; Ho, Kwok Ming; Ong, Yang Jian; Kolybaba, Marlene L

2017-11-01

The 'weekend' effect is a controversial theory that links reduced staffing levels, staffing seniority and supportive services at hospitals during 'out-of-office hours' time periods with worsening patient outcomes. It is uncertain whether admitting elective surgery patients to intensive care units (ICU) during 'out-of-office hours' time periods mitigates this affect through higher staffing ratios and seniority. Over a 3-year period in Western Australia's largest private hospital, this retrospective nested-cohort study compared all elective surgical patients admitted to the ICU based on whether their admission occurred 'in-office hours' (Monday-Friday 08.00-18.00 hours) or 'out-of-office hours' (all other times). The main outcomes were surgical complications using the Dindo-Clavien classification and length-of-stay data. Of the total 4363 ICU admissions, 3584 ICU admissions were planned following elective surgery resulting in 2515 (70.2%) in-office hours and 1069 (29.8%) out-of-office hours elective ICU surgical admissions. Out-of-office hours ICU admissions following elective surgery were associated with an increased risk of infection (P = 0.029), blood transfusion (P = 0.020), total parental nutrition (P < 0.001) and unplanned re-operations (P = 0.027). Out-of-office hours ICU admissions were also associated with an increased hospital length-of-stay, with (1.74 days longer, P < 0.0001) and without (2.8 days longer, P < 0.001) adjusting for severity of acute and chronic illnesses and inter-hospital transfers (12.3 versus 9.8%, P = 0.024). Hospital mortality (1.2 versus 0.7%, P = 0.111) was low and similar between both groups. Out-of-office hours ICU admissions following elective surgery is common and associated with serious post-operative complications culminating in significantly longer hospital length-of-stays and greater transfers with important patient and health economic implications. © 2017 Royal Australasian College of Surgeons.

Validation of a Novel Molecular Host Response Assay to Diagnose Infection in Hospitalized Patients Admitted to the ICU With Acute Respiratory Failure.

PubMed

Koster-Brouwer, Maria E; Verboom, Diana M; Scicluna, Brendon P; van de Groep, Kirsten; Frencken, Jos F; Janssen, Davy; Schuurman, Rob; Schultz, Marcus J; van der Poll, Tom; Bonten, Marc J M; Cremer, Olaf L

2018-03-01

Discrimination between infectious and noninfectious causes of acute respiratory failure is difficult in patients admitted to the ICU after a period of hospitalization. Using a novel biomarker test (SeptiCyte LAB), we aimed to distinguish between infection and inflammation in this population. Nested cohort study. Two tertiary mixed ICUs in the Netherlands. Hospitalized patients with acute respiratory failure requiring mechanical ventilation upon ICU admission from 2011 to 2013. Patients having an established infection diagnosis or an evidently noninfectious reason for intubation were excluded. None. Blood samples were collected upon ICU admission. Test results were categorized into four probability bands (higher bands indicating higher infection probability) and compared with the infection plausibility as rated by post hoc assessment using strict definitions. Of 467 included patients, 373 (80%) were treated for a suspected infection at admission. Infection plausibility was classified as ruled out, undetermined, or confirmed in 135 (29%), 135 (29%), and 197 (42%) patients, respectively. Test results correlated with infection plausibility (Spearman's rho 0.332; p < 0.001). After exclusion of undetermined cases, positive predictive values were 29%, 54%, and 76% for probability bands 2, 3, and 4, respectively, whereas the negative predictive value for band 1 was 76%. Diagnostic discrimination of SeptiCyte LAB and C-reactive protein was similar (p = 0.919). Among hospitalized patients admitted to the ICU with clinical uncertainty regarding the etiology of acute respiratory failure, the diagnostic value of SeptiCyte LAB was limited.

Severe cytomegalovirus infections in immunocompetent patients at admission as dengue mimic: successful treatment with intravenous ganciclovir.

PubMed

Tirumala, Suhasini; Behera, Bijayini; Lingala, Shilpa; Kumar, B Vijay; Mishra, Pradeep Kumar; Gurunath, J M; HariCharan; Kartik; Naresh

2012-11-01

Cytomegalovirus (CMV) infection is associated with adverse clinical outcomes in immunosuppressed persons. The incidence and association of CMV reactivation with adverse clinical outcomes in critically ill persons lacking evidence of immunosuppression at ICU admission has received great attention in the practice of critical care medicine. Critically ill patients in ICU who had associated risk factors such as mechanical ventilation, severe sepsis, or blood transfusion are more prone to CMV activation, which in turn led to increased mortality and morbidity in terms of increased ICU stay, longer duration of mechanical ventilation, and higher rates of nosocomial infections. However, severe CMV as initial presentation mimicking dengue infection is rare. We recently came across seven cases with positive CMV serology at ICU admission, which we discuss in the light of current literature. Copyright © 2012 Hainan Medical College. Published by Elsevier B.V. All rights reserved.

Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure.

PubMed

Wilson, Suprat Saely; Kwiatkowski, Gregory M; Millis, Scott R; Purakal, John D; Mahajan, Arushi P; Levy, Phillip D

2017-01-01

The purpose of this study was to compare health care resource utilization among patients who were given intravenous nitroglycerin for acute heart failure (AHF) in the emergency department (ED) by intermittent bolus, continuous infusion, or a combination of both. We retrospectively identified 395 patients that received nitroglycerin therapy in the ED for the treatment of AHF over a 5-year period. Patients that received intermittent bolus (n=124) were compared with continuous infusion therapy (n=182) and combination therapy of bolus and infusion (n=89). The primary outcomes were the frequency of intensive care unit (ICU) admission and hospital length of stay (LOS). On unadjusted analysis, rates of ICU admission were significantly lower in the bolus vs infusion and combination groups (48.4% vs 68.7% vs 83%, respectively; P<.0001) and median LOS (interquartile range) was shorter (3.7 [2.5-6.2 days]) compared with infusion (4.7 [2.9-7.1 days]) and combination (5.0 [2.9-6.7 days]) groups; P=.02. On adjusted regression models, the strong association between bolus nitroglycerin and reduced ICU admission rate remained, and hospital LOS was 1.9 days shorter compared with infusion therapy alone. Use of intubation (bolus [8.9%] vs infusion [8.8%] vs combination [16.9%]; P=.096) and bilevel positive airway pressure (bolus [26.6%] vs infusion [20.3%] vs combination [29.2%]; P=.21) were similar as was the incidence of hypotension, myocardial injury, and worsening renal function. In ED patients with AHF, intravenous nitroglycerin by intermittent bolus was associated with a lower ICU admission rate and a shorter hospital LOS compared with continuous infusion. Copyright © 2016 Elsevier Inc. All rights reserved.

Prevalence and Impact of Unknown Diabetes in the ICU.

PubMed

Carpenter, David L; Gregg, Sara R; Xu, Kejun; Buchman, Timothy G; Coopersmith, Craig M

2015-12-01

Many patients with diabetes and their care providers are unaware of the presence of the disease. Dysglycemia encompassing hyperglycemia, hypoglycemia, and glucose variability is common in the ICU in patients with and without diabetes. The purpose of this study was to determine the impact of unknown diabetes on glycemic control in the ICU. Prospective observational study. Nine ICUs in an academic, tertiary hospital and a hybrid academic/community hospital. Hemoglobin A1c levels were ordered at all ICU admissions from March 1, 2011 to September 30, 2013. Electronic medical records were examined for a history of antihyperglycemic medications or International Classification of Diseases, 9th Edition diagnosis of diabetes. Patients were categorized as having unknown diabetes (hemoglobin A1c > 6.5%, without history of diabetes), no diabetes (hemoglobin A1c < 6.5%, without history of diabetes), controlled known diabetes (hemoglobin A1c < 6.5%, with documented history of diabetes), and uncontrolled known diabetes (hemoglobin A1c > 6.5%, with documented history of diabetes). None. A total of 15,737 patients had an hemoglobin A1c and medical record evaluable for the history of diabetes, and 5,635 patients had diabetes diagnosed by either medical history or an elevated hemoglobin A1c in the ICU. Of these, 1,460 patients had unknown diabetes, accounting for 26.0% of all patients with diabetes. This represented 41.0% of patients with an hemoglobin A1c > 6.5% and 9.3% of all ICU patients. Compared with patients without diabetes, patients with unknown diabetes had a higher likelihood of requiring an insulin infusion (44.3% vs 29.3%; p < 0.0001), a higher average blood glucose (172 vs 126 mg/dL; p < 0.0001), an increased percentage of hyperglycemia (19.7% vs 7.0%; blood glucose > 180 mg/dL; p < 0.0001) and hypoglycemia (8.9% vs 2.5%; blood glucose < 70 mg/dL; p < 0.0001), higher glycemic variability (55.6 vs 28.8, average of patient SD of glucose; p < 0.0001), and increased

Unplanned admission to intensive care after emergency hospitalisation: risk factors and development of a nomogram for individualising risk.

PubMed

Frost, Steven A; Alexandrou, Evan; Bogdanovski, Tony; Salamonson, Yenna; Parr, Michael J; Hillman, Ken M

2009-02-01

Unplanned admission to an intensive care unit (ICU) is associated with high mortality, having the highest incidence among patients who are emergency admissions to the hospital. This study was designed to identify factors associated with unplanned ICU admission in emergency admissions to hospital and develop an absolute risk tool to individualise the risk of an event during a hospital stay. Emergency department (ED) and in-patient hospital data from a large teaching hospital of consecutive admissions from 1 January 1997 to 31 December 2007 aged over 14 years was included in this study. Patient data extracted from 126826 emergency presentations admitted as in-patients consisted of demographic and clinical variables. During an 11-year period 1582 incident unplanned ICU admissions occurred. Predictors of unplanned ICU admission included older age, being male, having a higher acuity triage category and a history of co-morbid conditions. Emergency department diagnostic groups associated with higher incidence of unplanned ICU admission included: sepsis, acute renal failure, lymphatic-hematopoietic tissue neoplasms, pneumonia, chronic-airways disease and bowel obstruction. The final model used to develop the nomogram had an ROC curve AUC of 0.7. This study identified factors associated with unplanned ICU admission and developed a nomogram to individualise risk prior to a patient being transferred from the ED. This nomogram provides clinicians the opportunity prior to transfer from the ED, to either (1) review the appropriateness of the ward level of planned transfer or (2) flag patients for follow-up on the general ward to assess for deterioration.

Characterisation of Candida within the Mycobiome/Microbiome of the Lower Respiratory Tract of ICU Patients

PubMed Central

Krause, Robert; Halwachs, Bettina; Thallinger, Gerhard G.; Klymiuk, Ingeborg; Gorkiewicz, Gregor; Hoenigl, Martin; Prattes, Jürgen; Valentin, Thomas; Heidrich, Katharina; Buzina, Walter; Salzer, Helmut J. F.; Rabensteiner, Jasmin; Prüller, Florian; Raggam, Reinhard B.; Meinitzer, Andreas; Moissl-Eichinger, Christine; Högenauer, Christoph; Quehenberger, Franz; Kashofer, Karl; Zollner-Schwetz, Ines

2016-01-01

Whether the presence of Candida spp. in lower respiratory tract (LRT) secretions is a marker of underlying disease, intensive care unit (ICU) treatment and antibiotic therapy or contributes to poor clinical outcome is unclear. We investigated healthy controls, patients with proposed risk factors for Candida growth in LRT (antibiotic therapy, ICU treatment with and without antibiotic therapy), ICU patients with pneumonia and antibiotic therapy and candidemic patients (for comparison of truly invasive and colonizing Candida spp.). Fungal patterns were determined by conventional culture based microbiology combined with molecular approaches (next generation sequencing, multilocus sequence typing) for description of fungal and concommitant bacterial microbiota in LRT, and host and fungal biomarkes were investigated. Admission to and treatment on ICUs shifted LRT fungal microbiota to Candida spp. dominated fungal profiles but antibiotic therapy did not. Compared to controls, Candida was part of fungal microbiota in LRT of ICU patients without pneumonia with and without antibiotic therapy (63% and 50% of total fungal genera) and of ICU patients with pneumonia with antibiotic therapy (73%) (p<0.05). No case of invasive candidiasis originating from Candida in the LRT was detected. There was no common bacterial microbiota profile associated or dissociated with Candida spp. in LRT. Colonizing and invasive Candida strains (from candidemic patients) did not match to certain clades withdrawing the presence of a particular pathogenic and invasive clade. The presence of Candida spp. in the LRT rather reflected rapidly occurring LRT dysbiosis driven by ICU related factors than was associated with invasive candidiasis. PMID:27206014

Protracted immune disorders at one year after ICU discharge in patients with septic shock.

PubMed

Riché, Florence; Chousterman, Benjamin G; Valleur, Patrice; Mebazaa, Alexandre; Launay, Jean-Marie; Gayat, Etienne

2018-02-21

Sepsis is a leading cause of mortality and critical illness worldwide and is associated with an increased mortality rate in the months following hospital discharge. The occurrence of persistent or new organ dysfunction(s) after septic shock raises questions about the mechanisms involved in the post-sepsis status. The present study aimed to explore the immune profiles of patients one year after being discharged from the intensive care unit (ICU) following treatment for abdominal septic shock. We conducted a prospective, single-center, observational study in the surgical ICU of a university hospital. Eighty-six consecutive patients admitted for septic shock of abdominal origin were included in this study. Fifteen different plasma biomarkers were measured at ICU admission, at ICU discharge and at one year after ICU discharge. Three different clusters of biomarkers were distinguished according to their functions, namely: (1) inflammatory response, (2) cell damage and apoptosis, (3) immunosuppression and resolution of inflammation. The primary objective was to characterize variations in the immune status of septic shock patients admitted to ICU up to one year after ICU discharge. The secondary objective was to evaluate the relationship between these biomarker variations and patient outcomes. At the onset of septic shock, we observed a cohesive pro-inflammatory profile and low levels of inflammation resolution markers. At ICU discharge, the immune status demonstrated decreased but persistent inflammation and increased immunosuppression, with elevated programmed cell death protein-1 (PD-1) levels, and a counterbalanced resolution process, with elevated levels of interleukin-10 (IL-10), resolvin D5 (RvD5), and IL-7. One year after hospital discharge, homeostasis was not completely restored with several markers of inflammation remaining elevated. Remarkably, IL-7 was persistently elevated, with levels comparable to those observed after ICU discharge, and PD-1, while lower

Sustaining critical care: using evidence-based simulation to evaluate ICU management policies.

PubMed

Mahmoudian-Dehkordi, Amin; Sadat, Somayeh

2017-12-01

Intensive Care Units (ICU) are costly yet critical hospital departments that should be available to care for patients needing highly specialized critical care. Shortage of ICU beds in many regions of the world and the constant fire-fighting to make these beds available through various ICU management policies motivated this study. The paper discusses the application of a generic system dynamics model of emergency patient flow in a typical hospital, populated with empirical evidence found in the medical and hospital administration literature, to explore the dynamics of intended and unintended consequences of such ICU management policies under a natural disaster crisis scenario. ICU management policies that can be implemented by a single hospital on short notice, namely premature transfer from ICU, boarding in ward, and general ward admission control, along with their possible combinations, are modeled and their impact on managerial and health outcome measures are investigated. The main insight out of the study is that the general ward admission control policy outperforms the rest of ICU management policies under such crisis scenarios with regards to reducing total mortality, which is counter intuitive for hospital administrators as this policy is not very effective at alleviating the symptoms of the problem, namely high ED and ICU occupancy rates that are closely monitored by hospital management particularly in times of crisis. A multivariate sensitivity analysis on parameters with diverse range of values in the literature found the superiority of the general ward admission control to hold true in every scenario.

Outcome and prognostic factors of patients with right-sided infective endocarditis requiring intensive care unit admission.

PubMed

Georges, Hugues; Leroy, Olivier; Airapetian, Norair; Lamblin, Nicolas; Zogheib, Elie; Devos, Patrick; Preau, Sebastien

2018-02-21

Right-sided infective endocarditis (RSIE) is an uncommon diagnosis accounting for less than 10% of cases of infective endocarditis. Optimal management for severely ill patients with RSIE remains challenging because few studies reported on management and outcome. The goal of our study was to determine outcome and associated prognostic factors in a population of ICU patients with a diagnosis of definite, active and severe RSIE. We performed a retrospective study in 10 French ICUs between January 2002 and December 2012. Main outcome was mortality at 30 days after ICU admission. Significant variables associated with 30-days mortality in the bivariate analysis were included in a logistic regression analysis. A total of 37 patients were studied. Mean age was 47.9 ± 18.4 years. Mean SAPS II, SOFA score and Charlson comorbidity index were 32.4 ± 17.4, 6.3 ± 4.4 and 3.1 ± 3.4, respectively. Causative pathogens, identified in 34 patients, were mainly staphylococci (n = 29). The source of endocarditis was a catheter related infection in 10 patients, intravenous drug abuse in 8 patients, cutaneous in 7 patients, urinary tract related in one patient and has an unknown origin in 7 patients. Vegetation size was higher than 20 mm for 14 patients. Valve tricuspid regurgitation was classified as severe in 11 patients. All patients received initial appropriate antimicrobial therapy. Aminoglycosides were delivered in combination with β-lactam antibiotics or vancomycin in 22 patients. Surgical procedure was performed in 14 patients. Eight patients (21.6%) died within 30 days following ICU admission. One independent prognostic factor was identified: use of aminoglycosides was associated with improved outcome (OR = 0.1; 95%CI = 0.0017-0.650; p = 0.007). Mortality of patients with RSIE needing ICU admission is high. Aminoglycosides used in combination with β-lactam or vancomycin could reduce 30 days mortality.

ICU early physical rehabilitation programs: financial modeling of cost savings.

PubMed

Lord, Robert K; Mayhew, Christopher R; Korupolu, Radha; Mantheiy, Earl C; Friedman, Michael A; Palmer, Jeffrey B; Needham, Dale M

2013-03-01

To evaluate the potential annual net cost savings of implementing an ICU early rehabilitation program. Using data from existing publications and actual experience with an early rehabilitation program in the Johns Hopkins Hospital Medical ICU, we developed a model of net financial savings/costs and presented results for ICUs with 200, 600, 900, and 2,000 annual admissions, accounting for both conservative- and best-case scenarios. Our example scenario provided a projected financial analysis of the Johns Hopkins Medical ICU early rehabilitation program, with 900 admissions per year, using actual reductions in length of stay achieved by this program. U.S.-based adult ICUs. Financial modeling of the introduction of an ICU early rehabilitation program. Net cost savings generated in our example scenario, with 900 annual admissions and actual length of stay reductions of 22% and 19% for the ICU and floor, respectively, were $817,836. Sensitivity analyses, which used conservative- and best-case scenarios for length of stay reductions and varied the per-day ICU and floor costs, across ICUs with 200-2,000 annual admissions, yielded financial projections ranging from -$87,611 (net cost) to $3,763,149 (net savings). Of the 24 scenarios included in these sensitivity analyses, 20 (83%) demonstrated net savings, with a relatively small net cost occurring in the remaining four scenarios, mostly when simultaneously combining the most conservative assumptions. A financial model, based on actual experience and published data, projects that investment in an ICU early rehabilitation program can generate net financial savings for U.S. hospitals. Even under the most conservative assumptions, the projected net cost of implementing such a program is modest relative to the substantial improvements in patient outcomes demonstrated by ICU early rehabilitation programs.

Triage of patients with acute gastrointestinal bleeding for intensive care unit admission based on risk factors for poor outcome.

PubMed

Afessa, B

2000-04-01

This study's aim was to determine the prognostic factors and to develop a triage system for intensive care unit (ICU) admission of patients with gastrointestinal bleeding (GIB). This prospective, observational study included 411 adults consecutively hospitalized for GIB. Each patient's selected clinical findings and laboratory values at presentation were obtained. The Acute Physiology and Chronic Health Evaluation (APACHE) II scores were calculated from the initial findings in the emergency department. Poor outcome was defined as recurrent GIB, emergency surgery, or death. The role of hepatic cirrhosis, APACHE II score, active GIB, end-organ dysfunction, and hypotension in predicting outcome was evaluated. Chi-square, Student's t, Mann-Whitney U, and logistic regression analysis tests were used for statistical comparisons. Poor outcome developed in 81 (20%) patients; 39 died, 23 underwent emergency surgery, and 47 rebled. End-organ dysfunction, active bleeding, hepatic cirrhosis, and high APACHE II scores were independent predictors of poor outcome with odds ratios of 3:1, 3:1, 2:3, and 1:1, respectively. The ICU admission rate was 37%. High APACHE II score, active bleeding, end-organ dysfunction, and hepatic cirrhosis are independent predictors of poor outcome in patients with GIB and can be used in the triage of these patients for ICU admission.

Tuberculosis in hospitalized patients: clinical characteristics of patients receiving treatment within the first 24 h after admission*

PubMed Central

Silva, Denise Rossato; da Silva, Larissa Pozzebon; Dalcin, Paulo de Tarso Roth

2014-01-01

Objective: To evaluate clinical characteristics and outcomes in patients hospitalized for tuberculosis, comparing those in whom tuberculosis treatment was started within the first 24 h after admission with those who did not. Methods: This was a retrospective cohort study involving new tuberculosis cases in patients aged ≥ 18 years who were hospitalized after seeking treatment in the emergency room. Results: We included 305 hospitalized patients, of whom 67 (22.0%) received tuberculosis treatment within the first 24 h after admission ( ≤24h group) and 238 (88.0%) did not (>24h group). Initiation of tuberculosis treatment within the first 24 h after admission was associated with being female (OR = 1.99; 95% CI: 1.06-3.74; p = 0.032) and with an AFB-positive spontaneous sputum smear (OR = 4.19; 95% CI: 1.94-9.00; p < 0.001). In the ≤24h and >24h groups, respectively, the ICU admission rate was 22.4% and 15.5% (p = 0.258); mechanical ventilation was used in 22.4% and 13.9% (p = 0.133); in-hospital mortality was 22.4% and 14.7% (p = 0.189); and a cure was achieved in 44.8% and 52.5% (p = 0.326). Conclusions: Although tuberculosis treatment was initiated promptly in a considerable proportion of the inpatients evaluated, the rates of in-hospital mortality, ICU admission, and mechanical ventilation use remained high. Strategies for the control of tuberculosis in primary care should consider that patients who seek medical attention at hospitals arrive too late and with advanced disease. It is therefore necessary to implement active surveillance measures in the community for earlier diagnosis and treatment. PMID:25029651

Bioelectrical impedance analysis-derived phase angle at admission as a predictor of 90-day mortality in intensive care patients.

PubMed

Stapel, Sandra N; Looijaard, Wilhelmus G P M; Dekker, Ingeborg M; Girbes, Armand R J; Weijs, Peter J M; Oudemans-van Straaten, Heleen M

2018-05-11

A low bioelectrical impedance analysis (BIA)-derived phase angle (PA) predicts morbidity and mortality in different patient groups. An association between PA and long-term mortality in ICU patients has not been demonstrated before. The purpose of the present study was to determine whether PA on ICU admission independently predicts 90-day mortality. This prospective observational study was performed in a mixed university ICU. BIA was performed in 196 patients within 24 h of ICU admission. To test the independent association between PA and 90-day mortality, logistic regression analysis was performed using the APACHE IV predicted mortality as confounder. The optimal cutoff value of PA for mortality prediction was determined by ROC curve analysis. Using this cutoff value, patients were categorized into low or normal PA group and the association with 90-day mortality was tested again. The PA of survivors was higher than of the non-survivors (5.0° ± 1.3° vs. 4.1° ± 1.2°, p < 0.001). The area under the ROC curve of PA for 90-day mortality was 0.70 (CI 0.59-0.80). PA was associated with 90-day mortality (OR = 0.56, CI: 0.38-0.77, p = 0.001) on univariate logistic regression analysis and also after adjusting for BMI, gender, age, and APACHE IV on multivariable logistic regression (OR = 0.65, CI: 0.44-0.96, p = 0.031). A PA < 4.8° was an independent predictor of 90-day mortality (adjusted OR = 3.65, CI: 1.34-9.93, p = 0.011). Phase angle at ICU admission is an independent predictor of 90-day mortality. This biological marker can aid in long-term mortality risk assessment of critically ill patients.

The Nociceptin/Orphanin FQ System Is Modulated in Patients Admitted to ICU with Sepsis and after Cardiopulmonary Bypass

PubMed Central

Serrano-Gomez, Alcira; McDonald, John; Ladak, Nadia; Bowrey, Sarah

2013-01-01

Background And Objectives Nociceptin/Orphanin FQ (N/OFQ) is a non-classical endogenous opioid peptide that modulates immune function in vitro. Its importance in inflammation and human sepsis is unknown. The objectives of this study were to determine the relationship between N/OFQ, transcripts for its precursor (pre-pro-N/OFQ [ppNOC]) and receptor (NOP), inflammatory markers and clinical outcomes in patients undergoing cardiopulmonary bypass and with sepsis. Methods A prospective observational cohort study of 82 patients admitted to Intensive Care (ICU) with sepsis and 40 patients undergoing cardiac surgery under cardiopulmonary bypass (as a model of systemic inflammation). Sixty three healthy volunteers, matched by age and sex to the patients with sepsis were also studied. Clinical and laboratory details were recorded. Polymorph ppNOC and NOP receptor mRNA were determined using quantitative PCR. Plasma N/OFQ was determined using ELISA and cytokines (TNF- α, IL-8, IL-10) measured using radioimmunoassay. Data from patients undergoing cardiac surgery were recorded before, 3 and 24 hours after cardiopulmonary bypass. ICU patients with sepsis were assessed on Days 1 and 2 of ICU admission, and after clinical recovery. Main Results Plasma N/OFQ concentrations increased (p<0.0001) on Days 1 and 2 of ICU admission with sepsis compared to matched recovery samples. Polymorph ppNOC (p= 0.019) and NOP mRNA (p<0.0001) decreased compared to healthy volunteers. TNF-α, IL-8 and IL-10 concentrations increased on Day 1 compared to matched recovery samples and volunteers (p<0.0001). Similar changes (increased plasma N/OFQ, [p=0.0058], decreased ppNOC [p<0.0001], increased IL-8 and IL-10 concentrations [both p<0.0001]) occurred after cardiac surgery but these were comparatively lower and of shorter duration. Conclusions The N/OFQ system is modulated in ICU patients with sepsis with similar but reduced changes after cardiac surgery under cardiopulmonary bypass. Further studies are

Performance of International Classification of Diseases-based injury severity measures used to predict in-hospital mortality and intensive care admission among traumatic brain-injured patients.

PubMed

Gagné, Mathieu; Moore, Lynne; Sirois, Marie-Josée; Simard, Marc; Beaudoin, Claudia; Kuimi, Brice Lionel Batomen

2017-02-01

The International Classification of Diseases (ICD) is the main classification system used for population-based traumatic brain injury (TBI) surveillance activities but does not contain direct information on injury severity. International Classification of Diseases-based injury severity measures can be empirically derived or mapped to the Abbreviated Injury Scale, but no single approach has been formally recommended for TBI. The aim of this study was to compare the accuracy of different ICD-based injury severity measures for predicting in-hospital mortality and intensive care unit (ICU) admission in TBI patients. We conducted a population-based retrospective cohort study. We identified all patients 16 years or older with a TBI diagnosis who received acute care between April 1, 2006, and March 31, 2013, from the Quebec Hospital Discharge Database. The accuracy of five ICD-based injury severity measures for predicting mortality and ICU admission was compared using measures of discrimination (area under the receiver operating characteristic curve [AUC]) and calibration (calibration plot and the Hosmer-Lemeshow goodness-of-fit statistic). Of 31,087 traumatic brain-injured patients in the study population, 9.0% died in hospital, and 34.4% were admitted to the ICU. Among ICD-based severity measures that were assessed, the multiplied derivative of ICD-based Injury Severity Score (ICISS-Multiplicative) demonstrated the best discriminative ability for predicting in-hospital mortality (AUC, 0.858; 95% confidence interval, 0.852-0.864) and ICU admissions (AUC, 0.813; 95% confidence interval, 0.808-0.818). Calibration assessments showed good agreement between observed and predicted in-hospital mortality for ICISS measures. All severity measures presented high agreement between observed and expected probabilities of ICU admission for all deciles of risk. The ICD-based injury severity measures can be used to accurately predict in-hospital mortality and ICU admission in TBI

[Epidemiology of acute kidney failure in Spanish ICU. Multicenter prospective study FRAMI].

PubMed

Herrera-Gutiérrez, M E; Seller-Pérez, G; Maynar-Moliner, J; Sánchez-Izquierdo-Riera, J A

2006-01-01

Multicenter study oriented at establishing the incidence and prognosis of acute kidney failure (AKF) in the ICU of our country. Prospective study of adult patients admitted over 8 months in 43 Spanish ICUs to detect AKF defined as creatinine>or=2 mg/dl or diuresis<400 ml/24 hours (in chronic patients 100% increase of creatinine, excluding those with baseline creatinine>or=4 mg/dl). 901 episodes of AKF (AKF episodes (incidence 5.7%), 55% of which occurred on admission. A total of 38.4% of the episodes were due to acute tubular necrosis (ATN), 36.6% to prerenal, and 21.2% to mixed. Renal depuration (RC) was required in 38%. Mortality was 42.3% during the AKF episode (34.1% in those who were admitted with AKF versus 50.9% in those who developed it after admission), 80% in patients with Hepatorenal Syndrome, 51.6% in ATN and 29.9% in prerenal. We detect an independent relationship with mortality for age (OR 1.03), background of diabetes (OR 2.06), development of AKF in the ICU (OR 2.51), oliguria (OR 5.76) and RC (OR 2.32). Recovery of the kidney function occurred in 85.6% of the survivors and RC was maintained in only 1.1% on discharge from the ICU. We calculated the area under the curve of APACHE II on admission (0.62), SOFA on onset of AKF (0.68), Liaño index (0.7) and maximum SOFA (0.79). AKF in ICU patients does not show an elevated incidence but does have high mortality, presenting greater seriousness when it appears after admission. However, recovery is elevated in patients who survive. The usual prognostic indexes are not exact in this patient group, the ISA and maximum SOFA being those which shows a closer relationship with mortality.

Experiences of ICU survivors in a low middle income country- a multicenter study.

PubMed

Pieris, Lalitha; Sigera, Ponsuge Chathurani; De Silva, Ambepitiyawaduge Pubudu; Munasinghe, Sithum; Rashan, Aasiyah; Athapattu, Priyantha Lakmini; Jayasinghe, Kosala Saroj Amarasiri; Samarasinghe, Kerstein; Beane, Abi; Dondorp, Arjen M; Haniffa, Rashan

2018-03-21

Stressful patient experiences during the intensive care unit (ICU) stay is associated with reduced satisfaction in High Income Countries (HICs) but has not been explored in Lower and Middle Income Countries (LMICs). This study describes the recalled experiences, stress and satisfaction as perceived by survivors of ICUs in a LMIC. This follow-up study was carried out in 32 state ICUs in Sri Lanka between July and December 2015.ICU survivors' experiences, stress factors encountered and level of satisfaction were collected 30 days after ICU discharge by a telephone questionnaire adapted from Granja and Wright. Of 1665 eligible ICU survivors, 23.3% died after ICU discharge, 49.1% were uncontactable and 438 (26.3%) patients were included in the study. Whilst 78.1% (n = 349) of patients remembered their admission to the hospital, only 42.3% (n = 189) could recall their admission to the ICU. The most frequently reported stressful experiences were: being bedridden (34.2%), pain (34.0%), general discomfort (31.7%), daily needle punctures (32.9%), family worries (33.6%), fear of dying and uncertainty in the future (25.8%). The majority of patients (376, 84.12%) found the atmosphere of the ICU to be friendly and calm. Overall, the patients found the level of health care received in the ICU to be "very satisfactory" (93.8%, n = 411) with none of the survivors stating they were either "dissatisfied" or "very dissatisfied". In common with HIC, survivors were very satisfied with their ICU care. In contrast to HIC settings, specific ICU experiences were frequently not recalled, but those remembered were reported as relatively stress-free. Stressful experiences, in common with HIC, were most frequently related to uncertainty about the future, dependency, family, and economic concerns.

Usefulness of Glycemic Gap to Predict ICU Mortality in Critically Ill Patients With Diabetes.

PubMed

Liao, Wen-I; Wang, Jen-Chun; Chang, Wei-Chou; Hsu, Chin-Wang; Chu, Chi-Ming; Tsai, Shih-Hung

2015-09-01

Stress-induced hyperglycemia (SIH) has been independently associated with an increased risk of mortality in critically ill patients without diabetes. However, it is also necessary to consider preexisting hyperglycemia when investigating the relationship between SIH and mortality in patients with diabetes. We therefore assessed whether the gap between admission glucose and A1C-derived average glucose (ADAG) levels could be a predictor of mortality in critically ill patients with diabetes.We retrospectively reviewed the Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores and clinical outcomes of patients with diabetes admitted to our medical intensive care unit (ICU) between 2011 and 2014. The glycosylated hemoglobin (HbA1c) levels were converted to the ADAG by the equation, ADAG = [(28.7 × HbA1c) - 46.7]. We also used receiver operating characteristic (ROC) curves to determine the optimal cut-off value for the glycemic gap when predicting ICU mortality and used the net reclassification improvement (NRI) to measure the improvement in prediction performance gained by adding the glycemic gap to the APACHE-II score.We enrolled 518 patients, of which 87 (17.0%) died during their ICU stay. Nonsurvivors had significantly higher APACHE-II scores and glycemic gaps than survivors (P < 0.001). Critically ill patients with diabetes and a glycemic gap ≥80 mg/dL had significantly higher ICU mortality and adverse outcomes than those with a glycemic gap <80 mg/dL (P < 0.001). Incorporation of the glycemic gap into the APACHE-II score increased the discriminative performance for predicting ICU mortality by increasing the area under the ROC curve from 0.755 to 0.794 (NRI = 13.6%, P = 0.0013).The glycemic gap can be used to assess the severity and prognosis of critically ill patients with diabetes. The addition of the glycemic gap to the APACHE-II score significantly improved its ability to predict ICU mortality.

Epidemiology of Obstetric-Related Intensive Care Unit Admissions in Maryland: 1999–2008

PubMed Central

Wanderer, Jonathan P.; Leffert, Lisa R.; Mhyre, Jill M.; Kuklina, Elena V.; Callaghan, William M.; Bateman, Brian T.

2013-01-01

Objective To define the incidence, indications, and temporal trends in obstetric-related intensive care unit (ICU) admissions Design Descriptive analysis of utilization patterns Setting All hospitals within the State of Maryland Patients All antepartum, delivery and postpartum patients who were hospitalized between 1999 and 2008 Interventions None Measurements and Main Results We identified 2,927 ICU admissions from 765,598 admissions for antepartum, delivery, or postpartum conditions using appropriate International Classification of Diseases, 9th revision-Clinical Modification (ICD-9 CM) codes. The overall rate of ICU utilization was 419.1 per 100,000 deliveries, with rates of 162.5, 202.6 and 54.0 per 100,000 deliveries for the antepartum, delivery and postpartum periods, respectively. The leading diagnoses associated with ICU admission were pregnancy-related hypertensive disease (present in 29.9% of admissions), hemorrhage (18.8%), cardiomyopathy or other cardiac disease (18.3%), genitourinary infection (11.5%), complications from ectopic pregnancies and abortions (10.3%), non-genitourinary infection (10.1%), sepsis (7.1%), cerebrovascular disease (5.8%) and pulmonary embolism (3.7%). We assessed for changes in the most common diagnoses in the ICU population over time and found rising rates of sepsis (10.1 per 100,000 deliveries to 16.6 per 100,000 deliveries, p=0.003) and trauma (9.2 per 100,000 deliveries to 13.6 per 100,000 deliveries, p=0.026) with decreasing rates of anesthetic complications (11.3 per 100,000 to 4.7 per 100,000, p=0.006). The overall frequency of obstetric-related ICU admission and the rates for other indications remained relatively stable. Conclusions Between 1999 and 2008, 419.1 per 100,000 deliveries in Maryland were complicated by ICU admission. Hospitals providing obstetric services should plan for appropriate critical care management and/or transfer of women with severe morbidities during pregnancy. PMID:23648568

Impact of a Respiratory Therapy Assess-and-Treat Protocol on Adult Cardiothoracic ICU Readmissions.

PubMed

Dailey, Robert T; Malinowski, Thomas; Baugher, Mitchel; Rowley, Daniel D

2017-05-01

The purpose of this retrospective medical record review was to report on recidivism to the ICU among adult postoperative cardiac and thoracic patients managed with a respiratory therapy assess-and-treat (RTAT) protocol. Our primary null hypothesis was that there would be no difference in all-cause unexpected readmissions and escalations between the RTAT group and the physician-ordered respiratory care group. Our secondary null hypothesis was that there would be no difference in primary respiratory-related readmissions, ICU length of stay, or hospital length of stay. We reviewed 1,400 medical records of cardiac and thoracic postoperative subjects between January 2015 and October 2016. The RTAT is driven by a standardized patient assessment tool, which is completed by a registered respiratory therapist. The tool develops a respiratory severity score for each patient and directs interventions for bronchial hygiene, aerosol therapy, and lung inflation therapy based on an algorithm. The protocol period commenced on December 1, 2015, and continued through October 2016. Data relative to unplanned admissions to the ICU for all causes as well as respiratory-related causes were evaluated. There was a statistically significant difference in the all-cause unplanned ICU admission rate between the RTAT (5.8% [95% CI 4.3-7.9]) and the physician-ordered respiratory care (8.8% [95% CI 6.9-11.1]) groups ( P = .034). There was no statistically significant difference in respiratory-related unplanned ICU admissions with RTAT (36% [95% CI 22.7-51.6]) compared with the physician-ordered respiratory care (53% [95% CI 41.1-64.8]) group ( P = .09). The RTAT protocol group spent 1 d less in the ICU ( P < .001) and in the hospital ( P < .001). RTAT protocol implementation demonstrated a statistically significant reduction in all-cause ICU readmissions. The reduction in respiratory-related ICU readmissions did not reach statistical significance. Copyright © 2017 by Daedalus Enterprises.

Urgent chemotherapy in hematological patients in the ICU.

PubMed

Moors, Ine; Pène, Frédéric; Lengline, Étienne; Benoit, Dominique

2015-12-01

Over the past decades, survival of critically ill hematological patients has dramatically improved, and these patients are more frequently referred to the ICU for intensive treatment, including a rising need for administering anticancer-therapy in this setting. The scarce literature on this subject provides evidence for feasibility of administering chemotherapy in the ICU, with expected ICU survival of 60-70%, and one in three patients surviving at least 1 year after discharge. We summarize the recent evidence concerning outcome, dosing and indications of chemotherapy in the ICU, and provide practical guidelines for some special oncological situations. Anticancer-therapy in the ICU is feasible and no longer futile as long as it is initiated in a selected, well-informed patient population with reasonable prognostic expectations. Accurate recognition of organ failure and early referral to the ICU for both supportive care and timely administration of chemotherapy is recommended before the development of multisystem organ failure.

Ventilator-associated pneumonia and ICU mortality in severe ARDS patients ventilated according to a lung-protective strategy

PubMed Central

2012-01-01

Introduction Ventilator-associated pneumonia (VAP) may contribute to the mortality associated with acute respiratory distress syndrome (ARDS). We aimed to determine the incidence, outcome, and risk factors of bacterial VAP complicating severe ARDS in patients ventilated by using a strictly standardized lung-protective strategy. Methods This prospective epidemiologic study was done in all the 339 patients with severe ARDS included in a multicenter randomized, placebo-controlled double-blind trial of cisatracurium besylate in severe ARDS patients. Patients with suspected VAP underwent bronchoalveolar lavage to confirm the diagnosis. Results Ninety-eight (28.9%) patients had at least one episode of microbiologically documented bacterial VAP, including 41 (41.8%) who died in the ICU, compared with 74 (30.7%) of the 241 patients without VAP (P = 0.05). After adjustment, age and severity at baseline, but not VAP, were associated with ICU death. Cisatracurium besylate therapy within 2 days of ARDS onset decreased the risk of ICU death. Factors independently associated with an increased risk to develop a VAP were male sex and worse admission Glasgow Coma Scale score. Tracheostomy, enteral nutrition, and the use of a subglottic secretion-drainage device were protective. Conclusions In patients with severe ARDS receiving lung-protective ventilation, VAP was associated with an increased crude ICU mortality which did not remain significant after adjustment. PMID:22524447

Outcomes of nighttime refusal of admission to the intensive care unit: The role of the intensivist in triage.

PubMed

Hinds, Nicholas; Borah, Amit; Yoo, Erika J

2017-06-01

To compare outcomes of patients refused medical intensive care unit (MICU) admission overnight to those refused during the day and to examine the impact of the intensivist in triage. Retrospective, observational study of patients refused MICU admission at an urban university hospital. Of 294 patients, 186 (63.3%) were refused admission overnight compared to 108 (36.7%) refused during the day. Severity-of-illness by the Mortality Probability Model was similar between the two groups (P=.20). Daytime triage refusals were more likely to be staffed by an intensivist (P=.01). After risk-adjustment, daytime refusals had a lower odds of subsequent ICU admission (OR 0.46, 95% CI 0.22-0.95, P=.04) than patients triaged at night. There was no evidence for interaction between time of triage and intensivist staffing of the patient (P=.99). Patients refused MICU admission overnight are more likely to be later admitted to an ICU than patients refused during the day. However, the mechanism for this observation does not appear to depend on the intensivist's direct evaluation of the patient. Further investigation into the clinician-specific effects of ICU triage and identification of potentially modifiable hospital triage practices will help to improve both ICU utilization and patient safety. Copyright © 2017 Elsevier Inc. All rights reserved.

Utility of the PRE-DELIRIC delirium prediction model in a Scottish ICU cohort.

PubMed

Paton, Lia; Elliott, Sara; Chohan, Sanjiv

2016-08-01

The PREdiction of DELIRium for Intensive Care (PRE-DELIRIC) model reliably predicts at 24 h the development of delirium during intensive care admission. However, the model does not take account of alcohol misuse, which has a high prevalence in Scottish intensive care patients. We used the PRE-DELIRIC model to calculate the risk of delirium for patients in our ICU from May to July 2013. These patients were screened for delirium on each day of their ICU stay using the Confusion Assessment Method for ICU (CAM-ICU). Outcomes were ascertained from the national ICU database. In the 39 patients screened daily, the risk of delirium given by the PRE-DELIRIC model was positively associated with prevalence of delirium, length of ICU stay and mortality. The PRE-DELIRIC model can therefore be usefully applied to a Scottish cohort with a high prevalence of substance misuse, allowing preventive measures to be targeted.

Effect of Weekend Admissions on the Treatment Process and Outcomes of Internal Medicine Patients

PubMed Central

Huang, Chun-Che; Huang, Yu-Tung; Hsu, Nin-Chieh; Chen, Jin-Shing; Yu, Chong-Jen

2016-01-01

Abstract Many studies address the effect of weekend admission on patient outcomes. This population-based study aimed to evaluate the relationship between weekend admission and the treatment process and outcomes of general internal medicine patients in Taiwan. A total of 82,340 patients (16,657 weekend and 65,683 weekday admissions) aged ≥20 years and admitted to the internal medicine departments of 17 medical centers between 2007 and 2009 were identified from the Taiwan National Health Insurance Research Database. A generalized estimating equation (GEE) analysis was used to compare patients admitted on weekends and those admitted on weekdays. Patients who were admitted on weekends were more likely to undergo intubation (odds ratio [OR]: 1.27; 95% confidence interval [CI]: 1.16–1.39; P < 0.001) and/or mechanical ventilation (OR, 1.25; 95% CI, 1.15–1.35; P < 0.001), cardio-pulmonary resuscitation (OR: 1.45; 95% CI: 1.05–2.01; P = 0.026), and be transferred to the intensive care unit (ICU) (OR: 1.16; 95% CI: 1.03–1.30; P = 0.015) compared with those admitted on weekdays. Weekend-admitted patients also had higher odds of in-hospital mortality (OR: 1.19; 95% CI: 1.09–1.30; P < 0.001) and hospital treatment cost (OR: 1.04; 95% CI: 1.01–1.06; P = 0.008) than weekday-admitted patients. General internal medicine patients who were admitted on weekends experienced more intensive care procedures and higher ICU admission, in-hospital mortality, and treatment cost. Intensive care utilization may serve as early indicator of poorer outcomes and a potential entry point to offer preventive intervention before proceeding to intensive treatment. PMID:26871788

Variable cost of ICU care, a micro-costing analysis.

PubMed

Karabatsou, Dimitra; Tsironi, Maria; Tsigou, Evdoxia; Boutzouka, Eleni; Katsoulas, Theodoros; Baltopoulos, George

2016-08-01

Intensive care unit (ICU) costs account for a great part of a hospital's expenses. The objective of the present study was to measure the patient-specific cost of ICU treatment, to identify the most important cost drivers in ICU and to examine the role of various contributing factors in cost configuration. A retrospective cost analysis of all ICU patients who were admitted during 2011 in a Greek General, seven-bed ICU and stayed for at least 24hours was performed, by applying bottom-up analysis. Data collected included demographics and the exact cost of every single material used for patients' care. Prices were yielded from the hospital's purchasing costs and from the national price list of the imaging and laboratory tests, which was provided by the Ministry of Health. A total of 138 patients were included. Variable cost per ICU day was €573.18. A substantial cost variation was found in the total costs obtained for individual patients (median: €3443, range: €243.70-€116,355). Medicines were responsible for more than half of the cost and antibiotics accounted for the largest part of it, followed by blood products and cardiovascular drugs. Medical cause of admission, severe illness and increased length of stay, mechanical ventilation and dialysis were the factors associated with cost escalation. ICU variable cost is patient-specific, varies according to each patient's needs and is influenced by several factors. The exact estimation of variable cost is a pre-requisite in order to control ICU expenses. Copyright © 2016 Elsevier Ltd. All rights reserved.

Effectiveness Trial of an Intensive Communication Structure for Families of Long-Stay ICU Patients

PubMed Central

Douglas, Sara L.; O’Toole, Elizabeth; Gordon, Nahida H.; Hejal, Rana; Peerless, Joel; Rowbottom, James; Garland, Allan; Lilly, Craig; Wiencek, Clareen; Hickman, Ronald

2010-01-01

Background: Formal family meetings have been recommended as a useful approach to assist in goal setting, facilitate decision making, and reduce use of ineffective resources in the ICU. We examined patient outcomes before and after implementation of an intensive communication system (ICS) to test the effect of regular, structured formal family meetings on patient outcomes among long-stay ICU patients. Methods: One hundred thirty-five patients receiving usual care and communication were enrolled as the control group, followed by enrollment of intervention patients (n = 346), from five ICUs. The ICS included a family meeting within 5 days of ICU admission and weekly thereafter. Each meeting discussed medical update, values and preferences, and goals of care; treatment plan; and milestones for judging effectiveness of treatment. Results: Using multivariate analysis, there were no significant differences between control and intervention patients in length of stay (LOS), the primary end point. Similarly, there were no significant differences in indicators of aggressiveness of care or treatment limitation decisions (ICU mortality, LOS, duration of ventilation, treatment limitation orders, or use of tracheostomy or percutaneous gastrostomy). Exploratory analysis suggested that in the medical ICUs, the intervention was associated with a lower prevalence of tracheostomy among patients who died or had do-not-attempt-resuscitation orders in place. Conclusions: The negative findings of the main analysis, in combination with preliminary evidence of differences among types of unit, suggest that further examination of the influence of patient, family, and unit characteristics on the effects of a system of regular family meetings may be warranted. Despite the lack of influence on patient outcomes, structured family meetings may be an effective approach to meeting information and support needs. Trial registry: ClinicalTrials.gov; No.: NCT01057238 ; URL: www.clinicaltrials.gov PMID

[Pain and fear in the ICU].

PubMed

Chamorro, C; Romera, M A

2015-10-01

Pain and fear are still the most common memories that refer patients after ICU admission. Recently an important politician named the UCI as the branch of the hell. It is necessary to carry out profound changes in terms of direct relationships with patients and their relatives, as well as changes in environmental design and work and visit organization, to banish the vision that our society about the UCI. In a step which advocates for early mobilization of critical patients is necessary to improve analgesia and sedation strategies. The ICU is the best place for administering and monitoring analgesic drugs. The correct analgesia should not be a pending matter of the intensivist but a mandatory course. Copyright © 2015 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.

Serial evaluation of the MODS, SOFA and LOD scores to predict ICU mortality in mixed critically ill patients.

PubMed

Khwannimit, Bodin

2008-09-01

To perform a serial assessment and compare ability in predicting the intensive care unit (ICU) mortality of the multiple organ dysfunction score (MODS), sequential organ failure assessment (SOFA) and logistic organ dysfunction (LOD) score. The data were collected prospectively on consecutive ICU admissions over a 24-month period at a tertiary referral university hospital. The MODS, SOFA, and LOD scores were calculated on initial and repeated every 24 hrs. Two thousand fifty four patients were enrolled in the present study. The maximum and delta-scores of all the organ dysfunction scores correlated with ICU mortality. The maximum score of all models had better ability for predicting ICU mortality than initial or delta score. The areas under the receiver operating characteristic curve (AUC) for maximum scores was 0.892 for the MODS, 0.907 for the SOFA, and 0.92for the LOD. No statistical difference existed between all maximum scores and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. Serial assessment of organ dysfunction during the ICU stay is reliable with ICU mortality. The maximum scores is the best discrimination comparable with APACHE II score in predicting ICU mortality.

The Utility of the Systemic Inflammatory Respsonse Syndrome Score on Admission in Children With Acute Pancreatitis.

PubMed

Grover, Amit S; Kadiyala, Vivek; Banks, Peter A; Grand, Richard J; Conwell, Darwin L; Lightdale, Jenifer R

2017-01-01

Pediatric patients with acute pancreatitis (AP) may meet criteria at admission for the systemic inflammatory response syndrome (SIRS). Early SIRS in adults with AP is associated with severe disease. Our aim was to evaluate the importance of SIRS in children presenting with AP on various outcomes. This is a retrospective cohort study of children hospitalized with AP at Boston Children's Hospital in 2010. Increased length of stay (LOS) and/or admission to the intensive care unit (ICU) served as the primary outcomes. Statistical analyses of measures studied included the presence of SIRS, demographic, and clinical information present on admission. Fifty encounters, in which AP was the primary admitting diagnosis, were documented. Patients had a median LOS of 4.5 (interquartile range, 2-9) days. Systemic inflammatory response syndrome was present in 22 (44%) of 50 patients at admission. Systemic inflammatory response syndrome at admission was an independent predictor of increased LOS (odds ratio, 7.99; P = 0.045) as well as admission to the ICU (odds ratio, 12.06; P = 0.027). The presence of SIRS criteria on admission serves as a useful and easy-to-calculate predictor of increased LOS and admission to ICU in children with AP.

Functional status and quality of life 12 months after discharge from a medical ICU in healthy elderly patients: a prospective observational study

PubMed Central

2011-01-01

Introduction Long-term outcomes of elderly patients after medical ICU care are little known. The aim of the study was to evaluate functional status and quality of life of elderly patients 12 months after discharge from a medical ICU. Methods We prospectively studied 112/230 healthy elderly patients (≥65 years surviving at least 12 months after ICU discharge) with full functional autonomy without cognitive impairment prior to ICU entry. The main diagnoses at admission using the Acute Physiology and Chronic Health Evaluation III (APACHE III) classification diagnosis and length of ICU stay and ICU scores (APACHE II, Sepsis-related Organ Failure Assessment (SOFA) and OMEGA) at admission and discharge were collected. Comprehensive geriatric assessment included the presence of the main geriatric syndromes and the application of Lawton, Barthel, and Charlson Indexes and Informant Questionnaire on Cognitive Decline to evaluate functionality, comorbidity and cognitive status, respectively. The EuroQol-5D assessed quality of life. Data were collected at baseline, during ICU and ward stay and 3, 6 and 12 months after hospital discharge. Paired or unpaired T-tests compared differences between groups (continuous variables), whereas the chi-square and Fisher exact tests were used for comparing dichotomous variables. For variables significant (P ≤ 0.1) on univariate analysis, a forward multiple regression analysis was performed. Results Only 48.9% of patients (mean age: 73.4 ± 5.5 years) were alive 12 months after discharge showing a significant decrease in functional autonomy (Lawton and Barthel Indexes) and quality of life (EuroQol-5D) compared to baseline status (P < 0.001, all). Multivariate analysis showed a higher Barthel Index and EQ-5D vas at hospital discharge to be associated factors of full functional recovery (P < 0.01, both). Thus, in patients with a Barthel Index ≥ 60 or EQ-5D vas ≥40 at discharge the hazard ratio for full functional recovery was 4.04 (95

Predictors of Hospitalization and Admission to Intensive Care Units of Influenza Patients in Serbia through Four Influenza Seasons from 2010/2011 to 2013/2014.

PubMed

Dimitrijević, Dragana; Ilić, Dragan; Rakić Adrović, Slavica; Šuljagić, Vesna; Pelemiš, Mijomir; Stevanović, Goran; Milinković, Milunka; Šipetić Grujićić, Sandra

2017-05-24

A retrospective analysis of the surveillance data on laboratory confirmed cases of influenza in 4 post pandemic seasons in Serbia was performed to evaluate predictors of hospitalization and admission to intensive care units (ICU). The specimens, including nasal and throat swabs were tested for influenza. Univariate and multivariate logistic regression analyses were performed. Data of a total of 777 confirmed influenza cases were analyzed. Age > 65 years, the presence of any co-morbidity or the presence of ≥ 2 comorbidities, infection with influenza virus subtype A (H1) pdm09, and an interval greater than 3 days between symptom onset and the first physician visit, were independently associated with hospital admission. These variables, as well as infection with non-subtype influenza virus A, were predictors for ICU admission. Obesity and chronic neurological disease were independent predictors for ICU admission but not hospitalization. Overall, 41.7% of patients with influenza had at least one co-morbidity, but only 3% of all patients were vaccinated against influenza. Identification of high risk groups and education of these groups regarding their increased susceptibility to severe forms of influenza, and in particular regarding the importance of influenza vaccination, is essential.

Incidence and preventability of adverse events requiring intensive care admission: a systematic review.

PubMed

Vlayen, Annemie; Verelst, Sandra; Bekkering, Geertruida E; Schrooten, Ward; Hellings, Johan; Claes, Neree

2012-04-01

Adverse events are unintended patient injuries or complications that arise from health care management resulting in death, disability or prolonged hospital stay. Adverse events that require critical care are a considerable financial burden to the health care system, but also their global impact on patients and society is probably underestimated. The objectives of this systematic review were to synthesize the best available evidence regarding the estimates of the incidence and preventability of adverse events that necessitate intensive care admission, to determine the type and consequences [mortality, length of intensive care unit (ICU) stay and costs] of these adverse events. MEDLINE (from 1966 to present), EMBASE (from 1974 to present) and CENTRAL (version 1-2010) were searched for studies reporting on unplanned admissions on ICUs. Several other sources were searched for additional studies. Only quantitative studies that used chart review for the detection of adverse events requiring intensive care admission were considered for eligibility. For the purposes of this systematic review, ICUs were defined as specialized hospital facilities which provide continuous monitoring and intensive care for acutely ill patients. Studies that were published in the English, Dutch, German, French or Spanish language were eligible for inclusion. Two reviewers independently extracted data and assessed the methodological quality of the included studies. A total of 27 studies were reviewed. Meta-analysis of the data was not appropriate because of methodological and statistical heterogeneity between studies; therefore, results are presented in a descriptive way. The percentage of surgical and medical adverse events that required ICU admission ranged from 1.1% to 37.2%. ICU readmissions varied from 0% to 18.3%. Preventability of the adverse events varied from 17% to 76.5%. Preventable adverse events are further synthesized by type of event. Consequences of the adverse events included a

Procalcitonin (PCT) levels for ruling-out bacterial coinfection in ICU patients with influenza: A CHAID decision-tree analysis.

PubMed

Rodríguez, Alejandro H; Avilés-Jurado, Francesc X; Díaz, Emili; Schuetz, Philipp; Trefler, Sandra I; Solé-Violán, Jordi; Cordero, Lourdes; Vidaur, Loreto; Estella, Ángel; Pozo Laderas, Juan C; Socias, Lorenzo; Vergara, Juan C; Zaragoza, Rafael; Bonastre, Juan; Guerrero, José E; Suberviola, Borja; Cilloniz, Catia; Restrepo, Marcos I; Martín-Loeches, Ignacio

2016-02-01

To define which variables upon ICU admission could be related to the presence of coinfection using CHAID (Chi-squared Automatic Interaction Detection) analysis. A secondary analysis from a prospective, multicentre, observational study (2009-2014) in ICU patients with confirmed A(H1N1)pdm09 infection. We assessed the potential of biomarkers and clinical variables upon admission to the ICU for coinfection diagnosis using CHAID analysis. Performance of cut-off points obtained was determined on the basis of the binominal distributions of the true (+) and true (-) results. Of the 972 patients included, 196 (20.3%) had coinfection. Procalcitonin (PCT; ng/mL 2.4 vs. 0.5, p < 0.001), but not C-reactive protein (CRP; mg/dL 25 vs. 38.5; p = 0.62) was higher in patients with coinfection. In CHAID analyses, PCT was the most important variable for coinfection. PCT <0.29 ng/mL showed high sensitivity (Se = 88.2%), low Sp (33.2%) and high negative predictive value (NPV = 91.9%). The absence of shock improved classification capacity. Thus, for PCT <0.29 ng/mL, the Se was 84%, the Sp 43% and an NPV of 94% with a post-test probability of coinfection of only 6%. PCT has a high negative predictive value (94%) and lower PCT levels seems to be a good tool for excluding coinfection, particularly for patients without shock. Copyright © 2015 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

Baclofen to prevent agitation in alcohol-addicted patients in the ICU: study protocol for a randomised controlled trial.

PubMed

Vourc'h, Mickael; Feuillet, Fanny; Mahe, Pierre-Joachim; Sebille, Véronique; Asehnoune, Karim

2016-08-19

Alcohol is the leading psychoactive substance consumed in France, with about 15 million regular consumers. The National institute on Alcohol Abuse and Alcoholism (NIAAA) considers alcohol abuse to be more than 14 units of alcohol a week for men and 7 units for women. The specific complication of alcoholism is the alcohol withdrawal syndrome. Its incidence reaches up to 30 % and its main complications are delirium tremens, restlessness, extended hospital stay, higher morbidity, and psychiatric and cognitive impairment. Without appropriate treatment, delirium tremens can lead to death in up to 50 % of patients. This prospective, double-blind, randomised controlled study versus placebo will be conducted in twelve French intensive care units (ICU). Patients with an alcohol intake level higher than the NIAAA threshold, who are under mechanical ventilation, will be included. The primary objective is to determine whether baclofen is more efficient than placebo in preventing restlessness-related side effects in the ICU. Secondary outcomes include mechanical ventilation duration, length of ICU stay, and cumulative doses of sedatives and painkillers received within 28 days of ICU admission. Restlessness-related side effects in the ICU are defined as unplanned extubation, medical disposal removal (such as urinary catheter, venous or arterial line or surgical drain), falling out of bed, ICU runaway (leaving ICU without physician's approval), immobilisation device removal, self-aggression or aggression towards medical staff. Daily doses of baclofen/placebo will be guided by daily creatinine clearance assessment. Restlessness in alcoholic patients is a life-threatening issue in ICUs. BACLOREA is a randomised study assessing the capacity of baclofen to prevent agitation in mechanically ventilated patients. Enrolment of 314 patients will begin in June 2016 and is expected to end in October 2018. ClinicalTrials.gov Identifier: NCT02723383 , registered on 3 March 2016.

Intensive Care Unit Admission and Death Rates of Infants Admitted With Respiratory Syncytial Virus Lower Respiratory Tract Infection in Mexico.

PubMed

Vizcarra-Ugalde, Sergio; Rico-Hernández, Montserrat; Monjarás-Ávila, César; Bernal-Silva, Sofía; Garrocho-Rangel, Maria E; Ochoa-Pérez, Uciel R; Noyola, Daniel E

2016-11-01

Respiratory syncytial virus (RSV) is the most common etiology for acute respiratory infection hospital admissions in young children. Case fatality rates for hospitalized patients range between 0% and 3.4%. Recent reports indicate that deaths associated with RSV are uncommon in developed countries. However, the role of this virus as a current cause of mortality in other countries requires further examination. Children with RSV infection admitted between May 2003 and December 2014 to a level 2 specialty hospital in Mexico were included in this analysis. Underlying risk factors, admission to the intensive care unit (ICU) and condition on discharge were assessed to determine the ICU admission and death rates associated to RSV infection. We analyzed data of 1153 patients with RSV infection in whom information regarding underlying illnesses and discharge status was available. Sixty patients (5.2 %) were admitted to the ICU and 12 (1.04 %) died. Relevant underlying conditions were present in 320 (27.7%) patients. Infants with underlying respiratory disorders (excluding asthma) and a history of prematurity had high ICU admission rates (17.1% and 13.8%, respectively). Mortality rates were highest for infants with respiratory disease (excluding asthma) (7.3%), cardiovascular diseases (5.9%) and neurologic disorders (5.3%). The ICU admission and death rates were higher in infants <6 months of age than in other age groups. The ICU admission rate and mortality rate in Mexican infants hospitalized with RSV infection were 5.2% and 1%, respectively. Mortality rates were high in infants with respiratory, cardiovascular and neurologic disorders.

Age as an independent risk factor for intensive care unit admission or death due to 2009 pandemic influenza A (H1N1) virus infection.

PubMed

Nickel, Katelin B; Marsden-Haug, Nicola; Lofy, Kathryn H; Turnberg, Wayne L; Rietberg, Krista; Lloyd, Jennifer K; Marfin, Anthony A

2011-01-01

This study evaluated risk factors for intensive care unit (ICU) admission or death among people hospitalized with 2009 pandemic influenza A (pH1N1) virus infection. We based analyses on data collected in Washington State from April 27 to September 18, 2009, on deceased or hospitalized people with laboratory-confirmed pH1N1 infection reported by health-care providers and hospitals as part of enhanced public health surveillance. We used bivariate analyses and multivariable logistic regression to identify risk factors associated with ICU admission or death due to pH1N1. We identified 123 patients admitted to the hospital but not an ICU and 61 patients who were admitted to an ICU or died. Independent of high-risk medical conditions, both older age and delayed time to hospital admission were identified as risk factors for ICU admission or death due to pH1N1. Specifically, the odds of ICU admission or death were 4.44 times greater among adults aged 18-49 years (95% confidence interval [CI] 1.97, 10.02) and 5.93 times greater among adults aged 50-64 years (95% CI 2.24, 15.65) compared with pediatric patients < 18 years of age. Likewise, hospitalized cases admitted more than two days after illness onset had 2.17 times higher odds of ICU admission or death than those admitted within two days of illness onset (95% CI 1.10, 4.25). Although certain medical conditions clearly influence the need for hospitalization among people infected with pH1N1 virus, older age and delayed time to admission each played an independent role in the progression to ICU admission or death among hospitalized patients.

Early Risk and Resiliency Factors Predict Chronic Posttraumatic Stress Disorder in Caregivers of Patients Admitted to a Neuroscience ICU.

PubMed

Choi, Karmel W; Shaffer, Kelly M; Zale, Emily L; Funes, Christopher J; Koenen, Karestan C; Tehan, Tara; Rosand, Jonathan; Vranceanu, Ana-Maria

2018-05-01

Informal caregivers-that is, close family and friends providing unpaid emotional or instrumental care-of patients admitted to ICUs are at risk for posttraumatic stress disorder. As a first step toward developing interventions to prevent posttraumatic stress disorder in ICU caregivers, we examined the predictive validity of psychosocial risk screening during admission for caregiver posttraumatic stress disorder at 3 and 6 months post hospitalization. An observational, prospective study. Ninety-nine caregivers were recruited as part of a longitudinal research program of patient-caregiver dyads in a neuroscience ICU. None. Caregiver posttraumatic stress disorder symptoms were assessed during admission (baseline), 3 months, and 6 months post hospitalization. We 1) characterized prevalence of clinically significant symptoms at each time point 2); calculated sensitivity and specificity of baseline posttraumatic stress disorder screening in predicting posttraumatic stress disorder at 3 and 6 months; and 3) used recursive partitioning to select potential baseline factors and examine the extent to which they helped predict clinically significant posttraumatic stress disorder symptoms at each time point. Rates of caregiver posttraumatic stress disorder remained relatively stable over time (16-22%). Screening for posttraumatic stress disorder at baseline predicted posttraumatic stress disorder at 3 and 6 months with moderate sensitivity (75-80%) and high specificity (92-95%). Screening for posttraumatic stress disorder at baseline was associated with caregiver anxiety, mindfulness (i.e., ability to be aware of one's thoughts and feelings in the moment), and bond with patient. Furthermore, baseline posttraumatic stress disorder screening was the single most relevant predictor of posttraumatic stress disorder at 3 and 6 months, such that other baseline factors did not significantly improve predictive ability. Screening neuroscience ICU caregivers for clinically significant

Clinical utility of urine neutrophil gelatinase-associated lipocalin measured at admission to predict outcomes in heterogeneous population of critically ill patients.

PubMed

Nayak, N M; Madhumitha, S; Annigeri, R A; Venkataraman, R; Balasubramaian, S; Seshadri, R; Vadamalai, V; Rao, B S; Kowdle, P C; Ramakrishnan, N; Mani, M K

2016-01-01

Urine neutrophil gelatinase-associated lipocalin (uNGAL) is a reliable early biomarker of acute kidney injury (AKI) in a homogeneous patient population. However, its utility in a heterogeneous population of critically ill, in whom the time of onset of renal insult is often unclear, is not clearly established. We evaluated the ability of a single measurement of uNGAL in a heterogeneous adult population, on admission to intensive care unit (ICU), to predict the occurrence of AKI and hospital mortality. One hundred and two consecutive adult patients had uNGAL measured within 8 h of admission to ICU. The demographic and laboratory data were collected at admission. The diagnosis of AKI was based on AKI Network (AKIN) criteria. The primary outcome was the development of AKI, and the secondary outcome was hospital mortality. The mean age was 54 ± 16.4 years and 65% were males. Urine NGAL (ng/ml) was 69 ± 42 in patients with AKI (n = 42) and 30.4 ± 41.7 in those without AKI (P < 0.001). The area under the receiver operating characteristic (ROC) curve for prediction of AKI was 0.79 and for serum creatinine (SCr) was 0.88. The sensitivity and specificity for a cut-off value of uNGAL of 75 ng/ml to predict AKI were 0.5 and 0.85 respectively. uNGAL > 75 ng/ml was a strong (odd ratio = 5.17, 95% confidence interval: 1.39-19.3) and independent predictor of hospital mortality. A single measurement of uNGAL at admission to ICU exhibited good predictive ability for AKI though the sensitivity was low. The predictive ability of uNGAL was inferior to simultaneously measured SCr at admission, hence limited its clinical utility to predict AKI. However, admission uNGAL was a strong, independent predictor of hospital mortality.

Clinical utility of urine neutrophil gelatinase-associated lipocalin measured at admission to predict outcomes in heterogeneous population of critically ill patients

PubMed Central

Nayak, N. M.; Madhumitha, S.; Annigeri, R. A.; Venkataraman, R.; Balasubramaian, S.; Seshadri, R.; Vadamalai, V.; Rao, B. S.; Kowdle, P. C.; Ramakrishnan, N.; Mani, M. K.

2016-01-01

Urine neutrophil gelatinase-associated lipocalin (uNGAL) is a reliable early biomarker of acute kidney injury (AKI) in a homogeneous patient population. However, its utility in a heterogeneous population of critically ill, in whom the time of onset of renal insult is often unclear, is not clearly established. We evaluated the ability of a single measurement of uNGAL in a heterogeneous adult population, on admission to intensive care unit (ICU), to predict the occurrence of AKI and hospital mortality. One hundred and two consecutive adult patients had uNGAL measured within 8 h of admission to ICU. The demographic and laboratory data were collected at admission. The diagnosis of AKI was based on AKI Network (AKIN) criteria. The primary outcome was the development of AKI, and the secondary outcome was hospital mortality. The mean age was 54 ± 16.4 years and 65% were males. Urine NGAL (ng/ml) was 69 ± 42 in patients with AKI (n = 42) and 30.4 ± 41.7 in those without AKI (P < 0.001). The area under the receiver operating characteristic (ROC) curve for prediction of AKI was 0.79 and for serum creatinine (SCr) was 0.88. The sensitivity and specificity for a cut-off value of uNGAL of 75 ng/ml to predict AKI were 0.5 and 0.85 respectively. uNGAL > 75 ng/ml was a strong (odd ratio = 5.17, 95% confidence interval: 1.39–19.3) and independent predictor of hospital mortality. A single measurement of uNGAL at admission to ICU exhibited good predictive ability for AKI though the sensitivity was low. The predictive ability of uNGAL was inferior to simultaneously measured SCr at admission, hence limited its clinical utility to predict AKI. However, admission uNGAL was a strong, independent predictor of hospital mortality. PMID:27051136

The Preschool Confusion Assessment Method for the ICU (psCAM-ICU): Valid and Reliable Delirium Monitoring for Critically Ill Infants and Children

PubMed Central

Smith, Heidi A.B.; Gangopadhyay, Maalobeeka; Goben, Christina M.; Jacobowski, Natalie L.; Chestnut, Mary Hamilton; Savage, Shane; Rutherford, Michael T.; Denton, Danica; Thompson, Jennifer L.; Chandrasekhar, Rameela; Acton, Michelle; Newman, Jessica; Noori, Hannah P.; Terrell, Michelle K.; Williams, Stacey R.; Griffith, Katherine; Cooper, Timothy J.; Ely, E. Wesley; Fuchs, D. Catherine; Pandharipande, Pratik P.

2015-01-01

RATIONALE and OBJECTIVE Delirium assessments in critically ill infants and young children pose unique challenges due to evolution of cognitive and language skills. The objectives of this study were to determine the validity and reliability of a fundamentally objective and developmentally appropriate delirium assessment tool for critically ill infants and preschool-aged children, and to determine delirium prevalence. DESIGN and SETTING Prospective, observational cohort validation study of the PreSchool Confusion Assessment Method for the ICU (psCAM-ICU) in a tertiary medical center pediatric ICU. PATIENTS Participants aged 6 months to 5 years and admitted to the pediatric ICU regardless of admission diagnosis were enrolled. INTERVENTIONS, MEASUREMENTS and MAIN RESULTS An interdisciplinary team created the psCAM-ICU for pediatric delirium monitoring. To assess validity, patients were independently assessed for delirium daily by the research team using the psCAM-ICU and by a child psychiatrist using the Diagnostic and Statistical Manual of Mental Disorders criteria. Reliability was assessed using blinded, concurrent psCAM-ICU evaluations by research staff. A total of 530-paired delirium assessments were completed among 300 patients, with a median age of 20 months (IQR 11, 37) and 43% requiring mechanical ventilation. The psCAM-ICU demonstrated a specificity of 91% (95%CI 90, 93), sensitivity of 75% (72, 78), negative predictive value of 86% (84, 88), positive predictive value of 84% (81, 87), and a reliability kappa statistic of 0.79 (0.76, 0.83). Delirium prevalence was 44% using the psCAM-ICU and 47% by the reference-rater. The rates of delirium were 53% vs. 56% in patients < 2 years of age and 33% vs. 35% in patients ≥ 2 - 5 years of age using the psCAM-ICU and reference-rater respectively. The short-form psCAM-ICU maintained a high specificity (87%) and sensitivity (78%) in post-hoc analysis. CONCLUSIONS The psCAM-ICU is a highly valid and reliable delirium

Does Admission to the ICU Prevent African American Disparities in Withdrawal of Life-Sustaining Treatment?

PubMed

Chertoff, Jason; Olson, Angela; Alnuaimat, Hassan

2017-10-01

We sought to determine whether black patients admitted to an ICU were less likely than white patients to withdraw life-sustaining treatments. We performed a retrospective cohort study of hospital discharges from October 20, 2015, to October 19, 2016, for inpatients 18 years old or older and recorded those patients, along with their respective races, who had an "Adult Comfort Care" order set placed prior to discharge. A two-sample test for equality of two proportions with continuity correction was performed to compare the proportions between blacks and whites. University of Florida Health. The study cohort included 29,590 inpatient discharges, with 21,212 Caucasians (71.69%), 5,825 African Americans (19.69%), and 2,546 non-Caucasians/non-African Americans (8.62%). Withdrawal of life-sustaining treatments. Of the total discharges (n = 29,590), 525 (1.77%) had the Adult Comfort Care order set placed. Seventy-eight of 5,825 African American patients (1.34%) had the Adult Comfort Care order set placed, whereas 413 of 21,212 Caucasian patients (1.95%) had this order set placed (p = 0.00251; 95% CI, 0.00248-0.00968). Of the 29,590 patients evaluated, 6,324 patients (21.37%) spent at least one night in an ICU. Of these 6,324 patients, 4,821 (76.24%) were white and 1,056 (16.70%) were black. Three hundred fifty of 6,324 (5.53%) were discharged with an Adult Comfort Care order set. Two hundred seventy-one White patients (5.62%) with one night in an ICU were discharged with an Adult Comfort Care order set, whereas 54 Black patients (5.11%) with one night in an ICU had the order set (p = 0.516). This study suggests that Black patients may be less likely to withdraw life-supportive measures than whites, but that this disparity may be absent in patients who spend time in the ICU during their hospitalization.

Effect upon mortality of the extension to holidays and weekends of the "ICU without walls" project. A before-after study.

PubMed

Abella, A; Enciso, V; Torrejón, I; Hermosa, C; Mozo, T; Molina, R; Janeiro, D; Díaz, M; Homez, M; Gordo, F; Salinas, I

2016-01-01

To determine whether extension to holidays and weekends of the protocol for the early proactive detection of severity in hospital ("ICU without walls" project) results in decreased mortality among patients admitted to the ICU during those days. A quasi-experimental before-after study was carried out. A level 2 hospital with 210 beds and a polyvalent ICU with 8 beds. The control group involved no "ICU without walls" activity on holidays or weekends and included those patients admitted to the ICU on those days between 1 January 2010 and 30 April 2013. The intervention group in turn extended the "ICU without walls" activity to holidays and weekends, and included those patients admitted on those days between 1 May 2013 and 31 October 2014. Patients arriving from the operating room after scheduled surgery were excluded. An analysis was made of the demographic variables (age, gender), origin (emergency room, hospital ward, operating room), type of patient (medical, surgical), reason for admission, comorbidities and SAPS 3 score as a measure of severity upon admission, stay in the ICU and in hospital, and mortality in the ICU and in hospital. A total of 389 and 161 patients were included in the control group and intervention group, respectively. There were no differences between the 2 groups except as regards cardiovascular comorbidity (49% in the control group versus 33% in the intervention group; P<.001), severity upon admission (median SAPS 3 score 52 [percentiles 25-75: 42-63) in the control group versus 48 [percentiles 25-75: 40-56] in the intervention group; P=.008) and mortality in the ICU (11% in the control group [95% CI 8-14] versus 3% [95% CI 1-7] in the intervention group; P=.003). In the multivariate analysis, the only 2 factors associated to mortality in the ICU were the SAPS 3 score (OR 1.08; 95% CI 1.06-1.11) and inclusion in the intervention group (OR 0.33; 95% CI 0.12-0.89). Extension of the "ICU without walls" activity to holidays and weekends results

Coping Strategies and Posttraumatic Stress Symptoms in Post-ICU Family Decision Makers.

PubMed

Petrinec, Amy B; Mazanec, Polly M; Burant, Christopher J; Hoffer, Alan; Daly, Barbara J

2015-06-01

To assess the coping strategies used by family decision makers of adult critical care patients during and after the critical care experience and the relationship of coping strategies to posttraumatic stress symptoms experienced 60 days after hospitalization. A single-group descriptive longitudinal correlational study. Medical, surgical, and neurological ICUs in a large tertiary care university hospital. Consecutive family decision makers of adult critical care patients from August 2012 to November 2013. Study inclusion occurred after the patient's fifth day in the ICU. None. Family decision makers of incapacitated adult ICU patients completed the Brief COPE instrument assessing coping strategy use 5 days after ICU admission and 30 days after hospital discharge or death of the patient and completed the Impact of Event Scale-Revised assessing posttraumatic stress symptoms 60 days after hospital discharge. Seventy-seven family decision makers of the eligible 176 completed all data collection time points of this study. The use of problem-focused (p=0.01) and emotion-focused (p<0.01) coping decreased over time while avoidant coping (p=0.20) use remained stable. Coping strategies 30 days after hospitalization (R2=0.50, p<0.001) were better predictors of later posttraumatic stress symptoms than coping strategies 5 days after ICU admission (R2=0.30, p=0.001) controlling for patient and decision-maker characteristics. The role of decision maker for a parent and patient death were the only noncoping predictors of posttraumatic stress symptoms. Avoidant coping use 30 days after hospitalization mediated the relationship between patient death and later posttraumatic stress symptom severity. Coping strategy use is a significant predictor of posttraumatic stress symptom severity 60 days after hospitalization in family decision makers of ICU patients.

Improved ICU design reduces acquisition of antibiotic-resistant bacteria: a quasi-experimental observational study

PubMed Central

2011-01-01

Introduction The role of ICU design and particularly single-patient rooms in decreasing bacterial transmission between ICU patients has been debated. A recent change in our ICU allowed further investigation. Methods Pre-move ICU-A and pre-move ICU-B were open-plan units. In March 2007, ICU-A moved to single-patient rooms (post-move ICU-A). ICU-B remained unchanged (post-move ICU-B). The same physicians cover both ICUs. Cultures of specified resistant organisms in surveillance or clinical cultures from consecutive patients staying >48 hours were compared for the different ICUs and periods to assess the effect of ICU design on acquisition of resistant organisms. Results Data were collected for 62, 62, 44 and 39 patients from pre-move ICU-A, post-move ICU-A, pre-move ICU-B and post-move ICU-B, respectively. Fewer post-move ICU-A patients acquired resistant organisms (3/62, 5%) compared with post-move ICU-B patients (7/39, 18%; P = 0.043, P = 0.011 using survival analysis) or pre-move ICU-A patients (14/62, 23%; P = 0.004, P = 0.012 on survival analysis). Only the admission period was significant for acquisition of resistant organisms comparing pre-move ICU-A with post-move ICU-A (hazard ratio = 5.18, 95% confidence interval = 1.03 to 16.06; P = 0.025). More antibiotic-free days were recorded in post-move ICU-A (median = 3, interquartile range = 0 to 5) versus post-move ICU-B (median = 0, interquartile range = 0 to 4; P = 0.070) or pre-move ICU-A (median = 0, interquartile range = 0 to 4; P = 0.017). Adequate hand hygiene was observed on 140/242 (58%) occasions in post-move ICU-A versus 23/66 (35%) occasions in post-move ICU-B (P < 0.001). Conclusions Improved ICU design, and particularly use of single-patient rooms, decreases acquisition of resistant bacteria and antibiotic use. This observation should be considered in future ICU design. PMID:21914222

Improved ICU design reduces acquisition of antibiotic-resistant bacteria: a quasi-experimental observational study.

PubMed

Levin, Phillip D; Golovanevski, Mila; Moses, Allon E; Sprung, Charles L; Benenson, Shmuel

2011-01-01

The role of ICU design and particularly single-patient rooms in decreasing bacterial transmission between ICU patients has been debated. A recent change in our ICU allowed further investigation. Pre-move ICU-A and pre-move ICU-B were open-plan units. In March 2007, ICU-A moved to single-patient rooms (post-move ICU-A). ICU-B remained unchanged (post-move ICU-B). The same physicians cover both ICUs. Cultures of specified resistant organisms in surveillance or clinical cultures from consecutive patients staying >48 hours were compared for the different ICUs and periods to assess the effect of ICU design on acquisition of resistant organisms. Data were collected for 62, 62, 44 and 39 patients from pre-move ICU-A, post-move ICU-A, pre-move ICU-B and post-move ICU-B, respectively. Fewer post-move ICU-A patients acquired resistant organisms (3/62, 5%) compared with post-move ICU-B patients (7/39, 18%; P = 0.043, P = 0.011 using survival analysis) or pre-move ICU-A patients (14/62, 23%; P = 0.004, P = 0.012 on survival analysis). Only the admission period was significant for acquisition of resistant organisms comparing pre-move ICU-A with post-move ICU-A (hazard ratio = 5.18, 95% confidence interval = 1.03 to 16.06; P = 0.025). More antibiotic-free days were recorded in post-move ICU-A (median = 3, interquartile range = 0 to 5) versus post-move ICU-B (median = 0, interquartile range = 0 to 4; P = 0.070) or pre-move ICU-A (median = 0, interquartile range = 0 to 4; P = 0.017). Adequate hand hygiene was observed on 140/242 (58%) occasions in post-move ICU-A versus 23/66 (35%) occasions in post-move ICU-B (P < 0.001). Improved ICU design, and particularly use of single-patient rooms, decreases acquisition of resistant bacteria and antibiotic use. This observation should be considered in future ICU design.

Physicians' perceptions and attitudes regarding inappropriate admissions and resource allocation in the intensive care setting.

PubMed

Giannini, A; Consonni, D

2006-01-01

Physicians' perceptions regarding intensive care unit (ICU) resource allocation and the problem of inappropriate admissions are unknown. We carried out an anonymous, self-administered questionnaire survey to assess the perceptions and attitudes of ICU physicians at all 20 ICUs in Milan, Italy, regarding inappropriate admissions and resource allocation. Eighty-seven percent (225/259) of physicians responded. Inappropriate admissions were acknowledged by 86% of respondents. The reasons given were clinical doubt (33%); limited decision time (32%); assessment error (25%); pressure from superiors (13%), referring clinician (11%) or family (5%); threat of legal action (5%); and an economically advantageous 'Diagnosis Related Group' (1%). Respondents reported being pressurized to make more 'productive' use of ICU beds by Unit heads (frequently 16%), hospital management (frequently 10%) and colleagues (frequently 4%). Five percent reported refusing appropriate admissions following 'indications' not to admit financially disadvantageous cases. Admissions after elective surgery prioritized patients from profitable surgical departments: frequently for 6% of respondents and occasionally for 15%. Sixty-seven percent said they frequently received requests for appropriate admissions when no beds were available. This was considered sufficient reason to withdraw treatment from patients with lower survival probability (sometimes 21%) or for whom nothing more could be done (sometimes 51%, frequently 11%). Inappropriate ICU admissions were perceived as a common event but were mainly attributed to difficulties in assessing suitability. Physicians were aware that their decisions were often influenced by factors other than medical necessity. Economic influences were perceived as limited but not negligible. Decisions to forgo treatment could be influenced by the need to admit other patients.

Being Overweight Is Associated With Greater Survival in ICU Patients: Results From the Intensive Care Over Nations Audit.

PubMed

Sakr, Yasser; Alhussami, Ilmi; Nanchal, Rahul; Wunderink, Richard G; Pellis, Tommaso; Wittebole, Xavier; Martin-Loeches, Ignacio; François, Bruno; Leone, Marc; Vincent, Jean-Louis

2015-12-01

To assess the effect of body mass index on ICU outcome and on the development of ICU-acquired infection. A substudy of the Intensive Care Over Nations audit. Seven hundred thirty ICUs in 84 countries. All adult ICU patients admitted between May 8 and 18, 2012, except those admitted for less than 24 hours for routine postoperative monitoring (n = 10,069). In this subanalysis, only patients with complete data on height and weight (measured or estimated) on ICU admission in order to calculate the body mass index were included (n = 8,829). None. Underweight was defined as body mass index less than 18.5 kg/m, normal weight as body mass index 18.5-24.9 kg/m, overweight as body mass index 25-29.9 kg/m, obese as body mass index 30-39.9 kg/m, and morbidly obese as body mass index greater than or equal to 40 kg/m. The mean body mass index was 26.4 ± 6.5 kg/m. The ICU length of stay was similar among categories, but overweight and obese patients had longer hospital lengths of stay than patients with normal body mass index (10 [interquartile range, 5-21] and 11 [5-21] vs 9 [4-19] d; p < 0.01 pairwise). ICU mortality was lower in morbidly obese than in normal body mass index patients (11.2% vs 16.6%; p = 0.015). In-hospital mortality was lower in morbidly obese and overweight patients and higher in underweight patients than in those with normal body mass index. In a multilevel Cox proportional hazard analysis, underweight was independently associated with a higher hazard of 60-day in-hospital death (hazard ratio, 1.32; 95% CI, 1.05-1.65; p = 0.018), whereas overweight was associated with a lower hazard (hazard ratio, 0.79; 95% CI, 0.71-0.89; p < 0.001). No body mass index category was associated with an increased hazard of ICU-acquired infection. In this large cohort of critically ill patients, underweight was independently associated with a higher hazard of 60-day in-hospital death and overweight with a lower hazard. None of the body mass index categories as independently

Electric versus manual tooth brushing among neuroscience ICU patients: is it safe?

PubMed

Prendergast, Virginia; Hagell, Peter; Hallberg, Ingalill Rahm

2011-04-01

Poor oral hygiene has been associated with ventilator-acquired pneumonia. Yet providing oral care for intubated patients is problematic. Furthermore, concerns that oral care could raise intracranial pressure (ICP) may cause nurses to use foam swabs to provide oral hygiene rather than tooth brushing as recommended by the American Association of Critical-Care Nurses. Evidence is needed to support the safety of toothbrushing during oral care. We therefore evaluated ICP and cerebral perfusion pressure (CPP) during oral care with a manual or electric toothbrush in intubated patients in a neuroscience intensive care unit (ICU). As part of a larger 2-year, prospective, randomized clinical trial, 47 adult neuroscience ICU patients with an ICP monitor received oral care with a manual or electric toothbrush. ICP and CPP were recorded before, during, and after oral care over the first 72 h of admission. Groups did not differ significantly in age, gender, or severity of injury. Of 807 ICP and CPP measurements obtained before, during, and after oral care, there were no significant differences in ICP (P = 0.72) or CPP (P = 0.68) between toothbrush methods. Analysis of pooled data from both groups revealed a significant difference across the three time points (Wilks' lambda, 12.56; P < 0.001; partial η(2), 0.36). ICP increased significantly (mean difference, 1.7 mm Hg) from before to during oral care (P = 0.001) and decreased significantly (mean difference, 2.1 mm Hg) from during to after oral care (P < 0.001). In the absence of preexisting intracranial hypertension during oral care, tooth brushing, regardless of method, was safely performed in intubated neuroscience ICU patients.

Obesity is associated with higher risk of intensive care unit admission and death in influenza A (H1N1) patients: a systematic review and meta-analysis.

PubMed

Fezeu, L; Julia, C; Henegar, A; Bitu, J; Hu, F B; Grobbee, D E; Kengne, A-P; Hercberg, S; Czernichow, S

2011-08-01

The aim of this study was to assess the association between obesity and the risk of intensive care unit (ICU) admission and death among patients hospitalized for influenza A (H1N1) viral infection. A systematic review of the Medline and Cochrane databases using 'obesity', 'hospitalization', 'influenza A viral infection', various synonyms, and reference lists of retrieved articles from January 2009 to January 2010. Studies comparing the prevalence of obesity among patients with confirmed infection for influenza A virus and who were either hospitalized or admitted to ICU/died were included. A total of 3059 subjects from six cross-sectional studies, who were hospitalized for influenza A (H1N1) viral infection, were included in this meta-analysis. Severely obese H1N1 patients (body mass index ≥ 40 kg m(-2), n = 804) were as twice as likely to be admitted to ICU or die (odds ration: 2.01, 95% confidence interval: 1.29-3.14, P < 0.002) compared with H1N1 patients who were not severely obese. Having a body mass index ≥ 30 kg m(-2) was similarly associated with a more than twofold increased risk of ICU admission or death although this did not reach statistical significance (2.14, 0.92-4.99, P < 0.07). This meta-analysis supports the view that obesity is associated with higher risks of ICU admission or death in patients with influenza A (H1N1) infection. Therefore, morbid obese patients should be monitored more intensively when hospitalized. © 2011 The Authors. obesity reviews © 2011 International Association for the Study of Obesity.

Anaerobic bacteria commonly colonize the lower airways of intubated ICU patients.

PubMed

Agvald-Ohman, C; Wernerman, J; Nord, C E; Edlund, C

2003-05-01

To investigate respiratory tract colonization by aerobic and anaerobic bacteria in mechanically ventilated patients. Bacterial colonization of the stomach and the respiratory tract was qualitatively and quantitatively analyzed over time in 41 consecutive mechanically ventilated patients in a Swedish intensive care unit (ICU), with special emphasis on elucidation of the role of anaerobic bacteria in the lower respiratory tract. Samples were taken from the oropharynx, gastric juice, subglottic space and trachea within 24 h (median 14 h) of intubation, and then every third day until day 18 and every fifth day until day 33. The patients were often heavily colonized with microorganisms not considered to belong to a healthy normal oropharyngeal and gastric flora on admission to the ICU. A majority harbored enterococci, coagulase-negative staphylococci and Candida spp. in at least one site on day 1. Anaerobic bacteria, mainly peptostreptococci and Prevotella spp., were isolated from subglottic and/or tracheal secretions in 59% of the patients. Different routes of tracheal colonization for different groups of microorganisms were found. Primary or concomitant colonization of the oropharynx with staphylococci, enterococci, enterobacteria and Candida was often seen, while Pseudomonas spp., other non-fermenting Gram-negative rods and several anaerobic species often primarily colonized the trachea, indicating exogenous or direct gastrointestinal routes of colonization. Mechanically ventilated patients were heavily colonized in their lower airways by potential pathogenic microorganisms, including a high load of anaerobic bacteria. Different routes of colonization were shown for different species.

The effect of intensive care unit admission on smokers' attitudes and their likelihood of quitting smoking.

PubMed

Polmear, C M; Nathan, H; Bates, S; French, C; Odisho, J; Skinner, E; Karahalios, A; McGain, F

2017-11-01

We sought to estimate the proportion of patients admitted to a metropolitan intensive care unit (ICU) who were current smokers, and the relationships between ICU survivors who smoked and smoking cessation and/or reduction six months post-ICU discharge. We conducted a prospective cohort study at a metropolitan level III ICU in Melbourne, Victoria. One hundred consecutive patients who met the inclusion criteria were included in the study. Inclusion criteria consisted of patients who were smokers at time of ICU admission, had an ICU length of stay greater than one day, survived to ICU discharge, and provided written informed consent. A purpose-designed questionnaire which included the Fagerstrom test for nicotine dependence and evaluation of patients' attitude towards smoking cessation was completed by participants following ICU discharge and prior to hospital discharge. Participants were re-interviewed over the phone at six months post-ICU discharge. Of the 1,062 patients admitted to ICU, 253 (23%) were current smokers and 100 were enrolled. Six months post-ICU discharge, 28 (33%) of the 86 participants who were alive and contactable had quit smoking and 35 (41%) had reduced smoking. The median number of reported cigarettes smoked per day reduced by 40%. Participants who initially believed their ICU admission was smoking-related were more likely to have quit six months post-ICU discharge (odds ratio 2.98; 95% confidence interval 1.07 to 8.26; P=0.036). Six months post-ICU discharge, 63/86 (74%) of participants had quit or reduced their smoking. Further research into targeted smoking cessation counselling for ICU survivors is indicated.

Comparison of the Mortality Probability Admission Model III, National Quality Forum, and Acute Physiology and Chronic Health Evaluation IV hospital mortality models: implications for national benchmarking*.

PubMed

Kramer, Andrew A; Higgins, Thomas L; Zimmerman, Jack E

2014-03-01

To examine the accuracy of the original Mortality Probability Admission Model III, ICU Outcomes Model/National Quality Forum modification of Mortality Probability Admission Model III, and Acute Physiology and Chronic Health Evaluation IVa models for comparing observed and risk-adjusted hospital mortality predictions. Retrospective paired analyses of day 1 hospital mortality predictions using three prognostic models. Fifty-five ICUs at 38 U.S. hospitals from January 2008 to December 2012. Among 174,001 intensive care admissions, 109,926 met model inclusion criteria and 55,304 had data for mortality prediction using all three models. None. We compared patient exclusions and the discrimination, calibration, and accuracy for each model. Acute Physiology and Chronic Health Evaluation IVa excluded 10.7% of all patients, ICU Outcomes Model/National Quality Forum 20.1%, and Mortality Probability Admission Model III 24.1%. Discrimination of Acute Physiology and Chronic Health Evaluation IVa was superior with area under receiver operating curve (0.88) compared with Mortality Probability Admission Model III (0.81) and ICU Outcomes Model/National Quality Forum (0.80). Acute Physiology and Chronic Health Evaluation IVa was better calibrated (lowest Hosmer-Lemeshow statistic). The accuracy of Acute Physiology and Chronic Health Evaluation IVa was superior (adjusted Brier score = 31.0%) to that for Mortality Probability Admission Model III (16.1%) and ICU Outcomes Model/National Quality Forum (17.8%). Compared with observed mortality, Acute Physiology and Chronic Health Evaluation IVa overpredicted mortality by 1.5% and Mortality Probability Admission Model III by 3.1%; ICU Outcomes Model/National Quality Forum underpredicted mortality by 1.2%. Calibration curves showed that Acute Physiology and Chronic Health Evaluation performed well over the entire risk range, unlike the Mortality Probability Admission Model and ICU Outcomes Model/National Quality Forum models. Acute

Ward mortality after ICU discharge: a multicenter validation of the Sabadell score.

PubMed

Fernandez, Rafael; Serrano, Jose Manuel; Umaran, Isabel; Abizanda, Ricard; Carrillo, Andres; Lopez-Pueyo, Maria Jesus; Rascado, Pedro; Balerdi, Begoña; Suberviola, Borja; Hernandez, Gonzalo

2010-07-01

Tools for predicting post-ICU patients' outcomes are scarce. A single-center study showed that the Sabadell score classified patients into four groups with clear-cut differences in ward mortality. To validate the Sabadell score using a prospective multicenter approach. Thirty-one ICUs in Spain. All patients admitted in the 3-month study period. We recorded variables at ICU admission (age, sex, severity of illness, and do-not-resuscitate orders), during the ICU stay (ICU-specific treatments, ICU-acquired infection, and acute renal failure), and at ICU discharge (Sabadell score). Statistical analyses included one-way ANOVA and multiple regression analysis with ward mortality as the dependent variable. We admitted 4,132 patients (mean age 61.5 +/- 16.7 years) with mean predicted mortality of 23.8 +/- 22.7%; 545 patients (13%) died in the ICU and 3,587 (87%) were discharged to the ward. Overall ward mortality was 6.7%; ward mortality was 1.5% (36/2,422) in patients with score 0 (good prognosis), 9% (64/725) in patients with score 1 (long-term poor prognosis), 23% (79/341) in patients with score 2 (short-term poor prognosis), and 64% (63/99) in patients with score 3 (expected hospital death). Variables associated with ward mortality in the multivariate analysis were predicted risk of death (OR 1.016), ICU readmission (OR 5.9), Sabadell score 1 (OR 4.7), Sabadell score 2 (OR 15.7), and Sabadell score 3 (OR 107.2). We confirm the ability of the Sabadell score at ICU discharge to define four groups of patients with very different likelihoods of hospital survival.

An Evaluation of the Usefulness of Extracorporeal Liver Support Techniques in Patients Hospitalized in the ICU for Severe Liver Dysfunction Secondary to Alcoholic Liver Disease

PubMed Central

Piechota, Mariusz; Piechota, Anna

2016-01-01

Background The mortality rate in patients with severe liver dysfunction secondary to alcoholic liver disease (ALD) who do not respond to the standard treatment is exceptionally high. Objectives The main aim of this study was to evaluate the usefulness of applying extracorporeal liver support techniques to treat this group of patients. Patients and Methods The data from 23 hospital admissions of 21 patients with ALD who were admitted to the department of anesthesiology and intensive therapy (A&IT) at the Dr Wł. Biegański Regional Specialist Hospital in Łódź between March 2013 and July 2015 were retrospectively analyzed. Results A total of 111 liver dialysis procedures were performed during the 23 hospitalizations, including 13 dialyses using fractionated plasma separation and adsorption (FPSA) with the Prometheus® system, and 98 procedures using the single pass albumin dialysis (SPAD) system. Upon admission to the intensive care unit (ICU), the median (interquartile range [IQR]) Glasgow coma scale (GCS), sequential organ failure assessment (SOFA), acute physiology and chronic health evaluation (APACHE) II, and simplified acute physiology score (SAPS) II scores were 15 (14 - 15), 9 (7 - 13), 17 (14 - 24), and 32 (22 - 50), respectively. The ICU, 30-day, and three-month mortality rates were 43.48%, 39.13%, and 73.91%, respectively. As determined by the receiver operative characteristic (ROC) analysis for single-factor models, the significant predictors of death in the ICU included the patients’ SOFA, APACHE II, SAPS II, and model of end-stage liver disease modified by the united network for organ sharing (MELD UNOS Modification) scores; the duration of stay (in days) in the A&IT Department; and bile acid, creatinine and albumin levels upon ICU admission. The ROC analysis indicated the significant discriminating power of the SOFA, APACHE II, SAPS II, and MELD UNOS modification scores on the three-month mortality rate. Conclusions The application of

Admission to dedicated pediatric cardiac intensive care units is associated with decreased resource use in neonatal cardiac surgery.

PubMed

Johnson, Joyce T; Wilkes, Jacob F; Menon, Shaji C; Tani, Lloyd Y; Weng, Hsin-Yi; Marino, Bradley S; Pinto, Nelangi M

2018-06-01

Neonates undergoing congenital heart surgery require highly specialized, resource-intensive care. Location of care and degree of specialization can vary between and within institutions. Using a multi-institutional cohort, we sought to determine whether location of admission is associated with an increase in health care costs, resource use and mortality. We retrospectively analyzed admission for neonates (<30 days) undergoing congenital heart surgery between 2004 and 2013 by using the Pediatric Health Information Systems database (44 children's hospitals). Multivariate generalized estimating equations adjusted for center- and patient-specific risk factors and stratified by age at admission were performed to examine the association of admission intensive care unit (ICU) with total hospital costs, mortality, and length of stay. Of 19,984 neonates (60% male) identified, 39% were initially admitted to a cardiac ICU (CICU), 48% to a neonatal ICU (NICU), and 13% to a pediatric ICU. In adjusted models, admission to a CICU versus NICU was associated with a $20,440 reduction in total hospital cost for infants aged 2 to 7 days at admission (P = .007) and a $23,700 reduction in total cost for infants aged 8 to 14 days at admission (P = .01). Initial admission to a CICU or pediatric ICU versus NICU at <15 days of age was associated with shorter hospital and ICU length of stay and fewer days of mechanical ventilation. There was no difference in adjusted mortality by admission location. Admission to an ICU specializing in cardiac care is associated with significantly decreased hospital costs and more efficient resource use for neonates requiring cardiac surgery. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

ICU scoring systems allow prediction of patient outcomes and comparison of ICU performance.

PubMed

Becker, R B; Zimmerman, J E

1996-07-01

Too much time and effort are wasted in attempts to pass final judgment on whether systems for ICU prognostication are "good or bad" and whether they "do or do not" provide a simple answer to the complex and often unpredictable question of individual mortality in the ICU. A substantial amount of data supports the usefulness of general ICU prognostic systems in comparing ICU performance with respect to a wide variety of endpoints, including ICU and hospital mortality, duration of stay, and efficiency of resource use. Work in progress is analyzing both general resource use and specific therapeutic interventions. It also is time to fully acknowledge that statistics never can predict whether a patient will die with 100% accuracy. There always will be exceptions to the rule, and physicians frequently will have information that is not included in prognostic models. In addition, the values of both physicians and patients frequently lead to differences in how a probability in interpreted; for some, a 95% probability estimate means that death is near and, for others, this estimate represents a tangible 5% chance for survival. This means that physicians must learn how to integrate such estimates into their medical decisions. In doing so, it is our hope that prognostic systems are not viewed as oversimplifying or automating clinical decisions. Rather, such systems provide objective data on which physicians may ground a spectrum of decisions regarding either escalation or withdrawal of therapy in critically ill patients. These systems do not dehumanize our decision-making process but, rather, help eliminate physician reliance on emotional, heuristic, poorly calibrated, or overly pessimistic subjective estimates. No decision regarding patient care can be considered best if the facts upon which it is based on imprecise or biased. Future research will improve the accuracy of individual patient predictions but, even with the highest degree of precision, such predictions are useful

Pathogen colonization of the gastrointestinal microbiome at intensive care unit admission and risk for subsequent death or infection.

PubMed

Freedberg, Daniel E; Zhou, Margaret J; Cohen, Margot E; Annavajhala, Medini K; Khan, Sabrina; Moscoso, Dagmara I; Brooks, Christian; Whittier, Susan; Chong, David H; Uhlemann, Anne-Catrin; Abrams, Julian A

2018-06-23

Loss of colonization resistance within the gastrointestinal microbiome facilitates the expansion of pathogens and has been associated with death and infection in select populations. We tested whether gut microbiome features at the time of intensive care unit (ICU) admission predict death or infection. This was a prospective cohort study of medical ICU adults. Rectal surveillance swabs were performed at admission, selectively cultured for vancomycin-resistant Enterococcus (VRE), and assessed using 16S rRNA gene sequencing. Patients were followed for 30 days for death or culture-proven bacterial infection. Of 301 patients, 123 (41%) developed culture-proven infections and 76 (25%) died. Fecal biodiversity (Shannon index) did not differ based on death or infection (p = 0.49). The presence of specific pathogens at ICU admission was associated with subsequent infection with the same organism for Escherichia coli, Pseudomonas spp., Klebsiella spp., and Clostridium difficile, and VRE at admission was associated with subsequent Enterococcus infection. In a multivariable model adjusting for severity of illness, VRE colonization and Enterococcus domination (≥ 30% 16S reads) were both associated with death or all-cause infection (aHR 1.46, 95% CI 1.06-2.00 and aHR 1.47, 95% CI 1.00-2.19, respectively); among patients without VRE colonization, Enterococcus domination was associated with excess risk of death or infection (aHR 2.13, 95% CI 1.06-4.29). Enterococcus status at ICU admission was associated with risk for death or all-cause infection, and rectal carriage of common ICU pathogens predicted specific infections. The gastrointestinal microbiome may have a role in risk stratification and early diagnosis of ICU infections.

Intensive care and pregnancy: Epidemiology and general principles of management of obstetrics ICU patients during pregnancy.

PubMed

Zieleskiewicz, Laurent; Chantry, Anne; Duclos, Gary; Bourgoin, Aurelie; Mignon, Alexandre; Deneux-Tharaux, Catherine; Leone, Marc

2016-10-01

In developed countries, the rate of obstetric ICU admissions (admission during pregnancy or the postpartum period) is between 0.5 and 4 per 1000 deliveries and the overall case-fatality rate is about 2%. The most two common causes of obstetric ICU admissions concerned direct obstetric pathologies: obstetric hemorrhage and hypertensive disorders of pregnancy. This review summarized the principles of management of critically ill pregnant patient. Its imply taking care of two patients in the same time. A coordinated multidisciplinary team including intensivists, anesthesiologists, obstetricians, pediatricians and pharmacists is therefore necessary. This team must work effectively together with regular staff aiming to evaluate daily the need to maintain the patient in intensive care unit or to prompt delivery. Keeping mother and baby together and fetal well-being must be balanced with the need of specialized advanced life support for the mother. The maternal physiological changes imply various consequences on management. The uterus aorto-caval compression implies tilting left the parturient. In case of cardiac arrest, uterus displacement and urgent cesarean delivery are needed. The high risk of aspiration and difficult tracheal intubation must be anticipated. Even during acute respiratory distress syndrome, hypoxemia and permissive hypercapnia must be avoided due to their negative impact on the fetus. Careful analysis of the benefit-risk ratio is needed before all drug administration. Streptococcal toxic shock syndrome and perineal fasciitis must be feared and a high level of suspicion of sepsis must be maintained. Finally the potential benefits of an ultrasound-based management are detailed. Copyright © 2016 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.

Economic Evaluation of a Patient-Directed Music Intervention for ICU Patients Receiving Mechanical Ventilatory Support.

PubMed

Chlan, Linda L; Heiderscheit, Annette; Skaar, Debra J; Neidecker, Marjorie V

2018-05-04

Music intervention has been shown to reduce anxiety and sedative exposure among mechanically ventilated patients. Whether music intervention reduces ICU costs is not known. The aim of this study was to examine ICU costs for patients receiving a patient-directed music intervention compared with patients who received usual ICU care. A cost-effectiveness analysis from the hospital perspective was conducted to determine if patient-directed music intervention was cost-effective in improving patient-reported anxiety. Cost savings were also evaluated. One-way and probabilistic sensitivity analyses determined the influence of input variation on the cost-effectiveness. Midwestern ICUs. Adult ICU patients from a parent clinical trial receiving mechanical ventilatory support. Patients receiving the experimental patient-directed music intervention received a MP3 player, noise-canceling headphones, and music tailored to individual preferences by a music therapist. The base case cost-effectiveness analysis estimated patient-directed music intervention reduced anxiety by 19 points on the Visual Analogue Scale-Anxiety with a reduction in cost of $2,322/patient compared with usual ICU care, resulting in patient-directed music dominance. The probabilistic cost-effectiveness analysis found that average patient-directed music intervention costs were $2,155 less than usual ICU care and projected that cost saving is achieved in 70% of 1,000 iterations. Based on break-even analyses, cost saving is achieved if the per-patient cost of patient-directed music intervention remains below $2,651, a value eight times the base case of $329. Patient-directed music intervention is cost-effective for reducing anxiety in mechanically ventilated ICU patients.

The clinical relevance of the Waterlow pressure sore risk scale in the ICU.

PubMed

Weststrate, J T; Hop, W C; Aalbers, A G; Vreeling, A W; Bruining, H A

1998-08-01

To evaluate whether the Waterlow pressure sore risk (PSR) scale has prognostic significance for intensive care patients. A prospective study. The surgical intensive care unit (ICU) of the University Hospital Rotterdam. Data were evaluated from 594 patients who had been admitted to the ICU during the year 1994. Each patient was assessed daily with respect to their Waterlow PSR score and the development of pressure sores in the sacral region. Actuarial statistical methods were used to analyse the predictive value of the risk score. When a patient had a Waterlow PSR score > 25 on admission, the risk of developing a pressure sore was significantly increased compared to patients with a PSR score < 25. After admission, the daily Waterlow PSR scores obtained were significantly associated with the risk of developing a pressure sore. For each additional point this risk increased by 23% (95% confidence interval 17 to 28%). The Waterlow PSR scale provides the medical and nursing staff at an early stage with reliable information about the risk patients have in developing a pressure sore.

Effect of Weekend Admissions on the Treatment Process and Outcomes of Internal Medicine Patients: A Nationwide Cross-Sectional Study.

PubMed

Huang, Chun-Che; Huang, Yu-Tung; Hsu, Nin-Chieh; Chen, Jin-Shing; Yu, Chong-Jen

2016-02-01

Many studies address the effect of weekend admission on patient outcomes. This population-based study aimed to evaluate the relationship between weekend admission and the treatment process and outcomes of general internal medicine patients in Taiwan.A total of 82,340 patients (16,657 weekend and 65,683 weekday admissions) aged ≥20 years and admitted to the internal medicine departments of 17 medical centers between 2007 and 2009 were identified from the Taiwan National Health Insurance Research Database. A generalized estimating equation (GEE) analysis was used to compare patients admitted on weekends and those admitted on weekdays.Patients who were admitted on weekends were more likely to undergo intubation (odds ratio [OR]: 1.27; 95% confidence interval [CI]: 1.16-1.39; P < 0.001) and/or mechanical ventilation (OR, 1.25; 95% CI, 1.15-1.35; P < 0.001), cardio-pulmonary resuscitation (OR: 1.45; 95% CI: 1.05-2.01; P = 0.026), and be transferred to the intensive care unit (ICU) (OR: 1.16; 95% CI: 1.03-1.30; P = 0.015) compared with those admitted on weekdays. Weekend-admitted patients also had higher odds of in-hospital mortality (OR: 1.19; 95% CI: 1.09-1.30; P < 0.001) and hospital treatment cost (OR: 1.04; 95% CI: 1.01-1.06; P = 0.008) than weekday-admitted patients.General internal medicine patients who were admitted on weekends experienced more intensive care procedures and higher ICU admission, in-hospital mortality, and treatment cost. Intensive care utilization may serve as early indicator of poorer outcomes and a potential entry point to offer preventive intervention before proceeding to intensive treatment.

There′s no place like home: Boarding surgical ICU patients in other ICUs and the effect of distances from the home unit

PubMed Central

Pascual, Jose L.; Blank, Nicholas W.; Holena, Daniel N.; Robertson, Matthew P.; Diop, Mouhamed; Allen, Steve R.; Martin, Niels D.; Kohl, Benjamin A.; Sims, Carrie A.; Schwab, C. William; Reilly, Patrick M.

2014-01-01

BACKGROUND Intensive care units (ICUs) function frequently at capacity, requiring incoming critically ill patients to be placed in alternate geographically distinct ICUs. In some medical ICU populations, “boarding” in an overflow ICU has been associated with increased mortality. We hypothesized that surgical ICU patients experience more complications when boarding in an overflow ICU and that the frequency of these complications are greatest in boarders farthest from the home unit (HU). METHODS A 5-year (June 2005 to June 2010) retrospective review of a prospectively maintained ICU database was performed, and demographics, severity of illness, length of stay, and incidence of ICU complications were extracted. Distances between boarding patients’ rooms and the HU were measured. Complications occurring in patients located in the same floor (BUSF) and different floor (BUDF) boarding units were compared and stratified by distance from HU to the patient room. Logistic regression was used to develop control for known confounders. RESULTS A total of 7,793 patients were admitted to the HU and 833 to a boarding unit (BUSF, n = 712; BUDF, n = 121). Boarders were younger, had a lower length of stay, and Acute Physiology and Chronic Health Evaluation II and were more of tentrauma/emergency surgery patients. Compared with in-HU patients, the incidence of aspiration pneumonia (2.2% vs. 3.6%, p < 0.01) was greater in BUSF patients and highest in those farthest from the HU (odds ratio [OR],2.39;p =0.01). Delirium occurred less often in HU than in BUDF patients (3.3% vs. 8.3 %, p < 0.01), and both delirium (OR, 6.09, p < 0.01) and ventilator-associated pneumonia (OR, 4.49, p < 0.05) were more frequent in patients farther from the HU. CONCLUSION Certain ICU complications occur more frequently in boarding patients particularly if they are located on a different floor or far from the HU. When surgical ICU bed availability forces overflow admissions to non–home ICUs, greater

Influenza-associated intensive-care unit admissions and deaths - California, September 29, 2013-January 18, 2014.

PubMed

Ayscue, Patrick; Murray, Erin; Uyeki, Timothy; Zipprich, Jennifer; Harriman, Kathleen; Salibay, Catheryn; Kang, Monica; Luu, Annie; Glenn-Finer, Rose; Watt, James; Glaser, Carol; Louie, Janice

2014-02-21

The California Department of Public Health (CDPH) conducts surveillance on severe influenza illness among California residents aged <65 years. Severe cases are defined as those resulting in admission to an intensive care unit (ICU) or death; reporting of ICU cases is voluntary, and reporting of fatal cases is mandatory. This report describes the epidemiologic, laboratory, and clinical characteristics of ICU and fatal influenza cases with symptom onset on or after September 29, 2013, and reported by January 18, 2014 of the 2013-14 influenza season. At the time of this report, local health jurisdictions (LHJs) in California had reported 94 deaths and 311 ICU admissions of patients with a positive influenza test result. The 405 reports of severe cases (i.e., fatal and ICU cases combined) were more than in any season since the 2009 pandemic caused by the influenza A (H1N1)pdm09 (pH1N1) virus. The pH1N1 virus is the predominant circulating influenza virus this season. Of 405 ICU and fatal influenza cases, 266 (66%) occurred among patients aged 41-64 years; 39 (10%) severe influenza illnesses occurred among children aged <18 years. Only six (21%) of 28 patients with fatal illness whose vaccination status was known had received 2013-14 seasonal influenza vaccine ≥2 weeks before symptom onset. Of 80 patients who died for whom sufficient information was available, 74 (93%) had underlying medical conditions known to increase the risk for severe influenza, as defined by the Advisory Committee on Immunization Practices (ACIP). Of 47 hospitalized patients with fatal illness and known symptom onset and antiviral therapy dates, only eight (17%) received neuraminidase inhibitors within 48 hours of symptom onset. This report supports previous recommendations that vaccination is important to prevent influenza virus infections that can result in ICU admission or death, particularly in high-risk populations, and that empiric antiviral treatment should be promptly initiated when

The New MIRUS System for Short-Term Sedation in Postsurgical ICU Patients.

PubMed

Romagnoli, Stefano; Chelazzi, Cosimo; Villa, Gianluca; Zagli, Giovanni; Benvenuti, Francesco; Mancinelli, Paola; Arcangeli, Giulio; Dugheri, Stefano; Bonari, Alessandro; Tofani, Lorenzo; Belardinelli, Andrea; De Gaudio, A Raffaele

2017-09-01

To evaluate the feasibility and safety of the MIRUS system (Pall International, Sarl, Fribourg, Switzerland) for sedation with sevoflurane for postsurgical ICU patients and to evaluate atmospheric pollution during sedation. Prospective interventional study. Surgical ICU. February 2016 to December 2016. Postsurgical patients requiring ICU admission, mechanical ventilation, and sedation. Sevoflurane was administered with the MIRUS system targeted to a Richmond Agitation Sedation Scale from -3 to -5 by adaptation of minimum alveolar concentration. Data collected included Richmond Agitation Sedation Scale, minimum alveolar concentration, inspired and expired sevoflurane fraction, wake-up times, duration of sedation, sevoflurane consumption, respiratory and hemodynamic data, Simplified Acute Physiology Score II, Sepsis-related Organ Failure Assessment, and laboratory data and biomarkers of organ injury. Atmospheric pollution was monitored at different sites: before sevoflurane delivery (baseline) and during sedation with the probe 15 cm up to the MIRUS system (S1) and 15 cm from the filter-Reflector group (S2). Sixty-two patients were enrolled in the study. No technical failure occurred. Median Richmond Agitation Sedation Scale was -4.5 (interquartile range, -5 to -3.6) with sevoflurane delivered at a median minimum alveolar concentration of 0.45% (interquartile range, 0.4-0.53) yielding a mean inspiratory and expiratory concentrations of 0.79% (SD, 0.24) and 0.76% (SD, 0.18), respectively. Median awakening time was 4 minutes (2.2-5 min). Median duration of sevoflurane administration was 3.33 hours (2.33-5.75 hr), range 1-19 hours with a mean consumption of 7.89 mL/hr (SD, 2.99). Hemodynamics remained stable over the study period, and no laboratory data indicated liver or kidney injury or dysfunction. Median sevoflurane room air concentration was 0.10 parts per million (interquartile range, 0.07-0.15), 0.17 parts per million (interquartile range, 0

Epidemiology of severe trauma in Spain. Registry of trauma in the ICU (RETRAUCI). Pilot phase.

PubMed

Chico-Fernández, M; Llompart-Pou, J A; Guerrero-López, F; Sánchez-Casado, M; García-Sáez, I; Mayor-García, M D; Egea-Guerrero, J; Fernández-Ortega, J F; Bueno-González, A; González-Robledo, J; Servià-Goixart, L; Roldán-Ramírez, J; Ballesteros-Sanz, M Á; Tejerina-Alvarez, E; García-Fuentes, C; Alberdi-Odriozola, F

2016-01-01

To describe the characteristics and management of severe trauma disease in Spanish Intensive Care Units (ICUs). Registry of trauma in the ICU (RETRAUCI). Pilot phase. A prospective, multicenter registry. Thirteen Spanish ICUs. Patients with trauma disease admitted to the ICU. None. Epidemiology, out-of-hospital attention, registry of injuries, resources utilization, complications and outcome were evaluated. Patients, n=2242. Mean age 47.1±19.02 years. Males 79%. Blunt trauma 93.9%. Injury Severity Score 22.2±12.1, Revised Trauma Score 6.7±1.6. Non-intentional in 84.4% of the cases. The most common causes of trauma were traffic accidents followed by pedestrian and high-energy falls. Up to 12.4% were taking antiplatelet medication or anticoagulants. Almost 28% had a suspected or confirmed toxic influence in trauma. Up to 31.5% required an out-of-hospital artificial airway. The time from trauma to ICU admission was 4.7±5.3hours. At ICU admission, 68.5% were hemodynamically stable. Brain and chest injuries predominated. A large number of complications were documented. Mechanical ventilation was used in 69.5% of the patients (mean 8.2±9.9 days), of which 24.9% finally required a tracheostomy. The median duration of stay in the ICU and in hospital was 5 (range 3-13) and 9 (5-19) days, respectively. The ICU mortality rate was 12.3%, while the in-hospital mortality rate was 16.0%. The pilot phase of the RETRAUCI offers a first impression of the epidemiology and management of trauma disease in Spanish ICUs. Copyright © 2015 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

Comparison of mortality prediction models in burns ICU patients in Pinderfields Hospital over 3 years.

PubMed

Douglas, Helen E; Ratcliffe, Andrew; Sandhu, Rajdeep; Anwar, Umair

2015-02-01

Many different burns mortality prediction models exist; however most agree that important factors that can be weighted include the age of the patient, the total percentage of body surface area burned and the presence or absence of smoke inhalation. A retrospective review of all burns primarily admitted to Pinderfields Burns ICU under joint care of burns surgeons and intensivists for the past 3 years was completed. Predicted mortality was calculated using the revised Baux score (2010), the Belgian Outcome in Burn Injury score (2009) and the Boston group score by Ryan et al. (1998). Additionally 28 of the 48 patients had APACHE II scores recorded on admission and the predicted and actual mortality of this group were compared. The Belgian score had the highest sensitivity and negative predictive value (72%/85%); followed by the Boston score (66%/78%) and then the revised Baux score (53%/70%). APACHE II scores had higher sensitivity (81%) and NPV (92%) than any of the burns scores. In our group of burns ICU patients the Belgian model was the most sensitive and specific predictor of mortality. In our subgroup of patients with APACHE II data, this score more accurately predicted survival and mortality. Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.

Aspergillosis in Intensive Care Unit (ICU) patients: epidemiology and economic outcomes.

PubMed

Baddley, John W; Stephens, Jennifer M; Ji, Xiang; Gao, Xin; Schlamm, Haran T; Tarallo, Miriam

2013-01-23

Few data are available regarding the epidemiology of invasive aspergillosis (IA) in ICU patients. The aim of this study was to examine epidemiology and economic outcomes (length of stay, hospital costs) among ICU patients with IA who lack traditional risk factors for IA, such as cancer, transplants, neutropenia or HIV infection. Retrospective cohort study using Premier Inc. Perspective™ US administrative hospital database (2005-2008). Adults with ICU stays and aspergillosis (ICD-9 117.3 plus 484.6) who received initial antifungal therapy (AF) in the ICU were included. Patients with traditional risk factors (cancer, transplant, neutropenia, HIV/AIDS) were excluded. The relationship of antifungal therapy and co-morbidities to economic outcomes were examined using Generalized linear models. From 6,424 aspergillosis patients in the database, 412 (6.4%) ICU patients with IA were identified. Mean age was 63.9 years and 53% were male. Frequent co-morbidities included steroid use (77%), acute respiratory failure (76%) and acute renal failure (41%). In-hospital mortality was 46%. The most frequently used AF was voriconazole (71% received at least once). Mean length of stay (LOS) was 26.9 days and mean total hospital cost was $76,235. Each 1 day lag before initiating AF therapy was associated with 1.28 days longer hospital stay and 3.5% increase in costs (p < 0.0001 for both). Invasive aspergillosis in ICU patients is associated with high mortality and hospital costs. Antifungal timing impacts economic outcomes. These findings underscore the importance of timely diagnosis, appropriate treatment, and consideration of Aspergillus as a potential etiology in ICU patients.

Risk factors for post-ICU red blood cell transfusion: a prospective study

PubMed Central

Marque, Sophie; Cariou, Alain; Chiche, Jean-Daniel; Mallet, Vincent Olivier; Pene, Frédéric; Mira, Jean-Paul; Dhainaut, Jean-François; Claessens, Yann-Erick

2006-01-01

Introduction Factors predictive of the need for red blood cell (RBC) transfusion in the intensive care unit (ICU) have been identified, but risk factors for transfusion after ICU discharge are unknown. This study aims identifies risk factors for RBC transfusion after discharge from the ICU. Methods A prospective, monocentric observational study was conducted over a 6-month period in a 24-bed medical ICU in a French university hospital. Between June and December 2003, 550 critically ill patients were consecutively enrolled in the study. Results A total of 428 patients survived after treatment in the ICU; 47 (11% of the survivors, 8.5% of the whole population) required RBC transfusion within 7 days after ICU discharge. Admission for sepsis (odds ratio [OR] 341.60, 95% confidence interval [CI] 20.35–5734.51), presence of an underlying malignancy (OR 32.6, 95%CI 3.8–280.1), female sex (OR 5.4, 95% CI 1.2–24.9), Logistic Organ Dysfunction score at ICU discharge (OR 1.45, 95% CI 1.1–1.9) and age (OR 1.06, 95% CI 1.02–1.12) were independently associated with RBC transfusion after ICU stay. Haemoglobin level at discharge predicted the need for delayed RBC transfusion. Use of vasopressors (OR 0.01, 95%CI 0.001–0.17) and haemoglobin level at discharge from the ICU (OR 0.02, 95% CI 0.007–0.09; P < 0.001) were strong independent predictors of transfusion of RBC 1 week after ICU discharge. Conclusion Sepsis, underlying conditions, unresolved organ failures and haemoglobin level at discharge were related to an increased risk for RBC transfusion after ICU stay. We suggest that strategies to prevent transfusion should focus on homogeneous subgroups of patients and take into account post-ICU needs for RBC transfusion. PMID:16965637

Utilizing multiple methods to classify malnutrition among elderly patients admitted to the medical and surgical intensive care units (ICU)

PubMed Central

Sheean, Patricia M.; Peterson, Sarah J.; Chen, Yimin; Liu, Dishan; Lateef, Omar; Braunschweig, Carol A.

2013-01-01

Background & Aims The nutritional status of elderly patients requiring ICU admission is largely unknown. This study evaluated the prevalence of malnutrition in patients (>65 years) admitted to the surgical and medical ICUs, agreement between assessment techniques and associations between malnutrition and adverse outcomes. Methods For this prospective cohort, nutritional status was classified concurrently using the Mini Nutrition Assessment (MNA), Subjective Global Assessment (SGA), Nutrition Risk Score 2002 (NRS 2002) and MNA-short form (MNA-SF). Demographic and relevant medical information were collected from the medical record prior to the nutrition interview and/or following hospital discharge. Descriptive statistics, inter-rater agreement and regression analyses were conducted. Results The average patient was 74.2 (± 6.8) yo with a mean APACHE II score 11.9 (± 3.6). Malnutrition was prevalent in 23–34% of patients (n=260) with excellent agreement between raters. Compared to MNA, NRS 2002 had the highest sensitivity, while SGA and MNA-SF had higher specificity. Malnutrition at ICU admission was associated with longer hospital LOS, a lower propensity for being discharged home and a greater need for hospice care or death at discharge (all p values <0.05). These relationships were diminished when controlling for severity of illness. Conclusions Future work in this elderly population needs to explore the role of disease acuity, inflammation and body composition in the nutrition assessment process and in the examination of outcomes. PMID:23340043

Outcome of Patients with Systemic Sclerosis in the Intensive Care Unit.

PubMed

Pène, Frédéric; Hissem, Tarik; Bérezné, Alice; Allanore, Yannick; Geri, Guillaume; Charpentier, Julien; Avouac, Jérôme; Guillevin, Loïc; Cariou, Alain; Chiche, Jean-Daniel; Mira, Jean-Paul; Mouthon, Luc

2015-08-01

Patients with systemic sclerosis (SSc) are prone to disease-specific or treatment-related life-threatening complications that may warrant intensive care unit (ICU) admission. We assessed the characteristics and current outcome of patients with SSc admitted to the ICU. We performed a single-center retrospective study over 6 years (November 2006-December 2012). All patients with SSc admitted to the ICU were enrolled. Short-term (in-ICU and in-hospital) and longterm (6-mo and 1-yr) mortality rates were studied, and the prognostic factors were analyzed. Forty-one patients with a median age of 50 years [interquartile range (IQR) 40-65] were included. Twenty-nine patients (72.5%) displayed diffuse cutaneous SSc. The time from diagnosis to ICU admission was 78 months (IQR 34-128). Twenty-eight patients (71.7%) previously had pulmonary fibrosis, and 12 (31.5%) had pulmonary hypertension. The main reason for ICU admission was acute respiratory failure in 27 patients (65.8%). Noninvasive ventilation was first attempted in 13 patients (31.7%) and was successful in 8 of them, whereas others required endotracheal intubation within 24 h. Altogether, 13 patients (31.7%) required endotracheal intubation and mechanical ventilation. The overall in-ICU, in-hospital, 6-month, and 1-year mortality rates were 31.8%, 39.0%, 46.4%, and 61.0%, respectively. Invasive mechanical ventilation was the worst prognostic factor, associated with an in-hospital mortality rate of 84.6%. This study provides reliable prognostic data in patients with SSc who required ICU admission. The devastating outcome of invasive mechanical ventilation in patients with SSc requires a reappraisal of indications for ICU admission and early identification of patients likely to benefit from noninvasive ventilation.

Pulmonary complications in patients with haematological malignancies treated at a respiratory ICU.

PubMed

Ewig, S; Torres, A; Riquelme, R; El-Ebiary, M; Rovira, M; Carreras, E; Raño, A; Xaubet, A

1998-07-01

Patients with haematological malignancies developing severe pulmonary complications have a poor outcome, especially after bone-marrow transplantation (BMT). We studied the aetiology, the yield of different diagnostic tools, as well as the outcome and prognostic factors in the corresponding population admitted to our respiratory intensive care unit (RICU). Overall, 89 patients with haematological malignancies and pulmonary complications treated within a 10 yr period were included. The underlying malignancies were predominantly acute leukaemia and chronic myeloid leukaemia (66/89, 74%). Fifty-two of 89 (58%) patients were bone marrow recipients. An aetiological diagnosis could be obtained in 61/89 (69%) of cases. The aetiology was infectious in 37/89 (42%) and noninfectious in 24/89 (27%). Blood cultures and cytological examinations of bronchoalveolar lavage fluid were the diagnostic tools with the highest yield (13/43 (30%) and 13/45 (29%) positive results, respectively). Necropsy results were coincident with results obtained during the lifetime in 43% of cases with infectious and 60% with noninfectious aetiologies. Overall mortality was 70/89 (79%), and 47/52 (90%) in transplant recipients. The requirement of mechanical ventilation, BMT, and an interval <90 days of BMT prior to ICU admission were independent adverse prognostic factors. The outcome in this patient population was uniformly poor. It was worst in bone marrow recipients developing pulmonary complications <90 days after transplantation and requiring mechanical ventilation. Decisions about intensive care unit admission and mech-anical ventilation should seriously consider the dismal prognosis of these patients.

Mindfulness and Coping are Inversely Related to Psychiatric Symptoms in Patients and Informal Caregivers in the Neuroscience ICU: Implications for Clinical Care

PubMed Central

Shaffer, Kelly M.; Riklin, Eric; Stagl, Jamie; Rosand, Jonathan; Vranceanu, Ana-Maria

2016-01-01

Objective To assess the correlation of psychosocial resiliency factors (mindfulness and coping) with symptoms of posttraumatic stress (PTS), anxiety, and depression in patients recently admitted to the Neuroscience Intensive Care Unit (Neuro-ICU) and their primary informal caregivers. Design A descriptive, cross-sectional correlational study. Setting Neuro-ICU in a major medical center. Participants 78 dyads of patients (total N= 81) and their primary caregivers (total N= 92) from June to December 2015. Study enrollment occurred within the first 2 weeks of patient admission to the Neuro-ICU. Intervention None Measurements and Main Results Dyads completed self-report measures of mindfulness (CAMS-R), coping (MOCS-A), PTS (PCL-S), anxiety (HADS), and depression (HADS). Rates of clinically significant PTS, anxiety, and depressive symptoms were high and comparable between patient and caregiver samples. Own psychological resilience factors and psychiatric symptoms were strongly correlated for both patients and caregivers. Depressive symptoms were interdependent between patients and their caregivers, and one’s own mindfulness was independently related to one’s partner’s depressive symptoms. Conclusions Rates of clinically significant psychiatric symptoms were high, equally prevalent in patients and caregivers, and interdependent between patients and their caregivers. For both patients and caregivers, psychological resiliency factors were associated with both self and partner psychiatric symptoms. Findings suggest that attending to the psychiatric health of both patients and caregivers in the Neuro-ICU is a priority, and that patients and their caregivers must be considered together in a system to fully address either individual’s psychiatric symptoms. PMID:27513536

Mindfulness and Coping Are Inversely Related to Psychiatric Symptoms in Patients and Informal Caregivers in the Neuroscience ICU: Implications for Clinical Care.

PubMed

Shaffer, Kelly M; Riklin, Eric; Jacobs, Jamie M; Rosand, Jonathan; Vranceanu, Ana-Maria

2016-11-01

To assess the correlation of psychosocial resiliency factors (mindfulness and coping) with symptoms of posttraumatic stress, anxiety, and depression in patients recently admitted to the neuroscience ICU and their primary informal caregivers. A descriptive, cross-sectional correlational study. Neuroscience ICU in a major medical center. A total of 78 dyads of patients (total n = 81) and their primary caregivers (total n = 92) from June to December 2015. Study enrollment occurred within the first 2 weeks of patient admission to the neuroscience ICU. None. Dyads completed self-report measures of mindfulness (Cognitive and Affective Mindfulness Scale-Revised), coping (Measure of Coping Status-A), posttraumatic stress (Posttraumatic Checklist-Specific Stressor), anxiety (Hospital Anxiety and Depression Scale-A), and depression (Hospital Anxiety and Depression Scale-D). Rates of clinically significant posttraumatic stress, anxiety, and depressive symptoms were high and comparable between patient and caregiver samples. Own psychological resilience factors and psychiatric symptoms were strongly correlated for both patients and caregivers. Depressive symptoms were interdependent between patients and their caregivers, and one's own mindfulness was independently related to one's partner's depressive symptoms. Rates of clinically significant psychiatric symptoms were high, equally prevalent in patients and caregivers, and interdependent between patients and their caregivers. For both patients and caregivers, psychological resiliency factors were associated with both self and partner psychiatric symptoms. Findings suggest that attending to the psychiatric health of both patients and caregivers in the neuroscience ICU is a priority and that patients and their caregivers must be considered together in a system to fully address either individual's psychiatric symptoms.

Hospital costs estimation and prediction as a function of patient and admission characteristics.

PubMed

Ramiarina, Robert; Almeida, Renan Mvr; Pereira, Wagner Ca

2008-01-01

The present work analyzed the association between hospital costs and patient admission characteristics in a general public hospital in the city of Rio de Janeiro, Brazil. The unit costs method was used to estimate inpatient day costs associated to specific hospital clinics. With this aim, three "cost centers" were defined in order to group direct and indirect expenses pertaining to the clinics. After the costs were estimated, a standard linear regression model was developed for correlating cost units and their putative predictors (the patients gender and age, the admission type (urgency/elective), ICU admission (yes/no), blood transfusion (yes/no), the admission outcome (death/no death), the complexity of the medical procedures performed, and a risk-adjustment index). Data were collected for 3100 patients, January 2001-January 2003. Average inpatient costs across clinics ranged from (US$) 1135 [Orthopedics] to 3101 [Cardiology]. Costs increased according to increases in the risk-adjustment index in all clinics, and the index was statistically significant in all clinics except Urology, General surgery, and Clinical medicine. The occupation rate was inversely correlated to costs, and age had no association with costs. The (adjusted) per cent of explained variance varied between 36.3% [Clinical medicine] and 55.1% [Thoracic surgery clinic]. The estimates are an important step towards the standardization of hospital costs calculation, especially for countries that lack formal hospital accounting systems.

Admission factors associated with hospital mortality in patients with haematological malignancy admitted to UK adult, general critical care units: a secondary analysis of the ICNARC Case Mix Programme Database

PubMed Central

2009-01-01

Introduction Patients with haematological malignancy admitted to intensive care have a high mortality. Adverse prognostic factors include the number of organ failures, invasive mechanical ventilation and previous bone marrow transplantation. Severity-of-illness scores may underestimate the mortality of critically ill patients with haematological malignancy. This study investigates the relationship between admission characteristics and outcome in patients with haematological malignancies admitted to intensive care units (ICUs) in England, Wales and Northern Ireland, and assesses the performance of three severity-of-illness scores in this population. Methods A secondary analysis of the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme Database was conducted on admissions to 178 adult, general ICUs in England, Wales and Northern Ireland between 1995 and 2007. Multivariate logistic regression analysis was used to identify factors associated with hospital mortality. The Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiology Score (SAPS) II and ICNARC score were evaluated for discrimination (the ability to distinguish survivors from nonsurvivors); and the APACHE II, SAPS II and ICNARC mortality probabilities were evaluated for calibration (the accuracy of the estimated probability of survival). Results There were 7,689 eligible admissions. ICU mortality was 43.1% (3,312 deaths) and acute hospital mortality was 59.2% (4,239 deaths). ICU and hospital mortality increased with the number of organ failures on admission. Admission factors associated with an increased risk of death were bone marrow transplant, Hodgkin's lymphoma, severe sepsis, age, length of hospital stay prior to intensive care admission, tachycardia, low systolic blood pressure, tachypnoea, low Glasgow Coma Score, sedation, PaO2:FiO2, acidaemia, alkalaemia, oliguria, hyponatraemia, hypernatraemia, low haematocrit, and uraemia. The ICNARC

Admission factors associated with hospital mortality in patients with haematological malignancy admitted to UK adult, general critical care units: a secondary analysis of the ICNARC Case Mix Programme Database.

PubMed

Hampshire, Peter A; Welch, Catherine A; McCrossan, Lawrence A; Francis, Katharine; Harrison, David A

2009-01-01

Patients with haematological malignancy admitted to intensive care have a high mortality. Adverse prognostic factors include the number of organ failures, invasive mechanical ventilation and previous bone marrow transplantation. Severity-of-illness scores may underestimate the mortality of critically ill patients with haematological malignancy. This study investigates the relationship between admission characteristics and outcome in patients with haematological malignancies admitted to intensive care units (ICUs) in England, Wales and Northern Ireland, and assesses the performance of three severity-of-illness scores in this population. A secondary analysis of the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme Database was conducted on admissions to 178 adult, general ICUs in England, Wales and Northern Ireland between 1995 and 2007. Multivariate logistic regression analysis was used to identify factors associated with hospital mortality. The Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiology Score (SAPS) II and ICNARC score were evaluated for discrimination (the ability to distinguish survivors from nonsurvivors); and the APACHE II, SAPS II and ICNARC mortality probabilities were evaluated for calibration (the accuracy of the estimated probability of survival). There were 7,689 eligible admissions. ICU mortality was 43.1% (3,312 deaths) and acute hospital mortality was 59.2% (4,239 deaths). ICU and hospital mortality increased with the number of organ failures on admission. Admission factors associated with an increased risk of death were bone marrow transplant, Hodgkin's lymphoma, severe sepsis, age, length of hospital stay prior to intensive care admission, tachycardia, low systolic blood pressure, tachypnoea, low Glasgow Coma Score, sedation, PaO2:FiO2, acidaemia, alkalaemia, oliguria, hyponatraemia, hypernatraemia, low haematocrit, and uraemia. The ICNARC model had the best discrimination

The effects of performance status one week before hospital admission on the outcomes of critically ill patients.

PubMed

Zampieri, Fernando G; Bozza, Fernando A; Moralez, Giulliana M; Mazza, Débora D S; Scotti, Alexandre V; Santino, Marcelo S; Ribeiro, Rubens A B; Rodrigues Filho, Edison M; Cabral, Maurício M; Maia, Marcelo O; D'Alessandro, Patrícia S; Oliveira, Sandro V; Menezes, Márcia A M; Caser, Eliana B; Lannes, Roberto S; Alencar Neto, Meton S; Machado, Maristela M; Sousa, Marcelo F; Salluh, Jorge I F; Soares, Marcio

2017-01-01

To assess the impact of performance status (PS) impairment 1 week before hospital admission on the outcomes in patients admitted to intensive care units (ICU). Retrospective cohort study in 59,693 patients (medical admissions, 67 %) admitted to 78 ICUs during 2013. We classified PS impairment according to the Eastern Cooperative Oncology Group (ECOG) scale in absent/minor (PS = 0-1), moderate (PS = 2) or severe (PS = 3-4). We used univariate and multivariate logistic regression analyses to investigate the association between PS impairment and hospital mortality. PS impairment was moderate in 17.3 % and severe in 6.9 % of patients. The hospital mortality was 14.4 %. Overall, the worse the PS, the higher the ICU and hospital mortality and length of stay. In addition, patients with worse PS were less frequently discharged home. PS impairment was associated with worse outcomes in all SAPS 3, Charlson Comorbidity Index and age quartiles as well as according to the admission type. Adjusting for other relevant clinical characteristics, PS impairment was associated with higher hospital mortality (odds-ratio (OR) = 1.96 (95 % CI 1.63-2.35), for moderate and OR = 4.22 (3.32-5.35), for severe impairment). The effects of PS on the outcome were particularly relevant in the medium range of severity-of-illness. These results were consistent in the subgroup analyses. However, adding PS impairment to the SAPS 3 score improved only slightly its discriminative capability. PS impairment was associated with worse outcomes independently of other markers of chronic health status, particularly for patients in the medium range of severity of illness.

Using simulation to determine the need for ICU beds for surgery patients.

PubMed

Troy, Philip Marc; Rosenberg, Lawrence

2009-10-01

As the need for surgical ICU beds at the hospital increases, the mismatch between demand and supply for those beds has led to the need to understand the drivers of ICU performance. A Monte Carlo simulation study of ICU performance was performed using a discrete event model that captured the events, timing, and logic of ICU patient arrivals and bed stays. The study found that functional ICU capacity, ie, the number of occupied ICU beds at which operative procedures were canceled if they were known to require an ICU stay, was the main determinant of the wait, the number performed, and the number of cancellations of operative procedures known to require an ICU stay. The study also found that actual and functional ICU capacity jointly explained ICU utilization and the mean number of patients that should have been in the ICU that were parked elsewhere. The study demonstrated the necessity of considering actual and functional ICU capacity when analyzing surgical ICU bed requirements, and suggested the need for additional research on synchronizing demand with supply. The study also reinforced the authors' sense that simulation facilitates the evaluation of trade-offs between surgical management alternatives proposed by experts and the identification of unexpected drawbacks or opportunities of those proposals.

MIMIC II: a massive temporal ICU patient database to support research in intelligent patient monitoring

NASA Technical Reports Server (NTRS)

Saeed, M.; Lieu, C.; Raber, G.; Mark, R. G.

2002-01-01

Development and evaluation of Intensive Care Unit (ICU) decision-support systems would be greatly facilitated by the availability of a large-scale ICU patient database. Following our previous efforts with the MIMIC (Multi-parameter Intelligent Monitoring for Intensive Care) Database, we have leveraged advances in networking and storage technologies to develop a far more massive temporal database, MIMIC II. MIMIC II is an ongoing effort: data is continuously and prospectively archived from all ICU patients in our hospital. MIMIC II now consists of over 800 ICU patient records including over 120 gigabytes of data and is growing. A customized archiving system was used to store continuously up to four waveforms and 30 different parameters from ICU patient monitors. An integrated user-friendly relational database was developed for browsing of patients' clinical information (lab results, fluid balance, medications, nurses' progress notes). Based upon its unprecedented size and scope, MIMIC II will prove to be an important resource for intelligent patient monitoring research, and will support efforts in medical data mining and knowledge-discovery.

An Interpretable Machine Learning Model for Accurate Prediction of Sepsis in the ICU.

PubMed

Nemati, Shamim; Holder, Andre; Razmi, Fereshteh; Stanley, Matthew D; Clifford, Gari D; Buchman, Timothy G

2018-04-01

Sepsis is among the leading causes of morbidity, mortality, and cost overruns in critically ill patients. Early intervention with antibiotics improves survival in septic patients. However, no clinically validated system exists for real-time prediction of sepsis onset. We aimed to develop and validate an Artificial Intelligence Sepsis Expert algorithm for early prediction of sepsis. Observational cohort study. Academic medical center from January 2013 to December 2015. Over 31,000 admissions to the ICUs at two Emory University hospitals (development cohort), in addition to over 52,000 ICU patients from the publicly available Medical Information Mart for Intensive Care-III ICU database (validation cohort). Patients who met the Third International Consensus Definitions for Sepsis (Sepsis-3) prior to or within 4 hours of their ICU admission were excluded, resulting in roughly 27,000 and 42,000 patients within our development and validation cohorts, respectively. None. High-resolution vital signs time series and electronic medical record data were extracted. A set of 65 features (variables) were calculated on hourly basis and passed to the Artificial Intelligence Sepsis Expert algorithm to predict onset of sepsis in the proceeding T hours (where T = 12, 8, 6, or 4). Artificial Intelligence Sepsis Expert was used to predict onset of sepsis in the proceeding T hours and to produce a list of the most significant contributing factors. For the 12-, 8-, 6-, and 4-hour ahead prediction of sepsis, Artificial Intelligence Sepsis Expert achieved area under the receiver operating characteristic in the range of 0.83-0.85. Performance of the Artificial Intelligence Sepsis Expert on the development and validation cohorts was indistinguishable. Using data available in the ICU in real-time, Artificial Intelligence Sepsis Expert can accurately predict the onset of sepsis in an ICU patient 4-12 hours prior to clinical recognition. A prospective study is necessary to determine the

Measuring tele-ICU impact: does it optimize quality outcomes for the critically ill patient?

PubMed

Goran, Susan F

2012-04-01

To determine the relationship between tele-ICU (intensive care unit) implementations and improvement in quality measures and patient outcomes. Tele-ICUs were designed to leverage scarce critical-care experts and promised to improve patient quality. Abstracts and peer-reviewed articles were reviewed to identify the associations between tele-ICU programmes and clinical outcomes, cost savings, and customer satisfaction. Few peer-reviewed studies are available and many variables in each study limit the ability to associate study conclusions to the overall tele-ICU programme. Further research is required to explore the impact of the tele-ICU on patient/family satisfaction. Research findings are highly dependent upon the level of ICU acceptance. The tele-ICU, in collaboration with the ICU team, can be a valuable tool for the enhancement of quality goals although the ability to demonstrate cost savings is extremely complex. Studies clearly indicate that tele-ICU nursing vigilance can enhance patient safety by preventing potential patient harm. Nursing managers and leaders play a vital part in optimizing the quality role of the tele-ICU through supportive modelling and the maximization of ICU integration. © 2012 Blackwell Publishing Ltd.

Epidemiological features of influenza in Canadian adult intensive care unit patients.

PubMed

Taylor, G; Abdesselam, K; Pelude, L; Fernandes, R; Mitchell, R; McGeer, A; Frenette, C; Suh, K N; Wong, A; Katz, K; Wilkinson, K; Mersereau, T; Gravel, D

2016-03-01

To identify predictive factors and mortality of patients with influenza admitted to intensive care units (ICU) we carried out a prospective cohort study of patients hospitalized with laboratory-confirmed influenza in adult ICUs in a network of Canadian hospitals between 2006 and 2012. There were 626 influenza-positive patients admitted to ICUs over the six influenza seasons, representing 17·9% of hospitalized influenza patients, 3·1/10,000 hospital admissions. Variability occurred in admission rate and proportion of hospital influenza patients who were admitted to ICUs (proportion range by year: 11·7-29·4%; 21·3% in the 2009-2010 pandemic). In logistic regression models ICU patients were younger during the pandemic and post-pandemic period, and more likely to be obese than hospital non-ICU patients. Influenza B accounted for 14·2% of all ICU cases and had a similar ICU admission rate as influenza A. Influenza-related mortality was 17·8% in ICU patients compared to 2·0% in non-ICU patients.

The number of mechanically ventilated ICU patients meeting communication criteria.

PubMed

Happ, Mary Beth; Seaman, Jennifer B; Nilsen, Marci L; Sciulli, Andrea; Tate, Judith A; Saul, Melissa; Barnato, Amber E

2015-01-01

(1) Estimate the proportion of mechanically ventilated (MV) intensive care unit (ICU) patients meeting basic communication criteria who could potentially be served by assistive communication tools and speech-language consultation. (2) Compare characteristics of patients who met communication criteria with those who did not. Observational cohort study in which computerized billing and medical records were screened over a 2-year period. Six specialty ICUs across two hospitals in an academic health system. Eligible patients were awake, alert, and responsive to verbal communication from clinicians for at least one 12-h nursing shift while receiving MV ≥ 2 consecutive days. Of the 2671 MV patients screened, 1440 (53.9%) met basic communication criteria. The Neurological ICU had the lowest proportion of MV patients meeting communication criteria (40.82%); Trauma ICU had the highest proportion (69.97%). MV patients who did not meet basic communication criteria (n = 1231) were younger, had shorter lengths of stay and lower costs, and were more likely to die during the hospitalization. We estimate that half of MV patients in the ICU could potentially be served by assistive communication tools and speech-language consultation. Copyright © 2015 Elsevier Inc. All rights reserved.

A Generic Simulation Model of the Relative Cost-Effectiveness of ICU Versus Step-Down (IMCU) Expansion.

PubMed

Mahmoudian-Dehkordi, Amin; Sadat, Somayeh

2017-01-01

Many jurisdictions are facing increased demand for intensive care. There are two long-term investment options: intensive care unit (ICU) versus step-down or intermediate care unit (IMCU) capacity expansion. Relative cost-effectiveness of the two investment strategies with regard to patient lives saved has not been studied to date. We expand a generic system dynamics simulation model of emergency patient flow in a typical hospital, populated with empirical evidence found in the medical and hospital administration literature, to estimate the long-term effects of expanding ICU versus IMCU beds on patient lives saved under a common assumption of 2.1% annual increase in hospital arrivals. Two alternative policies of expanding ICU by two beds versus introducing a two-bed IMCU are compared over a ten-year simulation period. Russel equation is used to calculate total cost of patients' hospitalization. Using two possible values for the ratio of ICU to IMCU cost per inpatient day and four possible values for the percentage of patients transferred from ICU to IMCU found in the literature, nine scenarios are compared against the baseline scenario of no capacity expansion. Expanding ICU capacity by two beds is demonstrated as the most cost-effective scenario with an incremental cost-effectiveness ratio of 3684 (US $) per life saved against the baseline scenario. Sensitivity analyses on the mortality rate of patients in IMCU, direct transfer of IMCU-destined patients to the ward upon completing required IMCU length of stay in the ICU, admission of IMCU patient to ICU, adding two ward beds, and changes in hospital size do not change the superiority of ICU expansion over other scenarios. In terms of operational costs, ICU beds are more cost effective for saving patients than IMCU beds. However, capital costs of setting up ICU versus IMCU beds should be considered for a complete economic analysis.

A Multi-Center Thai University-Based Surgical Intensive Care Units Study (THAI-SICU Study): Outcome of ICU Care and Adverse Events.

PubMed

Kongsayreepong, Suneerat; Chittawatanarat, Kaweesak; Thawitsri, Thammasak; Chatmongkolchart, Sunisa; Morakul, Sunthiti; Wacharasint, Petch; Chau-In, Waraporn; Poopipatpab, Sujaree; Kusumaphanyo, Chaiyapruk

2016-09-01

Surgical intensive care units (SICUs) are special units for critically ill surgical patients both in the pre and postoperative period. There is little aggregated information about surgical patients who are admitted to the Thai surgical ICU. The objective of this report was to describe patient characteristics, outcomes of ICU care, incidence and outcomes of adverse events in the SICU in the participating SICUs. This multi-center, prospective, observational study of nine university-based SICUs was done. All admitted patients with ages >18 years old were included. Information about patient characteristics, underlying medical problems, indication and type of ICU admission, severity score as ASA physical status in operative patients, APACHE II score and SOFA score, adverse events of interest, ventilator days, ICU and 28 days mortality. The association of outcome and predictors was reported by relative risk (RR) with 95% confidence interval (95% CI). Statistical significant difference was defined by p<0.05. During April 2011-January 2013 of total cohort time, a total of 4,652 patients from nine university-based SICUs were included in this study. Mode of patient age was 71-75 year old for both sexes. Median (IQR) of APACHE II scores and SOFA scores were 10 (7-10) and 2 (1-5), respectively. Seventy eight percent of patients were postoperative patients and 50% of them were ASA physical status III. The median of ICU stay was 2 (IQR 1-4) days. Each day of ICU increment was associated with increased 1.4 days of a hospital stay. Three percent of survived at discharge were clinically inappropriate discharge resulting in ICU readmission. Sixty-five percent were discharged home after ICU admission. ICU and 28 days mortality was 9.6% and 13.8%. The seven most common adverse events were sepsis (19.5%), acute kidney injury (AKI) (16.9%), new cardiac arrhythmias (6.2%), acute respiratory distress syndrome (ARDS) (5.8%), cardiac arrest (4.9%), delirium (3.5%) and reintubation within 72

Patients with cancer in the intensive monitoring unit. New perspectives.

PubMed

Prieto Del Portillo, I; Polo Zarzuela, M; Pujol Varela, I

2014-10-01

In recent years, there has been a significant improvement in the survival of patients with cancer in intensive care units (ICUs). Advances in medical and surgical treatments and better selection of patients has helped improve the life expectancy of this type of patient. An appropriate and early resuscitation in the ICU, without initial limitations on the life support techniques, has been shown to also decrease the mortality of patients with cancer. At present, we should not deny admission to the ICU based only on the underlying neoplastic disease. However, the mortality rate for patients with cancer in the ICU, especially those with hematologic disease, remains high. In some cases, an ICU admission test (ICU test) is required for at least 3 days to identify patients who can benefit from intensive treatment. We would like to propose a decision algorithm for ICU admission that will help in making decisions in an often complex situation. Copyright © 2013 Elsevier España, S.L.U. All rights reserved.

Cell Free DNA and Procalcitonin as Early Markers of Complications in ICU Patients with Multiple Trauma and Major Surgery.

PubMed

Ahmed, Asmaa I; Soliman, Randa A; Samir, Shereif

2016-12-01

Cell free DNA (cfDNA) was recently suggested as a new marker of sepsis and poor outcome in ICU patients. Procalcitonin has also been the focus of attention as an early marker for systemic inflammation and sepsis. cfDNA, procalcitonin (PCT), C-reactive protein (CRP), and lactate levels were measured in 30 ICU patients with multiple trauma or after major surgery on the first day of admission and on 5th and 7th days for PCT, CRP, and lactate. cfDNA was measured by real-time PCR, PCT by ELISA, CRP immunoturbidimetrically, and lactate spectrophotometrically. SOFA score and Injury Severity Score (ISS) for trauma patients were calculated. Significantly higher levels of cfDNA were observed in non-survivor patients in comparison to survivors and in patients with sepsis in comparison to those without sepsis (p = 0.002 and p = 0.02, respectively). The ROC curve was calculated for cfDNA as a predictor of outcome, the area under the curve (AUC) was 0.847 (95% CI: 0.669 - 0.952), at a cutoff value of 15500 ng/µL, sensitivity = 83.3%, specificity = 77.8% (p < 0.0001). As a prognostic marker of sepsis, the AUC for cfDNA was 0.788 (95% CI: 0.601 - 0.915), sensitivity = 56.25%, specificity = 100% (p = 0.0007). Day 5 PCT levels significantly correlated with SOFA scores on day 5, ISS on admission (p < 0.001 and p = 0.028, respectively), and a significant elevation of its levels was observed in non-survivor patients compared to survivors (p = 0.001). As a predictor of sepsis, PCT showed a sensitivity of 81.3%, specificity of 100% on day 5, (AUC: 0.987, 95% CI: 0.955 - 1.00); at a cutoff value of 202.90 pg/mL (p = 0.001). As a predictor of outcome, PCT on day 5 showed a sensitivity of 94.0% and a specificity of 78.0% at a cutoff value of 194.40 pg/mL (p = 0.001). Day 1 CRP correlated with ISS on admission, and on day 5 it correlated with SOFA score 5, while lactate correlated with length of stay on days 1, 5, and 7, and its levels were significantly higher in non-survivors on days 5

Tele-ICU and Patient Safety Considerations.

PubMed

Hassan, Erkan

The tele-ICU is designed to leverage, not replace, the need for bedside clinical expertise in the diagnosis, treatment, and assessment of various critical illnesses. Tele-ICUs are primarily decentralized or centralized models with differing advantages and disadvantages. The centralized model has sufficiently powered published data to be associated with improved mortality and ICU length of stay in a cost-effective manner. Factors associated with improved clinical outcomes include improved compliance with best practices; providing off-hours implementation of the bedside physician's care plan; and identification of and rapid response to physiological instability (initial clinical review within 1 hour) and rapid response to alerts, alarms, or direct notification by bedside clinicians. With improved communication and frequent review of patients between the tele-ICU and the bedside clinicians, the bedside clinician can provide the care that only they can provide. Although technology continues to evolve at a rapid pace, technology alone will most likely not improve clinical outcomes. Technology will enable us to process real or near real-time data into complex and powerful predictive algorithms. However, the remote and bedside teams must work collaboratively to develop care processes to better monitor, prioritize, standardize, and expedite care to drive greater efficiencies and improve patient safety.

Association of Gender With Outcome and Host Response in Critically Ill Sepsis Patients.

PubMed

van Vught, Lonneke A; Scicluna, Brendon P; Wiewel, Maryse A; Hoogendijk, Arie J; Klein Klouwenberg, Peter M C; Ong, David S Y; Cremer, Olaf L; Horn, Janneke; Franitza, Marek; Toliat, Mohammad R; Nürnberg, Peter; Bonten, Marc M J; Schultz, Marcus J; van der Poll, Tom

2017-11-01

To determine the association of gender with the presentation, outcome, and host response in critically ill patients with sepsis. A prospective observational cohort study in the ICU of two tertiary hospitals between January 2011 and January 2014. All consecutive critically ill patients admitted with sepsis, involving 1,815 admissions (1,533 patients). The host response was evaluated on ICU admission by measuring 19 plasma biomarkers reflecting organ systems implicated in sepsis pathogenesis (1,205 admissions) and by applying genome-wide blood gene expression profiling (582 admissions). Sepsis patients admitted to the ICU were more frequently males (61.0%; p < 0.0001 vs females). Baseline characteristics were not different between genders. Urosepsis was more common in females; endocarditis and mediastinitis in men. Disease severity was similar throughout ICU stay. Mortality was similar up to 1 year after ICU admission, and gender was not associated with 90-day mortality in multivariate analyses in a variety of subgroups. Although plasma proteome analyses (including systemic inflammatory and cytokine responses, and activation of coagulation) were largely similar between genders, females showed enhanced endothelial cell activation; this difference was virtually absent in patients more than 55 years old. More than 80% of the leukocyte blood gene expression response was similar in male and female patients. The host response and outcome in male and female sepsis patients requiring ICU admission are largely similar.

Innovative designs for the smart ICU: Part 3: Advanced ICU informatics.

PubMed

Halpern, Neil A

2014-04-01

This third and final installment of this series on innovative designs for the smart ICU addresses the steps involved in conceptualizing, actualizing, using, and maintaining the advanced ICU informatics infrastructure and systems. The smart ICU comprehensively and electronically integrates the patient in the ICU with all aspects of care, displays data in a variety of formats, converts data to actionable information, uses data proactively to enhance patient safety, and monitors the ICU environment to facilitate patient care and ICU management. The keys to success in this complex informatics design process include an understanding of advanced informatics concepts, sophisticated planning, installation of a robust infrastructure capable of both connectivity and interoperability, and implementation of middleware solutions that provide value. Although new technologies commonly appear compelling, they are also complicated and challenging to incorporate within existing or evolving hospital informatics systems. Therefore, careful analysis, deliberate testing, and a phased approach to the implementation of innovative technologies are necessary to achieve the multilevel solutions of the smart ICU.

Patient visibility and ICU mortality: a conceptual replication.

PubMed

Lu, Yi; Ossmann, Michelle M; Leaf, David E; Factor, Philip H

2014-01-01

This study reanalyzes the data from a study by Leaf, Homel, and Factor (2010) titled "Relationship between ICU Design and Mortality" by adopting and developing objective visibility measures. Various studies attribute healthcare outcomes (patient falls, satisfaction) to a vague notion of patient room visibility. The study by Leaf and colleagues was the first to draw an independent association between patient mortality and patient room visibility, however "visibility" remains imprecise. The original patient dataset was obtained from Dr. Leaf. The 664 patient sample assigned across 12 rooms at the medical ICU at Columbia University Medical Center was reanalyzed in terms of targeted visibility; the unit of analysis was the room, n = 12. Several computer-based visibility measures of patient rooms were used: patient head visibility, patient room visibility, and field of view to nursing station. Patient head visibility was defined as the percentage of area within the central nursing station from which the patient head could be seen; patient room visibility was defined as the percentage of area within the central nursing station that could see the patient room (average value of all patient room grids); field of view was defined as the maximum viewing angle from the patient head to the central nursing station. Among the sickest patients (those with Acute Physiology and Chronic Health Evaluation II > 30), field of view accounted for 33.5% of the variance in ICU mortality, p = 0.049. Subtle differences in patient room visibility may have important effects on clinical outcomes. Case study, critical care/intensive care, methodology, outcomes.

Adverse outcomes after planned surgery with anticipated intensive care admission in out-of-office-hours time periods: a multicentre cohort study.

PubMed

Morgan, D J; Ho, K M; Kolybaba, M L; Ong, Y J

2018-06-01

Increasing mortality for patients admitted to hospitals during the weekend is a contentious but well described phenomenon. However, it remains uncertain whether adverse outcomes, including prolonged hospital length-of-stay (LOS), may also occur after patients undergoing major planned surgery are admitted to an intensive care unit (ICU) out-of-office-hours, either during weeknights (after 18:00) or on weekends. All planned surgical admissions requiring admission to one of 183 ICUs across Australia and New Zealand between 2006 and 2016 were included in this retrospective population-based cohort study. Primary outcomes were hospital LOS and hospital mortality. Of the total 504 713 planned postoperative ICU admissions, 33.6% occurred during out-of-office-hours. After adjusting for available risk factors, out-of-office-hours ICU admissions were associated with a significant increase in hospital LOS [+2.6 days, 95% confidence interval (CI) 2.5-2.6], mortality [odd ratio (OR) 1.5, 95%CI 1.4-1.6], and a reduced chance of being directly discharged home (OR 0.8, 95%CI 0.8-0.8). The strongest association for adverse outcomes occurred with weekend ICU admissions (hospital LOS: +3.0 days, 95%CI 3.2-3.6; hospital mortality: OR 1.7, 95%CI 1.6-1.8). Clustering of adverse outcomes by hospitals was not observed in the generalised estimating equation analyses. Despite a greater clinical staff availability and higher monitoring levels, planned surgery requiring anticipated out-of-office-hours ICU admission was associated with a prolonged hospital LOS, reduced discharge directly home, and increased mortality compared with in-office-hours admissions. Our findings have potential clinical, economic and health policy implications on how complex planned surgery should be planned and managed. Copyright © 2018 British Journal of Anaesthesia. All rights reserved.

The Host Response in Patients with Sepsis Developing Intensive Care Unit-acquired Secondary Infections.

PubMed

van Vught, Lonneke A; Wiewel, Maryse A; Hoogendijk, Arie J; Frencken, Jos F; Scicluna, Brendon P; Klein Klouwenberg, Peter M C; Zwinderman, Aeilko H; Lutter, Rene; Horn, Janneke; Schultz, Marcus J; Bonten, Marc M J; Cremer, Olaf L; van der Poll, Tom

2017-08-15

Sepsis can be complicated by secondary infections. We explored the possibility that patients with sepsis developing a secondary infection while in the intensive care unit (ICU) display sustained inflammatory, vascular, and procoagulant responses. To compare systemic proinflammatory host responses in patients with sepsis who acquire a new infection with those who do not. Consecutive patients with sepsis with a length of ICU stay greater than 48 hours were prospectively analyzed for the development of ICU-acquired infections. Twenty host response biomarkers reflective of key pathways implicated in sepsis pathogenesis were measured during the first 4 days after ICU admission and at the day of an ICU-acquired infection or noninfectious complication. Of 1,237 admissions for sepsis (1,089 patients), 178 (14.4%) admissions were complicated by ICU-acquired infections (at Day 10 [6-13], median with interquartile range). Patients who developed a secondary infection showed higher disease severity scores and higher mortality up to 1 year than those who did not. Analyses of biomarkers in patients who later went on to develop secondary infections revealed a more dysregulated host response during the first 4 days after admission, as reflected by enhanced inflammation, stronger endothelial cell activation, a more disturbed vascular integrity, and evidence for enhanced coagulation activation. Host response reactions were similar at the time of ICU-acquired infectious or noninfectious complications. Patients with sepsis who developed an ICU-acquired infection showed a more dysregulated proinflammatory and vascular host response during the first 4 days of ICU admission than those who did not develop a secondary infection.

Admission time to hospital: a varying standard for a critical definition for admissions to an intensive care unit from the emergency department.

PubMed

Nanayakkara, Shane; Weiss, Heike; Bailey, Michael; van Lint, Allison; Cameron, Peter; Pilcher, David

2014-11-01

Time spent in the emergency department (ED) before admission to hospital is often considered an important key performance indicator (KPI). Throughout Australia and New Zealand, there is no standard definition of 'time of admission' for patients admitted through the ED. By using data submitted to the Australian and New Zealand Intensive Care Society Adult Patient Database, the aim was to determine the differing methods used to define hospital admission time and assess how these impact on the calculation of time spent in the ED before admission to an intensive care unit (ICU). Between March and December of 2010, 61 hospitals were contacted directly. Decision methods for determining time of admission to the ED were matched to 67,787 patient records. Univariate and multivariate analyses were conducted to assess the relationship between decision method and the reported time spent in the ED. Four mechanisms of recording time of admission were identified, with time of triage being the most common (28/61 hospitals). Reported median time spent in the ED varied from 2.5 (IQR 0.83-5.35) to 5.1 h (2.82-8.68), depending on the decision method. After adjusting for illness severity, hospital type and location, decision method remained a significant factor in determining measurement of ED length of stay. Different methods are used in Australia and New Zealand to define admission time to hospital. Professional bodies, hospitals and jurisdictions should ensure standardisation of definitions for appropriate interpretation of KPIs as well as for the interpretation of studies assessing the impact of admission time to ICU from the ED. WHAT IS KNOWN ABOUT THE TOPIC?: There are standards for the maximum time spent in the ED internationally, but these standards vary greatly across Australia. The definition of such a standard is critically important not only to patient care, but also in the assessment of hospital outcomes. Key performance indicators rely on quality data to improve decision

Admission Cell Free DNA Levels Predict 28-Day Mortality in Patients with Severe Sepsis in Intensive Care

PubMed Central

Almog, Yaniv; Perl, Yael; Novack, Victor; Galante, Ori; Klein, Moti; Pencina, Michael J.; Douvdevani, Amos

2014-01-01

Aim The aim of the current study is to assess the mortality prediction accuracy of circulating cell-free DNA (CFD) level at admission measured by a new simplified method. Materials and Methods CFD levels were measured by a direct fluorescence assay in severe sepsis patients on intensive care unit (ICU) admission. In-hospital and/or twenty eight day all-cause mortality was the primary outcome. Results Out of 108 patients with median APACHE II of 20, 32.4% have died in hospital/or at 28-day. CFD levels were higher in decedents: median 3469.0 vs. 1659 ng/ml, p<0.001. In multivariable model APACHE II score and CFD (quartiles) were significantly associated with the mortality: odds ratio of 1.05, p = 0.049 and 2.57, p<0.001 per quartile respectively. C-statistics for the models was 0.79 for CFD and 0.68 for APACHE II. Integrated discrimination improvement (IDI) analyses showed that CFD and CFD+APACHE II score models had better discriminatory ability than APACHE II score alone. Conclusions CFD level assessed by a new, simple fluorometric-assay is an accurate predictor of acute mortality among ICU patients with severe sepsis. Comparison of CFD to APACHE II score and Procalcitonin (PCT), suggests that CFD has the potential to improve clinical decision making. PMID:24955978

Elevated admission N-terminal pro-brain natriuretic peptide level predicts the development of atrial fibrillation in general surgical intensive care unit patients.

PubMed

Chokengarmwong, Nalin; Yeh, Daniel Dante; Chang, Yuchiao; Ortiz, Luis Alfonso; Kaafarani, Haytham M A; Fagenholz, Peter; King, David R; DeMoya, Marc; Butler, Kathryn; Lee, Jarone; Velmahos, George; Januzzi, James Louis; Lee-Lewandrowski, Elizabeth; Lewandrowski, Kent

2017-09-01

New onset atrial fibrillation (AF) in critically ill surgical patients is associated with significant morbidity and increased mortality. N-terminal pro-B type natriuretic peptide (NT-proBNP) is released by cardiomyocytes in response to stress and may predict AF development after surgery. We hypothesized that elevated NT-proBNP level at surgical intensive care unit (ICU) admission predicts AF development in a general surgical and trauma population. From July to October 2015, NT-proBNP concentrations were measured at ICU admission. Abnormal NT-proBNP concentrations were defined by age-adjusted cut-offs. We examined the relationship between the development of AF and demographics, clinical variables, and NT-proBNP level using univariate analysis and a multivariable logistic regression model. Three hundred eighty-seven subjects were included in the cohort, none of whom were in AF at ICU admission. The median age was 63 years (52-73 years), and 40.3% were women. The risk of developing AF was higher for abnormal versus normal NT-proBNP (22% vs. 4%; p < 0.0001). Using optimal derived cutoffs (regardless of age), the risk of developing AF was 2% for NT-proBNP less than 600 ng/L, 15% for NT-proBNP of 600 ng/L to 1,999 ng/L, and 27% for NT-proBNP of 2,000 ng/L or greater. Multiple logistic regression analysis identified three independent predictors for new-onset AF: age, older than 70 years (odds ratio [OR], 3.7, 95% confidence interval [CI], 1.5-9.3), history of AF (OR, 25.3; 95% CI, 9.6-67.0), and NT-proBNP of 600 or greater (OR, 4.3; 95% CI, 1.3-14.2). When none or only one predictor was present, AF incidence was less than 1%. When all three predictors were present, AF incidence was 66%. For subjects 70 years or older but no history of AF, AF incidence was 12.8% when NT-proBNP was 600 or greater compared with 0% when NT-proBNP was less than 600. For subjects younger than 70 years with a history of AF, AF incidence was 44.4% when NT-proBNP was 600 or higher compared to 0

The Changing Role of Palliative Care in the ICU

PubMed Central

Aslakson, Rebecca A.; Curtis, J. Randall; Nelson, Judith E.

2015-01-01

Objectives Palliative care is an interprofessional specialty as well as an approach to care by all clinicians caring for patients with serious and complex illness. Unlike hospice, palliative care is based not on prognosis but on need and is an essential component of comprehensive care for critically ill patients from the time of ICU admission. In this clinically focused article, we review evidence of opportunities to improve palliative care for critically ill adults, summarize strategies for ICU palliative care improvement, and identify resources to support implementation. Data Sources We searched the MEDLINE database from inception through January 2014. We also searched the Reference Library of The Improving Palliative Care in the ICU Project website sponsored by the National Institutes of Health and the Center to Advance Palliative Care, which is updated monthly. We hand-searched reference lists and author files. Study Selection Selected studies included all English-language articles concerning adult patients using the search terms "intensive care" or "critical care" with "palliative care," "supportive care," "end-of-life care," or "ethics." Data Extraction After examination of peer-reviewed original scientific articles, consensus statements, guidelines, and reviews resulting from our literature search, we made final selections based on author consensus. Data Synthesis Existing evidence is organized to address: 1) opportunities to alleviate physical and emotional symptoms, improve communication, and provide support for patients and families; 2) models and specific interventions for improving ICU palliative care; 3) available resources for ICU palliative care improvement; and 4) ongoing challenges and targets for future research. Key domains of ICU palliative care have been defined and operationalized as measures of quality. There is increasing recognition that effective integration of palliative care during acute and chronic critical illness may help patients and

Effect of air-supported, continuous, postural oscillation on the risk of early ICU pneumonia in nontraumatic critical illness.

PubMed

deBoisblanc, B P; Castro, M; Everret, B; Grender, J; Walker, C D; Summer, W R

1993-05-01

We hypothesized that continuous, automatic turning utilizing a patient-friendly, low air loss surface would reduce the incidence of early ICU pneumonia in selected groups of critically ill medical patients. Prospective, randomized, controlled clinical trial. Medical ICU of a large community teaching hospital. One hundred twenty-four critically ill new admissions to the medical ICU at Charity Hospital in New Orleans. Patients were prospectively randomized within one of five diagnosis-related groups (DRG)--sepsis (SEPSIS), obstructive airways disease (OAD), metabolic coma, drug overdose, and stroke--to either routine turning on a standard ICU bed or to continuous turning on an oscillating air-flotation bed for a total of five days. Patients were monitored daily during the treatment period for the development of pneumonia. The incidence of pneumonia during the first five ICU days was 22 percent in patients randomized to the standard ICU bed vs 9 percent for the oscillating bed (p = 0.05). This treatment effect was greatest in the SEPSIS DRG (23 percent vs 3 percent, p = 0.04). Continuous automatic oscillation did not significantly change the number of days of required mechanical ventilation, ICU stay, hospital stay, or hospital mortality overall or within any of the DRGs. We conclude that air-supported automated turning during the first five ICU days reduces the incidence of early ICU pneumonia in selected DRGs; however, this form of automated turning does not reduce other measured clinical outcome parameters.

Traceability in Patient Healthcare through the Integration of RFID Technology in an ICU in a Hospital.

PubMed

Martínez Pérez, María; Dafonte, Carlos; Gómez, Ángel

2018-05-19

Patient safety is a principal concern for health professionals in the care process and it is, therefore, necessary to provide information management systems to each unit of the hospital, capable of tracking patients and medication to reduce the occurrence of adverse events and therefore increase the quality of care received by patients during their stay in hospital. This work presents a tool for the Intensive Care Unit (ICU), a key service with special characteristics, which computerises and tracks admissions, care plans, vital monitoring, the prescription and medication administration process for patients in this service. To achieve this, it is essential that innovative and cutting-edge technologies are implemented such as Near Field Communication (NFC) technology which is now being implemented in diverse environments bringing a range of benefits to the tasks for which it is employed.

Deliberate drug poisonings admitted to an emergency department in Paris area - a descriptive study and assessment of risk factors for intensive care admission.

PubMed

Beaune, S; Juvin, P; Beauchet, A; Casalino, E; Megarbane, B

2016-01-01

Each year, approximately 165,000 poisonings are managed in the emergency departments (ED) in France. We performed a descriptive analysis of self-poisoned patients admitted to a university hospital ED in the Paris metropolitan area (France) aimed at investigating their outcome and the risk factors for transfer to the intensive care unit (ICU). We retrospectively reviewed patients' records and performed multivariate logistic regression analysis to identify risk factors for ICU admission. During 4 years, 882 self-poisoned patients (median age, 38 years [IQR, 26-47]; sex-ratio, 1M/3F) were admitted to the ED, representing 0.7% of all referred patients. Poisonings mainly resulted from multidrug exposures (53%), including benzodiazepines (78%), serotonin reuptake inhibitors (17%), acetaminophen (13%), antipsychotics (9.5%), imidazopyridines (9.5%), antihypertensive drugs (3%), and polycyclic antidepressants (1.3%). Ethanol was involved in 20% of the exposures. Patients were briefly (<24h) monitored in the ED (55%), transferred to the psychiatric department (30%), medical ward (2%) or ICU (6%), and took an irregular discharge (7%). Among the patients transferred to the ICU, 25% were mechanically ventilated and only one died. Risk factors for ICU admission included antihypertensive (Odds ratio (OR), 40.6; 95%-confidence interval (CI), 7.5-221.9) or antipsychotic drug ingestion (OR, 5.3; CI, 2.0-14.4), male gender (OR, 3.3; CI, 1.30-8.8), and consciousness impairment (OR, 2.1; CI, 1.8-2.5 per point lost in Glasgow coma score). Deliberate drug exposure represents a frequent cause of ED admission. Psychotropic drugs are most commonly involved. Transfer to the ICU is rare and predicted by male gender, drug class, and coma depth.

Measuring Patient Mobility in the ICU Using a Novel Noninvasive Sensor.

PubMed

Ma, Andy J; Rawat, Nishi; Reiter, Austin; Shrock, Christine; Zhan, Andong; Stone, Alex; Rabiee, Anahita; Griffin, Stephanie; Needham, Dale M; Saria, Suchi

2017-04-01

To develop and validate a noninvasive mobility sensor to automatically and continuously detect and measure patient mobility in the ICU. Prospective, observational study. Surgical ICU at an academic hospital. Three hundred sixty-two hours of sensor color and depth image data were recorded and curated into 109 segments, each containing 1,000 images, from eight patients. None. Three Microsoft Kinect sensors (Microsoft, Beijing, China) were deployed in one ICU room to collect continuous patient mobility data. We developed software that automatically analyzes the sensor data to measure mobility and assign the highest level within a time period. To characterize the highest mobility level, a validated 11-point mobility scale was collapsed into four categories: nothing in bed, in-bed activity, out-of-bed activity, and walking. Of the 109 sensor segments, the noninvasive mobility sensor was developed using 26 of these from three ICU patients and validated on 83 remaining segments from five different patients. Three physicians annotated each segment for the highest mobility level. The weighted Kappa (κ) statistic for agreement between automated noninvasive mobility sensor output versus manual physician annotation was 0.86 (95% CI, 0.72-1.00). Disagreement primarily occurred in the "nothing in bed" versus "in-bed activity" categories because "the sensor assessed movement continuously," which was significantly more sensitive to motion than physician annotations using a discrete manual scale. Noninvasive mobility sensor is a novel and feasible method for automating evaluation of ICU patient mobility.

Post-ICU psychological morbidity in very long ICU stay patients with ARDS and delirium.

PubMed

Bashar, Farshid R; Vahedian-Azimi, Amir; Hajiesmaeili, Mohammadreza; Salesi, Mahmood; Farzanegan, Behrooz; Shojaei, Seyedpouzhia; Goharani, Reza; Madani, Seyed J; Moghaddam, Kivan G; Hatamian, Sevak; Moghaddam, Hosseinali J; Mosavinasab, Seyed M M; Elamin, Elamin M; Miller, Andrew C

2018-02-01

We investigated the impact of delirium on illness severity, psychological state, and memory in acute respiratory distress syndrome patients with very long ICU stay. Prospective cohort study in the medical-surgical ICUs of 2 teaching hospitals. Very long ICU stay (>75days) and prolonged delirium (≥40days) thresholds were determined by ROC analysis. Subjects were ≥18years, full-code, and provided informed consent. Illness severity was assessed using Acute Physiology and Chronic Health Evaluation IV, Simplified Acute Physiology Score-3, and Sequential Organ Failure Assessment scores. Psychological impact was assessed using the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised, and the 14-question Post-Traumatic Stress Syndrome (PTSS-14). Memory was assessed using the ICU Memory Tool survey. 181 subjects were included. Illness severity did not correlate with delirium duration. On logistic regression, only PTSS-14<49 correlated with delirium (p=0.001; 95% CI 1.011, 1.041). 49% remembered their ICU stay clearly. 47% had delusional memories, 50% reported intrusive memories, and 44% reported unexplained feelings of panic or apprehension. Delirium was associated with memory impairment and PTSS-14 scores suggestive of PTSD, but not illness severity. Copyright © 2017. Published by Elsevier Inc.

An Integrative Literature Review of Organisational Factors Associated with Admission and Discharge Delays in Critical Care

PubMed Central

Peltonen, Laura-Maria; McCallum, Louise; Siirala, Eriikka; Haataja, Marjaana; Lundgrén-Laine, Heljä; Salanterä, Sanna; Lin, Frances

2015-01-01

The literature shows that delayed admission to the intensive care unit (ICU) and discharge delays from the ICU are associated with increased adverse events and higher costs. Identifying factors related to delays will provide information to practice improvements, which contribute to better patient outcomes. The aim of this integrative review was to explore the incidence of patients' admission and discharge delays in critical care and to identify organisational factors associated with these delays. Seven studies were included. The major findings are as follows: (1) explanatory research about discharge delays is scarce and one study on admission delays was found, (2) delays are a common problem mostly due to organisational factors, occurring in 38% of admissions and 22–67% of discharges, and (3) redesigning care processes by improving information management and coordination between units and interdisciplinary teams could reduce discharge delays. In conclusion, patient outcomes can be improved through efficient and safe care processes. More exploratory research is needed to identify factors that contribute to admission and discharge delays to provide evidence for clinical practice improvements. Shortening delays requires an interdisciplinary and multifaceted approach to the whole patient flow process. Conclusions should be made with caution due to the limited number of articles included in this review. PMID:26558286

Measuring Patient Mobility in the ICU Using a Novel Noninvasive Sensor

PubMed Central

Ma, Andy J.; Rawat, Nishi; Reiter, Austin; Shrock, Christine; Zhan, Andong; Stone, Alex; Rabiee, Anahita; Griffin, Stephanie; Needham, Dale M.; Saria, Suchi

2017-01-01

Objectives To develop and validate a noninvasive mobility sensor to automatically and continuously detect and measure patient mobility in the ICU. Design Prospective, observational study. Setting Surgical ICU at an academic hospital. Patients Three hundred sixty-two hours of sensor color and depth image data were recorded and curated into 109 segments, each containing 1,000 images, from eight patients. Interventions None. Measurements and Main Results Three Microsoft Kinect sensors (Microsoft, Beijing, China) were deployed in one ICU room to collect continuous patient mobility data. We developed software that automatically analyzes the sensor data to measure mobility and assign the highest level within a time period. To characterize the highest mobility level, a validated 11-point mobility scale was collapsed into four categories: nothing in bed, in-bed activity, out-of-bed activity, and walking. Of the 109 sensor segments, the noninvasive mobility sensor was developed using 26 of these from three ICU patients and validated on 83 remaining segments from five different patients. Three physicians annotated each segment for the highest mobility level. The weighted Kappa (κ) statistic for agreement between automated noninvasive mobility sensor output versus manual physician annotation was 0.86 (95% CI, 0.72–1.00). Disagreement primarily occurred in the “nothing in bed” versus “in-bed activity” categories because “the sensor assessed movement continuously,” which was significantly more sensitive to motion than physician annotations using a discrete manual scale. Conclusions Noninvasive mobility sensor is a novel and feasible method for automating evaluation of ICU patient mobility. PMID:28291092

Statin and Its Association With Delirium in the Medical ICU.

PubMed

Mather, Jeffrey F; Corradi, John P; Waszynski, Christine; Noyes, Adam; Duan, Yinghui; Grady, James; Dicks, Robert

2017-09-01

To examine the association between statin use and the risk of delirium in hospitalized patients with an admission to the medical ICU. Retrospective propensity-matched cohort analysis with accrual from September 1, 2012, to September 30, 2015. Hartford Hospital, Hartford, CT. An initial population of patients with an admission to a medical ICU totaling 10,216 visits were screened for delirium by means of the Confusion Assessment Method. After exclusions, a population of 6,664 was used to match statin users and nonstatin users. The propensity-matched cohort resulted in a sample of 1,475 patients receiving statin matched 1:1 with control patients not using statin. None. Delirium defined as a positive Confusion Assessment Method assessment was the primary end point. The prevalence of delirium was 22.3% in the unmatched cohort and 22.8% in the propensity-matched cohort. Statin use was associated with a significant decrease in the risk of delirium (odds ratio, 0.47; 95% CI, 0.38-0.56). Considering the type of statin used, atorvastatin (0.51; 0.41-0.64), pravastatin (0.40; 0.28-0.58), and simvastatin (0.33; 0.21-0.52) were all significantly associated with a reduced frequency of delirium. The use of statins was independently associated with a reduction in the risk of delirium in hospitalized patients. When considering types of statins used, this reduction was significant in patients using atorvastatin, pravastatin, and simvastatin. Randomized trials of various statin types in hospitalized patients prone to delirium should validate their use in protection from delirium.

The ABCDEF Bundle: Science and Philosophy of How ICU Liberation Serves Patients and Families.

PubMed

Ely, E Wesley

2017-02-01

Over the past 20 years, critical care has matured in a myriad of ways resulting in dramatically higher survival rates for our sickest patients. For millions of new survivors comes de novo suffering and disability called "the postintensive care syndrome." Patients with postintensive care syndrome are robbed of their normal cognitive, emotional, and physical capacity and cannot resume their previous life. The ICU Liberation Collaborative is a real-world quality improvement initiative being implemented across 76 ICUs designed to engage strategically the ABCDEF bundle through team- and evidence-based care. This article explains the science and philosophy of liberating ICU patients and families from harm that is both inherent to critical illness and iatrogenic. ICU liberation is an extensive program designed to facilitate the implementation of the pain, agitation, and delirium guidelines using the evidence-based ABCDEF bundle. Participating ICU teams adapt data from hundreds of peer-reviewed studies to operationalize a systematic and reliable methodology that shifts ICU culture from the harmful inertia of sedation and restraints to an animated ICU filled with patients who are awake, cognitively engaged, and mobile with family members engaged as partners with the ICU team at the bedside. In doing so, patients are "liberated" from iatrogenic aspects of care that threaten his or her sense of self-worth and human dignity. The goal of this 2017 plenary lecture at the 47th Society of Critical Care Medicine Congress is to provide clinical ICU teams a synthesis of the literature that led to the creation of ICU liberation philosophy and to explain how this patient- and family-centered, quality improvement program is novel, generalizable, and practice changing.

Prognosis of elderly patients subjected to mechanical ventilation in the ICU.

PubMed

Añon, J M; Gómez-Tello, V; González-Higueras, E; Córcoles, V; Quintana, M; García de Lorenzo, A; Oñoro, J J; Martín-Delgado, C; García-Fernández, A; Marina, L; Gordo, F; Choperena, G; Díaz-Alersi, R; Montejo, J C; López-Martínez, J

2013-04-01

To analyze the prognosis of mechanically ventilated elderly patients in the Intensive Care Unit (ICU). Sub-analysis of a prospective multicenter observational cohort study conducted over a period of two years in 13 medical-surgical ICUs in Spain. Adult patients who required mechanical ventilation (MV) for longer than 24 hours. None. Demographic data, APACHE II, SOFA, reason for MV, comorbidity, functional condition, reintubation, duration of MV, tracheotomy, ICU mortality, in-hospital mortality. A total of 1661 patients were recruited. Males accounted for 67.9% (n=1127), with a mean age of 62.1 ± 16.2 years. APACHE II: 20.3 ± 7.5. Total SOFA: 8.4 ± 3.5. Four hundred and twenty-three patients (25.4%) were ≥ 75 years of age. Comorbidity and functional condition rates were poorer in these patients (p<0.001 for both variables). Mortality in the ICU was higher in the elderly patients (33.6%) than in the younger subjects (25.9%) (p=0.002). Also, in-hospital mortality was higher in those ≥ 75 years of age. No differences in duration of MV, prevalence of tracheostomy or reintubation incidence were found. Regarding the indication for MV, only the patient ≥ 75 years of age with pneumonia, sepsis or trauma had a higher in-ICU mortality than the younger patients (46.3% vs 33.1%, p=0.006; 55% vs 25.8%, p=0.002; 63.6% vs 4.5%, p<0,001, respectively). No differences were found referred to other reasons for MV. Older patients (≥ 75 years) have significantly higher in-ICU and in-hospital mortality than younger patients without differences in the duration of mechanical ventilation. Differences in mortality were at the expense of pneumonia, sepsis and trauma. Copyright © 2012 Elsevier España, S.L. and SEMICYUC. All rights reserved.

Study of Obstetric Admissions to the Intensive Care Unit of a Tertiary Care Hospital.

PubMed

Rathod, Ashakiran T; Malini, K V

2016-10-01

To analyze obstetric admissions to intensive care unit and to identify the risk factors responsible for intensive care admission. This is a retrospective study of all obstetric cases admitted to the intensive care unit over a period of 3 years. Data were collected from case records. The risk factors responsible for ICU admission were analyzed. There were 765 obstetric admissions to ICU accounting for 1.24 % of all deliveries. 56.20 % were in the age group of 20-25 years. 38.43 % were in their first pregnancy. 36.48 % of cases were at 37-40 weeks of gestation. Postpartum admissions were 80.91 %. Major conditions responsible were obstetric hemorrhage in 44.05 %, hypertensive disorders of pregnancy in 28.88 %, severe anemia in 14.37 %, heart disease in 12.15 %, and sepsis in 7.97 % of ICU cases. 40.39 % cases required high dependency care. Maternal mortality was seen in 15.55 % of ICU cases. Commonest cause of mortality was hemorrhagic shock (26.89 %) and multiorgan dysfunction syndrome (26.05 %). Commonest risk factors for ICU admissions are obstetric hemorrhage and hypertensive disorders of pregnancy. Other major risk factors are severe anemia, heart disease, sepsis, more than one diagnosis on admission, and the need for cesarean delivery.

Team situation awareness and the anticipation of patient progress during ICU rounds.

PubMed

Reader, Tom W; Flin, Rhona; Mearns, Kathryn; Cuthbertson, Brian H

2011-12-01

The ability of medical teams to develop and maintain team situation awareness (team SA) is crucial for patient safety. Limited research has investigated team SA within clinical environments. This study reports the development of a method for investigating team SA during the intensive care unit (ICU) round and describes the results. In one ICU, a sample of doctors and nurses (n = 44, who combined to form 37 different teams) were observed during 34 morning ward rounds. Following the clinical review of each patient (n = 105), team members individually recorded their anticipations for expected patient developments over 48 h. Patient-outcome data were collected to determine the accuracy of anticipations. Anticipations were compared among ICU team members, and the degree of consensus was used as a proxy measure of team SA. Self-report and observational data measured team-member involvement and communication during patient reviews. For over half of 105 patients, ICU team members formed conflicting anticipations as to whether patients would deteriorate within 48 h. Senior doctors were most accurate in their predictions. Exploratory analysis found that team processes did not predict team SA. However, the involvement of junior and senior trainee doctors in the patient decision-making process predicted the extent to which those team members formed team SA with senior doctors. A new method for measuring team SA during the ICU round was successfully employed. A number of areas for future research were identified, including refinement of the situation awareness and teamwork measures.

The Feasibility and Impact of Routine Combined Limited Transthoracic Echocardiography and Lung Ultrasound on Diagnosis and Management of Patients Admitted to ICU: A Prospective Observational Study.

PubMed

Haji, Kavi; Haji, Darsim; Canty, David J; Royse, Alistair G; Tharmaraj, Dhaksha; Azraee, Meor; Hopkins, Lynda; Royse, Collin F

2018-02-01

Limited transthoracic echocardiography (TTE) and lung ultrasound increasingly is performed in the intensive care unit (ICU), though used in a goal-directed rather than routine manner. Prospective observational study. Tertiary ICU. Ninety-three critically ill participants within 24 hours of admission to ICU. A treating intensivist documented a clinical diagnosis and management plan before and after combined limited TTE and lung ultrasound. Ultrasound was performed by an independent intensivist and checked for accuracy offline by a second reviewer. Ultrasound images were interpretable in 99%, with good interobserver agreement. The hemodynamic diagnosis was altered in 66% of participants, including new (14%) or altered (25%) abnormal states or exclusion of clinically diagnosed abnormal state (27%). Valve pathology of at least moderate severity was diagnosed for mitral regurgitation (7%), aortic stenosis (1%), aortic stenosis and mitral regurgitation (1%), tricuspid regurgitation (3%), and 1 case of mitral regurgitation was excluded. Lung pathology diagnosis was changed in 58% of participants including consolidation (13%), interstitial syndrome (4%), and pleural effusion (23%), and exclusion of clinically diagnosed consolidation (6%), interstitial syndrome (3%), and pleural effusion (9%). Management changed in 65% of participants including increased (12%) or decreased (23%) fluid therapy, initiation (10%), changing (6%) or cessation (9%) of inotropic, vasoactive or diuretic drugs, non-invasive ventilation (3%), and pleural drainage (2%). Routine screening of patients with combined limited TTE and lung ultrasound on admission to ICU is feasible and frequently alters diagnosis and management. Copyright © 2018 Elsevier Inc. All rights reserved.

Oral intake evaluation in patients following critical illness: an ICU cohort study.

PubMed

Jarden, Rebecca J; Sutton-Smith, Lynsey; Boulton, Catherine

2018-04-16

Timely and adequate nutrition improves health outcomes for the critically ill patient. Despite clinical guidelines recommending early oral nutrition, survivors of critical illness experience significant nutritional deficits. This cohort study evaluates the oral nutrition intake in intensive care unit (ICU) patients who have experienced recent critical illness. The oral nutrition intake of a convenience sample of ICU patients post-critical illness was observed during a 1-month period. Data pertaining to both the amount of oral nutrition intake and factors impacting optimal oral nutrition intake were collected and analysed. Inadequate oral intake was identified in 62% of the 79 patients assessed (n = 49). This was noted early in the ICU stay, around day 1-2, for most of the patients. A significant proportion (25%) of patients remained in the hospital with poor oral intake that persisted beyond ICU day 5. Unsurprisingly, these were the patients who had longer ICU stays. Critical illness weakness was a factor in the assessment of poor oral intake. To conclude, patients who have experienced critical illness also experience suboptimal oral nutrition. The three key factors that were identified as impacting optimal oral nutrition were early removal of nasogastric tubes, critical illness weakness and poor appetite post-critical illness. Seven key recommendations are made based on this cohort study. These recommendations are related to patient assessment, monitoring, documentation and future guidelines. Future research opportunities are highlighted, including the investigation of strategies to improve the transition of patients' post-critical illness to oral nutrition. © 2018 British Association of Critical Care Nurses.

[Pandemic influenza A in the ICU: experience in Spain and Latin America. GETGAG/SEMICYUC/(Spanish Working Group on Severe Pandemic Influenza A/SEMICYUC)].

PubMed

Rodríguez, A; Socías, L; Guerrero, J E; Figueira, J C; González, N; Maraví-Poma, E; Lorente, L; Martín, M; Albaya-Moreno, A; Algora-Weber, A; Vallés, J; León-Gil, C; Lisboa, T; Balasini, C; Villabón, M; Pérez-Padilla, R; Barahona, D; Rello, J

2010-03-01

Pandemic Influenza A (H1N1)v infection is the first pandemic in which intensive care units (ICU) play a fundamental role. It has spread very rapidly since the first cases were diagnosed in Mexico with the subsequent spread of the virus throughout the Southern Cone and Europe during the summer season. This study has aimed to compare the clinical presentation and outcome among the critical patients admitted to the ICU until July 31, 2009 in Spain with some series from Latin America. Six series of critically ill patients admitted to the ICU were considered. Clinical characteristics, complications and outcome were compared between series. Young patients (35-45 years) with viral pneumonia as a predominant ICU admission cause with severe respiratory failure and a high need of mechanical ventilation (60-100%) were affected. Obesity, pregnancy and chronic lung disease were risk factors associated with a worse outcome, however there was a high number of patients without comorbidities (40-50%). Mortality rate was between 25-50% and higher in the Latin America series, demonstrating the specific potential pathogenesis of the new virus. The use of antiviral treatment was delayed (between 3 and 6 days) and not generalized, with greater delay in Latin America in regards to Spain. These data suggest that a more aggressive treatment strategy, with earlier and easier access to the antiviral treatment might reduce the number of ICU admissions and mortality. Copyright 2009 Elsevier España, S.L. y SEMICYUC. All rights reserved.

Risk, Predictors, and Outcomes of Acute Kidney Injury in Patients Admitted to Intensive Care Units in Egypt.

PubMed

Abd ElHafeez, Samar; Tripepi, Giovanni; Quinn, Robert; Naga, Yasmine; Abdelmonem, Sherif; AbdelHady, Mohamed; Liu, Ping; James, Matthew; Zoccali, Carmine; Ravani, Pietro

2017-12-07

Epidemiology of acute kidney injury (AKI) in developing countries is under-studied. We evaluated the risk and prognosis of AKI in patients admitted to intensive care units (ICUs) in Egypt. We recruited consecutive adults admitted to ICUs in Alexandria Teaching Hospitals over six months. We used the KDIGO criteria for AKI. We followed participants until the earliest of ICU discharge, death, day 30 from entry or study end. Of the 532 participants (median age 45 (Interquartile range [IQR]: 30-62) years, 41.7% male, 23.7% diabetics), 39.6% had AKI at ICU admission and 37.4% developed AKI after 24 hours of ICU admission. Previous need of diuretics, sepsis and low education were associated with AKI at ICU admission; APACHE II score independently predicted AKI after ICU admission. A total of 120 (22.6%) patients died during 30-day follow-up. Compared to patients who remained AKI-free, mortality was significantly higher in patients who had AKI at study entry (Hazard Ratio [HR] 2.14; 95% Confidence Interval [CI] 1.02-4.48) or developed AKI in ICU (HR 2.74; 95% CI 1.45-5.17). The risk of AKI is high in critically ill people and predicts poor outcomes. Further studies are needed to estimate the burden of AKI among patients before ICU admission.

Involvement of ICU families in decisions: fine-tuning the partnership

PubMed Central

2014-01-01

Families of patients are not simple visitors to the ICU. They have just been separated from a loved one, often someone they live with, either abruptly or, in nearly half the cases, because a chronic condition has suddenly worsened. They must cope with a serious illness of a loved one, while having to adapt to the unfamiliar and intimidating ICU environment. In many cases, the outcome of the critical illness is uncertain, a situation that causes considerable distress to the relatives. As shown by our research group and others, families exhibit symptoms of anxiety (70%) and depression (35%) in the first few days after admission, as well as symptoms of stress (33%) and difficulty understanding the information delivered by the healthcare staff (50%). Furthermore, relatives of patients who die in the ICU are at risk for psychiatric syndromes such as generalized anxiety, panic attacks, depression, and posttraumatic stress syndrome. In this setting of psychological distress, families are asked to consider sharing in healthcare decisions about their loved one in the ICU. This article aims to foster the debate about the shared decision-making process. We have three objectives: to transcend the overly simplistic position that opposes paternalism and autonomy, to build a view founded only on an evaluation of actual practice and experience in the field, and to keep the focus squarely on the patient. Families want information and communication time from the staff. Nurses and physicians need to understand that families can share in decisions only if the entire ICU staff actively promotes family involvement and, of course, if the family wants to participate in all or part of the decision-making process. PMID:25593753

Development and evaluation of an interprofessional communication intervention to improve family outcomes in the ICU.

PubMed

Curtis, J Randall; Ciechanowski, Paul S; Downey, Lois; Gold, Julia; Nielsen, Elizabeth L; Shannon, Sarah E; Treece, Patsy D; Young, Jessica P; Engelberg, Ruth A

2012-11-01

The intensive care unit (ICU), where death is common and even survivors of an ICU stay face the risk of long-term morbidity and re-admissions to the ICU, represents an important setting for improving communication about palliative and end-of-life care. Communication about the goals of care in this setting should be a high priority since studies suggest that the current quality of ICU communication is often poor and is associated with psychological distress among family members of critically ill patients. This paper describes the development and evaluation of an intervention designed to improve the quality of care in the ICU by improving communication among the ICU team and with family members of critically ill patients. We developed a multi-faceted, interprofessional intervention based on self-efficacy theory. The intervention involves a "communication facilitator" - a nurse or social worker - trained to facilitate communication among the interprofessional ICU team and with the critically ill patient's family. The facilitators are trained using three specific content areas: a) evidence-based approaches to improving clinician-family communication in the ICU, b) attachment theory allowing clinicians to adapt communication to meet individual family member's communication needs, and c) mediation to facilitate identification and resolution of conflict including clinician-family, clinician-clinician, and intra-family conflict. The outcomes assessed in this randomized trial focus on psychological distress among family members including anxiety, depression, and post-traumatic stress disorder at 3 and 6 months after the ICU stay. This manuscript also reports some of the lessons that we have learned early in this study. Copyright © 2012 Elsevier Inc. All rights reserved.

Staff perception of patient discharge from ICU to ward-based care.

PubMed

James, Stephen; Quirke, Sara; McBride-Henry, Karen

2013-11-01

The quality of information exchange between intensive care unit (ICU) and ward nurses, when patients are transferred out of intensive care, is important to the continuity of safe care. This research aimed to explore nurses' experiences of the discharge process from ICU to the ward environment. The study was conducted in a New Zealand Metropolitan hospital, using an exploratory descriptive design we adapted a questionnaire based on Whittaker and Ball's research on ICU patient handover. The questionnaires were then analysed using a descriptive thematic approach. The response rate of 48% included 45 ICU and 47 ward nurses. Key findings were that the written and verbal communication needs differ dependent upon setting and the timing of a discharge. Timing of handover also requires negotiation. Being able to negotiate the timing and nature of handover is important for nurses. In addition, standardized approaches to communication are believed to enhance patient safety. Standardized handover, with content and processes that are mutually negotiated, is crucial to providing the safest environment for patients. © 2013 The Authors. Nursing in Critical Care © 2013 British Association of Critical Care Nurses.

Critical illness among adults with cystic fibrosis in Texas, 2004-2013: Patterns of ICU utilization, characteristics, and outcomes.

PubMed

Oud, Lavi

2017-01-01

Available reports on critically ill adults with cystic fibrosis (CF) suggest improving short-term outcomes. However, there is marked heterogeneity in reported findings, with studies mostly based on single-centered data, limiting generalizability. We sought to examine population-level patterns of demand for critical care resources, and the characteristics, resource utilization, and outcomes of ICU-managed adults with CF. We used the Texas Inpatient Public Use Data File to identify ICU admissions with CF aged ≥18 years in Texas between 2004-2013. We examined ICU utilization at population level (using CF Foundation annual reports) and, among ICU admissions, socio-demographic characteristics, burden of comorbidities, organ failure, life-support utilization and hospital disposition. Linear regression and multilevel logistic regression were used to examine temporal trends and predictors of short-term mortality (hospital death and discharge to hospice), respectively. Of 9,579 hospitalizations of adults with CF, 1,249 (13%) were admitted to ICU. The incidence of ICU admission among adults with CF in Texas increased between 2004-2005 and 2012-2013 from 16.7 to 19.2 per 100 person-years (p = 0.0181), with ICU admissions aged ≥30 years accounting for 80.3% of the change. Among ICU admissions the following changes were noted between 2004-2005 and 2012-2013: any organ failure 30.2% vs. 56.3% (p = 0.0004), mechanical ventilation 11.5% vs. 19.2% (p = 0.0216), and hemodialysis 1.0% vs. 8.1% (p = 0.0007). Short-term mortality for the whole cohort and for those with mechanical ventilation was 11.4% and 41.8%, respectively, with corresponding home discharge among survivors 84% and 62.1%, respectively. Key predictors (adjusted odds ratios [aOR (95% CI)]) of short-term mortality included age ≥45 years (2.051 [1.231-3.415]), female gender (1.907 [1.237-2.941]), and mechanical ventilation (7.982 [5.001-12.739]). Adults with CF had high and rising population-level burden of critical

The impact of extracerebral organ failure on outcome of patients after cardiac arrest: an observational study from the ICON database.

PubMed

Nobile, Leda; Taccone, Fabio S; Szakmany, Tamas; Sakr, Yasser; Jakob, Stephan M; Pellis, Tommaso; Antonelli, Massimo; Leone, Marc; Wittebole, Xavier; Pickkers, Peter; Vincent, Jean-Louis

2016-11-14

We used data from a large international database to assess the incidence and impact of extracerebral organ dysfunction on prognosis of patients admitted after cardiac arrest (CA). This was a sub-analysis of the Intensive Care Over Nations (ICON) database, which contains data from all adult patients admitted to one of 730 participating intensive care units (ICUs) in 84 countries from 8-18 May 2012, except admissions for routine postoperative surveillance. For this analysis, patients admitted after CA (defined as those with "post-anoxic coma" or "cardiac arrest" as the reason for ICU admission) were included. Data were collected daily in the ICU for a maximum of 28 days; patients were followed up for outcome data until death, hospital discharge, or a maximum of 60 days in-hospital. Favorable neurological outcome was defined as alive at hospital discharge with a last available neurological Sequential Organ Failure Assessment (SOFA) subscore of 0-2. Among the 469 patients admitted after CA, 250 (53 %) had had out-of-hospital CA; 210 (45 %) patients died in the ICU and 357 (76 %) had an unfavorable neurological outcome. Non-survivors had a higher incidence of renal (43 vs. 16 %), cardiovascular (56 vs. 45 %), and respiratory (62 vs. 48 %) failure on admission and during the ICU stay than survivors (all p < 0.05). Similar results were found for patients with unfavorable vs. favorable neurological outcomes. In multivariable analysis, independent predictors of ICU mortality were renal failure on admission, high admission Simplified Acute Physiology Score (SAPS) II, high maximum serum lactate levels within the first 24 h after ICU admission, and development of sepsis. Independent predictors of unfavorable neurological outcome were mechanical ventilation on admission, high admission SAPS II score, and neurological dysfunction on admission. In this multicenter cohort, extracerebral organ dysfunction was common in CA patients. Renal failure on admission was the

End-of-life decision making in the ICU.

PubMed

Siegel, Mark D

2009-03-01

A large proportion of deaths, particularly in the developed world, follows admission to an ICU. Therefore, end-of life decision making is an essential facet of critical care practice. For intensivists, managing death in the critically ill has become a key professional skill. They must be thoroughly familiar with the ethical framework that guides end-of-life decision making. Decisions should generally be made collaboratively by clinicians partnering with patients' families. Treatment choices should be crafted to meet specific, achievable goals. A rational, empathic approach to working with families should encourage appropriate, mutually satisfactory outcomes.

Temperature variability during delirium in ICU patients: an observational study.

PubMed

van der Kooi, Arendina W; Kappen, Teus H; Raijmakers, Rosa J; Zaal, Irene J; Slooter, Arjen J C

2013-01-01

Delirium is an acute disturbance of consciousness and cognition. It is a common disorder in the intensive care unit (ICU) and associated with impaired long-term outcome. Despite its frequency and impact, delirium is poorly recognized by ICU-physicians and -nurses using delirium screening tools. A completely new approach to detect delirium is to use monitoring of physiological alterations. Temperature variability, a measure for temperature regulation, could be an interesting component to monitor delirium, but whether temperature regulation is different during ICU delirium has not yet been investigated. The aim of this study was to investigate whether ICU delirium is related to temperature variability. Furthermore, we investigated whether ICU delirium is related to absolute body temperature. We included patients who experienced both delirium and delirium free days during ICU stay, based on the Confusion Assessment method for the ICU conducted by a research- physician or -nurse, in combination with inspection of medical records. We excluded patients with conditions affecting thermal regulation or therapies affecting body temperature. Daily temperature variability was determined by computing the mean absolute second derivative of the temperature signal. Temperature variability (primary outcome) and absolute body temperature (secondary outcome) were compared between delirium- and non-delirium days with a linear mixed model and adjusted for daily mean Richmond Agitation and Sedation Scale scores and daily maximum Sequential Organ Failure Assessment scores. Temperature variability was increased during delirium-days compared to days without delirium (β(unadjuste)d=0.007, 95% confidence interval (CI)=0.004 to 0.011, p<0.001). Adjustment for confounders did not alter this result (β(adjusted)=0.005, 95% CI=0.002 to 0.008, p<0.001). Delirium was not associated with absolute body temperature (β(unadjusted)=-0.03, 95% CI=-0.17 to 0.10, p=0.61). This did not change after

Temperature Variability during Delirium in ICU Patients: An Observational Study

PubMed Central

van der Kooi, Arendina W.; Kappen, Teus H.; Raijmakers, Rosa J.; Zaal, Irene J.; Slooter, Arjen J. C.

2013-01-01

Introduction Delirium is an acute disturbance of consciousness and cognition. It is a common disorder in the intensive care unit (ICU) and associated with impaired long-term outcome. Despite its frequency and impact, delirium is poorly recognized by ICU-physicians and –nurses using delirium screening tools. A completely new approach to detect delirium is to use monitoring of physiological alterations. Temperature variability, a measure for temperature regulation, could be an interesting component to monitor delirium, but whether temperature regulation is different during ICU delirium has not yet been investigated. The aim of this study was to investigate whether ICU delirium is related to temperature variability. Furthermore, we investigated whether ICU delirium is related to absolute body temperature. Methods We included patients who experienced both delirium and delirium free days during ICU stay, based on the Confusion Assessment method for the ICU conducted by a research- physician or –nurse, in combination with inspection of medical records. We excluded patients with conditions affecting thermal regulation or therapies affecting body temperature. Daily temperature variability was determined by computing the mean absolute second derivative of the temperature signal. Temperature variability (primary outcome) and absolute body temperature (secondary outcome) were compared between delirium- and non-delirium days with a linear mixed model and adjusted for daily mean Richmond Agitation and Sedation Scale scores and daily maximum Sequential Organ Failure Assessment scores. Results Temperature variability was increased during delirium-days compared to days without delirium (βunadjusted=0.007, 95% confidence interval (CI)=0.004 to 0.011, p<0.001). Adjustment for confounders did not alter this result (βadjusted=0.005, 95% CI=0.002 to 0.008, p<0.001). Delirium was not associated with absolute body temperature (βunadjusted=-0.03, 95% CI=-0.17 to 0.10, p=0.61). This

Epidemiology of Australian Influenza-Related Paediatric Intensive Care Unit Admissions, 1997-2013.

PubMed

Kaczmarek, Marlena C; Ware, Robert S; Coulthard, Mark G; McEniery, Julie; Lambert, Stephen B

2016-01-01

Influenza virus predictably causes an annual epidemic resulting in a considerable burden of illness in Australia. Children are disproportionately affected and can experience severe illness and complications, which occasionally result in death. We conducted a retrospective descriptive study using data collated in the Australian and New Zealand Paediatric Intensive Care (ANZPIC) Registry of influenza-related intensive care unit (ICU) admissions over a 17-year period (1997-2013, inclusive) in children <16 years old. National laboratory-confirmed influenza notifications were used for comparison. Between 1997 and 2013, a total of 704 influenza-related ICU admissions were recorded, at a rate of 6.2 per 1,000 all-cause ICU admissions. Age at admission ranged from 0 days and 15.9 years (median = 2.1 years), with 135 (19.2%) aged <6 months. Pneumonia/pneumonitis and bronchiolitis were the most common primary diagnoses among influenza-related admissions (21.9% and 13.6%, respectively). More than half of total cases (59.2%) were previously healthy (no co-morbidities recorded), and in the remainder, chronic lung disease (16.7%) and asthma (12.5%) were the most common co-morbidities recorded. Pathogen co-detection occurred in 24.7% of cases, most commonly with respiratory syncytial virus or a staphylococcal species. Median length of all ICU admissions was 3.2 days (range 2.0 hours- 107.4 days) and 361 (51.3%) admissions required invasive respiratory support for a median duration of 4.3 days (range 0.2 hours- 107.5 days). There were 27 deaths recorded, 14 (51.9%) in children without a recorded co-morbidity. Influenza causes a substantial number of ICU admissions in Australian children each year with the majority occurring in previously healthy children.

Comparing the Incidence of Febrile Neutropenia Resulting in Hospital Admission Between the Branded Docetaxel and the Generic Formulations.

PubMed

Faqeer, Nour Al; Mashni, Ola; Dawoud, Rawan; Rumman, Asma; Hanoun, Esraa; Nazer, Lama

2017-02-01

Studies have raised concern about the safety of generic compared with branded drugs. Febrile neutropenia (FN) resulting in hospital admission was compared between the branded docetaxel (Taxotere®, Sanofi) and 2 generic formulations (docetaxel Ebewe and docetaxel Hospira) in patients with breast cancer. This was a retrospective study that included patients with breast cancer who received docetaxel between January 2012 and December 2014. Patients who had an admission diagnosis of FN and had received docetaxel within 14 days prior to admission were evaluated. The docetaxel brand and dose, patient characteristics, hospital length of stay, admission to the intensive care unit (ICU), and mortality were recorded. During the study period, 2904 cycles of docetaxel were given for 876 patients (1519 cycles of docetaxel Sanofi, 811 cycles of docetaxel Hospira, and 574 cycles of docetaxel Ebewe). Among the cycles given, 130 cycles were associated with FN that required hospital admission. The overall incidence of FN resulting in hospital admission was significantly higher in patients who had received docetaxel Hospira, compared with patients who had received docetaxel Sanofi (47[5.8%] cycles vs 53 [3.5%] cycles, P = .009), but there was no significant difference between docetaxel Ebewe and docetaxel Sanofi (30[5.2%] cycles vs 53 [3.5%] cycles, P = .069). All cases of FN resolved except for 1 patient who died in the ICU after receiving docetaxel Ebewe. There was a significant difference in the incidence of FN between docetaxel Sanofi and docetaxel Hospira, but all cases in both groups resolved completely. © 2016, The American College of Clinical Pharmacology.

The Effect of ARDS on Survival: Do Patients Die From ARDS or With ARDS?

PubMed

Fuchs, Lior; Feng, Mengling; Novack, Victor; Lee, Joon; Taylor, Jonathan; Scott, Daniel; Howell, Michael; Celi, Leo; Talmor, Daniel

2017-01-01

To investigate the contribution of acute respiratory distress syndrome (ARDS) in of itself to mortality among ventilated patients. A longitudinal retrospective study of ventilated intensive care unit (ICU) patients. The analysis included patients ventilated for more than 48 hours. Patients were classified as having ARDS on admission (early-onset ARDS), late-onset ARDS (ARDS not present during the first 24 hours of admission), or no ARDS. Primary outcomes were mortality at 28 days, and secondary outcomes were 2-year mortality rate from ICU admission. A total of 1411 ventilated patients were enrolled: 41% had ARDS on admission, 28.5% developed ARDS during their ICU stay, and 30.5% did not meet the ARDS criteria prior to ICU discharge or death. The non-ARDS group was used as the control. We also divided the cohort based on the severity of ARDS. After adjusting for covariates, mortality risk at 28 days was not significantly different among the different groups. Both early- and late-onset ARDS as well as the severity of ARDS were found to be significant risk factors for 2 years from ICU survival. Among patients who were ventilated on ICU admission, neither the presence, the severity, or the timing of ARDS contribute independently to the short-term mortality risk. However, acute respiratory distress syndrome does contribute significantly to 2-year mortality risk. This suggests that patients may not die acutely from ARDS itself but rather from the primary disease, and during the acute phase of ARDS, clinicians should focus on improving treatment strategies for the diseases that led to ARDS.

Current Trends of Using Antimicrobial Drugs in the ICU at a Tertiary Level Teaching Hospital in Mymensingh.

PubMed

Saha, S K; Shaha, K C; Haque, M F; Khatun, S; Akhter, S M; Akhter, H

2016-10-01

The aim of the present study was to investigate the current trends of using antimicrobial drugs in the ICU at a tertiary level teaching hospital in Mymensingh. The study of prescribing patterns seeks to monitor, evaluate and suggest modifications in clinicians prescribing habits so as to make medical care rational. It was an observational type of descriptive study, conducted in the Mymensingh medical college hospital, Mymensingh, during the study period of June 2016 to September 2016.The study was approved by the institutional ethical committee. Most patients in the ICU belonged to the older age group >60 years. Male patients were more than the female patients in ICU. Average duration of stay in ICU was 4.35 days. Admissions in ICU were common due to respiratory system related diseases and the present study showed that 31.68% of the reported cases belong to the respiratory system. Average number of drugs per prescription was 6.46. Average number of anti-microbial drugs per prescription was 1.38. Cephalosporin group and individually ceftriaxone was the most frequently prescribed antimicrobial group and agent respectively in the ICU. Most commonly used antimicrobial combination was Cephalosporin and Metronidazole (43.33%) followed by Carbapenem (Meropenem) and Metronidazole (13.33%). Most antimicrobial agents were prescribed without bacteriological culture and sensivity testing evidence. There is a need for motivating the physicians to prescribe antimicrobial agents with supportive bacteriological evidences.

Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen-ICU Randomized Clinical Trial.

PubMed

Girardis, Massimo; Busani, Stefano; Damiani, Elisa; Donati, Abele; Rinaldi, Laura; Marudi, Andrea; Morelli, Andrea; Antonelli, Massimo; Singer, Mervyn

2016-10-18

Despite suggestions of potential harm from unnecessary oxygen therapy, critically ill patients spend substantial periods in a hyperoxemic state. A strategy of controlled arterial oxygenation is thus rational but has not been validated in clinical practice. To assess whether a conservative protocol for oxygen supplementation could improve outcomes in patients admitted to intensive care units (ICUs). Oxygen-ICU was a single-center, open-label, randomized clinical trial conducted from March 2010 to October 2012 that included all adults admitted with an expected length of stay of 72 hours or longer to the medical-surgical ICU of Modena University Hospital, Italy. The originally planned sample size was 660 patients, but the study was stopped early due to difficulties in enrollment after inclusion of 480 patients. Patients were randomly assigned to receive oxygen therapy to maintain Pao2 between 70 and 100 mm Hg or arterial oxyhemoglobin saturation (Spo2) between 94% and 98% (conservative group) or, according to standard ICU practice, to allow Pao2 values up to 150 mm Hg or Spo2 values between 97% and 100% (conventional control group). The primary outcome was ICU mortality. Secondary outcomes included occurrence of new organ failure and infection 48 hours or more after ICU admission. A total of 434 patients (median age, 64 years; 188 [43.3%] women) received conventional (n = 218) or conservative (n = 216) oxygen therapy and were included in the modified intent-to-treat analysis. Daily time-weighted Pao2 averages during the ICU stay were significantly higher (P < .001) in the conventional group (median Pao2, 102 mm Hg [interquartile range, 88-116]) vs the conservative group (median Pao2, 87 mm Hg [interquartile range, 79-97]). Twenty-five patients in the conservative oxygen therapy group (11.6%) and 44 in the conventional oxygen therapy group (20.2%) died during their ICU stay (absolute risk reduction [ARR], 0.086 [95% CI, 0.017-0.150]; relative risk [RR], 0

Recall of ICU Stay in Patients Managed With a Sedation Protocol or a Sedation Protocol With Daily Interruption.

PubMed

Burry, Lisa; Cook, Deborah; Herridge, Margaret; Devlin, John W; Fergusson, Dean; Meade, Maureen; Steinberg, Marilyn; Skrobik, Yoanna; Olafson, Kendiss; Burns, Karen; Dodek, Peter; Granton, John; Ferguson, Niall; Jacka, Michael; Tanios, Maged; Fowler, Robert; Reynolds, Steven; Keenan, Sean; Mallick, Ranjeeta; Mehta, Sangeeta

2015-10-01

To 1) describe factual, emotional, and delusional memories of ICU stay for patients enrolled in the SLEAP (Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol) trial; 2) compare characteristics of patients with and without ICU recall, and patients with and without delusional memories; and 3) determine factors associated with delusional memories 28 days after ICU discharge. Prospective cohort. Sixteen North American medical and surgical ICUs. Critically ill, mechanically ventilated adults randomized in the SLEAP trial. Post-ICU interviews on days 3, 28, and 90 using the validated ICU Memory Tool. Overall, 289 of 297 ICU survivors (97%) (146 protocolized sedation and 143 protocolized sedation plus daily interruption patients) were interviewed at least once. Because there were no differences in recall status or types of memories between the two sedation groups, we present the findings for all patients rather than by study group. On days 3, 28, and 90, 28%, 26%, and 36% of patients, respectively, reported no recall of being in the ICU (overall perception, self-reported) (p = 0.75). Mean daily doses of benzodiazepines and opioids were lower in patients with no ICU recall than those with recall (p < 0.0001 for both). Despite one third of patients reporting no recall of ICU stay on day 3, 97% and 90% reported at least one factual and one emotional memory from ICU, respectively. Emotional memories declined with time after ICU discharge, particularly panic and confusion. Delusional memories 28 days after discharge were common (70%) yet unrelated to delirium (p = 0.84), recall status (p = 0.15), total dose of benzodiazepine (p = 0.78), or opioid (p = 0.21). Delusional memories were less likely with longer duration of mechanical ventilation (odds ratio, 0.955; 95% CI, 0.91-1.00; p = 0.04). Recall of ICU stay and types of memories reported were not influenced by the trial sedation strategy. Lack of ICU recall and

Sleep in the pediatric ICU: an empirical investigation.

PubMed

Cureton-Lane, R A; Fontaine, D K

1997-01-01

Although sleep is important for physical and psychological health, no research has assessed the sleep of children in a pediatric ICU and the factors that affect sleep. To observe the sleep of children in a pediatric ICU and to determine the relationship of noise, light, contact with caregivers, parental presence, and severity of illness to the sleep obtained by children in a pediatric ICU during a 10-hour night. At 5-minute intervals from 8 PM until 6 AM, a convenience sample of nine patients was observed. Sleep state, noise and light levels, contact with caregivers, and parental presence were recorded. Severity of illness was measured on admission and within 26 hours of data collection. Subjects slept for a mean total of 4.7 hours (SD = 0.49) during the 10-hour night, interrupted by a mean of 9.8 awakenings (SD = 2.48). The mean length of a sleep episode was only 27.6 minutes (SD = 25.85). Mean noise level was 55.1 dB(A) (SD = 6.82), with sudden, sharp elevations of up to 90 dB(A). Probit analysis indicated that noise, light, and contact with caregivers were significant predictors of sleep. Parental presence and severity of illness were not. Patients in the pediatric ICU sleep significantly less than is normal for children of the same ages, and their patterns of sleep are seriously disturbed. Because noise, light, and contact with caregivers are significant predictors of sleep state, health professionals can use these findings to structure the environment and the care they give to promote the sleep of critically ill children.

Role of organisational factors on the ‘weekend effect’ in critically ill patients in Brazil: a retrospective cohort analysis

PubMed Central

Zampieri, Fernando G; Lisboa, Thiago C; Correa, Thiago D; Bozza, Fernando A; Ferez, Marcus; Fernandes, Haggeas S; Japiassú, André M; Verdeal, Juan Carlos R; Carvalho, Ana Cláudia P; Knibel, Marcos F; Mazza, Bruno F; Colombari, Fernando; Vieira, José Mauro; Viana, William N; Costa, Roberto; Godoy, Michele M; Maia, Marcelo O; Caser, Eliana B; Salluh, Jorge I F; Soares, Marcio

2018-01-01

Introduction Higher mortality for patients admitted to intensive care units (ICUs) during the weekends has been occasionally reported with conflicting results that could be related to organisational factors. We investigated the effects of ICU organisational and staffing patterns on the potential association between weekend admission and outcomes in critically ill patients. Methods We included 59 614 patients admitted to 78 ICUs participating during 2013. We defined ‘weekend admission’ as any ICU admission from Friday 19:00 until Monday 07:00. We assessed the association between weekend admission with hospital mortality using a mixed logistic regression model controlling for both patient-level (illness severity, age, comorbidities, performance status and admission type) and ICU-level (decrease in nurse/bed ratio on weekend, full-time intensivist coverage, use of checklists on weekends and number of institutional protocols) confounders. We performed secondary analyses in the subgroup of scheduled surgical admissions. Results A total of 41 894 patients (70.3%) were admitted on weekdays and 17 720 patients (29.7%) on weekends. In univariable analysis, weekend admitted patients had higher ICU (10.9% vs 9.0%, P<0.001) and hospital (16.5% vs 13.5%, P<0.001) mortality. After adjusting for confounders, weekend admission was not associated with higher hospital mortality (OR 1.05, 95% CI 0.99 to 1.12, P=0.095). However, a ‘weekend effect’ was still observed in scheduled surgical admissions, as well as in ICUs not using checklists during the weekends. For unscheduled admissions, no ‘weekend effect’ was observed regardless of ICU’s characteristics. For scheduled surgical admissions, a ‘weekend effect’ was present only in ICUs with a low number of implemented protocols and those with a reduction in the nurse/bed ratio and not applying checklists during weekends. Conclusions ICU organisational factors, such as decreased nurse-to-patient ratio, absence of

Patient and Family Member-Led Research in the Intensive Care Unit: A Novel Approach to Patient-Centered Research.

PubMed

Gill, Marlyn; Bagshaw, Sean M; McKenzie, Emily; Oxland, Peter; Oswell, Donna; Boulton, Debbie; Niven, Daniel J; Potestio, Melissa L; Shklarov, Svetlana; Marlett, Nancy; Stelfox, Henry T

2016-01-01

Engaging patients and family members as partners in research increases the relevance of study results and enhances patient-centered care; how to best engage patients and families in research is unknown. We tested a novel research approach that engages and trains patients and family members as researchers to see if we could understand and describe the experiences of patients admitted to the intensive care unit (ICU) and their families. Former patients and family members conducted focus groups and interviews with patients (n = 11) and families of surviving (n = 14) and deceased (n = 7) patients from 13 ICUs in Alberta Canada, and analyzed data using conventional content analysis. Separate blinded qualitative researchers conducted an independent analysis. Participants described three phases in the patient/family "ICU journey"; admission to ICU, daily care in ICU, and post-ICU experience. Admission to ICU was characterized by family shock and disorientation with families needing the presence and support of a provider. Participants described five important elements of daily care: honoring the patient's voice, the need to know, decision-making, medical care, and culture in ICU. The post-ICU experience was characterized by the challenges of the transition from ICU to a hospital ward and long-term effects of critical illness. These "ICU journey" experiences were described as integral to appropriate interactions with the care team and comfort and trust in the ICU, which were perceived as essential for a community of caring. Participants provided suggestions for improvement: 1) provide a dedicated family navigator, 2) increase provider awareness of the fragility of family trust, 3) improve provider communication skills, 4) improve the transition from ICU to hospital ward, and 5) inform patients about the long-term effects of critical illness. Analyses by independent qualitative researchers identified similar themes. Patient and family member-led research is feasible and can

Nurses' Empowerment Scale for ICU patients' families: an instrument development study.

PubMed

Li, Hong; Liu, Ya-Lan; Qiu, Li; Chen, Qiao-Ling; Wu, Jing-Bing; Chen, Li-Li; Li, Na

2016-09-01

Family members provide essential support for ICU patients, contributing to their mental and physical recovery. Empowering ICU patients' families may help them overcome inadequacies and meet their own and patients' acknowledged needs. Nursing should understand and address patients' families' empowerment status. To develop a tool, the Nurses' Empowerment Scale for Intensive Care Unit (ICU) Patients' Families (NESIPF), to help ICU nursing staff assess the empowerment status of patients' families. Four-phase instrument development study. A 19-item instrument was initially generated based on literature review and interviews with family members of ICU patients. The Delphi research method was applied to gain expert opinion and consensus via rounds of questionnaires. A panel of 27 experts experienced in critical care medicine, nursing and psychology participated in two Delphi rounds and their input helped formulate an 18-item pretest instrument. Families of 20 patients were recruited to examine instrument readability. After a 2-week interval, another 20 patients' families were recruited to examine test-retest reliability. Two hundred questionnaires were then administered and analysed to examine the instrument's construct validity, criterion-related validity and internal consistency. Expert authority coefficients of two Delphi rounds reached 0·89 and 0·91. Kendall' W coefficients of 0·113 (P < 0·001) in round 1 and 0·220 (P < 0·001) in round 2 indicated slight to fair agreement among experts. Content validity index (CVI) reached 1·0 for 12 items; the CVI for item 13 was <0·7 so it was excluded. Cronbach's α coefficient was 0·92, indicating acceptable internal consistency reliability. The coefficient of internal consistency of each dimension was 0·717-0·921. The Pearson correlation coefficient >0·9 (P < 0·05) showed an acceptable test-retest reliability. The instrument has acceptable reliability and validity and can assess the empowerment status of families of

Evacuation of the ICU

PubMed Central

Niven, Alexander S.; Beninati, William; Fang, Ray; Einav, Sharon; Rubinson, Lewis; Kissoon, Niranjan; Devereaux, Asha V.; Christian, Michael D.; Grissom, Colin K.; Christian, Michael D.; Devereaux, Asha V.; Dichter, Jeffrey R.; Kissoon, Niranjan; Rubinson, Lewis; Amundson, Dennis; Anderson, Michael R.; Balk, Robert; Barfield, Wanda D.; Bartz, Martha; Benditt, Josh; Beninati, William; Berkowitz, Kenneth A.; Daugherty Biddison, Lee; Braner, Dana; Branson, Richard D; Burkle, Frederick M.; Cairns, Bruce A.; Carr, Brendan G.; Courtney, Brooke; DeDecker, Lisa D.; De Jong, Marla J.; Dominguez-Cherit, Guillermo; Dries, David; Einav, Sharon; Erstad, Brian L.; Etienne, Mill; Fagbuyi, Daniel B.; Fang, Ray; Feldman, Henry; Garzon, Hernando; Geiling, James; Gomersall, Charles D.; Grissom, Colin K.; Hanfling, Dan; Hick, John L.; Hodge, James G.; Hupert, Nathaniel; Ingbar, David; Kanter, Robert K.; King, Mary A.; Kuhnley, Robert N.; Lawler, James; Leung, Sharon; Levy, Deborah A.; Lim, Matthew L.; Livinski, Alicia; Luyckx, Valerie; Marcozzi, David; Medina, Justine; Miramontes, David A.; Mutter, Ryan; Niven, Alexander S.; Penn, Matthew S.; Pepe, Paul E.; Powell, Tia; Prezant, David; Reed, Mary Jane; Rich, Preston; Rodriquez, Dario; Roxland, Beth E.; Sarani, Babak; Shah, Umair A.; Skippen, Peter; Sprung, Charles L.; Subbarao, Italo; Talmor, Daniel; Toner, Eric S.; Tosh, Pritish K.; Upperman, Jeffrey S.; Uyeki, Timothy M.; Weireter, Leonard J.; West, T. Eoin; Wilgis, John; Ornelas, Joe; McBride, Deborah; Reid, David; Baez, Amado; Baldisseri, Marie; Blumenstock, James S.; Cooper, Art; Ellender, Tim; Helminiak, Clare; Jimenez, Edgar; Krug, Steve; Lamana, Joe; Masur, Henry; Mathivha, L. Rudo; Osterholm, Michael T.; Reynolds, H. Neal; Sandrock, Christian; Sprecher, Armand; Tillyard, Andrew; White, Douglas; Wise, Robert; Yeskey, Kevin

2014-01-01

BACKGROUND: Despite the high risk for patient harm during unanticipated ICU evacuations, critical care providers receive little to no training on how to perform safe and effective ICU evacuations. We reviewed the pertinent published literature and offer suggestions for the critical care provider regarding ICU evacuation. The suggestions in this article are important for all who are involved in pandemics or disasters with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. METHODS: The Evacuation and Mobilization topic panel used the American College of Chest Physicians (CHEST) Guidelines Oversight Committee’s methodology to develop seven key questions for which specific literature searches were conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. RESULTS: Based on current best evidence, we provide 13 suggestions outlining a systematic approach to prepare for and execute an effective ICU evacuation during a disaster. Interhospital and intrahospital collaboration and functional ICU communication are critical for success. Pre-event planning and preparation are required for a no-notice evacuation. A Critical Care Team Leader must be designated within the Hospital Incident Command System. A three-stage ICU Evacuation Timeline, including (1) no immediate threat, (2) evacuation threat, and (3) evacuation implementation, should be used. Detailed suggestions on ICU evacuation, including regional planning, evacuation drills, patient transport preparation and equipment, patient prioritization and distribution for evacuation, patient information and tracking, and federal and international evacuation assistance systems, are also provided. CONCLUSIONS: Successful ICU evacuation during a disaster requires

Levels of cytokines in broncho-alveolar lavage fluid, but not in plasma, are associated with levels of markers of lipid peroxidation in breath of ventilated ICU patients.

PubMed

Boshuizen, Margit; Leopold, Jan Hendrik; Zakharkina, Tetyana; Knobel, Hugo H; Weda, Hans; Nijsen, Tamara M E; Vink, Teunis J; Sterk, Peter J; Schultz, Marcus J; Bos, Lieuwe D J

2015-09-03

Alkanes and alkenes in the breath are produced through fatty acid peroxidation, which is initialized by reactive oxygen species. Inflammation is an important cause and effect of reactive oxygen species. We aimed to evaluate the association between fatty acid peroxidation products and inflammation of the alveolar and systemic compartment in ventilated intensive care unit (ICU) patients.Volatile organic compounds were measured by gas chromatography and mass spectrometry in the breath of newly ventilated ICU patients within 24 h after ICU admission. Cytokines were measured in non-directed bronchial lavage fluid (NBL) and plasma by cytometric bead array. Correlation coefficients were calculated and presented in heatmaps.93 patients were included. Peroxidation products in exhaled breath were not associated with markers of inflammation in plasma, but were correlated with those in NBL. IL-6, IL-8, IL-1β and TNF-α concentration in NBL showed inverse correlation coefficients with the peroxidation products of fatty acids. Furthermore, NBL IL-10, IL-13, GM-CSF and IFNγ demonstrated positive associations with breath alkanes and alkenes. Correlation coefficients for NBL cytokines were high regarding peroxidation products of n-6, n-7 and particularly in n-9 fatty acids.Levels of lipid peroxidation products in the breath of ventilated ICU patients are associated with levels of inflammatory markers in NBL, but not in plasma. Alkanes and alkenes in breath seems to be associated with an anti-inflammatory, rather than a pro-inflammatory state in the alveoli.

Causes of death in critically ill multiple sclerosis patients.

PubMed

Karamyan, A; Brandtner, H; Grinzinger, S; Chroust, V; Bacher, C; Otto, F; Reisp, M; Hauer, L; Sellner, J

2017-10-01

Patients with multiple sclerosis (MS) experience higher mortality rates as compared to the general population. While the risk of intensive care unit (ICU) admission is also reported to be higher, little is known about causes of death CoD in critically ill MS patients. To study the causes of death (CoD) in the series of critically ill patients with MS verified by autopsy. We reviewed hospital electronic charts of MS patients treated at the neurological ICU of a tertiary care hospital between 2000 and 2015. We compared clinical and pathological CoD for those who were autopsied. Overall, 10 patients were identified (seven female; median age at death 65 years, range 27-80), and six of them were autopsied. The median MS duration prior to ICU admission was 27.5 years (range 1-50), and the median EDSS score at the time of ICU admission was 9 (range 5-9.5). The median length of ICU stay was 3 days (range 2-213). All the individuals in our series had experienced respiratory insufficiency during their ICU stay. The autopsy examination of brain tissue did not reveal evidences of MS lesions in one patient. In another patient, Lewy bodies were found on brain immunohistochemistry. Mortality in critically ill MS patients is largely driven by respiratory complications. Sporadic disparities between clinical and pathological findings can be expected. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Parental satisfaction, involvement, and presence after pediatric intensive care unit admission.

PubMed

Ebrahim, Shanil; Singh, Simran; Parshuram, Christopher S

2013-02-01

To describe satisfaction, involvement, presence, and preferences of parents following their child's admission to an intensive care unit (ICU). A survey, administered 1 month after their child's ICU admission, described perceptions of parental satisfaction with their interaction with healthcare providers, their presence during resuscitation, involvement in treatment decision-making, and preferences if events were to be re-enacted. One hundred three parents of 91 patients were enrolled; 64 primary parents (70%) completed the survey at 1 month. The mean (SD) satisfaction rating was 87.6 (±14.8) and involvement rating was 70.2 (±34.4) on a scale from 0 (not satisfied/involved) to 100 (completely satisfied/involved). There were no differences in satisfaction (P = .46), involvement (P = .69) and change in preferences (P = .97) between parents who were present and not present. After adjusting for child's baseline illness, receipt of more ICU therapies was associated with worse parental satisfaction (P = .03). Twenty-four (38%) parents reported that if events were repeated, they would have changed their preferences. Overall, parental satisfaction ratings were high, lower in parents of children receiving more ICU therapies, and not associated with presence during resuscitation. These data contrast the American Heart Association's recommendation and suggestion of benefit from parental presence during periods of intensive therapies. Copyright © 2013 Elsevier Inc. All rights reserved.

Preventing Harm in the ICU-Building a Culture of Safety and Engaging Patients and Families.

PubMed

Thornton, Kevin C; Schwarz, Jennifer J; Gross, A Kendall; Anderson, Wendy G; Liu, Kathleen D; Romig, Mark C; Schell-Chaple, Hildy; Pronovost, Peter J; Sapirstein, Adam; Gropper, Michael A; Lipshutz, Angela K M

2017-09-01

Preventing harm remains a persistent challenge in the ICU despite evidence-based practices known to reduce the prevalence of adverse events. This review seeks to describe the critical role of safety culture and patient and family engagement in successful quality improvement initiatives in the ICU. We review the evidence supporting the impact of safety culture and provide practical guidance for those wishing to implement initiatives aimed at improving safety culture and more effectively integrate patients and families in such efforts. Literature review using PubMed including evaluation of key studies assessing large-scale quality improvement efforts in the ICU, impact of safety culture on patient outcomes, methodologies for quality improvement commonly used in healthcare, and patient and family engagement. Print and web-based resources from leading patient safety organizations were also searched. Our group completed a review of original studies, review articles, book chapters, and recommendations from leading patient safety organizations. Our group determined by consensus which resources would best inform this review. A strong safety culture is associated with reduced adverse events, lower mortality rates, and lower costs. Quality improvement efforts have been shown to be more effective and sustainable when paired with a strong safety culture. Different methodologies exist for quality improvement in the ICU; a thoughtful approach to implementation that engages frontline providers and administrative leadership is essential for success. Efforts to substantively include patients and families in the processes of quality improvement work in the ICU should be expanded. Efforts to establish a culture of safety and meaningfully engage patients and families should form the foundation for all safety interventions in the ICU. This review describes an approach that integrates components of several proven quality improvement methodologies to enhance safety culture in the ICU and

Inpatient dermatology: profile of patients and characteristics of admissions to a tertiary dermatology inpatient unit in São Paulo, Brazil.

PubMed

de Paula Samorano-Lima, Luciana; Quitério, Ligia M; Sanches, José A; Neto, Cyro Festa

2014-06-01

Dermatology is primarily an outpatient clinical and surgical specialty, but substantial numbers of patients are admitted to hospital for inpatient treatment in dermatology wards. We performed a retrospective study of patients admitted to dermatology beds between September 1, 2002, and September 30, 2010. Patient data were analyzed for age, gender, ethnicity, length of stay (LoS), dermatologic disease, comorbidities, hospital-acquired infection (HAI), transfer to the intensive care unit (ICU), and mortality. A total of 3308 patients admitted during this 8-year period were identified for analysis. The most frequent admissions were for eczema/dermatitis (17.5%) and cutaneous infections (15.9%). The mean LoS was 13.0 days. The mean ± standard deviation (SD) number of comorbidities per patient was 1.0 ± 1.2, among the most frequent of which were hypertension and diabetes mellitus. The rate of HAI was 6.2%; bloodstream infection was regarded as the most commonly acquired type and Staphylococcus aureus as the infectious agent most commonly found in culture. Of the patients admitted, 3.7% were transferred to the ICU and 2.5% died. In these latter two groups, the most common dermatologic diagnoses were immunobullous diseases, and the mean hospital LoS and rate of HAI were higher than in the total admissions cohort. Higher value should be placed on dermatology inpatient services in order to expand the availability of dermatology beds, mainly in tertiary hospitals, in view of the potentially high severity of the dermatologic diseases found in many patients referred to this type of service. © 2013 The International Society of Dermatology.

Early hospital mortality prediction of intensive care unit patients using an ensemble learning approach.

PubMed

Awad, Aya; Bader-El-Den, Mohamed; McNicholas, James; Briggs, Jim

2017-12-01

Mortality prediction of hospitalized patients is an important problem. Over the past few decades, several severity scoring systems and machine learning mortality prediction models have been developed for predicting hospital mortality. By contrast, early mortality prediction for intensive care unit patients remains an open challenge. Most research has focused on severity of illness scoring systems or data mining (DM) models designed for risk estimation at least 24 or 48h after ICU admission. This study highlights the main data challenges in early mortality prediction in ICU patients and introduces a new machine learning based framework for Early Mortality Prediction for Intensive Care Unit patients (EMPICU). The proposed method is evaluated on the Multiparameter Intelligent Monitoring in Intensive Care II (MIMIC-II) database. Mortality prediction models are developed for patients at the age of 16 or above in Medical ICU (MICU), Surgical ICU (SICU) or Cardiac Surgery Recovery Unit (CSRU). We employ the ensemble learning Random Forest (RF), the predictive Decision Trees (DT), the probabilistic Naive Bayes (NB) and the rule-based Projective Adaptive Resonance Theory (PART) models. The primary outcome was hospital mortality. The explanatory variables included demographic, physiological, vital signs and laboratory test variables. Performance measures were calculated using cross-validated area under the receiver operating characteristic curve (AUROC) to minimize bias. 11,722 patients with single ICU stays are considered. Only patients at the age of 16 years old and above in Medical ICU (MICU), Surgical ICU (SICU) or Cardiac Surgery Recovery Unit (CSRU) are considered in this study. The proposed EMPICU framework outperformed standard scoring systems (SOFA, SAPS-I, APACHE-II, NEWS and qSOFA) in terms of AUROC and time (i.e. at 6h compared to 48h or more after admission). The results show that although there are many values missing in the first few hour of ICU admission

Detection of Deteriorating Patients on Surgical Wards Outside the ICU by an Automated MEWS-Based Early Warning System With Paging Functionality.

PubMed

Heller, Axel R; Mees, Sören T; Lauterwald, Benjamin; Reeps, Christian; Koch, Thea; Weitz, Jürgen

2018-05-16

The establishment of early warning systems in hospitals was strongly recommended in recent guidelines to detect deteriorating patients early and direct them to adequate care. Upon reaching predefined trigger criteria, Medical Emergency Teams (MET) should be notified and directed to these patients. The present study analyses the effect of introducing an automated multiparameter early warning score (MEWS)-based early warning system with paging functionality on 2 wards hosting patients recovering from highly complex surgical interventions. The deployment of the system was accompanied by retrospective data acquisition during 12 months (intervention) using 4 routine databases: Hospital patient data management, anesthesia database, local data of the German Resuscitation Registry, and measurement logs of the deployed system (intervention period only). A retrospective 12-month data review using the same aforementioned databases before the deployment of the system served as control. Control and intervention phases were separated by a 6-month washout period for the installation of the system and for training. Data from 3827 patients could be acquired from 2 surgical wards during the two 12-month periods, 1896 patients in the control and 1931 in the intervention cohorts. Patient characteristics differed between the 2 observation phases. American Society of Anesthesiologists risk classification and duration of surgery as well as German DRG case-weight were significantly higher in the intervention period. However, the rate of cardiac arrests significantly dropped from 5.3 to 2.1 per 1000 admissions in the intervention period (P < 0.001). This observation was paralleled by a reduction of unplanned ICU admissions from 3.6% to 3.0% (P < 0.001), and an increase of notifications of critical conditions to the ward surgeon. The primary triggers for MET activation were abnormal ECG alerts, specifically asystole (n = 5), and pulseless electric activity (n = 8). In concert with a well

Predictors of ICU patients' pain management satisfaction: A descriptive cross-sectional survey.

PubMed

Darawad, Muhammad W; Al-Hussami, Mahmoud; Saleh, Ali M; Al-Sutari, Manal; Mustafa, Waddah Mohammad

2015-08-01

(1) To assess Jordanian ICU patients' pain characteristics (intensity and interference) and levels of pain management satisfaction; and (2) to determine potential predictors of pain management satisfaction among ICU patients. A descriptive cross-sectional design was utilised using the American Pain Society-Patient Outcome Questionnaire to survey 139 Jordanian ICU patients from different health care sectors in Jordan. High levels of pain and pain interferences were reported by participants, which were higher than those reported by previous studies in other countries. However, participants were relatively satisfied with pain management approaches. Also, the results showed a predictive model of three potential predictors, which accounted for 36% of the variance in participants' satisfaction with pain management (adjusted R(2)=0.36, F=12.14, df=7129, p<0.005). The strongest predictor to participants' satisfaction with pain management was time needed to get analgesia (beta=-0.480, p<0.001), followed by average pain interference (beta=0.218, p=0.02), and being told about importance of reporting pain (beta=0.198, p=0.006). Jordanian ICU patients reported high pain levels, which supports the need for applying a caring attitude in managing patients' pain reports. Also, such a study is among the first pain management studies in Jordan aiming at setting the stage for future research studies. Finally, results can be included in planning pain management strategies and protocols within hospitals. Copyright © 2014 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

Enteral vs. intravenous ICU sedation management: study protocol for a randomized controlled trial.

PubMed

Mistraletti, Giovanni; Mantovani, Elena S; Cadringher, Paolo; Cerri, Barbara; Corbella, Davide; Umbrello, Michele; Anania, Stefania; Andrighi, Elisa; Barello, Serena; Di Carlo, Alessandra; Martinetti, Federica; Formenti, Paolo; Spanu, Paolo; Iapichino, Gaetano

2013-04-03

A relevant innovation about sedation of long-term Intensive Care Unit (ICU) patients is the 'conscious target': patients should be awake even during the critical phases of illness. Enteral sedative administration is nowadays unusual, even though the gastrointestinal tract works soon after ICU admission. The enteral approach cannot produce deep sedation; however, it is as adequate as the intravenous one, if the target is to keep patients awake and adapted to the environment, and has fewer side effects and lower costs. A randomized, controlled, multicenter, single-blind trial comparing enteral and intravenous sedative treatments has been done in 12 Italian ICUs. The main objective was to achieve and maintain the desired sedation level: observed RASS = target RASS ± 1. Three hundred high-risk patients were planned to be randomly assigned to receive either intravenous propofol/midazolam or enteral melatonin/hydroxyzine/lorazepam. Group assignment occurred through online minimization process, in order to balance variables potentially influencing the outcomes (age, sex, SAPS II, type of admission, kidney failure, chronic obstructive pulmonary disease, sepsis) between groups. Once per shift, the staff recorded neurological monitoring using validated tools. Three flowcharts for pain, sedation, and delirium have been proposed; they have been designed to treat potentially correctable factors first, and, only once excluded, to administer neuroactive drugs. The study lasted from January 24 to December 31, 2012. A total of 348 patients have been randomized, through a centralized website, using a specific software expressly designed for this study. The created network of ICUs included a mix of both university and non-university hospitals, with different experience in managing enteral sedation. A dedicated free-access website was also created, in both Italian and English, for continuous education of ICU staff through CME courses. This 'educational research' project aims both to

Non-linear feature extraction from HRV signal for mortality prediction of ICU cardiovascular patient.

PubMed

Karimi Moridani, Mohammad; Setarehdan, Seyed Kamaledin; Motie Nasrabadi, Ali; Hajinasrollah, Esmaeil

2016-01-01

Intensive care unit (ICU) patients are at risk of in-ICU morbidities and mortality, making specific systems for identifying at-risk patients a necessity for improving clinical care. This study presents a new method for predicting in-hospital mortality using heart rate variability (HRV) collected from the times of a patient's ICU stay. In this paper, a HRV time series processing based method is proposed for mortality prediction of ICU cardiovascular patients. HRV signals were obtained measuring R-R time intervals. A novel method, named return map, is then developed that reveals useful information from the HRV time series. This study also proposed several features that can be extracted from the return map, including the angle between two vectors, the area of triangles formed by successive points, shortest distance to 45° line and their various combinations. Finally, a thresholding technique is proposed to extract the risk period and to predict mortality. The data used to evaluate the proposed algorithm obtained from 80 cardiovascular ICU patients, from the first 48 h of the first ICU stay of 40 males and 40 females. This study showed that the angle feature has on average a sensitivity of 87.5% (with 12 false alarms), the area feature has on average a sensitivity of 89.58% (with 10 false alarms), the shortest distance feature has on average a sensitivity of 85.42% (with 14 false alarms) and, finally, the combined feature has on average a sensitivity of 92.71% (with seven false alarms). The results showed that the last half an hour before the patient's death is very informative for diagnosing the patient's condition and to save his/her life. These results confirm that it is possible to predict mortality based on the features introduced in this paper, relying on the variations of the HRV dynamic characteristics.

For patients with terminal chronic illness, does more face-to-face time with a healthcare provider decrease aggressive end-of-life (EOL) care such as ICU admission, feeding tube placement, CPR, or intubation?

PubMed Central

Seaberg, Preston; Hamm, Robert M.; McCarthy, Laine H.

2016-01-01

Clinical Question For patients with terminal chronic illness, does more face-to-face time with a healthcare provider decrease aggressive end-of-life (EOL) care such as ICU admission, feeding tube placement, CPR, or intubation? Answer Inconclusive. Existing evidence does not provide a conclusive answer to this particular question. While multiple prospective, randomized, controlled trials demonstrate an association between increased patient-provider contact time and decreased aggressive EOL care, interventions in those studies contain multiple confounding elements that preclude isolation of the time factor from the other elements in the interventions. There is a need for research focusing on physician-patient communication time and EOL care. Level of Evidence for the Answer A Search Terms Terminal care, palliative care, terminal illness, communication, patient-provider relations, time factors, life support care, resuscitation orders, enteral nutrition Inclusion Criteria Systematic reviews, meta-analyses, and comparative studies published between 2008 and the current date comparing EOL care or EOL care preferences of patients who spend more face-to-face time with a healthcare provider to those of patients who spend less face-to-face time with a healthcare provider. Exclusion Criteria Studies that do not report the primary outcome of interest (EOL care or EOL care preferences) or that do not measure discussion time or provide interventions that include face-to-face discussion. PMID:25796765

Winning the war against ICU-acquired weakness: new innovations in nutrition and exercise physiology.

PubMed

Wischmeyer, Paul E; San-Millan, Inigo

2015-01-01

Over the last 10 years we have significantly reduced hospital mortality from sepsis and critical illness. However, the evidence reveals that over the same period we have tripled the number of patients being sent to rehabilitation settings. Further, given that as many as half of the deaths in the first year following ICU admission occur post ICU discharge, it is unclear how many of these patients ever returned home. For those who do survive, the latest data indicate that 50-70% of ICU "survivors" will suffer cognitive impairment and 60-80% of "survivors" will suffer functional impairment or ICU-acquired weakness (ICU-AW). These observations demand that we as intensive care providers ask the following questions: "Are we creating survivors ... or are we creating victims?" and "Do we accomplish 'Pyrrhic Victories' in the ICU?" Interventions to address ICU-AW must have a renewed focus on optimal nutrition, anabolic/anticatabolic strategies, and in the future employ the personalized muscle and exercise evaluation techniques utilized by elite athletes to optimize performance. Specifically, strategies must include optimal protein delivery (1.2-2.0 g/kg/day), as an athlete would routinely employ. However, as is clear in elite sports performance, optimal nutrition is fundamental but alone is often not enough. We know burn patients can remain catabolic for 2 years post burn; thus, anticatabolic agents (i.e., beta-blockers) and anabolic agents (i.e., oxandrolone) will probably also be essential. In the near future, evaluation techniques such as assessing lean body mass at the bedside using ultrasound to determine nutritional status and ultrasound-measured muscle glycogen as a marker of muscle injury and recovery could be utilized to help find the transition from the acute phase of critical illness to the recovery phase. Finally, exercise physiology testing that evaluates muscle substrate utilization during exercise can be used to diagnose muscle mitochondrial dysfunction and

Evaluation of delivery of enteral nutrition in mechanically ventilated Malaysian ICU patients.

PubMed

Yip, Keng F; Rai, Vineya; Wong, Kang K

2014-01-01

There are numerous challenges in providing nutrition to the mechanically ventilated critically ill ICU patient. Understanding the level of nutritional support and the barriers to enteral feeding interruption in mechanically ventilated patients are important to maximise the nutritional benefits to the critically ill patients. Thus, this study aims to evaluate enteral nutrition delivery and identify the reasons for interruptions in mechanically ventilated Malaysian patients receiving enteral feeding. A cross sectional prospective study of 77 consecutive patients who required mechanical ventilation and were receiving enteral nutrition was done in an open 14-bed intensive care unit of a tertiary hospital. Data were collected prospectively over a 3 month period. Descriptive statistical analysis were made with respect to demographical data, time taken to initiate feeds, type of feeds, quantification of feeds attainment, and reasons for feed interruptions. There are no set feeding protocols in the ICU. The usual initial rate of enteral nutrition observed in ICU was 20 ml/hour, assessed every 6 hours and the decision was made thereafter to increase feeds. The target calorie for each patient was determined by the clinician alongside the dietitian. The use of prokinetic agents was also prescribed at the discretion of the attending clinician and is commonly IV metoclopramide 10 mg three times a day. About 66% of patients achieved 80% of caloric requirements within 3 days of which 46.8% achieved full feeds in less than 12 hours. The time to initiate feeds for patients admitted into the ICU ranged from 0 - 110 hours with a median time to start feeds of 15 hours and the interquartile range (IQR) of 6-59 hours. The mean time to achieve at least 80% of nutritional target was 1.8 days ± 1.5 days. About 79% of patients experienced multiple feeding interruptions. The most prevalent reason for interruption was for procedures (45.1%) followed by high gastric residual volume (38

A Longitudinal Investigation of Alcohol Use over the Course of the Year Following Medical-Surgical Intensive Care Unit Admission

PubMed Central

Davydow, Dimitry S.; Zatzick, Douglas; Hough, Catherine L.; Katon, Wayne J.

2013-01-01

Background There have been no studies describing post-intensive care unit (ICU) alcohol use among medical-surgical ICU survivors. Objective To examine alcohol use and identify potentially modifiable risk factors, such as in-hospital probable acute stress disorder, for increased alcohol use following medical-surgical ICU admission. Method This longitudinal investigation included 150 medical-surgical ICU survivors. In-hospital interviews obtained baseline characteristics including pre-ICU alcohol use with the Alcohol Use Disorders Identification Test (AUDIT) and in-hospital probable acute stress disorder with the Posttraumatic Stress Disorder Checklist-civilian version. Clinical factors were obtained from medical records. Post-ICU alcohol use was ascertained via telephone interviews at 3 and 12 months post-discharge using the AUDIT. Mixed-model linear regression was used to examine potential risk factors for increased post-ICU alcohol use. Results There was a significant decline in the mean AUDIT score from baseline (3.9, 95%Confidence Interval [95%CI]: 2.9, 5.0) to 3 months post-ICU (1.5, 95%CI: 1.0, 2.1) (P < 0.001 by one-way analysis of variance [ANOVA]), with a significant increase between 3 and 12 months post-ICU (2.7, 95%CI: 1.8, 3.5) (P < 0.001 by one-way ANOVA). After adjusting for patient and clinical factors, in-hospital probable acute stress disorder (beta: 3.0, 95%CI: 0.9, 5.0) and pre-ICU unhealthy alcohol use (beta: 5.4, 95%CI: 3.4, 7.4) were independently associated with increased post-ICU alcohol use. Conclusions Alcohol use decreases in the early aftermath of medical-surgical ICU admission and then increases significantly by one year post-ICU. Interventions for unhealthy alcohol use among medical-surgical ICU survivors that take into account comorbid psychiatric symptoms are needed. PMID:23414847

Plasma suPAR as a prognostic biological marker for ICU mortality in ARDS patients.

PubMed

Geboers, Diederik G P J; de Beer, Friso M; Tuip-de Boer, Anita M; van der Poll, Tom; Horn, Janneke; Cremer, Olaf L; Bonten, Marc J M; Ong, David S Y; Schultz, Marcus J; Bos, Lieuwe D J

2015-07-01

We investigated the prognostic value of plasma soluble urokinase plasminogen activator receptor (suPAR) on day 1 in patients with the acute respiratory distress syndrome (ARDS) for intensive care unit (ICU) mortality and compared it with established disease severity scores on day 1. suPAR was determined batchwise in plasma obtained within 24 h after admission. 632 ARDS patients were included. Significantly (P = 0.02) higher median levels of suPAR were found with increasing severity of ARDS: 5.9 ng/ml [IQR 3.1-12.8] in mild ARDS (n = 82), 8.4 ng/ml [IQR 4.1-15.0] in moderate ARDS (n = 333), and 9.0 ng/ml [IQR 4.5-16.0] in severe ARDS (n = 217). Non-survivors had higher median levels of suPAR [12.5 ng/ml (IQR 5.1-19.5) vs. 7.4 ng/ml (3.9-13.6), P < 0.001]. The area under the receiver operator characteristic curve (ROC-AUC) for mortality of suPAR (0.62) was lower than the ROC-AUC of the APACHE IV score (0.72, P = 0.007), higher than that of the ARDS definition classification (0.53, P = 0.005), and did not differ from that of the SOFA score (0.68, P = 0.07) and the oxygenation index (OI) (0.58, P = 0.29). Plasma suPAR did not improve the discrimination of the established disease severity scores, but did improve net reclassification of the APACHE score (29%), SOFA score (23%), OI (38%), and Berlin definition classification (39%). As a single biological marker, the prognostic value for death of plasma suPAR in ARDS patients is low. Plasma suPAR, however, improves the net reclassification, suggesting a potential role for suPAR in ICU mortality prediction models.

Comparison of European ICU patients in 2012 (ICON) versus 2002 (SOAP).

PubMed

Vincent, Jean-Louis; Lefrant, Jean-Yves; Kotfis, Katarzyna; Nanchal, Rahul; Martin-Loeches, Ignacio; Wittebole, Xavier; Sakka, Samir G; Pickkers, Peter; Moreno, Rui; Sakr, Yasser

2018-03-01

To evaluate differences in the characteristics and outcomes of intensive care unit (ICU) patients over time. We reviewed all epidemiological data, including comorbidities, types and severity of organ failure, interventions, lengths of stay and outcome, for patients from the Sepsis Occurrence in Acutely ill Patients (SOAP) study, an observational study conducted in European intensive care units in 2002, and the Intensive Care Over Nations (ICON) audit, a survey of intensive care unit patients conducted in 2012. We compared the 3147 patients from the SOAP study with the 4852 patients from the ICON audit admitted to intensive care units in the same countries as those in the SOAP study. The ICON patients were older (62.5 ± 17.0 vs. 60.6 ± 17.4 years) and had higher severity scores than the SOAP patients. The proportion of patients with sepsis at any time during the intensive care unit stay was slightly higher in the ICON study (31.9 vs. 29.6%, p = 0.03). In multilevel analysis, the adjusted odds of ICU mortality were significantly lower for ICON patients than for SOAP patients, particularly in patients with sepsis [OR 0.45 (0.35-0.59), p < 0.001]. Over the 10-year period between 2002 and 2012, the proportion of patients with sepsis admitted to European ICUs remained relatively stable, but the severity of disease increased. In multilevel analysis, the odds of ICU mortality were lower in our 2012 cohort compared to our 2002 cohort, particularly in patients with sepsis.

Efficacy of Intravenous Haloperidol on the duration of Delirium and Coma in Critically Ill Patients (Hope-ICU): a Randomised, Placebo-Controlled Trial

PubMed Central

Page, Valerie J; Ely, E Wesley; Gates, Simon; Zhao, Xiao Bei; Alce, Timothy; Shintani, Ayumi; Jackson, Jim; Perkins, Gavin D; McAuley, Daniel F

2016-01-01

Background Delirium is frequently diagnosed in critically ill patients and is associated with poor clinical outcomes. Haloperidol is the most commonly used drug for delirium despite little evidence of its effectiveness. The aim of this study was to establish whether early treatment with haloperidol would decrease the time that survivors of critical illness spent in delirium or in coma. Methods We did this double-blind, placebo-controlled randomised trial in a general adult intensive care unit (ICU). Critically ill patients (≥18 years) needing mechanical ventilation within 72 of admission were enrolled. Patients were randomised (by an independent nurse, in 1:1 ratio, with permuted block size of four and six, using a centralised, secure web-based randomisation service) to receive haloperidol 2·5mgs or 0·9% saline placebo intravenously every 8 h irrespective of coma or delirium status. Study drug was discontinued on ICU discharge, once delirium-free and coma-free for 2 consecutive days, or after a maximum of 14 days treatment, which ever came first. Delirium was assessed using the confusion assessment method - for the ICU (CAM-ICU). The primary outcome was delirium-free and coma-free days, defined as the number of days in the first 14 days after randomisation during which the patient was alive without delirium and not in coma from any cause. Patients who died within the 14-day study period were recorded as having 0 days free of delirium and coma. ICU clinical and research staff and patients were masked to treatment throughout the study. Analyses were by intention to treat. This trial is registered with the International Standard Randomised Controlled Trial Registry, number ISRCTN83567338. Findings 142 patients were randomised, 141 were included in the final analysis (71 haloperidol, 70 placebo). Patients in the haloperidol group spent about the same number of days alive, without delirium, and without coma as did patients in the placebo group (median 5 days [IQR 0

Tele-ICU "myth busters".

PubMed

Venditti, Angelo; Ronk, Chanda; Kopenhaver, Tracey; Fetterman, Susan

2012-01-01

Tele-intensive care unit (ICU) technology has been proven to bridge the gap between available resources and quality care for many health care systems across the country. Tele-ICUs allow the standardization of care and provide a second set of eyes traditionally not available in the ICU. A growing body of literature supports the use of tele-ICUs based on improved outcomes and reduction in errors. To date, the literature has not effectively outlined the limitations of this technology related to response to changes in patient care, interventions, and interaction with the care team. This information can potentially have a profound impact on service expectations. Some misconceptions about tele-ICU technology include the following: tele-ICU is "watching" 24 hours a day, 7 days a week; tele-ICU is a telemetry unit; tele-ICU is a stand-alone crisis intervention tool; tele-ICU decreases staffing at the bedside; tele-ICU clinical roles are clearly defined and understood; and tele-ICUs are not cost-effective to operate. This article outlines the purpose of tele-ICU technology, reviews outcomes, and "busts" myths about tele-ICU technology.

Acute Kidney Injury Enhances Outcome Prediction Ability of Sequential Organ Failure Assessment Score in Critically Ill Patients

PubMed Central

Chang, Chih-Hsiang; Fan, Pei-Chun; Chang, Ming-Yang; Tian, Ya-Chung; Hung, Cheng-Chieh; Fang, Ji-Tseng; Yang, Chih-Wei; Chen, Yung-Chang

2014-01-01

Introduction Acute kidney injury (AKI) is a common and serious complication in intensive care unit (ICU) patients and also often part of a multiple organ failure syndrome. The sequential organ failure assessment (SOFA) score is an excellent tool for assessing the extent of organ dysfunction in critically ill patients. This study aimed to evaluate the outcome prediction ability of SOFA and Acute Physiology and Chronic Health Evaluation (APACHE) III score in ICU patients with AKI. Methods A total of 543 critically ill patients were admitted to the medical ICU of a tertiary-care hospital from July 2007 to June 2008. Demographic, clinical and laboratory variables were prospectively recorded for post hoc analysis as predictors of survival on the first day of ICU admission. Results One hundred and eighty-seven (34.4%) patients presented with AKI on the first day of ICU admission based on the risk of renal failure, injury to kidney, failure of kidney function, loss of kidney function, and end-stage renal failure (RIFLE) classification. Major causes of the ICU admissions involved respiratory failure (58%). Overall in-ICU mortality was 37.9% and the hospital mortality was 44.7%. The predictive accuracy for ICU mortality of SOFA (areas under the receiver operating characteristic curves: 0.815±0.032) was as good as APACHE III in the AKI group. However, cumulative survival rates at 6-month follow-up following hospital discharge differed significantly (p<0.001) for SOFA score ≤10 vs. ≥11 in these ICU patients with AKI. Conclusions For patients coexisting with AKI admitted to ICU, this work recommends application of SOFA by physicians to assess ICU mortality because of its practicality and low cost. A SOFA score of ≥ “11” on ICU day 1 should be considered an indicator of negative short-term outcome. PMID:25279844

Validation of SAPS3 admission score and its customization for use in Korean intensive care unit patients: a prospective multicentre study.

PubMed

Lim, So Yeon; Koh, Shin Ok; Jeon, Kyeongman; Na, Sungwon; Lim, Chae-Man; Choi, Won-Il; Lee, Young-Joo; Kim, Seok Chan; Chon, Gyu Rak; Kim, Je Hyeong; Kim, Jae Yeol; Lim, Jaemin; Rhee, Chin Kook; Park, Sunghoon; Kim, Ho Cheol; Lee, Jin Hwa; Lee, Ji Hyun; Park, Jisook; Koh, Younsuck; Suh, Gee Young

2013-08-01

To externally validate the simplified acute physiology score 3 (SAPS3) and to customize it for use in Korean intensive care unit (ICU) patients. This is a prospective multicentre cohort study involving 22 ICUs from 15 centres throughout Korea. The study population comprised patients who were consecutively admitted to participating ICUs from 1 July 2010 to 31 January 2011. A total of 4617 patients were enrolled. ICU mortality was 14.3%, and hospital mortality was 20.6%. The patients were randomly assigned into one of two cohorts: a development (n = 2309) or validation (n = 2308) cohort. In the development cohort, the general SAPS3 had good discrimination (area under the receiver operating characteristics curve = 0.829), but poor calibration (Hosmer-Lemeshow goodness-of-fit test H = 123.06, P < 0.001, C = 118.45, P < 0.001). The Australasia SAPS3 did not improve calibration (H = 73.53, P < 0.001, C = 70.52, P < 0.001). Customization was achieved by altering the logit of the original SAPS3 equation. The new equation for Korean ICU patients was validated in the validation cohort, and demonstrated both good discrimination (area under the receiver operating characteristics curve = 0.835) and good calibration (H = 4.61, P = 0.799, C = 5.67, P = 0.684). General and regional Australasia SAPS3 admission scores showed poor calibration for use in Korean ICU patients, but the prognostic power of the SAPS3 was significantly improved by customization. Prediction models should be customized before being used to predict mortality in different regions of the world. © 2013 The Authors. Respirology © 2013 Asian Pacific Society of Respirology.

Innovative Designs for the Smart ICU.

PubMed

Halpern, Neil A

2014-03-01

Successfully designing a new ICU requires clarity of vision and purpose and the recognition that the patient room is the core of the ICU experience for patients, staff, and visitors. The ICU can be conceptualized into three components: the patient room, central areas, and universal support services. Each patient room should be designed for single patient use and be similarly configured and equipped. The design of the room should focus upon functionality, ease of use, healing, safety, infection control, communications, and connectivity. All aspects of the room, including its infrastructure; zones for work, care, and visiting; environment, medical devices, and approaches to privacy; logistics; and waste management, are important elements in the design process. Since most medical devices used at the ICU bedside are really sophisticated computers, the ICU needs to be capable of supporting the full scope of medical informatics. The patient rooms, the central ICU areas (central stations, corridors, supply rooms, pharmacy, laboratory, staff lounge, visitor waiting room, on-call suite, conference rooms, and offices), and the universal support services (infection prevention, finishings and flooring, staff communications, signage and wayfinding, security, and fire and safety) work best when fully interwoven. This coordination helps establish efficient and safe patient throughput and care and fosters physical and social cohesiveness within the ICU. A balanced approach to centralized and decentralized monitoring and logistics also offers great flexibility. Synchronization of the universal support services in the ICU with the hospital's existing systems maintains unity of purpose and continuity across the enterprise and avoids unnecessary duplication of efforts. Copyright © 2014 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France: A Randomized Clinical Trial.

PubMed

Guidet, Bertrand; Leblanc, Guillaume; Simon, Tabassome; Woimant, Maguy; Quenot, Jean-Pierre; Ganansia, Olivier; Maignan, Maxime; Yordanov, Youri; Delerme, Samuel; Doumenc, Benoit; Fartoukh, Muriel; Charestan, Pierre; Trognon, Pauline; Galichon, Bertrand; Javaud, Nicolas; Patzak, Anabela; Garrouste-Orgeas, Maïté; Thomas, Caroline; Azerad, Sylvie; Pateron, Dominique; Boumendil, Ariane

2017-10-17

The high mortality rate in critically ill elderly patients has led to questioning of the beneficial effect of intensive care unit (ICU) admission and to a variable ICU use among this population. To determine whether a recommendation for systematic ICU admission in critically ill elderly patients reduces 6-month mortality compared with usual practice. Multicenter, cluster-randomized clinical trial of 3037 critically ill patients aged 75 years or older, free of cancer, with preserved functional status (Index of Independence in Activities of Daily Living ≥4) and nutritional status (absence of cachexia) who arrived at the emergency department of one of 24 hospitals in France between January 2012 and April 2015 and were followed up until November 2015. Centers were randomly assigned either to use a program to promote systematic ICU admission of patients (n=1519 participants) or to follow standard practice (n=1518 participants). The primary outcome was death at 6 months. Secondary outcomes included ICU admission rate, in-hospital death, functional status, and quality of life (12-Item Short Form Health Survey, ranging from 0 to 100, with higher score representing better self-reported health) at 6 months. One patient withdrew consent, leaving 3036 patients included in the trial (median age, 85 [interquartile range, 81-89] years; 1361 [45%] men). Patients in the systematic strategy group had an increased risk of death at 6 months (45% vs 39%; relative risk [RR], 1.16; 95% CI, 1.07-1.26) despite an increased ICU admission rate (61% vs 34%; RR, 1.80; 95% CI, 1.66-1.95). After adjustments for baseline characteristics, patients in the systematic strategy group were more likely to be admitted to an ICU (RR, 1.68; 95% CI, 1.54-1.82) and had a higher risk of in-hospital death (RR, 1.18; 95% CI, 1.03-1.33) but had no significant increase in risk of death at 6 months (RR, 1.05; 95% CI, 0.96-1.14). Functional status and physical quality of life at 6 months were not significantly

Severity scores in trauma patients admitted to ICU. Physiological and anatomic models.

PubMed

Serviá, L; Badia, M; Montserrat, N; Trujillano, J

2018-02-02

The goals of this project were to compare both the anatomic and physiologic severity scores in trauma patients admitted to intensive care unit (ICU), and to elaborate mixed statistical models to improve the precision of the scores. A prospective study of cohorts. The combined medical/surgical ICU in a secondary university hospital. Seven hundred and eighty trauma patients admitted to ICU older than 16 years of age. Anatomic models (ISS and NISS) were compared and combined with physiological models (T-RTS, APACHE II [APII], and MPM II). The probability of death was calculated following the TRISS method. The discrimination was assessed using ROC curves (ABC [CI 95%]), and the calibration using the Hosmer-Lemeshoẃs H test. The mixed models were elaborated with the tree classification method type Chi Square Automatic Interaction Detection. A 14% global mortality was recorded. The physiological models presented the best discrimination values (APII of 0.87 [0.84-0.90]). All models were affected by bad calibration (P<.01). The best mixed model resulted from the combination of APII and ISS (0.88 [0.83-0.90]). This model was able to differentiate between a 7.5% mortality for elderly patients with pathological antecedents and a 25% mortality in patients presenting traumatic brain injury, from a pool of patients with APII values ranging from 10 to 17 and an ISS threshold of 22. The physiological models perform better than the anatomical models in traumatic patients admitted to the ICU. Patients with low scores in the physiological models require an anatomic analysis of the injuries to determine their severity. Copyright © 2017 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

Outcome and prognostic factors in critically ill patients with systemic lupus erythematosus: a retrospective study.

PubMed

Hsu, Chia-Lin; Chen, Kuan-Yu; Yeh, Pu-Sheng; Hsu, Yeong-Long; Chang, Hou-Tai; Shau, Wen-Yi; Yu, Chia-Li; Yang, Pan-Chyr

2005-06-01

Systemic lupus erythematosus (SLE) is an archetypal autoimmune disease, involving multiple organ systems with varying course and prognosis. However, there is a paucity of clinical data regarding prognostic factors in SLE patients admitted to the intensive care unit (ICU). From January 1992 to December 2000, all patients admitted to the ICU with a diagnosis of SLE were included. Patients were excluded if the diagnosis of SLE was established at or after ICU admission. A multivariate logistic regression model was applied using Acute Physiology and Chronic Health Evaluation II scores and variables that were at least moderately associated (P < 0.2) with survival in the univariate analysis. A total of 51 patients meeting the criteria were included. The mortality rate was 47%. The most common cause of admission was pneumonia with acute respiratory distress syndrome. Multivariate logistic regression analysis showed that intracranial haemorrhage occurring while the patient was in the ICU (relative risk = 18.68), complicating gastrointestinal bleeding (relative risk = 6.97) and concurrent septic shock (relative risk = 77.06) were associated with greater risk of dying, whereas causes of ICU admission and Acute Physiology and Chronic Health Evaluation II score were not significantly associated with death. The mortality rate in critically ill SLE patients was high. Gastrointestinal bleeding, intracranial haemorrhage and septic shock were significant prognostic factors in SLE patients admitted to the ICU.

Costs and expected gain in lifetime health from intensive care versus general ward care of 30,712 individual patients: a distribution-weighted cost-effectiveness analysis.

PubMed

Lindemark, Frode; Haaland, Øystein A; Kvåle, Reidar; Flaatten, Hans; Norheim, Ole F; Johansson, Kjell A

2017-08-21

Clinicians, hospital managers, policy makers, and researchers are concerned about high costs, increased demand, and variation in priorities in the intensive care unit (ICU). The objectives of this modelling study are to describe the extra costs and expected health gains associated with admission to the ICU versus the general ward for 30,712 patients and the variation in cost-effectiveness estimates among subgroups and individuals, and to perform a distribution-weighted economic evaluation incorporating extra weighting to patients with high severity of disease. We used a decision-analytic model that estimates the incremental cost per quality-adjusted life year (QALY) gained (ICER) from ICU admission compared with general ward care using Norwegian registry data from 2008 to 2010. We assigned increasing weights to health gains for those with higher severity of disease, defined as less expected lifetime health if not admitted. The study has inherent uncertainty of findings because a randomized clinical trial comparing patients admitted or rejected to the ICU has never been performed. Uncertainty is explored in probabilistic sensitivity analysis. The mean cost-effectiveness of ICU admission versus ward care was €11,600/QALY, with 1.6 QALYs gained and an incremental cost of €18,700 per patient. The probability (p) of cost-effectiveness was 95% at a threshold of €22,000/QALY. The mean ICER for medical admissions was €10,700/QALY (p = 97%), €12,300/QALY (p = 93%) for admissions after acute surgery, and €14,700/QALY (p = 84%) after planned surgery. For individualized ICERs, there was a 50% probability that ICU admission was cost-effective for 85% of the patients at a threshold of €64,000/QALY, leaving 15% of the admissions not cost-effective. In the distributional evaluation, 8% of all patients had distribution-weighted ICERs (higher weights to gains for more severe conditions) above €64,000/QALY. High-severity admissions gained the most, and were more

Endothelial Cell-Specific Molecule-1 in Critically Ill Patients With Hematologic Malignancy.

PubMed

Zafrani, Lara; Resche-Rigon, Matthieu; De Freitas Caires, Nathalie; Gaudet, Alexandre; Mathieu, Daniel; Parmentier-Decrucq, Erika; Lemiale, Virginie; Mokart, Djamel; Pène, Frédéric; Kouatchet, Achille; Mayaux, Julien; Vincent, François; N'yunga, Martine; Bruneel, Fabrice; Rabbat, Antoine; Lebert, Christine; Perez, Pierre; Meert, Anne-Pascale; Benoit, Dominique; Darmon, Michael; Azoulay, Elie

2018-03-01

To assess whether serum concentration of endothelial cell-specific molecule-1 (Endocan) at ICU admission is associated with the use of ICU resources and outcomes in critically ill hematology patients. Prospective multicenter cohort study. Seventeen ICUs in France and Belgium. Seven hundred forty-four consecutive critically ill hematology patients; 72 critically ill septic patients without hematologic malignancy; 276 healthy subjects. None. Median total endocan concentrations were 4.46 (2.7-7.8) ng/mL. Endocan concentrations were higher in patients who had received chemotherapy before ICU admission (4.7 [2.8-8.1] ng/mL vs. 3.7 [2.5-6.3] ng/mL [p = 0.002]). In patients with acute respiratory failure, endocan levels were increased in patients with drug-induced pulmonary toxicity compared with other etiologies (p = 0.038). Total endocan levels higher than 4.46 ng/mL were associated with a higher cumulative probability of renal replacement therapy requirement (p = 0.006), a higher requirement of mechanical ventilation (p = 0.01) and a higher requirement of vasopressors throughout ICU stay (p < 0.0001). By multivariate analysis, total endocan levels at admission were independently associated with ICU mortality (odds ratios, 1.39; 95% CI, 1.06-1.83; p = 0.018). The predictive value of endocan peptide fragments of 14 kDa in terms of mortality and life-sustaining therapies requirement was inferior to that of total endocan. Endocan levels were higher in critically ill hematology patients compared with healthy subjects (p < 0.0001) but lower than endocan values in critically ill septic patients without hematologic malignancy (p = 0.005) CONCLUSIONS:: Serum concentrations of endocan at admission are associated with the use of ICU resources and mortality in critically ill hematology patients. Studies to risk-stratify patients in the emergency department or in the hematology wards based on endocan concentrations to identify those likely to benefit from early ICU management

Evaluation of an integrated graphical display to promote acute change detection in ICU patients

PubMed Central

Anders, Shilo; Albert, Robert; Miller, Anne; Weinger, Matthew B.; Doig, Alexa K.; Behrens, Michael; Agutter, Jim

2012-01-01

Objective The purpose of this study was to evaluate ICU nurses’ ability to detect patient change using an integrated graphical information display (IGID) versus a conventional tabular ICU patient information display (i.e. electronic chart). Design Using participants from two different sites, we conducted a repeated measures simulator-based experiment to assess ICU nurses’ ability to detect abnormal patient variables using a novel IGID versus a conventional tabular information display. Patient scenarios and display presentations were fully counterbalanced. Measurements We measured percent correct detection of abnormal patient variables, nurses’ perceived workload (NASA-TLX), and display usability ratings. Results 32 ICU nurses (87% female, median age of 29 years, and median ICU experience of 2.5 years) using the IGID detected more abnormal variables compared to the tabular display [F (1,119)=13.0, p < 0.05]. There was a significant main effect of site [F (1, 119)=14.2], with development site participants doing better. There were no significant differences in nurses’ perceived workload. The IGID display was rated as more usable than the conventional display, [F (1, 60)=31.7]. Conclusion Overall, nurses reported more important physiological information with the novel IGID than tabular display. Moreover, the finding of site differences may reflect local influences in work practice and involvement in iterative display design methodology. Information displays developed using user-centered design should accommodate the full diversity of the intended user population across use sites. PMID:22534099

ICU telemedicine and critical care mortality: a national effectiveness study

PubMed Central

Kahn, Jeremy M; Le, Tri Q.; Barnato, Amber E.; Hravnak, Marilyn; Kuza, Courtney C.; Pike, Francis; Angus, Derek C.

2015-01-01

Background Intensive care unit (ICU) telemedicine is an increasingly common strategy for improving the outcome of critical care, but its overall impact is uncertain. Objectives To determine the effectiveness of ICU telemedicine in a national sample of hospitals and quantify variation in effectiveness across hospitals. Research design We performed a multi-center retrospective case-control study using 2001–2010 Medicare claims data linked to a national survey identifying United States hospitals adopting ICU telemedicine. We matched each adopting hospital (cases) to up to 3 non-adopting hospitals (controls) based on size, case-mix and geographic proximity during the year of adoption. Using ICU admissions from 2 years before and after the adoption date, we compared outcomes between case and control hospitals using a difference-in-differences approach. Results 132 adopting case hospitals were matched to 389 similar non-adopting control hospitals. The pre- and post-adoption unadjusted 90-day mortality was similar in both case hospitals (24.0% vs. 24.3%, p=0.07) and control hospitals (23.5% vs. 23.7%, p<0.01). In the difference-in-differences analysis, ICU telemedicine adoption was associated with a small relative reduction in 90-day mortality (ratio of odds ratios: 0.96, 95% CI = 0.95–0.98, p<0.001). However, there was wide variation in the ICU telemedicine effect across individual hospitals (median ratio of odds ratios: 1.01; interquartile range 0.85–1.12; range 0.45–2.54). Only 16 case hospitals (12.2%) experienced statistically significant mortality reductions post-adoption. Hospitals with a significant mortality reduction were more likely to have large annual admission volumes (p<0.001) and be located in urban areas (p=0.04) compared to other hospitals. Conclusions Although ICU telemedicine adoption resulted in a small relative overall mortality reduction, there was heterogeneity in effect across adopting hospitals, with large-volume urban hospitals

Case mix, outcome and activity for patients with severe acute kidney injury during the first 24 hours after admission to an adult, general critical care unit: application of predictive models from a secondary analysis of the ICNARC Case Mix Programme Database

PubMed Central

Kolhe, Nitin V; Stevens, Paul E; Crowe, Alex V; Lipkin, Graham W; Harrison, David A

2008-01-01

Introduction This study pools data from the UK Intensive Care National Audit and Research Center (ICNARC) Case Mix Programme (CMP) to evaluate the case mix, outcome and activity for 17,326 patients with severe acute kidney injury (AKI) occurring during the first 24 hours of admission to intensive care units (ICU). Methods Severe AKI admissions (defined as serum creatinine ≥300 μmol/l and/or urea ≥40 mmol/l during the first 24 hours) were extracted from the ICNARC CMP database of 276,326 admissions to UK ICUs from 1995 to 2004. Subgroups of oliguric and nonoliguric AKI were identified by daily urine output. Data on surgical status, survival and length of stay were also collected. Severity of illness scores and mortality prediction models were compared (UK Acute Physiology and Chronic Health Evaluation [APACHE] II, Stuivenberg Hospital Acute Renal Failure [SHARF] T0, SHARF II0 and the Mehta model). Results Severe AKI occurred in 17,326 out of 276,731 admissions (6.3%). The source of admission was nonsurgical in 83.7%. Sepsis was present in 47.3% and AKI was nonoliguric in 63.9% of cases. Admission to ICU with severe AKI accounted for 9.3% of all ICU bed-days. Oliguric AKI was associated with longer length of stay for survivors and shorter length of stay for nonsurvivors compared with nonoliguric AKI. Oliguric AKI was associated with significantly greater ICU and hospital mortality (55.8% and 77.3%, respectively) compared with nonoliguric AKI (33.4% and 49.3%, respectively). Surgery during the 1 week before admission or during the first week in the CMP unit was associated with decreased odds of mortality. UK APACHE II and the Mehta scores under-predicted the number of deaths, whereas SHARF T0 and SHARF II0 over-predicted the number of deaths. Conclusions Severe AKI accounts for over 9% of all bed-days in adult, general ICUs, representing a considerable drain on resources. Although nonoliguric AKI continues to confer a survival benefit, overall survival from AKI

Distributions and Behavior of Vital Signs in Critically Ill Children by Admission Diagnosis.

PubMed

Eytan, Danny; Goodwin, Andrew J; Greer, Robert; Guerguerian, Anne-Marie; Mazwi, Mjaye; Laussen, Peter C

2018-02-01

Define the distributions of heart rate and intraarterial blood pressure in children at admission to an ICU based on admission diagnosis and examine trends in these physiologic signs over 72 hours from admission (or to discharge if earlier). A retrospective analysis of continuously acquired signals. A quaternary and primary referral children's hospital with a general PICU and cardiac critical care unit. One thousand two hundred eighty-nine patients less than 18 years old were analyzed. Data from individual patient admissions were divided into 19 groups by primary admission diagnosis or surgical procedure. None. Distributions at admission are dependent on patient age and admission diagnosis (p < 10). Heart rate decreases over time, whereas arterial blood pressure is relatively stable, with differences seen in the directions and magnitude of these trends when analyzed by diagnosis group (p < 10). Multiple linear regression analysis shows that patient age, diagnosis group, and physiologic vital sign value at admission explain 50-63% of the variation observed for that physiologic signal at 72 hours (or at discharge if earlier) with admission value having the greatest influence. Furthermore, the variance of either heart rate or arterial blood pressure for the individual patient is smaller than the variance measured at the level of the group of patients with the same diagnosis. This is the first study reporting distributions of continuously measured physiologic variables and trends in their behavior according to admission diagnosis in critically ill children. Differences detected between and within diagnostic groups may aid in earlier recognition of outliers as well as allowing refinement of patient monitoring strategies.

Improving the Patient Experience by Implementing an ICU Diary for Those at Risk of Post-intensive Care Syndrome.

PubMed

Blair, K Taylor A; Eccleston, Sarah D; Binder, Hannah M; McCarthy, Mary S

2017-03-01

The critical care literature in the US has recently brought attention to the impact an ICU experience can have long after the patient survives critical illness, particularly if delirium was present. Current recommendations to mitigate post-intensive care syndrome (PICS) are embedded in patient and family-centered care and aim to promote family presence in the ICU, provide support for decision-making, and enhance communication with the health-care team. Evidence-based interventions are few in number but include use of an ICU diary to minimize the psychological and emotional sequelae affecting patients and family members in the months following the ICU stay. In this paper we describe our efforts to implement an ICU diary and solicit feedback on its role in fostering teamwork and communication between patients, family members, and ICU staff. Next steps will involve a PICS follow-up clinic where trained staff will coordinate specialty referrals and perform long-term monitoring of mental health and other quality of life outcomes.

The Integrative Weaning Index in Elderly ICU Subjects.

PubMed

Azeredo, Leandro M; Nemer, Sérgio N; Barbas, Carmen Sv; Caldeira, Jefferson B; Noé, Rosângela; Guimarães, Bruno L; Caldas, Célia P

2017-03-01

With increasing life expectancy and ICU admission of elderly patients, mechanical ventilation, and weaning trials have increased worldwide. We evaluated a cohort with 479 subjects in the ICU. Patients younger than 18 y, tracheostomized, or with neurologic diseases were excluded, resulting in 331 subjects. Subjects ≥70 y old were considered elderly, whereas those <70 y old were considered non-elderly. Besides the conventional weaning indexes, we evaluated the performance of the integrative weaning index (IWI). The probability of successful weaning was investigated using relative risk and logistic regression. The Hosmer-Lemeshow goodness-of-fit test was used to calibrate and the C statistic was calculated to evaluate the association between predicted probabilities and observed proportions in the logistic regression model. Prevalence of successful weaning in the sample was 83.7%. There was no difference in mortality between elderly and non-elderly subjects ( P = .16), in days of mechanical ventilation ( P = .22) and days of weaning ( P = .55). In elderly subjects, the IWI was the only respiratory variable associated with mechanical ventilation weaning in this population ( P < .001). The IWI was the independent variable found in weaning of elderly subjects that may contribute to the critical moment of this population in intensive care. Copyright © 2017 by Daedalus Enterprises.

Association of cumulative dose of haloperidol with next-day delirium in older medical ICU patients.

PubMed

Pisani, Margaret A; Araujo, Katy L B; Murphy, Terrence E

2015-05-01

To evaluate the association between cumulative dose of haloperidol and next-day diagnosis of delirium in a cohort of older medical ICU patients, with adjustment for its time-dependent confounding with fentanyl and intubation. Prospective, observational study. Medical ICU at an urban, academic medical center. Age 60 years and older admitted to the medical ICU who received at least one dose of haloperidol (n = 93). Of these, 72 patients were intubated at some point in their medical ICU stay, whereas 21 were never intubated. None. Detailed data were collected concerning time, dosage, route of administration of all medications, as well as for important clinical covariates, and daily status of intubation and delirium using the confusion assessment method for the ICU and a chart-based algorithm. Among nonintubated patients, and after adjustment for time-dependent confounding and important covariates, each additional cumulative milligram of haloperidol was associated with 5% higher odds of next-day delirium with odds ratio of 1.05 (credible interval [CI], 1.02-1.09). After adjustment for time-dependent confounding and covariates, intubation was associated with a five-fold increase in odds of next-day delirium with odds ratio of 5.66 (CI, 2.70-12.02). Cumulative dose of haloperidol among intubated patients did not change their already high likelihood of next-day delirium. After adjustment for time-dependent confounding, the positive associations between indicators of intubation and of cognitive impairment and next-day delirium became stronger. These results emphasize the need for more studies regarding the efficacy of haloperidol for treatment of delirium among older medical ICU patients and demonstrate the value of assessing nonintubated patients.

Patient and Family Engagement in the ICU: Untapped Opportunities and Under Recognized Challenges.

PubMed

Burns, Karen E A; Misak, Cheryl; Herridge, Margaret; Meade, Maureen O; Oczkowski, Simon

2018-04-06

The call for meaningful patient and family engagement in healthcare and research is gaining impetus. Healthcare institutions and research funding agencies increasingly encourage clinicians and researchers to work actively with patients and their families to advance clinical care and research. Engagement is increasingly mandated by healthcare organizations and is becoming a prerequisite for research funding. In this article, we review the rationale and the current state of patient and family engagement in patient care and research in the intensive care unit (ICU). We identify opportunities to strengthen engagement in patient care by promoting greater patient and family involvement in care delivery and supporting their participation in shared decision-making. We also identify challenges related to patient willingness to engage, barriers to participation, participant risks, and participant expectations. To advance engagement, clinicians and researchers can develop the science behind engagement in the ICU context and demonstrate its impact on patient and process-related outcomes. Additionally, we provide practical guidance on how to engage, highlight features of successful engagement strategies, and identify areas for future research. At present, enormous opportunities remain to enhance engagement across the continuum of ICU care and research.

Validation of the ICU-DaMa tool for automatically extracting variables for minimum dataset and quality indicators: The importance of data quality assessment.

PubMed

Sirgo, Gonzalo; Esteban, Federico; Gómez, Josep; Moreno, Gerard; Rodríguez, Alejandro; Blanch, Lluis; Guardiola, Juan José; Gracia, Rafael; De Haro, Lluis; Bodí, María

2018-04-01

Big data analytics promise insights into healthcare processes and management, improving outcomes while reducing costs. However, data quality is a major challenge for reliable results. Business process discovery techniques and an associated data model were used to develop data management tool, ICU-DaMa, for extracting variables essential for overseeing the quality of care in the intensive care unit (ICU). To determine the feasibility of using ICU-DaMa to automatically extract variables for the minimum dataset and ICU quality indicators from the clinical information system (CIS). The Wilcoxon signed-rank test and Fisher's exact test were used to compare the values extracted from the CIS with ICU-DaMa for 25 variables from all patients attended in a polyvalent ICU during a two-month period against the gold standard of values manually extracted by two trained physicians. Discrepancies with the gold standard were classified into plausibility, conformance, and completeness errors. Data from 149 patients were included. Although there were no significant differences between the automatic method and the manual method, we detected differences in values for five variables, including one plausibility error and two conformance and completeness errors. Plausibility: 1) Sex, ICU-DaMa incorrectly classified one male patient as female (error generated by the Hospital's Admissions Department). Conformance: 2) Reason for isolation, ICU-DaMa failed to detect a human error in which a professional misclassified a patient's isolation. 3) Brain death, ICU-DaMa failed to detect another human error in which a professional likely entered two mutually exclusive values related to the death of the patient (brain death and controlled donation after circulatory death). Completeness: 4) Destination at ICU discharge, ICU-DaMa incorrectly classified two patients due to a professional failing to fill out the patient discharge form when thepatients died. 5) Length of continuous renal replacement

Potential Influence of Advance Care Planning and Palliative Care Consultation on ICU Costs for Patients With Chronic and Serious Illness.

PubMed

Khandelwal, Nita; Benkeser, David C; Coe, Norma B; Curtis, J Randall

2016-08-01

To estimate the potential ICU-related cost savings if in-hospital advance care planning and ICU-based palliative care consultation became standard of care for patients with chronic and serious illness. Decision analysis using literature estimates and inpatient administrative data from Premier. Patients with chronic, life-limiting illness admitted to a hospital within the Premier network. None. Using Premier data (2008-2012), ICU resource utilization and costs were tracked over a 1-year time horizon for 2,097,563 patients with chronic life-limiting illness. Using a Markov microsimulation model, we explored the potential cost savings from the hospital system perspective under a variety of scenarios by varying the interventions' efficacies and availabilities. Of 2,097,563 patients, 657,825 (31%) used the ICU during the 1-year time horizon; mean ICU spending per patient was 11.3k (SD, 17.6k). In the base-case analysis, if in-hospital advance care planning and ICU-based palliative care consultation were systematically provided, we estimated a mean reduction in ICU costs of 2.8k (SD, 14.5k) per patient and an ICU cost saving of 25%. Among the simulated patients who used the ICU, the receipt of both interventions could have resulted in ICU cost savings of 1.9 billion, representing a 6% reduction in total hospital costs for these patients. In-hospital advance care planning and palliative care consultation have the potential to result in significant cost savings. Studies are needed to confirm these findings, but our results provide guidance for hospitals and policymakers.

Predictors of nursing workload in elderly patients admitted to intensive care units.

PubMed

Sousa, Cleber Ricardo de; Gonçalves, Leilane Andrade; Toffoleto, Maria Cecília; Leão, Karine; Padilha, Kátia Grillo

2008-01-01

The age of patients is a controversial issue in admission to intensive care unit (ICU). The aim of this study was to compare severity and nursing workload of elderly patients with 60-69, 70-79, and e"80 years of age and to identify predictors of nursing workload in elderly patients. A cross sectional study was performed with a sample of 71 elderly patients admitted to three ICU in the city of Sao Paulo, Brazil from October to November 2004. Data were prospectively collected using Nursing Activities Score (NAS) and Simplified Acute Physiology Score II (SAPS II). There was no significant difference in nursing workload among the elderly patients age subgroups (p=0.84). Multiple regression analysis indicated that the independent risk factors of high nursing workload were severity, age e"70 years, and to be a surgical ICU patient. Age as an isolated factor should not be discriminative for elderly patients admission to ICU.

Correlation between high blood IL-6 level, hyperglycemia, and glucose control in septic patients.

PubMed

Nakamura, Masataka; Oda, Shigeto; Sadahiro, Tomohito; Watanabe, Eizo; Abe, Ryuzo; Nakada, Taka-Aki; Morita, Yasumasa; Hirasawa, Hiroyuki

2012-12-12

The aim of the present study was to investigate the relationship between the blood IL-6 level, the blood glucose level, and glucose control in septic patients. This retrospective observational study in a general ICU of a university hospital included a total of 153 patients with sepsis, severe sepsis, or septic shock who were admitted to the ICU between 2005 and 2010, stayed in the ICU for 7 days or longer, and did not receive steroid therapy prior to or after ICU admission. The severity of stress hyperglycemia, status of glucose control, and correlation between those two factors in these patients were investigated using the blood IL-6 level as an index of hypercytokinemia. A significant positive correlation between blood IL-6 level and blood glucose level on ICU admission was observed in the overall study population (n = 153; r = 0.24, P = 0.01), and was stronger in the nondiabetic subgroup (n = 112; r = 0.42, P < 0.01). The rate of successful glucose control (blood glucose level < 150 mg/dl maintained for 6 days or longer) decreased with increase in blood IL-6 level on ICU admission (P < 0.01). The blood IL-6 level after ICU admission remained significantly higher and the 60-day survival rate was significantly lower in the failed glucose control group than in the successful glucose control group (P < 0.01 and P < 0.01, respectively). High blood IL-6 level was correlated with hyperglycemia and with difficulties in glucose control in septic patients. These results suggest the possibility that hypercytokinemia might be involved in the development of hyperglycemia in sepsis, and thereby might affect the success of glucose control.

Case mix, outcome and activity for patients admitted to intensive care units requiring chronic renal dialysis: a secondary analysis of the ICNARC Case Mix Programme Database

PubMed Central

Hutchison, Colin A; Crowe, Alex V; Stevens, Paul E; Harrison, David A; Lipkin, Graham W

2007-01-01

Introduction This report describes the case mix, outcome and activity for admissions to intensive care units (ICUs) of patients who require prior chronic renal dialysis for end-stage renal failure (ESRF), and investigates the effect of case mix factors on outcome. Methods This was a secondary analysis of a high-quality clinical database, namely the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme Database, which includes 276,731 admissions to 170 adult ICUs across England, Wales and Northern Ireland from 1995 to 2004. Results During the eight year study period, 1.3% (n = 3,420) of all patients admitted to ICU were receiving chronic renal dialysis before ICU admission. This represents an estimated ICU utilization of six admissions (32 bed-days) per 100 dialysis patient-years. The ESRF group was younger (mean age 57.3 years versus 59.5 years) and more likely to be male (60.2% versus 57.9%) than those without ESRF. Acute Physiology and Chronic Health Evaluation II score and Acute Physiology Score revealed greater severity of illness on admission in patients with ESRF (mean 24.7 versus 16.6 and 17.2 versus 12.6, respectively). Length of stay in ICU was comparable between groups (median 1.9 days versus 1.8 days) and ICU mortality was only slightly elevated in the ESRF group (26.3% versus 20.8%). However, the ESRF group had protracted overall hospital stay (median 25 days versus 17 days), and increased hospital mortality (45.3% versus 31.2%) and ICU readmission (9.0% vs. 4.7%). Multiple logistic regression analysis adjusted for case mix identified the increased hospital mortality to be associated with increasing age, emergency surgery and nonsurgical cases, cardiopulmonary resuscitation before ICU admission and extremes of physiological norms. The adjusted odds ratio for ultimate hospital mortality associated with chronic renal dialysis was 1.24 (95% confidence interval 1.13 to 1.37). Conclusion Patients with ESRF admitted to UK ICUs are more

[Mortality of hematology-oncology patients with neutropenia in intensivecare].

PubMed

Suárez, I; Böll, B; Shimabukuro-Vornhagen, A; Michels, G; von Bergwelt-Baildon, M; Kochanek, M

2016-03-01

Febrile neutropenia remains one of the most common reasons for hospital admission of patients with underlying oncologic disease. These patients have an up to 10-fold increased risk of developing sepsis, which often leads to these patients being transferred to the intensive care unit (ICU). The survival of neutropenic patients with sepsis in particular has improved in recent years, due to advanced therapy in intensive care (surviving sepsis campaign); however few large international studies of neutropenic cancer patients in the ICU are available. In a retrospective study, 59 episodes of neutropenic cancer patients in the internal medicine ICU at the University Hospital of Cologne over a period of 2 years were analyzed. Pneumonia with or without sepsis are the main admission diagnoses of neutropenic cancer patients in the ICU. The mortality rate of these patients is very high (50.8 %). Pneumonia and sepsis, stem cell transplantation, mechanical ventilation, and acute renal failure with or without dialysis are correlated with mortality. Cancer patients should be admitted immediately to the ICU if they have signs of sepsis for early monitoring and treatment. Neutropenic patients have an increased risk for infectious complications and a risk for sepsis with higher mortality rates.

Views regarding the training of ethics consultants: a survey of physicians caring for patients in ICU

PubMed Central

Chwang, Eric; Landy, David C; Sharp, Richard R

2007-01-01

Background Despite the expansion of ethics consultation services, questions remain about the aims of clinical ethics consultation, its methods and the expertise of those who provide such services. Objective To describe physicians' expectations regarding the training and skills necessary for ethics consultants to contribute effectively to the care of patients in intensive care unit (ICU). Design Mailed survey. Participants Physicians responsible for the care of at least 10 patients in ICU over a 6‐month period at a 921‐bed private teaching hospital with an established ethics consultation service. 69 of 92 (75%) eligible physicians responded. Measurements Importance of specialised knowledge and skills for ethics consultants contributing to the care of patients in ICU; need for advanced disciplinary training; expectations regarding formal‐training programmes for ethics consultants. Results Expertise in ethics was described most often as important for ethics consultants taking part in the care of patients in ICU, compared with expertise in law (p<0.03), religious traditions (p<0.001), medicine (p<0.001) and conflict‐mediation techniques (p<0.001). When asked about the formal training consultants should possess, however, physicians involved in the care of patients in ICU most often identified advanced medical training as important. Conclusions Although many physicians caring for patients in ICU believe ethics consultants must possess non‐medical expertise in ethics and law if they are to contribute effectively to patient care, these physicians place a very high value on medical training as well, suggesting a “medicine plus one” view of the training of an ideal ethics consultant. As ethics consultation services expand, clear expectations regarding the training of ethics consultants should be established. PMID:17526680

Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial.

PubMed

Page, Valerie J; Ely, E Wesley; Gates, Simon; Zhao, Xiao Bei; Alce, Timothy; Shintani, Ayumi; Jackson, Jim; Perkins, Gavin D; McAuley, Daniel F

2013-09-01

Delirium is frequently diagnosed in critically ill patients and is associated with poor clinical outcomes. Haloperidol is the most commonly used drug for delirium despite little evidence of its effectiveness. The aim of this study was to establish whether early treatment with haloperidol would decrease the time that survivors of critical illness spent in delirium or coma. We did this double-blind, placebo-controlled randomised trial in a general adult intensive care unit (ICU). Critically ill patients (≥18 years) needing mechanical ventilation within 72 h of admission were enrolled. Patients were randomised (by an independent nurse, in 1:1 ratio, with permuted block size of four and six, using a centralised, secure web-based randomisation service) to receive haloperidol 2.5 mg or 0.9% saline placebo intravenously every 8 h, irrespective of coma or delirium status. Study drug was discontinued on ICU discharge, once delirium-free and coma-free for 2 consecutive days, or after a maximum of 14 days of treatment, whichever came first. Delirium was assessed using the confusion assessment method for the ICU (CAM-ICU). The primary outcome was delirium-free and coma-free days, defined as the number of days in the first 14 days after randomisation during which the patient was alive without delirium and not in coma from any cause. Patients who died within the 14 day study period were recorded as having 0 days free of delirium and coma. ICU clinical and research staff and patients were masked to treatment throughout the study. Analyses were by intention to treat. This trial is registered with the International Standard Randomised Controlled Trial Registry, number ISRCTN83567338. 142 patients were randomised, 141 were included in the final analysis (71 haloperidol, 70 placebo). Patients in the haloperidol group spent about the same number of days alive, without delirium, and without coma as did patients in the placebo group (median 5 days [IQR 0-10] vs 6 days [0-11] days; p=0

Augmented renal clearance in the ICU: results of a multicenter observational study of renal function in critically ill patients with normal plasma creatinine concentrations*.

PubMed

Udy, Andrew A; Baptista, João P; Lim, Noelle L; Joynt, Gavin M; Jarrett, Paul; Wockner, Leesa; Boots, Robert J; Lipman, Jeffrey

2014-03-01

To describe the prevalence and natural history of augmented renal clearance in a cohort of recently admitted critically ill patients with normal plasma creatinine concentrations. Multicenter, prospective, observational study. Four, tertiary-level, university-affiliated, ICUs in Australia, Singapore, Hong Kong, and Portugal. Study participants had to have an expected ICU length of stay more than 24 hours, no evidence of absolute renal impairment (admission plasma creatinine < 120 µmol/L), and no history of prior renal replacement therapy or chronic kidney disease. Convenience sampling was used at each participating site. Eight-hour urinary creatinine clearances were collected daily, as the primary method of measuring renal function. Augmented renal clearance was defined by a creatinine clearance more than or equal to 130 mL/min/1.73 m. Additional demographic, physiological, therapeutic, and outcome data were recorded prospectively. Nine hundred thirty-two patients were admitted to the participating ICUs over the study period, and 281 of which were recruited into the study, contributing 1,660 individual creatinine clearance measures. The mean age (95% CI) was 54.4 years (52.5-56.4 yr), Acute Physiology and Chronic Health Evaluation II score was 16 (15.2-16.7), and ICU mortality was 8.5%. Overall, 65.1% manifested augmented renal clearance on at least one occasion during the first seven study days; the majority (74%) of whom did so on more than or equal to 50% of their creatinine clearance measures. Using a mixed-effects model, the presence of augmented renal clearance on study day 1 strongly predicted (p = 0.019) sustained elevation of creatinine clearance in these patients over the first week in ICU. Augmented renal clearance appears to be a common finding in this patient group, with sustained elevation of creatinine clearance throughout the first week in ICU. Future studies should focus on the implications for accurate dosing of renally eliminated pharmaceuticals

Accuracy of height estimation and tidal volume setting using anthropometric formulas in an ICU Caucasian population.

PubMed

L'her, Erwan; Martin-Babau, Jérôme; Lellouche, François

2016-12-01

Knowledge of patients' height is essential for daily practice in the intensive care unit. However, actual height measurements are unavailable on a daily routine in the ICU and measured height in the supine position and/or visual estimates may lack consistency. Clinicians do need simple and rapid methods to estimate the patients' height, especially in short height and/or obese patients. The objectives of the study were to evaluate several anthropometric formulas for height estimation on healthy volunteers and to test whether several of these estimates will help tidal volume setting in ICU patients. This was a prospective, observational study in a medical intensive care unit of a university hospital. During the first phase of the study, eight limb measurements were performed on 60 healthy volunteers and 18 height estimation formulas were tested. During the second phase, four height estimates were performed on 60 consecutive ICU patients under mechanical ventilation. In the 60 healthy volunteers, actual height was well correlated with the gold standard, measured height in the erect position. Correlation was low between actual and calculated height, using the hand's length and width, the index, or the foot equations. The Chumlea method and its simplified version, performed in the supine position, provided adequate estimates. In the 60 ICU patients, calculated height using the simplified Chumlea method was well correlated with measured height (r = 0.78; ∂ < 1 %). Ulna and tibia estimates also provided valuable estimates. All these height estimates allowed calculating IBW or PBW that were significantly different from the patients' actual weight on admission. In most cases, tidal volume set according to these estimates was lower than what would have been set using the actual weight. When actual height is unavailable in ICU patients undergoing mechanical ventilation, alternative anthropometric methods to obtain patient's height based on lower leg and on forearm

Prevalence of iron deficiency on ICU discharge and its relation with fatigue: a multicenter prospective study.

PubMed

Lasocki, Sigismond; Chudeau, Nicolas; Papet, Thibaut; Tartiere, Deborah; Roquilly, Antoine; Carlier, Laurence; Mimoz, Olivier; Seguin, Philippe; Malledant, Yannick; Asehnoune, Karim; Hamel, Jean François

2014-09-30

Prevalence of iron deficiency (ID) at intensive care (ICU) admission is around 25 to 40%. Blood losses are important during ICU stay, leading to iron losses, but prevalence of ID at ICU discharge is unknown. ID has been associated with fatigue and muscular weakness, and may thus impair post-ICU rehabilitation. This study assessed ID prevalence at ICU discharge, day 28 (D28) and six months (M6) after and its relation with fatigue. We conducted this prospective, multicenter observational study at four University hospitals ICUs. Anemic (hemoglobin (Hb) less than 13 g/dL in male and less than 12 g/dL in female) critically ill adult patients hospitalized for at least five days had an iron profile taken at discharge, D28 and M6. ID was defined as ferritin less than 100 ng/L or less than 300 ng/L together with a transferrin saturation less than 20%. Fatigue was assessed by numerical scale and the Multidimensional Fatigue Inventory-20 questionnaire at D28 and M6 and muscular weakness by a hand grip test at ICU discharge. Among 107 patients (men 77%, median (IQR) age 63 (48 to 73) years) who had a complete iron profile at ICU discharge, 9 (8.4%) had ID. At ICU discharge, their hemoglobin concentration (9.5 (87.7 to 10.3) versus 10.2 (92.2 to 11.7) g/dL, P =0.09), hand grip strength (52.5 (30 to 65) versus 49.5 (15.5 to 67.7)% of normal value, P =0.61) and visual analog scale fatigue scale (57 (40 to 80) versus 60 (47.5 to 80)/100, P =0.82) were not different from non-ID patients. At D28 (n =80 patients) and M6 (n =78 patients), ID prevalence increased (to 25 and 35% respectively) while anemia prevalence decreased (from 100% to 80 and 25% respectively, P <0.0001). ID was associated with increased fatigue at D28, after adjustment for main confounding factors, including anemia (regression coefficient (95%CI), 3.19 (0.74 to 5.64), P =0.012). At M6, this association disappeared. The prevalence of ID increases from 8% at discharge to 35% six months after prolonged ICU stay (more

Outcome scoring systems for short-term prognosis in critically ill cirrhotic patients.

PubMed

Tu, Kun-Hua; Jenq, Chang-Chyi; Tsai, Ming-Hung; Hsu, Hsiang-Hao; Chang, Ming-Yang; Tian, Ya-Chung; Hung, Cheng-Chieh; Fang, Ji-Tseng; Yang, Chih-Wei; Chen, Yung-Chang

2011-11-01

Cirrhotic patients admitted to intensive care units (ICUs) have high mortality rates. This study evaluated specific predictors and scoring systems for hospital and 6-month mortality in critically ill cirrhotic patients. This investigation is a prospective clinical study performed in a 10-bed specialized hepatogastroenterology ICU in a tertiary care university hospital in Taiwan. Two hundred two consecutive cirrhotic patients admitted to the ICU during a 2-year period were enrolled in this study. Demographic, clinical, and laboratory variables recorded on the first day of ICU admission and scoring systems applied were prospectively recorded for post hoc analysis for predicting survival. The overall hospital mortality was 59.9%, and the 6-month mortality rate was 70.8%. The main causes of cirrhosis were hepatitis B (29%), hepatitis C (22%), and alcoholism (20%). The major cause of ICU admission was upper gastrointestinal bleeding (36%). Multiple logistic regression analysis revealed that the Acute Kidney Injury Network (AKIN) score at the 48th hour of ICU admission and the Sequential Organ Failure Assessment (SOFA) as well as the Model for End-Stage Liver Disease scores on the first day of ICU admission were independent risk factors for hospital mortality. The SOFA score had the best discriminatory power (0.872 ± 0.036), whereas the AKIN had the best Youden index (0.57) and the highest correctness of prediction (79%). Cumulative survival rates at the 6-month follow-up after hospital discharge differed significantly (P < 0.05) for AKIN stage 0 vs. stages 1, 2, and 3, and for AKIN stage 1 vs. stage 3. The AKIN, SOFA, and Model for End-stage Liver Disease (MELD) scores showed well discriminative power in predicting hospital mortality in this group of patients. The AKIN scoring system proved to be a reproducible evaluation tool with excellent prognostic abilities for these patients.

Clinical features and outcomes in patients with disseminated toxoplasmosis admitted to intensive care: a multicenter study.

PubMed

Schmidt, Matthieu; Sonneville, Romain; Schnell, David; Bigé, Naike; Hamidfar, Rebecca; Mongardon, Nicolas; Castelain, Vincent; Razazi, Keyvan; Marty, Antoine; Vincent, François; Dres, Martin; Gaudry, Stephane; Luyt, Charles Edouard; Das, Vincent; Micol, Jean-Baptiste; Demoule, Alexandre; Mayaux, Julien

2013-12-01

Characteristics and outcomes of adult patients with disseminated toxoplasmosis admitted to the intensive care unit (ICU) have rarely been described. We performed a retrospective study on consecutive adult patients with disseminated toxoplasmosis who were admitted from January 2002 through December 2012 to the ICUs of 14 university-affiliated hospitals in France. Disseminated toxoplasmosis was defined as microbiological or histological evidence of disease affecting >1 organ in immunosuppressed patients. Isolated cases of cerebral toxoplasmosis were excluded. Clinical data on admission and risk factors for 60-day mortality were collected. Thirty-eight patients were identified during the study period. Twenty-two (58%) had received an allogeneic hematopoietic stem cell transplant (median, 61 [interquartile range {IQR}, 43-175] days before ICU admission), 4 (10%) were solid organ transplant recipients, and 10 (27%) were infected with human immunodeficiency virus (median CD4 cell count, 14 [IQR, 6-33] cells/µL). The main indications for ICU admission were acute respiratory failure (89%) and shock (53%). The 60-day mortality rate was 82%. Allogeneic hematopoietic stem cell transplant (hazard ratio [HR] = 2.28; 95% confidence interval [CI], 1.05-5.35; P = .04) and systolic cardiac dysfunction (HR = 3.54; 95% CI, 1.60-8.10; P < .01) within 48 hours of ICU admission were associated with mortality. Severe disseminated toxoplasmosis leading to ICU admission has a poor prognosis. Recipients of allogeneic hematopoietic stem cell transplant appear to have the highest risk of mortality. We identified systolic cardiac dysfunction as a major determinant of outcome. Strategies aimed at preventing this fatal opportunistic infection may improve outcomes.

ICU-treated influenza A(H1N1) pdm09 infections more severe post pandemic than during 2009 pandemic: a retrospective analysis.

PubMed

Ylipalosaari, Pekka; Ala-Kokko, Tero I; Laurila, Jouko; Ahvenjärvi, Lauri; Syrjälä, Hannu

2017-11-21

We compared in a single mixed intensive care unit (ICU) patients with influenza A(H1N1) pdm09 between pandemic and postpandemic periods. Retrospective analysis of prospectively collected data in 2009-2016. Data are expressed as median (25th-75th percentile) or number (percentile). Seventy-six influenza A(H1N1) pdm09 patients were admitted to the ICU: 16 during the pandemic period and 60 during the postpandemic period. Postpandemic patients were significantly older (60 years vs. 43 years, p < 0.001) and less likely to have epilepsy or other neurological diseases compared with pandemic patients (5 [8.3%] vs. 6 [38%], respectively; p = 0.009). Postpandemic patients were more likely than pandemic patients to have cardiovascular disease (24 [40%] vs. 1 [6%], respectively; p = 0.015), and they had higher scores on APACHE II (17 [13-22] vs. 14 [10-17], p = 0.002) and SAPS II (40 [31-51] vs. 31 [25-35], p = 0.002) upon admission to the ICU. Postpandemic patients had higher maximal SOFA score (9 [5-12] vs. 5 [4-9], respectively; p = 0.03) during their ICU stay. Postpandemic patients had more often septic shock (40 [66.7%] vs. 8 [50.0%], p = 0.042), and longer median hospital stays (15.0 vs. 8.0 days, respectively; p = 0.006). During 2015-2016, only 18% of the ICU- treated patients had received seasonal influenza vaccination. Postpandemic ICU-treated A(H1N1) pdm09 influenza patients were older and developed more often septic shock and had longer hospital stays than influenza patients during the 2009 pandemic.

Alkalosis in Critically Ill Patients with Severe Sepsis and Septic Shock

PubMed Central

Jazrawi, Allan; Miller, Jan; Baigi, Amir; Chew, Michelle

2017-01-01

Introduction Although metabolic alkalosis is a common occurrence in intensive care units (ICUs), no study has evaluated its prevalence or outcomes in patients with severe sepsis or septic shock. Methods This is a retrospective cohort study of critically ill patients suffering from severe sepsis and septic shock admitted to the ICUs of Halmstad and Varberg County hospitals. From 910 patient records, 627 patients met the inclusion criteria. We investigated the relationship between metabolic alkalosis and mortality. Further, we studied the relationship between metabolic alkalosis and ICU length of stay (LOS). Results Metabolic alkalosis was associated with decreased 30-day and 12-month mortalities. This effect was however lost when a multivariate analysis was conducted, correcting for age, gender, pH on admission, base excess (BE) on admission, Simplified Acute Physiology Score III (SAPS III) and acute kidney injury (AKI). We then analyzed for any dose-response effect between the severity of metabolic alkalosis and mortality and found no relationship. Bivariate analysis showed that metabolic alkalosis had a significant effect on the length of ICU stay. When adjusting for age, sex, pH at admission, BE at admission, SAPS III and AKI in a multivariate analysis, metabolic alkalosis significantly contributed to prolonged ICU length of stay. In two separate sensitivity analyses pure metabolic alkalosis and late metabolic alkalosis (time of onset >48 hours) were the only significant predictor of increased ICU length of stay. Conclusion Metabolic alkalosis did not have any effect on 30-day and 12-month mortalities after adjusting for age, sex, SAPS III-score, pH and BE on admission and AKI in a multivariate analysis. The presence of metabolic alkalosis was independently associated with an increased ICU length of stay. PMID:28045915

Risk Factors for Colonization With Multidrug-Resistant Bacteria Among Patients Admitted to the Intensive Care Unit After Returning From Abroad.

PubMed

Angue, Marion; Allou, Nicolas; Belmonte, Olivier; Lefort, Yannick; Lugagne, Nathalie; Vandroux, David; Montravers, Philippe; Allyn, Jérôme

2015-01-01

Few national recommendations exist on management of patients returning from abroad and all focus on hospitalized patients. Our purpose was to compare, in an intensive care unit (ICU), the admission prevalence and acquisition of multidrug-resistant (MDR) bacteria carriage in patients with ("Abroad") or without ("Local") a recent stay abroad, and then identify the risk factors in "Abroad" patients. In this retrospective study, we reviewed charts of all the patients hospitalized in the ICU unit from January 2011 through July 2013 with hygiene samplings performed. We identified all patients who had stayed abroad ("Abroad") within 6 months prior to ICU admission. Of 1,842 ICU patients, 129 (7%) "Abroad" patients were reported. In the "Abroad" group, the rate of MDR strain carriage was higher at admission (33% vs 6.7%, p < 0.001) and also more often diagnosed during the ICU stay (acquisition rate: 17% vs 5.2%, p < 0.001) than in "Local" patients. Risk factors associated with MDR bacteria carriage at admission in "Abroad" patients were diabetes mellitus [odds ratio (OR) 5.1 (1.7-14.8), p = 0.003] and "hospitalization abroad with antibiotic treatment" [OR 10.7 (4.2-27.3), p < 0.001]. Hospitalization abroad without antibiotic treatment was not identified as a risk factor. The main factor associated with MDR bacteria carriage after a stay abroad seems to be a hospitalization abroad only in case of antibiotic treatment abroad. Screening and isolation of "Abroad" patients should be recommended, even in case of a first negative screening. © 2015 International Society of Travel Medicine.

The injury severity score or the new injury severity score for predicting mortality, intensive care unit admission and length of hospital stay: experience from a university hospital in a developing country.

PubMed

Tamim, Hala; Al Hazzouri, Adina Zeki; Mahfoud, Ziad; Atoui, Maria; El-Chemaly, Souheil

2008-01-01

Limited research has been performed to compare the predictive abilities of the injury severity score (ISS) and the new ISS (NISS) in the developing world. From January 2001 until January 2003 all trauma patients admitted to the American University of Beirut Medical Centre were enrolled. The statistical performance of the ISS/NISS in predicting mortality, admission to the intensive care unit (ICU) and length of hospital stay (LOS dichotomised as <10 or > or =10 days) was evaluated using receiver operating characteristic and the Hosmer-Lemeshow calibration statistic. A total of 891 consecutive patients were enrolled. The ISS and NISS were equivalent in predicting survival, and both performed better in patients younger than 65 years of age. However, the ISS predicted ICU admission and LOS better than the NISS. However, these predictive abilities were lower for the geriatric trauma patients aged 65 years and above compared to the other age groups. There are conflicting results in the literature about the abilities of ISS and NISS to predict mortality. However, this is the first study to report that ISS has a superior ability in predicting both LOS and ICU admission. The scoring of trauma severity may need to be individualised to different countries and trauma systems.

Pitfalls in gastrointestinal permeability measurement in ICU patients with multiple organ failure using differential sugar absorption.

PubMed

Oudemans-van Straaten, Heleen M; van der Voort, Peter J; Hoek, Frans J; Bosman, Rob J; van der Spoel, Johan I; Zandstra, Durk F

2002-02-01

To assess whether gastrointestinal permeability (GIP) at intensive care unit (ICU) admission, measured by differential sugar absorption, is related to severity of disease and multiple organ failure (MOF). Post hoc, to analyse the relation between the urinary sugar recovery and renal function. Prospective observational cohort study. Eighteen-bed general ICU of a teaching hospital. Sixty-four ventilated patients admitted with MOF. GIP was assessed within 24 h using cellobiose (C), sucrose (S) and mannitol (M) absorption. Severity of disease: APACHE II and III, SAPS II and MPM II systems. Organ failure: SOFA, MODS and Goris score. The median urinary recovery of C was 0.147% (range 0.004-2.145%), of S 0.249% (0.001-3.656%) and of M 10.7% (0.6-270%). In 16 patients, M recovery was over 100% of the oral dose. They received red blood cell transfusion (RBC). In the non-transfused, the median cellobiose/mannitol (CM) ratio was 0.015 (0.0004-0.550). CM ratio was not related to severity of disease and inversely related to the SOFA score ( r=-0.30, p=0.04). Post hoc regression analysis showed that recoveries of C, S and M were positively related to urinary volume. Recoveries of C and S, but not of M, were positively related to creatinine clearance. The CM ratio corrected for diuresis, but was inversely related to creatinine clearance. Differential C, S and M absorption testing is unreliable after RBC transfusion, since bank blood contains mannitol. The excretion of C and S, but not of M, is limited by renal dysfunction. Differential sugar absorption is not reliable to test GIP in MOF patients, since non-permeability related factors act as confounders.

A Conceptual Framework for Improving Critical Care Patient Flow and Bed Use.

PubMed

Mathews, Kusum S; Long, Elisa F

2015-06-01

High demand for intensive care unit (ICU) services and limited bed availability have prompted hospitals to address capacity planning challenges. Simulation modeling can examine ICU bed assignment policies, accounting for patient acuity, to reduce ICU admission delays. To provide a framework for data-driven modeling of ICU patient flow, identify key measurable outcomes, and present illustrative analysis demonstrating the impact of various bed allocation scenarios on outcomes. A description of key inputs for constructing a queuing model was outlined, and an illustrative simulation model was developed to reflect current triage protocol within the medical ICU and step-down unit (SDU) at a single tertiary-care hospital. Patient acuity, arrival rate, and unit length of stay, consisting of a "service time" and "time to transfer," were estimated from 12 months of retrospective data (n = 2,710 adult patients) for 36 ICU and 15 SDU staffed beds. Patient priority was based on acuity and whether the patient originated in the emergency department. The model simulated the following hypothetical scenarios: (1) varied ICU/SDU sizes, (2) reserved ICU beds as a triage strategy, (3) lower targets for time to transfer out of the ICU, and (4) ICU expansion by up to four beds. Outcomes included ICU admission wait times and unit occupancy. With current bed allocation, simulated wait time averaged 1.13 (SD, 1.39) hours. Reallocating all SDU beds as ICU decreased overall wait times by 7.2% to 1.06 (SD, 1.39) hours and increased bed occupancy from 80 to 84%. Reserving the last available bed for acute patients reduced wait times for acute patients from 0.84 (SD, 1.12) to 0.31 (SD, 0.30) hours, but tripled subacute patients' wait times from 1.39 (SD, 1.81) to 4.27 (SD, 5.44) hours. Setting transfer times to wards for all ICU/SDU patients to 1 hour decreased wait times for incoming ICU patients, comparable to building one to two additional ICU beds. Hospital queuing and simulation modeling

Muscle mass and physical recovery in ICU: innovations for targeting of nutrition and exercise.

PubMed

Wischmeyer, Paul E; Puthucheary, Zudin; San Millán, Iñigo; Butz, Daniel; Grocott, Michael P W

2017-08-01

We have significantly improved hospital mortality from sepsis and critical illness in last 10 years; however, over this same period we have tripled the number of 'ICU survivors' going to rehabilitation. Furthermore, as up to half the deaths in the first year following ICU admission occur post-ICU discharge, it is unclear how many of these patients ever returned home or a meaningful quality of life. For those who do survive, recent data reveals many 'ICU survivors' will suffer significant functional impairment or post-ICU syndrome (PICS). Thus, new innovative metabolic and exercise interventions to address PICS are urgently needed. These should focus on optimal nutrition and lean body mass (LBM) assessment, targeted nutrition delivery, anabolic/anticatabolic strategies, and utilization of personalized exercise intervention techniques, such as utilized by elite athletes to optimize preparation and recovery from critical care. New data for novel LBM analysis technique such as computerized tomography scan and ultrasound analysis of LBM are available showing objective measures of LBM now becoming more practical for predicting metabolic reserve and effectiveness of nutrition/exercise interventions. 13C-Breath testing is a novel technique under study to predict infection earlier and predict over-feeding and under-feeding to target nutrition delivery. New technologies utilized routinely by athletes such as muscle glycogen ultrasound also show promise. Finally, the role of personalized cardiopulmonary exercise testing to target preoperative exercise optimization and post-ICU recovery are becoming reality. New innovative techniques are demonstrating promise to target recovery from PICS utilizing a combination of objective LBM and metabolic assessment, targeted nutrition interventions, personalized exercise interventions for prehabilitation and post-ICU recovery. These interventions should provide hope that we will soon begin to create more 'survivors' and fewer victim's post-ICU

Autoimmune Encephalitis in the ICU: Analysis of Phenotypes, Serologic Findings, and Outcomes.

PubMed

Mittal, Manoj K; Rabinstein, Alejandro A; Hocker, Sara E; Pittock, Sean J; Wijdicks, Eelco F M; McKeon, Andrew

2016-04-01

To report the clinical and laboratory characteristics, clinical courses, and outcomes of Mayo Clinic, Rochester, MN, ICU-managed autoimmune encephalitis patients (January 1st 2003-December 31st 2012). Based on medical record review, twenty-five patients were assigned to Group 1 (had ≥1 of classic autoimmune encephalitis-specific IgGs, n = 13) or Group 2 (had ≥3 other characteristics supporting autoimmunity, n = 12). Median admission age was 47 years (range 22-88); 17 were women. Initial symptoms included ≥1 of subacute confusion or cognitive decline, 13; seizures, 12; craniocervical pain, 5; and personality change, 4. Thirteen Group 1 patients were seropositive for ≥1 of VGKC-complex-IgG (6; including Lgi1-IgG in 2), NMDA-R-IgG (4), AMPA-R-IgG (1), ANNA-1 (1), Ma1/Ma2 antibody (1), and PCA-1 (1). Twelve Group 2 patients had ≥3 other findings supportive of an autoimmune diagnosis (median 4; range 3-5): ≥1 other antibody type detected, 9; an inflammatory CSF, 8; ≥1 coexisting autoimmune disease, 7; an immunotherapy response, 7; limbic encephalitic MRI changes, 5; a paraneoplastic cause, 4; and diagnostic neuropathological findings, 2. Among 11 patients ICU-managed for ≥4 days, neurological improvements were attributable to corticosteroids (5/7 treated), plasmapheresis (3/7), or rituximab (1/3). At last follow-up, 10 patients had died. Of the remaining 15 patients, 6 (24%) had mild or no disability, 3 (12%) had moderate cognitive problems, and 6 (24%) had dementia (1 was bed bound). Median modified Rankin score at last follow-up was 3 (range 0-6). Good outcomes may occur in ICU-managed autoimmune encephalitis patients. Clinical and testing characteristics are diverse. Comprehensive diagnostics should be pursued to facilitate timely treatment.

Factors Associated With the Increasing Rates of Discharges Directly Home From Intensive Care Units-A Direct From ICU Sent Home Study.

PubMed

Lau, Vincent I; Priestap, Fran A; Lam, Joyce N H; Ball, Ian M

2018-02-01

To evaluate the relationship between rates of discharge directly to home (DDH) from the intensive care unit (ICU) and bed availability (ward and ICU). Also to identify patient characteristics that make them candidates for safe DDH and describe transfer delay impact on length of stay (LOS). Retrospective cohort study of all adult patients who survived their stay in our medical-surgical-trauma ICU between April 2003 and March 2015. Median age was 49 years (interquartile range [IQR]: 33.5-60.4), and the majority of the patients were males (54.8%). Median number of preexisting comorbidities was 5 (IQR: 2-7) diagnoses. Discharge directly to home increased from 28 (3.1% of all survivors) patients in 2003 to 120 (12.5%) patients in 2014. The mean annual rate of DDH was between 11% and 12% over the last 6 years. Approximately 62% (n = 397) of patients waited longer than 4 hours for a ward bed, with a median delay of 2.0 days (IQR: 0.5-4.7) before being DDH. There was an inverse correlation between ICU occupancy and DDH rates ( r P = -.55, P < .0001, 95% confidence interval [CI] = -0.36 to -0.69, R 2 = .29). There was no correlation with ward occupancy and DDH rates ( r s = -.055, P = .64, 95% CI = -0.25 to 0.21). The DDH rates have been increasing over time at our institution and were inversely correlated with ICU bed occupancy but were not associated with ward occupancy. The DDH patients are young, have few comorbidities on admission, and few discharge diagnoses, which are usually reversible single system problems with low disease burden. Transfers to the ward are delayed in a majority of cases, leading to increased ICU LOS and likely increased overall hospital LOS as well.

Predictive value of early near-infrared spectroscopy monitoring of patients with traumatic brain injury.

PubMed

Vilkė, Alina; Bilskienė, Diana; Šaferis, Viktoras; Gedminas, Martynas; Bieliauskaitė, Dalia; Tamašauskas, Arimantas; Macas, Andrius

2014-01-01

Traumatic brain injury (TBI) is the leading cause of death and disability in young adults. Study aimed to define the predictive value of early near-infrared spectroscopy (NIRS) monitoring of TBI patients in a Lithuanian clinical setting. Data of 61 patients was analyzed. Predictive value of early NIRS monitoring, computed tomography data and regular intensive care unit (ICU) parameters was investigated. Twenty-six patients expressed clinically severe TBI; 14 patients deceased. Patients who survived expressed higher NIRS values at the periods of admission to operative room (75.4%±9.8% vs. 71.0%±20.5%; P=0.013) and 1h after admission to ICU (74.7%±1.5% vs. 61.9%±19.4%; P=0.029). The NIRS values discriminated hospital mortality groups more accurately than admission GCS score, blood sugar or hemoglobin levels. Admission INR value and NIRS value at 1h after admission to ICU were selected by discriminant analysis into the optimal set of features when classifying hospital mortality groups. Average efficiency of classification using this method was 88.9%. When rsO2 values at 1h after admission to ICU did not exceed 68.0% in the left hemisphere and 68.3% in the right hemisphere, the hazard ratio for death increased by 17.7 times (P<0.01) and 5.1 times (P<0.05), respectively. NIRS plays an important role in the clinical care of TBI patients. Regional brain saturation monitoring provides accurate predictive data, which can improve the allocation of scarce medical resources, set the treatment goals and alleviate the early communication with patients' relatives. Copyright © 2014 Lithuanian University of Health Sciences. Production and hosting by Elsevier Urban & Partner Sp. z o.o. All rights reserved.

Clinical and Biological Predictors of Plasma Levels of Soluble RAGE in Critically Ill Patients: Secondary Analysis of a Prospective Multicenter Observational Study.

PubMed

Pranal, Thibaut; Pereira, Bruno; Berthelin, Pauline; Roszyk, Laurence; Godet, Thomas; Chabanne, Russell; Eisenmann, Nathanael; Lautrette, Alexandre; Belville, Corinne; Blondonnet, Raiko; Cayot, Sophie; Gillart, Thierry; Skrzypczak, Yvan; Souweine, Bertrand; Bouvier, Damien; Blanchon, Loic; Sapin, Vincent; Constantin, Jean-Michel; Jabaudon, Matthieu

2018-01-01

Although soluble forms of the receptor for advanced glycation end products (RAGE) have been recently proposed as biomarkers in multiple acute or chronic diseases, few studies evaluated the influence of usual clinical and biological parameters, or of patient characteristics and comorbidities, on circulating levels of soluble RAGE in the intensive care unit (ICU) setting. To determine, among clinical and biological parameters that are usually recorded upon ICU admission, which variables, if any, could be associated with plasma levels of soluble RAGE. Data for this ancillary study were prospectively obtained from adult patients with at least one ARDS risk factor upon ICU admission enrolled in a large multicenter observational study. At ICU admission, plasma levels of total soluble RAGE (sRAGE) and endogenous secretory (es)RAGE were measured by duplicate ELISA and baseline patient characteristics, comorbidities, and usual clinical and biological indices were recorded. After univariate analyses, significant variables were used in multivariate, multidimensional analyses. 294 patients were included in this ancillary study, among whom 62% were admitted for medical reasons, including septic shock (11%), coma (11%), and pneumonia (6%). Although some variables were associated with plasma levels of RAGE soluble forms in univariate analysis, multidimensional analyses showed no significant association between admission parameters and baseline plasma sRAGE or esRAGE. We found no obvious association between circulating levels of soluble RAGE and clinical and biological indices that are usually recorded upon ICU admission. This trial is registered with NCT02070536.

Designing Reliable Cohorts of Cardiac Patients across MIMIC and eICU

PubMed Central

Chronaki, Catherine; Shahin, Abdullah; Mark, Roger

2016-01-01

The design of the patient cohort is an essential and fundamental part of any clinical patient study. Knowledge of the Electronic Health Records, underlying Database Management System, and the relevant clinical workflows are central to an effective cohort design. However, with technical, semantic, and organizational interoperability limitations, the database queries associated with a patient cohort may need to be reconfigured in every participating site. i2b2 and SHRINE advance the notion of patient cohorts as first class objects to be shared, aggregated, and recruited for research purposes across clinical sites. This paper reports on initial efforts to assess the integration of Medical Information Mart for Intensive Care (MIMIC) and Philips eICU, two large-scale anonymized intensive care unit (ICU) databases, using standard terminologies, i.e. LOINC, ICD9-CM and SNOMED-CT. Focus of this work is lab and microbiology observations and key demographics for patients with a primary cardiovascular ICD9-CM diagnosis. Results and discussion reflecting on reference core terminology standards, offer insights on efforts to combine detailed intensive care data from multiple ICUs worldwide. PMID:27774488

Superiority of Serum Cystatin C Over Creatinine in Prediction of Long-Term Prognosis at Discharge From ICU.

PubMed

Ravn, Bo; Prowle, John R; Mårtensson, Johan; Martling, Claes-Roland; Bell, Max

2017-09-01

Renal outcomes after critical illness are seldom assessed despite strong correlation between chronic kidney disease and survival. Outside hospital, renal dysfunction is more strongly associated with mortality when assessed by serum cystatin C than by creatinine. The relationship between creatinine and longer term mortality might be particularly weak in survivors of critical illness. Retrospective observational cohort study. In 3,077 adult ICU survivors, we compared ICU discharge cystatin C and creatinine and their association with 1-year mortality. Exclusions were death within 72 hours of ICU discharge, ICU stay less than 24 hours, and end-stage renal disease. None. During ICU admission, serum cystatin C and creatinine diverged, so that by ICU discharge, almost twice as many patients had glomerular filtration rate less than 60 mL/min/1.73 m when estimated from cystatin C compared with glomerular filtration rate estimated from creatinine, 44% versus 26%. In 743 patients without acute kidney injury, where ICU discharge renal function should reflect ongoing baseline, discharge glomerular filtration rate estimated from creatinine consistently overestimated follow-up glomerular filtration rate estimated from creatinine, whereas ICU discharge glomerular filtration rate estimated from cystatin C well matched follow-up chronic kidney disease status. By 1 year, 535 (17.4%) had died. In survival analysis adjusted for age, sex, and comorbidity, cystatin C was near-linearly associated with increased mortality, hazard ratio equals to 1.78 (95% CI, 1.46-2.18), 75th versus 25th centile. Conversely, creatinine demonstrated a J-shaped relationship with mortality, so that in the majority of patients, there was no significant association with survival, hazard ratio equals to 1.03 (0.87-1.2), 75th versus 25th centile. After adjustment for both creatinine and cystatin C levels, higher discharge creatinine was then associated with lower long-term mortality. In contrast to creatinine

[Violent and intimidating behavior of psychiatric patients at admission].

PubMed

Moamaï, J; Moamaï, N

1994-05-01

The dangerousness of the mentally ill patient is still unknown. This study assesses the actual prevalence of violent and intimidating behaviours in psychiatric patients at the time of their admission, or in the days leading up to their admission to a Quebec hospital. These behaviours have been measured on a six-point scale whose reliability for this population is appropriate. The consecutive sample consists of 383 adult admissions, and the results show that 83.0 percent of the involuntary admissions and 40.7 percent of the voluntary admissions manifested violent or intimidating behaviours at the time of hospitalization. The results support the clinical experience that psychiatric patients often exhibit this type of behaviour on admission.

To everything there is a season: impact of seasonal change on admissions, acuity of injury, length of stay, throughput, and charges at an accredited, regional burn center.

PubMed

Hultman, C Scott; Tong, Winnie T; Surrusco, Matthew; Roden, Katherine S; Kiser, Michelle; Cairns, Bruce A

2012-07-01

Although previous studies have investigated the impact of weather and temporal factors on incidence of trauma admissions, there is a paucity of data describing the effect of seasonal change on burn injury. The purpose of this study was to examine the impact of the changing seasons on admissions to and resource utilization at an accredited burn center, with the goal of optimizing patient throughput and matching supply with demand. We performed a retrospective review of all burn admissions to an accredited, regional burn center, from Summer 2009 through Spring 2010. Patients were segregated into the seasonal cohorts of Summer, Fall, Winter, and Spring, based on admission date. Patient demographics included age, gender, mechanism of injury, and total body surface area (TBSA) injured. Main outcome measures included length of intensive care unit (ICU) stay, length of stay (LOS), and hospital charges, which served as a proxy for resource utilization (nursing, wound, and critical care; access to operating room (OR); inpatient rehabilitation). Groups were compared by T tests, with statistical significance assigned to P values <0.05. Seven hundred thirty patients were admitted to the burn center during this annual period, with a mean age of 31.6 years and a TBSA of 8.9%. Although Spring had the greatest the number of admissions at 219 (30%), patients from Summer and Winter had the largest burns, longest length of ICU and hospital stays, and highest hospital charges (P < 0.05). Furthermore, variability of these parameters, as measured by standard deviation, was greatest during Summer and Winter, serving to reduce throughput via uneven demand on resources. Highest throughput occurred during the Spring, which had the highest admission-to-LOS ratio. No differences were observed in age, gender, and incidence of electrical injuries, across the 4 seasons. Summer and winter were the peak seasons of resource utilization at our burn center, in terms of length and variability of ICU

A Coordinated Patient Transport System for ICU Patients Requiring Surgery: Impact on Operating Room Efficiency and ICU Workflow.

PubMed

Brown, Michael J; Kor, Daryl J; Curry, Timothy B; Marmor, Yariv; Rohleder, Thomas R

2015-01-01

Transfer of intensive care unit (ICU) patients to the operating room (OR) is a resource-intensive, time-consuming process that often results in patient throughput inefficiencies, deficiencies in information transfer, and suboptimal nurse to patient ratios. This study evaluates the implementation of a coordinated patient transport system (CPTS) designed to address these issues. Using data from 1,557 patient transfers covering the 2006-2010 period, interrupted time series and before and after designs were used to analyze the effect of implementing a CPTS at Mayo Clinic, Rochester. Using a segmented regression for the interrupted time series, on-time OR start time deviations were found to be significantly lower after the implementation of CPTS (p < .0001). The implementation resulted in a fourfold improvement in on-time OR starts (p < .01) while significantly reducing idle OR time (p < .01). A coordinated patient transfer process for moving patient from ICUs to ORs can significantly improve OR efficiency, reduce nonvalue added time, and ensure quality of care by preserving appropriate care provider to patient ratios.

Utilizing findings from the APACHE III research to develop operational information system for the ICU--the APACHE III ICU Management System.

PubMed Central

Knaus, W. A.; Draper, E. A.; Wagner, D. P.

1991-01-01

The APACHE III data base reflects the disease, physiologic status, and outcome data from 17,400 ICU patients at 40 hospitals, 26 of which were randomly selected from representative geographic regions, bed size, and teaching status. This provides a nationally representative standard for measuring several important aspects of ICU performance. Results from the study have now been used to develop an automated information system to provide real time information about expected ICU patient outcome, length of stay, production cost, and ICU performance. The information system provides several new capabilities to ICU clinicians, clinic, and hospital administrators. Among the system's capabilities are: the ability to compare local ICU performance against predetermined criteria; the ability to forecast nursing requirements; and, the ability to make both individual and group patient outcome predictions. The system also provides improved administrative support by tracking ICU charges at the point of origin and reduces staff workload eliminating the requirement for several manually maintained logs and patient lists. APACHE III has the capability to electronically interface with and utilize data already captured in existing hospital information systems, automated laboratory information systems, and patient monitoring systems. APACHE III will also be completely integrated with several CIS vendors' products. PMID:1807779

[Bacterial parotitis in an immunocompromised patient in adult ICU].

PubMed

Vassal, O; Bernet, C; Wallet, F; Friggeri, A; Piriou, V

2013-09-01

Bacterial parotitis is a common childhood disease with a favorable outcome. Staphylococcus aureus is the most frequently involved pathogen. Clinical presentation in adult patients can be misleading, Onset occurs in patients with multiple comorbidities, making diagnosis difficult--particularly in ICU. Different pathogens are found in adults with worse outcomes observed. We report here the case of a critically ill patient and discuss diagnosis and management of bacterial parotitis. Copyright © 2013 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.

First influenza season after the 2009 pandemic influenza: characteristics of intensive care unit admissions in adults and children in Vall d'Hebron Hospital.

PubMed

Poulakou, G; Souto, J; Balcells, J; Pérez, M; Laborda, C; Roca, O; Tórtola, T; Pujol, M; Palomar, M; Rello, J

2012-04-01

To assess potential differences in epidemiology and management of patients admitted with influenza infection in the intensive care unit (ICU) during the first post-pandemic influenza period. Observational prospective study comparing September 2009-January 2010 with September 2010-January 2011. Variables captured: demographics, co-morbidities, physiological parameters, outcomes and management. Analysis was performed using SPSS v. 13.0; significance was set at p 0.5. Data from 53 patients, 38 adults (age, median 41.5 years; interquartile range (IQR) 32.8-51.3) and 15 children (age, median 2 years, IQR 0.5-9) are presented. Vaccination rates were 0% and 4.3% during the first and second periods, respectively. Differences postpandemic were: 100% of episodes developed after December compared with 16.7% in the 2009 season. Younger children were affected (median age 0.8 years (IQR 0.3-4.8) vs 7 years (IQR 1.25-11.5), p 0.05) and influenza B caused 8.7% of ICU admissions. Influenza A (H1N1) 2009 and respiratory syncytial virus epidemics occurred simultaneously (42.8% of children) and bacterial co-infections doubled (from 10% to 21.7%); the prevalence of co-infections (viral or bacterial) increased from 10% to 39.1% (OR 5.8, 95% CI 1.3-24.8). Respiratory syndromes without chest X-ray opacities reflecting exacerbation of asthma or chronic obstructive pulmonary disease, bronchitis or bronchiolitis increased (from 6.9% to 39.1%, p<0.05) and pneumonia decreased (from 83.3% to 56.5%, p <0.05). Primary viral pneumonia predominated among ICU admissions. Postpandemic ICU influenza developed later, with some cases of influenza B, more frequent bacterial and viral co-infections and more patients with severe acute respiratory infection with normal chest X-ray. Increasing vaccination rates among risk-group individuals is warranted to prevent ICU admission and death. © 2011 The Authors. Clinical Microbiology and Infection © 2011 European Society of Clinical Microbiology and Infectious

ICU Telemedicine Program Financial Outcomes.

PubMed

Lilly, Craig M; Motzkus, Christine; Rincon, Teresa; Cody, Shawn E; Landry, Karen; Irwin, Richard S

2017-02-01

ICU telemedicine improves access to high-quality critical care, has substantial costs, and can change financial outcomes. Detailed information about financial outcomes and their trends over time following ICU telemedicine implementation and after the addition of logistic center function has not been published to our knowledge. Primary data were collected for consecutive adult patients of a single academic medical center. We compared clinical and financial outcomes across three groups that differed regarding telemedicine support: a group without ICU telemedicine support (pre-ICU intervention group), a group with ICU telemedicine support (ICU telemedicine group), and an ICU telemedicine group with added logistic center functions and support for quality-care standardization (logistic center group). The primary outcome was annual direct contribution margin defined as aggregated annual case revenue minus annual case direct costs (including operating costs of ICU telemedicine and its related programs). All monetary values were adjusted to 2015 US dollars using Producer Price Index for Health-Care Facilities. Annual case volume increased from 4,752 (pre-ICU telemedicine) to 5,735 (ICU telemedicine) and 6,581 (logistic center). The annual direct contribution margin improved from $7,921,584 (pre-ICU telemedicine) to $37,668,512 (ICU telemedicine) to $60,586,397 (logistic center) due to increased case volume, higher case revenue relative to direct costs, and shorter length of stay. The ability of properly modified ICU telemedicine programs to increase case volume and access to high-quality critical care with improved annual direct contribution margins suggests that there is a financial argument to encourage the wider adoption of ICU telemedicine. Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

Positive fluid balance as a major predictor of clinical outcome of patients with sepsis/septic shock after ICU discharge.

PubMed

Brotfain, Evgeni; Koyfman, Leonid; Toledano, Ronen; Borer, Abraham; Fucs, Lior; Galante, Ori; Frenkel, Amit; Kutz, Ruslan; Klein, Moti

2016-11-01

Sepsis and septic shock continue to be syndromes that carry a high mortality rate worldwide. Early aggressive fluid and vasopressor support have resulted in significant improvement in patient outcomes. The prognostic clinical significance of a positive fluid balance in septic intensive care unit (ICU) patients remains undetermined. We collected data from 297 septic patients hospitalized in our general and medical ICUs at Soroka Medical Center between January 2005 and June 2011 and divided the 4 study groups into the following 4 fluid balances: group 1, patients with fluid balance at discharge from ICU (FBD) less than 10 L; group 2, patients with an FBD of 10 to 20 L; group 3, patients with an FBD of 20 to 30 L; and group 4, patients with FBD in excess of 30 L. The ICU and in-hospital mortality rate was also significantly higher in groups 2 to 4 as compared with group 1 (P < .001 for both ICU and in-hospital mortality). The positive cumulative FBD was found to be an independent predictor of ICU mortality (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02-1.06; P < .001; Table 3) and in-hospital mortality (OR, 1.06; 95% CI, 1.03-1.08; P < .001; Table 5) and also to constitute a risk factor for new organ system dysfunction at hospital discharge (OR, 1.01; 95% CI, 1.01-1.013; P < .001; Table 6) in critically ill patients with severe sepsis/septic shock. Although it is a monocentric retrospective study, we suggest that positive cumulative fluid balance is one of the major factors that can predict the clinical outcome of critically ill patients during their ICU stay and after their discharge from the ICU. Copyright © 2016 Elsevier Inc. All rights reserved.

Amoxicillin/clavulanate (Augmentin) resistant Escherichia coli in bacterial peritonitis after abdominal surgery--clinical outcome in ICU patients.

PubMed

Rahnama'i, M S; Wagenvoort, J H T; van der Linden, C J

2009-05-01

Bacterial resistance to antimicrobial agents is of great concern to clinicians. Patient outcome after infection is mainly dependent on the sensitivity of the bacterium to the agent used. We retrospectively studied 89 postoperative intensive care unit (ICU) patients with proven Escherichia coli peritonitis and investigated the clinical consequences of the E. coli resistance to amoxicillin/clavulanate. Significantly increased mortality, days of ventilation and ICU stay were noted in the co-amoxicillin/clavulanate resistant group. Furthermore, our results demonstrate that the sensitivity of E. coli to amoxicillin/clavulanate in the postoperative ICU setting has decreased in recent years. We can conclude that the current antibiotic regimen for the empirical treatment of ICU patients with peritonitis, as used in our hospital, needs to be changed. A switch, for instance, to ceftriaxone (Rocephin) in combination with metronidazole and gentamicin, instead of the present regimen of amoxicillin/clavulanate in combination with gentamicin, seems preferable.

Low sensitivity of qSOFA, SIRS criteria and sepsis definition to identify infected patients at risk of complication in the prehospital setting and at the emergency department triage.

PubMed

Tusgul, Selin; Carron, Pierre-Nicolas; Yersin, Bertrand; Calandra, Thierry; Dami, Fabrice

2017-11-03

Sepsis is defined as life-threatening organ dysfunction caused by a host response to infection. The quick SOFA (qSOFA) score has been recently proposed as a new bedside clinical score to identify patients with suspected infection at risk of complication (intensive care unit (ICU) admission, in-hospital mortality). The aim of this study was to measure the sensitivity of the qSOFA score, SIRS criteria and sepsis definitions to identify the most serious sepsis cases in the prehospital setting and at the emergency department (ED) triage. We performed a retrospective study of all patients transported by emergency medical services (EMS) to the Lausanne University Hospital (CHUV) over twelve months. All patients with a suspected or proven infection after the ED workup were included. We retrospectively analysed the sensitivity of the qSOFA score (≥2 criteria), SIRS criteria (≥2 clinical criteria) and sepsis definition (SIRS criteria + one sign of organ dysfunction or hypoperfusion) in the pre-hospital setting and at the ED triage as predictors of ICU admission, ICU stay of ≥3 days and early (i.e. 48 h) mortality. No direct comparison between the three tools was attempted. Among 11,411 patients transported to the University hospital, 886 (7.8%) were included. In the pre-hospital setting, the sensitivity of qSOFA reached 36.3% for ICU admission, 17.4% for ICU stay of three days or more and 68.0% for 48 h mortality. The sensitivity of SIRS criteria reached 68.8% for ICU admission, 74.6% for ICU stay of three days or more and 64.0% for 48 h mortality. The sensitivity of sepsis definition did not reach 60% for any outcome. At ED triage, the sensitivity of qSOFA reached 31.2% for ICU admission, 30.5% for ICU stay of ≥3 days and 60.0% for mortality at 48 h. The sensitivity of SIRS criteria reached 58.8% for ICU admission, 57.6% for ICU stay of ≥3 days 80.0% for mortality at 48 h. The sensitivity of sepsis definition reached 60.0% for 48 h mortality. Incidence

Prospective evaluation of the prognostic scores for cirrhotic patients admitted to an intensive care unit.

PubMed

Levesque, Eric; Hoti, Emir; Azoulay, Daniel; Ichaï, Philippe; Habouchi, Houssam; Castaing, Denis; Samuel, Didier; Saliba, Faouzi

2012-01-01

Cirrhotic patients admitted to an Intensive Care Unit (ICU) have a poor prognosis. Identifying patients in whom ICU care will be useful can be challenging. The aim of this study was to assess the predictive value of prognostic scores with respect to mortality and to identify mortality risk factors. Three hundred and seventy-seven cirrhotic patients admitted to a Liver ICU between May 2005 and March 2009 were enrolled in this study. Their average age was 55.5±11.4 years. The etiology of cirrhosis was alcohol (68%), virus hepatitis (18%), or mixed (5.5%). The main causes of hospitalization were gastrointestinal hemorrhage (43%), sepsis (19%), and hepatic encephalopathy (12%). ICU and in-hospital mortality rates were 34.7% and 43.0%, respectively. Infection was the major cause of death (81.6%). ROC curve analysis demonstrated that SOFA (0.92) and SAPS II (0.89) scores calculated within 24h of admission predicted ICU mortality better than the Child-Pugh score (0.79) or MELD scores with (0.79-0.82) or without the incorporation of serum sodium levels (0.82). Statistical analysis showed that the prognostic severity scores, organ replacement therapy, and infection were accurate predictors of mortality. On multivariate analysis, mechanical ventilation, vasopressor therapy, bilirubin level at admission, and infection were independently associated with ICU mortality. For cirrhotic patients admitted to the ICU, SAPS II, and SOFA scores predicted ICU mortality better than liver-specific scores. Mechanical ventilation or vasopressor therapy, bilirubin levels at admission and infection in patients with advanced cirrhosis were associated with a poor outcome. Copyright © 2011 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

Prognostic value of severity by various visceral proteins in critically ill patients with SIRS during 7 days of stay.

PubMed

Bouharras-El Idrissi, Hicham; Molina-López, Jorge; Herrera-Quintana, Lourdes; Domínguez-García, Álvaro; Lobo-Támer, Gabriela; Pérez-Moreno, Irene; Pérez-de la Cruz, Antonio; Planells-Del Pozo, Elena

2016-11-29

Critically ill patients typically develop a catabolic stress state as a result of a systemic inflammatory response (SIRS) that alters clinical-nutritional biomarkers, increasing energy demands and nutritional requirements. To evaluate the status of albumin, prealbumin and transferrin in critically ill patients and the association between these clinical-nutritional parameters with the severity during a seven day stay in intensive care unit (ICU). Multicenter, prospective, observational and analytical follow-up study. A total of 115 subjects in critical condition were included in this study. Clinical and nutritional parameters and severity were monitored at admission and at the seventh day of the ICU stay. A significant decrease in APACHE II and SOFA (p < 0.05) throughout the evolution of critically ill patients in ICU. In general, patients showed an alteration of most of the parameters analyzed. The status of albumin, prealbumin and transferrin were below reference levels both at admission and the 7th day in ICU. A high percentage of patients presented an unbalanced status of albumin (71.3%), prealbumin (84.3%) and transferrin (69.0%). At admission, 27% to 47% of patients with altered protein parameters had APACHE II above 18. The number of patients with altered protein parameters and APACHE II below 18 were significantly higher than severe ones throughout the ICU stay (p < 0.01). Regarding the multivariate analysis, low prealbumin status was the best predictor of severity critical (p < 0.05) both at admission and 7th day of the ICU stay. The results of the present study support the idea of including low prealbumin status as a severity predictor in APACHE II scale, due to the association found between severity and poor status of prealbumin.

Comparison and Agreement Between the Richmond Agitation-Sedation Scale and the Riker Sedation-Agitation Scale in Evaluating Patients’ Eligibility for Delirium Assessment in the ICU

PubMed Central

Guzman, Oscar; Campbell, Noll L.; Walroth, Todd; Tricker, Jason L.; Hui, Siu L.; Perkins, Anthony; Zawahiri, Mohammed; Buckley, John D.; Farber, Mark O.; Ely, E. Wesley; Boustani, Malaz A.

2012-01-01

Background: Delirium evaluation in patients in the ICU requires the use of an arousal/sedation assessment tool prior to assessing consciousness. The Richmond Agitation-Sedation Scale (RASS) and the Riker Sedation-Agitation Scale (SAS) are well-validated arousal/sedation tools. We sought to assess the concordance of RASS and SAS assessments in determining eligibility of patients in the ICU for delirium screening using the confusion assessment method for the ICU (CAM-ICU). Methods: We performed a prospective cohort study in the adult medical, surgical, and progressive (step-down) ICUs of a tertiary care, university-affiliated, urban hospital in Indianapolis, Indiana. The cohort included 975 admissions to the ICU between January and October 2009. Results: The outcome measures of interest were the correlation and agreement between RASS and SAS measurements. In 2,469 RASS and SAS paired screens, the rank correlation using the Spearman correlation coefficient was 0.91, and the agreement between the two screening tools for assessing CAM-ICU eligibility as estimated by the κ coefficient was 0.93. Analysis showed that 70.1% of screens were eligible for CAM-ICU assessment using RASS (7.1% sedated [RASS −3 to −1]; 62.6% calm [0]; and 0.4% restless, agitated [+1 to +3]), compared with 72.1% using SAS (5% sedated [SAS 3]; 66.5% calm [4]; and 0.6% anxious, agitated [5, 6]). In the mechanically ventilated subgroup, RASS identified 19.1% CAM-ICU eligible patients compared with 24.6% by SAS. The correlation coefficient in this subgroup was 0.70 and the agreement was 0.81. Conclusion: Both SAS and RASS led to similar rates of delirium assessment using the CAM-ICU. PMID:22539644

Scoring severity in trauma: comparison of prehospital scoring systems in trauma ICU patients.

PubMed

Llompart-Pou, J A; Chico-Fernández, M; Sánchez-Casado, M; Salaberria-Udabe, R; Carbayo-Górriz, C; Guerrero-López, F; González-Robledo, J; Ballesteros-Sanz, M Á; Herrán-Monge, R; Servià-Goixart, L; León-López, R; Val-Jordán, E

2017-06-01

We evaluated the predictive ability of mechanism, Glasgow coma scale, age and arterial pressure (MGAP), Glasgow coma scale, age and systolic blood pressure (GAP), and triage-revised trauma Score (T-RTS) scores in patients from the Spanish trauma ICU registry using the trauma and injury severity score (TRISS) as a reference standard. Patients admitted for traumatic disease in the participating ICU were included. Quantitative data were reported as median [interquartile range (IQR), categorical data as number (percentage)]. Comparisons between groups with quantitative variables and categorical variables were performed using Student's T Test and Chi Square Test, respectively. We performed receiving operating curves (ROC) and evaluated the area under the curve (AUC) with its 95 % confidence interval (CI). Sensitivity, specificity, positive predictive and negative predictive values and accuracy were evaluated in all the scores. A value of p < 0.05 was considered significant. The final sample included 1361 trauma ICU patients. Median age was 45 (30-61) years. 1092 patients (80.3 %) were male. Median ISS was 18 (13-26) and median T-RTS was 11 (10-12). Median GAP was 20 (15-22) and median MGAP 24 (20-27). Observed mortality was 17.7 % whilst predicted mortality using TRISS was 16.9 %. The AUC in the scores evaluated was: TRISS 0.897 (95 % CI 0.876-0.918), MGAP 0.860 (95 % CI 0.835-0.886), GAP 0.849 (95 % CI 0.823-0.876) and T-RTS 0.796 (95 % CI 0.762-0.830). Both MGAP and GAP scores performed better than the T-RTS in the prediction of hospital mortality in Spanish trauma ICU patients. Since these are easy-to-perform scores, they should be incorporated in clinical practice as a triaging tool.

Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study.

PubMed

Hodgson, Carol; Bellomo, Rinaldo; Berney, Susan; Bailey, Michael; Buhr, Heidi; Denehy, Linda; Harrold, Megan; Higgins, Alisa; Presneill, Jeff; Saxena, Manoj; Skinner, Elizabeth; Young, Paul; Webb, Steven

2015-02-26

The aim of this study was to investigate current mobilization practice, strength at ICU discharge and functional recovery at 6 months among mechanically ventilated ICU patients. This was a prospective, multi-centre, cohort study conducted in twelve ICUs in Australia and New Zealand. Patients were previously functionally independent and expected to be ventilated for >48 hours. We measured mobilization during invasive ventilation, sedation depth using the Richmond Agitation and Sedation Scale (RASS), co-interventions, duration of mechanical ventilation, ICU-acquired weakness (ICUAW) at ICU discharge, mortality at day 90, and 6-month functional recovery including return to work. We studied 192 patients (mean age 58.1 ± 15.8 years; mean Acute Physiology and Chronic Health Evaluation (APACHE) (IQR) II score, 18.0 (14 to 24)). Mortality at day 90 was 26.6% (51/192). Over 1,351 study days, we collected information during 1,288 planned early mobilization episodes in patients on mechanical ventilation for the first 14 days or until extubation (whichever occurred first). We recorded the highest level of early mobilization. Despite the presence of dedicated physical therapy staff, no mobilization occurred in 1,079 (84%) of these episodes. Where mobilization occurred, the maximum levels of mobilization were exercises in bed (N = 94, 7%), standing at the bed side (N = 11, 0.9%) or walking (N = 26, 2%). On day three, all patients who were mobilized were mechanically ventilated via an endotracheal tube (N = 10), whereas by day five 50% of the patients mobilized were mechanically ventilated via a tracheostomy tube (N = 18). Early mobilization of patients receiving mechanical ventilation was uncommon. More than 50% of patients discharged from the ICU had developed ICU-acquired weakness, which was associated with death between ICU discharge and day-90. ClinicalTrials.gov NCT01674608. Registered 14 August 2012.

All-Cause Hospital Admissions Among Older Adults After a Natural Disaster.

PubMed

Bell, Sue Anne; Abir, Mahshid; Choi, HwaJung; Cooke, Colin; Iwashyna, Theodore

2017-08-05

We characterize hospital admissions among older adults for any cause in the 30 days after a significant natural disaster in the United States. The main outcome was all-cause hospital admissions in the 30 days after natural disaster. Separate analyses were conducted to examine all-cause hospital admissions excluding the 72 hours after the disaster, ICU admissions, all-cause inhospital mortality, and admissions by state. A self-controlled case series analysis using the 2011 Medicare Provider and Analysis Review was conducted to examine exposure to natural disaster by elderly adults located in zip codes affected by tornadoes during the 2011 southeastern superstorm. Spatial data of tornado events were obtained from the National Oceanic and Atmospheric Administration's Severe Report database, and zip code data were obtained from the US Census Bureau. All-cause hospital admissions increased by 4% for older adults in the 30 days after the April 27, 2011, tornadoes (incidence rate ratio 1.04; 95% confidence interval 1.01 to 1.07). When the first 3 days after the disaster that may have been attributed to immediate injuries were excluded, hospitalizations for any cause also remained higher than when compared with the other 11 months of the year (incidence rate ratio 1.04; 95% confidence interval 1.01 to 1.07). There was no increase in ICU admissions or inhospital mortality associated with the natural disaster. When data were examined by individual states, Alabama, which had the highest number of persons affected, had a 9% increase in both hospitalizations and ICU admissions. When all time-invariant characteristics were controlled for, this natural disaster was associated with a significant increase in all-cause hospitalizations. This analysis quantifies acute care use after disasters through examining all-cause hospitalizations and represents an important contribution to building models of resilience-the ability to recover from a disaster-and hospital surge capacity

Clinical and Biological Predictors of Plasma Levels of Soluble RAGE in Critically Ill Patients: Secondary Analysis of a Prospective Multicenter Observational Study

PubMed Central

Pranal, Thibaut; Pereira, Bruno; Berthelin, Pauline; Roszyk, Laurence; Chabanne, Russell; Eisenmann, Nathanael; Lautrette, Alexandre; Belville, Corinne; Blondonnet, Raiko; Gillart, Thierry; Skrzypczak, Yvan; Souweine, Bertrand; Bouvier, Damien; Constantin, Jean-Michel

2018-01-01

Rationale Although soluble forms of the receptor for advanced glycation end products (RAGE) have been recently proposed as biomarkers in multiple acute or chronic diseases, few studies evaluated the influence of usual clinical and biological parameters, or of patient characteristics and comorbidities, on circulating levels of soluble RAGE in the intensive care unit (ICU) setting. Objectives To determine, among clinical and biological parameters that are usually recorded upon ICU admission, which variables, if any, could be associated with plasma levels of soluble RAGE. Methods Data for this ancillary study were prospectively obtained from adult patients with at least one ARDS risk factor upon ICU admission enrolled in a large multicenter observational study. At ICU admission, plasma levels of total soluble RAGE (sRAGE) and endogenous secretory (es)RAGE were measured by duplicate ELISA and baseline patient characteristics, comorbidities, and usual clinical and biological indices were recorded. After univariate analyses, significant variables were used in multivariate, multidimensional analyses. Measurements and Main Results 294 patients were included in this ancillary study, among whom 62% were admitted for medical reasons, including septic shock (11%), coma (11%), and pneumonia (6%). Although some variables were associated with plasma levels of RAGE soluble forms in univariate analysis, multidimensional analyses showed no significant association between admission parameters and baseline plasma sRAGE or esRAGE. Conclusions We found no obvious association between circulating levels of soluble RAGE and clinical and biological indices that are usually recorded upon ICU admission. This trial is registered with NCT02070536. PMID:29861796

Outcomes of cancer therapy administered to treatment-naïve lung cancer patients in the intensive care unit

PubMed Central

Chen, Yen-Fu; Lin, Jou-Wei; Ho, Chao-Chi; Yang, Ching-Yao; Chang, Chia-Hao; Huang, Tao-Min; Chen, Chung-Yu; Chen, Kuan-Yu; Shih, Jin-Yuan; Yu, Chong-Jen

2017-01-01

Objectives: Therapy outcomes for newly diagnosed, critically ill lung cancer patients have seldom been evaluated. This study evaluated therapy outcomes for treatment-naïve lung cancer patients in the intensive care unit (ICU). Materials and Methods: Patients were excluded if they had previously received lung cancer treatment, such as systemic chemotherapy, targeted therapy, radiotherapy, or surgical lung resection before ICU admission. The therapeutic strategies for the treatment-naïve patients were determined while they were in the ICU. The patients' demographic data, clinical outcomes, and treatment-related toxicities were analyzed. Results: Newly diagnosed lung cancer patients (n = 72) who did not receive any anticancer treatment before ICU admission were included. Most patients had locally advanced disease, and 61 (84.7%) required intensive care due to cancer-related events. In the ICU, 24 (33.3%) patients received chemotherapy, 24 (33.3%) received epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) therapy and 24 (33.3%) received best supportive care (BSC). Patients receiving chemotherapy or EGFR-TKIs in the ICU demonstrated better ICU (p = 0.011) and in-hospital (p = 0.034) survival than those receiving BSC only. Among patients requiring mechanical ventilation, those receiving chemotherapy had higher weaning rates than those receiving EGFR-TKIs or BSC (p = 0.002). In multivariate analysis, receipt of chemotherapy (hazard ratio [HR], 0.443; p = 0.083) and mechanical ventilation (HR, 0.270; p = 0.022) were significantly associated with longer ICU survival after adjusting for clinical factors. Conclusions: Anticancer therapy in the ICU might provide better short-term ICU survival for treatment-naïve, critically ill lung cancer patients. PMID:28819399

Outcomes of cancer therapy administered to treatment-naïve lung cancer patients in the intensive care unit.

PubMed

Chen, Yen-Fu; Lin, Jou-Wei; Ho, Chao-Chi; Yang, Ching-Yao; Chang, Chia-Hao; Huang, Tao-Min; Chen, Chung-Yu; Chen, Kuan-Yu; Shih, Jin-Yuan; Yu, Chong-Jen

2017-01-01

Objectives: Therapy outcomes for newly diagnosed, critically ill lung cancer patients have seldom been evaluated. This study evaluated therapy outcomes for treatment-naïve lung cancer patients in the intensive care unit (ICU). Materials and Methods: Patients were excluded if they had previously received lung cancer treatment, such as systemic chemotherapy, targeted therapy, radiotherapy, or surgical lung resection before ICU admission. The therapeutic strategies for the treatment-naïve patients were determined while they were in the ICU. The patients' demographic data, clinical outcomes, and treatment-related toxicities were analyzed. Results: Newly diagnosed lung cancer patients (n = 72) who did not receive any anticancer treatment before ICU admission were included. Most patients had locally advanced disease, and 61 (84.7%) required intensive care due to cancer-related events. In the ICU, 24 (33.3%) patients received chemotherapy, 24 (33.3%) received epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) therapy and 24 (33.3%) received best supportive care (BSC). Patients receiving chemotherapy or EGFR-TKIs in the ICU demonstrated better ICU (p = 0.011) and in-hospital (p = 0.034) survival than those receiving BSC only. Among patients requiring mechanical ventilation, those receiving chemotherapy had higher weaning rates than those receiving EGFR-TKIs or BSC (p = 0.002). In multivariate analysis, receipt of chemotherapy (hazard ratio [HR], 0.443; p = 0.083) and mechanical ventilation (HR, 0.270; p = 0.022) were significantly associated with longer ICU survival after adjusting for clinical factors. Conclusions: Anticancer therapy in the ICU might provide better short-term ICU survival for treatment-naïve, critically ill lung cancer patients.

Assessment of satisfaction with care and decision-making among English and Spanish-speaking family members of neuroscience ICU patients.

PubMed

Hagerty, Thomas A; Velázquez, Ángela; Schmidt, J Michael; Falo, Cristina

2016-02-01

Patients' and family members' experiences of hospital care are important indicators of quality. "Black, Asian, and Hispanic patients are more at risk than White patients for decreased satisfaction with care." In addition, of any of these groups, Hispanic patients were most likely to report a lack of patient-centered care. In the intensive care setting, (ICU) previous research has indicated that the needs and satisfaction of family members of neurological ICU patients are different from those of family members of other types of ICU patients. The purpose of this study was to determine if there were any differences between English-speaking and Spanish-speaking family members of patients in a neurological ICU. This study was a single center prospective study conducted over a 10-month period from April 2013 to February 2014 in the 18-bed neuroscience ICU of a large, urban, academic medical center. The Family Satisfaction with ICU (FS-ICU) questionnaire was used; it provides an overall score and has two factors: satisfaction with care and satisfaction with decision-making. There was no statistical significance between the two groups in overall satisfaction or in satisfaction with care, however Spanish-speakers (n=22) were significantly less satisfied (p=.04) than English-speakers (n=50) with decision-making. There were three other discreet variables in which Spanish-speakers were also less satisfied: (a) management of patients' pain (OR 3.16, 95% CI [1.12, 8.9]) (b) management of patients' breathlessness (OR 3.5, 95% CI [1.23, 9.96]) as well as (c) ease of getting information (OR 3.25, 95% CI [1.09, 9.64]). Using a standardized survey it was found that Spanish-speakers were statistically less satisfied with decision-making than English-speakers. Additionally, Spanish-speakers were statistically less satisfied with management of patients' pain and breathlessness and ease of getting information. Based on these findings, increased vigilance is recommended regarding decision

Body weight-supported bedside treadmill training facilitates ambulation in ICU patients: An interventional proof of concept study.

PubMed

Sommers, Juultje; Wieferink, Denise C; Dongelmans, Dave A; Nollet, Frans; Engelbert, Raoul H H; van der Schaaf, Marike

2017-10-01

Early mobilisation is advocated to improve recovery of intensive care unit (ICU) survivors. However, severe weakness in combination with tubes, lines and machinery are practical barriers for the implementation of ambulation with critically ill patients. The aim of this study was to explore the feasibility of Body Weight-Supported Treadmill Training (BWSTT) in critically ill patients in the ICU. A custom build bedside Body Weight-Supported Treadmill was used and evaluated in medical and surgical patients in the ICU. Feasibility was evaluated according to eligibility, successful number of BWSTT, number of staff needed, adverse events, number of patients that could not have walked without BWSTT, patient satisfaction and anxiety. Twenty participants, underwent 54 sessions BWSTT. Two staff members executed the BWSTT and no adverse events occurred. Medical equipment did not have to be disconnected during all treatment sessions. In 74% of the sessions, the participants would not have been able to walk without the BWSTT. Patient satisfaction with BWSTT was high and anxiety low. This proof of concept study demonstrated that BWSTT is safe, reduces staff resource, and facilitates the first time to ambulation in critically ill patients with severe muscle weakness in the ICU. Copyright © 2017 Elsevier Inc. All rights reserved.

Palliative Care Consultations in the Neuro-ICU: A Qualitative Study.

PubMed

Tran, Len N; Back, Anthony L; Creutzfeldt, Claire J

2016-10-01

Integration of palliative care (PC) into the neurological intensive care unit (neuro-ICU) is increasingly recommended, but evidence regarding the best practice is lacking. We conducted a qualitative analysis exploring current practices and key themes of specialist PC consultations in patients admitted to a single neuro-ICU. We retrospectively identified all patients who were admitted to the neuro-ICU for ≥24 h and received a PC consultation between January and August 2014. We reviewed PC consultation notes and neuro-ICU progress notes from the electronic health records of these patients. We performed content analysis on the PC notes. Twenty-five neuro-ICU patients (4 %) received a PC consultation over 8 months with the most prevalent reason of clarifying goals of care. The main distinctions between patients with and those without (n = 580) a PC consultation were ICU length of stay (median 8.2 vs. 2.8 days) and death in the neuro-ICU (56 % vs. 11 %). The most prevalent themes addressed in the PC consultation notes were (1) discussing prognosis, (2) eliciting patient and family values, (3) understanding medical options, and (4) identifying conflict. PC consultations in the neuro-ICU emphasize family coping and decision-making by helping discuss prognosis and exploring patient and family values as well as their ability to understand the medical information. Several features suggest that earlier integration of PC into neuro-ICU care may enhance both coping and the decision-making process.

High Mortality in Severe Sepsis and Septic Shock Patients with Do-Not-Resuscitate Orders in East Asia.

PubMed

Huang, Chun-Ta; Chuang, Yu-Chung; Tsai, Yi-Ju; Ko, Wen-Je; Yu, Chong-Jen

2016-01-01

Severe sepsis is a potentially deadly illness and always requires intensive care. Do-not-resuscitate (DNR) orders remain a debated issue in critical care and limited data exist about its impact on care of septic patients, particularly in East Asia. We sought to assess outcome of severe sepsis patients with regard to DNR status in Taiwan. A retrospective cohort study was conducted in intensive care units (ICUs) between 2008 and 2010. All severe sepsis patients were included for analysis. Primary outcome was association between DNR orders and ICU mortality. Volume of interventions was used as proxy indicator to indicate aggressiveness of care. Sixty-seven (9.4%) of 712 patients had DNR orders on ICU admission, and these patients were older and had higher disease severity compared with patients without DNR orders. Notably, DNR patients experienced high ICU mortality (90%). Multivariate analysis revealed that the presence of DNR orders was independently associated with ICU mortality (odds ratio: 6.13; 95% confidence interval: 2.66-14.10). In propensity score-matched cohort, ICU mortality rate (91%) in the DNR group was statistically higher than that (62%) in the non-DNR group (p <0.001). Regarding ICU interventions, arterial and central venous catheterization were more commonly used in DNR patients than in non-DNR patients. From the Asian perspective, septic patients placed on DNR orders on ICU admission had exceptionally high mortality. In contrast to Western reports, DNR patients received more ICU interventions, reflecting more aggressive approach to dealing with this patient population. The findings in some ways reflect differences between East and West cultures and suggest that DNR status is an important confounder in ICU studies involving severely septic patients.