Am J Crit Care 2001 Sep;10(5):369
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PMID: 11548574, UI: 21433242
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Ann Intern Med 2002 Jan 1;136(1):S-68
PMID: 11797614, UI: 21655901
Ann Intern Med 2002 Jan 1;136(1):25-36
Division of Allergy, Center for Health Services Research, 6th Floor, #6109 Medical Center East, Vanderbilt University Medical Center, Nashville, TN 37232-8300, USA.
BACKGROUND: The incidence of acute respiratory failure requiring mechanical ventilation increases 10-fold from the ages of 55 to 85 years, yet the rate of recovery and outcomes in older persons who develop acute lung injury are poorly defined. OBJECTIVE: To examine age as an independent risk factor in recovery and intensive care unit discharge after acute lung injury. DESIGN: Prospective cohort study. SETTING: 10 U.S. university-based medical centers. PATIENTS: 902 mechanically ventilated patients enrolled in randomized, controlled trials for the treatment of acute lung injury. All patients were managed according to a standardized protocol for ventilator management and weaning. MEASUREMENTS: Frequency and time to achieve well-defined recovery landmarks, duration of ventilation and intensive care unit stay, and survival. RESULTS: Median duration of mechanical ventilation was 19 days (interquartile range, 7 to >28 days) for patients 70 years of age or older (n = 173) compared with 10 days (interquartile range, 5 to 26 days) for patients younger than 70 years of age (n = 729) (P < 0.001). The duration of intensive care unit stay was 21 days for the older group (interquartile range, 11 to >28 days) and 16 days for the younger group (8 to >28 days) (P = 0.004). Survival rates decreased across increasing decades of age (P < 0.001): Patients younger than 70 years of age had a greater 28-day survival rate than patients 70 years of age or older (74.6% vs. 50.3%; P < 0.001). The proportion of survivors achieving physiologic recovery landmarks did not differ between the older and younger age groups, and the median time to pass a 2-hour spontaneous breathing trial was similar between both the older and younger patients (4 days vs. 5 days; P > 0.2). After passing a spontaneous breathing trial, however, older patients required 1 more day than younger patients to achieve unassisted breathing (P = 0.002) and 3 more days to leave the intensive care unit (P = 0.005). In a multivariable Cox proportional hazards analysis, age of 70 years or older was a strong predictor of in-hospital death (hazard ratio, 2.5 [95% CI, 2.0 to 3.2]; P < 0.001). CONCLUSIONS: Although the survival rate among patients 70 years of age or older was high, these patients were twice as likely to die of acute lung injury compared with their younger counterparts, even after adjustment for covariates. Older survivors recovered from respiratory failure and achieved spontaneous breathing at the same rate as younger patients but had greater difficulty achieving liberation from the ventilator and being discharged from the intensive care unit.
PMID: 11777361, UI: 21636069
Intensive Care Med 2002 Jan;28(1):94
[Record supplied by publisher]
PMID: 11819009
Intensive Care Med 2002 Jan;28(1):44-47
Clinical Epidemiology Program, Mount Sinai Hospital, 600 University Avenue, Toronto, Ont., M5G?1X5, Canada.
PMID: 11818998
Intensive Care Med 2002 Jan;28(1):38-43
University Hospital Charite, Department of Anaesthesiology, Campus Mitte, Schumannstrasse 20/21, 10117 Berlin, Germany, ingrid.rundshagen@charite.de
OBJECTIVE: To define the incidence of recall and dreams during analgosedation in critically ill patients. DESIGN: Prospective clinical study. SETTING: Anaesthesiological intensive care unit (ICU) in a university hospital. Patients and participants: Two hundred and eighty-nine critically ill patients, who either arrived intubated and sedated at the ICU or required intubation, mechanical ventilation, and sedation during their ICU stay. INTERVENTIONS: none. MEASUREMENTS AND RESULTS: The patients were interviewed 48?72?h after discharge from the ICU. By a structured interview they were asked whether they recalled any event before they had regained consciousness at the ICU. Moreover they were asked for dreams. Descriptive statistics: 64.7% of all patients did not recall any event, before they regained consciousness. However, 17% ( n=49) of all patients indicated that they remembered the tracheal tube or being on the ventilator, before they woke up. Some patients (21.1%) reported dreams or dreamlike sensations. Some patients (9.3%) recalled nightmares, while 6.6% reported hallucinations. CONCLUSIONS: Critically ill patients reported a high incidence of recall for unpleasant events, which they thought to have taken place before they regained consciousness. The patients, who stayed longer than 24?h at the ICU, indicated vivid memory for nightmares and hallucinations. Further studies are suggested to evaluate: 1) whether there is an impact of the present findings on outcome; and 2) whether clinical scores for sedation or neurophysiological monitoring help to define the exact time, when recall happens, in order to guide therapeutic intervention.
PMID: 11818997
Intensive Care Med 2001 Nov;27(11):1744-9
Hospital Universitario de Getafe, Carretera de Toledo Km 12,500, Getafe 28905, Madrid, Spain, aesteban@hug.es
[Medline record in process]
OBJECTIVE: To determine how frequently life support is withheld or withdrawn from adult critically ill patients, and how physicians and patients families agree on the decision regarding the limitation of life support. DESIGN: Prospective multi-centre cohort study. SETTING: Six adult medical-surgical Spanish intensive care units (ICUs). PATIENTS AND PARTICIPANTS: Three thousand four hundred ninety-eight consecutive patients admitted to six ICUs were enrolled. MEASUREMENTS AND RESULTS: Data collected included age, sex, SAPS II score on admission and within 24 h of the decision to limit treatment, length of ICU stay, outcome at ICU discharge, cause and mode of death, time to death after the decision to withhold or withdraw life support, consultation and agreement with patient's family regarding withholding or withdrawal, and the modalities of therapies withdrawn or withheld. Two hundred twenty-six (6.6%) of 3,498 patients had therapy withheld or withdrawn and 221 of them died in the ICU. Age, SAPS II and length of ICU stay were significantly higher in patients dying patients who had therapy withheld or withdrawn than in patients dying despite active treatment. The proposal to withhold or withdraw life support was initiated by physicians in 210 (92.9%) of 226 patients and by the family in the remaining cases. The patient's family was not involved in the decision to withhold or withdraw life support therapy in 64 (28.3%) of 226 cases. Only 21 (9%) patients had expressed their wish to decline life-prolonging therapy prior to ICU admission. CONCLUSIONS: The withholding and withdrawing of treatment was frequent in critically ill patients and was initiated primarily by physicians.
PMID: 11810117, UI: 21668274
Lancet 2002 Jan 12;359(9301):99-107
Background UK recommendations suggest that large neonatal intensive-care units (NICUs) have better outcomes than small units, although this suggestion remains unproven. We assessed whether patient volume, staffing levels, and workload are associated with risk-adjusted outcomes, and with costs or staff wellbeing.Methods 186 UK NICUs were stratified according to volume of patients, nursing provision, and neonatal consultant provision. Primary outcomes were hospital mortality, mortality or cerebral damage, and nosocomial bacteraemia. We studied 13515 infants of all birthweights consecutively admitted to 54 randomly selected NICUs. Multiple logistic regression analyses were done with every primary outcome as the dependent variable. Staff wellbeing and stress were assessed by anonymous mental health index (MHI)-5 questionnaires.Findings Data were available for 13334 (99%) infants. High-volume NICUs treated the sickest infants and had highest crude mortality. Risk-adjusted mortality and mortality or cerebral damage were unrelated to patient volume or staffing provision; however, nosocomial bacteraemia was less frequent in NICUs with low neonatal consultant provision (odds ratio 0.65, 95% CI 0.43-0.98). Mortality was raised with increasing workload in all types of NICUs. Infants admitted at full capacity versus half capacity were about 50% more likely to die, but there was wide uncertainty around this estimate. Most staff had MHI-5 scores that suggested good mental health.Interpretation The implications of this report for staffing policy, medicolegal risk management, and ethical practice remain to be tested. Centralisation of only the sickest infants could improve efficiency, provided that this does not create excessive workload for staff. Assessment of increased staffing levels that are closer to those in adult intensive care might be appropriate.
PMID: 11809250, UI: 21668728
Lancet 2002 Jan 12;359(9301):95-6
George Washington University School of Medicine, Washington, DC, Critical Care Medicine, Children's National Medical Center, 20010, Washington, DC, USA
PMID: 11809247, UI: 21668725
Pediatrics 2001 Dec;108(6):1269-74
Department of Pediatrics, Columbia University, New York, New York, USA. jl1084@columbia.edu
OBJECTIVE: To quantify differences in resource expenditure in the perinatal period and long-term outcome of extremely premature infants who received systematically different approaches to neonatal intensive care. METHODS: Perinatal management, mortality, prevalence of disabling cerebral palsy (DCP), and resource expenditure of 2 population-based inception cohorts of extremely premature infants born in the mid-1980s were compared. Electronic fetal monitoring, tocolysis, cesarean section delivery, and assisted ventilation were used to characterize management approaches. Participants included all live births at 23 to 26 weeks' gestation in a 3-county area of central New Jersey (NJ) from 1984 to 1987 (N = 146) and throughout the Netherlands (NETH) in 1983 (N = 142). Mortality and the prevalence of DCP were the primary outcomes. Numbers of hospital days with and without assisted ventilation were the measures of resource expenditure. RESULTS: Electronic fetal monitoring (100% vs 38%), cesarean section (28% vs 6%), and assisted ventilation (95% vs 64%) were all more commonly used in NJ than in NETH. Ten percent of NJ deaths occurred without assisted ventilation, compared with 45% of Dutch deaths. A total of 1820 ventilator days were expended per 100 live births in NJ, compared with 448 in NETH. The increase in the number of nonventilator days (3174 vs 2265 days per 100 live births) did not reach statistical significance. Survival to age 2 (46 vs 22%) and the prevalence of DCP among survivors (17.2 vs 3.4%) were significantly greater in NJ at age 2 than in NETH at age 5. CONCLUSIONS: Near universal initiation of intensive care in NJ, compared with selective initiation of intensive care in NETH, was associated with 24.1 additional survivors per 100 live births, 7.2 additional cases of DCP per 100 live births, and a cost of 1372 additional ventilator days per 100 live births.
PMID: 11731647, UI: 21588863
Pediatrics 2001 Dec;108(6):E116
Department of Pediatrics, Pennsylvania State College of Medicine, Hershey, Pennsylvania, USA. jkendig@psu.edu
In 1950, Allan P. Bloxsom (1901-1991), a pediatrician at the St Joseph Hospital in Houston, introduced his positive pressure oxygen air lock (AL) for the delivery room resuscitation of the asphyxiated newborn. The infant's entire body was placed into a cylindrical steel chamber that was tightly sealed and infused with warmed humidified 60% oxygen. The positive pressure within the AL was cycled between 1 and 3 lb/in(2) at 1-minute intervals to simulate the intrauterine pressures during the second stage of labor. Bloxsom developed the AL device in response to his hypothesis that the contractions of labor help to "condition: the infant for extrauterine survival. Parmalee said that the AL "certainly locks the infant up, safe from meddlesome and unintelligent treatment." When clear plastic versions of the AL became commercially available, it received widespread use in delivery rooms and newborn nurseries throughout the United States. In 1953, Apgar and Kreiselman produced apnea in adult dogs using pentobarbital and a muscle relaxant, and found that the AL device was unsuccessful with the oxygenation and ventilation of the animals. In 1954, Townsend in Rochester, New York, reported on his experience with the AL in 150 premature infants. He concluded that the AL should be "more accurately referred to as an oxygenator" and that, "the truly apneic infant cannot be maintained in a acyanotic state by the AL." The AL was finally subjected to the scrutiny of a randomized, controlled clinical trial that was published in 1956. Reichelderfer and Nitowski at Johns Hopkins randomized 171 infants to receive care in the AL or in an Isolette. Routine resuscitation, including positive pressure ventilation, was administered, as needed, to both study groups before placement into the AL or Isolette (Air Shields Inc, Hatboro, PA). They did not find any differences in the outcomes of the 2 study groups. By the mid 1950s, new information linking oxygen therapy and retrolental fibroplasia, led to a rapid decline in the use of the AL, even before the publication of the randomized trial.
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Thorax 2002 Jan;57(1):29-33
Intensive Care Unit, Royal Prince Alfred Hospital, Sydney, Australia.
BACKGROUND: Traditionally, patients with acute respiratory failure due to chronic obstructive pulmonary disease (COPD) admitted to the intensive care unit (ICU) are believed to have a poor outcome. A study was undertaken to explore both hospital and long term outcome in this group and to identify clinical predictors. METHODS: A retrospective review was carried out of consecutive admissions to a tertiary referral ICU over a 6 year period. This group was then followed prospectively for a minimum of 3 years following ICU admission. RESULTS: A total of 74 patients were admitted to the ICU with acute respiratory failure due to COPD during the study period. Mean forced expiratory volume in 1 second (FEV1) was 0.74 (0.34) l. Eighty five per cent of the group underwent invasive mechanical ventilation for a median of 2 days (range 1-17). The median duration of stay in the ICU was 3 days (range 2-17). Survival to hospital discharge was 79.7%. Admission arterial carbon dioxide tension (PaCO2) and APACHE II score were independent predictors of hospital mortality on multiple regression analysis. Mortality at 6 months, 1, 2, and 3 years was 40.5%, 48.6%, 58.1%, and 63.5%, respectively. There were no independent predictors of mortality in the long term. CONCLUSIONS: Despite the need for invasive mechanical ventilation in most of the study group, good early survival was observed. Mortality in the long term was significant but acceptable, given the degree of chronic respiratory impairment of the group.
PMID: 11809986, UI: 21669352
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