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Am J Crit Care 2002 Mar;11(2):96, 98, 100
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PMID: 11888132, UI: 21884964
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Am J Respir Crit Care Med 2002 Sep 1;166(5):717-23
The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Laboratory, Department of Critical Care Medicine, and Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine.
[Medline record in process]
Despite careful evaluation of changes in hospital care for community-acquired pneumonia (CAP), little is known about intensive care unit (ICU) use in the treatment of this disease. There are criteria that define CAP as "severe," but evaluation of their predictive value is limited. We compared characteristics, course, and outcome of inpatients who did (n = 170) and did not (n = 1,169) receive ICU care in the Pneumonia Patient Outcomes Research Team prospective cohort. We also assessed the predictive characteristics of four prediction rules (the original and revised American Thoracic Society criteria, the British Thoracic Society criteria, and the Pneumonia Severity Index [PSI]) for ICU admission, mechanical ventilation, medical complications, and death (as proxies for severe CAP). ICU patients were more likely to be admitted from home and had more comorbid conditions. Reasons for ICU admission included respiratory failure (57%), hemodynamic monitoring (32%), and shock (16%). ICU patients incurred longer hospital stays (23.2 vs. 9.1 days, p < 0.001), higher hospital costs ($21,144 vs. $5,785, p < 0.001), more nonpulmonary organ dysfunction, and higher hospital mortality (18.2 vs. 5.0%, p < 0.001). Although ICU patients were sicker, 27% were of low risk (PSI Risk Classes I-III). Severity-adjusted ICU admission rates varied across institutions, but mechanical ventilation rates did not. The revised American Thoracic Society criteria rule was the best discriminator of ICU admission and mechanical ventilation (area under the receiver operating characteristic curve, 0.68 and 0.74, respectively) but none of the prediction rules were particularly good. The PSI was the best predictor of medical complications and death (area under the receiver operating characteristic curve, 0.65 and 0.75, respectively), but again, none of the prediction rules were particularly good. In conclusion, ICU use for CAP is common and expensive but admission rates are variable. Clinical prediction rules for severe CAP do not appear adequately robust to guide clinical care at the current time.
PMID: 12204871, UI: 22193460
Am J Respir Crit Care Med 2002 Aug 15;166(4):518-624
PMID: 12186831, UI: 22174250
Am J Respir Crit Care Med 2002 Aug 15;166(4):433-4
PMID: 12186813, UI: 22174232
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Anaesth Intensive Care 2002 Feb;30(1):60-5
Department of Anaesthesia, Intensive Care, Pain Management, John Hunter Hospital, Newcastle, New South Wales.
Arterial cannulation is frequently used in the critical care environment. Literaturefocuses on insertion techniques and complications. This report utilized data from the Australian Incident Monitoring Study (AIMS-ICU) national database to identify common problems and contributing factors associated with the use and maintenance of arterial lines. A review of narratives, keywords and contributing factors yielded 251 reports outlining 376 incidents. Of these, 15% describing line insertion problems, 66% line use and maintenance problems and 19% patient injuries. Inadequate line securing, accidental line dislodgement, incorrect set-up, distal ischaemia and infection featured prominently. As a result of the incident, 49% of patients involved suffered no ill effect, 28% minor physiological complications and 15% suffered major adverse effects. Multiple contributing factors were selected for each report, with lack of knowledge, rule-based errors, high unit activity, and lack of support staff or supervision selected most frequently. This study highlights the need to employ meticulous insertion technique, line set-up, securing, frequent line assessment and the early removal of lines no longer essential to patient care. Support and education of staff as well as the development of protocols are important for the safe use of arterial lines.
PMID: 11939443, UI: 21936500
Crit Care Nurse 2002 Jun;22(3):15-6
PMID: 12092287, UI: 22087659
Intensive Care Med 2002 Sep;28(9):1316-23
Istituto di Anestesia e Rianimazione, University of Brescia, Piazzale Spedali Civili 1, 25125 Brescia, Italy, latronic@master.cci.unibs.it
OBJECTIVE. To assess the number and quality of the reporting of randomised controlled trials (RCTs) published in Intensive Care Medicine. DESIGN. Systematic revision. SETTING Randomised controlled trials published in Intensive Care Medicine. STUDY SELECTION. All RCTs published in this journal from its birth to December 2000 identified by MEDLINE and our own research. MEASUREMENTS AND RESULTS. The Jadad scale and the individual assessment of key methodological components, namely the randomisation process, blinding and reporting and handling of loss to follow-up, were used to evaluate the quality of reporting. Other information was extracted regarding the design characteristics and the analytical approach. 173 RCTs, 63% of which were from European countries, were analysed. Adequately reported RCTs according to a Jadad scale score of more than 2 were 44 (25.4%). Analysis of individual methodological components revealed a variable percentage of adequate reporting ranging from 3.5% for randomisation to 10.4% for blinding and to 49.1% for loss to follow-up. Sample sizes were small with a median of 30 patients and rationale for its estimation was reported in 7.5%. Despite this, 81.5% of RCTs reported statistically significant results, suggesting that the treatment effects were strong or that a publication bias existed or that the uncertainty principle was not fulfilled. CONCLUSIONS. Randomised controlled trials offer the best evidence of the efficacy of medical interventions, provided that high standards of transparent reporting are used. More resolute attention to the methodological quality of reporting and adherence to recently published guidelines (CONSORT II) may help to achieve this result.
PMID: 12209283, UI: 22198388
Intensive Care Med 2002 Sep;28(9):1309-15
Service de reanimation, Centre Hospitalier, Route de Paris, 01012 Bourg en Bresse, France, lholzapfel@ch-bourg01.fr
OBJECTIVE. To describe a four-step protocol for withholding and withdrawal of life support (WH/WDLS) in intensive care unit (ICU) terminal patients. DESIGN. Observational study. SETTING. A 10-bed ICU of a general hospital. PATIENTS. Eighty-three patients out of 475 consecutive patients admitted over a 1 year period had WH/WDLS. INTERVENTIONS. The healthcare team chose a pattern of treatment limitation on a four-step protocol for every patient every day. There were four alternatives: group 1: no limitation of care; group 2: patient designated do not resuscitate (DNR) and pressors limited to dopamine at a maximum dose of 20 micro g/kg per min; others therapies were continued; group 3: active withdrawal of all therapy except comfort care, i.e., the patient continued to receive nursing, sedation/analgesia, hydration and mechanical ventilation with FIO(2)=0.21 and no positive end-expiratory pressure (PEEP). Sedation was adjusted to Ramsay 3-4. The group 4 was treated the same as group 3 except that minute ventilation was 5 l/min and sedation/analgesia adjusted to Ramsay 6. WH/WDLS was performed only if the full ICU staff and all family members agreed with the procedure. WH/WDLS was documented in the patient's chart. RESULTS. Withholding and withdrawal of life support was performed in 83 patients (17%): 25 patients in group 2 (15 deaths), 36 patients in group 3 (36 deaths) and 22 patients in group 4 (22 deaths). Finally, 73 patients died after WH/WDLS. ICU stay was 10+/-17 days, time from admission to WH/WDLS was 184+407 h and time from WH/WDLS to death was 64+/-84 h. CONCLUSION. This four-step protocol may promote medical decision making on end-of-life care.
PMID: 12209282, UI: 22198387
Intensive Care Med 2002 Sep;28(9):1294-300
Medizinische Klinik und Poliklinik I, Universitatsklinikum Carl Gustav Carus, Technische Universitat, Fetscherstrasse 74, 01307 Dresden, Germany, kroschinsky@mk1.med.tu-dresden.de
OBJECTIVE. To assess the outcome of intensive care unit (ICU) treatment in patients with hematological malignancies. DESIGN AND SETTING. Retrospective cohort study in the medical ICU of a university hospital. PATIENTS. 104 critically ill patients after receiving conventional chemotherapy or autologous hematopoietic stem cell transplantation. INTERVENTIONS. We analyzed demographic data, underlying disease, intensity of antineoplastic regimen, cause of admission, need for mechanical ventilation, and hemofiltration, ICU survival, and survival after discharge, furthermore neutrophil count, C-reactive protein (</=150 vs. >150 mg/l), antithrombin III, prothrombin time, and SAPS II (</=50 vs. >50) at ICU admission. All recorded variables were evaluated for prognostic relevance by univariate and multivariate analyses. MEASUREMENTS AND RESULTS. Overall ICU mortality was 44%, with significantly higher mortality in ventilated patients (74% vs. 12% in nonventilated patients, p<0.001). Overall survival for the entire group 6 months and 1 year after ICU admission was 33% and 29%, respectively. Multivariate analysis revealed mechanical ventilation and SAPS II as independent prognostic factors of both ICU mortality and long-term survival, while C-reactive protein predicted only ICU mortality. CONCLUSIONS. The outcome of patients not requiring ventilatory support in this study was encouraging, while invasive ventilation was again confirmed as predicting a dismal prognosis in this population. Efforts should be directed to avoiding this procedure by reducing the pulmonary toxicity of antineoplastic treatment and to making ventilatory support more tolerable.
PMID: 12209280, UI: 22198385
Intensive Care Med 2002 Sep;28(9):1287-93
Department of Anaesthesiology and Intensive Care, Charite Hospital, Humboldt University, Schumannstr. 20-21, 10098 Berlin, Germany, dieter.beck@rz.hu-berlin.de
OBJECTIVE. To assess the effects of discharge Therapeutic Intervention Scoring System (TISS) scores, discharge time and type of discharge facility on ultimate hospital mortality after intensive care. DESIGN. Retrospective cohort study. SETTING. General intensive care unit (ICU) in a district general hospital. PATIENTS AND PARTICIPANTS. One thousand six hundred fifty-four ICU patients discharged to hospital wards or high dependency units (HDUs). MAIN MEASUREMENTS AND RESULTS. Vital status at ultimate hospital discharge was the main outcome measurement. The crude hospital mortality after ICU discharge (12.6%) was significantly associated with increasing discharge TISS scores (chi(2) for trend =9.0, p=0.028). This trend was similarly observed after adjusting for severity of disease. Patients with high TISS scores (>30) who were discharged to hospital wards had a higher risk (1.31; CI: 1.02-1.83) of in-hospital death compared with patients discharged to HDUs. Crude mortality was significantly higher for late 20.00 h to 7.59 h) than for early (8.00 h to 19.59 h) discharges (18.8% versus 11.2%, chi(2) =12.1, p=0.0004). Adjusted for disease severity, the mortality risk was 1.70-fold (CI: 1.28-2.25) increased for late ICU discharges. Patients discharged late to hospital wards had significantly higher severity-adjusted risks (1.87; CI:1.36-2.56) than had patients discharged to HDUs (1.35; CI: 0.77-2.36). CONCLUSIONS. Both late discharge and high discharge TISS scores are indicators of "premature" ICU discharge and were associated with increased mortality. Intermediate care reduced the mortality of patients discharged "prematurely" from ICU. This adds to the growing evidence of the benefits of intermediate care after ICU discharge.
PMID: 12209279, UI: 22198384
Pediatrics 2002 Sep;110(3):481-5
Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St Louis, Missouri 63110, USA.
OBJECTIVE: The objective of this study was to determine the rate, risk factors, and outcomes of nosocomial primary bloodstream infection in pediatric intensive care unit (PICU) patients. DESIGN: Prospective cohort study. SETTINGS: This study was performed at St Louis Children's Hospital, a 235-bed academic tertiary care center with a combined 22-bed medical and surgical PICU. PATIENTS: Subjects for this study were patients admitted to the PICU between September 1, 1999, and May 31, 2000. INTERVENTIONS: None. OUTCOME MEASURES: Patients were monitored for the development of nosocomial bloodstream infections from the day of PICU admission until 48 hours after PICU discharge. RESULTS: Of 911 patients, 526 (58%) were male and 674 (74%) were white. Congenital heart disease (29%), lung disease (25%), and genetic syndrome (18%) were common. There were 65 episodes of primary bloodstream infection in 57 patients; 5 were polymicrobial and 7 patients had multiple bloodstream infections. Coagulase-negative Staphylococcus was the leading cause of bloodstream infection (n = 28), followed by Enterobacter cloacae (n = 8). The rate of bloodstream infection was 13.8 per 1000 central venous catheter days. In multiple logistic regression analysis, patients with bloodstream infection were more likely to have multiple central venous catheters (adjusted odds ratio [aOR]: 5.7; 95% confidence interval [CI]: 2.9-10.9), arterial catheters (aOR: 5.5; 95% CI: 1.8-16.3), invasive procedures performed in the PICU (aOR: 4.0; 95%CI: 2.0-7.8), and be transported out of the PICU (aOR: 3.4; 95% CI: 1.8-6.7) to the radiology or operating room suites. Severity of illness as measured by admission Pediatric Risk of Mortality score, underlying illnesses, and medications were not associated with increased risk of nosocomial bloodstream infection. Conclusions This study identified a high rate of bloodstream infection among St Louis Children's Hospital PICU patients. Risk factors for bloodstream infection were related more to process of care than to severity of illness. Additional research is needed to develop interventions to reduce nosocomial bloodstream infections in children.
PMID: 12205248, UI: 22194974
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