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Anaesthesia 2003 Jan;58(1):87
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PMID: 12492672, UI: 22380322
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Anaesthesia 2003 Jan;58(1):1-3
PMID: 12492660, UI: 22380310
Anesth Analg 2003 Jan;96(1):229-32, table of contents
Department of Anesthesiology and Intensive Care Medicine, Katharina Kasper Kliniken, Germany.
IMPLICATIONS: PercuTwist is a new technique for percutaneous tracheostomy in that stoma dilation is achieved with a unique screwlike dilating device. We describe the technique itself and our first clinical experiences with PercuTwist.
PMID: 12505957, UI: 22392431
Anesth Analg 2003 Jan;96(1):82-4, table of contents
SenTec Inc., Therwil, Switzerland. tschupp@sentec.ch
IMPLICATIONS: A new combined ear sensor was tested for accuracy in 20 critically ill children. It provides noninvasive and continuous monitoring of arterial oxygen saturation, arterial carbon dioxide tension, and pulse rate. The sensor proved to be clinically accurate in the tested range.
PMID: 12505928, UI: 22392402
Br J Anaesth 2003 Feb;90(2):155-160
Universite Claude Bernard Lyon 1, Faculte de Pharmacie, Departement de Pharmacie, Clinique de Pharmacocinetique et d'Evaluation du Medicament, 8 Avenue Rockefeller, F-69373 Lyon, Cedex 08, France. Laboratoire de Pharmacocinetique Clinique and Service de Soins Intensifs Post-operatoires, Hopital Neuro-Cardiologique, 59 Boulevard Pinel, F-69394 Lyon, Cedex 03, France.
[Record supplied by publisher]
BACKGROUND: Ketamine is used as an anaesthetic agent for short surgical procedures, and as a sedative and analgesic in intensive care patients. Intensive care patients with brain or spinal cord injury may have physiological changes that could alter the pharmacokinetics of ketamine. The pharmacokinetics of ketamine have been studied in healthy volunteers and in patients undergoing different types of surgery, but no data are available in intensive care patients. METHODS: We determined the pharmacokinetics of ketamine and its active metabolites, norketamine and dehydronorketamine, in 12 intensive care patients with brain or spinal cord injury. The effect of ketamine on haemodynamic variables was also investigated. RESULTS: The total clearance of ketamine, mean (SD), was 36.0 (13.3) ml min(-1) kg(-1), the volume of distribution (Vbeta) was 16.0 (8.6) litre kg(-1), and the elimination half-life was 4.9 (1.6) h. Ketamine did not alter any haemodynamic variables in the patients studied. CONCLUSIONS: Pharmacokinetic variables of ketamine in intensive care patients are greater than in healthy volunteers and in surgical patients. The increase in the volume of distribution is greater than the increase in clearance, resulting in a longer estimated half-life of ketamine in this patient group. Br J Anaesth 2003; 90: 155-60
PMID: 12538370
Crit Care Med 2003 Jan;31(1):293-8
[Medline record in process]
OBJECTIVE To identify a consensus of opinion regarding the content of an intensive care core syllabus for undergraduate medical students and factors that may limit its teaching.DESIGN Cross-sectional postal survey containing 35 items ranging from department structure to curriculum content and factors that limit the teaching of intensive care.SETTING English-speaking medical schools (n = 210) listed in the 1986 World Health Organization Directory.MEASUREMENTS AND MAIN RESULTS Of 122 (58%) returned questionnaires, a 45% return was achieved from the United States and 86% from non-U.S. countries. Most respondents (84%) considered teaching undergraduate intensive care to be essential; however, teaching intensive care was compulsory in only 31% of schools. Many schools (43%) reported recent changes to their intensive care curriculum. Most respondents (60%) thought that intensive care specialists should teach and that each student required a median (interquartile range) of 20 (10-80) hrs of teacher contact time. Resuscitation skills were taught in 98% of schools. In comparison, 63% of schools had no intensive care syllabus. More than 90% of respondents thought that the intensive care syllabus should include the following: cardiopulmonary resuscitation, assessment and management of the acutely ill patient; management of respiratory, circulatory, and multiple organ system failure (including systemic inflammatory response syndrome and sepsis); management of the unconscious patient; early postoperative care; and communication skills and ethics as they relate to end-of-life issues. Factors that limited intensive care teaching were lack of staff, funding, and time dedicated to teaching and excessive clinical workload. Student performance in intensive care was assessed by 66% of schools, but only 28% used a written or oral examination.CONCLUSIONS By surveying a wide range of medical schools internationally, we have been able to define an undergraduate intensive care syllabus that could be delivered in 20 hrs or 1 wk of dedicated teaching time. Factors that impede the provision of undergraduate intensive care teaching are a lack of staff, funding, and dedicated teaching time.
PMID: 12545032, UI: 22431173
Crit Care Med 2003 Jan;31(1):120-5
OBJECTIVE This study was performed to quantify the quality benefits and staff perceptions of a computerized clinical information system implementation in an intensive care unit. Although clinical information systems have been available and implemented in many intensive care units for more than a decade, there is little objective evidence of their impact on the quality of care and staff perceptions.DESIGN A longitudinal observational study before and after clinical information system implementation.SETTING A 12-bed adult general intensive care unit in a large Australian tertiary referral teaching hospital.INTERVENTION Implementation of a fully featured clinical information system to replace paper-based charts of patient observations, clinical records, results reporting, and drug prescribing.MEASUREMENTS AND MAIN RESULTS The frequency of clinical adverse events over a 4-yr period using an established reporting system was examined. Pre- and postimplementation staff questionnaires were distributed and analyzed. There were significant reductions in the rates of medication, intravenous therapy, and ventilator incidents. There was a trend toward a reduction in pressure sores. The survey, utilizing a validated questionnaire, demonstrated a positive perception of the clinical information system by nursing staff, with less time spent in documentation and more time in patient care. Nursing staff recruitment and retention improved after clinical information system implementation.CONCLUSIONS Implementation of a fully featured clinical information system was associated with significant improvements in key quality indicators, positive nursing staff perceptions, and some positive resource implications.
PMID: 12545004, UI: 22431145
Crit Care Med 2003 Jan;31(1):113-9
OBJECTIVE To measure and describe hospital noise and determine whether noise can be correlated with nursing stress measured by questionnaire, salivary amylase, and heart rate.DESIGN Cohort observational study.SETTING Tertiary care center pediatric intensive care unit.SUBJECTS Registered nurses working in the unit.INTERVENTIONS None.MEASUREMENTS AND MAIN RESULTS Eleven nurse volunteers were recruited. An audiogram, questionnaire data, salivary amylase, and heart rate were collected in a quiet room. Each nurse was observed for a 3-hr period during patient care. Heart rate and sound level were recorded continuously; saliva samples and stress/annoyance ratings were collected every 30 mins. Variables assessed as potential confounders were years of nursing experience, caffeine intake, patients' Pediatric Risk of Mortality Score, shift assignment, and room assignment. Data were analyzed by random effects multiple linear regression using Stata 6.0. The average daytime sound level was 61 dB(A), nighttime 59 dB(A). Higher average sound levels significantly predicted higher heart rates ( =.014). Other significant predictors of tachycardia were higher caffeine intake, less nursing experience, and daytime shift. Ninety percent of the variability in heart rate was explained by the regression equation. Amylase measurements showed a large variability and were not significantly affected by noise levels. Higher average sound levels were also predictive of greater subjective stress ( =.021) and annoyance ( =.016).CONCLUSIONS In this small study, noise was shown to correlate with several measures of stress including tachycardia and annoyance ratings. Further studies of interventions to reduce noise are essential.
PMID: 12545003, UI: 22431144
Crit Care Med 2003 Jan;31(1):104-12
OBJECTIVES To assess the outcome and to identify early prognostic indicators in a global population of patients with hematologic malignancy admitted to the intensive care unit for a life-threatening complication.DESIGN Retrospective observational study.SETTING Medical intensive care unit at a tertiary university hospital.PATIENTS A total of 124 consecutive critically ill patients with a hematologic malignancy admitted to the intensive care unit during a 3.5-yr period.MEASUREMENTS We collected variables at admission and during admission and identified predictors of in-hospital mortality by stepwise logistic regression analysis.MAIN RESULTS Mean Acute Physiology and Chronic Health Evaluation II score was 26 +/- 7.7. Sixty-one percent had a high-grade malignancy, and 27% had active disease. Thirty-five percent were leukopenic (leukocyte count, <1.0 x 10 /L) at admission. Respiratory failure (48%), sepsis (18.5%), and neurologic impairment (17%) were the major reasons for admission at the intensive care unit. Seventy-one percent of the patients required ventilatory support for a median duration of 6 (3-17) days, 46% received vasopressors at admission, and 26.6% needed renal replacement therapy during their intensive care unit stay. A recent bacteremia precipitating intensive care unit admission was found in 21.8% of the patients. Crude intensive care unit, in-hospital, and 6-month mortality rates were 42%, 54%, and 66%, respectively. Four variables were independently associated with outcome in a multivariate logistic regression analysis: leukopenia (odds ratio, 2.9; 95% confidence interval, 1.1-7.7), vasopressors (odds ratio, 3.74; 95% confidence interval, 1.4-9.8), and urea of >0.75 g/L (>12 mmol/L) (odds ratio, 9.4; 95% confidence interval, 4.2-26) at admission were associated with poor outcome, whereas recent bacteremia (odds ratio, 0.17; 95% confidence interval, 0.05-0.58) was associated with better prognosis. Using these variables, we arbitrarily categorized our population into three groups for survival analysis: a low-risk group (low urea with or without either leukopenia or vasopressors, n = 60), an intermediate-risk group (high urea or a combination of leukopenia and vasopressors, n = 34), and a high-risk group (high urea in combination with leukopenia or vasopressors, n = 27). Patients with a bacteremia prompting intensive care unit admission were allocated to a one-step-lower risk group. Survival probabilities at 30 days and 6 months were 75% and 55% in the first group, 35% and 21% in the second group, and 4% and 0%, respectively, in the third group ( <.001).CONCLUSION The general reluctance to admit patients with a hematologic malignancy to the intensive care unit, even with severe critical illness, is unjustified. However, we identified four early predictors of outcome that may be of value in deciding in which patients advanced or prolonged support should not be continued.
PMID: 12545002, UI: 22431143
Crit Care Med 2003 Jan;31(1):98-103
OBJECTIVE To compare low level albumin excretion (microalbuminuria), a marker of systemic capillary permeability, with mortality, Acute Physiologic And Chronic Health Evaluation (APACHE II) score, the Simplified Acute Physiologic (SAP II) score, and their derived mortality probabilities in patients admitted to a general intensive care unit.DESIGN Prospective observational study.SETTING A 14-bed intensive care unit in a university teaching hospital.PATIENTS A total of 140 consecutive patients (59 surgical, 48 medical, 22 trauma, and 11 burns).INTERVENTIONS Urine collection within 15 mins of intensive care unit admission for assessment of microalbuminuria.MEASUREMENTS AND MAIN RESULTS Microalbuminuria, expressed as the albumin-creatinine ratio (ACR: normal, <2.3 mg/mmol), was compared with mortality, APACHE II and SAP II scores and their derived mortality probabilities after 24 hrs, intensive care unit stay, and markers of organ function and inflammation. Median (95% confidence interval) ACR at admission for survivors (n = 115) and nonsurvivors (n = 25) were 4.2 (3.6-6.5) and 17.8 (8.0-40.8) mg/mmol, respectively ( =.0002 Mann Whitney). For 92 surgical, trauma, and burn patients, of whom 81 survived, ACR of >5.9 mg/mmol gave a sensitivity for death of 100%, specificity of 59%, positive predictive value of 25%, and negative predictive value of 100%. Mortality probability receiver operator characteristic curve areas for ACR, APACHE II, and SAP II were 0.843 ( <.0001), 0.793 ( =.0004), and 0.770 ( =.0017), respectively. ACR was associated with intensive care unit stay ( =.0021) and highest serum C-reactive protein ( =.0002), serum creatinine ( <.0001), and bilirubin ( =.0009). For 48 medical patients, of whom 34 survived, admission ACRs for survivors and nonsurvivors were 8.3 (5.7-10.8) and 10.7 (4.1-48.2) mg/mmol, respectively ( =.32). SAP II, but not APACHE II, score was significantly higher for nonsurvivors.CONCLUSIONS For surgical, trauma, and burn patients, but not medical patients, microalbuminuria within 15 mins of intensive care unit admission predicted death as well as APACHE II and SAP II scores calculated after 24 hrs, and it shows promise as a predictor of outcome.
PMID: 12545001, UI: 22431142
Crit Care Med 2003 Jan;31(1):45-51
OBJECTIVE Scoring systems that predict mortality do not necessarily predict prolonged length of stay or costs in the intensive care unit (ICU). Knowledge of characteristics predicting prolonged ICU stay would be helpful, particularly if some factors could be modified. Such factors might include process of care, including active involvement of full-time ICU physicians and length of hospital stay before ICU admission.DESIGN Demographic data, clinical diagnosis at ICU admission, Simplified Acute Physiology Score, and organizational characteristics were examined by logistic regression for their effect on ICU and hospital length of stay and weighted hospital days (WHD), a proxy for high cost of care.SETTING A total of 34 ICUs at 27 hospitals participating in Project IMPACT during 1998.PATIENTS A total of 10,900 critically ill medical, surgical, and trauma patients qualifying for Simplified Acute Physiology Score assessment.INTERVENTIONS None.RESULTS Overall, 9.8% of patients had excess WHD, but the percentage varied by diagnosis. Factors predicting high WHD include Simplified Acute Physiology Score survival probability, age of 40 to 80 yrs, presence of infection or mechanical ventilation 24 hrs after admission, male sex, emergency surgery, trauma, presence of critical care fellows, and prolonged pre-ICU hospital stay. Mechanical ventilation at 24 hrs predicts high WHD across diagnostic categories, with a relative risk of between 2.4 and 12.9. Factors protecting against high WHD include do-not-resuscitate order at admission, presence of coma 24 hrs after admission, and active involvement of full-time ICU physicians.CONCLUSIONS Patients with high WHD, and thus high costs, can be identified early. Severity of illness only partially explains high WHD. Age is less important as a predictor of high WHD than presence of infection or ventilator dependency at 24 hrs. Both long ward stays before ICU admission and lack of full-time ICU physician involvement in care increase the probability of long ICU stays. These latter two factors are potentially modifiable and deserve prospective study.
PMID: 12544992, UI: 22431133
Crit Care Med 2003 Jan;31(1):28-33
OBJECTIVES To determine whether children who experience longer intensive care unit (ICU) stays after open heart surgery may be identified at admission by clinical criteria. To identify factors associated with longer ICU stays that are potential targets for quality improvement.SETTING Tertiary pediatric cardiac surgical center.DESIGN A retrospective review was performed of pre-, intra-, and postoperative factors for children undergoing open heart surgery. All factors were evaluated for strength of association with length of ICU stay (LOS) using a negative binomial model. After multiple analysis, factors were deemed significant if associated with a LOS with <.02.PATIENTS A total of 355 pediatric patients who had cardiac surgery with cardiopulmonary bypass in a 1-yr period from April 1999 until March 2000.MEASUREMENTS AND MAIN RESULTS Children who fell above the 95th percentile for LOS in our institution occupied 30% of bed days and had a three-fold greater mortality. Of all clinical factors considered, those significantly associated with LOS were as follows: -mechanical ventilation, neonatal status, medical problems, and transfer from abroad; -higher operative complexity, increased cardiopulmonary bypass time or ischemic time, and circulatory arrest; and -delayed sternal closure, sepsis, renal failure, pulmonary hypertension, chylothorax, diaphragm paresis, and arrhythmia. A model combining all factors identified preoperative mechanical ventilation, neonatal status, major medical problems, operative complexity, cardiopulmonary bypass time, and a postoperative complication score as independently associated with LOS ( <.01).CONCLUSIONS At the time of ICU admission after open heart surgery, clinical criteria are evident that highlight a child's risk of longer ICU stay. These pre- and intraoperative factors relate to LOS independent of subsequent postoperative events. Those postoperative complications that are most strongly associated with increased LOS are identified and, therefore, made accessible to quality control.
PMID: 12544989, UI: 22431130
Crit Care Med 2003 Jan;31(1):S25-8
Antibiotic use will always be an important part of medical practice in the intensive care unit. Antibiotic resistance increases the chance that empirical therapy will be inadequate to cover the organisms implicated in any particular infection. Therefore, strategies that can allow for optimal empirical antibiotic choice, while at the same time minimizing emergence of antibiotic resistance, are particularly important. In many situations, such strategies require some external stewardship of antibiotic use to be maximally effective. Antibiotic stewardship programs may take the form of management teams comprising infectious disease physicians and pharmacists. These clinicians work in concert with critical care specialists in choosing optimal empirical regimens and in streamlining therapy once culture results are available. Alternatively, computer-based clinical support systems have been developed that can guide physicians to utilize optimal antibiotic choices. External stewardship of antibiotic use may be particularly necessary in circumstances of increased antibiotic resistance, especially exhibited by Gram-negative bacilli. A number of examples exist in which antibiotic control programs can work when traditional infection control programs have failed. Mutation of organisms to produce antibiotic resistance is undoubtedly going to outstrip availability of new antibiotics in the near future. Antibiotic stewardship in concert with improved diagnostic methods may be our only hope in preventing endemic panresistant organisms.
PMID: 12544973, UI: 22431114
Crit Care Med 2003 Jan;31(1):S17-24
OBJECTIVE To determine the cost impact of intensive care unit (ICU) drug use on a hospital's total drug expense and to compare ICU pharmacy resource utilization with resource utilization of other hospital departments that provided services to the ICU. Additionally, to suggest strategies, based on these methods and results, to optimize ICU drug use.METHODS Financial transactions for all ICU patients (n = 23,107) treated during fiscal years 1999-2002 were retrieved from the hospital's data repository. ICU drug costs were calculated both as the percentage of total drug costs for each fiscal year and adjusted for hospital volume (ICU patient days). ICU department charges were calculated as a percentage of total ICU charges and analyzed by simple descriptive statistics (mean +/- sd). Drug utilization was retrieved for those patients accounting for the highest percentage of ICU pharmacy charges.MAIN RESULTS ICU drug costs accounted for 38.4% (+/-4.1% sd) of the total drug costs and have increased at a rate greater than non-ICU drug costs (12% vs. 6%). ICU pharmacy charges accounted for an average of 11.1% (+/-9.2% sd) of the total ICU charges, ranking as the fourth most costly of ICU charges. Both costly and highly used ICU therapies were identified for focus on cost-effectiveness analyses or application of an evidence-based drug use and disease state management program model to ICU pharmacotherapy.CONCLUSIONS ICU drug therapies have a significant impact on hospital costs, and effective clinical informatics services and multidisciplinary collaboration programs are necessary to optimize ICU pharmacotherapy.
PMID: 12544972, UI: 22431113
Crit Care Med 2002 Nov;30(11 Suppl):S500-14
Burn Surgery Service, Shriners Burns Hospital, Sumner Redstone Burn Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
During the past 20 yrs, as burn care has evolved as a specialty of surgery, survival and outcome quality have soared. Public expectations for survival and long-term outcomes are at previously unprecedented levels. These changes are the result of a number of advances in aspects of burn care that have occurred in parallel and have fostered increasing regionalization of this resource-intensive activity into fewer specialized centers. These are complex hospitalizations and can be divided into four phases: initial evaluation and resuscitation, initial wound excision and biological closure, definitive wound closure, and rehabilitation and reconstruction.
PMID: 12528792, UI: 22416126
Crit Care Med 2002 Nov;30(11 Suppl):S489-99
Children's Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA. Mark.proctor@tch.harvard.edu
Pediatric spinal cord injury is a relatively uncommon problem, responsible for approximately 5% of all spinal cord injuries. Anatomic and behavioral differences between adults and children lead to variation in injury type and severity. Young children are more prone to high cervical injuries, with nearly 80% of injuries in children < 2 yrs old affecting this area. As the child approaches 8-10 yrs of age, the spinal anatomy and therefore injury pattern more closely approximates adult injuries. Although the prevalence of spine injuries is lower in children, clearing the spine becomes more complex due to radiographic differences and the inability to "clinically" clear the cervical spine in young children. In this article, the types of injuries seen in children are discussed, with an emphasis on acute management and clearance of the cervical spine. Treatment options and long-term issues are also discussed.
PMID: 12528791, UI: 22416125
Crit Care Med 2002 Nov;30(11 Suppl):S468-77
Department of Anesthesiology Critical Care Medicine, Childrens Hospital of Los Angeles, 4650 Sunset Boulevard, MS# 12, Los Angeles, CA 90027-6062, USA.
Multiple trauma is more than the sum of the injuries. Management not only of the physiologic injury but also of the pathophysiologic responses, along with integration of the child's emotional and developmental needs and the child's family, forms the basis of trauma care. Multiple trauma in children also elicits profound psychological responses from the healthcare providers involved with these children. This overview will address the pathophysiology of multiple trauma in children and the general principles of trauma management by an integrated trauma team. Trauma is a systemic disease. Multiple trauma stimulates the release of multiple inflammatory mediators. A lethal triad of hypothermia, acidosis, and coagulopathy is the direct result of trauma and secondary injury from the systemic response to trauma. Controlling and responding to the secondary pathophysiologic sequelae of trauma is the cornerstone of trauma management in the multiply injured, critically ill child. Damage control surgery is a new, rational approach to the child with multiple trauma. The selection of children for damage control surgery depends on the severity of injury. Major abdominal vascular injuries and multiple visceral injuries are best considered for this approach. The effective management of childhood multiple trauma requires a combined team approach, consideration of the child and family, an organized trauma system, and an effective quality assurance and improvement mechanism.
PMID: 12528789, UI: 22416123
Crit Care Med 2002 Nov;30(11 Suppl):S457-67
Department of Pediatrics, Section of Critical Care, University of California-Davis Children's Hospital, Sacramento, CA, USA.
Trauma triage scores, severity of illness measures, and mortality prediction models quantitate severity of injury and stratify patients according to a specified outcome. Triage scoring systems are typically used to assist prehospital personnel determine which patients require trauma center care, but they are not recommended as the sole determinant of triage. Severity of illness measures and mortality prediction models are used in clinical and health services research for risk-adjusted outcomes analyses and institutional benchmarking. As clinicians and researchers, it is imperative that we be knowledgeable of the methodologies and applications of these scoring and risk prediction systems to ensure their quality and appropriate utilization.
PMID: 12528788, UI: 22416122
Crit Care Med 2002 Nov;30(11 Suppl):S393-401
Department of Neurosurgery, University of Pittsburgh, Children's Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, PA 15213, USA.
Trauma is the leading cause of both morbidity and mortality in the pediatric population, and traumatic injury causes > 50% of all childhood deaths. Significant mortality rates have been reported for children with traumatic brain injury. Although children have better survival rates as compared with adults with traumatic brain injury, the long-term sequelae and consequences are often more devastating in children due to their age and developmental potential. The costs involved in the care of a child with severe traumatic brain injury, extended over that child's lifetime, are significant. It is unfortunate that despite preventive measures, traumatic brain injury remains the major morbidity and mortality factor for children.
PMID: 12528780, UI: 22416114
Intensive Care Med 2003 Jan 24;
Department of Radiology, Charite Campus Virchow KlinikumHumboldt University, Augustenburgerplatz 1, 13353, Berlin, Germany.
OBJECTIVE. We report on the use of portable computed tomography (CT) in an ICU setting. The additional diagnostic gain and therapeutic consequences were assessed. PATIENTS. Ten ICU patients underwent 14 portable chest CT examinations. In 64% maximum intensive care was required, according to TISS28 (>40), and 42% were at a risk of mortality higher than 25% (MODS) on the day of portable CT examination. In three portable CT examinations the patients were considered not transportable and were examined directly in the patient room. All other examinations were performed in a special interventional suite directly on the ICU. RESULTS. Of 14 examinations 8 (57%) resulted in a change in patient management within 48 h. All patients profited from portable CT and no hazards occurred related to CT. CONCLUSIONS. To perform portable CT in the interventional suite on the ICU allows immediate minimally invasive therapeutic interventions and provides full ICU monitoring.
PMID: 12545344
Intensive Care Med 2003 Jan 22;
Department of Anesthesiology and Intensive Care, CHU PontchaillouUniversite Rennes 1, 2 rue Henri Le Guilloux, 35033, Rennes Cedex 9, France.
OBJECTIVE. To assess the relationship between the base deficit value in the immediate postoperative period of coronary surgery for cardiopulmonary bypass and the length of stay in the ICU. DESIGN AND SETTING. Prospective descriptive study in the department of anesthesia and cardiovascular surgery of a university hospital. PATIENTS. 185 consecutive patients. INTERVENTIONS. Coronary artery bypass graft with cardiopulmonary by pass. MEASUREMENTS AND RESULTS. Thirty variables were determined during the pre-, intra-, and postoperative periods; a statistical univariate analysis was performed differentiating patients whose length of stay in the ICU was 2 days or less and those whose stay was more than 2 days. Secondly, a logistic regression model was performed on the variables shown to have a statistically significant difference in univariate analysis, with determination of the odd ratio. Fourteen variables had a statistically significant difference in univariate analysis and three of them highlighted by the logistic regression model: administration of catecholamines, base deficit value in the 1st h postoperatively, and age with odd ratios, respectively, of 3.15, 1.51, and 1.07). CONCLUSIONS. The value of base deficit measured during the 1st h after coronary surgery for cardiopulmonary bypass is correlated with the length of stay in ICU.
PMID: 12541160
Intensive Care Med 2003 Jan 23;
Women's and Children's Hospital, 72 King William Road, SA 5006, North Adelaide, Australia.
OBJECTIVE. To describe the uniform diagnostic coding system used in Australia and New Zealand to code reasons for admitting children to intensive care, and to highlight the benefits of a uniform approach. DESIGN. International, multicentre, observational study. SETTING. A registry of children admitted to intensive care in Australia and New Zealand. PATIENTS. The records of 19,249 children admitted to intensive care between 1997 and 2000 were analysed. MEASUREMENTS AND RESULTS. The system was designed empirically using expert consensus. The principal diagnosis or main reason for intensive care admission and up to five associated diagnoses are coded. The system has four levels of coding: non-operative or post-procedural admission, diagnostic group, specific condition, and for injury and infection the aetiological factor. The main reason for intensive care admission was coded in all patient records, however, for 11.1% of records the code was limited to diagnostic group with the specific condition coded as "other diagnosis". Two or more diagnoses were coded in 61% of records. The most frequent reason for admission was asthma. CONCLUSIONS. The major advantage of the system is that units in the region use the same method of coding. A uniform international approach to coding reasons for admitting children to intensive care is needed.
PMID: 12541153
Intensive Care Med 2003 Jan 21;
CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Laboratory, Department of Critical Care Medicine, School of MedicineUniversity of Pittsburgh, 3550 Terrace Street, 15261, Pittsburgh, PA, USA.
The traditional goal of intensive care has been to decrease short-term mortality. While worthy, this goal fails to address the issue of what it means to survive intensive care. Key questions include whether intensive care survivors have optimal long-term outcomes and whether ICU care decisions would change if we knew more about these outcomes. The 2002 Brussels Roundtable, "Surviving Intensive care", highlighted these issues, summarizing the available evidence on natural history and risk factors for critical illness and outlining future directions for care and research. Critical illness is associated with a wide array of serious and concerning long-term sequelae that interfere with optimal patient-centered outcomes. Although traditional short-term outcomes, such as hospital mortality, remain extremely important, they are not likely to be adequate surrogates for subsequent patient-centered outcomes. As such, it is important to focus specifically on how critical illness and intensive care affects a patient's and relatives' long-term health and well-being. There are a large number of potential pre-, intra-, and post-ICU factors that may improve or worsen these outcomes, and these factors are subjects for future research. In addition, future clinical trials of ICU therapies should include long-term follow-up of survival, quality of life, morbidity, functional status, and costs of care. Follow-up ought to be for at least six months. The SF-36 and EuroQOL EQ-5D are the best-suited instruments for measuring quality of life in multicenter critical care trials though further methodologic research and instrument design is encouraged. There are also opportunities today to improve care. Key to taking advantage of such opportunities is the need for a global awareness of critical illness as an entity that begins and ends outside the ICU 'box'. Specific interventions that show promise for improving care include ICU discharge screening tools and ICU follow-up clinics.
PMID: 12536269
Surgical Intensive Care DivisionGeneva University Hospitals, 1211, Geneva 14, Switzerland.
OBJECTIVE. In mechanically ventilated patients the indices which assess preload are used with increasing frequency to predict the hemodynamic response to volume expansion. We discuss the clinical utility and accuracy of some indices which were tested as bedside indicators of preload reserve and fluid responsiveness in hypotensive patients under positive pressure ventilation. RESULTS AND CONCLUSIONS. Although preload assessment can be obtained with fair accuracy, the clinical utility of volume responsiveness-guided fluid therapy still needs to be demonstrated. Indeed, it is still not clear whether any form of monitoring-guided fluid therapy improves survival.
PMID: 12536268
Lancet 2003 Jan 4;361(9351):92
Joal.Hill@advocatehealth.com
PMID: 12517519, UI: 22406102