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Items 1 - 26 of 26 |
One page. |
Comment on:
Renal function in critically ill, morbidly obese patients.
Vincent F, El-Khoury N, Rondeau E.
Publication Types:
PMID: 15187012 [PubMed - indexed for MEDLINE]
Comment on:
Transmission of severe acute respiratory syndrome in critical care: do we need a change?
Hugonnet S, Pittet D.
Publication Types:
PMID: 15161609 [PubMed - indexed for MEDLINE]
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An update on otolaryngology in critical care.
Ramadan HH, El Solh AA.
Department of Otolaryngology-Head and Neck Surgery, West Virginia University, Morgantown, West Virginia, USA.
Publication Types:
PMID: 15087296 [PubMed - indexed for MEDLINE]
Abdominal muscle action during expiration can impair pressure controlled ventilation.
Prasad CV, Drummond GB.
Department of Anaesthesia, Hope Hospital, Manchester, M6 8HD, UK.
Pressure controlled ventilation, and pressure support for spontaneous breathing are often used in intensive care because coordination of the ventilator with patient efforts can improve comfort and possibly reduce sedation. However we report a series of 10 patients whose efforts did not synchronise with pressure controlled ventilation. This was incorrectly diagnosed as inadequate sedation, and treated with increased sedation or muscle paralysis. Better recognition of this condition showed that slow respiratory rates and increased abdominal muscle action during expiration can affect pressure-controlled ventilation and pressure assisted breathing. If the condition is not recognised, treatment for poor synchronisation may delay weaning or be inappropriate.
Publication Types:
PMID: 15200547 [PubMed - indexed for MEDLINE]
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The effects of tracheostomy cuff deflation during continuous positive airway pressure.
Conway DH, Mackie C.
Department of Anaesthesia, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK. daniel.conway@cmmc.nhs.uk
Continuous flow positive pressure devices bridge the gap between mechanical and unsupported ventilation in patients recovering from critical illness. At this point, patients are often fully awake, yet the inflated tracheostomy cuff prevents them from speaking or swallowing. The aim of this study was to investigate the effects of cuff deflation. After ethics committee approval and informed consent, we recorded airway pressures with catheters placed 3 cm beyond the distal tracheostomy tip, respiratory rate, heart rate and peripheral oxygen saturation with continuous positive airway pressures set at 5, 7.5 and 10 cmH(2)O with the cuff inflated and deflated. Sixteen patients completed the study. There were small falls in end expiratory pressure on cuff deflation. The median (interquartile range) pressure drop with set airway pressure of 5 cmH(2)O was 0.25 (0-1.4) mmHg, which increased to 1 (0-3) mmHg at 7.5 cmH(2)O and 1.5 (0-4) mmHg at 10 cmH(2)O. These changes were not clinically significant and cardiopulmonary parameters remained stable. All patients were able to vocalise following cuff deflation. Twelve patients passed a blue dye swallow screen within a day of tolerating cuff deflation. These results suggest that pressures fall slightly following cuff deflation but this is associated with respiratory stability and may allow patients to talk and swallow.
Publication Types:
PMID: 15200539 [PubMed - indexed for MEDLINE]
Comment on:
Protective ventilation of patients with acute respiratory distress syndrome.
Baba R, Paramesh K, Zwaal JW.
Publication Types:
PMID: 15192007 [PubMed - indexed for MEDLINE]
Comment on:
Surgical critical care--a rose by any other name.
Day CJ.
Publication Types:
PMID: 15192006 [PubMed - indexed for MEDLINE]
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The heart and circulation in severe sepsis.
Young JD.
Adult Intensive Care Unit, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK. duncan.young@nda.ox.ac.uk
Publication Types:
PMID: 15121730 [PubMed - indexed for MEDLINE]
Comment in:
Septic shock of early or late onset: does it matter?
Roman-Marchant O, Orellana-Jimenez CE, De Backer D, Melot C, Vincent JL.
Department of Intensive Care Medicine, Erasme University Hospital, Free University of Brussels, Belgium.
STUDY OBJECTIVES: To determine possible differences in morbidity and mortality between early and late onset of septic shock in ICU patients. DESIGN: Systematic data collection. SETTING: Thirty-one-bed, mixed, medicosurgical ICU in a university hospital. PATIENTS: All 65 patients who acquired septic shock after admission to the ICU between February 1999 and April 2000. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Forty-one of the 65 patients presented with septic shock within 24 h of admission to the ICU (early septic shock [ESS]); the other 21 patients acquired septic shock > 24 h after ICU admission (late septic shock [LSS]). Eleven patients had a second episode (7 patients in the ESS group, and 4 patients in the LSS group), and 1 patient in the LSS group had a third episode of septic shock. Patients with ESS had higher APACHE (acute physiology and chronic health evaluation) II (mean +/- SD, 26 +/- 6 vs 20 +/- 6; p = 0.002) and sequential organ failure assessment (SOFA) scores (11 +/- 3 vs 7 +/- 3, p < 0.001) on ICU admission, and a higher blood lactate concentration at the onset of shock (median 3.70 mEq/L; interquartile range, 2.6 to 6.6 mEq/L; vs median, 2.50 mEq/L [interquartile range, 1.8 to 4.0 mEq/L], p = 0.03) than patients with LSS. However, the duration of septic shock (median, 42 h [interquartile range, 21 to 97 h] vs median, 93 h [interquartile range, 32 to 241 h], p = 0.058) and the length of ICU stay after the onset of septic shock (median, 75 h; [interquartile range, 38 to 203 h] vs median, 321 h [interquartile range, 96 to 438 h], p = 0.018), was shorter in patients with ESS than patients with LSS. The ICU mortality rate was 63% (26 patients) in the ESS group, and 88% (21 patients) in the LSS group (p = 0.071). At the onset of the first episode of shock, patients with ESS had higher SOFA scores (11 +/- 3 vs 9 +/- 3, p = 0.045), lower pH (7.24 +/- 0.15 vs 7.33 +/- 0.12, p = 0.01), and were treated with higher doses of dopamine (median, 20 microg/kg/min [interquartile range, 14 to 20 microg/kg/min] vs median, 12 microg/kg/min [interquartile range, 8 to 20 microg/kg/min], p = 0.028) than patients with LSS. CONCLUSIONS: Septic shock is more severe when of early onset, as reflected by more severe organ dysfunction, greater lactic acidosis, and higher vasopressor requirements, yet the outcome is better, as reflected by a shorter duration of the shock episode, shorter ICU stay, and slightly lower mortality rates. These differences may influence clinical trials of therapeutic agents for sepsis, and should be taken into account when analyzing the results.
PMID: 15249459 [PubMed - indexed for MEDLINE]
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The use of noninvasive ventilation in acute respiratory failure at a tertiary care center.
Paus-Jenssen ES, Reid JK, Cockcroft DW, Laframboise K, Ward HA.
Department of Medicine, Royal University Hospital, Saskatoon, SK, Canada.
OBJECTIVE: Financial constraints and bed limitations frequently prevent admission of ill patients to a critical care setting. We surveyed the use of treatment with noninvasive ventilation (NIV) in clinical practice by physicians in a tertiary care, university-based teaching hospital and compared our findings with published recommendations for the use of NIV. METHODS: Data were collected prospectively on all patients with acute respiratory failure (ARF) for whom NIV was ordered over a 5-month period. The respiratory therapy department was responsible for administering NIV on written order by a physician. The respiratory therapist completed a survey form with patient tracking data for each initiation of NIV. The investigators then surveyed the clinical chart for clinical data. RESULTS: NIV was utilized for the treatment of ARF on 75 occasions during the 5-month period. Fourteen patients (18%) received NIV for a COPD exacerbation, and 61 patients (82%) received it for respiratory failure of other etiologies. NIV was initiated in the emergency department in 32% of patients, in a critical care setting in 27% of patients, in a ward observation unit in 23% of patients, and on a general medical or surgical ward in 18% of patients. Arterial blood gases (ABGs) were measured on 68 occasions prior to the initiation of NIV, and 51 patients had an ABG measurement within the first 6 h of treatment. The mean pH at baseline was 7.29, and 33% of patients had a baseline pH of < 7.25. Seven patients required endotracheal intubation (ETI) [13%], and there were 18 deaths (24%) with patients having do-not-resuscitate orders, accounting for 12 deaths. CONCLUSION: NIV is commonly used outside of a critical care setting. Our outcomes of ETI and death were similar to those cited in the literature despite less aggressive monitoring of these patients.
PMID: 15249458 [PubMed - indexed for MEDLINE]
Comment on:
Timing is everything.
Higgins TL.
Publication Types:
PMID: 15249432 [PubMed - indexed for MEDLINE]
Caring for the caregiver.
Levy MM.
Medical Intensive Care Unit, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA.
There are certainly many coping behaviors that may assist ICU caregivers in the process of caring for themselves. Staff support groups,regular interdisciplinary meetings to discuss difficult cases,and bringing trained personnel into the intensive care unit (ICU)environment to offer staff training in communication and conflict resolution skills have been suggested as methods for alleviating caregiver stress. Combining these as well as other tools with a deeper look at the caregiver-patient relationship are important building blocks for creating a sane, healthy environment in the ICU. Over the next years, as the population ages, and as technologic advances continue, the critical care units will play an even more prominent role in health care. Given the threat posed by the severe nursing shortage, it becomes apparent that, to prepare for this increased need for critical care services, efforts must be directed to identify the sources of distress for ICU caregivers and develop focused training programs that alleviate the inevitably strains and pressures that arise in the process of compassionate caring for the critically ill.
Publication Types:
PMID: 15183218 [PubMed - indexed for MEDLINE]
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The dying patient in the ICU: role of the interdisciplinary team.
Baggs JG, Norton SA, Schmitt MH, Sellers CR.
School of Nursing and School of Medicine and Dentistry, University of Rochester, 601 Elmwood Avenue, Box SON, Rochester, NY 14642, USA. Judith.Baggs@urms.rochester.edu
Expert opinion supports the application of broad interdisciplinary team approaches to the care of the dying patient in the intensive care unit (ICU). Current literature contains many suggestions about how core team members-physicians, nurses, and patients/family members-could systematically enhance interdisciplinary collaboration in the care of the dying patient. In the few studies of ICU interdisciplinary collaborative care of the dying patient, investigator shave demonstrated improvement in care. In addition, ethics consultants and interdisciplinary palliative care teams, working with the core team members, have improved care for the dying.Further studies are needed to document alternative interdisciplinary models for achieving improved and durable patient, family,and provider outcomes in the care of the dying ICU patient.
Publication Types:
PMID: 15183217 [PubMed - indexed for MEDLINE]
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Spirituality in health: the role of spirituality in critical care.
Puchalski C.
Department of Medicine, The George Washington University, 2131 K Street NW, 5th Floor, Washington, DC 20052, USA. hscsmp@gwumc.edu
Caring for critically ill patients requires that physicians and other health care professionals recognize the potential importance of spirituality in the lives of patients, families, and loved ones and in their own lives. Patients and loved ones undergo tremendous stress and suffering in facing critical illness. Professional caregivers also face similar stress and sadness. Spirituality offers people away to understand suffering and illness. Spiritual beliefs can also impact how people cope with illness. By addressing spiritual issues of patients, loved ones, and ourselves, we can create more holistic and compassionate systems of care.
Publication Types:
PMID: 15183215 [PubMed - indexed for MEDLINE]
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Caring for the family of the critically ill patient.
Kirchhoff KT, Song MK, Kehl K.
School of Nursing, Clinical Science Center K6/358, 600 Highland Avenue, Madison, WI 53792-2455, USA. ktkirchoff@wisc.edu
Family's needs and considerations are an essential component of intensive care unit (ICU) care. Family satisfaction is related to clinician communication and decision making. Indeed, timely, honest communication is vital to the psychosocial health and satisfaction of the family. Conflict often arises within the family and between the family and the clinicians, over decision making. Again, good communication skills are critical to family satisfaction with decision making and comfort with the care received. Family members have numerous psychosocial changes, and may experience depression,anxiety, or anticipatory grief while their family member is dying in the ICU. Awareness of these conditions, providing support to the families, and allowing family access to the dying individual can assist with meeting the family's desire to see their family member have a peaceful death.
Publication Types:
PMID: 15183213 [PubMed - indexed for MEDLINE]
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Principles and practice of withdrawing life-sustaining treatments.
Rubenfeld GD.
Harborview Medical Center, Division of Pulmonary and Critical Care Medicine, University of Washington, 325 Ninth Avenue, Seattle, WA 98104-2499, USA. nodrog@u.washington.edu
The clinician's responsibility to the patient does not end with a decision to limit medical treatment, but continues through the dying process. Every effort should be made to ensure that withdrawing life support occurs with the same quality and attention to detail as is routinely provided when life support is initiated. Approaching the withdrawal of life support as a medical procedure provides clinicians with a recognizable framework for their actions. Key steps in this process are identifying and communicating explicit shared goals for the process, approaching withdrawal of life-sustaining treatments asa medical procedure, and preparing protocols and materials to assure consistent care. Our hope is that adopting a more formal approach to this common procedure will improve the care of patients dying in intensive care units.
Publication Types:
PMID: 15183212 [PubMed - indexed for MEDLINE]
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Delirium and sedation.
Kress JP, Hall JB.
Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, 5841 South Maryland Avenue, MC 6026, Chicago, IL 60637, USA. jkress@medicine.bsd.uchicago.edu
Critically ill patients nearing the end of life frequently present with needs for aggressive sedation and analgesia. Optimizing patient comfort while permitting effective communication are challenging goals in this patient population. This article discusses delirium and sedation as it applies to dying patients, and provides recommendations for effective management strategies to optimize the experience of such patients at the end of life.
Publication Types:
PMID: 15183211 [PubMed - indexed for MEDLINE]
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Terminal dyspnea and respiratory distress.
Campbell ML.
Palliative Care Service, Nursing Administration, Detroit Receiving Hospital, 4201 St. Antoine Boulevard, Detroit, MI 48201, USA. mcampbe3@dmc.org
Dyspnea is a subjective experience that can be reported by the patient. Respiratory distress is an observable corollary, and represents the physical or emotional suffering that results from the experience of dyspnea. Recognizing and understanding this subjective phenomenon poses a challenge to intensive care unit (ICU) clinicians when caring for the patient who is dying in the ICU. Dyspnea and cognitive impairment are highly prevalent in the terminally ill ICU patient. A Respiratory Distress Observation Model may provide a theoretical foundation for the assessment of this phenomenon that is grounded in emotional and autonomic domains of neurologic function.Treatment of dyspnea and respiratory distress relies on nonpharmacologic interventions and opioids and sedatives. As with pain, the treatment of dyspnea and respiratory distress relies on close evaluation of the patient and treatment to satisfactory effect. Empirical evidence suggests that quality care with control of distressing symptoms does not hasten death. Withholding opioids or sedatives in the face of unrelieved dyspnea or respiratory distress has no moral foundation.
Publication Types:
PMID: 15183210 [PubMed - indexed for MEDLINE]
Winter excess mortality in intensive care in the UK: an analysis of outcome adjusted for patient case mix and unit workload.
Harrison DA, Lertsithichai P, Brady AR, Carpenter JR, Rowan K.
Intensive Care National Audit and Research Centre, Tavistock House, Tavistock Square, WC1H 9HR, London, UK.
OBJECTIVE. To investigate whether mortality in UK intensive care units is higher in winter than in non-winter and to explore the importance of variations in case mix and increased pressure on ICUs. DESIGN AND SETTING. Cohort study in 115 adult, general ICUs in England, Wales and Northern Ireland. PATIENTS AND PARTICIPANTS. 113,389 admissions from 1995 to 2000. MEASUREMENTS AND RESULTS. Hospital mortality following admission to ICU was compared between winter (December-February) and non-winter (March-November). The causes of any observed differences were explored by adjusting for the case mix of admissions and the workload of the ICUs. Crude hospital mortality was higher in winter. After adjusting for case mix using the APACHE II mortality probability this effect was reduced but still significant. When additional factors reflecting case mix and workload were introduced into the model, the overall effect of winter admission was no longer significant. Factors reflecting both the case mix of the individual patient and of the patients in surrounding beds were found to be significantly associated with outcome. After adjustment for other factors, the occupancy of the unit (proportion of beds occupied) was not significantly associated with mortality. CONCLUSIONS. The excess winter mortality observed in UK ICUs can be explained by variation in the case mix of admissions. Unit occupancy was not associated with mortality.
PMID: 15300367 [PubMed - as supplied by publisher]
Comment on:
Transport of critically ill children in a resource-limited setting: alternatives to a specialized retrieval team.
Goh AY, El-Amin Abdel-Latif M.
Publication Types:
PMID: 14727017 [PubMed - indexed for MEDLINE]
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Effects on skeletal muscle of intravenous glutamine supplementation to ICU patients.
Tjader I, Rooyackers O, Forsberg AM, Vesali RF, Garlick PJ, Wernerman J.
Department of Anesthesiology and Intensive Care, Clinical Metabolic Research Center, Huddinge University Hospital, Karolinska Institutet, SE-141 86 Stockholm, Sweden. inga.tjader@hs.se
OBJECTIVE: To evaluate the effect of four doses of intravenous glutamine supplementation on skeletal muscle metabolism. DESIGN: A prospective, blinded, randomized study. SETTING: The general Intensive Care Unit (ICU) of a university hospital. PATIENTS: ICU patients with multiple organ failure (n=40), who were expected to stay in the unit for more than five days. INTERVENTION: Patients received 0, 0.28, 0.57 or 0.86 g of glutamine per kg bodyweight per day intravenously for five days as part of an isocaloric, isonitrogenous and isovolumetric diet. RESULTS: Plasma glutamine concentration responded to glutamine supplementation with normalization of plasma levels in a dose-dependent way, while free muscle glutamine concentration, as well as muscle protein synthesis and muscle protein content, did not change significantly. CONCLUSION: Intravenous glutamine supplementation to ICU patients for a period of five days resulted in normalization of plasma glutamine concentrations in a dose-dependent way whereas muscle glutamine concentrations were unaffected.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14722645 [PubMed - indexed for MEDLINE]
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Airway colonisation in long-term mechanically ventilated patients. Effect of semi-recumbent position and continuous subglottic suctioning.
Girou E, Buu-Hoi A, Stephan F, Novara A, Gutmann L, Safar M, Fagon JY.
Infection Control Unit, Hopital Henri Mondor, Assistance Publique-Hopitaux de Paris, 51 avenue Mal de Lattre de Tassigny, 94010 Creteil, France. emmanuelle.girou@hmn.ap-hop-paris.fr
OBJECTIVE: To evaluate the impact of continuous subglottic suctioning and semi-recumbent body position on bacterial colonisation of the lower respiratory tract. DESIGN: A randomised controlled trial. SETTING: The ten-bed medical ICU of a French university hospital. PATIENTS: Critically ill patients expected to require mechanical ventilation for more than 5 days. INTERVENTIONS: Patients were randomly assigned to receive either continuous suctioning of subglottic secretions and semi-recumbent body position or to receive standard care and supine position. MEASUREMENTS AND RESULTS: Oropharyngeal and tracheal secretions were sampled daily and quantitatively cultured. All included patients were followed up from day 1 (intubation) to day 10, extubation or death. Ninety-seven samples of oropharynx and trachea were analysed (40 for the suctioning group and 57 for the control group). The median bacterial counts in trachea were 6.6 Log10 CFU/ml (interquartile range, IQR, 4.4-8.3) in patients who received continuous suctioning and 5.1 Log10 CFU/ml (IQR 3.6-5.5) in control patients. Most of the patients were colonised in the trachea after 1 day of mechanical ventilation (75% in the suctioning group, 80% in the control group). No significant difference was found in the daily bacterial counts in the oropharynx and in the trachea between the two groups of patients. CONCLUSION: Tracheal colonisation in long-term mechanically ventilated ICU patients was not modified by the use of continuous subglottic suctioning and semi-recumbent body position.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14647884 [PubMed - indexed for MEDLINE]
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Citrate vs. heparin for anticoagulation in continuous venovenous hemofiltration: a prospective randomized study.
Monchi M, Berghmans D, Ledoux D, Canivet JL, Dubois B, Damas P.
General Intensive Care and Department of Nephrology, University Hospital, 4000 Liege, Belgium. m.monchi@free.fr
OBJECTIVE: To compare the efficacy and safety of adjusted-dose unfractionated heparin with that of regional citrate anticoagulation in intensive care patients treated by continuous venovenous hemofiltration (CVVH). DESIGN AND SETTING: Prospective, randomized, clinical trial in a 32-bed medical and surgical ICU in a university teaching hospital. PATIENTS: ICU patients with acute renal failure requiring continuous renal replacement therapy, without cirrhosis, severe coagulopathy, or known sensitivity to heparin. INTERVENTIONS: Before the first CVVH run patients were randomized to receive anticoagulation with heparin or trisodium citrate. Patients eligible for another CVVH run received the other study medication in a cross-over fashion until the fourth circuit. MEASUREMENTS AND RESULTS: Forty-nine circuits (hemofilters) were analyzed: 23 with heparin and 26 with citrate. The median lifetime of hemofilters was 70 h (interquartile range 44-140) with citrate anticoagulation and 40 h (17-48) with heparin (p=0.0007). One major bleeding occurred during heparin anticoagulation and one metabolic alkalosis (pH=7.60) was noted with citrate after a protocol violation. Transfusion rates (units of red cells per day of CVVH) were, respectively, 0.2 (0.0-0.4) with citrate and 1.0 (0.0-2.0) with heparin (p=0.0008). CONCLUSIONS: Regional citrate anticoagulation seems superior to heparin for the filter lifetime and transfusion requirements in ICU patients treated by continuous renal replacement therapy.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14600809 [PubMed - indexed for MEDLINE]
Admission and discharge guidelines for the pediatric patient requiring intermediate care.
Jaimovich DG; American Academy of Pediatrics Committee on Hospital Care and Section on Critical Care.
During the past 3 decades, the specialty of pediatric critical care medicine has grown rapidly, leading to a number of pediatric intensive care units opening across the country. Many patients who are admitted to the hospital require a higher level of care than routine inpatient general pediatric care, yet not to the degree of intensity of pediatric critical care; therefore, an intermediate care level has been developed in institutions providing multidisciplinary subspecialty pediatric care. These patients may require frequent monitoring of vital signs and nursing interventions, but usually they do not require invasive monitoring. The admission of the pediatric intermediate care patient is guided by physiologic parameters depending on the respective organ system involved relative to an institution's resources and capacity to care for a patient in a general care environment. This report provides admission and discharge guidelines for intermediate pediatric care. Intermediate care promotes greater flexibility in patient triage and provides a cost-effective alternative to admission to a pediatric intensive care unit. This level of care may enhance the efficiency of care and make health care more affordable for patients receiving intermediate care.
Publication Types:
PMID: 15121967 [PubMed - indexed for MEDLINE]
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Preterm delivery, level of care, and infant death in sweden: a population-based study.
Johansson S, Montgomery SM, Ekbom A, Olausson PO, Granath F, Norman M, Cnattingius S.
Women and Child Health, Karolinska Institutet, Stockholm, Sweden. stefan.johansson@ks.se
OBJECTIVE: To elucidate the role of level of care in combination with other perinatal risk factors for infant death in very preterm deliveries. DESIGN: Population-based cohort study. SETTING: Sweden, 1992-1998. SUBJECTS: Singleton infants (2285) born at 24 to 31 completed weeks of gestation to primiparous women. MAIN OUTCOME MEASURE: Infant mortality. RESULTS: The rate of infant mortality increased from 5% among infants born at 31 weeks' gestation to 56% among infants born at 24 weeks' gestation. Compared with infants born at university hospitals, the unadjusted odds ratio (OR) of infant death was 0.70 (95% confidence interval [CI]: 0.54-0.90) among infants delivered at general hospitals. However, after adjustment, the OR of infant death shifted to 1.33 (95% CI: 0.88-2.02) for preterm births at general hospitals. This shift was primarily due to different gestational age distributions in regional and general hospitals. Among infants born at 24 to 27 weeks' gestation, infant mortality rates were 23% (87 deaths) in university hospitals and 32% (73 deaths) in general hospitals, giving an adjusted OR of 2.00 for general versus university hospitals (95% CI: 1.15-3.49). The risk of death at 24 to 27 weeks' gestation in general hospitals was increased specifically in pregnancies with placental complications. CONCLUSION: Taking obstetric complications into account, there is an excess mortality risk among extremely preterm infants born at general hospitals.
PMID: 15121934 [PubMed - indexed for MEDLINE]
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Changes in mortality for extremely low birth weight infants in the 1990s: implications for treatment decisions and resource use.
Meadow W, Lee G, Lin K, Lantos J.
Department of Pediatrics and MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA. wlm1@midway.uchicago.edu
OBJECTIVE: Much has changed in neonatal intensive care unit (NICU) care over the past decade. High-frequency oscillation, inhaled nitric oxide, and antenatal corticosteroids are now widely available. We wondered how these medical advances had affected both the epidemiology and ethics of life and death for extremely low birth weight (ELBW) infants in the NICU. METHODS: We identified 1142 ELBW infants (birth weight [BW] < 1000 g) consecutively admitted to our NICU between 1991 and 2001. We abstracted BW, gestational age, survival or death, and length of stay in the NICU. Statistical analyses were performed by using linear regression and 2-way analysis of variance. RESULTS: Both increasing BW and later year were significantly associated with improved survival. However, for larger ELBW infants, survival was approximately 90% for the entire decade, and large-scale improvement was hardly possible. For smaller infants, greater improvements were both possible and observed, at least early in the decade. From 1991 to 1997, overall ELBW survival increased steadily (approximately 4% per year). However, from 1997 to 2001, there was no significant improvement in survival for ELBW infants. There was no change in the distribution of deaths accounted for by BW subgroups within the ELBW population from 1991 to 2001. Median length of stay for infants who eventually expired before discharge rose from 2 days in 1991 to 10 days in 2001. As a consequence, during the past decade, the percentage of infants whose outcome was "undeclared" by day of life 4 rose from 10% to 20% for ELBW infants overall and to 33% for infants with BWs of 450 to 700 g. The percentage of ELBW NICU bed-days occupied by nonsurvivors remained very low (approximately 7%) from 1991 to 2001. CONCLUSIONS: 1) Fewer infants in all ELBW subgroups are dying, compared with a decade ago, and the improvement has been most prominent for BWs of 450 to 700 g, at which mortality was and remains to be greatest. 2) This progress seems to have slowed, or even stopped, by the end of the decade. 3) Although most NICU nonsurvivors still expire early, doomed infants are lingering longer. 4) Nonsurvivors continue to occupy a constant (and extremely small) fraction of NICU bed-days.
PMID: 15121933 [PubMed - indexed for MEDLINE]
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