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Critical care teams managing floor patients: The continuing evolution of hospitals into intensive care units?
Szalados JE.
Unity Health System; Westside Anesthesiology Associates of Rochester; University of Rochester School of Medicine; Rochester, NY.
PMID: 15071404 [PubMed - in process]
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Risk factors for mortality in 137 pediatric cardiac intensive care unit patients managed with extracorporeal membrane oxygenation.
Morris MC, Ittenbach RF, Godinez RI, Portnoy JD, Tabbutt S, Hanna BD, Hoffman TM, Gaynor JW, Connelly JT, Helfaer MA, Spray TL, Wernovsky G.
Children's Hospital of Philadelphia, Department of Anesthesia and Critical Care Medicine (MCM, RIG, JDP, ST, MAH), Department of Biostatistics (RFI), Department of Pediatrics (ST, BDH, TMH, GW), Department of Surgery (JWG, TLS), and Department of Nursing (JTC).
OBJECTIVE: To identify factors associated with mortality in children with heart disease managed with extracorporeal membrane oxygenation (ECMO). DESIGN: Retrospective chart review. SETTING: Tertiary care university-affiliated children's hospital. PATIENTS: All pediatric cardiac intensive care unit patients managed with ECMO between January 1, 1995, and June 30, 2001. INTERVENTIONS: None. RESULTS: During the study period, 137 patients were managed with ECMO in the pediatric cardiac intensive care unit. Of the 137 patients, 80 (58%) survived >/=24 hrs after decannulation, and 53 (39%) survived to hospital discharge. Patients managed with ECMO following cardiac surgery were analyzed separately from patients not in the postoperative period. Factors associated with an increased probability of mortality in the postoperative patients were age <1 month, male gender, longer duration of mechanical ventilation before ECMO, and development of renal or hepatic dysfunction while on ECMO. Single ventricle physiology and failure to separate from cardiopulmonary bypass were not associated with an increased risk of mortality. Cardiac physiology and indication for ECMO were not associated with mortality rate. Although longer duration of ECMO was not associated with increased mortality risk, patients with longer duration of ECMO were less likely to survive without heart transplantation. CONCLUSIONS: In a series of 137 patients managed with ECMO in a pediatric cardiac intensive care unit, survival to hospital discharge was 39%. In postoperative patients only, mortality risk was increased in males, patients <1 month old, patients with a longer duration of mechanical ventilation before initiation of ECMO, and patients who developed renal or hepatic failure while on ECMO.
PMID: 15071402 [PubMed - as supplied by publisher]
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Obesity-related excess mortality rate in an adult intensive care unit: A risk-adjusted matched cohort study.
Bercault N, Boulain T, Kuteifan K, Wolf M, Runge I, Fleury JC.
Service de Reanimation Medicale Polyvalente, Centre Hospitalier Regional d' Orleans, Hopital de la Source, Orleans, France.
OBJECTIVE: To evaluate the obesity-related mortality rate in an intensive care unit. DESIGN: An exposed/unexposed matched cohort study. SETTING: An 18-bed adult medical-surgical intensive care unit in a 1,100-bed regional and teaching hospital in France. PATIENTS: From January 1, 1999, to December 31, 2001, 170 mechanically ventilated exposed patients (obese patients with body mass index of >30 kg/m) were matched with 170 mechanically ventilated unexposed patients (with ideal body mass index of 18.5-24.9 kg/m). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The matching process was conducted according to eight criteria: cause of admission, indication for ventilatory support, immunologic status, cardiac status, probability of death (+/-5%), age (+/-7 yrs), gender, and acquisition of severe events appearing within 24 hrs before admission (defined as resuscitated cardiac arrest, acute respiratory distress syndrome, or septic shock). The mortality rate between exposed and unexposed patients was compared by univariate analysis and then was adjusted for other possible confounding factors by multivariate analysis, using conditional logistic regression. The matching process was successful for 1,360 of 1,360 criteria. Obesity was significantly associated with intensive care unit mortality (odds ratio, 2.1; 95% confidence interval, 1.2-3.6). Obesity-related excess mortality was verified mainly for the youngest patients (odds ratio, 2.5; 95% confidence interval, 1.6-6.1) and for the patients with a probability of intensive care unit death of 11-50% (odds ratio, 2.6; 95% confidence interval, 1.2-5.5). This excess mortality rate could be explained by the higher risk of intensive care unit acquired complications among obese patients than among the unexposed ones (odds ratio, 4; 95% confidence interval, 1.4-11.8). CONCLUSIONS: Obesity is an independent risk factor for intensive care unit death and should be regarded as a severe comorbidity in such units.
PMID: 15071392 [PubMed - as supplied by publisher]
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Osmole gap in neurologic-neurosurgical intensive care unit: Its normal value, calculation, and relationship with mannitol serum concentrations.
Garcia-Morales EJ, Cariappa R, Parvin CA, Scott MG, Diringer MN.
Department of Neurology (EJG-M, MND) and Department of Laboratory Medicine (RC, CAP, MGS), Washington University School of Medicine, St. Louis, MO.
OBJECTIVE: To determine a) if the admission osmole gap, the difference between osmolality and osmolarity, is the same in the neurologic-neurosurgical intensive care unit (NNICU) population as in healthy controls; b) which of 11 osmole gap formulas, or osmolality, correlates best with mannitol serum concentrations; c) whether osmole gap correction for plasma water content improves this correlation; and d) whether the osmole gap can predict mannitol serum concentrations. DESIGN: Prospectively collected data. SETTINGS: NNICU of a tertiary teaching hospital. SUBJECTS: Ten NNICU patients on mannitol and eight not on mannitol, and 95 healthy controls. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We compared the admission osmole gap between all 18 NNICU patients and healthy controls and the correlation between osmole gap or osmolality and mannitol serum concentrations in ten NNICU patients while receiving mannitol. The osmole gap was calculated using 11 osmolarity formulas (six corrected for plasma water content). Student's t-test was used to compare the mean osmole gap between control and patient groups.We found that the mean osmole gap in healthy subjects and NNICU patients was not different. There were no statistically significant differences between any of the 11 osmole gap formulas and the correlation of osmole gap with serum mannitol concentrations; the highest R =.80, with formula 4, 1.86 (sodium + potassium) + (blood urea nitrogen/2.8) + (glucose/18) + 10, requires the least laboratory measurements. Osmolality had the lowest correlation with mannitol concentration (R =.60), significantly lower than any of the osmole gap calculations. Plasma water content correction did not improve this correlation. The osmole gap-mannitol serum concentrations relationship is 1 to 0.81, not accurate enough to predict specific mannitol serum concentrations. CONCLUSIONS: The osmole gap correlates better with mannitol serum concentrations than osmolality, and although it cannot predict a specific mannitol serum concentration, a normal osmole gap concentration, as we find at trough times, indicates sufficient clearance for a new mannitol dose.
PMID: 15071390 [PubMed - as supplied by publisher]
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Causes and predictors of nonresponse to treatment of intensive care unit-acquired pneumonia.
Ioanas M, Ferrer M, Cavalcanti M, Ferrer R, Ewig S, Filella X, De La Bellacasa JP, Torres A.
Institut Clinic de Pneumologia i Cirurgia Toracica (MI, MF, MC, AT), Servei de Bioquimica Clinica (XF), and Servei de Microbiologia (JPdlB), Hospital Clinic, Barcelona, Spain; Corporacio Sanitaria Parc Tauli, Sabadell, Spain (RF); and Augustinenspital, Bochum, Germany (SE).
OBJECTIVE: To prospectively evaluate the predictive factors for the nonresponse to empirical antibiotic treatment and mortality in patients with intensive care unit-acquired pneumonia. DESIGN: A 1-yr prospective cohort of patients with suspicion of intensive care unit-acquired pneumonia. SETTING: Five medical and surgical intensive care units of Hospital Clinic in Barcelona. PATIENTS: A total of 71 patients with intensive care unit-acquired pneumonia were studied. The definition of nonresponse included at least one of the following: failure to improve the Pao2/Fio2 ratio or need of intubation because of pneumonia, persistence of fever or hypothermia and purulent respiratory secretions, worsening of pulmonary infiltrates, or occurrence of septic shock or multiple organ dysfunction not present at onset of pneumonia. INTERVENTIONS: Clinical assessment, including severity scores, blood and quantitative cultures of respiratory secretions, and cytokine measurements in serum and bronchoalveolar lavage at onset of pneumonia and 72 hrs after antimicrobial treatment. MEASUREMENTS AND RESULTS: A total of 44 patients (62%) fulfilled criteria of nonresponse, and at least one cause of nonresponse could be determined in 28 cases (64%): inappropriate treatment in ten (23%), superinfection in six (14%), concomitant foci of infection in 12 (27%), and noninfectious causes in seven cases (16%). The remaining 16 patients with no definite cause of nonresponse presented with septic shock, multiple organ dysfunction, or acute respiratory distress syndrome. Increased levels of interleukin-6 at onset of pneumonia (odds ratio, 9.7; p =.014) was an independent predictor of nonresponse to treatment. Likewise, increased level of interleukin-6 at follow-up (odds ratio, 27; p =.001) was the only independent predictor for hospital mortality. CONCLUSION: Increased systemic inflammatory response was the main predictor of nonresponse to treatment and mortality.
PMID: 15071382 [PubMed - as supplied by publisher]
Intensive care physicians' attitudes concerning distribution of intensive care resourcesA comparison of Israeli, North American and European cohorts.
Einav S, Soudry E, Levin PD, Grunfeld GB, Sprung CL.
Department of Anesthesiology and Critical Care Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, POB 12000, 91120, Jerusalem, Israel.
OBJECTIVE. To evaluate the attitudes of Israeli intensive care physicians regarding intensive care unit (ICU) triage issues. DESIGN. An opinion survey using questionnaires similar to those used in a previous study in the United States. SETTING AND PARTICIPANTS. Forty-three physicians, members of the Israel Society of Critical Care Medicine (45%). RESULTS. Important factors for admission to the last ICU bed were: small likelihood of surviving hospitalization, irreversibility of acute disorder, nature of chronic disorders and the physician's personal attitude. Most respondents would admit a patient with a predicted survival of a few weeks (70%) or a patient whose quality of life would be poor according to the physician's (98%) or patient's (77%) definition, to the last ICU bed. The personal attitude of the respondents and their own view of the patient's quality of life were considered as important as the quality of life as viewed by the patient. Israeli physicians tended to refuse patient admission into the ICU more than their US counterparts. Most Israeli physicians refused to discharge an ICU patient in order to admit another, despite bed shortage. CONCLUSIONS. The attitudes of Israeli intensive care physicians towards distribution of ICU resources differ from those of their United States counterparts; they are more paternalistic and comply less with requests for admission. Such attitudes are comparable to those expressed by some European intensive care physicians, highlighting the existence of diversity in the factors important to physicians' decision-making.
PMID: 15067504 [PubMed - as supplied by publisher]
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Adverse events in a paediatric intensive care unit: relationship to workload, skill mix and staff supervision.
Tibby SM, Correa-West J, Durward A, Ferguson L, Murdoch IA.
Department of Paediatric Intensive Care, Guy's Hospital, SE1 9RT, London, UK.
OBJECTIVES. A systems approach proposes that hospital adverse events (AE) represent a failure of the organization rather than the individual, and are more likely when sub-optimal working conditions occur. We analysed AE using a systems approach to (a) investigate the association between AE occurrence and "latent" risk factors, which included temporal, workload, skill mix and supervision issues, and (b) document interactions between clinically related risk factors. DESIGN. Prospective observational study. SETTING. Regional paediatric intensive care unit. MEASUREMENTS AND RESULTS. Data from 730 consecutive nursing shifts over 12 months (816 patient episodes, crude mortality 7.2%) were analysed using logistic regression modelling. Two hundred eighty-four AE occurred during 220 of 730 (30%) shifts. There were 103 unit- and 181 patient-related AE; the latter occurred at a rate of 6.0 per 100 patient days. Factors associated with increased AE included day shift, average patient dependency, number of occupied beds and the presence of multiple, simultaneous management-related issues that compromised the supervisory ability of the nurse in charge. Factors associated with decreased AE included the presence of a senior nurse in charge, a high proportion of the shift filled by rostered permanent staff, and/or senior nurses, the number of admissions and discharges and, surprisingly, the presence of new junior doctors. Interaction effects were demonstrated between patient workload factors (bed occupancy and patient acuity) and also between nursing supervision factors (seniority of the nurse in charge and factors compromising the nurse's supervisory ability). CONCLUSIONS. These findings may provide a framework for strategies to reduce AE occurrence.
PMID: 15067503 [PubMed - as supplied by publisher]
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Changes in cholesterol and its precursors during the first days after major trauma.
Bakalar B, Hyspler R, Pachl J, Zadak Z.
Department of Anaesthesiology and Critical Care Medicine, Charles University, 3rd Medical School, Kralovske Vinohrady Hospital, Prague, Czech Republic. bakalar@fnkv.cz
BACKGROUND: The causes of hypocholesterolemia in the critically ill, including major trauma patients, have not yet been fully elucidated. OBJECTIVE: We tested the hypothesis that hypocholesterolemia is caused by decreased production of cholesterol precursors. DESIGN: Serum concentrations of squalene, lanosterol, and lathosterol were measured on admission, and then at 24 and 48 hours after injury using gas chromatography coupled with mass spectrometry. Serum concentrations of total low-density and high-density lipoprotein cholesterol were measured on admission and every day in the first week after injury. RESULTS: 83 consecutive patients with multiple trauma were examined. Significant drops in concentrations of lanosterol and lathosterol were found in the patients in comparison with the control group. The most profound drop was in lathosterol. CONCLUSION: Decreased synthesis of cholesterol precursors is the major cause of hypocholesterolemia in patients with multiple trauma. Lathosterol concentration is proposed as a marker of cholesterol synthesis.
PMID: 14743581 [PubMed - indexed for MEDLINE]
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