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Comment in:
Short-term outcome after active perinatal management at 23-25 weeks of gestation. A study from two Swedish perinatal centres. Part 3: neonatal morbidity.
Serenius F, Ewald U, Farooqi A, Holmgren PA, Hakansson S, Sedin G.
Department of Paediatrics, Umea University, Umea, Sweden. fredrik.serenius.us@vll.se
AIM: To determine major neonatal morbidity in surviving infants born at 23-25 weeks, and to identify maternal and infant factors associated with major morbidity. METHODS: The medical records of 224 infants who were delivered at two tertiary care centres in 1992-1998 were reviewed retrospectively. At these centres, policies of active perinatal and neonatal management were universally applied. Of the 213 liveborn infants, 140 (66%) survived to discharge. Data were analysed by gestational age and considered in three time periods. Logistic regression models were used to identify factors associated with morbidity. RESULTS: Of the survivors, 6% had intraventricular haemorrhage grade > or = 3 (severe IVH) or periventricular leukomalacia (PVL), 15% retinopathy of prematurity > or = stage 3 (severe ROP) and 36% bronchopulmonary dysplasia (BPD). On logistic regression analysis, severe IVH or PVL was associated with duration of mechanical ventilation (odds ratio, OR: 1.53 per 1-wk increment in duration; 95% confidence interval, CI: 1.01-2.33). Severe ROP was associated with the presence of a patent ductus arteriosus (PDA) (OR: 3.31; 95% CI: 1.11-9.90) and birth in time period 3 versus time periods 1 and 2 combined (OR: 6.28; 95% CI: 2.10-18.74). BPD was associated with duration of mechanical ventilation (OR: 2.71 per 1-wk increment in duration; 95% CI: 1.76-4.18) and with the presence of any obstetric complication (OR: 2.67; 95% CI: 1.07-6.65). Gestational age and birthweight were not associated with major morbidity. Of all survivors, 81% were discharged home without severe IVH, PVL or severe ROP. CONCLUSIONS: Increased survival as a result of active perinatal and neonatal management was associated with favourable morbidity rates compared with those in recent studies. Among survivors born at 23-25 weeks, neither gestational age nor birthweight was a significant determinant of major morbidity.
PMID: 15456201 [PubMed - indexed for MEDLINE]
Comment in:
Short-term outcome after active perinatal management at 23-25 weeks of gestation. A study from two Swedish tertiary care centres. Part 2: infant survival.
Serenius F, Ewald U, Farooqi A, Holmgren PA, Hakansson S, Sedin G.
Department of Paediatrics, Umea University, Umea, Sweden.
AIM: To determine neonatal survival rates based on both foetal (stillborn) and neonatal deaths among infants delivered at 23-25 wk, and to identify maternal and neonatal factors associated with survival. METHODS: The medical records of 224 infants who were delivered in two tertiary care centres in 1992-1998 were reviewed retrospectively. At these centres, policies of active perinatal and neonatal management were universally applied. Data were analysed by gestational age groups and considered in three time periods. Logistic regression models were used to identify factors associated with survival. RESULTS: The rate of foetal death was 5%. Of infants born alive, 63% survived to discharge. Survival rates including foetal deaths in the denominator at 23, 24 and 25 wk were 37%, 61% and 74%, respectively, and survival rates excluding foetal deaths were 43%, 63% and 77%, respectively. Of infants born with 1-min Apgar scores of 0-1, 43% survived. In the total cohort, survival rates including foetal deaths in the denominator increased from 52% in time period 1 to 61% in time period 2 and 74% in time period 3 (p < 0.02). On multivariate logistic regression analysis, higher birthweight (OR: 1.91 per 100 g increment; 95% CI: 1.45-2.52), female gender (OR: 3.33; 95% CI: 1.65-6.75), administration of antenatal steroids (OR: 2.95; 95% CI: 1.46-5.98) and intrauterine referral from a peripheral hospital (OR: 2.35; 95% CI: 1.18-4.68) were associated with survival. Apgar score < or = 3 at 1 min (OR: 0.46; 95% CI: 0.22-0.95) was associated with decreased survival. The use of antenatal steroids was protective at 23-24 wk (OR: 5.2; 95% CI: 2.0-13.7), but not at 25 wk. CONCLUSIONS: Active perinatal management that included universal initiation of neonatal intensive care virtually eliminated intrapartum stillbirths and delivery room deaths, and resulted in survival rates that compare favourably with those of recent studies. However, the policies of active care postponed death in non-survivors. Individual variations in outcome in relation to the infant's condition at birth as reflected by the Apgar scores preclude the making of treatment decisions in the delivery room.
Publication Types:
PMID: 15456200 [PubMed - indexed for MEDLINE]
Prescription errors in UK critical care units.
Ridley SA, Booth SA, Thompson CM; Intensive Care Society's Working Group on Adverse Incidents.
Norfolk & Norwich University Hospital, Colney Lane, Norwich, Norfolk, NR4 7UY, UK. saxon@domum.globalnet.co.uk
Drug prescription errors are a common cause of adverse incidents and may be largely preventable. The incidence of prescription errors in UK critical care units is unknown. The aim of this study was to collect data about prescription errors and so calculate the incidence and variation of errors nationally. Twenty-four critical care units took part in the study for a 4-week period. The total numbers of new and re-written prescriptions were recorded daily. Errors were classified according to the nature of the error. Over the 4-week period, 21,589 new prescriptions (or 15.3 new prescriptions per patient) were written. Eighty-five per cent (18,448 prescriptions) were error free, but 3141 (15%) prescriptions had one or more errors (2.2 erroneous prescriptions per patient, or 145.5 erroneous prescriptions per 1000 new prescriptions). The five most common incorrect prescriptions were for potassium chloride (10.2% errors), heparin (5.3%), magnesium sulphate (5.2%), paracetamol (3.2%) and propofol (3.1%). Most of the errors were minor or would have had no adverse effects but 618 (19.6%) errors were considered significant, serious or potentially life threatening. Four categories (not writing the order according to the British National Formulary recommendations, an ambiguous medication order, non-standard nomenclature and writing illegibly) accounted for 47.9% of all errors. Although prescription rates (and error rates) in critical care appear higher than elsewhere in hospital, the number of potentially serious errors is similar to other areas of high-risk practice.
Publication Types:
PMID: 15549978 [PubMed - indexed for MEDLINE]
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Transoesophageal echocardiography is unreliable for cardiac output assessment after cardiac surgery compared with thermodilution.
Bettex DA, Hinselmann V, Hellermann JP, Jenni R, Schmid ER.
Division of Cardiovascular Anaesthesia, University Hospital of Zurich, Switzerland. dominique.bettex@usz.ch
This randomised, single-blind, double-control study compared and established prospectively the best transoesophageal echocardiography methods for determining cardiac output in patients after cardiac surgery. Thirty patients undergoing coronary artery bypass grafting were included. Measurements were taken postoperatively, after stabilisation in the intensive care unit. Cardiac output was determined by transoesophageal echocardiography in randomised order through the aortic, mitral, and pulmonary valves, right and left ventricular outflow tracts, transgastric surface areas of the left ventricle and left ventricle two-dimensional volumes (Simpson's rules). 'Eyeball guessing' was done off-line. The best results were transaortic measurements using the triangular shape assumption of valve opening, but some values deviated considerably, and none of these approaches reached the limit of agreement set at 30% when compared to thermodilution. Eyeball guessing was comparable to the best transoesophageal echocardiography measurements. We conclude that transoesophageal echocardiography is an unreliable tool for determination of cardiac output in intensive care after cardiac surgery.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15549977 [PubMed - indexed for MEDLINE]
Comment on:
Critical care rosters and workload.
Ridley SA.
Publication Types:
PMID: 15488050 [PubMed - indexed for MEDLINE]
Comment in:
Blindness in the intensive care unit: possible role for vasopressors?
Lee LA, Nathens AB, Sires BS, McMurray MK, Lam AM.
Harborview Medical Center, Department of Anesthesiology, Box 359724, 325 Ninth Ave., Seattle, WA 98104, USA. lorlee@u.washington.edu
Blindness caused by ischemic optic neuropathy in the hospital setting occurs perioperatively and in critically ill patients, but its etiology remains ill defined. We describe four critically ill patients who developed blindness within 1 mo of one another. Three cases occurred outside of the operative arena. Potential risk factors for the development of ischemic optic neuropathy, such as use of vasopressors, venous congestion, and hypotension, are described.
Publication Types:
PMID: 15616077 [PubMed - indexed for MEDLINE]
Comment on:
Blindness in the intensive care unit.
Jakob SM.
Publication Types:
PMID: 15616076 [PubMed - indexed for MEDLINE]
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Post mortem examination in the intensive care unit: still useful?
Zijlstra JG, Ligtenberg JJ, Tulleken JE, van der Werf TS.
Respiratory and Intensive Care, Department of Internal Medicine, Groningen University Medical Centre, P.O. 30.001, 9700 RB, Groningen, The Netherlands, j.g.zijlstra@int.azg.nl.
PMID: 15625583 [PubMed - as supplied by publisher]
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Post mortem examination in the intensive care unit: still useful?
Vincent JL, Dimopoulos G, Salmon I.
Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Route de Lennik 808, 1070, Brussels, Belgium.
PMID: 15614520 [PubMed - as supplied by publisher]
Antibiotic prescription practice in an intensive care unit using twice-weekly collection of screening specimens: a prospective audit in a large UK teaching hospital.
Warren MM, Gibb AP, Walsh TS.
The Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK.
Controversy exists regarding the optimal method of managing intensive care unit (ICU)-acquired infection. Antibiotic prescriptions in 177 sequential admissions to our ICU, which collected twice-weekly screening samples, were audited. Seventy-seven percent of patients received at least one antibiotic prescription, and 45% of patients received at least one prescription for suspected or proven sepsis. Of the 353 antibiotic prescriptions audited, 86 were prophylactic and 61 were first prescribed prior to ICU admission. One hundred and eighty-three were prescribed for sepsis; of these, 108 (59%) were empirical prescriptions and only 21% of these were subsequently changed. For the 75 prescriptions for specific organisms, 28% targeted organisms isolated at least four days previously. Clinicians in our ICU reviewed the data and reached consensus that screening was associated with decision making that did not represent current evidence-based practice, because empirical prescriptions were rarely changed or stopped on the basis of new samples, and those prescribed for confirmed infection frequently targeted organisms isolated before the septic episode. After our audit, we stopped regular collection of screening samples and used more targeted and invasive sampling, in response to clinical suspicion, to guide therapy and maintain data concerning local microbial epidemiology.
PMID: 15620441 [PubMed - in process]
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Impact of restricting fluoroquinolone prescription on bacterial resistance in an intensive care unit.
Aubert G, Carricajo A, Vautrin AC, Guyomarc'h S, Fonsale N, Page D, Brunel P, Rusch P, Zeni F.
Bacteriology Department, Bellevue University Hospital, Saint-Etienne, France. gerald.aubert@chu-st-etienne.fr
The purpose of this study was to assess the effect of reducing prescription of fluoroquinolones in an intensive care unit (ICU) upon bacterial resistance, particularly as regards Pseudomonas aeruginosa. For six months between January 2001 and June 2001, administration of fluoroquinolones was kept to a minimum. A bacteriological screening of patients was performed to assess the incidence of fluoroquinolone-resistant bacteria. There was a 75.8% restriction in prescriptions of fluoroquinolones. There was no significant change in bacterial ecology between the periods preceding (12 months) and following (12 months) restriction. There was a significant recovery of sensitivity of P. aeruginosa to ciprofloxacin (P<or=0.01), with a decrease in resistant strains from 71.3% in the pre-restriction period to 52.4% in the post-restriction period. Regarding clinical data, no significant differences were noted between the pre-restriction and the post-restriction periods, except for the number of cases of ventilator-associated pneumonia with P. aeruginosa resistant to ciprofloxacin. This study demonstrated the possibility of introducing rotation of antibiotics in an ICU.
PMID: 15620440 [PubMed - in process]
Comment on:
The cost-benefit threshold for low birth weight infants.
Mehl AL.
Publication Types:
PMID: 15286243 [PubMed - indexed for MEDLINE]
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[The "intensive" insulin therapy in artificial feeding. Beneficial effects through normal blood sugar level or insulin therapy?]
[Article in German]
Druml W.
Publication Types:
PMID: 15515873 [PubMed - indexed for MEDLINE]
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