Images in clinical medicine. Superficial thrombophlebitis.
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Antiphospholipid Syndrome↗
Biomedical subjects
E W Ely
Publications and source records attributed to E W Ely.
Efficacy and safety of recombinant human activated protein C for severe sepsis.
BACKGROUND: Drotrecogin alfa (activated), or recombinant human activated protein C, has antithrombotic, antiinflammatory, and profibrinolytic properties. In a previous study, drotrecogin alfa activated produced dose-dependent reductions in the levels of markers of coagulation and inflammation in patients with severe sepsis. In this phase 3 trial, we assessed whether treatment with drotrecogin alfa activated reduced the rate of death from any cause among patients with severe sepsis. METHODS: We conducted a randomized, double-blind, placebo-controlled, multicenter trial. Patients with systemic inflammation and organ failure due to acute infection were enrolled and assigned to receive an intravenous infusion of either placebo or drotrecogin alfa activated (24 microg per kilogram of body weight per hour) for a total duration of 96 hours. The prospectively defined primary end point was death from any cause and was assessed 28 days after the start of the infusion. Patients were monitored for adverse events; changes in vital signs, laboratory variables, and the results of microbiologic cultures; and the development of neutralizing antibodies against activated protein C. RESULTS: A total of 1690 randomized patients were treated (840 in the placebo group and 850 in the drotrecogin alfa activated group). The mortality rate was 30.8 percent in the placebo group and 24.7 percent in the drotrecogin alfa activated group. On the basis of the prospectively defined primary analysis, treatment with drotrecogin alfa activated was associated with a reduction in the relative risk of death of 19.4 percent (95 percent confidence interval, 6.6 to 30.5) and an absolute reduction in the risk of death of 6.1 percent (P=0.005). The incidence of serious bleeding was higher in the drotrecogin alfa activated group than in the placebo group (3.5 percent vs. 2.0 percent, P=0.06). CONCLUSIONS: Treatment with drotrecogin alfa activated significantly reduces mortality in patients with severe sepsis and may be associated with an increased risk of bleeding.
Anti-Inflammatory Agents, Non-Steroidal↗
Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).
OBJECTIVE: To develop and validate an instrument for use in the intensive care unit to accurately diagnose delirium in critically ill patients who are often nonverbal because of mechanical ventilation. DESIGN: Prospective cohort study. SETTING: The adult medical and coronary intensive care units of a tertiary care, university-based medical center. PATIENTS: Thirty-eight patients admitted to the intensive care units. MEASUREMENTS AND MAIN RESULTS: We designed and tested a modified version of the Confusion Assessment Method for use in intensive care unit patients and called it the CAM-ICU. Daily ratings from intensive care unit admission to hospital discharge by two study nurses and an intensivist who used the CAM-ICU were compared against the reference standard, a delirium expert who used delirium criteria from the Diagnostic and Statistical Manual of Mental Disorders (fourth edition). A total of 293 daily, paired evaluations were completed, with reference standard diagnoses of delirium in 42% and coma in 27% of all observations. To include only interactive patient evaluations and avoid repeat-observer bias for patients studied on multiple days, we used only the first-alert or lethargic comparison evaluation in each patient. Thirty-three of 38 patients (87%) developed delirium during their intensive care unit stay, mean duration of 4.2 +/- 1.7 days. Excluding evaluations of comatose patients because of lack of characteristic delirium features, the two critical care study nurses and intensivist demonstrated high interrater reliability for their CAM-ICU ratings with kappa statistics of 0.84, 0.79, and 0.95, respectively (p <.001). The two nurses' and intensivist's sensitivities when using the CAM-ICU compared with the reference standard were 95%, 96%, and 100%, respectively, whereas their specificities were 93%, 93%, and 89%, respectively. CONCLUSIONS: The CAM-ICU demonstrated excellent reliability and validity when used by nurses and physicians to identify delirium in intensive care unit patients. The CAM-ICU may be a useful instrument for both clinical and research purposes to monitor delirium in this challenging patient population.
Aged↗
Radiologic determination of intravascular volume status using portable, digital chest radiography: a prospective investigation in 100 patients.
OBJECTIVE: To answer the following questions: Can the digital chest roentgenogram (CXR) be used to differentiate patients' volume status? Do clinical data alter radiologists' accuracy in interpreting the digital CXR? DESIGN: Prospective cohort study. SETTING: Nine adult intensive care units of a tertiary care medical center. PATIENTS: One hundred thirty-five consecutive patients with pulmonary artery catheters, of whom 35 were excluded because of unacceptable pulmonary artery occlusion pressure (PAOP) tracings. METHODS: Each patient had a portable, anteroposterior, supine digital CXR. Clinicians evaluated volume status and then measured hemodynamic data within 1 hr of the CXR. Digital CXRs were independently interpreted on two separate occasions (with and without clinical information) by three experienced chest radiologists, and these interpretations were compared with hemodynamic data. RESULTS: Of the 100 patients, 39 had PAOP >18 mm Hg, whereas 61 had PAOP <18 mm Hg. Radiologists' accuracy in differentiating volume status increased with incorporation of clinical data (56% without vs. 65% with clinical data, p =.009). Using objective receiver operating characteristic-derived cutoffs of 70 mm for vascular pedicle width and 0.55 for cardiothoracic ratio, radiologists' accuracy in differentiating PAOP >18 mm Hg from PAOP <18 mm Hg was 70%. The intrareader and the inter-reader correlation coefficients were very high. The likelihood ratio of the CXR in determining volume status using the objective vascular pedicle width and cardiothoracic ratio measures was 3.1 (95% confidence interval, 1.9-6.0), significantly higher than subjective CXR interpretations with and without clinical data (p <.001). CONCLUSIONS: Differentiating intravascular volume status with portable, supine, digital CXRs may be improved by using objective cutoffs of vascular pedicle width >70 mm and cardiothoracic ratio >0.55 or by incorporating clinical data.
Adult↗
New ways to reduce unnecessary variation and improve outcomes in the intensive care unit.
The care of critically ill patients and the advent of the modern day intensive care unit (ICU) present a large person power and cost burden to society. The high cost of critical care is attributed to high overhead expenses (eg, experienced staff and equipment), high resource utilization (eg, pharmaceutical resources, lab testing, imaging procedures), and high demand for services. Pathways to standardize numerous facets of patient care have been shown to improve the efficiency of delivery of care and to reduce resource utilization, and are becoming the most sought-after means of improving patient outcomes and reducing overall ICU expenditures. A number of large, randomized, prospective trials have demonstrated that protocol-based strategies can not only reduce variation and cost of ICU medicine but also improve morbidity and mortality of critically ill patients requiring ICU support. In this article, we discuss examples of these trials investigating four major areas of modern ICU medicine: ventilator management, ventilator weaning, sedation and analgesia, and blood transfusions.
Humans↗
Treating dyspnea in a patient with advanced chronic obstructive pulmonary disease.
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Administration, Inhalation↗
Predictors of successful extubation in neurosurgical patients.
A respiratory therapist-driven weaning protocol incorporating daily screens, spontaneous breathing trials (SBT), and prompts to caregivers has been associated with superior outcomes in mechanically ventilated medical patients. To determine the effectiveness of this approach in neurosurgical (NSY) patients, we conducted a randomized controlled trial involving 100 patients over a 14-mo period. All had daily screens of weaning parameters. If these were passed, a 2-h SBT was performed in the Intervention group. Study physicians communicated positive SBT results, and the decision to extubate was made by the primary NSY team. Patients in the Intervention (n = 49) and Control (n = 51) groups had similar demographic characteristics, illness severity, and neurologic injuries. Among all patients, 87 (45 in the Control and 42 in the Intervention group) passed at least one daily screen. Forty (82%) patients in the Intervention group passed SBT, but a median of 2 d passed before attempted extubation, primarily because of concerns about the patient's sensorium (84%). Of 167 successful SBT, 126 (75%) did not lead to attempted extubation on the same day. The median time of mechanical ventilation was 6 d in both study groups, and there were no differences in outcomes. Overall complications included death (36%), reintubation (16%), and pneumonia (9%). Tracheostomies were created in 29% of patients. Multivariate analysis showed that Glasgow Coma Scale (GCS) score (p < 0.0001) and partial pressure of arterial oxygen/fraction of inspired oxygen ratio (p < 0.0001) were associated with extubation success. The odds of successful extubation increased by 39% with each GCS score increment. A GCS score > or = 8 at extubation was associated with success in 75% of cases, versus 33% for a GCS score < 8 (p < 0.0001). Implementation of a weaning protocol based on traditional respiratory physiologic parameters had practical limitations in NSY patients, owing to concerns about neurologic impairment. Whether protocols combining respiratory parameters with neurologic measures lead to superior outcomes in this population requires further investigation.
Adolescent↗
Education of physicians-in-training can decrease the risk for vascular catheter infection.
BACKGROUND: Procedure instruction for physicians-in-training is usually nonstandardized. The authors observed that during insertion of central venous catheters (CVCs), few physicians used full-size sterile drapes (an intervention proven to reduce the risk for CVC-related infection). OBJECTIVE: To improve standardization of infection control practices and techniques during invasive procedures. DESIGN: Nonrandomized pre-post observational trial. SETTING: Six intensive care units and one step-down unit at Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina. PARTICIPANTS: Third-year medical students and physicians completing their first postgraduate year. INTERVENTION: A 1-day course on infection control practices and procedures given in June 1996 and June 1997. MEASUREMENTS: Surveys assessing physician attitudes toward use of sterile techniques during insertion of CVCs were administered during the baseline year and just before, immediately after, and 6 months after the first course. Preintervention and postintervention use of full-size sterile drapes was measured, and surveillance for vascular catheter-related infection was performed. RESULTS: The perceived need for full-size sterile drapes was 22% in the year before the course and 73% 6 months after the course (P < 0.001). The perceived need for small sterile towels at the insertion site decreased reciprocally (P < 0.001). Documented use of full-size sterile drapes increased from 44% to 65% (P < 0.001). The rate of catheter-related infection decreased from 4.51 infections per 1000 patient-days before the first course to 2.92 infections per 1000 patient-days 18 months after the first course (average decrease, 3.23 infections per 1000 patient-days; P < 0.01). The estimated cost savings of this 28% decrease was at least $63000 and may have exceeded $800000. CONCLUSIONS: Standardization of infection control practices through a course is a cost-effective way to decrease related adverse outcomes. If these findings can be reproduced, this approach may serve as a model for physicians-in-training.
Bacteremia↗
Active CMV infection before lung transplantation: risk factors and clinical implications.
BACKGROUND: Cytomegalovirus (CMV) infection is a major cause of morbidity following lung transplantation, but active CMV infection has not been described before transplantation. Since 1990, we have screened all lung-transplant recipients for CMV infection with viral urine cultures on the day of transplantation. We retrospectively reviewed the medical records of all 102 lung-allograft recipients transplanted between March 1990 and September 1998. Patients with positive urine cultures for CMV were compared to culture negative patients for age, gender, pretransplant diagnosis, time from diagnosis to transplantation, CMV serostatus, use of pretransplant immunosuppression, T-lymphocyte subsets, and presence of fever. Posttransplant outcomes assessed were duration of intubation and hospitalization, acute rejection, frequency of CMV disease, duration of Nashville rabbit antithymocyte serum or globulin (N-RATS/G) and ganciclovir, and survival. Five (5%) of 102 patients had positive urine cultures for CMV; none had symptoms of CMV infection. All 5 had idiopathic pulmonary fibrosis (IPF) (5/5 vs 27/97; p = 0.002). The age, gender, and CMV serostatus of these patients did not differ from the 97 patients in the culture negative group. Four (80%) of the 5 patients with positive cultures were receiving treatment with azathioprine or cyclophosphamide vs only 18 (19%) of the 97 patients with negative cultures (p = 0.007), and all 5 (100%) were receiving steroids compared to 50 (52%) of 97 patients with negative cultures (p = 0.06). Culture-positive IPF patients, when compared with the 27 culture-negative IPF patients, did not differ in any demographic variable or in the use of immunosuppression, but culture-positive patients were more likely to have a CD4/CD8 T-cell subset ratio <1.0 (p = 0.02). Following transplantation, 3 (60%) of 5 IPF patients with positive CMV cultures developed CMV disease compared to 3 (11%) of 27 IPF patients with negative cultures (p = 0.03). Patients with positive cultures also received more days of parenteral antiviral therapy (mean 44 +/- 11 days vs 16 +/- 10 days; p < 0.001). Utilizing pretransplant screening, we have discovered that 16% of patients with IPF had active CMV infection, which was associated with both alterations in their T-cell subsets and a greater risk for CMV disease after transplantation. This occurrence of occult CMV infection in patients with IPF has not been previously recognized, and has important implications.
Animals↗
Lung allocation in the United States, 1995-1997: an analysis of equity and utility.
BACKGROUND: Waiting time for organ transplantation varies widely between programs of different sizes and by geographic regions. The purpose of this study was to determine if the current lung-allocation policy is equitable for candidates waiting at various-sized centers, and to model how national allocation based solely on waiting time might affect patients and programs. METHODS: UNOS provided data on candidate registrations; transplants and outcomes; waiting times; and deaths while waiting for all U.S. lung-transplant programs during 1995-1997. Transplant centers were categorized based on average yearly volume: small (< or = 10 pounds sterling transplants/year; n = 46), medium (11-30 transplants/year; n = 29), or large (>30 transplants/year; n = 6). This data was used to model national organ allocation based solely on accumulated waiting time for candidates listed at the end of 1997. RESULTS: Median waiting time for patients transplanted was longest at large programs (724-848 days) compared to small and medium centers (371-552 days and 337-553 days, respectively) and increased at programs of all sizes during the study period. Wait-time-adjusted risk of death correlated inversely with program size (365 vs 261 vs 148 deaths per 1,000 patient-years-at-risk at small, medium, and large centers, respectively). Mortality as a percentage of new candidate registrations was similar for all program categories, ranging from 21 to 25%. Survival rates following transplantation were equivalent at medium-sized centers vs large centers (p = 0.50), but statistically lower when small centers were compared to either large- or medium-size centers (p < or = 0.05). Using waiting time as the primary criterion lung allocation would acutely shift 10 to 20% of lung-transplant activity from medium to large programs. CONCLUSIONS: 1) Waiting list mortality rates are not higher at large lung-transplant programs with long average waiting times. 2) A lung-allocation algorithm based primarily on waiting-list seniority would probably disadvantage candidates at medium-size centers without improving overall lung-transplant outcomes. 3) If fairness is measured by equal distribution of opportunity and risk, we conclude that the current allocation system is relatively equitable for patients currently entering the lung-transplant system.
Actuarial Analysis↗
The utility of weaning protocols to expedite liberation from mechanical ventilation.
Over the past decade, a number of studies have examined methods of hastening liberation of patients from mechanical ventilation. This article outlines weaning protocols that have been proven superior to weaning performed by board-certified intensivists. The author also presents techniques to faciliate the implementation of weaning protocols based on the published experience of one hospital.
Clinical Protocols↗
The distribution of costs of care in mechanically ventilated patients with chronic obstructive pulmonary disease.
OBJECTIVES: To delineate the costs of care of patients with Chronic Obstructive Pulmonary Disease (COPD) and respiratory failure and to compare them with those of other mechanically ventilated patients. DESIGN: A post hoc analysis of a prospective investigation. SETTING: Medical and coronary intensive care units (ICUs) of an 804-bed, university-based hospital. PATIENTS: A total of 300 mechanically ventilated patients, 44 with COPD and 256 others, were included. MEASUREMENTS AND MAIN RESULTS: Despite similar lengths of ICU stay (9 days) and mechanical ventilation (5.5 days COPD vs. 5 days other, p = .11), ICU respiratory care costs for patients with COPD were $2,422 ($1,157-$6,110) [median U.S. dollars (interquartile range)] vs. $1,580 ($738-$3,322) for the others (p = .01). Ventilator costs for COPD patients were $1,795 ($943-$5,782) vs. $1,574 ($613-$3,112) (p = .12). Total hospitalization respiratory care costs for COPD patients were higher, $4,064 ($2,422-$9,572) vs. $2,342 ($1,186-$4,591), (p = .0001), and 74.4% of the median difference in cost between COPD patients and others was accounted for by spontaneous nebulizers (p = .001), metered dose inhalers (p = .01), and pulse oximetry (p = .02). By using multiple linear regression analyses, we found that COPD remained associated with higher respiratory costs (p<.05). Respiratory Care was the third largest category of hospital costs after beds (27%) and pharmacy expenses (25%), and it comprised approximately 14% of total cost. Total hospital costs were large for both groups, but did not differ between COPD and the others [$24,217 ($16,211-$58,834) vs. $27,672 ($15,692-$53,766), respectively (p = .96)]. Linear regression analyses showed that only Acute Lung Injury score was significantly related to total ICU and hospital costs of care (p<.05). CONCLUSIONS: Costs of ICU and non-ICU respiratory care for patients with COPD are higher than costs of care for other mechanically ventilated patients. Although the increased cost of bronchodilators and oximetry in these patients may serve as target areas for reductions in respiratory care costs, it may also be true that these modalities of therapy and management are necessary and need to be used with even greater intensity to achieve better outcomes. The predominant contributions of bed and pharmacy costs in all of our patients with respiratory failure support research efforts addressing these aspects of care.
Aged↗
Living and dying with chronic obstructive pulmonary disease.
OBJECTIVE: To characterize chronic obstructive pulmonary disease (COPD) over patients' last 6 months of life. STUDY DESIGN: A retrospective analysis of a prospective cohort from the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). SETTING: Hospitalization for exacerbation of COPD at five US teaching hospitals. PARTICIPANTS: COPD patients who died within 1 year (n = 416) among 1016 enrolled. METHODS: Interview and medical record data were organized into time windows beginning with death and ending 6 months earlier. OUTCOME MEASURES: Days in hospital, prognosis, illness severity, function, symptoms, patients' preferences, and impacts on families. RESULTS: One-year survival was 59%, 39% had > or = 3 comorbidities, and 15 to 25% of the patients' last 6 months were in hospitals. Exacerbation etiologies included respiratory infection (47%) and cardiac problems (30%). Better quality of life predicted longer survival (ARR: 0.36; 95% CI, 0.19-0.87) as did heart failure etiology of exacerbation (ARR: 0.57; CI, 0.40, 0.82). Estimates of survival by physicians and by prognostic model were well calibrated, although patients with the worst prognoses survived longer than predicted. Patients' estimates of prognosis were poorly calibrated. One-quarter of patients had serious pain throughout, and two-thirds had serious dyspnea. Patients' illnesses had a major impact on more than 25% of families. Patients' preferences for Do-Not-Resuscitate orders increased from 40% at 3 to 6 months before death to 77% within 1 month of death; their decisions not to use mechanical ventilation increased from 12 to 31%, and their preferences for resuscitation decreased from 52 to 23%. CONCLUSIONS: Patients with advanced COPD often die within 1 year and have substantial comorbidities and symptoms. Adequate description anchors improved care.
Aged↗
Flock worker's lung: broadening the spectrum of clinicopathology, narrowing the spectrum of suspected etiologies.
STUDY OBJECTIVES: Workers in the nylon flocking industry recently have been found to be at increased risk of chronic nongranulomatous interstitial lung disease. Although a spectrum of cytologic and histopathologic abnormalities has been observed, nonspecific interstitial pneumonia, lymphoid nodules, and lymphocytic bronchiolitis predominated in the 19 previously reported cases of flock worker's lung. Here we describe five additional patients who appear to expand the histopathologic spectrum and add to the evidence suggesting a causative role for respirable-sized nylon fragments. METHODS: We studied all North American patients (n = 5) found in 1998 to satisfy our previous case definition of flock worker's lung. Two pulmonary pathologists independently reviewed each biopsy specimen. RESULTS: All five patients reported cough and dyspnea. Only one patient had crackles on chest auscultation. High-resolution CT scan, interpreted with attention to subtle ground-glass attenuation, remained a highly sensitive diagnostic test. Pulmonary function tests and plain chest radiograph were less sensitive. One patient's wedge biopsy showed previously described prototypical findings. Two others had transbronchial biopsies showing some of the same features. The fourth patient's wedge biopsy showed desquamative interstitial pneumonia. The fifth patient had bilateral synchronous adenocarcinoma but with radiographic evidence of diffuse interstitial fibrosis. These 5 patients and the 19 patients studied previously were exposed to nylon flock manufactured by a rarely used cutting technology. CONCLUSION: Findings in these five patients appear to broaden the spectrum of the clinicopathology of flock worker's lung and add to the evidence incriminating respirable-sized nylon particulates produced during the manufacture and use of rotary-cut nylon flock.
Adult↗
Pulmonary veno-occlusive disease: a case series and new observations.
STUDY OBJECTIVES: The aim of this study was to describe our experience at one institution with pulmonary veno-occlusive disease (PVOD) during the past 10 years, with particular reference to new findings and long-term outcome. SETTING: Tertiary care, academic medical center. PATIENTS AND METHODS: Eleven patients who were evaluated and treated for PVOD at our institution were retrospectively studied. Included were all available clinical, radiographic, hemodynamic, and pathologic data. RESULTS: All 11 patients in our series had at least one symptom or clinical finding that, in conjunction with known pulmonary hypertension, suggested the diagnosis of PVOD. Digital clubbing, not previously reported in PVOD, was found in 5 patients, rales in 6, and increased interstitial markings on chest radiograph in 10. Half of the 10 patients who underwent acute vasodilator testing exhibited a decrease in pulmonary artery pressure of > 20%, although one patient died shortly after receiving IV calcium-channel blockers. Three patients have demonstrated sustained clinical improvement with therapy, which includes calcium-channel blockers, epoprostenol, and lung transplantation in one patient each. However, outcome was generally poor, with a 72% mortality within 1 year of diagnosis. CONCLUSION: The diagnosis of PVOD requires a high clinical suspicion. However, both physical examination findings and radiographic studies often provide clues to the diagnosis, which may obviate the need for lung biopsy in the majority of cases. Although there may be patients who respond to medical therapy, the use of vasoactive medications in patients with PVOD should be undertaken with great caution. Long-term survival is poor, and lung transplantation remains the only proven therapy.
Adult↗
Mechanical ventilation in a cohort of elderly patients admitted to an intensive care unit.
BACKGROUND: It has been argued that life support for the elderly should be limited to conserve resources. As this population increases, so will the importance of evaluating appropriate use of mechanical ventilation in this group. OBJECTIVE: To determine whether age has an independent effect on the outcomes of patients treated with mechanical ventilation after admission to an intensive care unit (ICU). DESIGN: Prospective cohort study. SETTING: University-based tertiary care medical center. PATIENTS: 63 patients 75 years of age or older and 237 patients younger than 75 years of age enrolled from medical and coronary ICUs. MEASUREMENTS: In-hospital mortality rate, duration of mechanical ventilation, lengths of stay in the ICU and in the hospital, and cost of care. RESULTS: Median duration of mechanical ventilation was 4.2 days (interquartile range, 2.1 to 9.3 days) for patients 75 years of age or older and 6.4 days (interquartile range, 3.4 to 11.4 days) for patients younger than 75 years of age (P = 0.14). When the length of time required to "pass" a daily screening test of weaning variables was used as an indicator of recovery from respiratory failure, elderly patients passed earlier than younger patients (risk ratio, 1.58 [95% CI, 1.13 to 2.22]; P = 0.03). The cost of ICU care was lower for older ($12,822 [CI, $9821 to $26,313] than for younger ($19,316 [CI, $9699 to $39,950]) patients (P = 0.03). Median hospital costs tended to be lower in the older group ($21,292 compared with $29,049; P = 0.17). After adjustment for ethnicity, sex, and severity of illness in a multivariate logistic regression analysis, patient age of 75 years or older was predictive of 1 less day on the ventilator (CI, -2.8 to 1.2 days). Lengths of stay in the ICU (beta-coefficient, -0.5 days [CI, -3.0 to 2.7 days]) and in the hospital (beta-coefficient, 0.3 days [CI, -3.7 to 5.5 days]) did not differ for persons 75 years of age or older after these adjustments (P > 0.1). Intensive care unit and hospital costs, however, were lower for elderly persons (P = 0.02). The in-hospital mortality rate was 38.1% among elderly patients and 38.8% among younger patients (P > 0.2); Cox proportional hazards analysis confirmed that survival did not differ between the two groups (relative risk for older patients, 0.82 [CI, 0.52 to 1.29]). CONCLUSIONS: After adjustment for severity of illness, elderly patients spent similar time on mechanical ventilation and in the ICU and hospital but had a lower cost of care than younger patients. These outcomes are not explained by differences in mortality rate and suggest that mechanical ventilation should not be restricted in elderly patients with respiratory failure on the basis of chronologic age.
APACHE↗
Transfusions in critically ill patients.
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APACHE↗
The prognostic significance of passing a daily screen of weaning parameters.
OBJECTIVE: While "weaning parameters" are commonly used to guide removal of mechanical ventilation devices, little information exists concerning their prognostic value. We evaluated whether passing weaning parameters was associated with survival. DESIGN: A prospectively followed cohort of mechanically ventilated patients. SETTING: Medical and coronary adult intensive care units of an 806-bed medical center. PATIENTS: 300 consecutively enrolled mechanically ventilated patients. MEASUREMENTS AND RESULTS: 216 patients who passed a daily screen of weaning parameters were more likely to be extubated successfully (87 vs 30%, p = 0.0001), less likely to require ventilation for > 21 days (3 vs 30%, p = 0.0001), and had a higher survival to hospital discharge (74 vs 29%, p = 0.0001) than 84 patients who never passed the screen. The overall accuracy of the daily screen for predicting successful extubation and in-hospital survival was 82 and 73%, respectively. Multivariate proportional hazards analysis of time until hospital death confirmed the beneficial effect of passing the daily screen (p = 0.01) and of duration of mechanical ventilation (p = 0.001) even after adjustment for differences in severity of illness, age, race, gender, diagnosis, and treatment assignment. While liberation from mechanical ventilation was predictive of survival at any time during the hospital stay (p = 0.001), the prognostic significance of the daily screen for hospital survival was related to how early after intubation it was passed. The difference in survival between patients who had passed and those who had not passed the daily screen was significant for 1 1/2 weeks postintubation but progressively decreased over time. The average time to extubation after passing the daily screen increased from 3 days (range 0 to 56), for those passing within 5 days of intubation, to 8 days (0 to 35), for those passing after 10 days of intubation (r = 0.26, p = 0.001). CONCLUSIONS: Passing a daily screen of weaning parameters is an independent predictor of successful extubation and survival, but its prognostic value decreases over time. Time spent on mechanical ventilation after passing the daily screen presents an important opportunity to optimize liberation from the ventilator.
Adult↗