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Biomedical subjects

M H Kollef

Publications and source records attributed to M H Kollef.

At least 37 records · Page 2Linked to original sources
PubMed2000

The effect of respiratory therapist-initiated treatment protocols on patient outcomes and resource utilization.

CONTEXT: Physicians frequently prescribe respiratory treatments to hospitalized patients, but the influence of such treatments on clinical outcomes is difficult to assess. OBJECTIVE: To compare the clinical outcomes of patients receiving respiratory treatments managed by respiratory care practitioner (RCP)-directed treatment protocols or physician-directed orders. DESIGN: A single center, quasi-randomized, clinical study. SETTING: Three internal medicine firms from an urban teaching hospital. PATIENTS: Six hundred ninety-four consecutive hospitalized non-ICU patients ordered to receive respiratory treatments. MAIN OUTCOME MEASURES: Discordant respiratory care orders, respiratory care charges, hospital length of stay, and patient-specific complications. Discordant orders were defined as written orders for respiratory treatments that were not clinically indicated as well as orders omitting treatments that were clinically indicated according to protocol-based treatment algorithms. RESULTS: Firm A patients (n = 239) received RCP-directed treatments and had a statistically lower rate of discordant respiratory care orders (24.3%) as compared with patients receiving physician-directed treatments in firms B (n = 205; 58.5%) and C (n = 250; 56.8%; p < 0.001). No statistically significant differences in patient complications were observed. The average number of respiratory treatments and respiratory care charges were statistically less for firm A patients (10.7 +/- 13.7 treatments; $868 +/- 1,519) as compared with patients in firms B (12.4 +/- 12.7 treatments, $1,124 +/- 1,339) and C (12.3 +/- 13.4 treatments, $1, 054 +/- 1,346; p = 0.009 [treatments] and p < 0.001 [respiratory care charges]). CONCLUSIONS: Respiratory care managed by RCP-directed treatment protocols for non-ICU patients is safe and showed greater agreement with institutional treatment algorithms as compared with physician-directed respiratory care. Additionally, the overall utilization of respiratory treatments was significantly less among patients receiving RCP-directed respiratory care.

Adult↗
PubMed2000

A comparative analysis of patients with early-onset vs late-onset nosocomial pneumonia in the ICU setting.

STUDY OBJECTIVE: To compare the clinical outcomes of critically ill patients developing early-onset nosocomial pneumonia (NP; ie, within 96 h of ICU admission) and late-onset NP (ie, occurring after 96 h of ICU admission). DESIGN: Prospective cohort study. SETTING: A medical ICU and a surgical ICU from a university-affiliated urban teaching hospital. PATIENTS: Between July 1997 and November 1998, 3, 668 patients were prospectively evaluated. INTERVENTION: Prospective patient surveillance and data collection. RESULTS: Four hundred twenty patients (11.5%) developed NP. Early-onset NP was observed in 235 patients (56.0%), whereas 185 patients (44.0%) developed late-onset NP. Among patients with early onset NP, 114 patients (48. 5%) spent at least 24 h in the hospital prior to ICU admission, compared to 57 patients (30.8%) with late-onset NP (p = 0.001). One hundred eighty-three patients (77.9%) with early-onset NP received antibiotics prior to the development of NP, as compared to 162 patients (87.6%) with late-onset NP (p = 0.010). The most common pathogens associated with early-onset NP were Pseudomonas aeruginosa (25.1%), oxacillin-sensitive Staphylococcus aureus (OSSA; 17.9%), oxacillin-resistant S aureus (ORSA; 17.9%), and Enterobacter species (10.2%). P aeruginosa (38.4%), ORSA (21.1%), Stenotrophomonas maltophilia (11.4%), OSSA (10.8%), and Enterobacter species (10.3%) were the most common pathogens associated with late-onset NP. The ICU length of stay was significantly longer for patients with early-onset NP (10.3 +/- 8.3 days; p < 0.001) and late-onset NP (21. 0 +/- 13.7 days; p < 0.001), as compared to patients without NP (3.5 +/- 3.2 days). Hospital mortality was significantly greater for patients with early-onset NP (37.9%; p = 0.001) and late-onset NP (41.1%; p = 0.001) compared to patients without NP (13.1%). CONCLUSIONS: Both early-onset and late-onset NP are associated with increased hospital mortality rates and prolonged lengths of stay. The pathogens associated with NP were similar for both groups. This may be due, in part, to the prior hospitalization and use of antibiotics in many patients developing early-onset NP. These data suggest that P aeruginosa and ORSA can be important pathogens associated with early-onset NP in the ICU setting. Additionally, clinicians should be aware of the common microorganisms associated with both early-onset NP and late-onset NP in their hospitals in order to avoid the administration of inadequate antimicrobial treatment.

Adult↗
PubMed2000

The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting.

STUDY OBJECTIVE: To evaluate the relationship between the adequacy of antimicrobial treatment for bloodstream infections and clinical outcomes among patients requiring ICU admission. DESIGN: Prospective cohort study. SETTING: A medical ICU (19 beds) and a surgical ICU (18 beds) from a university-affiliated urban teaching hospital. PATIENTS: Between July 1997 and July 1999, 492 patients were prospectively evaluated. INTERVENTION: Prospective patient surveillance and data collection. RESULTS: One hundred forty-seven patients (29.9%) received inadequate antimicrobial treatment for their bloodstream infections. The hospital mortality rate of patients with a bloodstream infection receiving inadequate antimicrobial treatment (61.9%) was statistically greater than the hospital mortality rate of patients with a bloodstream infection who received adequate antimicrobial treatment (28.4%; relative risk, 2. 18; 95% confidence interval [CI], 1.77 to 2.69; p < 0.001). Multiple logistic regression analysis identified the administration of inadequate antimicrobial treatment as an independent determinant of hospital mortality (adjusted odds ratio [AOR], 6.86; 95% CI, 5.09 to 9.24; p < 0.001). The most commonly identified bloodstream pathogens and their associated rates of inadequate antimicrobial treatment included vancomycin-resistant enterococci (n = 17; 100%), Candida species (n = 41; 95.1%), oxacillin-resistant Staphylococcus aureus (n = 46; 32.6%), coagulase-negative staphylococci (n = 96; 21.9%), and Pseudomonas aeruginosa (n = 22; 10.0%). A statistically significant relationship was found between the rates of inadequate antimicrobial treatment for individual microorganisms and their associated rates of hospital mortality (Spearman correlation coefficient = 0.8287; p = 0.006). Multiple logistic regression analysis also demonstrated that a bloodstream infection attributed to Candida species (AOR, 51.86; 95% CI, 24.57 to 109.49; p < 0.001), prior administration of antibiotics during the same hospitalization (AOR, 2.08; 95% CI, 1.58 to 2.74; p = 0.008), decreasing serum albumin concentrations (1-g/dL decrements) (AOR, 1.37; 95% CI, 1.21 to 1.56; p = 0.014), and increasing central catheter duration (1-day increments) (AOR, 1.03; 95% CI, 1.02 to 1.04; p = 0.008) were independently associated with the administration of inadequate antimicrobial treatment. CONCLUSIONS: The administration of inadequate antimicrobial treatment to critically ill patients with bloodstream infections is associated with a greater hospital mortality compared with adequate antimicrobial treatment of bloodstream infections. These data suggest that clinical efforts should be aimed at reducing the administration of inadequate antimicrobial treatment to hospitalized patients with bloodstream infections, especially individuals infected with antibiotic-resistant bacteria and Candida species.

Aged↗
PubMed2000

Early versus late tracheostomy in patients who require prolonged mechanical ventilation.

OBJECTIVES: To compare the clinical outcomes of early versus late tracheostomy in patients who require prolonged mechanical ventilation. METHODS: A prospective observational study was done. The sample was a cohort of 90 patients who had tracheostomy in the medical intensive care unit of a university-affiliated teaching hospital. Primary outcome measures were duration of mechanical ventilation and total cost of hospitalization. Tracheostomy was defined as early if performed by day 10 of mechanical ventilation and late if performed thereafter. RESULTS: Fifty-three patients had early tracheostomy (mean +/- SD = day 5.9 +/- 7.2 of ventilation), and 37 patients had late tracheostomy (mean +/- SD = day 16.7 +/- 2.9) (P < .001). The mean (+/- SD) duration of mechanical ventilation was 28.3 +/- 28.2 days in the early-tracheostomy group versus 34.4 +/- 17.8 days in the late-tracheostomy group (P = .005). Total cost of hospitalization was significantly lower in the early-tracheostomy group (mean +/- SD = $86,189 +/- $53,570) than in the late-tracheostomy group (mean +/- SD = $124,649 +/- $54,282) (P = .001). Male sex (adjusted odds ratio = 3.84; 95% CI = 2.32-6.34; P = .007) and higher ratios of PaO2 to fraction of inspired oxygen (adjusted odds ratio = 1.01; 95% CI = 1.00-1.01; P = .03) were associated with early tracheostomy. The timing of tracheostomy was not associated with hospital mortality. CONCLUSION: Early tracheostomy is associated with shorter lengths of stay and lower hospital costs than is late tracheostomy among patients in the medical intensive care unit. Prospective clinical trials are necessary to determine the optimal timing of tracheostomy in that setting.

APACHE↗
PubMed1999

Delays in the suspicion and treatment of tuberculosis among hospitalized patients.

BACKGROUND: Despite increased awareness of tuberculosis, delays in management are common. OBJECTIVE: To investigate management delays among hospitalized patients with tuberculosis. DESIGN: Retrospective cohort study. SETTING: The Barnes-Jewish-Christian Health System, a network of eight community and tertiary-care facilities serving the St. Louis, Missouri, metropolitan area. PATIENTS: All 203 patients with tuberculosis hospitalized in the Barnes-Jewish-Christian Health System from 1988 to 1996. MEASUREMENTS: Time from admission to first consideration of the diagnosis (suspicion interval), first consideration and treatment initiation (treatment interval), and admission and treatment initiation (overall management interval) were determined. Delays were defined as intervals longer than 24 hours. RESULTS: The overall management interval (median, 6 days [5th and 95th percentiles, 1 and 52 days]) exceeded 24 hours in 152 patients (74.9% [95% CI, 68.9% to 80.9%]). The suspicion interval (median, 1 day [5th and 95th percentiles, 0 and 16 days]) exceeded 24 hours in 54 patients (26.6% [CI, 20.5% to 32.7%]), and the treatment interval (median, 3 days [5th and 95th percentiles, 0 and 51 days]) was prolonged in 130 patients (64.0% [CI, 57.4% to 70.6%]). Overall management delays of more than 10 and 25 days occurred in 33.5% (CI, 27.0% to 40.0%) and 18.7% (CI, 13.3% to 24.1%) of patients, respectively. The 55 patients with smears that were positive for acid-fast bacilli had a median treatment interval of 3 days (5th and 95th percentiles, 0 and 33 days); in 58.2% of patients (CI, 45.2% to 71.2%), this interval exceeded 24 hours. CONCLUSIONS: Delays in initiation of treatment were more common than delays in the initial suspicion of tuberculosis. Both types of delays were common even in patients with disease that was confirmed by a positive smear. These data illustrate a need for improved education of physicians about the benefits of early initiation of therapy for tuberculosis.

Adolescent↗
PubMed1999

Epidemiology and risk factors for nosocomial pneumonia. Emphasis on prevention.

UNLABELLED: VAP is a complex nosocomial infection, the disease expression and resulting patient outcome of which is dependent on host factors, the causative organism, the timing and adequacy of treatment, and the presence of intrinsic or inducible antibiotic resistance. Significant improvements have been achieved in our ability to reduce the occurrence of VAP in the hospital setting. Clinicians caring for mechanically ventilated patients should strive to develop focused programs for the prevention of VAP, other nosocomial infections, and the occurrence of antibiotic-resistant infections at their institutions. The benefits of such programs are well demonstrated. The components of a PDSA (Plan-Do-STUDY-Act) model that can be simply employed to develop a VAP prevention program are as follows: Stages Plan: 1. Identify potentially modifiable risk factors for VAP at the institutional level. 2. Develop a strategy to modify or prevent the occurrence of these risk factors. [figure: see text] Do: 1. Carry out the planned intervention strategy. 2. Identify problems in the implementation of the designed intervention. 3. Update the intervention with solutions for the identified problems. 4. Collect basic data (e.g., VAP rates, severity of illness). STUDY: 1. Analyze data. 2. Summarize the results. Act: 1. Determine the overall success or failure of the intervention. 2. Identify potential modifications to improve the intervention strategy. 3. Prepare for next PDSA cycle. Inherent in the development and application of such programs is the concept that they are continuous processes striving to improve clinical performance over time (Fig. 3). At any given institution, the most likely approach to the prevention of NP and VAP will be a multifaceted one, employing interventions aimed at reducing the occurrence of aerodigestive tract colonization with pathogenic bacteria and aspiration. To be successful, such quality improvement programs must be embraced at the institutional level. Only in this way can hospitals hope to successfully reduce their rates of VAP and sustain or improve upon those efforts over time.

Adult↗
PubMed1999

Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit.

OBJECTIVE: To identify clinical predictors for tracheostomy among patients requiring mechanical ventilation in the intensive care unit (ICU) setting and to describe the outcomes of patients receiving a tracheostomy. DESIGN: Prospective cohort study. SETTING: Intensive care units of Barnes-Jewish Hospital, an urban teaching hospital. PATIENTS: 521 patients requiring mechanical ventilation in an ICU for >12 hours. INTERVENTIONS: Prospective patient surveillance and data collection. MEASUREMENTS AND MAIN RESULTS: The main variables studied were hospital mortality, duration of mechanical ventilation, length of stay in the ICU and the hospital, and acquired organ-system derangements. Fifty-one (9.8%) patients received a tracheostomy. The hospital mortality of patients with a tracheostomy was statistically less than the hospital mortality of patients not receiving a tracheostomy (13.7% vs. 26.4%; p = .048), despite having a similar severity of illness at the time of admission to the ICU (Acute Physiology and Chronic Health Evaluation [APACHE] II scores, 19.2 +/- 6.1 vs. 17.8 +/- 7.2; p = .173). Patients receiving a tracheostomy had significantly longer durations of mechanical ventilation (19.5 +/- 15.7 days vs. 4.1 +/- 5.3 days; p < .001) and hospitalization (30.9 +/- 18.1 days vs. 12.8 +/- 10.1 days; p < .001) compared with patients not receiving a tracheostomy. Similarly, the average duration of intensive care was significantly longer among the hospital nonsurvivors receiving a tracheostomy (n = 7) compared with the hospital nonsurvivors without a tracheostomy (n = 124; 30.9 +/- 16.3 days vs. 7.9 +/- 7.3 days; p < .001). Multiple logistic regression analysis demonstrated that the development of nosocomial pneumonia (adjusted odds ratio [AOR], 4.72; 95% confidence interval [CI], 3.24-6.87; p < .001), the administration of aerosol treatments (AOR, 3.00; 95% CI, 2.184.13; p < .001), having a witnessed aspiration event (AOR, 3.79; 95% CI, 2.30-6.24; p = .008), and requiring reintubation (AOR, 2.21; 95% CI, 1.54-3.18; p = .028) were variables independently associated with patients undergoing tracheostomy and receiving prolonged ventilatory support. Among the 44 survivors receiving a tracheostomy in the ICU, 38 (86.4%) were alive 30 days after hospital discharge and 31 (70.5%) were living at home. CONCLUSIONS: Despite having longer lengths of stay in the ICU and hospital, patients with respiratory failure who received a tracheostomy had favorable outcomes compared with patients who did not receive a tracheostomy. These data suggest that physicians are capable of selecting critically ill patients who most likely will benefit from placement of a tracheostomy. Additionally, specific clinical variables were identified as risk factors for prolonged ventilatory assistance and the need for tracheostomy.

APACHE↗
PubMed1999

The influence of access to a private attending physician on the withdrawal of life-sustaining therapies in the intensive care unit.

OBJECTIVE: To assess the influence of patient access to a private attending physician on the withdrawal of life-sustaining therapies in a medical intensive care unit (ICU). DESIGN: Prospective cohort study. SETTING: A university-affiliated teaching hospital. PATIENTS: A total of 501 consecutive patients admitted to the medical ICU during a 5-month period. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Among patients dying in the medical ICU, those without a private attending physician (n = 26) were statistically more likely to undergo the active withdrawal of life-sustaining therapies than patients with a private attending physician (n = 87) (80.8% vs. 29.9%; relative risk = 2.70; 95% confidence interval = 1.86-3.92; p < .001). Despite having similar predicted mortality rates by Acute Physiology and Chronic Health Evaluation II score (60.5% +/- 27.0% vs. 66.1% +/- 21.3%; p = .280), patients dying in the medical ICU without a private attending physician had statistically shorter hospital and ICU lengths of stay, a shorter duration of mechanical ventilation, and fewer total hospital costs and charges compared with patients with access to a private attending physician. Multiple logistic regression analysis, controlling for severity of illness, demographic characteristics, and patient diagnoses, demonstrated that lack of access to a private attending physician (adjusted odds ratio = 23.10; 95% confidence interval = 9.10-58.57; p < .001) and the presence of a do-not-resuscitate order while in the ICU (adjusted odds ratio = 7.33; 95% confidence interval = 3.69-14.54; p = .004) were the only variables independently associated with the withdrawal of life-sustaining therapies before death. CONCLUSIONS: Patients dying in a medical ICU setting without access to a private attending physician are more likely to undergo the active withdrawal of life-sustaining therapies before death than patients with a private attending physician. Health care providers should be aware of possible variations in the practice of withdrawal of life-sustaining therapies in their ICUs based on this patient characteristic.

Adolescent↗
PubMed1999

Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation.

OBJECTIVE: To compare a practice of protocol-directed sedation during mechanical ventilation implemented by nurses with traditional non-protocol-directed sedation administration. DESIGN: Randomized, controlled clinical trial. SETTING: Medical intensive care unit (19 beds) in an urban teaching hospital. PATIENTS: Patients requiring mechanical ventilation (n = 321). INTERVENTIONS: Patients were randomly assigned to receive either protocol-directed sedation (n = 162) or non-protocol-directed sedation (n = 159). MEASUREMENTS AND MAIN RESULTS: The median duration of mechanical ventilation was 55.9 hrs (95% confidence interval, 41.0-90.0 hrs) for patients managed with protocol-directed sedation and 117.0 hrs (95% confidence interval, 96.0-155.6 hrs) for patients receiving non-protocol-directed sedation. Kaplan-Meier analysis demonstrated that patients in the protocol-directed sedation group had statistically shorter durations of mechanical ventilation than patients in the non-protocol-directed sedation group (chi-square = 7.00, p = .008, log rank test; chi-square = 8.54, p = .004, Wilcoxon's test; chi-square = 9.18, p = .003, -2 log test). Lengths of stay in the intensive care unit (5.7+/-5.9 days vs. 7.5+/-6.5 days; p = .013) and hospital (14.0+/-17.3 days vs. 19.9+/-24.2 days; p < .001) were also significantly shorter among patients in the protocol-directed sedation group. Among the 132 patients (41.1%) receiving continuous intravenous sedation, those in the protocol-directed sedation group (n = 66) had a significantly shorter duration of continuous intravenous sedation than those in the non-protocol-directed sedation group (n = 66) (3.5+/-4.0 days vs. 5.6+/-6.4 days; p = .003). Patients in the protocol-directed sedation group also had a significantly lower tracheostomy rate compared with patients in the non-protocol-directed sedation group (10 of 162 patients [6.2%] vs. 21 of 159 patients [13.2%], p = .038). CONCLUSIONS: The use of protocol-directed sedation can reduce the duration of mechanical ventilation, the intensive care unit and hospital lengths of stay, and the need for tracheostomy among critically ill patients with acute respiratory failure.

Algorithms↗
PubMed1999

Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients.

STUDY OBJECTIVE: To evaluate the relationship between inadequate antimicrobial treatment of infections (both community-acquired and nosocomial infections) and hospital mortality for patients requiring ICU admission. DESIGN: Prospective cohort study. SETTING: Barnes-Jewish Hospital, a university-affiliated urban teaching hospital. PATIENTS: Two thousand consecutive patients requiring admission to the medical or surgical ICU. INTERVENTIONS: Prospective patient surveillance and data collection. MEASUREMENTS AND RESULTS: One hundred sixty-nine (8.5%) infected patients received inadequate antimicrobial treatment of their infections. This represented 25.8% of the 655 patients assessed to have either community-acquired or nosocomial infections. The occurrence of inadequate antimicrobial treatment of infection was most common among patients with nosocomial infections, which developed after treatment of a community-acquired infection (45.2%), followed by patients with nosocomial infections alone (34.3%) and patients with community-acquired infections alone (17.1%) (p < 0.001). Multiple logistic regression analysis, using only the cohort of infected patients (n = 655), demonstrated that the prior administration of antibiotics (adjusted odds ratio [OR], 3.39; 95% confidence interval [CI], 2.88 to 4.23; p < 0.001), presence of a bloodstream infection (adjusted OR, 1.88; 95% CI, 1.52 to 2.32; p = 0.003), increasing acute physiology and chronic health evaluation (APACHE) II scores (adjusted OR, 1.04; 95% CI, 1.03 to 1.05; p = 0.002), and decreasing patient age (adjusted OR, 1.01; 95% CI, 1.01 to 1.02; p = 0.012) were independently associated with the administration of inadequate antimicrobial treatment. The hospital mortality rate of infected patients receiving inadequate antimicrobial treatment (52.1%) was statistically greater than the hospital mortality rate of the remaining patients in the cohort (n = 1,831) without this risk factor (12.2%) (relative risk [RR], 4.26; 95% CI, 3.52 to 5.15; p < 0.001). Similarly, the infection-related mortality rate for infected patients receiving inadequate antimicrobial treatment (42.0%) was significantly greater than the infection-related mortality rate of infected patients receiving adequate antimicrobial treatment (17.7%) (RR, 2.37; 95% CI, 1.83 to 3.08; p < 0.001). Using a logistic regression model, inadequate antimicrobial treatment of infection was found to be the most important independent determinant of hospital mortality for the entire patient cohort (adjusted OR, 4.27; 95% CI, 3.35 to 5.44; p < 0.001). The other identified independent determinants of hospital mortality included the number of acquired organ system derangements, use of vasopressor agents, the presence of an underlying malignancy, increasing APACHE II scores, increasing age, and having a nonsurgical diagnosis at the time of ICU admission. CONCLUSIONS: Inadequate treatment of infections among patients requiring ICU admission appears to be an important determinant of hospital mortality. These data suggest that clinical efforts aimed at reducing the occurrence of inadequate antimicrobial treatment could improve the outcomes of critically ill patients. Additionally, prior antimicrobial therapy should be recognized as an important risk factor for the administration of inadequate antimicrobial treatment among ICU patients with clinically suspected infections.

APACHE↗
PubMed1999

A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients.

STUDY OBJECTIVES: To determine whether the application of continuous aspiration of subglottic secretions (CASS) is associated with a decreased incidence of ventilator-associated pneumonia (VAP). DESIGN: Prospective clinical trial. SETTING: Cardiothoracic ICU (CTICU) of Barnes-Jewish Hospital, St. Louis, a university-affiliated teaching hospital. PATIENTS: Three hundred forty-three patients undergoing cardiac surgery and requiring mechanical ventilation in the CTICU. INTERVENTIONS: Patients were assigned to receive either CASS, using a specially designed endotracheal tube (Hi-Lo Evac; Mallinckrodt Inc; Athlone, Ireland), or routine postoperative medical care without CASS. RESULTS: One hundred sixty patients were assigned to receive CASS, and 183 were assigned to receive routine postoperative medical care without CASS. The two groups were similar at the time of randomization with regard to demographic characteristics, surgical procedures performed, and severity of illness. Risk factors for the development of VAP were also similar during the study period for both treatment groups. VAP was seen in 8 patients (5.0%) receiving CASS and in 15 patients (8. 2%) receiving routine postoperative medical care without CASS (relative risk, 0.61%; 95% confidence interval, 0.27 to 1.40; p = 0. 238). Episodes of VAP occurred statistically later among patients receiving CASS ([mean +/- SD] 5.6 +/- 2.3 days) than among patients who did not receive CASS (2.9 +/- 1.2 days); (p = 0.006). No statistically significant differences for hospital mortality, overall duration of mechanical ventilation, lengths of stay in the hospital or CTICU, or acquired organ system derangements were found between the two treatment groups. No complications related to CASS were observed in the intervention group. CONCLUSIONS: Our findings suggest that CASS can be safely administered to patients undergoing cardiac surgery. The occurrence of VAP can be significantly delayed among patients undergoing cardiac surgery using this simple-to-apply technique.

Cardiac Surgical Procedures↗
PubMed1999

Acquired organ system derangements and hospital mortality: are all organ systems created equally?

BACKGROUND: Acquired organ system derangements are common among patients who require intensive care, but the relative importance of different derangements as determinants of patients' outcomes is unclear. OBJECTIVES: To determine organ system derangements that occur in patients who require intensive care and the relative importance of different derangements to hospital mortality. METHODS: A prospective cohort study design was used to evaluate the occurrence of organ system derangements and hospital mortality in 617 adults admitted to the medical and surgical intensive care units of a university-affiliated teaching hospital. RESULTS: Eighty-three patients (13.5%) died while hospitalized. Patients who died had significantly more derangements than did patients who survived (3.3 +/- 1.2 vs 0.9 +/- 0.9; P < .001). The crude hospital mortality rate varied with the specific organ system involved (pulmonary, 23.6%; gastrointestinal, 25.0%; hepatic, 42.4%; hematological, 47.9%; cardiac, 54.0%; renal, 54.8%; neurological, 65.9%). Derangements of neurological function (adjusted odds ratio, 3.20; 95% CI, 2.0-5.3; P = .019) and cardiac function (adjusted odds ratio, 3.96; 95% CI, 2.63-5.99; P < .001) were independently associated with hospital mortality. Additionally, derangements occurred later during the stay in the intensive care unit in patients who died in the hospital than in patients who survived, especially for derangements of pulmonary, neurological, and renal function. CONCLUSION: Among critically ill patients, neurological and cardiac dysfunction are the acquired organ system derangements most closely associated with hospital mortality. These data suggest that hospital mortality depends on both the specific types of derangements that occur and the total number of such derangements. Interventions to prevent cardiac and neurological dysfunction have the greatest potential for improving outcomes for patients in the intensive care unit.

APACHE↗