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PubMed1993

Trends from the United States with end of life decisions in the intensive care unit.

OBJECTIVE: To describe the changes that have occurred in the United States since medicine has moved away from a paternalistic model to one that promotes patient autonomy and self-determination. To discuss the implications for cardiopulmonary resuscitation (CPR) and the increasing use of when not to perform CPR and other life-sustaining therapies. To describe the various interpretations of the ritual term Do-Not-Resuscitate (DNR) and to introduce the concept of futility in the context of non-beneficial over-treatment and discriminatory under-treatment. SETTING: Selected clinical, philosophical and public policy literature and two illustrative case examples. RESULTS: 1. There is no longer a mandate to perform CPR on all dying patients, even though the Council on Ethical and Judicial Affairs of the American Medical Association in 1991 said that the only restrictions should be in patients with an irreversible terminal condition or when the physician writes the order, DNR. 2. The DNR order usually requires the informed refusal of CPR by the patient or family. There is only minimal support for a unilateral decision even for patients with far advanced disease. 3. DNR is often the first step in the negotiated process of forgoing care in the ICU. There are multiple interpretations of DNR both in and outside of the ICU. 4. Health Proxy is the latest attempt to have a person clarify his/her wishes and preferences by naming a decision maker, if the individual losses mental capacity. 5. Although ethical principles seem well established, there are inconsistent interpretations and practices at the bedside in the United States in part due to the restructuring of the relationship between physicians and patients, providers and consumers/clients. 6. Objective severity scores such as Apache III, SAPS II, MPM II are generally not applicable for individual patient end-of-life decisions. CONCLUSIONS: Although Health Proxy in its current formulation has been disappointing, there is a clear trend for wider application of DNR and for more active discussions about withholding or forgoing other life-sustaining therapies. DNR has a different interpretation late into the ICU course (> 72 h) than when applied at or shortly after ICU admission. Late in the ICU course, it has been decided by the medical team and family or surrogate decision maker/Health Proxy that the patient has failed or is in the process of failing aggressive ICU therapy. Early use of DNR may be related to limitations based on pre-existing chronic or subacute disease burden or an unwillingness to proceed with a full ICU course of therapy. It is unclear how Ethics Committees, risk management and hospital administrators, national practice guidelines, governmental sponsored health care reform will interface with the highly complex individual patient--physician--family--Health Proxy interface as practiced in the United States. Dialogue between the Society of Critical Care Medicine and the European Society of Critical Care Medicine and among interested physicians could provide a format for a multi-cultural context to discuss end of life issues in the ICU setting.

Cardiopulmonary Resuscitation↗

PubMed1997

[Ethics in intensive medicine].

In more than 30 years of development of intensive care medicine (ICM), our specialty has acquired moral and ethical standpoints, although not without public pressure and discussions. Special commissions dealing, e.g., with brain death, terminal care, ethics of foregoing life-sustaining treatment in the critically ill, withholding or withdrawing mechanical ventilation, and other issues have been formed in a number of medical societies. International consensus conferences have helped to clarify some of the issues. With increasing experience, a multitude of ethical problems have arisen in ICM that have to be dealt with, such as the issue of quality of life. What is an unworthy life? Are we allowed to make judgments for our patients? What is cost-effectiveness in ICM? Other restrictions include bed and equipment shortages in the intensive care unit (ICU), the necessity for triage--undisputed in catastrophe medicine--and how one should proceed in managing elective patients? In situations of limited ICU bed availability, sicker patients will be admitted, sparing out patients who are less ill for observation and those with poor quality of life and poor prognosis. For the future, it will likely be necessary to define the patients who should be admitted to an ICU more than those who should not be admitted. An ICU treatment entitlement index would be directly proportional to the probability of successful outcome and the quality of the remaining life, and would be inversely related to costs for achieving success. The ICU outcome with survival, hospital mortality, and follow-up of ICU patients is considered. DNR (do not resuscitate), the dying patient, terminal care, terminal weaning--DNT (do not treat)--active and passive euthanasia, living wills, quality of life, and cost-effectiveness for ICU patients are defined. Their application in the ICU will be discussed and problems pointed out. Outcome predictions using scores (APACHE III, SAPS II, MPM) have been developed based on previous experience, but should only be applied to patient groups and for quality assurance in ICUs. The most frequent and difficult problem in the ICUs is the vegetative state, which requires an exact diagnosis. The differential diagnosis from other comatose states such as coma, brain death, and locked-in-syndrome is depicted. The ethics of interrupting life-sustaining treatment in critically ill patients have been worked out by a Task Force on Ethics of the Society of Critical Care Medicine (1990). A consensus was found that the patient may judge to forego therapy; ethically it is then appropriate to withhold or withdraw therapy. According to the consensus, withdrawing an already initiated treatment should not necessarily be regarded as more problematic than a decision not to initiate treatment. In my mind, however, there is a great difference between withdrawing or withholding, e.g., ventilation. A dissentive opinion by some members of the Task Force stated that hydration and nutrition other than high-technology or parenteral nutrition are key components of patient care, and should not be equated with medical intervention. The ethical problems associated with active euthanasia (physician-assisted suicide or death) as practised in the Netherlands are also discussed. In most countries this practice seems unacceptable. From 30 years experience in ICM, there are many more ethical questions and case reports without clear solutions. Care decisions for single patients in unacceptable situations should be made after medical evaluation by the intensivist with the medical team and, if possible, by the patient and/or his or her surrogate. Legislation and solutions cannot be expected for single patients, but ethics committees could be helpful in decision-making.

Critical Care↗

PubMed1997

[Prognostic scores in intensive care].

Since the development of prognostic score systems in intensive care medicine in the 1980s score models have improved substantially and are now based on much larger databases. They have been validated in many multicenter and international studies all over the world. Prognostic scoring systems may be used for assessment of severity of illness, stratifying patients prior to randomization in clinical trials, evaluation and comparing outcome and survival (hospital mortality), quality assessment, cost-benefit analysis, and in clinical decision making. Validated time points for predicting hospital mortality of ICU patients are at admission and at 24 hours. The relationship of the observed hospital mortality rate to the estimated mortality provides the basis for clinical performance measurement. Since each ICU serves a different patient population, each score system must be calibrated in the individual hospital to ensure that the model is applicable. General scores covering more than one disease are Acute Physiology And Chronic Health Evaluation (APACHE II, APACHE III), Simplified Acute Physiology Score (SAPS) and Mortality Predicting Model (MPM). The Therapeutic Intervention Scoring System (TISS) and in part the Hannover Intensive Score (HIS) evaluate exclusively the amount of medical therapy required. The TISS-Score might serve as a possible measure of resource use for the ICU portion of the hospital stay. Disease (e.g. Trauma Score, Injury of Severity Score) and patient (e.g. PRISM = Pediatric Risk of Mortality) specific scores take into account the influence of disease and patient population in relation to outcome. They are not always of more predictive value than general score models. Score models have been criticized for a number of reasons. Outcome of ICU therapy should incorporate not only survival but should also take into account quality of life, morbidity and disability. Severity scores have no role in clinical decision making for an individual patient (e.g. patient triage for ICU admission, discharge criteria, withdrawal of life support). This is due to the current low sensitivity. Subsequent validation of variables could improve the sensitivity and the value of severity scoring in the future. Nevertheless, illness severity scores will never be indicative of absolute irreversibility of disease or impossibility of survival. Advances in computer technology should assist in achieving many of the future goals of prognostic scoring systems. Most of the physiological data are available from ICU monitors and computerized laboratory systems. By electronically interfacing with the ICU monitor an automated patient data entry is possible and will provide that prognostic scores can be made available to the clinician daily.

Critical Care↗

PubMedDate not supplied

Electronic voice-output communication aids for temporarily nonspeaking patients in a medical intensive care unit: a feasibility study.

BACKGROUND: The inability to speak during mechanical ventilation is recognized as a terrifying and isolating experience that is related to feelings of panic, insecurity, anger, worry, fear, sleep disturbances, and stress among critically ill patients. Alternative methods of communicating with temporarily nonspeaking patients in the intensive care unit (ICU) have received little study. Although electronic voice output communication aids (VOCAs) are available for disabled children and adults, the effectiveness of VOCA systems with adult medical ICU patients who may have multisystem illness, prolonged intubation, and longer ICU stays has not been explored. OBJECTIVES: The purpose of this pilot study was to describe (1) the characteristics of intubated MICU patients who use VOCAs, (2) the usage patterns (message categories, frequency, assistance required), (3) communication quality (ease, user satisfaction), and (4) barriers to communication with VOCAs. METHODS: This pilot study used participant observation, semi-structured interviews, questionnaires, and clinical record review in a complementary design to obtain data on communication events and VOCA use with 11 critically ill adults. RESULTS: Study participants, 45.5 +/- 16.0 years of age with 13 +/- 1.9 years of education and moderately severe illness (APACHE III=27.5 +/- 16.1), used the VOCA for 5.7 +/- 4.6 days. Ease of Communication Scale measurements showed significantly less difficulty with communication after device use (t>2.62; P=.047). Almost half (n=5) of the participants demonstrated some independent use of the device. VOCAS were used in one quarter of observed communication events. Patients used VOCAs most often to communicate with family visitors and initiated communication interactions more often when VOCAs were used than when communicating by other nonvocal methods. Poor device positioning, deterioration in patient condition, staff time constraints, staff unfamiliarity with device, and complex message screens were primary barriers to VOCA use. CONCLUSIONS: This study showed that use of VOCAs is possible with selected critically ill adults and may contribute to greater ease of communication during respiratory tract intubation particularly with family members. Further clinical research using control or comparison groups is needed.

Adult↗

PubMed2004

Partnering for quality.

This article discusses efforts being made by multiple stakeholders to improve quality and safety in intensive care units (ICUs). The Leapfrog Group (Washington, DC), a consortium of purchasers, is reaching for quality by implementing safety standards. One standard, staffing ICUs with intensivists, is associated with a 30% reduction in hospital mortality and a 40% reduction in ICU mortality. While Leapfrog is addressing quality improvements on a structural level, JCAHO is developing empiric measures for ICU quality, which are being beta tested, to complement Leapfrogs' efforts. JCAHO used rigorously defined processes to develop and refine these measures. These measures include deep venous thrombosis prophylaxis, peptic ulcer disease prophylaxis, catheter-related blood stream infections, mortality and length of stay-APACHE III risk adjustment. Finally, ICU providers at Hopkins implemented an 8-step unit-based safety program. This comprehensive program is run at the unit level, works to improve safety culture, addresses staff safety concerns, partners hospital leaders with unit workers, helps staff implement improvement initiatives, uses rigorous data collection methods, and easily disseminated in other clinical areas. Providers can frame their efforts after 3 fundamental concepts from these initiatives: create a culture that supports quality and safety, standardize work processes by reducing complexity and using independent redundancy, and automate. The take home message is, when we come to work every day, we must be committed to quality and safety, and lead our teams to do the same.

Hospital Mortality↗

PubMed1998

Predictors of adverse outcome in cancer patients with candidemia.

BACKGROUND: Many factors, including severity of illness, neutropenia, intravenous catheter management, and drug therapy may affect the outcome of candidemia in cancer patients. METHODS: The records of all patients at M. D. Anderson Cancer Center who developed one or more positive blood cultures for Candida spp between January 1, 1988, and December 31, 1992, were retrospectively reviewed. Four hundred ninety-one episodes of candidemia were identified, for which 476 had complete medical records, which were reviewed in detail. RESULTS: By 3-month follow-up, 52% of the patients had died. Neutropenia, higher APACHE III score, and visceral dissemination were associated with poor prognosis. Cure rates, adjusted for severity of illness, were similar for fluconazole and amphotericin B treatment. Exchange of central venous catheters was associated with a modest improvement in prognosis. CONCLUSION: Several factors that influence the outcome of candidemia in cancer patients have been identified. These factors may be relevant for the clinical management of cancer patients with candidemia, and for the design of therapeutic trials.

Adult↗

PubMed2000

Effect of highly active antiretroviral therapy on the incidence of bacterial pneumonia in HIV-infected subjects.

The aim of the study was to assess the incidence of hospital and community acquired bacterial pneumonia in HIV-infected subjects prior to and after the introduction of highly active antiretroviral therapy (HAART). We studied 266 patients with bacterial pneumonia over two separate periods, 154 in the first period and 112 in the second period. A statistically significant difference in the incidence of bacterial pneumonia in the two study periods was observed ranging from 13.1 to 8.5 episodes per 100 persons. The incidence of community-acquired bacterial pneumonia decreased from 10.7 to 7.7 (P=0.01), while that of nosocomial episodes decreased from 2.4 to 0.8 episodes (P=0.003). Low levels of peripheral CD(4+) cells (<100/mm(3)) and intravenous drug abuse (IVDA) were significantly associated with the development of community-acquired bacterial pneumonia, while an increasing value of APACHE III score and prolonged hospitalisation increased the risk of nosocomial bacterial pneumonia in both study periods.

AIDS-Related Opportunistic Infections↗

PubMed1998

A comparative analysis of lipid-complexed and liposomal amphotericin B preparations in haematological oncology.

No comparative clinical information on the properties of lipid-associated amphotericin preparations is presently available. In this single-centre retrospective analysis over a 5-year period the indications, efficacy and toxicity of true liposomal amphotericin (AmBisome) were compared with a lipid complexed preparation (Abelcet). In a novel approach APACHE III scores were used in addition to neutrophil counts, disease status and additional immunosuppression to accurately assess the severity of illness in both groups and enable valid comparison. Overall, AmBisome at a median dose of 1.9 mg/kg/d was found to have similar clinical outcome to Abelcet at a median dose of 4.8 mg/kg/d. Nephrotoxicity and electrolyte abnormalities were similar in both groups. Rigors and febrile episodes were more common with Abelcet. Prospective randomized comparative trials are required to clarify the optimum dosages and therapeutic and economic issues associated with these agents.

Adult↗

PubMed2003

Is there a July phenomenon? The effect of July admission on intensive care mortality and length of stay in teaching hospitals.

BACKGROUND: It has been suggested that inexperience of new housestaff early in an academic year may worsen patient outcomes. Yet, few studies have evaluated the "July Phenomenon," and no studies have investigated its effect in intensive care patients, a group that may be particularly susceptible to deficiencies in management stemming from housestaff inexperience. OBJECTIVE: Compare hospital mortality and length of stay (LOS) in intensive care unit (ICU) admissions from July to September to admissions during other months, and compare that relationship in teaching and nonteaching hospitals, and in surgical and nonsurgical patients. DESIGN, SETTING, AND PATIENTS: Retrospective cohort analysis of 156,136 consecutive eligible patients admitted to 38 ICUs in 28 hospitals in Northeast Ohio from 1991 to 1997. RESULTS: Adjusting for admission severity of illness using the APACHE III methodology, the odds of death was similar for admissions from July through September, relative to the mean for all months, in major (odds ratio [OR], 0.96; 95% confidence interval [95% CI], 0.91 to 1.02; P =.18), minor (OR, 1.02; 95% CI, 0.93 to 1.10; P =.66), and nonteaching hospitals (OR, 0.96; 95% CI, 0.91 to 1.01; P =.09). The adjusted difference in ICU LOS was similar for admissions from July through September in major (0.3%; 95% CI, -0.7% to 1.2%; P =.61) and minor (0.2%; 95% CI, -0.9% to 1.4%; P =.69) teaching hospitals, but was somewhat shorter in nonteaching hospitals (-0.8%; 95% CI, -1.4% to -0.1%; P =.03). Results were similar when individual months and academic years were examined separately, and in stratified analyses of surgical and nonsurgical patients. CONCLUSIONS: We found no evidence to support the existence of a July phenomenon in ICU patients. Future studies should examine organizational factors that allow hospitals and residency programs to compensate for inexperience of new housestaff early in the academic year.

Cohort Studies↗

PubMed1993

[Potentialities and limitations of the score system in intensive medicine].

In intensive-care medicine, score systems serve to quantify the severity of diseases and to characterise patient groups on the basis of objective criteria. The principle is to describe the severity by adding up points. Objectives are to assess the prognosis, to establish the amount of treatment required and assist in clinical decision making. The most important examples of general scores covering more than one disease are Acute Physiology And Chronic Health Evaluation (APACHE-II, APACHE-III), Simplified Acute Physiology Score (SAPS) and Mortality Prediction Model (MPM). General scores assess the deviation of physiological parameters from the normal assuming that the degree of deviation reflects the severity of the disease. The Therapeutic Intervention Scoring System (TISS) constitutes a particular form which evaluates exclusively the amount of therapy required. Disease-specific scores (trauma scores, sepsis scores) take into account the fact that the nature and stage of specific disease determine the outcome in a typical way. Scores are adequately validated and suitable for evaluation of clinical studies or cost-benefit analyses by characterisation of patient populations. The use of score systems for individual prognosis is at present controversial. Their clinical significance might increase in that scores help to make medical decisions by contributing to early identification of endangered patients by systematic establishment and evaluation of investigation results. Scores are likely to be used increasingly in intensive-care medicine.

Critical Care↗

PubMed2001

Risk factors and predictors of outcome in patients with cancer and breakthrough candidemia.

Hematogenous candidiasis adds substantially to the morbidity and mortality rates of patients with cancer. Little is known about the risk factors and outcome in patients with breakthrough (BT) candidemia while on systemic antifungal therapy. All 479 episodes of candidemia in 474 consecutive patients with candidemia that was diagnosed at M. D. Anderson Cancer Center from 1988 through 1992 were studied retrospectively. A total of 49 patients had BT candidemia, defined as candidemia that developed after at least 5 days of systemic antifungal therapy. Risk factors for BT candidemia and predictors of mortality were investigated. Multivariate analysis revealed that intensive care unit stay, neutropenia, use of corticosteroids, and duration of neutropenia as significant risk factors for BT candidemia. Seventy-six percent of patients with BT candidemia died, compared with 50% of patients with non-BT infection. In multivariate analysis, intensive care unit stay, being and remaining neutropenic, APACHE III score, and disseminated disease were independent prognostic factors. In conclusion, identification of risk factors and predictors of a poor outcome in patients with cancer with BT candidemia may have important implications in early diagnosis and appropriate therapy of these patients.

Candidiasis↗

PubMed2000

Diagnosis and treatment of intra-abdominal abscesses.

Despite recent advances in the diagnosis and management of intra-abdominal abscesses, these infections still cause substantial morbidity and mortality. Low pH, large bacterial inocula, poor perfusion, the presence of hemoglobin, and large amounts of fibrin (which impedes antibiotic penetration) make the abscess a cloistered environment that is penetrated poorly by many antimicrobial therapies. Therefore, management of these infections requires prompt recognition, early localization, and effective drainage, as well as appropriate antimicrobial use. Although various imaging techniques, such as ultrasonography, gallium scans, and indium-labeled white-blood-cell scans, can be used for the diagnosis and localization of intra-abdominal abscesses, computer-assisted tomography is the most useful study. Once the diagnosis is made and the abscess is localized, treatment should begin promptly. Percutaneous or open surgical drainage should be used. Broad-spectrum antibiotics should be given until culture and sensitivity data are obtained. Once these data are obtained, a therapy with appropriate coverage that is likely to work in the abscess environment should be chosen. Percutaneous drainage is inappropriate for abscesses in the posterior subphrenic space or in the porta hepatis, for those among loops of small bowel, for suspected echinococcal cysts, and for abscesses containing necrotic or neoplastic tissues. Finally, surgeons need to be cognizant of risk factors, such as advanced age, obesity, complex abscesses, and high Acute Physiology and Chronic Health Evaluation (APACHE) II or APACHE III scores, which correlate with poor outcomes for these patients.

Abdominal Abscess↗

PubMed2004

Longitudinal outcomes of intra-abdominal infection complicated by critical illness.

BACKGROUND: Critically ill surgical patients remain at high risk of adverse outcomes as a result of intra-abdominal infections, including prolonged length of stay, organ dysfunction, and death despite advances in critical care and innovations in management of the peritoneal cavity. We evaluated the causes and consequences of intra-abdominal infections among critically ill surgical patients in a single tertiary-care intensive care unit (ICU) over a decade. METHODS: Prospective study of 465 critically ill surgical patients with hollow viscus perforation and peritonitis or abscess from 1991-2002. Data collected were age, gender, admission APACHE III score, multiple organ dysfunction score, ICU and hospital length of stay, abscess (yes/no), site and type of perforation (colon vs. other), de novo vs. nosocomial origin, and mortality. Statistical analysis was by univariate ANOVA for coordinate data, Fisher exact test for continuous data, and logistic regression analysis. RESULTS: The incidence of intra-abdominal infection was 5.75%, 73.7% of the patients developed organ dysfunction, and mortality was 22.6%. Females comprised 46.8% of the patients. De novo infection represented 71.8% of cases, whereas nosocomial infection comprised 28.2% of cases. Perforations were of the colon (including the appendix) 49.9% of the time. An abscess formed in 22.3% of patients; the remainder had peritonitis but no abscess. Patients in the cohort with peritonitis were older (p = 0.0157), sicker on admission (p = 0.0411) and developed more organ dysfunction (p = 0.0072), but had the same rate of mortality. Despite steadily increasing acuity since 1991 (r(2) = .71, p < 0.0001), the magnitude of organ dysfunction (r(2) = 0.11) and the mortality rate remained constant (r(2) = .01). By logistic regression, abscess correlated with less severe organ dysfunction (score > or = 5 [odds ratio 0.54, 95% CI 0.33-0.90] and > or =9 points [odds ratio 0.38, 95% CI 0.20-0.74]), and increasing magnitude of organ dysfunction was associated with mortality (each point [odds ratio 1.46, 95% CI 1.32-1.61]). CONCLUSIONS: Although outcomes are improving, generalized peritonitis still causes high organ dysfunction-related mortality among critically ill surgical patients. Further improvements in resuscitation, surgical technique, and pharmacotherapy of severe intra-abdominal infections are needed.

Abdominal Abscess↗

PubMed1999

Troponin I and myocardial injury in the ICU.

Cardiac troponin I (cTnI) is a protein that is specific to heart muscle. Increased concentrations appear in serum after myocardial cell injury. cTnI was compared with creatinine kinase MB (CK MB), myoglobin and the 12-lead ECG for detection of myocardial injury in an unselected series of 109 medical and surgical ICU patients. Clinical observations and daily 12-lead ECG were recorded prospectively. Samples for cTnI, myoglobin and CK MB serum analysis were collected each day. Increased serum cTnI concentrations (> 0.1 microgram litre-1) were observed in 70.6% (n = 77) of the ICU group. Tachycardia, arrhythmia, hypotension and treatment with inotropic drugs were associated with higher concentrations. The standardized mortality ratio by APACHE III for the ICU sample was 0.98. All subjects in an unmatched control group of 98 medical unit emergency admissions without a primary cardiac diagnosis had serum cTnI concentrations < 0.1 microgram litre-1. We conclude that increased serum cTnI concentrations occur frequently in the ICU suggesting that there is a high incidence of cardiac injury in these patients.

Aged↗

PubMed2000

Comparison of cellulose diacetate and polysulfone membranes in the outcome of acute renal failure. A prospective randomized study.

BACKGROUND: Whether the nature of haemodialysis (HD) membranes can influence the outcome of acute renal failure (ARF) remains debatable. Recent studies have suggested that dialysis with bioincompatible unsubstituted cellulosic membranes is associated with a less favourable patient outcome than dialysis with biocompatible synthetic membranes. Since we generally use a modified cellulosic membrane with substantially lower complement- and leukocyte-activating potential than cuprophane, for dialysis of patients with ARF, and because there are no data in the literature regarding the influence of modified cellulosic membranes on the outcome of patients with ARF, we compared the outcome of ARF patients dialysed either with cellulose diacetate or with a synthetic polysulfone membrane. We also investigated the potential role of permeability by comparing membranes with high-flux versus low-flux characteristics. METHODS: This prospective, randomized, single centre study included 159 patients with ARF requiring HD. Patients were stratified according to age, gender, and APACHE II score and then randomized in chronological order to one of three dialysis membranes: low-flux polysulfone, high-flux polysulfone and meltspun cellulose diacetate. RESULTS: Aetiologies of ARF and the prevalence of oliguria were similarly distributed among the three groups. There was no significant difference between the three groups for survival (multivariate Cox's proportional hazards model, P=0.57), time necessary to recover renal function (P=0.82), and number of dialysis sessions required before recovery (P=0.86). Multivariate analysis showed that survival was significantly influenced only by the severity of the disease state (APACHE III score, P<0.0001), but not by the nature of the dialysis membrane (P=0.57) or the presence of oliguria (P=0.24). CONCLUSIONS: Among patients with ARF requiring HD survival and recovery time are not significantly influenced by the use of either meltspun cellulose diacetate or the more biocompatible high-flux or low-flux polysulfone. Dialysis using modified cellulose membranes is just as effective as dialysis using synthetic polysulfone membranes, but at a lower cost. In addition, the flux of the membrane did not influence patient outcome.

Acute Kidney Injury↗

PubMed1998

Beta-adrenergic blockade accelerates conversion of postoperative supraventricular tachyarrhythmias.

BACKGROUND: Postoperative supraventricular tachyarrhythmia is a common complication of surgery. Because chemical cardioversion is often ineffective, ventricular rate control remains a principal goal of therapy. The authors hypothesized that patients with supraventricular tachyarrhythmia after major noncardiac surgery who receive intravenous beta-adrenergic blockade for ventricular rate control would experience conversion to sinus rhythm at a rate that differs from those receiving intravenous calcium channel blockade. METHODS: The rate of conversion to sinus rhythm at 2 and 12 h after treatment was examined in 64 cases of postoperative supraventricular tachyarrhythmia. After adenosine administration, patients who remained in supraventricular tachyarrhythmia were prospectively randomized to receive either intravenous diltiazem or intravenous esmolol for ventricular rate control (unblinded). Loading and infusion rates were adjusted to achieve equivalent degrees of ventricular rate control. RESULTS: Patients were similar with regard to age and Apache III score. Most patients in both groups had atrial fibrillation (esmolol, 79%; diltiazem, 81%), and none experienced stable conversion with adenosine. Patients randomized to receive esmolol experienced a 59% rate of conversion to sinus rhythm within 2 h of treatment, compared with only 33% for patients randomized to receive diltiazem (intention to treat, P = 0.049; odds ratio, 2.9; 95% confidence interval, 1.046 to 7.8). After 12 h of therapy, the number of patients converting to sinus rhythm increased in both groups (esmolol, 85%; diltiazem, 62%), and the rates of conversion no longer differed significantly. Ventricular rates when supraventricular tachyarrhythmia began and after 2 and 12 h of rate control therapy were similar in the two treatment groups. The in-hospital mortality rate and length of stay in the intensive care unit were not significantly influenced by treatment group. CONCLUSIONS: Among adenosine-resistant patients in the intensive care unit with atrial fibrillation after noncardiac surgery, intravenous esmolol produced a more rapid (2-h) conversion to sinus rhythm than did intravenous diltiazem.

Adrenergic beta-Antagonists↗

PubMed1994

Daily prognostic estimates for critically ill adults in intensive care units: results from a prospective, multicenter, inception cohort analysis.

OBJECTIVE: To develop daily prognostic estimates for individual patients treated in adult intensive care units (ICU). DESIGN: Prospective, multicenter, inception cohort analysis. SETTING: Forty-two ICUs at 40 U.S. hospitals with > 200 beds including 20 ICUs in tertiary care centers with major teaching activities. PATIENTS: A consecutive sample of 17,440 ICU admissions. MEASUREMENTS AND MAIN RESULTS: A series of multivariate equations were developed using the patient's primary reason for ICU admission, age, chronic health status, treatment before ICU admission, admission Acute Physiology Score, current day Acute Physiology Score, and change between the current and previous day's Acute Physiology Score. The equations were used to create daily risk predictions and cross-validated within the 17,440-patient sample. The single most important factor determining daily risk of hospital death during each of the initial 7 days of ICU care was the current day's Acute Physiology Score of the Acute Physiology and Chronic Health Evaluation (APACHE) III score. The admission Acute Physiology Score and change from previous to current day's Acute Physiology Score were also important, as were ICU admission diagnosis, age, chronic health status, and treatment before ICU admission. Equations incorporating these risk factors had receiver operating characteristics areas ranging from 0.9 on the first ICU day to 0.84 for patients remaining in the ICU for 7 days. The percent of cases with cross-validated predicted risks over 90% increased from 2.3% (n = 406) of cases on day 1 to 9% of all patients remaining in the ICU on ICU day 7 (n = 218). The 1,033 patients who had a daily risk estimate of > 90% during any of their initial 7 ICU days had a 90% mortality rate and represented 47% of all ICU deaths and 31% of the total number of hospital deaths. CONCLUSIONS: Equations using initial and repeated physiologic measurements provide a high degree of explanatory power for subsequent hospital mortality rate. These daily prognostic estimates deserve evaluation for their potential role in improving the process and outcome from clinical decision-making.

Adult↗

PubMed1994

The performance of intensive care units: does good management make a difference?

A significant portion of health care resources are spent in intensive care units with, historically, up to two-fold variation in risk-adjusted mortality. Technological, demographic, and social forces are likely to lead to an increased volume of intensive care in the future. Thus, it is important to identify ways of more efficiently managing intensive care units and reducing the variation in patient outcomes. Based on data collected from 17,440 patients across 42 ICUs, the present study examines the factors associated with risk-adjusted mortality, risk-adjusted average length of stay, nurse turnover, evaluated technical quality of care, and evaluated ability to meet family member needs. Using the Apache III methodology for risk-adjustment, findings reveal that: 1) technological availability is significantly associated with lower risk-adjusted mortality (beta = -.42); 2) diagnostic diversity is significantly associated with greater risk-adjusted mortality (beta = .46); and 3) caregiver interaction comprising the culture, leadership, coordination, communication, and conflict management abilities of the unit is significantly associated with lower risk-adjusted length of stay (beta = .34), lower nurse turnover (beta = -.36), higher evaluated technical quality of care (beta = .81), and greater evaluated ability to meet family member needs (beta = .74). Furthermore, units with greater technological availability are significantly more likely to be associated with hospitals that are more profitable, involved in teaching activities, and have unit leaders actively participating in hospital-wide quality improvement activities. The findings hold a number of important managerial and policy implications regarding technological adoption, specialization, and the quality of interaction among ICU team members. They suggest intervention "leverage points" for care givers, managers, and external policy makers in efforts to continuously improve the outcomes of intensive care.

Caregivers↗