Effects of ambulance transport in critically ill patients.

Two groups of critically ill patients were transferred by ambulance from other hospitals to a central intensive therapy unit. The effect of transport was reviewed retrospectively in 46 patients and prospectively in 20 patients. Of the 46 patients reviewed retrospectively six became hypotensive, six became hypertensive, and seven developed delayed hypotension. One patient developed fits and six out of 13 patients had a rise in arterial PCO-2 of 1-6-4-1 kPa (12-31 mm Hg). Of the 20 patients reviewed prospectively, one patient became hypertensive due to overtransfusion, one had a fit, but none became hypotensive. Three out of four cases of delayed hypotension were related to starting intermittent positive pressure ventilation. Arterial PCO-2 fell in one patient and arterial PCO-2 rose in two, each change being related to changed oxygen therapy or narcotics. There were no changes in other cardiovascular or respiratory indices, body temperature, or urine production. Earlier transfer, resuscitation before transfer, continuing medical care during the journey, and hence a slower smoother journey seemed to be important factors in the management of these patients. Our findings, may have important implications in the future regional organization of the care of critically ill patients.     

Effective use of regional intensive therapy units.

OBJECTIVE--To determine the effectiveness of regional intensive therapy units. DESIGN--Retrospective and prospective study of patients transferred to a regional intensive therapy unit over four years. SETTING--Glasgow regional intensive therapy unit. MAIN OUTCOME MEASURES--Severity of illness was assessed at the time of referral to the unit with the acute physiological and chronic health evaluation (APACHE) scoring system. Mortality was calculated. RESULTS--A significant association was found between increasing duration of illness before transfer and mortality, which was independent of the severity of illness. Mortality also varied depending on the referring hospital. CONCLUSIONS--When transfer of critically ill patients is required this should be done as early as possible to make best use of the services available. The mortality of patients transferred after 10 days casts doubt on whether further aggressive intensive therapy is appropriate.     

Prognosis of patients receiving intensive care for lifethreatening medical complications of haematological malignancy

The mortality of patients admitted to intensive care units with haematological malignancy is high. A humane approach to the management of the critically ill as well as efficient use of limited resources requires careful selection of those patients who are most likely to benefit from intensive care. To delineate more accurately the factors influencing outcome in these patients the records of 60 consecutive admissions to the intensive care unit (37 male, 23 female) with haematological malignancy were reviewed retrospectively. Fifty patients were in acute respiratory failure, most commonly (34 patients) with a combination of pneumonia and septicaemic shock. The severity of the acute illness was assessed by the APACHE II (acute physiology and chronic health evaluation II) score and number of organ systems affected. Thirteen patients survived to leave hospital. The mortality of patients with haematological malignancy was consistently higher than predicted from a large validation study of APACHE II in a mixed population of critically ill patients. Moreover, no patient with an APACHE II score of greater than 26 survived. Mortality among the 22 patients with relapsed malignancy (21 deaths), was significantly higher than among the 35 patients at first presentation (26 deaths). On discharge from the intensive care unit all survivors had responded well to chemotherapy and had normal or raised peripheral white cell counts. They included seven patients who had recovered from leucopenia (white cell count <0.5 × 10⁹/1). In contrast, 36 of the 47 patients who died were leucopenic at the time of death.The overall mortality of critically ill patients with haematological malignancy is higher than equivalently ill patients without cancer. The dysfunction of an increasing number of organ systems, an APACHE II score of greater than 30, failure of the malignancy to respond to chemotherapy, and persistent leucopenia all point to a poor outcome.     

Provision of facilities for secondary transport of seriously ill patients in the United Kingdom

A survey by questionnaire of 280 hospitals with general intensive care units was carried out to find out what facilities were provided for secondary transport of seriously ill patients in the United Kingdom. Replies were received from 181 units. Extrapolating from the survey data showed that about 10 000 patients were transported each year, although many units transferred only a few patients. An appreciable minority of units reported that facilities for secondary transport were inadequate and many were obliged to send inexperienced medical staff with patients. Almost half of the respondents thought that arrangements for transfer were unsatisfactory, but only a tenth said that they delayed or refused transfer for this reason. This undoubtedly reflects a policy of “making do” despite inadequate resources.We believe that these results support the concept of regional transport services, where each major unit would be adequately equipped and staffed and unnecessary duplication of resources avoided.     

Clinical Usefulness of Procalcitonin and C-Reactive Protein as Outcome Predictors in Critically Ill Patients with Severe Sepsis and Septic Shock

Sepsis is a major cause of mortality and morbidity in critically ill patients. Procalcitonin (PCT) and C-reactive protein (CRP) are the most frequently used biomarkers in sepsis. We investigated changes in PCT and CRP concentrations in critically ill patients with sepsis to determine which biochemical marker better predicts outcome. We retrospectively analyzed 171 episodes in 157 patients with severe sepsis and septic shock who were admitted to the Samsung Medical Center intensive care unit from March 2013 to February 2014. The primary endpoint was patient outcome within 7 days from ICU admission (treatment failure). The secondary endpoint was 28-day mortality. Severe sepsis was observed in 42 (25%) episodes from 41 patients, and septic shock was observed in 129 (75%) episodes from 120 patients. Fifty-five (32%) episodes from 42 patients had clinically-documented infection, and 116 (68%) episodes from 99 patients had microbiologically-documented infection. Initial peak PCT and CRP levels were not associated with treatment failure and 28-day mortality. However, PCT clearance (PCTc) and CRP (CRPc) clearance were significantly associated with treatment failure (p = 0.027 and p = 0.030, respectively) and marginally significant with 28-day mortality (p = 0.064 and p = 0.062, respectively). The AUC for prediction of treatment success was 0.71 (95% CI, 0.61–0.82) for PCTc and 0.71 (95% CI, 0.61–0.81) for CRPc. The AUC for survival prediction was 0.77 (95% CI, 0.66–0.88) for PCTc and 0.77 (95% CI, 0.67–0.88) for CRPc. Changes in PCT and CRP concentrations were associated with outcomes of critically ill septic patients. CRP may not be inferior to PCT in predicting outcome in these patients.     

Importance of invasive candidiasis in critical non-neutropenic patients

Invasive candidiasis (IC) is the most frequent fungal infection in high risk patients in intensive care setting. IC is associated with high attributable mortality and increased healthcare cost. In this review current, epidemiological, diagnostic and clinical management is updated and discussed in the critically ill non netropenic patient.     

An economical mobile intensive care unit.

A mobile intensive care unit is an important extension of a regional intensive treatment service. The treatment and monitoring of critically ill patients can be maintained during transfer for specialist investigation or treatment. Such units can be brought into service with low construction and running costs.     

Guideline-Concordant Insulin Infusion Initiation Among Critically Ill Patients With Sepsis

ObjectiveOur objective was to benchmark rates of guideline-concordant insulin infusion initiation, identify factors associated with guideline-concordant insulin practices, and examine the association between hospital-level guideline concordance and mortality among critically ill patients with sepsis.MethodsWe performed a multicenter retrospective cohort study of intensive care patients with sepsis who were eligible for insulin infusion initiation according to American Diabetes Association and Surviving Sepsis guidelines (persistent blood sugar ≥180 mg/dL). We then identified patients who were initiated on insulin infusions within 24 hours of eligibility. We examined patient- and hospital-level factors associated with guideline-concordant insulin infusion initiation and explored the association between the hospital-level proportion of patients who received guideline-concordant insulin infusions and hospital mortality.ResultsAmong 5453 guideline-eligible patients with sepsis, 13.4% were initiated on insulin infusions. Factors most strongly associated with guideline-concordant insulin infusion initiation were mechanical ventilation and hospital of admission. The hospital-level proportion of patients who received guideline-concordant insulin infusions were not associated with mortality. Among 1501 intensive care unit patients with sepsis who were started on insulin infusions, 37.0% were initiated at a blood glucose level below 180 mg/dL, the guideline-recommended starting threshold.ConclusionGuideline-concordant insulin infusion initiation was uncommon among patients with sepsis admitted to U.S. intensive care units and was determined in large part by hospital of admission. The degree to which hospitals were guideline-concordant were not associated with mortality.     

Pathways to Care for Critically Ill or Injured Children: A Cohort Study from First Presentation to Healthcare Services through to Admission to Intensive Care or Death

Purpose

Critically ill or injured children require prompt identification, rapid referral and quality emergency management. We undertook a study to evaluate the care pathway of critically ill or injured children to identify preventable failures in the care provided.

Methods

A year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation to healthcare services until paediatric intensive care unit (PICU) admission or emergency department death, using expert panel review of medical records and caregiver interview. Main outcomes were expert assessment of overall quality of care; avoidability of severity of illness and PICU admission or death and the identification of modifiable factors.

Results

The study enrolled 282 children, 252 emergency PICU admissions, and 30 deaths. Global quality of care was graded good in 10% of cases, with half having at least one major impact modifiable factor. Key modifiable factors related to access to care and identification of the critically ill, assessment of severity, inadequate resuscitation, and delays in decision making and referral. Children were transferred with median time from first presentation to PICU admission of 12.3 hours. There was potentially avoidable severity of illness in 185 (74%) of children, and death prior to PICU admission was avoidable in 17/30 (56.7%) of children.

Conclusions

The study presents a novel methodology, examining quality of care across an entire system, and highlighting the complexity of the pathway and the modifiable events amenable to interventions, that could reduce mortality and morbidity, and optimize utilization of scarce critical care resources; as well as demonstrating the importance of continuity and quality of care.     

Hematologic and oncologic complications in the critically ill child

Admission of a patient to an intensive care unit for management of direct consequences of a hematologic or oncologic disease is occasionally necessary. Such problems included exchange transfusion, sepsis, compression of vital structures by malignant tumor, metabolic derangements, leukostasis, post-operative care, major sickling episodes in vital organs, and disseminated coagulopathy. More often, however, hematologic complications arise in the child critically ill from other causes, such as trauma or infections. The first two sections of this review address blood transfusion and hemostasis, topics likely to have wide application in the care of critically ill children. The last portion discusses problems unique to patients with sickling or malignant disease.     

Validation of a prognostic score in critically ill patients undergoing transport.

Fifty consecutive critically ill patients transported between hospitals by a mobile intensive care team were assessed prospectively using a modification of the acute physiology and chronic health evaluation (APACHE II) sickness scoring system. Assessments were made before and after resuscitation, on return to base, and after 24 hours of intensive care. No patient died during transport. Twenty two patients died subsequently in hospital and 28 survived to return home. The mean score for the non-survivors before resuscitation was 21.7 and for the survivors 12.2 (p less than 0.0005). Among the non-survivors there was a significant fall in score with resuscitation but this did not alter their subsequent outcome. Neither group deteriorated during transport. The sickness score is a powerful method for determining prognosis, and employed longitudinally it may be useful in the assessment of treatment. It has important implications for the administration and organisation of regional intensive care services.     

Impaired High-Density Lipoprotein Anti-Oxidant Function Predicts Poor Outcome in Critically Ill Patients

Introduction

Oxidative stress affects clinical outcome in critically ill patients. Although high-density lipoprotein (HDL) particles generally possess anti-oxidant capacities, deleterious properties of HDL have been described in acutely ill patients. The impact of anti-oxidant HDL capacities on clinical outcome in critically ill patients is unknown. We therefore analyzed the predictive value of anti-oxidant HDL function on mortality in an unselected cohort of critically ill patients.

Method

We prospectively enrolled 270 consecutive patients admitted to a university-affiliated intensive care unit (ICU) and determined anti-oxidant HDL function using the HDL oxidant index (HOI). Based on their HOI, the study population was stratified into patients with impaired anti-oxidant HDL function and the residual study population.

Results

During a median follow-up time of 9.8 years (IQR: 9.2 to 10.0), 69% of patients died. Cox regression analysis revealed a significant and independent association between impaired anti-oxidant HDL function and short-term mortality with an adjusted HR of 1.65 (95% CI 1.22–2.24; p = 0.001) as well as 10-year mortality with an adj. HR of 1.19 (95% CI 1.02–1.40; p = 0.032) when compared to the residual study population. Anti-oxidant HDL function correlated with the amount of oxidative stress as determined by Cu/Zn superoxide dismutase (r = 0.38; p<0.001).

Conclusion

Impaired anti-oxidant HDL function represents a strong and independent predictor of 30-day mortality as well as long-term mortality in critically ill patients.     

Prognostic Value of Blood Zinc, Iron, and Copper Levels in Critically Ill Children with Pediatric Risk of Mortality Score III

We aimed to explore the association of blood Zn, Fe, and Cu concentrations and changes in the pediatric risk of mortality (PRISM) score in critically ill children, to predict prognosis. We included 31 children (22 boys and 9 girls, 1 month to 5 years old), who had been admitted to the intensive care unit of our hospital and who were critically ill according to PRISM score of III. Another 20 children (12 boys, 8 girls, 3 months to 5 years old) who were brought to the hospital for a health checkup were included as controls. We recorded clinical data, time in the intensive care unit, prognosis, and PRISM III score for critically ill children. Blood Cu, Zn, and Fe values were measured by inductively coupled plasma atomic emission spectrophotometry. Zn and Fe levels were significantly lower in patients than in controls (all p?<?0.05). Cu levels differed between patients and controls, but not significantly (p?>?0.05). In ill children, blood Zn and Fe concentrations were inversely correlated with PRISM III score (Zn: r?=??0.36; Fe: r?=??0.50, both p?<?0.05), with no significant correlation of blood Cu level and PRISM III score (r?=??0.13, p?>?0.05). Serious illness in children may lead to decreased Zn and Fe blood concentrations. Zn and Fe supplements may be beneficial for critically ill children.     

Does HIV status influence the outcome of patients admitted to a surgical intensive care unit? A prospective double blind study.

OBJECTIVES: (a) To assess the impact of HIV status (HIV negative, HIV positive, AIDS) on the outcome of patients admitted to intensive care units for diseases unrelated to HIV; (b) to decide whether a positive test result for HIV should be a criterion for excluding patients from intensive care for diseases unrelated to HIV. DESIGN: A prospective double blind study of all admissions over six months. HIV status was determined in all patients by enzyme linked immunosorbent assay (ELISA), immunofluorescence assay, western blotting, and flow cytometry. The ethics committee considered the clinical implications of the study important enough to waive patients'' right to informed consent. Staff and patients were blinded to HIV results. On discharge patients could be advised of their HIV status if they wished. SETTING: A 16 bed surgical intensive care unit. SUBJECTS: All 267 men and 135 women admitted to the unit during the study period. INTERVENTIONS: None. MAIN OUTCOME MEASURES: APACHE II score (acute physiological, age, and chronic health evaluation), organ failure, septic shock, durations of intensive care unit and hospital stay, and intensive care unit and hospital mortality. RESULTS: No patient had AIDS. 52 patients were tested positive for HIV and 350 patients were tested negative. The two groups were similar in sex distribution but differed significantly in age, incidence of organ failure (37 (71%) v 171 (49%) patients), and incidence of septic shock (20 (38%) v 54 (15%)). After adjustment for age there were no differences in intensive care unit or hospital mortality or in the durations of stay in the intensive care unit or hospital. CONCLUSIONS: Morbidity was higher in HIV positive patients but there was no difference in mortality. In this patient population a positive HIV test result should not be a criterion for excluding a patient from intensive care.     

Use of intravenous peramivir for treatment of severe influenza A(H1N1)pdm09

Oral antiviral agents to treat influenza are challenging to administer in the intensive care unit (ICU). We describe 57 critically ill patients treated with the investigational intravenous neuraminidase inhibitor drug peramivir for influenza A (H1N1)pdm09 [pH1N1]. Most received late peramivir treatment following clinical deterioration in the ICU on enterically-administered oseltamivir therapy. The median age was 40 years (range 5 months-81 years). Common clinical complications included pneumonia or acute respiratory distress syndrome requiring mechanical ventilation (54; 95%), sepsis requiring vasopressor support (34/53; 64%), acute renal failure requiring hemodialysis (19/53; 36%) and secondary bacterial infection (14; 25%). Over half (29; 51%) died. When comparing the 57 peramivir-treated cases with 1627 critically ill cases who did not receive peramivir, peramivir recipients were more likely to be diagnosed with pneumonia/acute respiratory distress syndrome (p?=?0.0002) or sepsis (p?=?<0.0001), require mechanical ventilation (p?=?<0.0001) or die (p?=?<0.0001). The high mortality could be due to the pre-existing clinical severity of cases prior to request for peramivir, but also raises questions about peramivir safety and effectiveness in hospitalized and critically ill patients. The use of peramivir merits further study in randomized controlled trials, or by use of methods such as propensity scoring and matching, to assess clinical effectiveness and safety.     

Effect of CD14 -260C>T polymorphism on the mortality of critically ill patients

The CD14 receptor seems to be an important part of the innate immune system. A mutant CD14 can produce a reduced signal in response to infection, as a result of which an adequate inflammatory innate response is not induced, leading to a systemic infection. Defects in the innate immunity increase patient susceptibility to systemic infections and can produce a deregulated inflammatory response causing sepsis, organ failure or death in critically ill patients. We evaluated the CD14 -260C>T polymorphism genotyping as a genetic tool for risk evaluation of critically ill patients admitted to an intensive care unit (ICU) in Southern Brazil. We monitored the patients daily during their entire ICU and post-ICU (hospital) stay (measured from the ICU admission day to a maximum of 224 days). A total of 85 patients, aged 19-95 years (mean = 56 years, median = 58 years), were included in this study. Patient mortality was 58.8%. The genotypic (TT = 0.27, TC = 0.41, CC = 0.32) and allelic (T = 0.48, C = 0.52) frequencies did not differ from the values expected by the Hardy-Weinberg model and genotype distribution was random for all clinical characteristics at ICU admission. We found a statistically significant difference favouring the survival of patients with TT genotype (P = 0.042), suggesting that this CD14 gene polymorphism could be a candidate for further study in the search for a complementary prognostic tool for patient risk evaluation. Our study describes, for the first time, the effect of the CD14 gene polymorphism in critically ill Brazilian patients. Our data suggest that patients carrying the TT genotype have a better survival outcome.     

Methicillin-resistant Staphylococcus aureus infection is associated with increased mortality

Methicillin resistance is a widespread and major source of treatment complication in Staphylococcus aureus infections. Whether infections with methicillin-resistant S. aureus are associated with a worse clinical outcome, such as higher mortality, has remained controversial. Analyzing data from a large, global multicenter study, Hanberger et al. demonstrate that methicillin-resistant S. aureus infections are associated with approximately 50% higher mortality in the intensive care unit and significantly more frequent among critically ill patients than infections with methicillin-susceptible S. aureus. These findings call for the implementation or continuation of active methicillin-resistant S. aureus surveillance measures.     

Short term outcome in babies refused perinatal intensive care.

OBJECTIVE--To compare the mortality in babies refused admission to a regional perinatal centre with that in babies accepted for intensive care in the centre. DESIGN--Retrospective study with group comparison. SETTING--Based at the Royal Maternity Hospital, Belfast, with follow up of patients in all obstetric units in Northern Ireland. PATIENTS--Requests for transfer of 675 babies to the regional perinatal centre (prenatally and postnatally) were made from hospitals in Northern Ireland between January 1984 and December 1986. In all, 343 babies were refused admission to the centre, and complete data were available for 332 of them. These babies were either admitted to other neonatal intensive care units (261 babies) or remained in hospitals with only special care cots (71 babies). MAIN OUTCOME MEASURE--Short term mortality. RESULTS--Seventy of the 332 babies refused admission to the centre died compared with 51 of the 333 who were admitted. Multivariate analysis based on a logistic model showed a non-significant increase in mortality among babies treated in other intensive care units compared with babies treated in the centre (relative odds 1.2; 95% confidence interval 0.7 to 1.9). The increase in mortality in babies who remained in a special care baby unit, however, was significant (3.5; 1.7 to 7.0). This increase was particularly significant in babies born at less than or equal to 32 weeks'' gestation and who weighed less than 1500 g (8.4; 2.5 to 28.1). CONCLUSIONS--The results of the study confirm the benefits of neonatal intensive care and its particular value in improving survival in babies of low birth weight. As the babies were refused admission to the regional perinatal centre because intensive care cots were not available this deficiency should be corrected.     

Cytomegalovirus and Herpes Simplex Virus Effect on the Prognosis of Mechanically Ventilated Patients Suspected to Have Ventilator-Associated Pneumonia

Objective

Cytomegalovirus (CMV) and herpes simplex virus (HSV) are common viruses that can affect critically ill patients who are not immunocompromised. The aim of this study was to determine whether the identification of CMV and/or HSV in mechanically ventilated critically ill patients suspected of having pneumonia was associated with an increased mortality.

Design

Prospective epidemiological study.

Setting

Medical intensive care unit of a tertiary medical center.

Patients

Ninety-three patients with suspected pneumonia.

Interventions

Patients with suspected pneumonia had bronchoalveolar lavage and blood samples taken to confirm the diagnosis. Antigenemia was used to detect CMV in the blood. Bronchoalveolar lavage samples were submitted to testing using quantitative real-time Polymerase Chain Reaction.

Measurements and Main Results

We identified 22 patients with a CMV infection, 26 patients with an HSV infection and 45 patients without CMV or HSV infection (control group). Mortality at day 60 was higher in patients with a CMV infection than in patients from the control group (55% vs. 20%, P<0.01). Mortality at day 60 was not significantly increased in the group with HSV infection. Duration of ICU stay and ICU mortality were significantly higher in patients with CMV infections when compared to patients from the control group, whereas ventilator free days were significantly lower in patients with CMV infections when compared to patients from the control group.

Conclusions

In critically ill patients, a CMV infection is associated with an increased mortality. Further interventional studies are needed to evaluate whether treatment could improve the prognosis.