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Cammarota G, Simonte R, De Robertis E. Treatment of patients with 'do not intubate orders'. Curr Opin Anaesthesiol 2023; 36:183-187. [PMID: 36794875 DOI: 10.1097/aco.0000000000001238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
PURPOSE OF REVIEW Do-not-intubate (DNI) orders are more frequently encountered over time. This widespread diffusion of DNI orders make it essential to develop therapeutic strategies matching patient's and his family willingness. The present review sheds light on the therapeutic approaches employed to support respiratory function of patients with DNI orders. RECENT FINDINGS In DNI patients, several approaches have been described to relieve dyspnoea and address acute respiratory failure (ARF). Despite its extensive use, supplemental oxygen is not so useful in assuring dyspnoea relief. Noninvasive respiratory support (NIRS) is frequently employed to treat ARF in DNI patients. Also, to enhance DNI patients comfort during NIRS, it is worthy to point out the role of analgo-sedative medications. Lastly, a particular aspect concerns the first waves of coronavirus disease 2019 pandemic, when DNI orders have been pursued on factors unrelated to patient's wishes, in the total absence of family support due to the lockdown policy. In this setting, NIRS has been extensively employed in DNI patients with a survival rate of around 20%. SUMMARY In dealing with DNI patients, the individualization of treatments is of pivotal importance to respect patient's preferences and improve quality of life at the same time.
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Göbölös L, Hogan M, Kakar V, Raposo N, Sänger S, Bhatnagar G, Park WM. Alternative option for limb reperfusion cannula placement for percutaneous femoral veno-arterial ECMO. Perfusion 2021; 37:456-460. [PMID: 33765883 DOI: 10.1177/02676591211003282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is an established last line support for severe, acute cardiorespiratory failure. In the case of VA ECMO, peripheral cannulation via the femoral vessels is often advantageous when compared with the alternative central cannulation, and is associated with better clinical outcomes. One of the specific potential complications of peripheral femoral arterial cannulation for ECMO, however, is ipsilateral distal lower limb ischemia; a consideration especially when cannulating the vessel directly, as distal limb perfusion is invariably compromised by an occlusive effect of the arterial cannula within the femoral artery. The gold standard technique for lower limb reperfusion is a separate size 6-7 Fr cannula inserted proximally into the femoral artery, just below the insertion point of the ECMO return cannula, and connected directly to the ECMO circuit so that the blood flow is also directed distally to perfuse the entire limb. This functions well whether the ECMO cannula has been placed percutaneously or by surgical cut-down. Although proximal femoral arterial placement of the reperfusion cannula is the established and preferred technique, there are many technical challenges which may preclude its placement. Local haematoma or bleeding post ECMO insertion, peripheral vascular disease, constricted vasculature in severely shocked patients, or patient obesity are all common reasons why placement of the proximal reperfusion cannula may be difficult, or impossible. In such instances, our retrograde perfusion technique may maintain limb perfusion and may even be limb saving for patients on VA ECMO support.
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Affiliation(s)
- Laszlo Göbölös
- Department of Cardiac Surgery, Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Maurice Hogan
- Departments of Cardiac Anesthesia and Intensive Care, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Vivek Kakar
- Departments of Cardiac Anesthesia and Intensive Care, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Nuno Raposo
- Department of Cardiac Surgery, Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Stefan Sänger
- Department of Cardiac Surgery, Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Gopal Bhatnagar
- Department of Cardiac Surgery, Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Woosup Michael Park
- Department of Vascular Surgery, Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
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Optimal Sedation in Patients Who Receive Neuromuscular Blocking Agent Infusions for Treatment of Acute Respiratory Distress Syndrome-A Retrospective Cohort Study From a New England Health Care Network. Crit Care Med 2021; 49:1137-1148. [PMID: 33710031 DOI: 10.1097/ccm.0000000000004951] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Two previously published trials (ARDS et Curarisation Systematique [ACURASYS] and Reevaluation of Systemic Early Neuromuscular Blockade [ROSE]) presented equivocal evidence on the effect of neuromuscular blocking agent infusions in patients with acute respiratory distress syndrome (acute respiratory distress syndrome). The sedation regimen differed between these trials and also within the ROSE trial between treatment and control groups. We hypothesized that the proportion of deeper sedation is a mediator of the effect of neuromuscular blocking agent infusions on mortality. DESIGN Retrospective cohort study. SETTING Seven ICUs in an academic hospital network, Beth Israel Deaconess Medical Center (Boston, MA). PATIENTS Intubated and mechanically ventilated ICU patients with acute respiratory distress syndrome (Berlin definition) admitted between January 2008 until June 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The proportion of deeper sedation was defined as days with nonlight sedation as a fraction of mechanical ventilation days in the ICU after acute respiratory distress syndrome diagnosis. Using clinical data obtained from a hospital network registry, 3,419 patients with acute respiratory distress syndrome were included, of whom 577 (16.9%) were treated with neuromuscular blocking agent infusions, for a mean (sd) duration of 1.8 (±1.9) days. The duration of deeper sedation was prolonged in patients receiving neuromuscular blocking agent infusions (4.6 ± 2.2 d) compared with patients without neuromuscular blocking agent infusions (2.4 ± 2.2 d; p < 0.001). The proportion of deeper sedation completely mediated the negative effect of neuromuscular blocking agent infusions on in-hospital mortality (p < 0.001). Exploratory analysis in patients who received deeper sedation revealed a beneficial effect of neuromuscular blocking agent infusions on mortality (49% vs 51%; adjusted odds ratio, 0.80; 95% CI, 0.63-0.99, adjusted absolute risk difference, -0.05; p = 0.048). CONCLUSIONS In acute respiratory distress syndrome patients who receive neuromuscular blocking agent infusions, a prolonged, high proportion of deeper sedation is associated with increased mortality. Our data support the view that clinicians should minimize the duration of deeper sedation after recovery from neuromuscular blocking agent infusion.
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Effect of SIS3 on Extracellular Matrix Remodeling and Repair in a Lipopolysaccharide-Induced ARDS Rat Model. J Immunol Res 2020; 2020:6644687. [PMID: 33294466 PMCID: PMC7714568 DOI: 10.1155/2020/6644687] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 12/14/2022] Open
Abstract
The remodeling of the extracellular matrix (ECM) in the parenchyma plays an important role in the development of acute respiratory distress syndrome (ARDS), a disease characterized by lung injury. Although it is clear that TGF-β1 can modulate the expression of the extracellular matrix (ECM) through intracellular signaling molecules such as Smad3, its role as a therapeutic target against ARDS remains unknown. In this study, a rat model was established to mimic ARDS via intratracheal instillation of lipopolysaccharide (LPS). A selective inhibitor of Smad3 (SIS3) was intraperitoneally injected into the disease model, while phosphate-buffered saline (PBS) was used in the control group. Animal tissues were then evaluated using histological analysis, immunohistochemistry, RT-qPCR, ELISA, and western blotting. LPS was found to stimulate the expression of RAGE, TGF-β1, MMP2, and MMP9 in the rat model. Moreover, treatment with SIS3 was observed to reverse the expression of these molecules. In addition, pretreatment with SIS3 was shown to partially inhibit the phosphorylation of Smad3 and alleviate symptoms including lung injury and pulmonary edema. These findings indicate that SIS3, or the blocking of TGF-β/Smad3 pathways, could influence remodeling of the ECM and this may serve as a therapeutic strategy against ARDS.
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Zante B, Schefold JC. Teaching End-of-Life Communication in Intensive Care Medicine: Review of the Existing Literature and Implications for Future Curricula. J Intensive Care Med 2017; 34:301-310. [PMID: 28659041 DOI: 10.1177/0885066617716057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES: End-of-life (EOL) situations are common in the intensive care unit (ICU). Poor communication in respective situations may result in conflict and/or post-traumatic stress disorder in patients' next of kin. Thus, training for EOL communication seems pivotal. Primary objective of the current report was to identify approaches for educational programs in the ICU with regard to EOL communication as well as to conclude on implications for future curricula. MATERIALS AND METHODS: A literature review in MEDLINE, EMBASE, and PsychINFO was performed. A total of 3484 articles published between 2000 until 2016 were assessed for eligibility. Nine articles reporting on education in EOL communication in the ICU were identified and analyzed further. RESULTS: The duration of EOL workshops ranged from 3 hours to 3 days, with several different educational methods being applied. Mounting data suggest improved comfort, preparedness, and communication performance in EOL providers following specific EOL training. Due to missing data, the effect of EOL training programs on respective patients' next of kin remains unclear. CONCLUSION: Few scientific investigations focus on EOL communication in intensive care medicine. The available evidence points to increased comfort and EOL communication performance following specific individual EOL training. Given the general importance of EOL communication, we suggest implementation of educational EOL programs. When developing future educational programs, educators should consider previous experience of participants, clearly defined objectives based on institutional needs, and critical care society recommendations to ensure best benefit of all involved parties.
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Affiliation(s)
- Bjoern Zante
- 1 Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joerg C Schefold
- 1 Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Papazian L, Herridge M, Combes A. Focus on veno-venous ECMO in adults with severe ARDS. Intensive Care Med 2016; 42:1655-1657. [PMID: 27272761 DOI: 10.1007/s00134-016-4398-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 05/17/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Laurent Papazian
- Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Réanimation des Détresses Respiratoires et des Infections Sévères, 13015, Marseille, France.
- Faculté de Médecine, Aix-Marseille Université, URMITE UMR CNRS 7278, 13005, Marseille, France.
| | - Margaret Herridge
- Critical Care and Respiratory Medicine, Toronto General Research Institute, University Health Network, University of Toronto, Munk Building 11 PMB 127, 585 University Avenue, Toronto, ON, M5G 2N2, Canada
| | - Alain Combes
- Service de Réanimation Médicale, INSERM, UMRS-1166, iCAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie, Paris 6, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France
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Herridge MS, Moss M, Hough CL, Hopkins RO, Rice TW, Bienvenu OJ, Azoulay E. Recovery and outcomes after the acute respiratory distress syndrome (ARDS) in patients and their family caregivers. Intensive Care Med 2016; 42:725-738. [PMID: 27025938 DOI: 10.1007/s00134-016-4321-8] [Citation(s) in RCA: 244] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 03/09/2016] [Indexed: 02/06/2023]
Abstract
Outcomes after acute respiratory distress syndrome (ARDS) are similar to those of other survivors of critical illness and largely affect the nerve, muscle, and central nervous system but also include a constellation of varied physical devastations ranging from contractures and frozen joints to tooth loss and cosmesis. Compromised quality of life is related to a spectrum of impairment of physical, social, emotional, and neurocognitive function and to a much lesser extent discrete pulmonary disability. Intensive care unit-acquired weakness (ICUAW) is ubiquitous and includes contributions from both critical illness polyneuropathy and myopathy, and recovery from these lesions may be incomplete at 5 years after ICU discharge. Cognitive impairment in ARDS survivors ranges from 70 to 100 % at hospital discharge, 46 to 80 % at 1 year, and 20 % at 5 years, and mood disorders including depression and post-traumatic stress disorder (PTSD) are also sustained and prevalent. Robust multidisciplinary and longitudinal interventions that improve these outcomes are still uncertain and data in our literature are conflicting. Studies are needed in family members of ARDS survivors to better understand long-term outcomes of the post-ICU family syndrome and to evaluate how it affects patient recovery.
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Affiliation(s)
- Margaret S Herridge
- Critical Care and Respiratory Medicine, Toronto General Research Institute, University of Toronto, Toronto, ON, Canada.
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Catherine L Hough
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Ramona O Hopkins
- Psychology Department, Brigham Young University, Provo, UT, USA.,Neuroscience Center, Brigham Young University, Provo, UT, USA.,Department of Medicine, Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA.,Center for Humanizing Critical Care, Intermountain Health Care, Murray, UT, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Department of Medicine, Nashville, TN, USA
| | - O Joseph Bienvenu
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elie Azoulay
- Medical ICU of the Saint-Louis Hospital, Paris Diderot Sorbonne University, Paris, France
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Abrams D, Baldwin MR, Champion M, Agerstrand C, Eisenberger A, Bacchetta M, Brodie D. Thrombocytopenia and extracorporeal membrane oxygenation in adults with acute respiratory failure: a cohort study. Intensive Care Med 2016; 42:844-852. [PMID: 27007099 DOI: 10.1007/s00134-016-4312-9] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 03/07/2016] [Indexed: 12/12/2022]
Abstract
PURPOSE The association between extracorporeal membrane oxygenation (ECMO) use and the development of thrombocytopenia is widely presumed yet weakly demonstrated. We hypothesized that longer duration of ECMO support would be independently associated with worsened thrombocytopenia. METHODS We performed a single-center retrospective cohort study of 100 adults who received ECMO for acute respiratory failure. We used generalized estimating equations to test the association between days on ECMO and daily percentage of platelets compared to the first post-cannulation platelet count. We constructed a multivariable logistic regression model with backwards stepwise elimination to identify clinical predictors of severe thrombocytopenia (≤50,000/μL) while on ECMO. RESULTS Days on ECMO was not associated with a decrease in platelet count in the unadjusted analysis (β -0.85, 95 % CI -2.05 to 0.36), nor after considering and controlling for days hospitalized prior to ECMO, APACHE II score, platelet transfusions, and potential thrombocytopenia-inducing medications (β -0.83, 95 % CI -1.9 to 0.25). Twenty-two subjects (22 %) developed severe thrombocytopenia. The APACHE II score and platelet count at the time of cannulation predicted the development of severe thrombocytopenia. The odds of developing severe thrombocytopenia increased 35 % for every 5-point increase in APACHE II score (OR 1.35, 95 % CI 0.94-1.94) and increased 35 % for every 25,000/μL platelets below a mean at cannulation of 188,000/μL (OR 1.35, 95 % CI 1.10-1.64). CONCLUSIONS Duration of ECMO is not associated with the development of thrombocytopenia. The severity of critical illness and platelet count at the time of cannulation predict the development of severe thrombocytopenia while receiving ECMO for respiratory failure. Future studies should validate these findings, especially in cohorts with more venoarterial ECMO patients, and should characterize the association between thrombocytopenia and bleeding events while on ECMO.
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Affiliation(s)
- Darryl Abrams
- Division of Pulmonary and Critical Care, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Matthew R Baldwin
- Division of Pulmonary and Critical Care, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Matthew Champion
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Cara Agerstrand
- Division of Pulmonary and Critical Care, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Andrew Eisenberger
- Division of Hematology and Oncology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Matthew Bacchetta
- Division of Thoracic Surgery, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Daniel Brodie
- Division of Pulmonary and Critical Care, College of Physicians and Surgeons, Columbia University, New York, NY, USA.
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Vilaça M, Aragão I, Cardoso T, Dias C, Cabral-Campello G. The Role of Noninvasive Ventilation in Patients with "Do Not Intubate" Order in the Emergency Setting. PLoS One 2016; 11:e0149649. [PMID: 26901060 PMCID: PMC4763309 DOI: 10.1371/journal.pone.0149649] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 02/03/2016] [Indexed: 12/15/2022] Open
Abstract
Background Noninvasive ventilation (NIV) is being used increasingly in patients who have a “do not intubate” (DNI) order. However, the impact of NIV on the clinical and health-related quality of life (HRQOL) in the emergency setting is not known, nor is its effectiveness for relieving symptoms in end-of-life care. Objective The aim of this prospective study was to determine the outcome and HRQOL impact of regular use of NIV outcomes on patients with a DNI order who were admitted to the emergency room department (ED). Methods: Eligible for participation were DNI-status patients who receive NIV for acute or acute-on-chronic respiratory failure when admitted to the ED of a tertiary care, university-affiliated, 600-bed hospital between January 2014 and December 2014. Patients were divided into 2 groups: (1) those whose DNI order related to a decision to withhold therapy and (2) those for whom any treatment, including NIV, was provided for symptom relief only. HRQOL was evaluated only in group 1, using the 12-item Short Form Health Survey (SF-12). Long-term outcome was evaluated 90 days after hospital discharge by means of a telephone interview. Results During the study period 1727 patients were admitted to the ED, 243 were submitted to NIV and 70 (29%) were included in the study. Twenty-nine (41%) of the 70 enrollees received NIV for symptom relief only (group2). Active cancer [7% vs 35%, p = 0,004] and neuromuscular diseases [0% vs. 17%] were more prevalent in this group. NIV was stopped in 59% of the patients in group 2 due to lake of clinical benefit. The in-hospital mortality rate was 37% for group 1 and 86% for group 2 0,001). Among patients who were discharged from hospital, 23% of the group 1 and all patients in group 2 died within 90 days. Relative to baseline, no significant decline in HRQOL occurred in group 1 by 90 days postdischarge. Conclusion The survival rate was 49% among DNI-status patients for whom NIV was used as a treatment in ED, and these patients did not experience a decline in HRQOL throughout the study. NIV did not provide significant relief of symptoms in more than half the patients who receive it for that purpose.
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Affiliation(s)
- Marta Vilaça
- Medicine Integrated Master (MIM), Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Oporto University (UP), Porto, Portugal
- * E-mail:
| | - Irene Aragão
- Intensive Care Unit (UCIP), Oporto Hospital Center, Porto, Portugal
| | - Teresa Cardoso
- Intensive Care Unit (UCIP), Oporto Hospital Center, Porto, Portugal
| | - Cláudia Dias
- Center for Health Technology and Services Research (CINTESIS) and Information Sciences and Decision on Health Department (CIDES), Faculty of Medicine, Oporto University (UP), Porto, Portugal
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Partial extracorporeal lung support in acute respiratory distress syndrome: preliminary experience in a second level hospital. Intensive Care Med 2016; 42:944-945. [PMID: 26862019 DOI: 10.1007/s00134-016-4251-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2016] [Indexed: 10/22/2022]
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11
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Ventilator-associated pneumonia in ARDS patients: the impact of prone positioning. A secondary analysis of the PROSEVA trial. Intensive Care Med 2015; 42:871-878. [PMID: 26699917 DOI: 10.1007/s00134-015-4167-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 11/23/2015] [Indexed: 01/15/2023]
Abstract
BACKGROUND The goal of this study was to assess the impact of prone positioning on the incidence of ventilator-associated pneumonia (VAP) and the role of VAP in mortality in a recent multicenter trial performed on patients with severe ARDS. METHODS An ancillary study of a prospective multicenter randomized controlled trial on early prone positioning in patients with severe ARDS. In suspected cases of VAP the diagnosis was based on positive quantitative cultures of bronchoalveolar lavage fluid or tracheal aspirate at the 10(4) and 10(7) CFU/ml thresholds, respectively. The VAP cases were then subject to central, independent adjudication. The cumulative probabilities of VAP were estimated in each position group using the Aalen-Johansen estimator and compared using Gray's test. A univariate and a multivariate Cox model was performed to assess the impact of VAP, used as a time-dependent covariate for mortality hazard during the ICU stay. RESULTS In the supine and prone position groups, the incidence rate for VAP was 1.18 (0.86-1.60) and 1.54 (1.15-2.02) per 100 days of invasive mechanical ventilation (p = 0.10), respectively. The cumulative probability of VAP at 90 days was estimated at 46.5 % (27-66) in the prone group and at 33.5 % (23-44) in the supine group. The difference between the two cumulative probability curves was not statistically significant (p = 0.11). In the univariate Cox model, VAP was associated with an increase in the mortality rate during the ICU stay [HR 1.65 (1.05-2.61), p = 0.03]. HR increased to 2.2 (1.39-3.52) (p < 0.001) after adjustment for position group, age, SOFA score, McCabe score, and immunodeficiency. CONCLUSIONS In severe ARDS patients prone positioning did not reduce the incidence of VAP and VAP was associated with higher mortality.
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Ranzani OT, Zampieri FG, Besen BAMP, Azevedo LCP, Park M. One-year survival and resource use after critical illness: impact of organ failure and residual organ dysfunction in a cohort study in Brazil. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:269. [PMID: 26108673 PMCID: PMC4512155 DOI: 10.1186/s13054-015-0986-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 06/12/2015] [Indexed: 12/15/2022]
Abstract
Introduction In this study, we evaluated the impacts of organ failure and residual dysfunction on 1-year survival and health care resource use using Intensive Care Unit (ICU) discharge as the starting point. Methods We conducted a historical cohort study, including all adult patients discharged alive after at least 72 h of ICU stay in a tertiary teaching hospital in Brazil. The starting point of follow-up was ICU discharge. Organ failure was defined as a value of 3 or 4 in its corresponding component of the Sequential Organ Failure Assessment score, and residual organ dysfunction was defined as a score of 1 or 2. We fit a multivariate flexible Cox model to predict 1-year survival. Results We analyzed 690 patients. Mortality at 1 year after discharge was 27 %. Using multivariate modeling, age, chronic obstructive pulmonary disease, cancer, organ dysfunctions and albumin at ICU discharge were the main determinants of 1-year survival. Age and organ failure were non-linearly associated with survival, and the impact of organ failure diminished over time. We conducted a subset analysis with 561 patients (81 %) discharged without organ failure within the previous 24 h of discharge, and the number of residual organs in dysfunction remained strongly associated with reduced 1-year survival. The use of health care resources among hospital survivors was substantial within 1 year: 40 % of the patients were rehospitalized, 52 % visited the emergency department, 90 % were seen at the outpatient clinic, 14 % attended rehabilitation outpatient services, 11 % were followed by the psychological or psychiatric service and 7 % used the day hospital facility. Use of health care resources up to 30 days after hospital discharge was associated with the number of organs in dysfunction at ICU discharge. Conclusions Organ failure was an important determinant of 1-year outcome of critically ill survivors. Nevertheless, the impact of organ failure tended to diminish over time. Resource use after critical illness was elevated among ICU survivors, and a targeted action is needed to deliver appropriate care and to reduce the late critical illness burden. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0986-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Otavio T Ranzani
- Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clínicas, University of São Paulo, Rua Dr. Enéas de Carvalho Aguiar, 255, 5th floor, Room 5023, São Paulo, 05403-010, Brazil.
| | - Fernando G Zampieri
- Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clínicas, University of São Paulo, Rua Dr. Enéas de Carvalho Aguiar, 255, 5th floor, Room 5023, São Paulo, 05403-010, Brazil.
| | - Bruno A M P Besen
- Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clínicas, University of São Paulo, Rua Dr. Enéas de Carvalho Aguiar, 255, 5th floor, Room 5023, São Paulo, 05403-010, Brazil.
| | - Luciano C P Azevedo
- Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clínicas, University of São Paulo, Rua Dr. Enéas de Carvalho Aguiar, 255, 5th floor, Room 5023, São Paulo, 05403-010, Brazil. .,Research and Education Institute, Hospital Sirio-Libanes, São Paulo, Brazil.
| | - Marcelo Park
- Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clínicas, University of São Paulo, Rua Dr. Enéas de Carvalho Aguiar, 255, 5th floor, Room 5023, São Paulo, 05403-010, Brazil. .,Research and Education Institute, Hospital Sirio-Libanes, São Paulo, Brazil.
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Papazian L, Jaber S. CO2 removal: Is a new simplified device could extended the indications? Anaesth Crit Care Pain Med 2015; 34:131-2. [PMID: 26048631 DOI: 10.1016/j.accpm.2015.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Laurent Papazian
- Intensive care unit "acute respiratory failure and severe infections", Assistance publique-hôpitaux de Marseille, CHU Nord, 13015 Marseille, France; Faculté de médecine, Aix-Marseille university, URMITE UMR CNRS 7278, 13005 Marseille, France.
| | - Samir Jaber
- Intensive Care Unit and Transplantation, Critical Care and Anesthesia Department (DAR B), Saint-Eloi Hospital, University of Montpellier, INSERM U1046, CNRS UMR 9214, 34295 Montpellier cedex 5, France
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Rusinova K, Cerny V, Kukal J, Pokorna E. Expanding the DCD donor pool: prediction of time to death after removal of life-sustaining treatments. Intensive Care Med 2015; 41:1719-20. [DOI: 10.1007/s00134-015-3838-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2015] [Indexed: 11/30/2022]
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15
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Bodí M, Olona M, Martín MC, Alceaga R, Rodríguez JC, Corral E, Pérez Villares JM, Sirgo G. Feasibility and utility of the use of real time random safety audits in adult ICU patients: a multicentre study. Intensive Care Med 2015; 41:1089-98. [PMID: 25869404 DOI: 10.1007/s00134-015-3792-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 03/31/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE The two aims of this study were first to analyse the feasibility and utility (to improve the care process) of implementing a new real time random safety tool and second to explore the efficacy of this tool in core hospitals (those participating in tool design) versus non-core hospitals. METHODS This was a prospective study conducted over a period of 4 months in six adult intensive care units (two of which were core hospitals). Safety audits were conducted 3 days per week during the entire study period to determine the efficacy of the 37 safety measures (grouped into ten blocks). In each audit, 50% of patients and 50% of measures were randomized. Feasibility was calculated as the proportion of audits completed over those scheduled and time spent, and utility was defined as the changes in the care process resulting from tool application. RESULTS A total of 1323 patient-days were analysed. In terms of feasibility, 87.6% of the scheduled audits were completed. The average time spent per audit was 34.5 ± 29 min. Globally, changes in the care process occurred in 5.4% of the measures analysed. In core hospitals, utility was significantly higher in 16 of the 37 measures, all of which were included in good clinical practice guidelines. Most of the clinical changes brought about by the tool occurred in the mechanical ventilation and haemodynamics blocks. Multivariate analyses demonstrated that changes in the care process in each block were associated with the core hospital variable, staffing ratios and severity of patient disease. CONCLUSIONS Real time safety audits improved the care process and adherence to the clinical practice guidelines and proved to be most useful in situations of high care load and in patients with more severe disease. The effect was greater in core hospitals.
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Affiliation(s)
- M Bodí
- Intensive Care Unit, Hospital Universitario Joan XXIII, Instituto de Investigación Sanitaria Pere Virgili, Rovira I Virgili University, Tarragona, Spain,
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16
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Predictors of noninvasive ventilation success in children with acute respiratory failure. Intensive Care Med 2015; 41:950-1. [PMID: 25821906 DOI: 10.1007/s00134-015-3769-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2015] [Indexed: 12/27/2022]
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17
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Diagnostic yield and safety of CT scans in ICU. Intensive Care Med 2014; 41:436-43. [DOI: 10.1007/s00134-014-3592-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 11/28/2014] [Indexed: 12/18/2022]
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18
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Extubation and extracorporeal membrane oxygenation: what a difference a decade makes!! Pediatr Crit Care Med 2014; 15:907-9. [PMID: 25370061 DOI: 10.1097/pcc.0000000000000265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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