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Précarité et réanimation : épidémiologie et pronostic. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1080-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Evans EE, Wang XQ, Moore CC. Distance from care predicts in-hospital mortality in HIV-infected patients with severe sepsis from rural and semi-rural Virginia, USA. Int J STD AIDS 2015; 27:370-6. [PMID: 25931237 DOI: 10.1177/0956462415584489] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 04/02/2015] [Indexed: 11/16/2022]
Abstract
There are few data regarding outcomes from severe sepsis for HIV-infected patients living in rural or semi-rural settings. We aim to describe the characteristics and predictors of mortality in HIV-infected patients admitted with severe sepsis to the University of Virginia located in semi-rural Charlottesville, Virginia, USA. We queried the University of Virginia Clinical Data Repository for cases with ICD-9 codes that included: (1) infection, (2) acute organ dysfunction, and (3) HIV infection. We reviewed each case to confirm the presence of HIV infection and severe sepsis. We recorded socio-demographic, clinical, and laboratory data. We used a generalised linear mixed-effects model to assess pre-specified predictors of mortality. We identified 74 cases of severe sepsis in HIV-infected patients admitted to University of Virginia since 2001. The median (IQR) age was 44 (36-49), 32 (43%) were women, and 56 (76%) were from ethnic minorities. The median (IQR) CD4+ T-cell count was 81 (7-281) cells/µL. In-hospital mortality was 20%. When adjusted for severity of illness and respiratory failure, patients who lived >40 miles away from care or had a CD4+ T cell count <50 cells/µL had > four-fold increased risk of death compared to the rest of the study population (AOR = 4.18, 95% CI: 1.09-16.07, p = 0.037; AOR = 4.33, 95% CI: 1.15-16.29, p = 0.03). In HIV-infected patients from rural and semi-rural Virginia with severe sepsis, mortality was increased in those that lived far from University of Virginia or had a low CD4+ T cell counts. Our data suggest that rural HIV-infected patients may have limited access to care, which predisposes them to critical illness and a high associated mortality.
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Affiliation(s)
- Emily E Evans
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Xin-Qun Wang
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Christopher C Moore
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, VA, USA
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Lyon SM, Benson NM, Cooke CR, Iwashyna TJ, Ratcliffe SJ, Kahn JM. The effect of insurance status on mortality and procedural use in critically ill patients. Am J Respir Crit Care Med 2011; 184:809-15. [PMID: 21700910 DOI: 10.1164/rccm.201101-0089oc] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Lack of health insurance maybe an independent risk factor for mortality and differential treatment in critical illness. OBJECTIVES To determine whether uninsured critically ill patients had differences in 30-day mortality and critical care service use compared with those with private insurance and to determine if outcome variability could be attributed to patient-level or hospital-level effects. METHODS Retrospective cohort study using Pennsylvania hospital discharge data with detailed clinical risk adjustment, from fiscal years 2005 and 2006, consisting of 167 general acute care hospitals, with 138,720 critically ill adult patients 64 years of age or younger. MEASUREMENTS AND MAIN RESULTS Measurements were 30-day mortality and receipt of five critical care procedures. Uninsured patients had an absolute 30-day mortality of 5.7%, compared with 4.6% for those with private insurance and 6.4% for those with Medicaid. Increased 30-day mortality among uninsured patients persisted after adjustment for patient characteristics (odds ratio [OR], 1.25 for uninsured vs. insured; 95% confidence interval [CI], 1.04–1.50) and hospital-level effects (OR, 1.26; 95% CI, 1.05–1.51). Compared with insured patients, uninsured patients had decreased risk-adjusted odds of receiving a central venous catheter (OR, 0.84; 95% CI,0.72–0.97), acute hemodialysis (OR, 0.59; 95% CI, 0.39–0.91), and tracheostomy (OR, 0.43; 95% CI, 0.29–0.64). CONCLUSIONS Lack of health insurance is associated with increased 30-day mortality and decreased use of common procedures for the critically ill in Pennsylvania. Differences were not attributable to hospital-level effects, suggesting that the uninsured have a higher mortality and receive fewer procedures when compared with privately insured patients treated at the same hospitals.
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Affiliation(s)
- Sarah M Lyon
- Division of Pulmonary, Allergey, and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
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Critical illness in HIV-infected patients in the era of combination antiretroviral therapy. Ann Am Thorac Soc 2011; 8:301-7. [PMID: 21653532 DOI: 10.1513/pats.201009-060wr] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
As HIV-infected persons on combination antiretroviral therapy (ART) are living longer and rates of opportunistic infections have declined, serious non-AIDS-related diseases account for an increasing proportion of deaths. Consistent with these changes, non-AIDS-related illnesses account for the majority of ICU admissions in more recent studies, in contrast to earlier eras of the AIDS epidemic. Although mortality after ICU admission has improved significantly since the earliest HIV era, it remains substantial. In this article, we discuss the current state of knowledge regarding the impact of ART on incidence, etiology, and outcomes of critical illness among HIV-infected patients. In addition, we consider issues related to administration of ART in the ICU and identify important areas of future research.
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Corona A, Raimondi F. Critical care of HIV-infected patients: still a dilemma for Italian intensivists--results of a multicentre survey. Eur J Anaesthesiol 2010; 27:377-82. [PMID: 20090538 DOI: 10.1097/eja.0b013e3283333ac7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVE To survey the Italian intensivist policy towards critically ill patients with HIV or AIDS in the era of highly active antiretroviral therapy (HAART). METHODS This was a multicentre questionnaire survey involving all of the 239 ICUs of the GiViTI (Italian Group for Evaluation of Interventions in ICU) network. In January 2006, a detailed questionnaire (see Appendix) was e-mailed to the GiViTI referring ICU physician in each of the 239 ICUs on the GiViTI list. There were no interventions. RESULTS A total of 126 ICU physicians (52.7%) responded. The number of referred yearly admissions was low: 85.7% of ICUs usually admit five or fewer patients infected with HIV or AIDS per year; only 10.2 and 4.2% of them admitted at least 15 HIV-infected and at least 15 AIDS patients, respectively; the admission of patients with HIV or AIDS is perceived as always appropriate in only 30.4 and 14.3% of ICUs, respectively. A bivariate correlation was found between the presence of an infectious disease ward and the number of referred yearly admissions of both HIV-infected (Spearman rho=0.295, P<0.05) and AIDS patients (Spearman rho=0.304, P<0.05) and the decision to admit or not patients with HIV or AIDS patients to ICU. If an infectious disease ward was available, the intensivist was more likely to take the decision to admit a patient with HIV (Spearman rho=0.637, P<0.05) or AIDS in consultation with an infectious disease specialist (Spearman rho=0.578, P=0.01). CONCLUSION The recorded wide variation in intensivists' approach towards patients with HIV or AIDS requires the production of high-quality evidence to identify an optimal shared policy for such patients.
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Affiliation(s)
- Alberto Corona
- ICU Department, Azienda Ospedaliera Luigi Sacco, Milano-Polo Universitario, Milan, Italy
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Fowler RA, Noyahr LA, Thornton JD, Pinto R, Kahn JM, Adhikari NKJ, Dodek PM, Khan NA, Kalb T, Hill A, O'Brien JM, Evans D, Curtis JR. An official American Thoracic Society systematic review: the association between health insurance status and access, care delivery, and outcomes for patients who are critically ill. Am J Respir Crit Care Med 2010; 181:1003-11. [PMID: 20430926 PMCID: PMC3269233 DOI: 10.1164/rccm.200902-0281st] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE One in three Americans under 65 years of age does not have health insurance during some portion of each year. Patients who are critically ill and lack health insurance may be at particularly high risk of morbidity and mortality due to the high cost of intensive care. OBJECTIVES To systematically review the medical and nonmedical literature to determine whether differences in critical care access, delivery, and outcomes are associated with health insurance status. METHODS Nine electronic databases (inception to 11 April 2008) were independently screened and abstracted in duplicate. MEASUREMENTS AND MAIN RESULTS From 5,508 citations, 29 observational studies met eligibility criteria. Among the general U.S. population, patients who were uninsured were less likely to receive critical care services than those with insurance (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.55-0.56). Once admitted to the intensive care unit, patients who were uninsured had 8.5% (95% CI, 6.0-11.1) fewer procedures, were more likely to experience hospital discharge delays (OR 4.51; 95% CI, 1.46-13.93), and were more likely to have life support withdrawn (OR 2.80; 95% CI, 1.12-7.02). Lack of insurance may confer an independent risk of death for patients who are critically ill (OR 1.16; 95% CI, 1.01-1.33). Patients in managed care systems had 14.3% (95% CI, 11.5-17.2) fewer procedures in intensive care, but were also less likely to receive "potentially ineffective" care. Differences in unmeasured confounding factors may contribute to these findings. CONCLUSIONS Patients in the United States who are critically ill and do not have health insurance receive fewer critical care services and may experience worse clinical outcomes. Improving preexisting health care coverage, as opposed to solely delivering more critical care services, may be one mechanism to reduce such disparities.
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Barbier F, Coquet I, Legriel S, Pavie J, Darmon M, Mayaux J, Molina JM, Schlemmer B, Azoulay E. Etiologies and outcome of acute respiratory failure in HIV-infected patients. Intensive Care Med 2009; 35:1678-86. [PMID: 19575179 PMCID: PMC7094937 DOI: 10.1007/s00134-009-1559-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2009] [Accepted: 06/07/2009] [Indexed: 01/20/2023]
Abstract
Objective To assess the etiologies and outcome of acute respiratory failure (ARF) in HIV-infected patients over the first decade of combination antiretroviral therapy (ART) use. Methods Retrospective study of all HIV-infected patients (n = 147) admitted to a single intensive care unit (ICU) for ARF between 1996 and 2006. Results ARF revealed the diagnosis of HIV infection in 43 (29.2%) patients. Causes of ARF were bacterial pneumonia (n = 74), Pneumocystis jirovecii pneumonia (PCP, n = 52), other opportunistic infections (n = 19), and noninfectious pulmonary disease (n = 33); the distribution of causes did not change over the 10-year study period. Two or more causes were identified in 33 patients. The 43 patients on ART more frequently had bacterial pneumonia and less frequently had opportunistic infections (P = 0.02). Noninvasive ventilation was needed in 49 patients and endotracheal intubation in 42. Hospital mortality was 19.7%. Factors independently associated with mortality were mechanical ventilation [odds ratio (OR) = 8.48, P < 0.0001], vasopressor use (OR, 4.48; P = 0.03), time from hospital admission to ICU admission (OR, 1.05 per day; P = 0.01), and number of causes (OR, 3.19; P = 0.02). HIV-related variables (CD4 count, viral load, and ART) were not associated with mortality. Conclusion Bacterial pneumonia and PCP remain the leading causes of ARF in HIV-infected patients in the ART era. Hospital survival has improved, and depends on the extent of organ dysfunction rather than on HIV-related characteristics.
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Affiliation(s)
- François Barbier
- Medical ICU and Infectious Disease Department, AP-HP, Hôpital Saint-Louis, 1 avenue Claude Vellefaux, 75010, Paris, France
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Abstract
OBJECTIVE To describe critical illnesses that occur commonly in patients with human immunodeficiency virus (HIV) infection. METHODS We reviewed and summarized the literature on critical illness in HIV infection using a computerized MEDLINE search. SUMMARY In the last 10 yrs, our perception of HIV infection and acquired immune deficiency syndrome (AIDS) has changed from an almost uniformly fatal disease into a manageable chronic illness. Even patients with advanced immunosuppression may have prolonged survival, although usually with exacerbations and remissions, complicated by therapy-related toxicity and medical and psychiatric co-morbidity. The prevalence of opportunistic infections and the mortality have decreased considerably since early in the epidemic. The most common reason for intensive care unit admission in patients with AIDS is respiratory failure, but they are less likely to be admitted for Pneumocystis pneumonia and other HIV-associated opportunistic infections. HIV-infected persons are more likely to receive intensive care unit care for complications of end-stage liver disease and sepsis. Hepatitis C has emerged as a common cause of morbidity and mortality in patients with HIV infection. In addition, some develop life-threatening complications from antiretroviral drug toxicity and the immune reconstitution inflammatory syndrome.
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Affiliation(s)
- Mark J Rosen
- Division of Pulmonary and Critical Care Medicine, Beth Israel Medical Center, New York, NY, USA
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Khouli H, Afrasiabi A, Shibli M, Hajal R, Barrett CR, Homel P. Outcome of critically ill human immunodeficiency virus-infected patients in the era of highly active antiretroviral therapy. J Intensive Care Med 2006; 20:327-33. [PMID: 16280405 DOI: 10.1177/0885066605281087] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this study was to determine the effect of prior use of highly active antiretroviral therapy (HAART) on outcome of human immunodeficiency virus (HIV)- patients admitted to intensive care units (ICUs). This study was a retrospective chart review of 242 HIV-infected patients who required 259 consecutive admissions to a university-affiliated hospital ICU during a 3-year period. Patient demographics, CD4 count, admission diagnosis, prior HAART, Pneumocystis jiroveci prophylaxis, length of stay, and ICU and hospital mortality were determined. Overall hospital mortality was 39%. Comparing patients who had received HAART before an ICU admission to those who had not, we found no difference between ICU or hospital mortality, need of mechanical ventilation, ICU and hospital length of stay, and incidence of P jiroveci. Pulmonary diagnosis was the most frequent ICU admission diagnosis (30%). Logistic regression analysis showed HIV-related illness and mechanical ventilation were significant independent predictors of increased hospital mortality.
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Affiliation(s)
- Hassan Khouli
- St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York 10019, USA.
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Curtis JR. Interventions to Improve Care during Withdrawal of Life-Sustaining Treatments. J Palliat Med 2005; 8 Suppl 1:S116-31. [PMID: 16499459 DOI: 10.1089/jpm.2005.8.s-116] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Withdrawal of life-sustaining therapies is a common occurrence in the intensive care unit (ICU) setting and also occurs in other hospital settings, long-term care facilities, and even at home. Many studies have documented dramatic geographic variations in the prevalence of withdrawal of life-sustaining therapies, and some evidence suggests this variation may be driven more by physician attitudes and biases than by factors such as patient preferences or cultural differences. A number of studies of interventions in the ICU setting have provided some evidence that withdrawal of life-sustaining therapies is a process of care that can be improved. The interventions have included routine ethics or palliative care consultations, routine family conferences, and standardized order protocol for withdrawal of life support. For some of the interventions, for example, ethics consultations or palliative care consultations, the precise mechanisms by which the process of care is improved are not clear. Furthermore, many of these studies have used surrogate outcomes for quality, such as ICU length of stay. Emerging research suggests more direct outcome measures may be useful, including family satisfaction with care and assessments of the quality of dying. Despite these relative limitations, these studies provide convincing evidence that withdrawal of life-sustaining therapy is a process of care that presents opportunities for quality improvement and that interventions are successful at improving this care. Further research is needed to identify and test the most appropriate and responsive outcome measures and to identify the most effective and cost-effective interventions.
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Affiliation(s)
- J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, University of Washington, Seattle, Washington 98104-2499, USA.
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Curtis JR, Rubenfeld GD. Improving Palliative Care For Patients In The Intensive Care Unit. J Palliat Med 2005; 8:840-54. [PMID: 16128659 DOI: 10.1089/jpm.2005.8.840] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Harborview Medical Center, Box 359761, 325 Ninth Avenue, Seattle, WA 98104-2499, USA.
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Boyton RJ, Mitchell DM, Kon OM. The pulmonary physician in critical care * Illustrative case 5: HIV associated pneumonia. Thorax 2003; 58:721-5. [PMID: 12885994 PMCID: PMC1746787 DOI: 10.1136/thorax.58.8.721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- R J Boyton
- Chest and Allergy Department, St Mary's Hospital NHS Trust, London W2 1NY, UK.
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Heyland DK, Rocker GM, O'Callaghan CJ, Dodek PM, Cook DJ. Dying in the ICU: perspectives of family members. Chest 2003; 124:392-7. [PMID: 12853551 DOI: 10.1378/chest.124.1.392] [Citation(s) in RCA: 159] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE To describe the perspectives of family members to the care provided to critically ill patients who died in the ICU. DESIGN Multicenter, prospective, observational study. SETTING Six university-affiliated ICUs across Canada. METHODS Patients who received mechanical ventilation for > 48 h and who died in the ICU were eligible for this study. Three to four weeks after the patient's death, we mailed a validated questionnaire to one selected family member who made at least one visit to the patient in the ICU. We obtained self-rated levels of satisfaction with key aspects of end-of-life care, communication, and decision making, and the overall ICU experience. MAIN RESULTS Questionnaires were mailed to 413 family members; 256 completed surveys were returned (response rate, 62.0%). In the final hours before the death of the patient, family members reported that patients were "totally comfortable" (34.8%), "very comfortable" (23.8%), or "mostly comfortable" (32.0%). Family members felt "very supported" (57.0%) and "supported" (30.7%) by the health-care team. Most (82.0%) believed that the patient's life was neither prolonged nor shortened unnecessarily. Most family members (90.4%) preferred some form of shared decision making. Overall, 52% of families rated their satisfaction with care as "excellent," 31% rated care as "very good," 10% as "good," 4% as "fair," and 2% as "poor." Overall satisfaction with end-of-life care was significantly associated with completeness of information received by the family member, respect and compassion shown to patient and family member, and satisfaction with amount or level of health care received. CONCLUSIONS The majority of families of patients who died in participating ICUs were satisfied with the end-of-life care provided. Adequate communication, good decision making, and respect and compassion shown to both the dying patient and their family are key determinants to family satisfaction.
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Affiliation(s)
- Daren K Heyland
- Department of Medicine, Kingston General Hospital, Kingston, ON, Canada.
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Abstract
During the past 20 years, ICU risk-prediction models have undergone significant development, validation, and refinement. Among the general ICU severity of illness scoring systems, the Acute Physiology and Chronic Health Evaluation (APACHE), Mortality Prediction Model (MPM), and the Simplified Acute Physiology Score (SAPS) have become the most accepted and used. To risk-adjust patients with longer, more severe illnesses like sepsis and acute respiratory distress syndrome, several models of organ dysfunction or failure have become available, including the Multiple Organ Dysfunction Score (MODS), the Sequential Organ Failure Assessment (SOFA), and the Logistic Organ Dysfunction Score (LODS). Recent innovations in risk adjustment include automatic physiology and diagnostic variable retrieval and the use of artificial intelligence. These innovations have the potential of extending the uses of case-mix and severity-of-illness adjustment in the areas of clinical research, patient care, and administration. The challenges facing intensivists in the next few years are to further develop these models so that they can be used throughout the IUC stay to assess quality of care and to extend them to more specific patient groups such as the elderly and patients with chronic ICU courses.
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Affiliation(s)
- Andrew L Rosenberg
- Robert Wood Johnson Clinical Scholars Program, Department of Anesthesiology and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan 48109-4270, USA.
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Morris A, Creasman J, Turner J, Luce JM, Wachter RM, Huang L. Intensive care of human immunodeficiency virus-infected patients during the era of highly active antiretroviral therapy. Am J Respir Crit Care Med 2002; 166:262-7. [PMID: 12153955 DOI: 10.1164/rccm.2111025] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Highly active antiretroviral therapy for human immunodeficiency virus (HIV) infection has produced significant declines in morbidity and mortality from acquired immunodeficiency syndrome (AIDS). Whether this therapy has resulted in changes in epidemiology and outcomes of intensive care among HIV-infected patients is unknown. We performed chart review of all intensive care unit admissions for HIV-infected patients at San Francisco General Hospital from 1996 through 1999. There were an average of 88.5 admissions per year with 71% survival to hospital discharge. Univariate analysis demonstrated that prior highly active antiretroviral therapy (odds ratio [OR] = 1.8, p = 0.04), a non-AIDS-associated admission diagnosis (OR = 3.7, p = 0.001), a lower Acute Physiology and Chronic Health Evaluation II score (OR = 5.4, p = 0.001), and higher serum albumin (OR = 4.4, p = 0.001) predicted improved survival. Pneumocystis carinii pneumonia (OR = 0.24, p = 0.001), mechanical ventilation (OR = 0.19, p = 0.001), or a pneumothorax (OR = 0.08, p = 0.001) were associated with worse survival. In multivariate logistic regression, all variables except prior use of highly active antiretroviral therapy and pneumothorax were significant independent predictors of outcome. At our institution, overall survival for HIV-infected intensive care unit patients has improved, especially among patients receiving highly active antiretroviral therapy. These patients may have an improved survival because of effects of therapy on variables such as likelihood of non-AIDS-associated admission diagnoses and serum albumin levels.
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Affiliation(s)
- Alison Morris
- Department of Medicine, San Francisco General Hospital, University of California, San Francisco, CA, USA.
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Abstract
BACKGROUND The intensive care unit (ICU) represents a unique clinical setting in which mortality is relatively high and the professional culture tends to be one of "rescue therapy" using technological and invasive interventions. For these reasons, the ICU is an important environment for understanding and improving end-of-life care. Although there have been consensus statements and review articles on end-of-life care in the ICU, there is limited evidence on which to base an assessment of best practices for providing high-quality end-of-life care in this setting. OBJECTIVE To convene a Working Group of experts in critical care, palliative medicine, medical ethics, and medical law to address the question "What research needs to be done to improve end-of-life care to patients in the ICU?" METHODS Participants were identified for membership in the Working Group by purposive sampling within the fields of critical care medicine and nursing, palliative medicine, and medical ethics; others were chosen to represent social work and hospital chaplains. Through a process of breakout and plenary sessions, the group identified important questions that need to be addressed in the areas of defining the problem, identifying solutions, evaluating solutions, and overcoming barriers. CONCLUSIONS Outlining unanswered questions on end-of-life care in the ICU is a first step to providing the answers that will allow us to improve care to patients dying in the ICU. These questions also serve to focus clinicians and educators on the important areas for improving quality of care.
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Affiliation(s)
- G D Rubenfeld
- Division of Pulmonary and Critical Care Medicine, the Department of Medicine, University of Washington, Seattle, WA 98104-2499, USA.
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Kim B, Lyons TM, Parada JP, Uphold CR, Yarnold PR, Hounshell JB, Sipler AM, Goetz MB, DeHovitz JA, Weinstein RA, Campo RE, Bennett CL. HIV-related Pneumocystis carinii pneumonia in older patients hospitalized in the early HAART era. J Gen Intern Med 2001; 16:583-9. [PMID: 11556938 PMCID: PMC1495267 DOI: 10.1046/j.1525-1497.2001.016009583.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine whether older age continues to influence patterns of care and in-hospital mortality for hospitalized persons with HIV-related Pneumocystis carinii pneumonia (PCP), as determined in our prior study from the 1980s. DESIGN Retrospective chart review. PATIENTS/SETTING Patients (1,861) with HIV-related PCP at 78 hospitals in 8 cities from 1995 to 1997. MEASUREMENTS Medical record notation of possible HIV infection; alveolar-arterial oxygen gradient; CD4 lymphocyte count; presence or absence of wasting; timely use of anti-PCP medications; in-hospital mortality. MAIN RESULTS Compared to younger patients, patients > or =50 years of age were less likely to have HIV mentioned in their progress notes (70% vs 82%, P <.001), have mild or moderately severe PCP cases at admission (89% vs 96%, P <.002), receive anti-PCP medications within the first 2 days of hospitalization (86% vs 93%, P <.002), and survive hospitalization (82% vs 90%, P <.003). However, age was not a significant predictor of mortality after adjustment for severity of PCP and timeliness of therapy. CONCLUSIONS While inpatient PCP mortality has improved by 50% in the past decade, 2-fold age-related mortality differences persist. As in the 1980s, these differences are associated with lower rates of recognition of HIV, increased severity of illness at admission, and delays in initiation of PCP-specific treatments among older individuals--factors suggestive of delayed recognition of HIV infection, pneumonia, and PCP, respectively. Continued vigilance for the possibility of HIV and HIV-related PCP among persons > or =50 years of age who present with new pulmonary symptoms should be encouraged.
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Affiliation(s)
- B Kim
- Department of Medicine, Northwestern University Medical School, Chicago, Ill, USA
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Curtis JR, Yarnold PR, Schwartz DN, Weinstein RA, Bennett CL. Improvements in outcomes of acute respiratory failure for patients with human immunodeficiency virus-related Pneumocystis carinii pneumonia. Am J Respir Crit Care Med 2000; 162:393-8. [PMID: 10934059 DOI: 10.1164/ajrccm.162.2.9909014] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In the early 1990s, hospital survival among patients with human immunodeficiency virus (HIV)-related Pneumocystis carinii pneumonia (PCP) and respiratory failure was poor, approximately 20%. We examined ICU use and outcomes for patients with acute respiratory failure from PCP from 1995 to 1997. We conducted a retrospective medical record review using a random sample of 71 hospitals in seven regions of the United States. Among 1,660 patients with confirmed or presumed PCP, 155 (9%) received mechanical ventilation for respiratory failure. Factors that predicted use of mechanical ventilation, independent of severity of illness on hospital admission, included African-American ethnicity and geographic location (p </= 0.002). Hospital survival for patients receiving mechanical ventilation was 38% (95% CI 30, 46). Controlling for severity of illness, patients who were on PCP prophylaxis prior to developing PCP were less likely to survive to hospital discharge (p </= 0.02). There were no significant differences in hospital survival regardless of whether patients had received less than or more than 5 d of PCP treatment prior to respiratory failure (39 versus 29%; p = 0.5). In conclusion, from 1995 to 1997, hospital survival after PCP requiring mechanical ventilation was approximately 40%. Physicians caring for patients with severe HIV-related PCP should be aware of the improvements in outcomes for this disease before making recommendations about withholding or withdrawing ventilatory support for respiratory failure.
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Affiliation(s)
- J R Curtis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
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Afessa B, Green B. Clinical course, prognostic factors, and outcome prediction for HIV patients in the ICU. The PIP (Pulmonary complications, ICU support, and prognostic factors in hospitalized patients with HIV) study. Chest 2000; 118:138-45. [PMID: 10893371 DOI: 10.1378/chest.118.1.138] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE To describe the clinical course and prognostic factors in patients with HIV admitted to the ICU. DESIGN Prospective, observational. SETTING A university-affiliated medical center. METHODS : We included 169 consecutive ICU admissions, from April 1995 through March 1999, of 141 adults with HIV. Data collected included APACHE (acute physiology and chronic health evaluation) II score, CD4(+) lymphocyte count, serum albumin level, in-hospital mortality, and the development of organ failure, systemic inflammatory response syndrome (SIRS), and ARDS. RESULTS The ICU admission rate of hospitalized patients with HIV infection was 12%. The most common reason for ICU admission was respiratory failure, occurring in 65 patient admissions. Mechanical ventilation was required in 91 admissions (54%), ARDS developed in 37 admissions (22%), Pneumocystis carinii pneumonia was diagnosed in 24 admissions (14%), and SIRS developed in 126 admissions (75%). One or more organ failures developed in 131 admissions (78%). The actual and predicted mortality rates were 29.6% and 45.2%, respectively, with a standardized mortality ratio of 0.65. The most frequent immediate cause of death was bacterial infection. The CD4(+) lymphocyte count (median, 27.5 cells/microL vs 59 cells/microL; p = 0.0310) and serum albumin level (median 2.2 g/dL vs 2.6 g/dL; p = 0.0355) of nonsurvivors were lower and the APACHE II score (median, 30 vs 21; p < 0.0001) was higher, compared to those of survivors. A higher APACHE II score (odds ratio [OR], 1.11; 95% confidence interval [CI], 1.05 to 1.16) and a transfer from another hospital ward (OR, 3.03; 95% CI, 1.20 to 7.68) were independently associated with increased mortality. The median number of organ failures that developed in survivors was one, compared to four in nonsurvivors (p < 0.0001). CONCLUSIONS The outcome of HIV-infected patients admitted to the ICU has improved over the years. The CD4 count does not correlate with in-hospital mortality. Higher APACHE II scores and a transfer from another hospital ward are associated with a poor outcome.
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Affiliation(s)
- B Afessa
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Florida Health Science Center, Jacksonville, FL, USA.
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Gill JK, Greene L, Miller R, Pozniak A, Cartledge J, Fisher M, Nelson MR, Soni N. ICU admission in patients infected with the human immunodeficiency virus - a multicentre survey. Anaesthesia 1999; 54:727-32. [PMID: 10460523 DOI: 10.1046/j.1365-2044.1999.00903.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We conducted a retrospective study to assess the reasons for admission to the intensive care unit, and subsequent outcome, in patients infected with the human immunodeficiency virus (HIV). Four hospitals in the south of England participated, all with specialist HIV units. Data were collected on 127 patients admitted to ICU on 133 separate occasions between June 1993 and October 1997. The mean age on admission was 38 years (range 23-60 years). Ninety-four patients (70.7%) were documented HIV-positive before admission and 36 (27%) were diagnosed HIV-positive for the first time during admission; 36.1% were admitted with Pneumocystis carinii pneumonia. Overall ICU mortality was 33%, in-hospital mortality was 56% and the eventual mortality at the end of follow-up (March 1998) was 72%. Survival was highest in those admitted with respiratory HIV-related disease or HIV-unrelated illness. Associations with poor outcome included a prior AIDS-defining illness, a CD4 cell count of less than 100 cells.ml-1 and admission secondary to sepsis.
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Affiliation(s)
- J K Gill
- Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH
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Walker R, Kaner RJ. Pneumocystis pneumonia in the intensive care unit: location, location, location? Crit Care Med 1998; 26:640-1. [PMID: 9559597 DOI: 10.1097/00003246-199804000-00007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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