1
|
Nanah A, Abdeljaleel F, Matsubara JK, Garcia MVF. Outcomes and Practices of Endotracheal Intubation Using the Glasgow Coma Scale in Acute Non-Traumatic Poisoning: A Systematic Review and Meta-Analysis of Proportions. J Intensive Care Med 2024:8850666241275041. [PMID: 39150325 DOI: 10.1177/08850666241275041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
BACKGROUND Acute poisoning often results in decreased consciousness, necessitating airway assessment and management. Existing literature in the trauma setting suggests the importance of airway protection in unconscious patients to prevent complications, including aspiration. Practices for endotracheal intubation in non-traumatic acute poisoning are poorly described and variable, particularly regarding the use of a Glasgow Coma Scale (GCS) ≤ 8 threshold for intubation. METHODS A systematic review and meta-analysis of proportions was conducted to evaluate intubation rates and outcomes in patients presenting for acute non-traumatic poisoning. Studies were excluded if the primary indication for intubation was not airway protection. We analyzed rates of intubation, mortality, and aspiration by subgrouping patients into GCS ≤ 8, GCS 9-15, or mixed GCS. Common and random-effects analysis were used, supplemented by subgroup analyses. RESULTS 39 studies were included in the analysis, involving 15,959 patients. Random-effects pooled intubation rates varied significantly across GCS categories: GCS ≤ 8 (30.0%, I2 = 92%, p < 0.01), GCS 9-15 (1.0%, I2 = 0%, p = 0.91), and mixed GCS (11.0%, I2 = 94%, p < 0.01), p-value <0.01 for subgroup difference. Aspiration rates also varied: GCS ≤ 8 (19.0%, I2 = 84%, p < 0.01), GCS 9-15 (4.0%, I2 = 78%, p < 0.01), and mixed group (5.0%, I2 = 72%, p < 0.01), p-value <0.01 for subgroup difference. Mortality rates remained low across all groups: GCS ≤ 8 (1.0%, I2 = 0%, p = 0.62), GCS 9-15 (1.0%, I2 = 0%, p = 0.99), and mixed group (2.0%, I2 = 68%, p < 0.01). CONCLUSION The conventional "less than 8, intubate" approach may not be directly applicable to acute poisoning patients due to heterogeneity in patient presentation, intubation practices, and low mortality. Therefore, a nuanced approach is warranted to optimize airway management strategies tailored to individual patient needs.
Collapse
Affiliation(s)
- Abdelrahman Nanah
- Cleveland Clinic Foundation, Fairview Hospital, Cleveland, Ohio, USA
| | | | | | | |
Collapse
|
2
|
Flack M, Koop F, Zellner T, Heier EC, Geith S, Eyer F, Rabe C, Schmoll S. The Tanta University risk model could help identify patients with acute poisoning who would require intensive care unit level of care. Clin Toxicol (Phila) 2024; 62:352-356. [PMID: 38874423 DOI: 10.1080/15563650.2024.2364030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 05/30/2024] [Indexed: 06/15/2024]
Abstract
OBJECTIVE To independently validate the negative predictive value of the Tanta University risk model for intensive care requirements in poison center telephone consultations with other physicians. METHODS This study included 400 consecutive patients with acute poisoning. Clinical and laboratory parameters were recorded during the initial consultation with the poison center. Patients who were already ventilated or on vasopressors at the time of consultation were excluded. The Tanta University risk model score was calculated from the data according to the following equation: Tanta University risk model score = 1.966*Glasgow Coma Scale + 0.329*oxygen saturation (percent) + 0.212*diastolic blood pressure (mmHg) - 0.27*respiratory rate (breaths/minute) + 0.33*standard bicarbonate (mmol/L). Twenty-four hours later, the patients' courses were followed up by telephone. The Tanta University risk model was then compared to a composite endpoint indicating the requirement for admission to an intensive care unit (vasopressors, need for intubation, or death). RESULTS Four hundred patients with acute poisoning were included. Thirty-seven patients had a complicated clinical course as defined by the composite endpoint. Receiver operating characteristic analysis revealed the area under the curve to be 0.87 (95 percent confidence interval 0.83-0.90). An unfavorable Tanta University risk model score was defined as less than 73.46, using a cut-off derived from a previous study of an unrelated series of patients with acute poisoning admitted to our service. Thirty-one of 37 patients with complicated courses had an unfavorable Tanta University risk model score compared to six patients with complicated courses among 306 patients with a favorable Tanta University risk model score (P < 0.0002, Fisher's exact test). Sixty-three patients had an unfavorable Tanta University risk model score but an uneventful course. The negative predictive value of the Tanta University risk model was 0.98 (95 percent confidence interval 0.96-0.99), sensitivity was 0.84, and specificity 0.83. CONCLUSIONS In the present study of poison center telephone consultations, the Tanta University risk model was significantly related to the outcomes in patients with acute poisoning. Patients with a favorable Tanta University risk model score (greater than or equal to 73.46) were unlikely to need intensive care unit level of care.
Collapse
Affiliation(s)
- Maria Flack
- Department of Clinical Toxicology, Klinikum rechts der Isar, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Felix Koop
- Department of Clinical Toxicology, Klinikum rechts der Isar, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Tobias Zellner
- Department of Clinical Toxicology, Klinikum rechts der Isar, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Eva-Carina Heier
- Department of Clinical Toxicology, Klinikum rechts der Isar, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Stefanie Geith
- Department of Clinical Toxicology, Klinikum rechts der Isar, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Florian Eyer
- Department of Clinical Toxicology, Klinikum rechts der Isar, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Christian Rabe
- Department of Clinical Toxicology, Klinikum rechts der Isar, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Sabrina Schmoll
- Department of Clinical Toxicology, Klinikum rechts der Isar, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| |
Collapse
|
3
|
Reisinger AC, Schneider N, Schreiber N, Janisch M, Rauch I, Kaufmann P, Wünsch G, Eller P, Hackl G. Critical care management of acute intoxications, dynamics and changes over time: a cohort study. Intern Emerg Med 2024:10.1007/s11739-024-03570-2. [PMID: 38502464 DOI: 10.1007/s11739-024-03570-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/22/2024] [Indexed: 03/21/2024]
Abstract
Acute intoxications and poisonings are a relevant cause for ICU admission of critically ill patients. This study aimed to determine the characteristics of intoxicated patients in a tertiary center medical ICU in Austria over time and to investigate parameters associated with ICU mortality. This study was a retrospective data analysis including adult ICU patients from the years 2007 to 2021. In addition to ICU documentation, pre-hospital, and emergency department documents as well as autopsy reports were utilized. In an exploratory subanalysis, we compared these findings to a historical dataset from our facility from 1992 to 1996. We identified 581 cases admitted to the medical ICU because of acute poisoning (2007-2021), of which 45% were female and 46.6% were mixed intoxications. Suicidal intent was the primary cause of intoxication (48.2%) and ICU length of stay was median 1.2 days. The majority of deceased patients received pre-hospital mechanical CPR. Primary and secondary poison/toxin removal modalities were used in 29.9% and 11.7% of cases, whereas antidotes were administered in 54.4%. Comparing the data with a historical cohort (n = 168), we found a shift in primary detoxification away from gastric lavage and an increase in alternative secondary poison/toxin removal techniques. The ICU mortality was 4.1% and 4.2% in the present and historic cohort, respectively. Pre-existing psychiatric illnesses increased from 49% in the historic to 69% in the present cohort. Psychiatric illness predisposes patients to severe intoxications necessitating ICU care, thus increasing prevention measures seems warranted. Females did present with a different spectrum of intoxications compared to males. ICU mortality remained low over time and most deceased patients had a grim prognosis already on ICU arrival.
Collapse
Affiliation(s)
- Alexander Christian Reisinger
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Nikolaus Schneider
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Nikolaus Schreiber
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Martina Janisch
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Ines Rauch
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
- Department of Anesthesiology, LKH Hochsteiermark, Bruck an der Mur, Austria
| | - Peter Kaufmann
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Gerrit Wünsch
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Philipp Eller
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
| | - Gerald Hackl
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| |
Collapse
|
4
|
Jensen TL, Tejlbo Frost M, Dalhoff K, Studsgaard Petersen T. Repeated poisonings in Denmark - a nationwide study. Clin Toxicol (Phila) 2023; 61:392-399. [PMID: 37171194 DOI: 10.1080/15563650.2023.2205006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE Poisonings contribute significantly to morbidity and mortality of patients. Some patients have numerous contacts to a poison information center, indicating repeated poisoning exposures. Information on the involved substances is necessary to explore methods to prevent self-harm and reduce mortality. The objective of this study was to characterize the patient population with repeated poison exposures in Denmark and identify the substances involved. METHODS This study was a retrospective cohort study of enquiries to the nationwide Danish Poison Information Centre and the Danish National Patient Registry. The databases were used to identify patients with more than five individual poisoning episodes within a 12-month-period between 1 January 2013, and 31 December 2017. RESULTS One hundred and thirty-seven patients and 995 patients met the inclusion criteria in the Danish Poison Information Centre and the Danish National Patient Registry, respectively. The majority were women (82.5% and 66.3% for the Danish Poison Information Centre and the Danish National Patient Registry cohorts, respectively). The mean age was 24.7 and 29.5 years. Psychiatric comorbidities were frequent with 74.5% and 67.0% suffering from personality disorders and 70.1% and 54.5% from affective disorders in the Danish Poison Information Centre and the Danish National Patient Registry cohorts, respectively. One thousand seven hundred and fifty-two poisoning episodes were identified in the Danish Poison Information Centre database, and the most common types of substance were 'pharmaceuticals' (1,420 episodes). The most common medications ingested were quetiapine, paracetamol and cyclizine. Median number of contacts to the Danish Poison Information Centre was 10. Patients with one or more poisoning episodes involving cyclizine had on average 11.4 poisoning episodes involving cyclizine. In the Danish National Patient Registry cohort 80.9% were alive after 10 years compared to 97.7% in the background population. CONCLUSION AND IMPLICATIONS Most poisonings were intentional and occurred among younger women. Psychiatric comorbidity was frequent. Most often, pharmaceuticals were the toxic substance, mainly quetiapine, paracetamol and cyclizine. Changing the status of cyclizine from over the counter to prescription only medication, and implementing stricter rules for prescribing quetiapine, could limit future poisoning incidences.
Collapse
Affiliation(s)
- Thomas Leth Jensen
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Matilde Tejlbo Frost
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Kim Dalhoff
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tonny Studsgaard Petersen
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
5
|
Sayde GE, Prince E. ICU Survivors of Self-Harm: A Call for Follow-Through. Chest 2023; 163:738-739. [PMID: 37031976 DOI: 10.1016/j.chest.2022.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 04/11/2023] Open
Affiliation(s)
- George E Sayde
- Department of Internal Medicine and Psychiatry, Tulane University School of Medicine, New Orleans, LA.
| | - Elizabeth Prince
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
6
|
Koskela L, Raatiniemi L, Ehrola A, Kaakinen T, Lahtinen S, Liisanantti J. Accuracy of dispatch and prehospital triage performance in poisonings - A retrospective study from northern Finland. Acta Anaesthesiol Scand 2023; 67:112-119. [PMID: 36183301 PMCID: PMC10092780 DOI: 10.1111/aas.14152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/23/2022] [Accepted: 09/04/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Increasing numbers of dispatches place a burden on EMS; this study sought to assess the prehospital evaluation of poisoned patients transported to hospital. The primary aim of this study was to measure dispatch centre and EMS provider performance as well as factors contributing to the recognition of poisoning among prehospital patients. The secondary aim was to compare triage performance between dispatch centres and EMS providers. METHODS A retrospective single-centre study in Northern Finland was conducted. Patients suspected as poisonings by dispatch centres as well as other EMS-transported patients who received a diagnosis of poisoning in hospital between June 1, 2015 and June 1, 2017, were included. RESULTS There were a total of 1668 poisoning-related EMS missions. Dispatch centres suspected poisonings with sensitivity of 79.9% (95% CI 76.7-82.9) and specificity of 98.9% (95% CI 98.9-99.0) when all EMS missions were taken into account. In a logistic regression model, decreased state of consciousness as dispatch code (OR 7.18, 95% CI 1.90-27.05) and intravenous fluid resuscitation (OR 6.58, 95% CI 1.34-32.37) were associated with EMS transport providers not recognizing poisoning. Overtriage rate appeared significantly higher (33.6%, 95% CI 28.6-39.2) for dispatch when compared with transport (17.8%, 95% CI 13.9-22.6). CONCLUSION Dispatch centres seem to suspect poisonings fairly accurately. Poisonings unrecognized by EMS providers may be linked with intravenous fluid resuscitation and decreased patient consciousness. Overtriage appears to resolve somewhat from dispatch to transport. There were no fatal poisonings in this study population.
Collapse
Affiliation(s)
- Lauri Koskela
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu, Finland
| | - Lasse Raatiniemi
- Centre for prehospital emergency care, Oulu University Hospital, Oulu, Finland
| | - Ari Ehrola
- Emergency Medical Services, Northern Ostrobothnian Hospital District, Oulu, Finland
| | - Timo Kaakinen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu, Finland.,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Sanna Lahtinen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu, Finland.,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Janne Liisanantti
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu, Finland.,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| |
Collapse
|
7
|
Outpatient Mental Health Follow-up and Recurrent Self-harm and Suicide Among Patients Admitted to the ICU for Self-harm: A Population-based Cohort Study. Chest 2022; 163:815-825. [PMID: 36445799 DOI: 10.1016/j.chest.2022.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 10/16/2022] [Accepted: 10/23/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Patients surviving an ICU admission for deliberate self-harm are at high risk of recurrent self-harm or suicide after discharge. It is unknown whether mental health follow-up after discharge (with either a family physician or psychiatrist) reduces this risk. RESEARCH QUESTION What is the association between mental health follow-up after discharge and recurrent self-harm among patients admitted to the ICU for intentional self-harm? STUDY DESIGN AND METHODS Population-based cohort study of consecutive adults (≥ 18 years of age) from Ontario, Canada, who were admitted to ICU because of intentional self-harm between 2009 and 2017. We categorized patients according to follow-up, with 'early follow-up' indicating 1 to 21 days after discharge, 'late follow-up' indicating 22 to 60 days after discharge, and 'no follow-up' indicating no follow-up within 60 days of discharge. We conducted analyses using a cause-specific extended Cox regression model to account for varying time for mental health follow-up relative to the outcomes of interest. The primary outcome was recurrent ICU admission for self-harm within 1 year of discharge. RESULTS We included 9,569 consecutive adults admitted to the ICU for deliberate self-harm. Compared with receiving no mental health follow-up, both early follow-up (hazard ratio [HR], 1.37; 95% CI, 1.07-1.75) and late follow-up (HR, 1.69; 95% CI, 1.22-2.35) were associated with increased risk in recurrent ICU admission for self-harm. As compared with no follow-up, neither early follow-up (HR, 1.10; 95% CI, 0.70-1.73) nor late follow-up (HR, 1.54; 95% CI, 0.84-2.83) were associated with increased risk of death by suicide. INTERPREATION Among adults admitted to the ICU for deliberate self-harm, mental health follow-up after discharge was not associated with reduced risk of recurrent ICU admission for self-harm or death resulting from suicide, and patients seeking outpatient follow-up may be those at highest risk of these outcomes. Future research should focus on additional and novel methods of risk mitigation in this vulnerable population.
Collapse
|
8
|
Naïm G, Lacoste-Palasset T, M'Rad A, Sutterlin L, Pépin-Lehalleur A, Grant C, Ekhérian JM, Deye N, Malissin I, Voicu S, Mégarbane B. Factors associated with prolonged intensive care stay among self-poisoned patients. Clin Toxicol (Phila) 2022; 60:997-1005. [PMID: 35451892 DOI: 10.1080/15563650.2022.2064870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
CONTEXT Since recovery or death is generally observed within a few days after intensive care unit (ICU) admission of self-poisoned patients in the developed countries, reasons for the prolonged ICU stay are of interest as they have been poorly investigated. We aimed to identify the characteristics, risk factors, outcome, and predictors of death in self-poisoned patients requiring prolonged ICU management. METHODS We conducted an eight-year single-center cohort study including all self-poisoned patients who stayed at least seven days in the ICU. Patients admitted with drug adverse events and chronic overdoses were excluded. Using multivariate analyses, we investigated risk factors for prolonged ICU stay in comparison with a group of similar size of self-poisoned patients with <7day-ICU stay and studied risk factors for death. RESULTS Among 2,963 poisoned patients admitted in the ICU during the study period, the number who stayed beyond seven days was small (398/2,963, 13.1%), including 239 self-poisoned patients (125 F/114M; age, 51 years [38-65] (median [25th-75th percentiles]); SAPSII, 56 [43-69]). Involved toxicants included psychotropic drugs (59%), cardiotoxicants (31%), opioids (15%) and street drugs (13%). When compared with patients who stayed <7days in the ICU, acute kidney injury (odds ratio (OR), 3.15; 95% confidence interval (1.36-7.39); p = .008), multiorgan failure (OR, 8.06 (3.43-19.9); p < .001), aspiration pneumonia (OR, 8.48 (4.28-17.3); p < .001), and delayed awakening related to the persistent toxicant effects, hypoxic encephalopathy and/or oversedation (OR, 8.64 (2.58-40.7); p = .002) were independently associated with prolonged ICU stay. In-hospital mortality rate was 9%. Cardiac arrest occurring in the prehospital setting and during the first hours of ICU management (OR, 27.31 (8.99-158.76); p < .001) and delayed awakening (OR, 14.94 (6.27-117.44); p < .001) were independently associated with increased risk of death, whereas exposure to psychotropic drugs (OR, 0.08 (0.02-0.36); p = .002) was independently associated with reduced risk of death. CONCLUSION Self-poisoned patients with prolonged ICU stay of ≥7days are characterized by concerning high rates of morbidities and poisoning-attributed complications. Acute kidney injury, multiorgan failure, aspiration pneumonia, and delayed awakening are associated with ICU stay prolongation. Cardiac arrest occurrence and delayed awakening are predictive of death. Further studies should focus on the role of early goal-directed therapy and patient-targeted sedation in reducing ICU length of stay among self-poisoned patients.
Collapse
Affiliation(s)
- Giulia Naïm
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France.,Paris University, Paris, France
| | - Thomas Lacoste-Palasset
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France.,Paris University, Paris, France
| | - Aymen M'Rad
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France
| | - Laetitia Sutterlin
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France.,Paris University, Paris, France
| | - Adrien Pépin-Lehalleur
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France.,Paris University, Paris, France
| | - Caroline Grant
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France
| | - Jean-Michel Ekhérian
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France
| | - Nicolas Deye
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France
| | - Isabelle Malissin
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France.,INSERM UMRS-1144, Paris University, Paris, France
| | - Sebastian Voicu
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France.,INSERM UMRS-1144, Paris University, Paris, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France.,Paris University, Paris, France.,INSERM UMRS-1144, Paris University, Paris, France
| |
Collapse
|
9
|
Wiersma T, van den Oever HLA, van Hout FJHA, Twijnstra MJ, Mauritz GJ, van 't Riet E, Jansman FGA. The performance of COBRA, a decision rule to predict the need for intensive care interventions in intentional drug overdose. Eur J Emerg Med 2022; 29:126-133. [PMID: 34560700 DOI: 10.1097/mej.0000000000000877] [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: 11/26/2022]
Abstract
BACKGROUND COBRA was developed as a decision rule to predict which patients visiting the emergency department (ED) following intentional drug overdose will not require intensive care unit (ICU) interventions. COBRA uses parameters from five vital systems (cardiac conduction, oxygenation, blood pressure, respiration, and awareness) that are readily available in the ED. COBRA recommends against ICU admission when all these parameters are normal. OBJECTIVE The primary aim of this study was to determine the negative predictive value (NPV) of COBRA in predicting ICU interventions. Secondary outcomes were the sensitivity, specificity and positive predictive value (PPV), and the observation time required for a reliable prediction. DESIGN Observational cohort study. SETTINGS AND PARTICIPANTS Patients with a reported intentional overdose with drugs having potential acute effects on neurological, circulatory or ventilatory function were included, and data necessary to complete the decision rule was collected. The attending physician in the ED made the actual admission decision, on the basis of clinical judgement. COBRA was measured 0, 3 and 6 h after arrival at the ED. OUTCOME MEASURES Need for ICU interventions (treatment of convulsion; defibrillation; mechanical or noninvasive ventilation; intravenous administration of vasopressive agents, antiarrhythmics, atropine, calcium, magnesium or sedation; continuous hemofiltration or administration of antagonist/antidote and fluid resuscitation). MAIN RESULTS Of 230 new cases (144 unique patients), 59 were immediately referred to the psychiatric services and/or sent home by the attending physician, 27 went to a regular ward, and 144 were admitted to the ICU. Of these 144 cases, 40 required one or more ICU interventions. By the time the first parameters were collected, the NPV of COBRA was 95.6%. After 3 h of observation, NPV was 100%, while sensitivity, specificity and PPV were 100, 61.1 and 35.1%, respectively. None of these values improved by prolonging the observation time to 6 h. CONCLUSION In patients with a reported intentional overdose with drugs having potential acute effects on neurological, circulatory or ventilatory function, the COBRA decision rule showed good performances in predicting the need for intensive care interventions, with a NPV of 100% after 3 h of observation.
Collapse
Affiliation(s)
| | | | | | | | - Gert-Jan Mauritz
- Department of Emergency Medicine, Rijnstate Teaching Hospital, Arnhem
| | | | - Frank G A Jansman
- Department of Clinical Pharmacy, Deventer Hospital, Deventer
- Unit of PharmacoTherapy, Epidemiology & Economics, Groningen Research Institute of Pharmacy (GRIP), University of Groningen, Groningen, The Netherlands
| |
Collapse
|
10
|
Şen B, Öztürk İ. A Retrospective Evaluation of Suicidal and Accidental Drug Intoxication in Intensive Care Unit. CYPRUS JOURNAL OF MEDICAL SCIENCES 2022. [DOI: 10.4274/cjms.2020.1827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
11
|
Rezar R, Jung C, Mamandipoor B, Seelmaier C, Felder TK, Lichtenauer M, Wernly S, Zwaag SM, De Lange DW, Wernly B, Osmani V. Management of intoxicated patients – a descriptive outcome analysis of 4,267 ICU patients. BMC Emerg Med 2022; 22:38. [PMID: 35279068 PMCID: PMC8917674 DOI: 10.1186/s12873-022-00602-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 03/02/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Introduction
Intoxications are common in intensive care units (ICUs). The number of causative substances is large, mortality usually low. This retrospective cohort study aims to characterize differences of intoxicated compared to general ICU patients, point out variations according to causative agents, as well as to highlight differences between survivors and non-survivors among intoxicated individuals in a large-scale multi-center analysis.
Methods
A total of 105,998 general ICU patients and 4,267 individuals with the admission diagnoses “overdose” and “drug toxicity” from the years 2014 and 2015 where included from the eICU Collaborative Research Database. In addition to comparing these groups with respect to baseline characteristics, intensive care measures and outcome parameters, differences between survivors and non-survivors from the intoxication group, as well as the individual groups of causative substances were investigated.
Results
Intoxicated patients were younger (median 41 vs. 66 years; p<0.001), more often female (55 vs. 45%; p<0.001), and normal weighted (36% vs. 30%; p<0.001), whereas more obese individuals where observed in the other group (37 vs. 31%; p<0.001). Intoxicated individuals had a significantly lower mortality compared to general ICU patients (1% vs. 10%; aOR 0.07 95%CI 0.05-0.11; p<0.001), a finding which persisted after multivariable adjustment (aOR 0.17 95%CI 0.12-0.24; p<0.001) and persisted in all subgroups. Markers of disease severity (SOFA-score: 3 (1-5) vs. 4 (2-6) pts.; p<0.001) and frequency of vasopressor use (5 vs. 15%; p<0.001) where lower, whereas rates of mechanical ventilation where higher (24 vs. 26%; p<0.001) in intoxicated individuals. There were no differences with regard to renal replacement therapy in the first three days (3 vs. 4%; p=0.26). In sensitivity analysis (interactions for age, sex, ethnicity, hospital category, maximum initial lactate, mechanical ventilation, and vasopressor use), a trend towards lower mortality in intoxicated patients persisted in all subgroups.
Conclusion
This large-scale retrospective analysis indicates a significantly lower mortality of intoxicated individuals compared to general ICU patients.
Collapse
|
12
|
Vujaklija Brajković A, Grgat M, Bielen L, Brajković J, Zlopaša O, Vrdoljak NG, Radonić R. Self-poisoning as a cause of admission in a medical intensive care unit and a question of misuse of prescription medications. Heart Lung 2021; 51:17-21. [PMID: 34731692 DOI: 10.1016/j.hrtlng.2021.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 09/08/2021] [Accepted: 09/08/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Self-poisoning accounts for between 3 and 17% of intensive care unit (ICU) admissions. OBJECTIVES To display the misused substances, intention, and outcome of patients admitted to the ICU due to self-poisoning. METHODS A retrospective review of ICU admissions using an electronic patient database was performed. RESULTS A total of 149 patients were admitted, accounting for 4.6% of ICU admissions. Self-poisoning with self-harm was more frequent than without self-harm intent (62.4% vs. 37.6%). 64.4% of ingested substances were misused prescribed drugs. Females used antipsychotics (X2 = 15, p< 0.05) and benzodiazepines (X2 =11.52, p< 0.05), and males ingested antipsychotics (X2 = 12, p< 0.05) with a self-harm intent. Antipsychotics were always used with a self-harm intent. Illicit drugs (X2 =9.14, p< 0.05) and ethanol (X2 =7.34, p< 0.05) were mostly used without self-harm intent. 102 patients (68.5%) continued treatment in a psychiatric clinic, more often women (X2 (1,N = 145)=7.94, p< 0.005). The readmission rate was low. Mortality was 2.6%. CONCLUSION Self-poisoning is an infrequent cause of ICU admission. Prescribed psychotropic medications, including benzodiazepines, antipsychotics, and antidepressants were the most frequently misused substances. Psychiatric consultation before the ICU discharge and subsequent psychiatric treatment might lower the repetition and readmission rate.
Collapse
Affiliation(s)
- Ana Vujaklija Brajković
- School of Medicine, University of Zagreb, Šalata 3, Zagreb 10000, Croatia; Department of Internal Medicine, Division of Intensive Care Medicine, University Hospital Centre Zagreb, Kišpatićeva 12, Zagreb 10000, Croatia.
| | - Marta Grgat
- School of Medicine, University of Zagreb, Šalata 3, Zagreb 10000, Croatia
| | - Luka Bielen
- School of Medicine, University of Zagreb, Šalata 3, Zagreb 10000, Croatia; Department of Internal Medicine, Division of Intensive Care Medicine, University Hospital Centre Zagreb, Kišpatićeva 12, Zagreb 10000, Croatia
| | - Jurica Brajković
- Zagreb School of Economics and Management, Jordanovac 110, Zagreb 10000, Croatia
| | - Ozrenka Zlopaša
- Department of Internal Medicine, Division of Intensive Care Medicine, University Hospital Centre Zagreb, Kišpatićeva 12, Zagreb 10000, Croatia
| | - Nina Gubarev Vrdoljak
- Department of Internal Medicine, Division of Intensive Care Medicine, University Hospital Centre Zagreb, Kišpatićeva 12, Zagreb 10000, Croatia
| | - Radovan Radonić
- School of Medicine, University of Zagreb, Šalata 3, Zagreb 10000, Croatia; Department of Internal Medicine, Division of Intensive Care Medicine, University Hospital Centre Zagreb, Kišpatićeva 12, Zagreb 10000, Croatia
| |
Collapse
|
13
|
El Gharbi F, El Bèze N, Jaffal K, Sutterlin L, Mora P, Malissin I, Deye N, Voicu S, Mégarbane B. Does the ICU Requirement Score allow the poisoned patient to be safely managed without admission to the intensive care unit? - a validation cohort study. Clin Toxicol (Phila) 2021; 60:298-303. [PMID: 34378997 DOI: 10.1080/15563650.2021.1961145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The Intensive care unit (ICU) Requirement Score (IRS) has been defined as identifying poisoned patients on hospital admission who do not require ICU referral, in an effort to reduce health expenses. However, this score has been poorly validated. We aimed to evaluate the IRS in a large cohort of poisoned patients. METHODS We performed a single-center retrospective cohort study. IRS was calculated using clinical parameters obtained on admission including age, systolic blood pressure, heart rate, Glasgow coma score, intoxication type, co-morbidities (i.e., arrhythmia, cirrhosis, and respiratory insufficiency), and the combination of the intoxication with another reason for ICU admission. We evaluated the ability of IRS < 6 determined on admission to predict the lack of need for ICU treatment, defined as the need for mechanical ventilation, vasopressors, and/or renal replacement therapy in the first 24 h post-admission and/or death during the hospital stay. This score was compared to the usual prognostic scores, i.e., SAPS II and III, SOFA score, and PSS. RESULTS During the 10-year study period, 2,514 poisoned patients were admitted, 1,011 excluded as requiring ICU treatment on admission, and 1,503 included. Among these patients, 232 met the endpoint whereas only 23/510 patients with IRS < 6 (4.5%) presented the endpoint and one patient died. The area under the curve of the IRS ROC curve was 0.736 (95% confidence interval (CI), 0.702-0.770). The negative predictive value of IRS < 6 was 95% (95% CI, 93-97), sensitivity 89% (95% CI, 85-93), specificity 38% (95% CI, 36-41), and positive predictive value 21% (95% CI, 18-24). IRS performance was similar to those of the other tested scores, which are however not readily available on admission. CONCLUSION Our data demonstrate the excellent negative predictive value of the IRS, allowing the exclusion of ICU requirements for poisoned patients with IRS < 6. IRS usefulness should be confirmed based on a prospective multicenter cohort study before extensive routine use.
Collapse
Affiliation(s)
- Foued El Gharbi
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris, France
| | - Nathan El Bèze
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris, France
| | - Karim Jaffal
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris, France
| | - Laetitia Sutterlin
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris, France
| | - Pierre Mora
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris, France
| | - Isabelle Malissin
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris, France.,University of Paris, Inserm UMRS-1144, Paris, France
| | - Nicolas Deye
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris, France
| | - Sebastian Voicu
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris, France.,University of Paris, Inserm UMRS-1144, Paris, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris, France.,University of Paris, Inserm UMRS-1144, Paris, France
| |
Collapse
|
14
|
[Acute intoxications in the intensive care unit: A 10-year analysis]. Med Klin Intensivmed Notfmed 2021; 117:129-136. [PMID: 34302193 DOI: 10.1007/s00063-021-00839-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 04/15/2021] [Accepted: 06/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Acute intoxications play a special role in preclinical emergency medicine, in the emergency department, and in intensive care. This study characterizes cases of acute intoxications from an intensive care perspective. OBJECTIVES All cases of acute intoxications admitted to the intensive care units at the University Hospital Hamburg-Eppendorf between 01 January 2007 and 30 June 2017 were retrospectively analyzed. RESULTS During the study period, 587 patients with acute intoxications were admitted to the university hospital's intensive care units. Median age was 45 years (interquartile range [IQR] 31 years); 83.1% of patients were younger than 70 years. The most common cause of intoxication in the younger patients was a suicide attempt (55.1%), while in older patients it was an iatrogenic event (47.5%). Cases involving intoxications with psychotropic medication (48.7%), alcohol (32.9%), analgesics (23.3%), and drugs (17.0%) were most frequent. In 50.6% of cases, intoxication was due to more than one substance. Intoxication-specific therapy was performed in 40.0% of cases and intensive care therapy in 42.4% of cases. The median length of intensive care unit stay was 2 days (IQR 3). Hospital mortality was 5.5%. In older patients (≥ 70 years) compared with younger patients, the need for intensive care treatment (56.6% vs. 39.5% of cases, p = 0.002), the length of intensive care unit stay (3 days [IQR 5] vs. 2 days [IQR 3], p = 0.0004) and in-hospital mortality (17.2% vs. 3.1%, p < 0.001) were significantly higher. CONCLUSIONS Acute intoxications are part of the spectrum of disorders treated in the intensive care unit. In older patients, iatrogenic causes are frequently found, which is associated with an increased risk of death.
Collapse
|
15
|
Hulme J, Sheikh H, Xie E, Gatov E, Nagamuthu C, Kurdyak P. Mortality among patients with frequent emergency department use for alcohol-related reasons in Ontario: a population-based cohort study. CMAJ 2021; 192:E1522-E1531. [PMID: 33229348 DOI: 10.1503/cmaj.191730] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Little is known about the risk of death among people who visit emergency departments frequently for alcohol-related reasons, including whether mortality risk increases with increasing frequency of visits. Our primary objective was to describe the sociodemographic and clinical characteristics of this high-risk population and examine their 1-year overall mortality, premature mortality and cause of death as a function of emergency department visit frequency in Ontario, Canada. METHODS We conducted a population-based retrospective cohort study using linked health administrative data (Jan. 1, 2010, to Dec. 31, 2016) in Ontario for people aged 16-105 years who made at least 2 emergency department visits for mental or behavioural disorders due to alcohol within 1 year. We subdivided the cohort based on visit frequency (2, 3 or 4, or ≥ 5). The primary outcome was 1-year mortality, adjusted for age, sex, income, rural residence and presence of comorbidities. We examined premature mortality using years of potential life lost (YPLL). RESULTS Of the 25 813 people included in the cohort, 17 020 (65.9%) had 2 emergency department visits within 1 year, 5704 (22.1%) had 3 or 4 visits, and 3089 (12.0%) had 5 or more visits. Males, people aged 45-64 years, and those living in urban centres and lower-income neighbourhoods were more likely to have 3 or 4 visits, or 5 or more visits. The all-cause 1-year mortality rate was 5.4% overall, ranging from 4.7% among patients with 2 visits to 8.8% among those with 5 or more visits. Death due to external causes (e.g., suicide, accidents) was most common. The adjusted mortality rate was 38% higher for patients with 5 or more visits than for those with 2 visits (adjusted hazard ratio 1.38, 95% confidence interval 1.19-1.59). Among 25 298 people aged 16-74 years, this represented 30 607 YPLL. INTERPRETATION We observed a high mortality rate among relatively young, mostly urban, lower-income people with frequent emergency department visits for alcohol-related reasons. These visits are opportunities for intervention in a high-risk population to reduce a substantial mortality burden.
Collapse
Affiliation(s)
- Jennifer Hulme
- University Health Network (Hulme, Sheikh, Xie); Department of Family and Community Medicine (Hulme, Sheikh, Xie), University of Toronto; ICES (Gatov, Nagamuthu, Kurdyak); Institute for Mental Health Policy Research (Kurdyak), Centre for Addiction and Mental Health, Toronto, Ont
| | - Hasan Sheikh
- University Health Network (Hulme, Sheikh, Xie); Department of Family and Community Medicine (Hulme, Sheikh, Xie), University of Toronto; ICES (Gatov, Nagamuthu, Kurdyak); Institute for Mental Health Policy Research (Kurdyak), Centre for Addiction and Mental Health, Toronto, Ont
| | - Edward Xie
- University Health Network (Hulme, Sheikh, Xie); Department of Family and Community Medicine (Hulme, Sheikh, Xie), University of Toronto; ICES (Gatov, Nagamuthu, Kurdyak); Institute for Mental Health Policy Research (Kurdyak), Centre for Addiction and Mental Health, Toronto, Ont
| | - Evgenia Gatov
- University Health Network (Hulme, Sheikh, Xie); Department of Family and Community Medicine (Hulme, Sheikh, Xie), University of Toronto; ICES (Gatov, Nagamuthu, Kurdyak); Institute for Mental Health Policy Research (Kurdyak), Centre for Addiction and Mental Health, Toronto, Ont
| | - Chenthila Nagamuthu
- University Health Network (Hulme, Sheikh, Xie); Department of Family and Community Medicine (Hulme, Sheikh, Xie), University of Toronto; ICES (Gatov, Nagamuthu, Kurdyak); Institute for Mental Health Policy Research (Kurdyak), Centre for Addiction and Mental Health, Toronto, Ont
| | - Paul Kurdyak
- University Health Network (Hulme, Sheikh, Xie); Department of Family and Community Medicine (Hulme, Sheikh, Xie), University of Toronto; ICES (Gatov, Nagamuthu, Kurdyak); Institute for Mental Health Policy Research (Kurdyak), Centre for Addiction and Mental Health, Toronto, Ont.
| |
Collapse
|
16
|
Martín-Rodríguez F, López-Izquierdo R, Castro-Villamor MA, Martín-Conty JL, Herrero-Antón RM, Del Pozo-Vegas C, Guillén-Gil D, Dueñas-Laita A. A predictive model for serious adverse events in adults with acute poisoning in prehospital and hospital care. Aust Crit Care 2021; 34:209-216. [PMID: 33067102 DOI: 10.1016/j.aucc.2020.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/01/2020] [Accepted: 07/11/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE The objective of this study was to design a risk model with variables determined before hospital arrival to predict the risk of serious adverse events in patients with acute poisoning. METHODS A preliminary prospective, multicentre cohort study of adults with prehospital diagnosis of acute intoxication was conducted. The study was carried out in the Public Health System of the Community of Castilla-Leon (Spain), including seven advanced life support units and five hospitals, between April 1, 2018, and June 30, 2019. People aged >18 years with a main prehospital diagnosis of acute poisoning admitted to a referral hospital on advanced life support were included. The main outcome measure was prehospital and hospital serious adverse events in patients with acute poisoning. RESULTS We included 221 patients, with a median age of 47 years (interquartile range: 33-61). The most frequent cause of poisoning was psychopharmaceuticals (111 cases, 49.8%): 38 (17.2%) patients had a serious adverse event, with a hospital mortality of 4.1% (nine cases) in the 30 days after the index event. The final model included age ≥65 years (odds ratio [OR]: 9.59, 95% confidence interval [CI]: 3.48-26.45; p < 0.001), oxygen saturation/fraction of inspired oxygen index ≤300 (OR: 15.03, 95% CI: 5.74-39.33; p < 0.001), and point-of-care lactate ≥4 mmol/L (OR: 7.68, 95% CI: 2.88-20.45; p < 0.001). The poisoning Early Warning Score was constructed from these three variables, and 1 point was assigned to each variable. The area under the curve of the score was 0.896 (95% CI: 0.82-0.96; p < 0.001). CONCLUSIONS The poisoning Early Warning Score may help in decision-making and promote early identification of high-risk patients with acute poisoning in the prehospital context.
Collapse
Affiliation(s)
- Francisco Martín-Rodríguez
- Advanced Life Support, Emergency Medical Services, Valladolid, Spain; School of Medicine, Universidad de Valladolid, Avda. Ramón y Cajal, 7, 47005, Valladolid, Spain.
| | - Raúl López-Izquierdo
- Emergency Department, Hospital Universitario Río Hortega, Calle Dulzaina, 2, 47012, Valladolid, Spain.
| | - Miguel A Castro-Villamor
- School of Medicine, Universidad de Valladolid, Avda. Ramón y Cajal, 7, 47005, Valladolid, Spain.
| | - José L Martín-Conty
- Faculty of Health Sciences, Universidad de Castilla La Mancha, Avda. Real Fábrica de Seda, S/n, 45600, Talavera de La Reina, Spain.
| | - Rosa M Herrero-Antón
- Emergency Department, Complejo Asistencial Universitario de Salamanca, Paseo de San Vicente, 182, 37007, Salamanca, Spain.
| | - Carlos Del Pozo-Vegas
- Emergency Department, Hospital Clínico Universitario, Avda. Ramón y Cajal, 3, 47003, Valladolid, Spain.
| | - David Guillén-Gil
- Advanced Life Support of Burgos, Emergency Medical Services, Paseo Hospital Militar, 24, 47007, Valladolid, Spain.
| | - Antonio Dueñas-Laita
- Toxicology Department, Hospital Universitario Rio Hortega, Valladolid. School of Medicine, Universidad de Valladolid, Avda. Ramón y Cajal, 7, 47005, Valladolid, Spain.
| |
Collapse
|
17
|
Maiden MJ, Trisno R, Finnis ME, Norrish CM, Mulvey A, Nasr-Esfahani S, Orford NR, Moylan S. Long-term outcomes of patients admitted to an intensive care unit with intentional self-harm. Anaesth Intensive Care 2021; 49:173-182. [PMID: 33853393 DOI: 10.1177/0310057x20978987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Self-harm is one of the most common reasons for admission to an intensive care unit (ICU). While most patients with self-harm survive the ICU admission, little is known about their outcomes after hospital discharge. We conducted a retrospective cohort study of patients in the Barwon region in Victoria admitted to the ICU with self-harm (between 1998 and 2018) who survived to hospital discharge. The primary objective was to determine mortality after hospital discharge, and secondarily estimate relative survival, years of potential life lost, cause of death and factors associated with death. Over the 20-year study period, there were 710 patients in the cohort. The median patient age was 37 years (interquartile range (IQR) 26-48 years). A total of 406 (57%) were female, and 527 (74%) had a prior psychiatric diagnosis. The incidence of ICU admission increased over time (incidence rate ratio 1.05; 95% confidence interval (CI) 1.03-1.06 per annum). There were 105 (15%) patients who died after hospital discharge. Relative survival decreased each year after discharge, with the greatest decrement during the first 12 months. At ten years, relative survival was 0.85 (95% CI 0.81-0.88). The median years of potential life lost was 35 (IQR 22-45). Cause of death was self-harm in 27%, possible self-harm in 32% and medical disease in 41%. The only factors associated with mortality were male sex, older age and re-admission to ICU with self-harm. Further population studies are required to confirm these findings, and to understand what interventions may improve long-term survival in this relatively young group of critically ill patients.
Collapse
Affiliation(s)
- Matthew J Maiden
- Intensive Care Unit, Barwon Health, Geelong, Australia.,Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Roth Trisno
- Mental Health, Drugs and Alcohol Service, Barwon Health, Geelong, Australia.,School of Medicine, Deakin University, Waurn Ponds, Australia
| | - Mark E Finnis
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Anne Mulvey
- Intensive Care Unit, Barwon Health, Geelong, Australia
| | | | - Neil R Orford
- Intensive Care Unit, Barwon Health, Geelong, Australia.,School of Medicine, Deakin University, Waurn Ponds, Australia.,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Steven Moylan
- Mental Health, Drugs and Alcohol Service, Barwon Health, Geelong, Australia.,School of Medicine, Deakin University, Waurn Ponds, Australia
| |
Collapse
|
18
|
Tollisen KH, Hadley CL, Bjerva M, Dahl GT, Högvall LM, Sandvik L, Andersen GØ, Heyerdahl F, Jacobsen D. Clinical impact of chronic substance abuse in a Norwegian ICU-population. Acta Anaesthesiol Scand 2021; 65:515-524. [PMID: 33340102 DOI: 10.1111/aas.13766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/18/2020] [Accepted: 12/05/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The clinical impact of chronic substance abuse of alcohol and drugs-referred to as substance use disorders (SUD)-is often overlooked in the intensive care (ICU) setting. The aims of the present study were to identify patients with SUD-regardless of cause of admission-in a mixed Norwegian ICU-population, and to compare patients with and without SUD with regard to clinical characteristics and mortality. METHODS Cross-sectional prospective study of a mixed medical and surgical ICU-population aged ≥18 years in Oslo, Norway. Data were collected consecutively, using a questionnaire including the AUDIT-C test, medical records and toxicology results. Patients classified with SUD were divided into the subgroups alcohol use disorders (AUD) and drug use disorders (DUD). RESULTS Overall, 222 (26%) of the 861 patients included were classified with SUD; 137 (16%) with AUD and 85 (10%) with DUD. 130/222 (59%) of the SUD-patients had substance abuse-related cause of ICU-admission. Compared to non-SUD patients, DUD-patients were younger (median age 42 vs 65 years) and had lower SAPS II scores (41 vs 46), while AUD-patients had higher SOFA scores (8.0 vs 7.3). Overall, age-adjusted logistic regression analysis showed similar hospital mortality for SUD-patients and non-SUD patients, but AUD was associated with increased mortality among medical patients and in patients with sepsis (OR 1.7 (95% CI 1.0-2.8), and OR 2.6 (95% CI 1.1-6.2)). CONCLUSION One in four ICU-patients had SUD regardless of cause of admission. Alcohol use disorder was associated with increased mortality in medical patients and in patients with sepsis.
Collapse
Affiliation(s)
- K H Tollisen
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | - C L Hadley
- Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | - M Bjerva
- Department of Anesthesiology, Oslo University Hospital, Oslo, Norway
| | - G T Dahl
- Department of Anesthesiology, Diakonhjemmet Hospital, Oslo, Norway
| | - L M Högvall
- Department of Postoperative and Intensive care, Oslo University Hospital, Oslo, Norway
| | - L Sandvik
- Department of Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - G Ø Andersen
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - F Heyerdahl
- Division of Prehospital Services, Oslo University Hospital, Norwegian Air Ambulance Foundation, Oslo, Norway
| | - D Jacobsen
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
19
|
Chen CK, Chan YL, Su TH. Incidence of intoxication events and patient outcomes in Taiwan: A nationwide population-based observational study. PLoS One 2020; 15:e0244438. [PMID: 33362242 PMCID: PMC7757892 DOI: 10.1371/journal.pone.0244438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 12/09/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Intoxicated patients were frequently managed in the emergency departments (ED) with few studies at national level. The study aimed to reveal the incidence, outcomes of intoxications and trend in Taiwan. METHODS Adults admitted to an ED due to an intoxication event between 2006 and 2013 were identified using the Taiwan National Health Insurance Research Database. The rate of intoxication and severe intoxication events, mortality rate, hospital length of stay (LOS), and daily medical costs of these patients were analyzed. Changes over time were analyzed using Joinpoint models. Multivariable generalized regressions with GEE were used to assess the effect of sex, age, and presence of prior psychiatric illness. RESULTS A total of 20,371 ED admissions due to intoxication events were identified during the study period, and the incidence decreased with annual percentage change of 4.7% from 2006 to 2013. The mortality rate, hospital LOS, and daily medical costs were not decreased over time. Males and geriatric patients had more severe intoxication events, greater mortality rates, and greater daily medical costs. Patients with psychiatric illnesses had higher mortality rates and a longer hospital LOS, but lower daily medical expenses. CONCLUSION From 2006 to 2013, there was a decline in the incidence of ED admission for intoxication events in Taiwan. Males, geriatric patients, and those with psychiatric illnesses had greater risks for severe intoxication and mortality.
Collapse
Affiliation(s)
- Chun-Kuei Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Ling Chan
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tse-Hsuan Su
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- * E-mail:
| |
Collapse
|
20
|
Resiere D, Kallel H, Oxybel O, Chabartier C, Florentin J, Brouste Y, Gueye P, Megarbane B, Mehdaoui H. Clinical and Epidemiological Characteristics of Severe Acute Adult Poisoning Cases in Martinique: Implicated Toxic Exposures and Their Outcomes. TOXICS 2020; 8:toxics8020028. [PMID: 32283693 PMCID: PMC7356022 DOI: 10.3390/toxics8020028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 12/27/2022]
Abstract
The epidemiology of severe acute poisonings in the French overseas departments of the Americas remains poorly reported. The main objective of this study was to determine the epidemiology and characteristics of severe acutely poisoned adult patients. METHODS A retrospective descriptive study was conducted from 1 January 2000 to 31 December 2010 in severely poisoned patients presenting to the emergency department (ED) of the University Hospital of Martinique, and the general public hospitals of Lamentin and Trinité. RESULTS During the study period, 291 patients were admitted for severe poisoning, giving an incidence rate of 7.7 severe cases/100,000 inhabitants. The mean age was 46 ± 19 years and 166 (57%) were male. Psychiatric disorders were recorded in 143 (49.8%) patients. Simplified Acute Psychological Score (SAPS II) at admission was 39 ± 23 points and Poisoning Severity Score (PSS) was 2.7 ± 0.8 points. Death was recorded in 30 (10.3%) patients and hospital length of stay was 6 ± 7 days. The mode of intoxication was intentional self-poisoning in 87% of cases and drug overdose was recorded in 13% of cases. The toxic agent involved was a therapeutic drug in 58% and a chemical product in 52% of cases. The predominant clinical manifestations were respiratory failure (59%), hemodynamic failure (27%), neurologic failure (45%), gastrointestinal manifestations (27%), and renal failure (11%). Polypnea, shock, ventricular fibrillation or tachycardia, and gastro-intestinal disorders were the main symptoms associated with death. The main biological abnormalities associated with death in our patients were metabolic acidosis, hypokalemia, hyperlactatemia, hypocalcemia, renal injury, rhabdomyolysis, increased aspartate aminotransferases, and thrombocytopenia. Extracorporal membrane oxygenation (ECMO) was used in three patients and specific antidotes were used in 21% of patients. CONCLUSIONS Acute poisonings remain a major public health problem in Martinique with different epidemiological characteristics to those in mainland France, with a high incidence of poisoning by rural and household toxins.
Collapse
Affiliation(s)
- Dabor Resiere
- Intensive Care Unit, University Hospital of Martinique, Fort-de-France, 97261 Martinique, France; (O.O.); (C.C.); (H.M.)
- Correspondence: ; Tel.: +1-(596)-6-9620-3184
| | - Hatem Kallel
- Intensive Care Unit, Cayenne General Hospital; 97300 Cayenne, French Guiana,
| | - Odile Oxybel
- Intensive Care Unit, University Hospital of Martinique, Fort-de-France, 97261 Martinique, France; (O.O.); (C.C.); (H.M.)
| | - Cyrille Chabartier
- Intensive Care Unit, University Hospital of Martinique, Fort-de-France, 97261 Martinique, France; (O.O.); (C.C.); (H.M.)
| | - Jonathan Florentin
- Department of Emergency Medicine, University Hospital of Martinique, Fort-de-France, 97261 Martinique, France; (J.F.); (Y.B.)
| | - Yannick Brouste
- Department of Emergency Medicine, University Hospital of Martinique, Fort-de-France, 97261 Martinique, France; (J.F.); (Y.B.)
| | - Papa Gueye
- Emergency Medical Services (Service d’aide médicale d’urgence 972), 97261 Martinique, France;
| | - Bruno Megarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris-Diderot University, INSERM UMR-S 1144, 75013 Paris, France;
| | - Hossein Mehdaoui
- Intensive Care Unit, University Hospital of Martinique, Fort-de-France, 97261 Martinique, France; (O.O.); (C.C.); (H.M.)
| |
Collapse
|
21
|
Al Alaywa K, Jouffroy R, Le Beller C, Rapalen JH, Lamhaut L, Le Louet AL, Baud F. Toxicological Analysis Unveiling the Low Rate of Self-Reporting of Addictive/Recreative Substances in Acute Severe Drug Overdose Cases. Turk J Anaesthesiol Reanim 2020; 48:148-155. [PMID: 32259147 PMCID: PMC7101186 DOI: 10.5152/tjar.2019.28003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 07/17/2019] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE Toxicological analysis (TA) is advised when assessing the prognosis and the treatment of drug overdose patients. Apart from this use, the value of TA has remained unclear. This study aimed at defining the value of TA regarding the toxicological diagnosis in severe overdose cases that involved addictive or recreational drugs (ARDs) that were used either alone or in combination with medicinal drugs. METHODS The patients who were enrolled in the study had been admitted to our intensive care unit for the treatment of poisoning. TA was performed using advanced technologies such as mass spectrometry of blood/urine on admission. An occurrence indicated the supposed ingestion of a defined substance. Patients were included in a group depending on the combination of the occurrences of supposed ingested drugs (SID) and the results of the 1) TA: SID+, TA+; 2) SID+, not searched by TA; 3) SID-, TA+. RESULTS There were 224 occurrences of 90 substances in 70 patients. ARDs were present in 30 patients (43%). ARD accounted for 24 occurrences in the SID+, TA+ group, 10 occurrences in the SID+, not searched group and 196 occurrences in the SID-, TA+ group. In the SID+, TA+ group, 9 occurrences (69%) of ethanol were confirmed by TA. Ingestion of ethanol was invalidated in 4 occurrences (31%). In the patients who denied ethanol ingestion, TA confirmed the non-ingestion of ethanol using 30 blood measures (81%). Ethanol was involved in 57% of the patients, being the lone substance in only 1 case. CONCLUSION In drug overdose instances that result in organ failure(s) and involve ARDs, self-reporting is of limited value in assessing the patients' exposure to ARD. Multiple consumptions expose patients to unexpected drug interactions.
Collapse
Affiliation(s)
- Khadija Al Alaywa
- UMR - 8257, Cognitive Action Group; University Paris Descartes, Paris, France
| | - Romain Jouffroy
- Department of Anaesthesiology, Intensive Care Unit, SAMU de Paris, Necker Hospital Paris, APHP, Paris, France
| | - Christine Le Beller
- Regional Center of Pharmacovigilance of Paris-HEGP, European Hospital of Georges Pompidou, Paris, France
| | - Jean-herlé Rapalen
- Department of Anaesthesiology, Intensive Care Unit, SAMU de Paris, Necker Hospital Paris, APHP, Paris, France
| | | | - Agnes Lillo Le Louet
- Regional Center of Pharmacovigilance of Paris-HEGP, European Hospital of Georges Pompidou, Paris, France
| | | |
Collapse
|
22
|
Reisinger A, Rabensteiner J, Hackl G. Diagnosis of acute intoxications in critically ill patients: focus on biomarkers - part 1: epidemiology, methodology and general overview. Biomarkers 2019; 25:9-19. [PMID: 31735069 DOI: 10.1080/1354750x.2019.1694994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Acute intoxications account for a significant proportion of the patient population in intensive care units and sedative medications, ethanol, illicit drugs, inhalable poisons and mixed intoxications are the most common causes. The aim of this article is to describe biomarkers for screening and diagnosis of acute intoxications in critically ill patients. For this purpose, a survey of the relevant literature was conducted, and guidelines, case reports, expert assessments, and scientific publications were reviewed. In critical care, it should always be attempted to identify and quantify the poison or toxin with the assistance of enzyme immunoassay (EIA), chromatography, and mass spectrometry techniques and this section is critically appraised in this publication. The principles for anion gap, osmol gap and lactate gap and their usage in intoxications is shown. Basic rules in test methodology and pre-analytics are reviewed. Biomarkers in general are presented in part one and biomarkers for specific intoxications including ethanol, paracetamol, cardiovascular drugs and many others are presented in part two of these publications.
Collapse
Affiliation(s)
- Alexander Reisinger
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jasmin Rabensteiner
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Gerald Hackl
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| |
Collapse
|
23
|
Knapik P, Trejnowska E, Knapik M, Kręt M, Cieśla D, Krzych ŁJ, Kucewicz-Czech E. Young Adults Among Patients Admitted to Polish Intensive Care Units in the Silesian ICU Registry. Med Sci Monit 2019; 25:5727-5737. [PMID: 31371694 PMCID: PMC6689200 DOI: 10.12659/msm.913852] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Patients under 30 years of age constitute a unique population in the Intensive Care Unit (ICU). The aim of this study was to obtain information on young adults admitted to Polish ICUs and to identify independent predictors of favorable outcome in this population. Material/Methods Data from 20 651 adult patients from the Silesian Registry of Intensive Care Units conducted in the Silesian Region of Poland since October 2010 were analyzed. Patients aged 18–29 years were identified and their data were compared to the remaining population. Preadmission and admission variables that independently influence the favorable outcome (defined as survival of ICU stay and discharge in a condition other than vegetative state or minimally conscious state) were identified. Results Among 20 609 analyzed adult patients, 850 (4.1%) were under the age of 30 years. Young adults had a lower mean APACHE II and SAPS III score at admission and were more frequently admitted to the ICU due to trauma, poisonings, acute neurological disorders, and obstetric complications. ICU mortality was over 2 times lower (20.1% vs. 45.3%, p<0.001). Independent variables affecting favorable outcome in this population were: admission to ICU from the operating theatre and multiple trauma as a primary cause of admission. Conclusions The greater chance of favorable outcome in adults under the age of 30 years admitted to the ICU is due to their unique characteristics. Favorable outcome in young adults is most likely among patients admitted to the ICU following multiple trauma or admitted from the operating theatre.
Collapse
Affiliation(s)
- Piotr Knapik
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Ewa Trejnowska
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Małgorzata Knapik
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Michał Kręt
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Daniel Cieśla
- Department of Science, Education and New Medical Technologies, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Łukasz J Krzych
- Department of Anaesthesiology and Intensive Care, School of Medicine, Medical University of Silesia, Katowice, Poland
| | - Ewa Kucewicz-Czech
- Department of Anaesthesiology and Intensive Care, School of Medicine, Medical University of Silesia, Katowice, Poland
| |
Collapse
|
24
|
[Acute intoxications: markers for screening, diagnosis and therapy monitoring]. Med Klin Intensivmed Notfmed 2019; 114:302-312. [PMID: 30944942 DOI: 10.1007/s00063-019-0566-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 01/21/2019] [Accepted: 03/04/2019] [Indexed: 10/27/2022]
Abstract
Acute poisonings account for a significant proportion of the patient population presenting to intensive care units, whereby mixed drug overdoses and prescription drug overdoses predominate. The aim of this article was to describe indications for screening, diagnosis and therapy monitoring in acute overdoses in the intensive care unit. To conduct this work, a literature search was carried out and a review was written based on guidelines, case reports, expert opinions and scientific publications. Toxidromes are a useful tool for classification of clinical characteristics when the causative agent is initially unknown. Especially in critical care medicine, identifying and quantifying of the causative toxin by enzyme immunoassays, chromatography and mass spectrometry should be attempted. Intensive care treatment of patients with acute overdoses includes not only monitoring and support of vital functions but also methods for primary and secondary elimination of toxins. The indication for the use of extracorporeal procedures should be carefully evaluated and the method should be chosen based on protein binding and molecular size. Lipid emulsion therapy, high-dose insulin euglycaemia therapy and hyperbaric oxygenation are also increasingly used.
Collapse
|
25
|
Lindqvist E, Edman G, Hollenberg J, Nordberg P, Forsberg S. Long-term mortality and cause of death for patients treated in Intensive Care Units due to poisoning. Acta Anaesthesiol Scand 2019; 63:500-505. [PMID: 30397914 DOI: 10.1111/aas.13289] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 09/10/2018] [Accepted: 10/09/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Poisoned patients treated in the Intensive Care Unit are common, representing up to 6% of all ICU admissions. The in-hospital mortality is generally low but little is known about the long-term mortality in these patients. The aim of this study was to describe long-term mortality and cause of death in patients treated in the ICU for poisoning. METHOD A national observational study based on three registers: the National Patient Register, the Swedish Intensive Care Register and the Cause of Death Register. All patients ≥19 years admitted to a Swedish Intensive Care Unit between January 1, 2010 and December 31, 2011 with an ICD-10 code for poisoning were included. RESULTS A total of 6730 patients were included. The one-year mortality was 4.5% (n = 303), with an overweight of men among the deceased (59.1%, P = 0.002). Patients aged 19-39 years had a 48 times increased one-year mortality compared to the age-matched general population and 94% of these patients died from suicide and/or accident, of which 70% were from a new poisoning. The two-year mortality was 7.2%. Women have a slightly higher overall long-term survival over two years (P< 0.001). CONCLUSION The risk of premature death is markedly increased in younger patients one and two years after an ICU hospitalisation for non-fatal poisoning compared to the general population. A large majority die due to a new poisoning incident despite a previously known recent severe poisoning. EDITORIAL COMMENT Admission to ICU with poisoning, and particularly self-poisoning, may be associated with long-term mortaliity. In this study of 6730 patients admitted to a Swedish ICU for poisoning, the in-hospital mortality was low for that admission, but there is an increased risk of later mortality in young patients one and two years after hospital discharge.
Collapse
Affiliation(s)
- Elin Lindqvist
- Department of Anaesthesiology and Intensive Care; Norrtälje Hospital; Norrtälje Sweden
- Department of Medicine, Centre for Resuscitation Science; Karolinska Institutet; Stockholm Sweden
| | - Gunnar Edman
- Department of Clinical Sciences; Danderyd Hospital, Karolinska Institutet; Stockholm Sweden
- Department of Psychiatry; Norrtälje Hospital; Norrtälje Sweden
| | - Jacob Hollenberg
- Department of Medicine, Centre for Resuscitation Science; Karolinska Institutet; Stockholm Sweden
| | - Per Nordberg
- Department of Medicine, Centre for Resuscitation Science; Karolinska Institutet; Stockholm Sweden
| | - Sune Forsberg
- Department of Anaesthesiology and Intensive Care; Norrtälje Hospital; Norrtälje Sweden
- Department of Medicine, Centre for Resuscitation Science; Karolinska Institutet; Stockholm Sweden
- Swedish Poisons Information Centre; Stockholm Sweden
| |
Collapse
|
26
|
van Beusekom I, Bakhshi-Raiez F, de Keizer NF, de Lange DW. The healthcare costs of intoxicated patients who survive ICU admission are higher than non-intoxicated ICU patients: a retrospective study combining healthcare insurance data and data from a Dutch national quality registry. BMC Emerg Med 2019; 19:6. [PMID: 30634921 PMCID: PMC6329083 DOI: 10.1186/s12873-019-0224-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 01/07/2019] [Indexed: 11/16/2022] Open
Abstract
Background The aim of this study was to describe the healthcare costs of intoxicated ICU patients in the year before and the year after ICU admission, and to compare their healthcare costs with non-intoxicated ICU patients and a population based control group. Methods We conducted a retrospective cohort study, combining a national health insurance claims database and a national quality registry database for ICUs. Claims data in the timeframe 2012 until 2014 were combined with the clinical data of patients who had been admitted to an ICU during 2013. Three study populations were compared and matched according to socioeconomic status, type of admission, age and gender: an “ICU population”, an “intoxication population” and a “control population” (who had never been on the ICU). Results 2591 individual “intoxicated ICU patients” were compared to 2577 general “ICU patients” and 2591 patients from the “control population”. The median and interquartile ranges (IQR) healthcare costs per day alive for the “intoxicated ICU patients” were higher during the year before ICU admission (€20.3 (IQR €3.6–€76.4)) and the year after ICU admission (€23.9 (IQR €5.1–€82.4)) compared to the ICU population (€6.1 (IQR €0.9–€29.3) and €13.6 (IQR €3.3–€54.9) respectively) and a general control population (€1.1 (IQR €0.3–€4.6) and €1.1 (IQR €0.4–€4.9) respectively). The healthcare associated costs in intoxicated ICU patients were correlated with the number of chronic conditions present prior ICU admission (p < 0.0001). Conclusions Intoxicated patients admitted to the ICU had in the year before and after ICU admission much higher median healthcare costs per day alive compared to other ICU patients and a general population control group. Healthcare costs are greatly influenced by the number of psychiatric and other chronic conditions of these intoxicated patients. Electronic supplementary material The online version of this article (10.1186/s12873-019-0224-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Ilse van Beusekom
- Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, the Netherlands
| | - Ferishta Bakhshi-Raiez
- Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, the Netherlands
| | - Nicolette F de Keizer
- Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, the Netherlands
| | - Dylan W de Lange
- Dutch Poisons Information Center (DPIC), University Medical Center, University Utrecht, Utrecht, the Netherlands. .,Department of Intensive Care, University Medical Center, University Utrecht, Utrecht, the Netherlands.
| |
Collapse
|
27
|
Naidech AM, Beaumont J, Muldoon K, Liotta EM, Maas MB, Potts MB, Jahromi BS, Cella D, Prabhakaran S, Holl JL. Prophylactic Seizure Medication and Health-Related Quality of Life After Intracerebral Hemorrhage. Crit Care Med 2018; 46:1480-1485. [PMID: 29923930 PMCID: PMC6095719 DOI: 10.1097/ccm.0000000000003272] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Prophylactic levetiracetam is currently used in ~40% of patients with intracerebral hemorrhage, and the potential impact of levetircetam on health-related quality of life is unknown. We tested the hypothesis that prophylactic levetiracetam is independently associated with differences in cognitive function health-related quality of life. DESIGN Patients with intracerebral hemorrhage were enrolled in a prospective cohort study. We performed mixed models for T-scores of health-related quality of life, referenced to the U.S. population at 50 ± 10, accounting for severity of injury and time to follow-up. SETTING Academic medical center. PATIENTS One-hundred forty-two survivors of intracerebral hemorrhage. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS T-scores of Neuro-Quality of Life Cognitive Function v2.0 was the primary outcome, whereas Neuro-Quality of Life Mobility v1.0 and modified Rankin Scale (a global functional scale) were secondary measures. We prospectively documented if prophylactic levetiracetam was administered and retrieved administration data from the electronic health record. Patients who received prophylactic levetiracetam had worse cognitive function health-related quality of life (T-score 5.1 points lower; p = 0.01) after adjustment for age (p = 0.3), National Institutes of Health Stroke Scale (p < 0.000001), lobar hematoma (p = 0.9), and time of assessment; statistical models controlling for prophylactic levetiracetam and the Intracerebral Hemorrhage Score, a global measure of intracerebral hemorrhage severity, yielded similar results. Lower T-scores of cognitive function health-related quality of life at 3 months were correlated with more total levetiracetam dosage (p = 0.01) and more administered doses of levetiracetam in the hospital (p = 0.03). Patients who received prophylactic levetiracetam were more likely to have a lobar hematoma (27/38 vs 19/104; p < 0.001), undergo electroencephalography monitoring (15/38 vs 21/104; p = 0.02), but not more likely to have clinical seizures (4/38 vs 7/104; p = 0.5). Levetiracetam was not independently associated with the modified Rankin Scale scores or mobility health-related quality of life (p > 0.1). CONCLUSIONS Prophylactic levetiracetam was independently associated with lower cognitive function health-related quality of life at follow-up after intracerebral hemorrhage.
Collapse
Affiliation(s)
- Andrew M Naidech
- Department of Neurology, Northwestern University, Chicago, IL
- Center for Healthcare Studies, Institute for Public Health and Medicine (IPHAM), Northwestern University, Chicago, IL
- Department of Medical Social Sciences and Center for Patient Centered Outcomes, Institute for Public Health and Medicine (IPHAM), Chicago, IL
| | - Jennifer Beaumont
- Department of Medical Social Sciences and Center for Patient Centered Outcomes, Institute for Public Health and Medicine (IPHAM), Chicago, IL
| | - Kathryn Muldoon
- Center for Healthcare Studies, Institute for Public Health and Medicine (IPHAM), Northwestern University, Chicago, IL
- Department of Neurological Surgery, Northwestern University, Chicago, IL
| | - Eric M Liotta
- Department of Neurology, Northwestern University, Chicago, IL
| | - Matthew B Maas
- Department of Neurology, Northwestern University, Chicago, IL
- Center for Healthcare Studies, Institute for Public Health and Medicine (IPHAM), Northwestern University, Chicago, IL
| | - Matthew B Potts
- Department of Neurological Surgery, Northwestern University, Chicago, IL
| | - Babak S Jahromi
- Department of Neurological Surgery, Northwestern University, Chicago, IL
| | - David Cella
- Department of Medical Social Sciences and Center for Patient Centered Outcomes, Institute for Public Health and Medicine (IPHAM), Chicago, IL
| | - Shyam Prabhakaran
- Department of Neurology, Northwestern University, Chicago, IL
- Center for Healthcare Studies, Institute for Public Health and Medicine (IPHAM), Northwestern University, Chicago, IL
| | - Jane L Holl
- Center for Healthcare Studies, Institute for Public Health and Medicine (IPHAM), Northwestern University, Chicago, IL
| |
Collapse
|
28
|
Fernando SM, Reardon PM, Ball IM, van Katwyk S, Thavorn K, Tanuseputro P, Rosenberg E, Kyeremanteng K. Outcomes and Costs of Patients Admitted to the Intensive Care Unit Due to Accidental or Intentional Poisoning. J Intensive Care Med 2018; 35:386-393. [PMID: 29357777 DOI: 10.1177/0885066617754046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Acute poisoning represents a major cause of morbidity and mortality, and many of these patients are admitted to the intensive care unit (ICU). However, little is known regarding ICU costs of acute poisoning. METHODS This was a retrospective matched database analysis of patients admitted to the ICU with acute poisoning from 2011 to 2014. It was performed in 2 ICUs within a single tertiary care hospital system. All patient information, outcomes, and costs were stored in the hospital data warehouse. Control patients were defined as randomly selected age-, sex-, severity index-, and comorbidity index-matched nonpoisoned ICU patients (1:4 matching ratio). RESULTS A total of 8452 critically ill patients were admitted during the study period, of whom 277 had a diagnosis of acute poisoning. The mean age was 44.5 years, and the most common xenobiotics implicated were sedative hypnotics (20.2%), antidepressants (15.2%), and opioids (10.5%). Of these, 73.6% of poisonings were deemed intentional. In-hospital mortality of poisoned patients was 5.1%, compared to 11.1% for control patients (P < .01). The median ICU length of stay (LOS) for poisoned patients was 3.0 days, compared with 4.0 days for control patients (P < .01). The mean total cost for poisoned patients was CAD$18 958. Control patients had a significantly higher mean total cost of CAD$60 628 (P < .01). The xenobiotics associated with the highest costs were acetaminophen (CAD$18 585), toxic alcohols (CAD$16 771), and opioids (CAD$12 967). CONCLUSIONS In our cohort, we confirmed the long-held belief that patients admitted to the ICU with a primary diagnosis of poisoning have a lower mortality rate, ICU LOS, and overall cost per ICU admission than nonpoisoned patients. However, poisoned patients still accrue significant daily costs, with the highest costs attributed to xenobiotics with known antidotes, such as acetaminophen, toxic alcohols, and opioids.
Collapse
Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter M Reardon
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian M Ball
- Division of Critical Care Medicine, Department of Medicine, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Sasha van Katwyk
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyere Research Institute, Ottawa, Ontario, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Erin Rosenberg
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
29
|
Böll R, Romanek K, Schmoll S, Stich R, Ott A, Stenzel J, Geith S, Eyer F, Rabe C. Independent validation of the ICU requirement score in a cohort of acutely poisoned adults. Clin Toxicol (Phila) 2017; 56:664-666. [DOI: 10.1080/15563650.2017.1401635] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Regina Böll
- Department of Clinical Toxicology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Katrin Romanek
- Department of Clinical Toxicology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sabrina Schmoll
- Department of Clinical Toxicology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Raphael Stich
- Department of Clinical Toxicology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Armin Ott
- Institute of Medical Informatics, Statistics, and Epidemiology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jochen Stenzel
- Department of Clinical Toxicology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Stefanie Geith
- Department of Clinical Toxicology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Florian Eyer
- Department of Clinical Toxicology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christian Rabe
- Department of Clinical Toxicology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| |
Collapse
|
30
|
Lindqvist E, Edman G, Hollenberg J, Nordberg P, Ösby U, Forsberg S. Intensive care admissions due to poisoning. Acta Anaesthesiol Scand 2017; 61:1296-1304. [PMID: 28990178 DOI: 10.1111/aas.13005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 09/11/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Poisoning represents a significant part of admissions to intensive care units. The aim of this nationwide study was to describe recent national quality register data of demographics and mortality for these patients. METHOD A retrospective national observational study including all patients over 19 years admitted to an ICU in Sweden, between 1 January 2010 and 31 December 2011, with an ICD-10 code for poisoning. The data were collected from three national registers (The Swedish Intensive Care Register, The National Patient Register, and The Cause of Death Register). RESULTS The incidence of ICU-treated poisonings was 43/100,000. Twenty-one per cent (n = 8155) of all poisoned patients seeking medical care were admitted to the ICU. Their median age was 38 years (q1-q3: 26-51), as many men as women and 46.5% (n = 3790) had a previous registered poisoning. A mix of different substances was the most common type of suspected poisoning (29.7%, n = 2424). The in-hospital mortality was 1.9% and was correlated to invasive mechanical ventilation (OR 6.91 CI 95% 4.59-10.42), age > 40 (OR 4.54 CI 95% 2.86-7.21) and no previous hospitalisation for poisoning (OR 3.23 CI 95% 2.06-5.07). For 78.3% (n = 119) of the deceased patients, the fatal poisoning was their first diagnosed poisoning. The 30-day mortality was 2.7%, a majority died from poisoning (P < 0.01). CONCLUSION In Sweden, patients treated in the ICU due to poisoning represent a fifth of all poisoned patients seeking medical care. Older men with no previous poisoning were considered a high-risk group.
Collapse
Affiliation(s)
- E. Lindqvist
- Department of Anaesthesiology and Intensive Care; Norrtälje Hospital; Norrtälje Sweden
- Department of Clinical Science and Education; Södersjukhuset; Karolinska Institutet; Stockholm Sweden
| | - G. Edman
- Department of Clinical Sciences; Danderyd Hospital; Karolinska Institutet; Stockholm Sweden
- Department of Psychiatry; Norrtälje Hospital; Norrtälje Sweden
| | - J. Hollenberg
- Karolinska Institutet; Department of Medicine; Centre for Resuscitation Science; Stockholm Sweden
| | - P. Nordberg
- Karolinska Institutet; Department of Medicine; Centre for Resuscitation Science; Stockholm Sweden
| | - U. Ösby
- Center for Molecular Medicine; Karolinska University Hospital Solna; Stockholm Sweden
- Department of Neurobiology; Care Sciences and Society; Center for Family Medicine; Karolinska Institutet; Stockholm Sweden
| | - S. Forsberg
- Department of Anaesthesiology and Intensive Care; Norrtälje Hospital; Norrtälje Sweden
- Department of Clinical Science and Education; Södersjukhuset; Karolinska Institutet; Stockholm Sweden
- Swedish Poisons Information Centre; Stockholm Sweden
| |
Collapse
|
31
|
Orsini J, Din N, Elahi E, Gomez A, Rajayer S, Malik R, Jean E. Clinical and epidemiological characteristics of patients with acute drug intoxication admitted to ICU. J Community Hosp Intern Med Perspect 2017; 7:202-207. [PMID: 29046744 PMCID: PMC5637637 DOI: 10.1080/20009666.2017.1356189] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 07/13/2017] [Indexed: 02/06/2023] Open
Abstract
Background: Drug overdose continues to be the most common cause of acute poisoning worldwide. There has been a substantial increase in drug overdose incidence and prevalence over the past decade, probably as a result of the emergence of new synthetic designer drugs. The purpose of this study is to describe the clinical and epidemiological characteristics of patients with acute drug intoxication admitted to the Intensive Care Unit (ICU). Methods: A single center, prospective, observational study was conducted among all adult patients with clinical signs suggestive of acute drug intoxication admitted from the Emergency Department (ED) to ICU during a 6-month period (September to March). Results: Sixty-five patients were admitted. Their median age was 49 years (mean 48.2, range 20–72), and the majority were male (48, 74%). Median Sequential Organ Failure Assessment (SOFA) score on admission to ICU was 6 (mean 6, range 0–13). Fifty-five patients (85%) had a positive urine and/or serum toxicology screen. Most commonly detected substances were: opiates (18, 33%), cocaine (13, 24%), methadone (12, 22%), benzodiazepines (10, 18%), and marijuana (9, 16%). In 16 patients (29%), >1 substance was isolated. Twenty-three patients (35%) had negative urine toxicology screen. Ethyl alcohol was detected in the serum of 23 patients (35%). Five patients (8%) expired in ICU. Conclusion: Classic recreational drugs remain the most common substances involved in acute drug poisoning. More sensitive detection methods are warranted to identify new designer drugs of abuse such as synthetic cannabinoids.
Collapse
Affiliation(s)
- Jose Orsini
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
| | - Nanda Din
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
| | - Ershad Elahi
- Department of Emergency Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
| | - Anthony Gomez
- Department of Emergency Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
| | - Salil Rajayer
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
| | - Ryan Malik
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
| | - Elie Jean
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
| |
Collapse
|
32
|
Patients Admitted to Three Spanish Intensive Care Units for Poisoning: Type of Poisoning, Mortality, and Functioning of Prognostic Scores Commonly Used. BIOMED RESEARCH INTERNATIONAL 2017; 2017:5261264. [PMID: 28459061 PMCID: PMC5387818 DOI: 10.1155/2017/5261264] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 02/05/2017] [Accepted: 02/26/2017] [Indexed: 11/18/2022]
Abstract
Objectives. To evaluate the gravity and mortality of those patients admitted to the intensive care unit for poisoning. Also, the applicability and predicted capacity of prognostic scales most frequently used in ICU must be evaluated. Methods. Multicentre study between 2008 and 2013 on all patients admitted for poisoning. Results. The results are from 119 patients. The causes of poisoning were medication, 92 patients (77.3%), caustics, 11 (9.2%), and alcohol, 20 (16,8%). 78.3% attempted suicides. Mean age was 44.42 ± 13.85 years. 72.5% had a Glasgow Coma Scale (GCS) ≤8 points. The ICU mortality was 5.9% and the hospital mortality was 6.7%. The mortality from caustic poisoning was 54.5%, and it was 1.9% for noncaustic poisoning (p < 0.001). After adjusting for SAPS-3 (OR: 1.19 (1.02–1.39)) the mortality of patients who had ingested caustics was far higher than the rest (OR: 560.34 (11.64–26973.83)). There was considerable discrepancy between mortality predicted by SAPS-3 (26.8%) and observed (6.7%) (Hosmer-Lemeshow test: H = 35.10; p < 0.001). The APACHE-II (7,57%) and APACHE-III (8,15%) were no discrepancies. Conclusions. Admission to ICU for poisoning is rare in our country. Medication is the most frequent cause, but mortality of caustic poisoning is higher. APACHE-II and APACHE-III provide adequate predictions about mortality, while SAPS-3 tends to overestimate.
Collapse
|
33
|
Abstract
INTRODUCTION The objective of this study was to investigate the long-term mortality and cause of death after deliberate self-poisoning with antipsychotics. Furthermore, we investigated the risk of repeated self-poisoning after a first episode of poisoning with antipsychotics. METHODS We identified patients with antipsychotic poisoning from the Danish Poison Information Centre Database and correlated their personal identification number with four Danish national registries related to health aspects. RESULTS From August 2006 to December 2013 we identified 2289 patients poisoned with antipsychotic agents. The average age of the patients was 35.6 years (SD 14.3) and 68.5% were women. Eleven patients died during the first 30 days, and at the end of follow-up in March 2014, 150 patients were deceased, leading to a mortality rate of 2.1 per 100 person-years and a standardized mortality ratio of 9.0. The most common causes of death were poisoning (29%) and violent suicide (18%) - however half of the patients died from natural reasons. 643 patients (28%) repeated the poisoning once or more. CONCLUSIONS Poisoning with antipsychotics was associated with an increased risk of death. Most of these deaths were preventable, and this highlights the need for secondary prophylaxis following a suicide attempt.
Collapse
Affiliation(s)
- Stine Toft
- a Department of Clinical Pharmacology , Bispebjerg and Frederiksberg University Hospital , Copenhagen , Denmark
| | - Henrik Horwitz
- a Department of Clinical Pharmacology , Bispebjerg and Frederiksberg University Hospital , Copenhagen , Denmark
| | - Kim Peder Dalhoff
- a Department of Clinical Pharmacology , Bispebjerg and Frederiksberg University Hospital , Copenhagen , Denmark
| |
Collapse
|
34
|
van den Oever HLA, van Dam M, van 't Riet E, Jansman FGA. Clinical parameters that predict the need for medium or intensive care admission in intentional drug overdose patients: A retrospective cohort study. J Crit Care 2016; 37:156-161. [PMID: 27744235 DOI: 10.1016/j.jcrc.2016.09.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 08/04/2016] [Accepted: 09/21/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Many patients with intentional drug overdose (IDO) are admitted to a medium (MC) or intensive care unit (IC) without ever requiring MC/IC related interventions. The objective of this study was to develop a decision tool, using parameters readily available in the emergency room (ER) for patients with an IDO, to identify patients requiring admission to a monitoring unit. METHODS Retrospective cohort study among cases of IDO with drugs having potentially acute effects on neurological, circulatory or ventilatory function, admitted to the MC/IC unit between 2007 and 2013. A decision tool was developed, using 6 criteria, representing intubation, breathing, oxygenation, cardiac conduction, blood pressure, and consciousness. Cases were labeled as 'high acuity' if one or more criteria were present. RESULTS Among 255 cases of IDO that met the inclusion criteria, 197 were identified as "high acuity". Only 70 of 255 cases underwent one or more MC/IC related interventions, of which 67 were identified as 'high acuity by the decision tool (sensitivity 95.7%). CONCLUSION In a population of patients with intentional drug overdose with agents having potentially acute effect on vital functions, 95.7% of MC/IC interventions could be predicted by clinical assessment, supplemented with electrocardiogram and blood gas analysis, in the ER.
Collapse
Affiliation(s)
- Huub L A van den Oever
- Intensive Care Unit, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE Deventer, The Netherlands.
| | - Mirja van Dam
- Intensive Care Unit, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE Deventer, The Netherlands.
| | - Esther van 't Riet
- Teaching Hospital Deventer, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE Deventer, The Netherlands.
| | - Frank G A Jansman
- Department of Clinical Pharmacy, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE Deventer, The Netherlands; Department of Pharmacotherapy, -Epidemiology and -Economics, University Groningen, Antonius Deusinglaan 1, 9713AV, Groningen, The Netherlands.
| |
Collapse
|
35
|
Brandenburg R, Brinkman S, de Keizer NF, Kesecioglu J, Meulenbelt J, de Lange DW. The need for ICU admission in intoxicated patients: a prediction model. Clin Toxicol (Phila) 2016; 55:4-11. [DOI: 10.1080/15563650.2016.1222616] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Raya Brandenburg
- Department of Intensive Care Medicine, University Medical Center, University of Utrecht, Utrecht, The Netherlands
- Dutch National Poisons Information Centre (NPIC), University Medical Center, University of Utrecht, Utrecht, The Netherlands
| | - Sylvia Brinkman
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicolette F. de Keizer
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center, University of Utrecht, Utrecht, The Netherlands
| | - Jan Meulenbelt
- Department of Intensive Care Medicine, University Medical Center, University of Utrecht, Utrecht, The Netherlands
- Dutch National Poisons Information Centre (NPIC), University Medical Center, University of Utrecht, Utrecht, The Netherlands
- Institute for Risk Assessment Sciences (IRAS), University of Utrecht, Utrecht, The Netherlands
| | - Dylan W. de Lange
- Department of Intensive Care Medicine, University Medical Center, University of Utrecht, Utrecht, The Netherlands
- Dutch National Poisons Information Centre (NPIC), University Medical Center, University of Utrecht, Utrecht, The Netherlands
| |
Collapse
|
36
|
Vodovar D, El Balkhi S, Curis E, Deye N, Mégarbane B. Lithium poisoning in the intensive care unit: predictive factors of severity and indications for extracorporeal toxin removal to improve outcome. Clin Toxicol (Phila) 2016; 54:615-23. [DOI: 10.1080/15563650.2016.1185110] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
37
|
Zhao XH, Jiang JK, Lu YQ. Evaluation of efficacy of resin hemoperfusion in patients with acute 2,4-dinitrophenol poisoning by dynamic monitoring of plasma toxin concentration. J Zhejiang Univ Sci B 2016; 16:720-6. [PMID: 26238547 DOI: 10.1631/jzus.b1500101] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The intoxications caused by 2,4-dinitrophenol (2,4-DNP), even death, have been frequently reported in recent years. This study aims to investigate the dynamic changes of plasma toxin concentration and explore the clinical value of resin hemoperfusion (HP) in the treatment of patients with acute 2,4-DNP poisoning. METHODS We reported 16 cases of acute 2,4-DNP poisoning through occupational exposure due to ignoring the risk of poisoning. The blood samples were collected from the 14 survivors. According to the different treatments of resin HP, the survivors were divided into routine HP (n=5) and intensive HP (n=9) groups. Ultra high performance liquid chromatography/ tandem mass spectroscopy (UPLC-MS/MS) was used to detect the 2,4-DNP concentration in plasma in this study. RESULTS The 14 survivors recovered very well after treatment. The initial plasma 2,4-DNP concentrations (C1) of survivors ranged from 0.25 to 41.88 µg/ml (mean (12.56±13.93) µg/ml). A positive correlation existed between initial plasma 2,4-DNP concentration (C1) and temperature. The elimination of 2,4-DNP was slow and persistent, and the total clearance rates of plasma toxin from the 1st to 3rd day (R3), the 3rd to 7th day (R3-7), and the 1st to 7th day (R7), were only (53.03±14.04)%, (55.25±10.50)%, and (78.29±10.22)%, respectively. The plasma toxin was cleared up to 25 d after poisoning in most of the patients. The R3, R3-7, and R7 in the intensive HP group were all apparently higher than those in the routine HP group, with statistical significance (P<0.05). Simultaneously, the elimination half-life (t1/2) of 2,4-DNP in the intensive HP group was apparently shorter than that in the routine HP group, with statistical significance (P<0.05). CONCLUSIONS The clinicians should be aware of this slow and persistent process in the elimination of plasma 2,4-DNP. Higher initial plasma toxin concentration resulted in a more severe fever for the patient. According to the limited data, longer and more frequent resin HP may accelerate to eliminate the poison.
Collapse
Affiliation(s)
- Xue-hong Zhao
- Department of Emergency Medicine, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Jiu-kun Jiang
- Department of Emergency Medicine, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Yuan-qiang Lu
- Department of Emergency Medicine, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China;
| |
Collapse
|
38
|
Hyperbaric Oxygen Therapy Alleviates Carbon Monoxide Poisoning-Induced Delayed Memory Impairment by Preserving Brain-Derived Neurotrophic Factor-Dependent Hippocampal Neurogenesis. Crit Care Med 2016; 44:e25-39. [PMID: 26488220 DOI: 10.1097/ccm.0000000000001299] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To test the hypothesis that hyperbaric oxygen therapy ameliorates delayed cognitive impairment after acute carbon monoxide poisoning by promoting neurogenesis through upregulating the brain-derived neurotrophic factor in the hippocampus. DESIGN Laboratory animal experiments. SETTING University/Medical center research laboratory. SUBJECTS Adult, male Sprague-Dawley rats. INTERVENTIONS Rats were divided into five groups: (1) non-carbon monoxide-treated control, (2) acute carbon monoxide poisoning, (3) acute carbon monoxide poisoning followed by 7-day hyperbaric oxygen treatment, (4) carbon monoxide + hyperbaric oxygen with additional intracerebroventricular infusion of Fc fragment of tyrosine kinase receptor B protein (TrkB-Fc) chimera, and (5) acute carbon monoxide poisoning followed by intracerebroventricular infusion of brain-derived neurotrophic factor. Acute carbon monoxide poisoning was achieved by exposing the rats to carbon monoxide at 2,500 ppm for 40 minutes, followed by 3,000 ppm for 20 minutes. Hyperbaric oxygen therapy (at 2.5 atmospheres absolute with 100% oxygen for 60 min) was conducted during the first 7 days after carbon monoxide poisoning. Recombinant human TrkB-Fc chimera or brain-derived neurotrophic factor was infused into the lateral ventricle via the implanted osmotic minipump. For labeling of mitotic cells in the hippocampus, bromodeoxyuridine was injected into the peritoneal cavity. Distribution of bromodeoxyuridine and two additional adult neurogenesis markers, Ki-67 and doublecortin, in the hippocampus was evaluated by immunohistochemistry or immunofluorescence staining. Tissue level of brain-derived neurotrophic factor was assessed by enzyme-linked immunosorbent assay. Cognitive behavior was evaluated by the use of eight-arm radial maze. MEASUREMENTS AND MAIN RESULTS Acute carbon monoxide poisoning significantly suppressed adult hippocampal neurogenesis evident by the reduction in number of bromodeoxyuridine-positive, Ki-67⁺, and doublecortin⁺ cells in the subgranular zone of the dentate gyrus. This suppression of adult neurogenesis by the carbon monoxide poisoning was appreciably alleviated by early treatment of hyperbaric oxygen. The hyperbaric oxygen treatment also promoted a sustained increase in hippocampal brain-derived neurotrophic factor level. Blockade of hippocampal brain-derived neurotrophic factor signaling with intracerebroventricular infusion of recombinant human TrkB-Fc chimera significantly blunted the protection by the hyperbaric oxygen on hippocampal neurogenesis; whereas intracerebroventricular infusion of brain-derived neurotrophic factor mimicked the action of hyperbaric oxygen and preserved hippocampal neurogenesis after acute carbon monoxide poisoning. Furthermore, acute carbon monoxide poisoning resulted in a delayed impairment of cognitive function. The hyperbaric oxygen treatment notably restored the cognitive impairment in a brain-derived neurotrophic factor-dependent manner. CONCLUSIONS The early hyperbaric oxygen treatment may alleviate delayed memory impairment after acute carbon monoxide poisoning by preserving adult neurogenesis via an increase in hippocampal brain-derived neurotrophic factor content.
Collapse
|
39
|
Sorge M, Weidhase L, Bernhard M, Gries A, Petros S. Self-poisoning in the acute care medicine 2005-2012. Anaesthesist 2016; 64:456-62. [PMID: 25951922 DOI: 10.1007/s00101-015-0030-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the trend of acute self-poisoning in the emergency and intensive care. METHODS Electronic charts of adults who presented to the emergency department of the University Hospital Leipzig with self-poisoning following a suicide attempt (suicide group), intoxication (intoxication group), drug overdose for relief of pain or discomfort (drug overdose group) between 2005 and 2012 were analyzed. RESULTS 3533 adults (62.6% males) were identified, with the yearly admissions increasing from 305 in 2005 to 624 in 2012. The admission rate in relation to the total emergency department admissions also increased, from 1.2% in 2005 to 1.9% in 2012. 31.7% of the patients were younger than 25 years. The reasons for self-poisoning were suicide attempt (18.1%), intoxication (76.8%) and drug overdose (2.9%). The reason could not be clearly classified in 80 patients. Psychotropic drugs were used in 71.6% of suicide attempts, while alcohol was the sole cause of intoxication in 80.1% of cases in the intoxication group. Self-poisoning using at least two substances was observed in 52.0% of the suicide attempts, 10.3% of those with intoxication and 29.7% of those with drug overdose. While alcohol remains the most common cause of intoxication, there was a drastic increase in the consumption of cannabinoids, Crystal Meth and gamma-hydroxybutyrate in the years 2011 and 2012. ICU admission was necessary in 16.6% of the cases. There were 22 deaths (0.6% of the study population), of whom 15 were in the suicide group (2.3%), four (0.15%) in the intoxication group, and three in the not clearly classified group (3.8%). CONCLUSION Acute self-poisoning is an increasing medical issue. Psychotropic drugs remain the most common means of suicide attempt. Although alcohol intoxication is very frequent, intake of illicit drugs as the cause of emergency admission is increasing.
Collapse
Affiliation(s)
- M Sorge
- Medical Intensive Care Unit, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | | | | | | | | |
Collapse
|
40
|
Viglino D, Bourez D, Collomb-Muret R, Schwebel C, Tazarourte K, Dumanoir P, Paquier C, Danel V, Debaty G, Maignan M. Noninvasive End Tidal CO2 Is Unhelpful in the Prediction of Complications in Deliberate Drug Poisoning. Ann Emerg Med 2016; 68:62-70.e1. [PMID: 26810758 DOI: 10.1016/j.annemergmed.2015.11.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 11/19/2015] [Accepted: 11/25/2015] [Indexed: 12/26/2022]
Abstract
STUDY OBJECTIVE We study the performance of capnometry in the detection of early complications after deliberate drug poisoning. METHODS This was a prospective cohort study of self-poisoned adult patients who presented at an emergency department (ED) between April 20, 2012, and May 6, 2014. Patients who ingested at least 1 neurologic or respiratory depressant drug were included. The primary outcome was the predictive value of an end tidal CO2 (etco2) measurement greater than or equal to 50 mm Hg for the detection of early complications defined a priori by hypoxia requiring oxygen greater than or equal to 3 L/min, bradypnea less than or equal to 10 breaths/min, or ICU admission after intubation or antidote administration because of unresponsiveness to pain or respiratory arrest. Consciousness scales and clinical data were recorded at admission and every 30 minutes. Noninvasive etco2 was continuously measured for 2 hours after inclusion unless the patient was admitted to the ICU. Patients and physicians were blinded to etco2 values. RESULTS Two hundred one patients were included, 35 of whom exhibited at least 1 complication. An etco2 measurement greater than or equal to 50 mm Hg predicted the onset of a complication, with a sensitivity of 46% (95% confidence interval [CI] 29% to 63%) and a specificity of 80% (95% CI 73% to 86%), leading to a positive predictive value of 33% (95% CI 20% to 48%) and a negative predictive value of 88% (95% CI 81% to 92%). etco2 was less able to predict complications than the Glasgow Coma Scale score at inclusion. CONCLUSION Capnometry in isolation does not provide adequate prediction of early complications in self-poisoned patients referred to the ED. A dynamic minute-by-minute assessment of etco2 could be more predictive.
Collapse
Affiliation(s)
- Damien Viglino
- University Grenoble Alps-Emergency Department and Mobile Intensive Care Unit, CHU Michallon, Grenoble, France; INSERM U1042, HP2 Laboratory, University Grenoble Alps, Grenoble, France
| | - Delphine Bourez
- University Grenoble Alps-Emergency Department and Mobile Intensive Care Unit, CHU Michallon, Grenoble, France
| | - Roselyne Collomb-Muret
- University Grenoble Alps-Emergency Department and Mobile Intensive Care Unit, CHU Michallon, Grenoble, France
| | - Carole Schwebel
- University Grenoble Alps-Medical Intensive Care Unit, CHU Michallon, Grenoble, France
| | | | - Perrine Dumanoir
- University Grenoble Alps-Emergency Department and Mobile Intensive Care Unit, CHU Michallon, Grenoble, France
| | - Carole Paquier
- University Grenoble Alps-Emergency Department and Mobile Intensive Care Unit, CHU Michallon, Grenoble, France
| | - Vincent Danel
- University Grenoble Alps-Emergency Department and Mobile Intensive Care Unit, CHU Michallon, Grenoble, France
| | - Guillaume Debaty
- University Grenoble Alps-Emergency Department and Mobile Intensive Care Unit, CHU Michallon, Grenoble, France; CNRS UMR 5525, TIMC-IMAG Laboratory, Team PRETA, University Grenoble Alps, Grenoble, France
| | - Maxime Maignan
- University Grenoble Alps-Emergency Department and Mobile Intensive Care Unit, CHU Michallon, Grenoble, France; CNRS UMR 5525, TIMC-IMAG Laboratory, Team PRETA, University Grenoble Alps, Grenoble, France.
| |
Collapse
|
41
|
van de Klundert N, Holman R, Dongelmans DA, de Keizer NF. Data Resource Profile: the Dutch National Intensive Care Evaluation (NICE) Registry of Admissions to Adult Intensive Care Units. Int J Epidemiol 2015; 44:1850-1850h. [DOI: 10.1093/ije/dyv291] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2015] [Indexed: 01/04/2023] Open
|
42
|
Brandenburg R, Soliman IW, Meulenbelt J, de Lange DW. Raising awareness for a low health-related quality of life in intoxicated ICU patients. Clin Toxicol (Phila) 2015; 53:585. [DOI: 10.3109/15563650.2015.1045068] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
43
|
Abstract
PURPOSE OF REVIEW There are few first-hand accounts that describe the history of outcome prediction in critical care. This review summarizes the authors' personal perspectives about the development and evolution of Acute Physiology and Chronic Health Evaluation over the past 35 years. RECENT FINDINGS We emphasize what we have learned in the past and more recently our perspectives about the current status of outcome prediction, and speculate about the future of outcome prediction. SUMMARY There is increasing evidence that superior accuracy in outcome prediction requires complex modeling with detailed adjustment for diagnosis and physiologic abnormalities. Thus, an automated electronic system is recommended for gathering data and generating predictions. Support, either public or private, is required to assist users and to update and improve models. Current outcome prediction models have increasingly focused on benchmarks for resource use, a trend that seems likely to increase in the future.
Collapse
|
44
|
Horsting MWB, Franken MD, Meulenbelt J, van Klei WA, de Lange DW. The etiology and outcome of non-traumatic coma in critical care: a systematic review. BMC Anesthesiol 2015; 15:65. [PMID: 25924678 PMCID: PMC4424591 DOI: 10.1186/s12871-015-0041-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 04/20/2015] [Indexed: 01/31/2023] Open
Abstract
Background Non-traumatic coma (NTC) is a serious condition requiring swift medical or surgical decision making upon arrival at the emergency department. Knowledge of the most frequent etiologies of NTC and associated mortality might improve the management of these patients. Here, we present the results of a systematic literature search on the etiologies and prognosis of NTC. Methods Two reviewers independently performed a systematic literature search in the Pubmed, Embase and Cochrane databases with subsequent reference and citation checking. Inclusion criteria were retrospective or prospective observational studies on NTC, which reported on etiologies and prognostic information of patients admitted to the emergency department or intensive care unit. Results Eventually, 14 studies with enough data on NTC, were selected for this systematic literature review. The most common causes of NTC were stroke (6-54%), post-anoxic coma (3-42%), poisoning (<1-39%) and metabolic causes (1-29%). NTC was also often caused by infections, especially in African studies affecting 10-51% of patients. The NTC mortality rate ranged from 25 to 87% and the mortality rate continued to increase long after the event had occurred. Also, 5-25% of patients remained moderately-severely disabled or in permanent vegetative state. The mortality was highest for stroke (60-95%) and post-anoxic coma (54-89%) and lowest for poisoning (0-39%) and epilepsy (0-10%). Conclusion NTC represents a challenge to the emergency and the critical care physicians with an important mortality and moderate-severe disability rate. Even though, included studies were very heterogeneous, the most common causes of NTC are stroke, post anoxic, poisoning and various metabolic etiologies. The best outcome is achieved for patients with poisoning and epilepsy, while the worst outcome was seen in patients with stroke and post-anoxic coma. Adequate knowledge of the most common causes of NTC and prioritizing the causes by mortality ensures a swift and adequate work-up in diagnosis of NTC and may improve outcome. Electronic supplementary material The online version of this article (doi:10.1186/s12871-015-0041-9) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Marlene Wb B Horsting
- Division of Anaesthesiology, Intensive Care and Emergency Medicine, University Medical Centre Utrecht, mailstop Q04.2.313, PO Box 85500, 3508 GA, Utrecht, Netherlands.
| | - Mira D Franken
- Division of Anaesthesiology, Intensive Care and Emergency Medicine, University Medical Centre Utrecht, mailstop Q04.2.313, PO Box 85500, 3508 GA, Utrecht, Netherlands.
| | - Jan Meulenbelt
- Division of Anaesthesiology, Intensive Care and Emergency Medicine, University Medical Centre Utrecht, mailstop Q04.2.313, PO Box 85500, 3508 GA, Utrecht, Netherlands. .,Department of Intensive Care Medicine and National Poison Information Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, Netherlands.
| | - Wilton A van Klei
- Division of Anaesthesiology, Intensive Care and Emergency Medicine, University Medical Centre Utrecht, mailstop Q04.2.313, PO Box 85500, 3508 GA, Utrecht, Netherlands.
| | - Dylan W de Lange
- Division of Anaesthesiology, Intensive Care and Emergency Medicine, University Medical Centre Utrecht, mailstop Q04.2.313, PO Box 85500, 3508 GA, Utrecht, Netherlands. .,Department of Intensive Care Medicine and National Poison Information Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, Netherlands.
| |
Collapse
|
45
|
XXXV International Congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) 26–29 May 2015, St Julian's, Malta. Clin Toxicol (Phila) 2015. [DOI: 10.3109/15563650.2015.1024953] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
|
46
|
|
47
|
Why Did Poisoned Patients Eventually Die Long After Their ICU Stay? Crit Care Med 2015; 43:e25-6. [DOI: 10.1097/ccm.0000000000000642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
48
|
Clark BJ, Binswanger IA, Moss M. The intoxicated ICU patient: another opportunity to improve long-term outcomes. Crit Care Med 2014; 42:1563-4. [PMID: 24836800 DOI: 10.1097/ccm.0000000000000274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Brendan James Clark
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, Aurora, CO Division of General Internal Medicine, University of Colorado Denver, Aurora, CO Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, Aurora, CO
| | | | | |
Collapse
|
49
|
Clinical news. Br J Hosp Med (Lond) 2014. [DOI: 10.12968/hmed.2014.75.4.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|