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Abstract
Contemplating the future should be grounded in history. The rise of post-polio ICUs was inextricably related to mechanical ventilation. Critically ill patients who developed acute respiratory failure often had "congestive atelectasis" (ie, a term used to describe ARDS prior to 1967). Initial mechanical ventilation strategies for treating this condition and others inadvertently led to ventilator-induced lung injury. Both injurious ventilation and later use of overly cautious weaning practices resulted from both limited technology and understanding of ARDS and other aspects of critical illness. The resulting misperceptions, misconceptions, and missed opportunities took decades to rectify and in some instances still persist. This suggests a reluctance to acknowledge that all therapeutic strategies reflect the historical period in which they were developed and the corresponding limited understanding of ARDS pathophysiology at that time. We are at the threshold of a revolutionary moment in critical care. The confluence of enormous clinical data production, massive computing power, advances in understanding the biomolecular and genetic aspects of critical illness, and the emergence of neural networks will have enormous impact on how critical care is practiced in the decades to come. Therefore, it is imperative we understand the long-crooked path needed to reach the era of protective ventilation in order to avoid similar mistakes moving forward. The emerging era is as difficult to fathom as our current practices and technologies were to those practicing 60 years ago. This review explores the history of mechanical ventilation in treating ARDS, describes current protective ventilation strategies, and speculates how ARDS management might look 20 years from now.
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Affiliation(s)
- Richard H Kallet
- Department of Anesthesia and Perioperative Care, University of California, San Francisco at San Francisco General Hospital, San Francisco, California.
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2
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Factors affecting adult intensive care units costs by using the bottom-up and top-down costing methodology in OECD countries: A systematic review. Intensive Crit Care Nurs 2021; 66:103080. [PMID: 34059412 DOI: 10.1016/j.iccn.2021.103080] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To review the studies, which calculated the total intensive care unit costs and indicated the main cost drivers in the intensive care by using either top-down, bottom-up approach or the combination of them. RESEARCH METHODOLOGY/DESIGNS A systematic review of papers published until October 2020 was conducted. Search was performed on PubMed, Medline, Scopus and Science Direct databases. SETTING This review i examined costs in adult intensive care units, in countries belonging to the Organisation for Economic Co-operation and Development (OECD) (medical, surgical or general adult , paediatric and neonatal were not included). MAIN OUTCOME MEASURES Eighteen articles were included in the review. RESULTS Eight of the studies used the top-down costing methodology, six of them used the bottom-up approach and four of them used both of them. The mean total patient cost per day ranged from €200.75 to €4321.91 (all costs are presented in 2020 values for euro). Human resources were identified as the largest proportion of total costs. Length of stay, mechanical ventilation, continuous haemodialysis and severe illness are the main cost drivers of intensive care unit total costs. CONCLUSION There are a variety of methods and study designs used to calculate costs of an intensive care unit stay.t It is necessary to evolve standardised costing methods in order to make comparisons and succeed in cost-effective management.
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Sayed M, Riaño D, Villar J. Novel criteria to classify ARDS severity using a machine learning approach. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:150. [PMID: 33879214 PMCID: PMC8056190 DOI: 10.1186/s13054-021-03566-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/05/2021] [Indexed: 12/15/2022]
Abstract
Background Usually, arterial oxygenation in patients with the acute respiratory distress syndrome (ARDS) improves substantially by increasing the level of positive end-expiratory pressure (PEEP). Herein, we are proposing a novel variable [PaO2/(FiO2xPEEP) or P/FPE] for PEEP ≥ 5 to address Berlin’s definition gap for ARDS severity by using machine learning (ML) approaches. Methods We examined P/FPE values delimiting the boundaries of mild, moderate, and severe ARDS. We applied ML to predict ARDS severity after onset over time by comparing current Berlin PaO2/FiO2 criteria with P/FPE under three different scenarios. We extracted clinical data from the first 3 ICU days after ARDS onset (N = 2738, 1519, and 1341 patients, respectively) from MIMIC-III database according to Berlin criteria for severity. Then, we used the multicenter database eICU (2014–2015) and extracted data from the first 3 ICU days after ARDS onset (N = 5153, 2981, and 2326 patients, respectively). Disease progression in each database was tracked along those 3 ICU days to assess ARDS severity. Three robust ML classification techniques were implemented using Python 3.7 (LightGBM, RF, and XGBoost) for predicting ARDS severity over time. Results P/FPE ratio outperformed PaO2/FiO2 ratio in all ML models for predicting ARDS severity after onset over time (MIMIC-III: AUC 0.711–0.788 and CORR 0.376–0.566; eICU: AUC 0.734–0.873 and CORR 0.511–0.745). Conclusions The novel P/FPE ratio to assess ARDS severity after onset over time is markedly better than current PaO2/FiO2 criteria. The use of P/FPE could help to manage ARDS patients with a more precise therapeutic regimen for each ARDS category of severity. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03566-w.
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Affiliation(s)
- Mohammed Sayed
- Banzai Research Group On Artificial Intelligence, Department of Computer Engineering, Universitat Rovira I Virgili, Av Paisos Catalans 26, 43007, Tarragona, Spain.
| | - David Riaño
- Banzai Research Group On Artificial Intelligence, Department of Computer Engineering, Universitat Rovira I Virgili, Av Paisos Catalans 26, 43007, Tarragona, Spain.
| | - Jesús Villar
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain. .,Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr Negrín, Barranco de la Ballena s/n, 4th Floor -South Wing, 35019, Las Palmas de Gran Canaria, Spain. .,Keenan Research Center for Biomedical Science at the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.
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Li S, Zhao D, Cui J, Wang L, Ma X, Li Y. Prevalence, potential risk factors and mortality rates of acute respiratory distress syndrome in Chinese patients with sepsis. J Int Med Res 2020; 48:300060519895659. [PMID: 32043378 PMCID: PMC7105739 DOI: 10.1177/0300060519895659] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To investigate the prevalence, risk factors and mortality rate for acute respiratory distress syndrome (ARDS) in Chinese patients with sepsis. Methods This prospective study was based on data from consecutive patients with sepsis who attended Cangzhou Central Hospital between January 2017 and May 2019 and who developed ARDS. Multivariate logistic regression was used to identify risk factors associated independently with ARDS development. Results Of the 150 sepsis patients, 41 (27%) developed ARDS. Smoking history, presence of chronic obstructive pulmonary disease (COPD), the C-reactive protein (CRP) levels and the Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were associated with developing ARDS. Moreover, combination of the four factors had an even better predictive value for risk of ARDS than each factor alone. 28-day mortality was higher in sepsis patients with ARDS compared with those without ARDS. Conclusions In Chinese patients with sepsis, ARDS is relatively common and is associated with increased mortality. Smoking, COPD, CRP levels and APACHE II scores may be useful in predicting sepsis patients who may be at risk of developing ARDS.
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Affiliation(s)
- Shilei Li
- Emergency Department, Cangzhou Central Hospital, Cangzhou, China
| | - Danna Zhao
- Laboratory Department, Cangzhou People Hospital, Cangzhou, China
| | - Jie Cui
- Emergency Department, Cangzhou Central Hospital, Cangzhou, China
| | - Lizeng Wang
- Emergency Department, Cangzhou Central Hospital, Cangzhou, China
| | - Xiaohua Ma
- Emergency Department, Cangzhou Central Hospital, Cangzhou, China
| | - Yong Li
- Emergency Department, Cangzhou Central Hospital, Cangzhou, China
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Zhang C, He Y, Shen Y. L-Lysine protects against sepsis-induced chronic lung injury in male albino rats. Biomed Pharmacother 2019; 117:109043. [PMID: 31238259 DOI: 10.1016/j.biopha.2019.109043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/23/2019] [Accepted: 05/29/2019] [Indexed: 01/03/2023] Open
Abstract
Sepsis is a severe, life-threatening condition primarily caused by the cellular response to infection. Sepsis leads to increased tissue damage and mortality in patients in the intensive care unit. L-Lysine is an essential amino acid required for protein biosynthesis and is abundant in lamb, pork, eggs, red meat, fish oil, cheese, beans, peas, and soy. Male albino rats were divided into sham, control, 10-mg/kg bwt L-lysine, and 20-mg/kg bwt L-lysine groups. At the end of treatment, we determined the levels of oxidative and inflammatory markers, myeloperoxidase (MPO) and catalase activities, total cell count, the wet/dry ratio of lung tissue, and total protein content. Furthermore, the effect of L-lysine on the cellular architecture of lung tissue was evaluated. L-Lysine significantly reduced the magnitude of lipid peroxidation; total protein content; wet/dry ratio of lung tissue; tumor necrosis factor-alpha, interleukin-8, and macrophage inhibitory factor levels; MPO activity; and total cell, neutrophil, and lymphocyte counts, and it increased the reduced glutathione levels and the glutathione peroxidase, superoxide dismutase, and catalase activities. A normal cellular architecture was noted in rats in the sham group, whereas proinflammatory changes, such as edema and neutrophilic infiltration, were detected in rats in the control group. L-lysine significantly ameliorated these proinflammatory changes. Thus, L-lysine has the potential for the treatment of sepsis-induced CLI.
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Affiliation(s)
- Chunyun Zhang
- Department of Critical Care Medicine, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510700, China.
| | - Yaojun He
- Department of Critical Care Medicine, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510700, China
| | - Yifeng Shen
- Guangzhou Wondfo Biotech Co.Ltd, Guangzhou, Guangdong, 510700, China
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Dai Q, Wang S, Liu R, Wang H, Zheng J, Yu K. Risk factors for outcomes of acute respiratory distress syndrome patients: a retrospective study. J Thorac Dis 2019; 11:673-685. [PMID: 31019754 DOI: 10.21037/jtd.2019.02.84] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background The determination of risk factors for acute respiratory distress syndrome (ARDS) patients remains a challenge. Our study aims to explore the epidemiology and risk factors affecting outcomes of ARDS patients and provide a theoretical basis for patients' prognosis. Methods This retrospective study included 207 ARDS patients admitted to the general intensive care unit (ICU) in the Second Affiliated Hospital of Harbin Medical University from Jan 1st, 2016 to Jan 1st, 2017. The criteria were defined according to the Berlin Definition, and clinical data were collected from the medical record system. The mortality rate and duration of mechanical ventilation were compared in ARDS patients. Furthermore, logistic regression analysis was applied to screen clinically accessible risk factors for survival and duration of mechanical ventilation. Results The total mortality in ARDS patients was 39.13% (81/207) compared to 13.57% (151/1,113) in the whole ICU population. The period prevalence of mild, moderate and severe ARDS was 39.61% (82/207), 37.20% (77/207) and 23.19% (48/207), respectively. Logistic regression analysis showed that acute physiology and chronic health evaluation II (APACHE II) score (OR 3.4316; 95% CI: 1.3130-8.9686; P=0.0119), number of organ failure (OR 3.4928; 95% CI: 1.9775-6.1693; P<0.0001), mean arterial pressure (MAP) (OR 5.1049; 95% CI: 1.8317-14.2274; P=0.0018), driving pressure (OR 6.0017; 95% CI: 2.1746-16.5641; P=0.0005) and lactate level (OR 4.0754; 95% CI: 1.6114-10.3068; P=0.0030) were influence factors for survival; severity of ARDS (OR 1.6715; 95% CI: 1.0307-2.7108; P=0.0373), ventilator-associated pneumonia (VAP) (OR 7.3746; 95% CI: 2.9799-18.2505; P<0.0001) and transfusion history (OR 2.2822; 95% CI: 1.0462-4.9783; P=0.0381) were influence factors for duration of mechanical ventilation. Conclusions Higher APACHE II score, more organ failures, lower MAP, higher driving pressure and higher lactate level are risk factors for survival. Higher severity of ARDS, VAP and transfusion history are risk factors for prolonged duration of mechanical ventilation. Application of these parameters would enable intensivists to treat their patients more precisely and comprehensively.
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Affiliation(s)
- Qingqing Dai
- Department of Critical Care Medicine, the Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Sicong Wang
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, China
| | - Ruijin Liu
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, China
| | - Hongliang Wang
- Department of Critical Care Medicine, the Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Junbo Zheng
- Department of Critical Care Medicine, the Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Kaijiang Yu
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, China
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Fuchs L, Feng M, Novack V, Lee J, Taylor J, Scott D, Howell M, Celi L, Talmor D. The Effect of ARDS on Survival: Do Patients Die From ARDS or With ARDS? J Intensive Care Med 2017; 34:374-382. [PMID: 28681644 DOI: 10.1177/0885066617717659] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE: To investigate the contribution of acute respiratory distress syndrome (ARDS) in of itself to mortality among ventilated patients. DESIGN AND SETTING: A longitudinal retrospective study of ventilated intensive care unit (ICU) patients. PATIENTS: The analysis included patients ventilated for more than 48 hours. Patients were classified as having ARDS on admission (early-onset ARDS), late-onset ARDS (ARDS not present during the first 24 hours of admission), or no ARDS. Primary outcomes were mortality at 28 days, and secondary outcomes were 2-year mortality rate from ICU admission. RESULTS: A total of 1411 ventilated patients were enrolled: 41% had ARDS on admission, 28.5% developed ARDS during their ICU stay, and 30.5% did not meet the ARDS criteria prior to ICU discharge or death. The non-ARDS group was used as the control. We also divided the cohort based on the severity of ARDS. After adjusting for covariates, mortality risk at 28 days was not significantly different among the different groups. Both early- and late-onset ARDS as well as the severity of ARDS were found to be significant risk factors for 2 years from ICU survival. CONCLUSION: Among patients who were ventilated on ICU admission, neither the presence, the severity, or the timing of ARDS contribute independently to the short-term mortality risk. However, acute respiratory distress syndrome does contribute significantly to 2-year mortality risk. This suggests that patients may not die acutely from ARDS itself but rather from the primary disease, and during the acute phase of ARDS, clinicians should focus on improving treatment strategies for the diseases that led to ARDS.
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Affiliation(s)
- Lior Fuchs
- 1 Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,2 Clinical Research Center, Soroka University Medical Center, Beersheba, Israel
| | - Mengling Feng
- 3 The Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA.,4 Institute for Infocomm Research, Agency for Science, Technology and Research, Singapore, Singapore
| | - Victor Novack
- 1 Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,2 Clinical Research Center, Soroka University Medical Center, Beersheba, Israel
| | - Joon Lee
- 3 The Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA.,6 School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Jonathan Taylor
- 7 Medical School for International Health, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Daniel Scott
- 3 The Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Michael Howell
- 5 Department of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,8 Department of Medicine, University of Chicago, Chicago, USA
| | - Leo Celi
- 3 The Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA.,5 Department of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daniel Talmor
- 1 Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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8
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Moskowitz A, Andersen LW, Karlsson M, Grossestreuer AV, Chase M, Cocchi MN, Berg K, Donnino MW. Predicting in-hospital mortality for initial survivors of acute respiratory compromise (ARC) events: Development and validation of the ARC Score. Resuscitation 2017; 115:5-10. [PMID: 28267618 DOI: 10.1016/j.resuscitation.2017.02.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 11/25/2022]
Abstract
AIM Acute respiratory compromise (ARC) is a common and highly morbid event in hospitalized patients. To date, however, few investigators have explored predictors of outcome in initial survivors of ARC events. In the present study, we leveraged the American Heart Association's Get With The Guidelines®-Resuscitation (GWTG-R) ARC data registry to develop a prognostic score for initial survivors of ARC events. METHODS Using GWTG-R ARC data, we identified 13,193 index ARC events. These events were divided into a derivation cohort (9807 patients) and a validation cohort (3386 patients). A score for predicting in-hospital mortality was developed using multivariable modeling with generalized estimating equations. RESULTS The two cohorts were well balanced in terms of baseline demographics, illness-types, pre-event conditions, event characteristics, and overall mortality. After model optimization, nine variables associated with the outcome of interest were included. Age, hypotension preceding the event, and intubation during the event were the greatest predictors of in-hospital mortality. The final score demonstrated good discrimination in both the derivation and validation cohorts. The score was also very well calibrated in both cohorts. Observed average mortality was <10% in the lowest score category of both cohorts and >70% in the highest category, illustrating a wide range of mortality separated effectively by the scoring system. CONCLUSIONS In the present study, we developed and internally validated a prognostic score for initial survivors of in-hospital ARC events. This tool will be useful for clinical prognostication, selecting cohorts for interventional studies, and for quality improvement initiatives seeking to risk-adjust for hospital-to-hospital comparisons.
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Affiliation(s)
- Ari Moskowitz
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Boston, MA, United States.
| | - Lars W Andersen
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA, United States; Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Mathias Karlsson
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA, United States; Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anne V Grossestreuer
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA, United States; University of Pennsylvania, Department of Emergency Medicine, Philadelphia, PA, United States
| | - Maureen Chase
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA, United States
| | - Michael N Cocchi
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA, United States; Beth Israel Deaconess Medical Center, Department of Anesthesia Critical Care and Pain Medicine, Division of Critical Care, United States
| | - Katherine Berg
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Boston, MA, United States
| | - Michael W Donnino
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Boston, MA, United States; Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA, United States
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Nakimuli A, Nakubulwa S, Kakaire O, Osinde MO, Mbalinda SN, Kakande N, Nabirye RC, Kaye DK. The burden of maternal morbidity and mortality attributable to hypertensive disorders in pregnancy: a prospective cohort study from Uganda. BMC Pregnancy Childbirth 2016; 16:205. [PMID: 27492552 PMCID: PMC4973370 DOI: 10.1186/s12884-016-1001-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 07/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy are a major cause of morbidity and mortality. The objective was to estimate the disease burden attributable to hypertensive disorders of pregnancy in two referral hospitals in Uganda. METHODS Through a prospective cohort study conducted in Jinja and Mulago hospitals in Uganda from March 1, 2013 and February 28, 2014, hypertension-related cases were analyzed. Maternal near miss cases were defined according to the WHO criteria. Maternal deaths were also analyzed. The maternal near miss incidence ratio, the case-specific severe maternal outcome ratio, the case-specific maternal mortality ratio and the case-fatality ratio were computed. RESULTS Of 403 women with hypertensive disorders of pregnancy, 218 (54.1 %) had severe preeclampsia, 172 (42.7 %) had eclampsia, and 13 had chronic hypertension or Hemolysis, elevated liver enzymes or low platelets (HELLP) syndrome. The case-specific maternal near miss incidence ratios was 8.60 per 1,000 live births for all hypertensive disorders, 3.06 per 1,000 live births for severe preeclampsia and 5.11 per 1,000 live births for eclampsia. The case-specific severe maternal outcome ratio was 9.37 per 1,000 live births for all hypertensive disorders, and was 3.25 per 1,000 live births for severe preeclampsia and 5.61 per 1,000 live births for eclampsia. The case-specific maternal mortality ratio was 780 per 100,000 live births for all hypertensive disorders, and was 1940 per 100,000 live births for severe preeclampsia and 501 per 100,000 live births for eclampsia. The case-fatality ratio was 5.1 % overall (for all hypertensive disorders), but was 8 times higher for eclampsia compared to severe preeclampsia. Cyanosis, abnormal respiration, oliguria, circulatory collapse, coagulopathy, thrombocytopenia, and elevated serum lactate were significantly associated with severe maternal outcomes. CONCLUSION There is high morbidity attributable to hypertensive disorders in pregnancy. Since some of the complications associated with morbidity can be recognized early, it is possible to prevent severe morbidity through early intervention with delivery, antihypertensive therapy and prophylactic magnesium sulphate treatment. The findings highlight the feasibility of implementing a facility-based surveillance system for severe maternal morbidity due to hypertensive disorders.
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Affiliation(s)
- Annettee Nakimuli
- Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Sarah Nakubulwa
- Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Othman Kakaire
- Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | | | - Scovia Nalugo Mbalinda
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Nelson Kakande
- Clinical, Operations and Health Services Research Program, Joint Clinical Research Centre, P. O. Box 10005, Kampala, Uganda
| | - Rose Chalo Nabirye
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Dan Kabonge Kaye
- Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda.
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Acute respiratory compromise on inpatient wards in the United States: Incidence, outcomes, and factors associated with in-hospital mortality. Resuscitation 2016; 105:123-9. [PMID: 27255952 DOI: 10.1016/j.resuscitation.2016.05.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 05/15/2016] [Accepted: 05/17/2016] [Indexed: 11/23/2022]
Abstract
AIM To estimate the United States' incidence and in-hospital mortality of acute respiratory events on inpatient wards and to identify factors associated with mortality. METHODS This is an analysis of prospectively collected data from the Get With the Guidelines(®) - Resuscitation registry. We included adult patients with index acute respiratory events on inpatient wards from January 2005 to December 2013. A negative binomial regression model was used to estimate the 2012 United States incidence and a multivariable logistic regression model was used to examine time trends and characteristics associated with in-hospital mortality. RESULTS There were 13,086 index events from 320 hospitals included in the analysis. Using 2012 data, the estimated number of events in the United States was 44,551 (95%CI: 25,170-95,371). The in-hospital mortality for the entire cohort was 39.4% (95%CI: 38.5, 40.2) and rose to 82.6% (95%CI: 79.9, 85.2) for events leading to cardiac arrest. There was a decrease in in-hospital mortality over time (48.3% in 2005 to 34.5% in 2013, p<0.001). Characteristics associated with mortality included agonal breathing, hypotension and septicemia. CONCLUSIONS Acute respiratory events on inpatient wards in the US is common with an associated in-hospital mortality of approximately 40% that has been decreasing over the past decade. Multiple factors were associated with in-hospital mortality.
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Karabatsou D, Tsironi M, Tsigou E, Boutzouka E, Katsoulas T, Baltopoulos G. Variable cost of ICU care, a micro-costing analysis. Intensive Crit Care Nurs 2016; 35:66-73. [PMID: 27080569 DOI: 10.1016/j.iccn.2016.01.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 11/11/2015] [Accepted: 01/11/2016] [Indexed: 10/22/2022]
Abstract
Intensive care unit (ICU) costs account for a great part of a hospital's expenses. The objective of the present study was to measure the patient-specific cost of ICU treatment, to identify the most important cost drivers in ICU and to examine the role of various contributing factors in cost configuration. A retrospective cost analysis of all ICU patients who were admitted during 2011 in a Greek General, seven-bed ICU and stayed for at least 24hours was performed, by applying bottom-up analysis. Data collected included demographics and the exact cost of every single material used for patients' care. Prices were yielded from the hospital's purchasing costs and from the national price list of the imaging and laboratory tests, which was provided by the Ministry of Health. A total of 138 patients were included. Variable cost per ICU day was €573.18. A substantial cost variation was found in the total costs obtained for individual patients (median: €3443, range: €243.70-€116,355). Medicines were responsible for more than half of the cost and antibiotics accounted for the largest part of it, followed by blood products and cardiovascular drugs. Medical cause of admission, severe illness and increased length of stay, mechanical ventilation and dialysis were the factors associated with cost escalation. ICU variable cost is patient-specific, varies according to each patient's needs and is influenced by several factors. The exact estimation of variable cost is a pre-requisite in order to control ICU expenses.
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Affiliation(s)
- Dimitra Karabatsou
- University ICU, Ag. Anargiroi General Hospital, Kaliftaki 41, 14564 Kiffissia, Greece.
| | | | - Evdoxia Tsigou
- University ICU, Ag. Anargiroi General Hospital, Kaliftaki 41, 14564 Kiffissia, Greece.
| | - Eleni Boutzouka
- University ICU, Ag. Anargiroi General Hospital, Kaliftaki 41, 14564 Kiffissia, Greece.
| | - Theodoros Katsoulas
- Nursing Department, National and Kapodistrian University of Athens, Greece; University ICU, Ag. Anargiroi General Hospital, Kaliftaki 41, 14564 Kiffissia, Greece.
| | - George Baltopoulos
- Nursing Department, National and Kapodistrian University of Athens, Greece; University ICU, Ag. Anargiroi General Hospital, Kaliftaki 41, 14564 Kiffissia, Greece.
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Fialkow L, Farenzena M, Wawrzeniak IC, Brauner JS, Vieira SRR, Vigo A, Bozzetti MC. Mechanical ventilation in patients in the intensive care unit of a general university hospital in southern Brazil: an epidemiological study. Clinics (Sao Paulo) 2016; 71:144-51. [PMID: 27074175 PMCID: PMC4785851 DOI: 10.6061/clinics/2016(03)05] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 01/21/2016] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVES To determine the characteristics, the frequency and the mortality rates of patients needing mechanical ventilation and to identify the risk factors associated with mortality in the intensive care unit (ICU) of a general university hospital in southern Brazil. METHOD Prospective cohort study in patients admitted to the ICU who needed mechanical ventilation for at least 24 hours between March 2004 and April 2007. RESULTS A total of 1,115 patients admitted to the ICU needed mechanical ventilation. The mortality rate was 51%. The mean age (± standard deviation) was 57±18 years, and the mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 22.6±8.3. The variables independently associated with mortality were (i) conditions present at the beginning of mechanical ventilation, age (hazard ratio: 1.01; p<0.001); the APACHE II score (hazard ratio: 1.01; p<0.005); acute lung injury/acute respiratory distress syndrome (hazard ratio: 1.38; p=0.009), sepsis (hazard ratio: 1.33; p=0.003), chronic obstructive pulmonary disease (hazard ratio: 0.58; p=0.042), and pneumonia (hazard ratio: 0.78; p=0.013) as causes of mechanical ventilation; and renal (hazard ratio: 1.29; p=0.011) and neurological (hazard ratio: 1.25; p=0.024) failure, and (ii) conditions occurring during the course of mechanical ventilation, acute lung injuri/acute respiratory distress syndrome (hazard ratio: 1.31; p<0.010); sepsis (hazard ratio: 1.53; p<0.001); and renal (hazard ratio: 1.75; p<0.001), cardiovascular (hazard ratio: 1.32; p≤0.009), and hepatic (hazard ratio: 1.67; p≤0.001) failure. CONCLUSIONS This large cohort study provides a comprehensive profile of mechanical ventilation patients in South America. The mortality rate of patients who required mechanical ventilation was higher, which may have been related to the severity of illness of the patients admitted to our ICU. Risk factors for hospital mortality included conditions present at the start of mechanical ventilation conditions that occurred during mechanical support.
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Affiliation(s)
- Léa Fialkow
- Universidade Federal do Rio Grande do Sul, Departamento de Medicina Interna
- E-mail:
| | - Maurício Farenzena
- Universidade Federal do Rio Grande do Sul, Departamento de Medicina Interna
- Hospital de Clínicas de Porto Alegre, Divisão de Cuidados Intensivos, Porto Alegre/, RS, Brazil
| | | | - Janete Salles Brauner
- Hospital de Clínicas de Porto Alegre, Divisão de Cuidados Intensivos, Porto Alegre/, RS, Brazil
| | | | - Alvaro Vigo
- Universidade Federal do Rio Grande do Sul, Instituto de Matemática, Departamento de Estatística, Porto Alegre/, RS, Brazil
| | - Mary Clarisse Bozzetti
- Departamento de Medicina Social, Porto Alegre/, RS, Brazil
- Hospital de Clínicas de Porto Alegre, Divisão de Cuidados Intensivos, Porto Alegre/, RS, Brazil
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Patel SP, Pena ME, Babcock CI. Cost-effectiveness of noninvasive ventilation for chronic obstructive pulmonary disease-related respiratory failure in Indian hospitals without ICU facilities. Lung India 2015; 32:549-56. [PMID: 26664158 PMCID: PMC4663855 DOI: 10.4103/0970-2113.168137] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Introduction: The majority of Indian hospitals do not provide intensive care unit (ICU) care or ward-based noninvasive positive pressure ventilation (NIV). Because no mechanical ventilation or NIV is available in these hospitals, the majority of patients suffering from respiratory failure die. Objective: To perform a cost-effective analysis of two strategies (ward-based NIV with concurrent standard treatment vs standard treatment alone) in chronic obstructive pulmonary disease (COPD) respiratory failure patients treated in Indian hospitals without ICU care. Materials and Methods: A decision-analytical model was created to compare the cost-effectiveness for the two strategies. Estimates from the literature were used for parameters in the model. Future costs were discounted at 3%. All costs were reported in USD (2012). One-way, two-way, and probabilistic sensitivity analysis were performed. The time horizon was lifetime and perspective was societal. Results: The NIV strategy resulted in 17.7% more survival and was slightly more costly (increased cost of $101 (USD 2012) but resulted in increased quality-adjusted life-years (QALYs) (1.67 QALY). The cost-effectiveness (2012 USD)/QALY in the standard and NIV groups was $78/QALY ($535.02/6.82) and $75/QALY ($636.33/8.49), respectively. Incremental cost-effectiveness ratio (ICER) was only $61 USD/QALY. This was substantially lower than the gross domestic product (GDP) per capita for India (1489 USD), suggesting the NIV strategy was very cost effective. Using a 5% discount rate resulted in only minimally different results. Probabilistic analysis suggests that NIV strategy was preferred 100% of the time when willingness to pay was >$250 2012 USD. Conclusion: Ward-based NIV treatment is cost-effective in India, and may increase survival of patients with COPD respiratory failure when ICU is not available.
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Affiliation(s)
- Shraddha P Patel
- Department of Emergency Medicine, St. John Hospital and Medical Center, Wayne State University, Detroit, Michigan, USA
| | - Margarita E Pena
- Department of Emergency Medicine, St. John Hospital and Medical Center, Wayne State University, Detroit, Michigan, USA
| | - Charlene Irvin Babcock
- Department of Emergency Medicine, St. John Hospital and Medical Center, Wayne State University, Detroit, Michigan, USA
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Braune S, Burchardi H, Engel M, Nierhaus A, Ebelt H, Metschke M, Rosseau S, Kluge S. The use of extracorporeal carbon dioxide removal to avoid intubation in patients failing non-invasive ventilation--a cost analysis. BMC Anesthesiol 2015; 15:160. [PMID: 26537233 PMCID: PMC4634813 DOI: 10.1186/s12871-015-0139-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 10/22/2015] [Indexed: 11/17/2022] Open
Abstract
Background To evaluate the economic implications of the pre-emptive use of extracorporeal carbon dioxide removal (ECCO2R) to avoid invasive mechanical ventilation (IMV) in patients with hypercapnic ventilatory insufficiency failing non-invasive ventilation (NIV). Methods Retrospective ancillary cost analysis of data extracted from a recently published multicentre case–control-study (n = 42) on the use of arterio-venous ECCO2R to avoid IMV in patients with acute on chronic ventilatory failure. Cost calculations were based on average daily treatment costs for intensive care unit (ICU) and normal medical wards as well as on the specific costs of the ECCO2R system. Results In the group treated with ECCO2R IMV was avoided in 90 % of cases and mean hospital length of stay (LOS) was shorter than in the matched control group treated with IMV (23.0 vs. 42.0 days). The overall average hospital treatment costs did not differ between the two groups (41.134 vs. 39.366 €, p = 0.8). A subgroup analysis of patients with chronic obstructive pulmonary disease (COPD) revealed significantly lower median ICU length of stay (11.0 vs. 35.0 days), hospital length of stay (17.5 vs. 51.5 days) and treatment costs for the ECCO2R group (19.610 vs. 46.552 €, p = 0.01). Conclusions Additional costs for the use of arterio-venous ECCO2R to avoid IMV in patients with acute-on-chronic ventilatory insufficiency failing NIV may be offset by a cost reducing effect of a shorter length of ICU and hospital stay.
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Affiliation(s)
- Stephan Braune
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | | | - Markus Engel
- Department of Cardiology and Intensive Care, Klinikum Bogenhausen, Munich, Germany.
| | - Axel Nierhaus
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Henning Ebelt
- Department of Medicine III, University of Halle (Saale), Halle, Germany.
| | - Maria Metschke
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Simone Rosseau
- Department of Internal Medicine, Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Berlin, Germany.
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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Thongprayoon C, Cheungpasitporn W, Srivali N, Erickson SB. Admission serum magnesium levels and the risk of acute respiratory failure. Int J Clin Pract 2015. [PMID: 26205345 DOI: 10.1111/ijcp.12696] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The association between admission serum magnesium (Mg) levels and risk of acute respiratory failure (ARF) in hospitalised patients is limited. The aim of this study was to assess the risk of developing ARF in all hospitalised patients with various admission Mg levels. METHODS This is a single-center retrospective study conducted at a tertiary referral hospital. All hospitalised adult patients who had admission Mg available from January to December 2013 were analysed in this study. Admission Mg was categorised based on its distribution into six groups (less than 1.5, 1.5-1.7, 1.7-1.9, 1.9-2.1, 2.1-2.3 and greater than 2.3 mg/dl). The primary outcome was in-hospital ARF occurring after hospital admission. Logistic regression analysis was performed to obtain the odds ratio of ARF of various admission Mg levels using Mg of 1.7-1.9 mg/dl as the reference group. RESULTS Of 9780 patients enrolled, ARF occurred in 619 patients (6.3%). The lowest incidence of ARF was when serum Mg within 1.7-1.9 mg/dl. A U-shaped curve emerged demonstrating higher incidences of ARF associated with both hypomagnesemia (< 1.7) and hypermagnesemia (> 1.9). After adjusting for potential confounders, both hypomagnesemia (< 1.5 mg/dl) and hypermagnesemia (> 2.3 mg/dl) were associated with an increased risk of developing ARF with odds ratios of 1.69 (95% CI: 1.19-2.36) and 1.40 (95% CI: 1.02-1.91) respectively. CONCLUSION Both admission hypomagnesemia and hypermagnesemia were associated with an increased risk for in-hospital ARF.
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Affiliation(s)
- C Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - W Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - N Srivali
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - S B Erickson
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Turunen H, Jakob SM, Ruokonen E, Kaukonen KM, Sarapohja T, Apajasalo M, Takala J. Dexmedetomidine versus standard care sedation with propofol or midazolam in intensive care: an economic evaluation. Crit Care 2015; 19:67. [PMID: 25887576 PMCID: PMC4391080 DOI: 10.1186/s13054-015-0787-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 02/04/2015] [Indexed: 11/14/2022] Open
Abstract
Introduction Dexmedetomidine was shown in two European randomized double-blind double-dummy trials (PRODEX and MIDEX) to be non-inferior to propofol and midazolam in maintaining target sedation levels in mechanically ventilated intensive care unit (ICU) patients. Additionally, dexmedetomidine shortened the time to extubation versus both standard sedatives, suggesting that it may reduce ICU resource needs and thus lower ICU costs. Considering resource utilization data from these two trials, we performed a secondary, cost-minimization analysis assessing the economics of dexmedetomidine versus standard care sedation. Methods The total ICU costs associated with each study sedative were calculated on the basis of total study sedative consumption and the number of days patients remained intubated, required non-invasive ventilation, or required ICU care without mechanical ventilation. The daily unit costs for these three consecutive ICU periods were set to decline toward discharge, reflecting the observed reduction in mean daily Therapeutic Intervention Scoring System (TISS) points between the periods. A number of additional sensitivity analyses were performed, including one in which the total ICU costs were based on the cumulative sum of daily TISS points over the ICU period, and two further scenarios, with declining direct variable daily costs only. Results Based on pooled data from both trials, sedation with dexmedetomidine resulted in lower total ICU costs than using the standard sedatives, with a difference of €2,656 in the median (interquartile range) total ICU costs—€11,864 (€7,070 to €23,457) versus €14,520 (€7,871 to €26,254)—and €1,649 in the mean total ICU costs. The median (mean) total ICU costs with dexmedetomidine compared with those of propofol or midazolam were €1,292 (€747) and €3,573 (€2,536) lower, respectively. The result was robust, indicating lower costs with dexmedetomidine in all sensitivity analyses, including those in which only direct variable ICU costs were considered. The likelihood of dexmedetomidine resulting in lower total ICU costs compared with pooled standard care was 91.0% (72.4% versus propofol and 98.0% versus midazolam). Conclusions From an economic point of view, dexmedetomidine appears to be a preferable option compared with standard sedatives for providing light to moderate ICU sedation exceeding 24 hours. The savings potential results primarily from shorter time to extubation. Trial registration ClinicalTrials.gov NCT00479661 (PRODEX), NCT00481312 (MIDEX). Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0787-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Heidi Turunen
- Orion Corporation Orion Pharma, Orionintie 1, FI-02100, Espoo, Finland.
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Bern University Hospital and University of Bern, Freiburgstrasse, CH-3010, Bern, Switzerland.
| | - Esko Ruokonen
- Department of Intensive Care Medicine, Kuopio University Hospital, Puijonlaaksontie 2, FI-70210, Kuopio, Finland.
| | - Kirsi-Maija Kaukonen
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, 99 Commercial Road, 3004, Melbourne, Victoria, Australia. .,Intensive Care Units, Helsinki University Central Hospital, Haartmaninkatu 2, 00029 HUS, Helsinki, Finland.
| | - Toni Sarapohja
- Orion Corporation Orion Pharma, Orionintie 1, FI-02100, Espoo, Finland.
| | - Marjo Apajasalo
- Orion Corporation Orion Pharma, Orionintie 1, FI-02100, Espoo, Finland.
| | - Jukka Takala
- Department of Intensive Care Medicine, Bern University Hospital and University of Bern, Freiburgstrasse, CH-3010, Bern, Switzerland.
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Evaluation of some new parameters predicting outcome of patients with acute respiratory failure needing invasive mechanical ventilation due to CAP. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2014. [DOI: 10.1016/j.ejcdt.2014.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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18
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Fuller BM, Mohr NM, Graetz TJ, Lynch IP, Dettmer M, Cullison K, Coney T, Gogineni S, Gregory R. The impact of cardiac dysfunction on acute respiratory distress syndrome and mortality in mechanically ventilated patients with severe sepsis and septic shock: an observational study. J Crit Care 2014; 30:65-70. [PMID: 25179413 DOI: 10.1016/j.jcrc.2014.07.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 07/28/2014] [Accepted: 07/30/2014] [Indexed: 12/29/2022]
Abstract
PURPOSE Acute respiratory distress syndrome (ARDS) is associated with significant mortality and morbidity in survivors. Treatment is only supportive, therefore elucidating modifiable factors that could prevent ARDS could have a profound impact on outcome. The impact that sepsis-associated cardiac dysfunction has on ARDS is not known. MATERIALS AND METHODS In this retrospective observational cohort study of mechanically ventilated patients with severe sepsis and septic shock, 122 patients were assessed for the impact of sepsis-associated cardiac dysfunction on incidence of ARDS (primary outcome) and mortality. RESULTS Sepsis-associated cardiac dysfunction occurred in 44 patients (36.1%). There was no association of sepsis-associated cardiac dysfunction with ARDS incidence (p= 0.59) or mortality, and no association with outcomes in patients that did progress to ARDS after admission. Multivariable logistic regression demonstrated that higher BMI was associated with progression to ARDS (adjusted OR 11.84, 95% CI 1.24 to 113.0, p= 0.02). CONCLUSIONS Cardiac dysfunction in mechanically ventilated patients with sepsis did not impact ARDS incidence, clinical outcome in ARDS patients, or mortality. This contrasts against previous investigations demonstrating an influence of nonpulmonary organ dysfunction on outcome in ARDS. Given the frequency of ARDS as a sequela of sepsis, the impact of cardiac dysfunction on outcome should be further studied.
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Affiliation(s)
- Brian M Fuller
- Department of Anesthesiology, Division of Critical Care, Division of Emergency Medicine, Washington University School of Medicine, St Louis, MO.
| | - Nicholas M Mohr
- Department of Emergency Medicine, Department of Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Thomas J Graetz
- Department of Anesthesiology, Division of Critical Care, Division of Cardiothoracic Anesthesiology, Washington University School of Medicine, St Louis, MO
| | - Isaac P Lynch
- Department of Anesthesiology, Division of Critical Care, Division of Cardiothoracic Anesthesiology, Washington University School of Medicine, St Louis, MO
| | - Matthew Dettmer
- Division of Emergency Medicine, Washington University School of Medicine, St Louis, MO
| | - Kevin Cullison
- Division of Emergency Medicine, Washington University School of Medicine, St Louis, MO
| | - Talia Coney
- Saint Louis University School of Medicine, St Louis, MO
| | | | - Robert Gregory
- Southern Illinois University School of Medicine, Springfield, IL
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Aliberti S, Brambilla AM, Chalmers JD, Cilloniz C, Ramirez J, Bignamini A, Prina E, Polverino E, Tarsia P, Pesci A, Torres A, Blasi F, Cosentini R. Phenotyping community-acquired pneumonia according to the presence of acute respiratory failure and severe sepsis. Respir Res 2014; 15:27. [PMID: 24593040 PMCID: PMC4015148 DOI: 10.1186/1465-9921-15-27] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 02/20/2014] [Indexed: 01/16/2023] Open
Abstract
Background Acute respiratory failure (ARF) and severe sepsis (SS) are possible complications in patients with community-acquired pneumonia (CAP). The aim of the study was to evaluate prevalence, characteristics, risk factors and impact on mortality of hospitalized patients with CAP according to the presence of ARF and SS on admission. Methods This was a multicenter, observational, prospective study of consecutive CAP patients admitted to three hospitals in Italy, Spain, and Scotland between 2008 and 2010. Three groups of patients were identified: those with neither ARF nor SS (Group A), those with only ARF (Group B) and those with both ARF and SS (Group C) on admission. Results Among the 2,145 patients enrolled, 45% belonged to Group A, 36% to Group B and 20% to Group C. Patients in Group C were more severe than patients in Group B. Isolated ARF was correlated with age (p < 0.001), COPD (p < 0.001) and multilobar infiltrates (p < 0.001). The contemporary occurrence of ARF and SS was associated with age (p = 0.002), residency in nursing home (p = 0.007), COPD (p < 0.001), multilobar involvement (p < 0.001) and renal disease (p < 0.001). 4.2% of patients in Group A died, 9.3% in Group B and 26% in Group C, p < 0.001. After adjustment, the presence of only ARF had an OR for in-hospital mortality of 1.85 (p = 0.011) and the presence of both ARF and SS had an OR of 6.32 (p < 0.001). Conclusions The identification of ARF and SS on hospital admission can help physicians in classifying CAP patients into three different clinical phenotypes.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Francesco Blasi
- Department of Pathophysiology and Transplantation, IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Via F, Sforza 35, Milan, Italy.
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Wang S, Feng X, Li S, Liu C, Xu B, Bai B, Yu P, Feng Q, Zhao Q. The ability of current scoring systems in differentiating transient and persistent organ failure in patients with acute pancreatitis. J Crit Care 2014; 29:693.e7-11. [PMID: 24581950 DOI: 10.1016/j.jcrc.2014.01.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 12/31/2013] [Accepted: 01/19/2014] [Indexed: 12/26/2022]
Abstract
PURPOSE The purpose of this study is to investigate the accuracy of currently used scoring systems in differentiating transient and persistent organ failure in patients with acute pancreatitis (AP). MATERIALS AND METHODS In this retrospective study, 127 consecutive patients with AP and organ failure were included. Patients were divided into transient and persistent organ failure groups. The Acute Physiology and Chronic Health Examination II score, bedside index of severity in acute pancreatitis, harmless acute pancreatitis score, and modified Marshall scores within the first 24 hours of organ failure were collected, and their accuracy in predicting transient organ failure was assessed. RESULTS Transient organ failure occurred in 46 patients (36.2%). Fewer patients with transient organ failure initiated with multiple organ failure (13.0% vs 37.0%, P=.004) and renal failure (17.4% vs 44.4%, P=.002). In predicting transient organ failure, the area under the curves of the 4 scoring systems is from 0.66 to 0.71. The area under the curve of serum amylase was 0.78, which was slightly better than that of the modified Marshall and Acute Physiology and Chronic Health Examination II score and was significantly better than that of the bedside index of severity in acute pancreatitis and harmless acute pancreatitis score (P<.05). CONCLUSIONS Current scoring systems are not accurate enough in differentiating transient and persistent organ failure in patients with AP.
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Affiliation(s)
- Shiqi Wang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi Province, China
| | - Xiangying Feng
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi Province, China
| | - Shujun Li
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi Province, China
| | - Chaoxu Liu
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi Province, China
| | - Bin Xu
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi Province, China
| | - Bin Bai
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi Province, China
| | - Pengfei Yu
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi Province, China
| | - Quanxin Feng
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi Province, China.
| | - Qingchuan Zhao
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi Province, China.
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Serum activin A and B levels predict outcome in patients with acute respiratory failure: a prospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R263. [PMID: 24172607 PMCID: PMC4057391 DOI: 10.1186/cc13093] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 09/30/2013] [Indexed: 12/31/2022]
Abstract
INTRODUCTION 30 day mortality in patients with Acute Respiratory Failure (ARF) is approximately 30%, defined as patients requiring ventilator support for more than 6 hours. Novel biomarkers are needed to predict patient outcomes and to guide potential future therapies. The activins A and B, members of the Transforming Growth Factor β family of proteins, and their binding protein, follistatin, have recently been shown to be important regulators of inflammation and fibrosis but no substantial data are available concerning their roles in ARF. METHODS Specific assays for activin A, B and follistatin were used and the results analyzed according to diagnostic groups as well as according to standard measures in intensive care. Multivariable logistic regression was used to create a model to predict death at 90 days and 12 months from the onset of the ARF. RESULTS Serum activin A and B were significantly elevated in most patients and in most of the diagnostic groups. Patients who had activin A and/or B concentrations above the reference maximum were significantly more likely to die in the 12 months following admission [either activin A or B above reference maximum: Positive Likelihood Ratio [LR+] 1.65 [95% CI 1.28-2.12, P = 0.00013]; both activin A and B above reference maximum: LR + 2.78 [95% CI 1.96-3.95, P < 0.00001]. The predictive model at 12 months had an overall accuracy of 80.2% [95% CI 76.6-83.3%]. CONCLUSIONS The measurement of activin A and B levels in these patients with ARF would have assisted in predicting those at greatest risk of death. Given the existing data from animal studies linking high activin A levels to significant inflammatory challenges, the results from this study suggest that approaches to modulate activin A and B bioactivity should be explored as potential therapeutic agents.
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LINKO R, PETTILÄ V, KUITUNEN A, KORHONEN AM, NISULA S, ALILA S, KIVINIEMI O, LARU-SOMPA R, VARPULA T, KARLSSON S. Plasma neutrophil gelatinase-associated lipocalin and adverse outcome in critically ill patients with ventilatory support. Acta Anaesthesiol Scand 2013; 57:855-62. [PMID: 23556459 DOI: 10.1111/aas.12112] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2013] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Plasma neutrophil gelatinase-associated lipocalin (pNGAL) has been introduced as an early and sensitive biomarker of acute kidney injury (AKI), with an increased risk for renal replacement therapy (RRT) and adverse outcome in selected critically ill patient groups. Acute respiratory failure is the most common organ dysfunction in critically ill patients with an increased risk for AKI. Accordingly, we hypothesized that pNGAL would independently predict adverse outcome in a heterogeneous group of critically ill adult patients with acute respiratory failure. DESIGN AND SETTING Prospective, multi-centre study in 25 Finnish intensive care units. PATIENTS AND METHODS pNGAL was measured from critically ill patients with acute respiratory failure. We evaluated the predictive value of pNGAL for RRT, and hospital and 90-day mortality first separately, second in addition to the Simplified Acute Physiology Score (SAPS II), and third to RIFLE (Risk, Injury, Failure, Loss, End-Stage Renal Disease) AKI classification. Additionally, we assessed the factors associated with pNGAL by linear regression analysis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We included 369 patients. Median (interquartile range) baseline pNGAL was 169 (92-370) ng/ml. The areas under receiver operating characteristic curves of baseline pNGAL were as follows: 0.733 [95% confidence interval (CI) 0.656-0.810] for RRT, 0.627 (95% CI 0.561-0.693) for hospital, and 0.582 (95% CI 0.520-0.645) for 90-day mortality. Present infection, baseline creatinine, operative status, and pancreatitis were independently associated with baseline pNGAL. CONCLUSIONS Baseline pNGAL gives no additional value into prediction of hospital and 90-day mortality compared with RIFLE or SAPS II, and has only moderate predictive power regarding RRT in critically ill adult patients with acute respiratory failure.
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Affiliation(s)
- R. LINKO
- Department of Anaesthesia and Intensive Care Medicine; Helsinki University Hospital; Helsinki; Finland
| | | | | | - A. -M. KORHONEN
- Department of Anaesthesia and Intensive Care Medicine; Helsinki University Hospital; Helsinki; Finland
| | - S. NISULA
- Department of Anaesthesia and Intensive Care Medicine; Helsinki University Hospital; Helsinki; Finland
| | - S. ALILA
- Department of Anaesthesia and Intensive Care Medicine; Kymenlaakso Central Hospital; Kotka; Finland
| | - O. KIVINIEMI
- Department of Anaesthesia and Intensive Care Medicine; Lapland Central Hospital; Rovaniemi; Finland
| | - R. LARU-SOMPA
- Department of Anaesthesia and Intensive Care Medicine; Central Hospital of Central Finland; Jyväskylä; Finland
| | - T. VARPULA
- Department of Anaesthesia and Intensive Care Medicine; Helsinki University Hospital; Helsinki; Finland
| | - S. KARLSSON
- Department of Intensive Care Medicine; Tampere University Hospital; Tampere; Finland
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Sequential oxygenation index and organ dysfunction assessment within the first 3 days of mechanical ventilation predict the outcome of adult patients with severe acute respiratory failure. ScientificWorldJournal 2013; 2013:413216. [PMID: 23476133 PMCID: PMC3588184 DOI: 10.1155/2013/413216] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 01/17/2013] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To determine early predictors of outcomes of adult patients with severe acute respiratory failure. METHOD 100 consecutive adult patients with severe acute respiratory failure were evaluated in this retrospective study. Data including comorbidities, Sequential Organ Failure Assessment (SOFA) score, Acute Physiological Assessment and Chronic Health Evaluation II (APACHE II) score, PaO2, FiO2, PaO2/FiO2, PEEP, mean airway pressure (mPaw), and oxygenation index (OI) on the 1st and the 3rd day of mechanical ventilation, and change in OI within 3 days were recorded. Primary outcome was hospital mortality; secondary outcome measure was ventilator weaning failure. RESULTS 38 out of 100 (38%) patients died within the study period. 48 patients (48%) failed to wean from ventilator. Multivariate analysis showed day 3 OI (P=0.004) and SOFA (P=0.02) score were independent predictors of hospital mortality. Preexisting cerebrovascular accident (CVA) (P=0.002) was the predictor of weaning failure. Results from Kaplan-Meier method demonstrated that higher day 3 OI was associated with shorter survival time (log-Rank test, P<0.001). CONCLUSION Early OI (within 3 days) and SOFA score were predictors of mortality in severe acute respiratory failure. In the future, prospective studies measuring serial OIs in a larger scale of study cohort is required to further consolidate our findings.
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Effects of IgM-Enriched Immunoglobulin Therapy in Septic-Shock–Induced Multiple Organ Failure: Pilot Study. J Anesth 2013; 27:618-22. [DOI: 10.1007/s00540-012-1553-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 12/26/2012] [Indexed: 10/27/2022]
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King KM, Langley GD, Rolston KV, Pratt GF, Canada TW, Botz GH. Economic evaluation in critical care: a focus on severe sepsis in oncology. Expert Rev Pharmacoecon Outcomes Res 2012; 6:49-58. [PMID: 20528538 DOI: 10.1586/14737167.6.1.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Hospital care, physician and clinical services, and prescription drugs continue to drive healthcare expenditures across healthcare systems and nations. The critical-care setting, owing to the complexity and intensity of care, is a high user of the resources that drive healthcare spending. Information regarding the cost and effectiveness of critical-care therapies is necessary to properly guide care and policies for this unique population. Many challenges exist for conducting and comparing economic evaluation in critical care. Recently, recommendations on cost and cost-effectiveness analysis in critical care have been developed that will guide future research. A focus area, severe sepsis in oncology, is reviewed to highlight the challenges and opportunities of economic evaluation in this setting.
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Affiliation(s)
- Krista M King
- Division of Pharmacy, Department of Pharmaceutical Policy & Outcomes Research, The University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 706, Houston, TX 77030, USA.
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REIS MIRANDA D, JEGERS M. Monitoring costs in the ICU: a search for a pertinent methodology. Acta Anaesthesiol Scand 2012; 56:1104-13. [PMID: 22967197 DOI: 10.1111/j.1399-6576.2012.02735.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Attempts to determine costs in the intensive care unit (ICU) were not successful until now, as they failed to detect differences of costs between patients. The methodology and/or the instruments used might be at the origin of this failure. Based on the results of the European ICUs studies and on the descriptions of the activities of care in the ICU, we gathered and analysed the relevant literature concerning the monitoring of costs in the ICU. The aim was to formulate a methodology, from an economic perspective, in which future research may be framed. A bottom-up microcosting methodology will enable to distinguish costs between patients. The resulting information will at the same time support the decision-making of top management and be ready to include in the financial system of the hospital. Nursing staff explains about 30% of the total costs. This relation remains constant irrespective of the annual nurse/patient ratio. In contrast with other scoring instruments, the nursing activities score (NAS) covers all nursing activities. (1) NAS is to be chosen for quantifying nursing activities; (2) an instrument for measuring the physician's activities is not yet available; (3) because the nursing activities have a large impact on total costs, the standardisation of the processes of care (following the system approach) will contribute to manage costs, making also reproducible the issue of quality of care; (4) the quantification of the nursing activities may be the required (proxy) input for the automated bottom-up monitoring of costs in the ICU.
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Affiliation(s)
- D. REIS MIRANDA
- University Medical Centre of Groningen; Groningen; Netherlands
| | - M. JEGERS
- Vrije Universiteit Brussel; Brussels; Belgium
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Del Sorbo L, Goffi A, Ranieri VM. Mechanical ventilation during acute lung injury: current recommendations and new concepts. Presse Med 2011; 40:e569-83. [PMID: 22104487 DOI: 10.1016/j.lpm.2011.05.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 05/05/2011] [Accepted: 05/13/2011] [Indexed: 01/08/2023] Open
Abstract
Despite a very large body of investigations, no effective pharmacological therapies have been found to cure acute lung injury. Hence, supportive care with mechanical ventilation remains the cornerstone of treatment. However, several experimental and clinical studies showed that mechanical ventilation, especially at high tidal volumes and pressures, can cause or aggravate ALI. Therefore, current clinical recommendations are developed with the aim of avoiding ventilator-induced lung injury (VILI) by limiting tidal volume and distending ventilatory pressure according to the results of the ARDS Network trial, which has been to date the only intervention that has showed success in decreasing mortality in patients with ALI/ARDS. In the past decade, a very large body of investigations has determined significant achievements on the pathophysiological knowledge of VILI. Therefore, new perspectives, which will be reviewed in this article, have been defined in terms of the efficiency and efficacy of recognizing, monitoring and treating VILI, which will eventually lead to further significant improvement of outcome in patients with ARDS.
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Affiliation(s)
- Lorenzo Del Sorbo
- Università di Torino, Dipartimento di Anestesiologia e Medicina degli Stati Critici, Ospedale S. Giovanni Battista-Molinette, 10126 Torino, Italy
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Nates JL, Cárdenas-Turanzas M, Wakefield C, Kish Wallace S, Shaw A, Samuels JA, Ensor J, Price KJ. Automating and simplifying the SOFA score in critically ill patients with cancer. Health Informatics J 2011; 16:35-47. [PMID: 20413411 DOI: 10.1177/1460458209353558] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim was to demonstrate the performance of a modified version of the Sequential Organ Failure Assessment (SOFA) score to predict mortality in medical and surgical patients with cancer. We performed an electronic retrospective review of databases. We included adult patients with cancer admitted into a 53-bed ICU over 28 months. We electronically calculated a modified SOFA (mSOFA) score at admission. A majority of the patients were admitted into the surgical ICU. Of 328 nonsurvivors, 85.1 per cent were medical patients and only 14.9 per cent surgical patients. The mean admission mSOFA scores for medical and surgical patients were 4.7 +/- 3.2 and 1.7 +/- 1.9, respectively. The overall area under the curve (AUC) of the mSOFA score was 0.84. The AUCs for medical and surgical patients were 0.72 and 0.78, respectively. Our results demonstrate that electronic assessment of mSOFA score has potential in resource allocation decisions as well as in critical care outreach programs.
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Affiliation(s)
- Joseph L Nates
- Department of Critical Care Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
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Vincent JL, Sakr Y, Groeneveld J, Zandstra DF, Hoste E, Malledant Y, Lei K, Sprung CL. ARDS of early or late onset: does it make a difference? Chest 2009; 137:81-7. [PMID: 19820081 DOI: 10.1378/chest.09-0714] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Differences in outcomes have been demonstrated for critically ill patients with late-onset compared with early-onset renal failure and late-onset compared with early-onset shock, which could cause a lead-time bias in clinical trials assessing potential therapies for these conditions. We used data from a large, multicenter observational study to assess whether late-onset ARDS was similarly associated with worse outcomes compared with early-onset ARDS. METHODS Data were extracted from the Sepsis Occurrence in Acutely Ill Patients (SOAP) study, which involved 198 ICUs from 24 European countries. All adult patients admitted to a participating ICU between May 1, 2002 and May 15, 2002, were eligible, except those admitted for uncomplicated postoperative surveillance. Early/late onset acute lung injury (ALI)/ARDS was defined as ALI/ARDS occurring within/after 48 h of ICU admission. RESULTS Of the 3,147 patients included in the SOAP study, 393 (12.5%) had a diagnosis of ALI/ARDS; 254 had early-onset ALI/ARDS (64.6%), and 139 (35.5%) late-onset. Patients with early-onset ALI/ARDS had higher Simplified Acute Physiology II scores on admission and higher initial Sequential Organ Failure Assessment scores. Patients with late-onset ALI/ARDS had longer ICU and hospital lengths of stay than patients with early-onset ALI/ARDS. ICU and hospital mortality rates were, if anything, lower in late-onset ALI/ARDS than in early-onset ALI/ARDS, but these differences were not statistically significant. CONCLUSIONS There were no significant differences in mortality rates between early- and late-onset ARDS, but patients with late-onset ALI/ARDS had longer ICU and hospital lengths of stay.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Route de Lennik 808, B-1070 Brussels, Belgium
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Linko R, Okkonen M, Pettilä V, Perttilä J, Parviainen I, Ruokonen E, Tenhunen J, Ala-Kokko T, Varpula T. Acute respiratory failure in intensive care units. FINNALI: a prospective cohort study. Intensive Care Med 2009; 35:1352-61. [PMID: 19526218 DOI: 10.1007/s00134-009-1519-z] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Accepted: 05/07/2009] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the incidence, treatment and mortality of acute respiratory failure (ARF) in Finnish intensive care units (ICUs). STUDY DESIGN Prospective multicentre cohort study. METHODS All adult patients in 25 ICUs were screened for use of invasive or non-invasive ventilatory support during an 8-week period. Patients needing ventilatory support for more than 6 h were included and defined as ARF patients. Risk factors for ARF and details of prior chronic health status were assessed. Ventilatory and concomitant treatments were evaluated and recorded daily throughout the ICU stay. ICU and 90-day mortalities were assessed. RESULTS A total of 958 (39%) from the 2,473 admitted patients were treated with ventilatory support for more than 6 h. Incidence of ARF, acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) was 149.5, 10.6 and 5.0/100,000 per year, respectively. Ventilatory support was started with non-invasive interfaces in 183 of 958 (19%) patients. Ventilatory modes allowing triggering of spontaneous breaths were preferred (81%). Median tidal volume/predicted body weight was 8.7 (7.6-9.9) ml/kg and plateau pressure 19 (16-23) cmH2O. The 90-day mortality of ARF was 31%. CONCLUSIONS While the incidence of ARF requiring ventilatory support is higher, the incidence of ALI and ARDS seems to be lower in Finland than previously reported in other countries. Tidal volumes are higher than recommended in the concept of lung protective strategy. However, restriction of peak airway pressure was used in the majority of ARF patients.
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Affiliation(s)
- Rita Linko
- Intensive Care Units, Department of Anaesthesia and Intensive Care Medicine, Division of Surgery, Helsinki University Hospital, Helsinki, Finland.
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Cost savings attributable to reductions in intensive care unit length of stay for mechanically ventilated patients. Med Care 2009; 46:1226-33. [PMID: 19300312 DOI: 10.1097/mlr.0b013e31817d9342] [Citation(s) in RCA: 127] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To estimate the actual cost savings that could be achieved through reductions in intensive care unit (ICU) length of stay and duration of mechanical ventilation by determining the short-run marginal variable cost of an ICU and ventilator day. RESEARCH DESIGN Retrospective cohort study in a university-affiliated teaching hospital. SUBJECTS All patients receiving mechanical ventilation in the ICU for more than 48 hours (n = 1778) from July 1, 2005 to June 30, 2006. MEASURES The hospital's administrative and cost databases were used to determine total costs, variable costs, and direct-variable costs for each patient on each individual ICU and hospital day. RESULTS Direct-variable costs comprised 19.3% of total ICU costs and 18.4% of total hospital costs. Marginal direct-variable costs (the cost of each additional ICU day) were small compared with the average daily total cost ($649 to $839 vs. $1751, in US dollars). In survivors with ICU lengths of stay more than 3 days, the mean direct-variable cost of the last ICU day was $397, while the mean direct-variable cost of the first ward day was $279, for a mean cost difference of $118 (95% CI, $21-$190). Reducing ICU and hospital length of stay by 1 day in all survivors with ICU lengths of stay more than 3 days would result in an immediate cost savings of only 0.2% of all hospital expenditures for these patients. CONCLUSIONS Marginal variable ICU costs are relatively small compared with average total costs and are only slightly greater than the cost of a ward day.
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Halvorsen K, Førde R, Nortvedt P. Professional challenges of bedside rationing in intensive care. Nurs Ethics 2009; 15:715-28. [PMID: 18849363 DOI: 10.1177/0969733008095383] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
As the pressure on available health care resources grows, an increasing moral challenge in intensive care is to secure a fair distribution of nursing care and medical treatment. The aim of this article is to explore how limited resources influence nursing care and medical treatment in intensive care, and to explore whether intensive care unit clinicians use national prioritization criteria in clinical deliberations. The study used a qualitative approach including participant observation and in-depth interviews with intensive care unit physicians and nurses working at the bedside. Scarcity of resources regularly led to suboptimal professional standards of medical treatment and nursing care. The clinicians experienced a rising dilemma in that very ill patients with a low likelihood of survival were given advanced and expensive treatment. The clinicians rarely referred to national priority criteria as a rationale for bedside priorities. Because prioritization was carried out implicitly, and most likely partly without the clinician's conscious awareness, central patient rights such as justice and equality could be at risk.
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Martin J, Neurohr C, Bauer M, Weiss M, Schleppers A. [Cost of intensive care in a German hospital: cost-unit accounting based on the InEK matrix]. Anaesthesist 2008; 57:505-12. [PMID: 18389191 DOI: 10.1007/s00101-008-1353-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to determine the actual cost per intensive care unit (ICU) day in Germany based on routine data from an electronic patient data management system as well as analysis of cost-driving factors. A differentiation between days with and without mechanical ventilation was performed. METHODS On the ICU of a German focused-care hospital (896 beds, 12 anesthesiology ICU beds), cost per treatment day was calculated with or without mechanical ventilation from the perspective of the hospital. Costs were derived retrospectively with respect to the period between January and October 2006 by cost-unit accounting based on routine data collected from the ICU patients. Patients with a length of stay of at least 2 days on the ICU were included. Demographic, clinical and economical data were analyzed for patient characterization. RESULTS Data of 407 patients (217 male and 190 female) were included in the analysis, of which 159 patients (100 male, 59 female) were completely or partially mechanically ventilated. The mean simplified acute physiology (SAPS) II score at the onset of ICU stay was 28.2. Average cost per ICU day was 1,265 EUR and costs for ICU days with and without mechanical ventilation amounted to 1,426 EUR and 1,145 EUR, respectively. Personnel costs (50%) showed the largest cost share followed by drugs plus medicinal products (18%) and infrastructure (16%). CONCLUSIONS For the first time, a cost analysis of intensive care in Germany was performed with routine data based on the matrix of the institute for reimbursement in hospitals (InEK). The results revealed a higher resource use on the ICU than previously expected. The large share of personnel costs on the ICU was evident but is comparable to other medical departments in the hospital. The need for mechanical ventilation increases the daily costs of resources by approximately 25%.
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Affiliation(s)
- J Martin
- Klinik am Eichert, Kliniken des Landkreises Göppingen gGmbH, Eichertstr. 3, 73035 Göppingen.
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Tan SS, Hakkaart-van Roijen L, Al MJ, Bouwmans CA, Hoogendoorn ME, Spronk PE, Bakker J. Review of A Large Clinical Series: A Microcosting Study of Intensive Care Unit Stay in the Netherlands. J Intensive Care Med 2008; 23:250-7. [DOI: 10.1177/0885066608318661] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The primary objective of this study was to estimate the actual daily costs of intensive care unit stay using a microcosting methodology. As a secondary objective, the degree of association between daily intensive care unit costs and some patient characteristics was examined. This multicenter, retrospective cost analysis was conducted in the medical-surgical adult intensive care units of 1 university and 2 general hospitals in the Netherlands for 2006, from a hospital perspective. A total of 576 adult patients were included, consuming a total of 2868 nursing days. The mean total costs per intensive care unit day were 1911, with labour (33%) and indirect costs (33%) as the most important cost drivers. An ordinary least squares analysis including age, Nine Equivalent of Nursing Manpower Use score/Therapeutic Intervention Scoring System score, mechanical ventilation, blood products, and renal replacement therapy was able to predict 50% of the daily intensive care unit costs.
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Affiliation(s)
- Siok Swan Tan
- Erasmus MC University Medical Center, Institute for Medical Technology Assessment, Rotterdam,
| | | | - Maiwenn J. Al
- Erasmus MC University Medical Center, Institute for Medical Technology Assessment, Rotterdam
| | - Clazien A. Bouwmans
- Erasmus MC University Medical Center, Institute for Medical Technology Assessment, Rotterdam
| | | | - Peter E. Spronk
- Department of Intensive Care Medicine, Gelre Hospital (Lukas site), Apeldoorn
| | - Jan Bakker
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, Netherlands
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Borba A, Lourenço S, Marcelino P, Marum S, Fernandes AP. Prevalência e caracterização clínica dos doentes com insuficiência respiratória parcial grave internados numa UCI. REVISTA PORTUGUESA DE PNEUMOLOGIA 2008. [DOI: 10.1016/s0873-2159(15)30242-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Suri HS, Li G, Gajic O. Epidemiology of Acute Respiratory Failure and Mechanical Ventilation. Intensive Care Med 2008. [PMCID: PMC7121586 DOI: 10.1007/978-0-387-77383-4_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Acute respiratory failure, and the need for mechanical ventilation, remains one of the most common reasons for admission to the intensive care unit (ICU). The burden of acute respiratory failure is high in terms of mortality and morbidity as well as the cost of its principal treatment, mechanical ventilation. Very few epidemiologic studies have evaluated the prevalence and outcome of acute respiratory failure and mechanical ventilation in general. Most of the published literature has focused on specific forms of acute respiratory failure, particularly acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). In this chapter, we provide a brief review of the pathophysiology of acute respiratory failure, its definition and classification, and then present the incidence and outcomes of specific forms of acute respiratory failure from epidemiologic studies.
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Epidemiology of Acute Respiratory Failure and Mechanical Ventilation. YEARBOOK OF INTENSIVE CARE AND EMERGENCY MEDICINE 2008. [PMCID: PMC7123201 DOI: 10.1007/978-3-540-77290-3_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Acute respiratory failure, and the need for mechanical ventilation, remains one of the most common reasons for admission to the intensive care unit (ICU). The burden of acute respiratory failure is high in terms of mortality and morbidity as well as the cost of its principal treatment, mechanical ventilation. Very few epidemiologic studies have evaluated the prevalence and outcome of acute respiratory failure and mechanical ventilation in general. Most of the published literature has focused on specific forms of acute respiratory failure, particularly acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). In this chapter, we provide a brief review of the pathophysiology of acute respiratory failure, its definition and classification, and then present the incidence and outcomes of specific forms of acute respiratory failure from epidemiologic studies.
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Aggarwal AN, Agarwal R, Gupta D, Jindal SK. Nonpulmonary organ dysfunction and its impact on outcome in patients with acute respiratory failure. Chest 2007; 132:829-35. [PMID: 17873193 DOI: 10.1378/chest.06-2783] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
PURPOSES This study aimed to define the prevalence, severity, and progression of nonpulmonary organ dysfunction, and its impact on outcome in patients with acute respiratory failure (ARF) at a respiratory ICU of a tertiary referral hospital in northern India. METHODS Daily patient data were collected on 711 adult patients with ARF to calculate component and total nonpulmonary sequential organ failure assessment (SOFA) scores. Hospital survival was the main outcome measure. Multiple logistic regression modeling was conducted to assess contribution of incremental dysfunction of various nonpulmonary organ systems to mortality. Kaplan-Meier curves were drawn to assess temporal trends in survival, and group comparisons were based on log-rank test. Cox proportional hazard modeling was performed to define hazards of earlier mortality. Discrimination was evaluated using receiver operating characteristic (ROC) curves. RESULTS Four hundred seventy-five patients (66.8%) had one or more nonpulmonary organ dysfunctions at hospital admission. The overall hospital mortality rate was 33.9%. Hospital survival rates and median survival declined steadily as the number of organs involved increased. Admission, maximum, and DeltaSOFA scores were significantly higher in nonsurvivors. Increasing baseline cardiovascular and neurologic SOFA scores, and corresponding DeltaSOFA scores, were associated with progressively higher odds of hospital mortality, as well as increasing hazard for earlier mortality after adjustment for etiology of respiratory failure. Maximum nonpulmonary SOFA score was the best discriminator in predicting mortality (area under ROC curve, 0.767). CONCLUSION Baseline and new-onset nonpulmonary organ dysfunction significantly influences hospital survival in patients with ARF.
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Affiliation(s)
- Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160012 India
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Hariharan S, Chen D, Merritt-Charles L. Cost evaluation in the intensive care units of Trinidad applying the cost-blocks method - an international comparison. Anaesthesia 2007; 62:244-9. [PMID: 17300301 DOI: 10.1111/j.1365-2044.2007.04953.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This study evaluated the costs of intensive care in Trinidad applying the cost-blocks method. Data regarding demographics, severity of illness, therapeutic interventions and length of stay were prospectively recorded for 111 patients admitted to four intensive care units during a 3-month period. Annual costs, cost per admission, cost per patient-day and cost per therapeutic intervention score point were derived. The cost-block for staff, especially medical staff, was the largest proportion of the expenditure. Process of care and outcome were comparable, whereas costs were lower than the developed countries. The median cost per intensive care unit bed per year and cost per patient per day in Trinidad were 133,117 pounds and 366 pounds, respectively, in comparison with 265,163 pounds and 904 pounds in the UK. The cost-blocks method is a useful framework for evaluating the costs of intensive care and for comparing costs between countries.
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Affiliation(s)
- S Hariharan
- Anaesthesia and Intensive Care Unit, The University of the West Indies, St. Augustine, Trinidad and Tobago, West Indies.
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Lobo SM, Lobo FRM, Lopes-Ferreira F, Bota DP, Melot C, Vincent JL. Initial and delayed onset of acute respiratory failure: factors associated with development and outcome. Anesth Analg 2006; 103:1219-23. [PMID: 17056958 DOI: 10.1213/01.ane.0000237433.00877.5a] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
In a prospective observational study of 1038 adult admissions to a 31-bed medical/surgical intensive care unit (ICU), acute respiratory failure (ARF, defined as a Pao(2)/Fio(2) ratio <or=200 mm Hg and the need for respiratory support) occurred in 182 (58%) of the 313 admissions with an ICU stay of more than 48 h. Initial ARF (onset within 48 h of ICU admission) occurred in 133 (42%) patients, and delayed onset ARF (onset >48 h after ICU admission) in 49 (16%). On admission, the cardiovascular sequential organ failure assessment (SOFA) score was higher in initial than in delayed onset ARF (1.1 +/- 1.5 vs 0.6 +/- 1.2, P < 0.05). High admission serum C-reactive protein concentrations (OR 1.08, 95% CI 1.04-1.12, P = 0.0001) and SOFA scores (OR 1.20, 95% CI 1.08-1.33, P = 0.0007) were the factors independently associated with initial ARF, and a low Glasgow coma scale (GCS) score (OR 1.13, 95% CI 1.04-1.21, P = 0.0018) was associated with delayed onset ARF. In initial ARF, a high SOFA score (OR 1.24, 95% CI 1.12-1.38, P = 0.0001) and a low GCS score (OR 0.89, 95% CI 0.83-0.96, P = 0.0013) on admission, and in delayed onset ARF, a low GCS score at 48 h (OR 0.67, 95% CI 0.54-0.84, P = 0.0011) were independently associated with death. The mortality rate was similar for initial and delayed onset ARF.
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Affiliation(s)
- Suzana M Lobo
- Department of Intensive Care Medicine, Erasme University Hospital, Route de Lennik 808, 1070 Brussels, Belgium
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Aggarwal AN, Sarkar P, Gupta D, Jindal SK. Performance of standard severity scoring systems for outcome prediction in patients admitted to a respiratory intensive care unit in North India. Respirology 2006; 11:196-204. [PMID: 16548906 DOI: 10.1111/j.1440-1843.2006.00828.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE There are little data on the value of using severity scoring systems developed in western countries to assess critically ill patients in India. The authors evaluated the performance of Acute Physiology and Chronic Health Evaluation version II (APACHE II), Simplified Acute Physiology Score version II (SAPS II) and Mortality Probability Models version II at admission and at 24 h (MPM(0) and MPM(24), respectively) in predicting patient outcomes in their Respiratory Intensive Care Unit. METHODS Data from 459 consecutive adult admissions were collected prospectively. Standardized mortality ratios were computed as an index of the overall model performance. Model calibration was assessed using Lemeshow-Hosmer goodness-of-fit tests and through calibration curves. Model discrimination was assessed through receiver operating curve analysis and by drawing 2 x 2 classification matrices. RESULTS Overall standardized mortality ratio exceeded 1.5 for all models. All models had modest discrimination (area under receiver-operating-characteristic curves 0.66-0.78) and poor calibration (high Lemeshow-Hosmer C and H statistic values). All models had a tendency to underpredict hospital death in patients with lower mortality probability estimates. There were no major differences between the models with regard to either discrimination or calibration performance. CONCLUSIONS Standard severity scoring systems developed in western countries are poor at predicting patient outcome in critically ill patients admitted to a respiratory intensive care unit in Northern India. Caution must be exercised in using such models in their present form on Indian patients until either they are customized for local use or fresh models are developed from Indian cohorts.
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Affiliation(s)
- Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Cao P, Toyabe SI, Abe T, Akazawa K. Profit and loss analysis for an intensive care unit (ICU) in Japan: a tool for strategic management. BMC Health Serv Res 2006; 6:1. [PMID: 16403235 PMCID: PMC1395358 DOI: 10.1186/1472-6963-6-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2005] [Accepted: 01/11/2006] [Indexed: 11/30/2022] Open
Abstract
Background Accurate cost estimate and a profit and loss analysis are necessary for health care practice. We performed an actual financial analysis for an intensive care unit (ICU) of a university hospital in Japan, and tried to discuss the health care policy and resource allocation decisions that have an impact on critical intensive care. Methods The costs were estimated by a department level activity based costing method, and the profit and loss analysis was based on a break-even point analysis. The data used included the monthly number of patients, the revenue, and the direct and indirect costs of the ICU in 2003. Results The results of this analysis showed that the total costs of US$ 2,678,052 of the ICU were mainly incurred due to direct costs of 88.8%. On the other hand, the actual annual total patient days in the ICU were 1,549 which resulted in revenues of US$ 2,295,044. However, it was determined that the ICU required at least 1,986 patient days within one fiscal year based on a break-even point analysis. As a result, an annual deficit of US$ 383,008 has occurred in the ICU. Conclusion These methods are useful for determining the profits or losses for the ICU practice, and how to evaluate and to improve it. In this study, the results indicate that most ICUs in Japanese hospitals may not be profitable at the present time. As a result, in order to increase the income to make up for this deficit, an increase of 437 patient days in the ICU in one fiscal year is needed, and the number of patients admitted to the ICU should thus be increased without increasing the number of beds or staff members. Increasing the number of patients referred from cooperating hospitals and clinics therefore appears to be the best strategy for achieving these goals.
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Affiliation(s)
- Pengyu Cao
- Division of Information Science and Biostatistics, Department of Medical Informatics and Pharmaceutics, Niigata University Graduate School of Medical and Dental Sciences, Asahimachi-dori 1-754, Niigata 951-8520, Japan
| | - Shin-ichi Toyabe
- Division of Information Science and Biostatistics, Department of Medical Informatics and Pharmaceutics, Niigata University Graduate School of Medical and Dental Sciences, Asahimachi-dori 1-754, Niigata 951-8520, Japan
- Department of Medical Informatics, Niigata University Medical and Dental Hospital Asahimachi-dori 1-754, Niigata 951-8520, Japan
| | - Toshikazu Abe
- Division of Information Science and Biostatistics, Department of Medical Informatics and Pharmaceutics, Niigata University Graduate School of Medical and Dental Sciences, Asahimachi-dori 1-754, Niigata 951-8520, Japan
| | - Kouhei Akazawa
- Division of Information Science and Biostatistics, Department of Medical Informatics and Pharmaceutics, Niigata University Graduate School of Medical and Dental Sciences, Asahimachi-dori 1-754, Niigata 951-8520, Japan
- Department of Medical Informatics, Niigata University Medical and Dental Hospital Asahimachi-dori 1-754, Niigata 951-8520, Japan
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Brander L, Slutsky A. Year in review in Critical Care, 2003 and 2004: respirology and critical care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:517-22. [PMID: 16277741 PMCID: PMC1297607 DOI: 10.1186/cc3764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
We summarize all original research in the field of respirology and critical care published in 2003 and 2004 in Critical Care. Articles were grouped into the following categories to facilitate a rapid overview: pathophysiology, therapeutic approaches, and outcome in acute lung injury and acute respiratory distress syndrome; hypoxic pulmonary arterial hypertension; mechanical ventilation; liberation from mechanical ventilation and tracheostomy; ventilator-associated pneumonia; multidrug-resistant infections; pleural effusion; sedation and analgesia; asthma; and techniques and monitoring.
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Affiliation(s)
- Lukas Brander
- Post-doctoral research fellow, Interdepartmental Division of Critical Care, Division of Respiratory Medicine, University of Toronto, St Michael's Hospital, Toronto, Ontario, Canada
| | - Arthur Slutsky
- Professor of Medicine, Surgery and Biomedical Engineering; Director, Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada; Vice President (Research), St Michael's Hospital, Toronto, Ontario, Canada
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Liffner G, Bak Z, Reske A, Sjöberg F. Inhalation injury assessed by score does not contribute to the development of acute respiratory distress syndrome in burn victims. Burns 2005; 31:263-8. [PMID: 15774279 DOI: 10.1016/j.burns.2004.11.003] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To establish the incidence, mortality, and time of onset of acute respiratory distress syndrome (ARDS) in relation to extent of burn and inhalation injury in patients who required mechanical ventilation. DESIGN Data about burn and inhalation injury were recorded prospectively whereas ARDS and multiple organ dysfunction were assessed by review of patient charts. SETTING National burn intensive care unit at Linkoping University Hospital, Sweden (a tertiary referral hospital). PATIENTS Between 1993 and 1999, we studied all patients with thermal injury (n=553) who required mechanical ventilation for more than two days (n=91). MEASUREMENTS AND RESULTS Out of the thirty-six burn victims who developed ARDS (40%), 25 (70%) did so early post burn (in less than 6 days). Patients with ARDS had higher multiple organ dysfunction scores (mean 10.5) than those who did not develop ARDS (mean 5.6) (p<0.01). The probable presence of inhalation injury as assessed by an inhalation lung injury score (ILIS) did not contribute to the development of ARDS. Mortality tended to be higher in patients who developed ARDS (14%) compared to those who did not (6%, p=0.2). CONCLUSIONS In our burn patients the incidence of ARDS was high whereas mortality was low. We found no association between inhalation injury as assessed using the ILIS and development of ARDS. Our data support a multi-factorial origin of ARDS in burn victims as a part of a multiple organ failure event.
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Affiliation(s)
- G Liffner
- The Burn unit, Department of Hand and Plastic Surgery and Intensive Care, University Hospital Linköping, S-58185 Linköping, Sweden
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Soares M, Salluh JIF, Spector N, Rocco JR. Characteristics and outcomes of cancer patients requiring mechanical ventilatory support for >24 hrs. Crit Care Med 2005; 33:520-6. [PMID: 15753742 DOI: 10.1097/01.ccm.0000155783.46747.04] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To describe the characteristics of a large cohort of cancer patients receiving mechanical ventilation for >24 hrs and to identify clinical features predictive of in-hospital death. DESIGN Prospective cohort study. SETTING Ten-bed oncologic medical-surgical intensive care unit. PATIENTS A total of 463 consecutive patients were included over a 45-month period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data were collected on the day of admission to the intensive care unit. The intensive care unit and hospital mortality rates were 50% and 64%, respectively. There were 359 (78%) patients with solid tumors and 104 (22%) with hematologic malignancies; 35 (8%) patients had leukopenia. Sepsis (63%), coma (15%), invasion or compression by tumor (11%), pulmonary embolism (7%), and cardiopulmonary arrest (6%) were the main reasons for mechanical ventilation. The independent unfavorable risk factors for mortality were older age (odds ratio, 3.09; 95% confidence interval, 1.61-5.93, for patients 40-70 yrs old, and odds ratio, 9.26; 95% confidence interval, 4.16-20.58, for patients >70 yrs old); performance status 3-4 (odds ratio, 2.51; 95% confidence interval, 1.40-4.51); cancer recurrence/progression (odds ratio, 3.43; 95% confidence interval, 1.81-6.53); Pao2/Fio2 ratio <150 (odds ratio, 2.64; 95% confidence interval, 1.40-4.99); Sequential Organ Failure Assessment score (excluding respiratory domain, each 4 points; odds ratio, 2.34; 95% confidence interval, 1.70-3.24); and airway/pulmonary invasion or compression by tumor as a reason for mechanical ventilation (odds ratio, 5.73; 95% confidence interval, 1.92-17.08). CONCLUSIONS Severity of acute organ failures, poor performance status, cancer status, and older age were the main determinants of mortality. The appropriate use of such easily available clinical characteristics may avoid forgoing intensive care for patients with a chance of survival.
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Affiliation(s)
- Márcio Soares
- Intensive Care Unit, Instituto Nacional de Câncer, Rio de Janeiro, Brazil.
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Burchardi H, Schneider H. Economic aspects of severe sepsis: a review of intensive care unit costs, cost of illness and cost effectiveness of therapy. PHARMACOECONOMICS 2004; 22:793-813. [PMID: 15294012 DOI: 10.2165/00019053-200422120-00003] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Severe sepsis remains both an important clinical challenge and an economic burden in intensive care. An estimated 750,000 cases occur each year in the US alone (300 cases per 100,000 population). Lower numbers are estimated for most European countries (e.g. Germany and Austria: 54-116 cases per year per 100,000). Sepsis patients are generally treated in intensive care units (ICUs) where close supervision and intensive care treatment by a competent team with adequate equipment can be provided. Staffing costs represent from 40% to >60% of the total ICU budget. Because of the high proportion of fixed costs in ICU treatment, the total cost of ICU care is mainly dependent on the length of ICU stay (ICU-LOS). The average total cost per ICU day is estimated at approximately 1200 Euro for countries with a highly developed healthcare system (based on various studies conducted between 1989 and 2001 and converted at 2003 currency rates). Patients with infections and severe sepsis require a prolonged ICU-LOS, resulting in higher costs of treatment compared with other ICU patients. US cost-of-illness studies focusing on direct costs per sepsis patient have yielded estimates of 34,000 Euro, whereas European studies have given lower cost estimates, ranging from 23,000 Euro to 29,000 Euro. Direct costs, however, make up only about 20-30% of the cost of illness of severe sepsis. Indirect costs associated with severe sepsis account for 70-80% of costs and arise mainly from productivity losses due to mortality. Because of increasing healthcare cost pressures worldwide, economic issues have become important for the introduction of new innovations. This is evident when introducing new biotechnology products, such as drotrecogin-alpha (activated protein C), into specific therapy for severe sepsis. Data so far suggest that when drotrecogin-alpha treatment is targeted to those patients most likely to achieve the greatest benefit, the drug is cost effective by the standards of other well accepted life-saving interventions.
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Affiliation(s)
- Hilmar Burchardi
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University Hospital Göttingen, Göttingen, Germany.
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Parviainen I, Herranen A, Holm A, Uusaro A, Ruokonen E. Results and costs of intensive care in a tertiary university hospital from 1996-2000. Acta Anaesthesiol Scand 2004; 48:55-60. [PMID: 14674974 DOI: 10.1111/j.1399-6576.2004.00257.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Costs of intensive care may be 20% of all hospital costs. Population aging likely increases the demand for intensive care services, while health care has financial limitations. Therefore data about outcome and costs of intensive care are needed. We studied changes in patient characteristics, outcome, intensity of care and costs of intensive care in a tertiary university hospital in Finland. METHODS We analyzed retrospectively data of patients admitted to the ICU between 1 January 1996 and 31 December 2000 using the patient data management system. Postoperative and ICU patients were analyzed separately. Data included age, Apache II score, cause of intensive care admission, length and intensity of ICU care. ICU, hospital and 6-month mortality were analyzed. Intensity of care was assessed by TISS points and the annual costs of intensive care were evaluated. RESULTS The number of ICU admissions from 1996-2000 was 11,323. The proportions of ICU and postoperative patients were 39% and 61%, respectively. The mean age of the patients did not change. The mean Apache II score increased over time both in the ICU and postoperative patients. There was no change in crude hospital mortality. Total ICU costs decreased from 8,660,000 euros (in 1997) to 7,480,000 euros (in 2000). In the ICU patients, the costs of hospital survival decreased towards the end of the study period. CONCLUSIONS We treated more severely ill patients with unchanged outcome but at lower costs towards the end of the study period. Costs of intensive care are not necessarily increasing.
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Affiliation(s)
- I Parviainen
- Department of Anesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland.
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Abstract
Recently, incidence ranges for acute respiratory failure (ARF), acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) in adults were reported and found to be 77.6–88.6, 17.9–34.0, and 12.6–28.0 cases/100 000 population per year, respectively. Mortality rates of approximately 40% were reported for patients with acute respiratory failure, and similar or slightly lower rates for those with ALI and ARDS. Some experts believe that there is a trend toward lower mortality rates in ALI and ARDS, but this suggestion has not been scientifically validated. Additional organ failures, but not oxygenation indices, appear to be crucial with regard to predicting outcome. Finally, it has remained uncertain whether there exists seasonal variability with respect to the frequency of various forms of respiratory failure.
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Affiliation(s)
- Klaus Lewandowski
- Klinik für Anästhesiologie und operative Intensivmedizin, Charité, Campus Virchow-Klinikum, Medizinische Fakultät der Humboldt-Universität zu Berlin, Berlin, Germany.
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