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Ikumi S, Shiga T, Ueda T, Takaya E, Iwasaki Y, Kaiho Y, Tarasawa K, Fushimi K, Ito Y, Fujimori K, Yamauchi M. Intensive care unit mortality and cost-effectiveness associated with intensivist staffing: a Japanese nationwide observational study. J Intensive Care 2023; 11:60. [PMID: 38049894 PMCID: PMC10694900 DOI: 10.1186/s40560-023-00708-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/21/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Japan has four types of intensive care units (ICUs) that are divided into two categories according to the management fee charged per day: ICU management fees 1 and 2 (ICU1/2) (equivalent to high-intensity staffing) and 3 and 4 (ICU3/4) (equivalent to low-intensity staffing). Although ICU1/2 charges a higher rate than ICU3/4, no cost-effectiveness analysis has been performed for ICU1/2. This study evaluated the clinical outcomes and cost-effectiveness of ICU1/2 compared with those of ICU3/4. METHODS This retrospective observational study used a nationwide Japanese administrative database to identify patients admitted to ICUs between April 2020 and March 2021 and divided them into the ICU1/2 and ICU3/4 groups. The ICU mortality rates and in-hospital mortality rates were determined, and the incremental cost-effectiveness ratio (ICER) (Japanese Yen (JPY)/QALY), defined as the difference between quality-adjusted life year (QALY) and medical costs, was compared between ICU1/2 and ICU3/4. Data analysis was performed using the Chi-squared test; an ICER of < 5 million JPY/QALY was considered cost-effective. RESULTS The ICU1/2 group (n = 71,412; 60.7%) had lower ICU mortality rates (ICU 1/2: 2.6% vs. ICU 3/4: 4.3%, p < 0.001) and lower in-hospital mortality rates (ICU 1/2: 6.1% vs. ICU 3/4: 8.9%, p < 0.001) than the ICU3/4 group (n = 46,330; 39.3%). The average cost per patient of ICU1/2 and ICU3/4 was 2,249,270 ± 1,955,953 JPY and 1,682,546 ± 1,588,928 JPY, respectively, with a difference of 566,724. The ICER was 718,659 JPY/QALY, which was below the cost-effectiveness threshold. CONCLUSIONS ICU1/2 is associated with lower ICU patient mortality than ICU3/4. Treatments under ICU1/2 are more cost-effective than those under ICU3/4, with an ICER of < 5 million JPY/QALY.
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Affiliation(s)
- Saori Ikumi
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
- AI Lab, Tohoku University Hospital, Sendai, Japan
| | - Takuya Shiga
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
- Experience Design and Alliance Section, Tohoku University Hospital, Sendai, Japan.
- Department of Biodesign, Center for Research, Education, and Innovation, Tohoku University Hospital, Sendai, Japan.
- Department of Intensive Care Unit, Tohoku University Hospital, Sendai, Japan.
| | - Takuya Ueda
- AI Lab, Tohoku University Hospital, Sendai, Japan
- Department of Clinical Imaging, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Eichi Takaya
- AI Lab, Tohoku University Hospital, Sendai, Japan
| | - Yudai Iwasaki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yu Kaiho
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kunio Tarasawa
- Department of Health Administration and Policy, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Yukiko Ito
- College of Policy Studies, Tsuda University, Tokyo, Japan
| | - Kenji Fujimori
- Department of Health Administration and Policy, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masanori Yamauchi
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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Kamdar BB, Suri R, Suchyta MR, Digrande KF, Sherwood KD, Colantuoni E, Dinglas VD, Needham DM, Hopkins RO. Return to work after critical illness: a systematic review and meta-analysis. Thorax 2020; 75:17-27. [PMID: 31704795 PMCID: PMC7418481 DOI: 10.1136/thoraxjnl-2019-213803] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/11/2019] [Accepted: 09/01/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Survivors of critical illness often experience poor outcomes after hospitalisation, including delayed return to work, which carries substantial economic consequences. OBJECTIVE To conduct a systematic review and meta-analysis of return to work after critical illness. METHODS We searched PubMed, Embase, PsycINFO, CINAHL and Cochrane Library from 1970 to February 2018. Data were extracted, in duplicate, and random-effects meta-regression used to obtain pooled estimates. RESULTS Fifty-two studies evaluated return to work in 10 015 previously employed survivors of critical illness, over a median (IQR) follow-up of 12 (6.25-38.5) months. By 1-3, 12 and 42-60 months' follow-up, pooled return to work prevalence (95% CI) was 36% (23% to 49%), 60% (50% to 69%) and 68% (51% to 85%), respectively (τ2=0.55, I2=87%, p=0.03). No significant difference was observed based on diagnosis (acute respiratory distress syndrome (ARDS) vs non-ARDS) or region (Europe vs North America vs Australia/New Zealand), but was observed when comparing mode of employment evaluation (in-person vs telephone vs mail). Following return to work, 20%-36% of survivors experienced job loss, 17%-66% occupation change and 5%-84% worsening employment status (eg, fewer work hours). Potential risk factors for delayed return to work include pre-existing comorbidities and post-hospital impairments (eg, mental health). CONCLUSION Approximately two-thirds, two-fifths and one-third of previously employed intensive care unit survivors are jobless up to 3, 12 and 60 months following hospital discharge. Survivors returning to work often experience job loss, occupation change or worse employment status. Interventions should be designed and evaluated to reduce the burden of this common and important problem for survivors of critical illness. TRIAL REGISTRATION NUMBER PROSPERO CRD42018093135.
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Affiliation(s)
- Biren B Kamdar
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Rajat Suri
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Mary R Suchyta
- InstaCare, Intermountain Health Care, Salt Lake City, Utah, USA
| | - Kyle F Digrande
- Department of Medicine, University of California Irvine, Irvine, California, USA
| | - Kyla D Sherwood
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Elizabeth Colantuoni
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Biostatistics, Johns Hopkins University-Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Victor D Dinglas
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ramona O Hopkins
- Center for Humanizing Critical Care, Intermountain Health Care, Murray, Utah, USA
- Psychology Department and Neuroscience Center, Brigham Young University, Provo, Utah, USA
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Return to Employment after Critical Illness and Its Association with Psychosocial Outcomes. A Systematic Review and Meta-Analysis. Ann Am Thorac Soc 2019; 16:1304-1311. [DOI: 10.1513/annalsats.201903-248oc] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Stewart S, Robertson C, Manoukian S, Haahr L, Mason H, McFarland A, Dancer S, Cook B, Reilly J, Graves N. How do we evaluate the cost of nosocomial infection? The ECONI protocol: an incidence study with nested case-control evaluating cost and quality of life. BMJ Open 2019; 9:e026687. [PMID: 31221878 PMCID: PMC6588979 DOI: 10.1136/bmjopen-2018-026687] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 04/08/2019] [Accepted: 05/08/2019] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Healthcare-associated or nosocomial infection (HAI) is distressing to patients and costly for the National Health Service (NHS). With increasing pressure to demonstrate cost-effectiveness of interventions to control HAI and notwithstanding the risk from antimicrobial-resistant infections, there is a need to understand the incidence rates of HAI and costs incurred by the health system and for patients themselves. METHODS AND ANALYSIS The Evaluation of Cost of Nosocomial Infection study (ECONI) is an observational incidence survey with record linkage and a nested case-control study that will include postdischarge longitudinal follow-up and qualitative interviews. ECONI will be conducted in one large teaching hospital and one district general hospital in NHS Scotland. The case mix of these hospitals reflects the majority of overnight admissions within Scotland. An incidence survey will record all HAI cases using standard case definitions. Subsequent linkage to routine data sets will provide information on an admission cohort which will be grouped into HAI and non-HAI cases. The case-control study will recruit eligible patients who develop HAI and twice that number without HAI as controls. Patients will be asked to complete five questionnaires: the first during their stay, and four others during the year following discharge from their recruitment admission (1, 3, 6 and 12 months). Multiple data collection methods will include clinical case note review; patient-reported outcome; linkage to electronic health records and qualitative interviews. Outcomes collected encompass infection types; morbidity and mortality; length of stay; quality of life; healthcare utilisation; repeat admissions and postdischarge prescribing. ETHICS AND DISSEMINATION The study has received a favourable ethical opinion from the Scotland A Research Ethics Committee (reference 16/SS/0199). All publications arising from this study will be published in open-access peer-reviewed journal. Lay-person summaries will be published on the ECONI website. TRIAL REGISTRATION NUMBER NCT03253640; Pre-results.
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Affiliation(s)
- Sally Stewart
- Safeguarding Health through Infection Prevention Research Group, Centre for Living, Glasgow Caledonian University, Glasgow, UK
| | - Chris Robertson
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
| | - Sarkis Manoukian
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Lynne Haahr
- Safeguarding Health through Infection Prevention Research Group, Centre for Living, Glasgow Caledonian University, Glasgow, UK
| | - Helen Mason
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Agi McFarland
- Safeguarding Health through Infection Prevention Research Group, Centre for Living, Glasgow Caledonian University, Glasgow, UK
| | - Stephanie Dancer
- Department of Microbiology, Hairmyres Hospital, NHS Lanarkshire, Scotland, UK
| | - Brian Cook
- University Hospitals & Support Services, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jacqui Reilly
- Safeguarding Health through Infection Prevention Research Group, Centre for Living, Glasgow Caledonian University, Glasgow, UK
| | - Nicholas Graves
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
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Why Did Poisoned Patients Eventually Die Long After Their ICU Stay? Crit Care Med 2015; 43:e25-6. [DOI: 10.1097/ccm.0000000000000642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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KARHU J, ALA-KOKKO TI, YLIPALOSAARI P, OHTONEN P, LAURILA JJ, SYRJÄLÄ H. Hospital and long-term outcomes of ICU-treated severe community- and hospital-acquired, and ventilator-associated pneumonia patients. Acta Anaesthesiol Scand 2011; 55:1254-60. [PMID: 22092131 DOI: 10.1111/j.1399-6576.2011.02535.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2011] [Indexed: 01/04/2023]
Abstract
BACKGROUND Our purpose was to analyse the association of pneumonia types with hospital and long-term outcomes of intensive care unit (ICU)-treated pneumonia patients. METHODS The occurrence of pneumonia was retrospectively evaluated among prospectively registered patients admitted into a mixed university-level ICU during a 14-month period. Their age, severity of underlying disease, malignancy, immunosuppressive therapy and organ dysfunctions were recorded, as well as the length of hospital stay and short- and long-term mortalities. RESULTS There were 117 severe community-acquired pneumonia (SCAP), 66 hospital-acquired pneumonia (HAP) and 25 ventilator-associated pneumonia (VAP) cases among the 817 patients admitted. ICU and hospital mortality did not differ between pneumonia groups. VAP and HAP patients had more malignant underlying diseases than SCAP patients (P < 0.001). HAP patients were older than SCAP and VAP patients (P = 0.023). The admission Acute Physiology and Chronic Health Evaluation II scores did not differ between the groups (P > 0.90). The patients with VAP had higher Sequential Organ Failure Assessment maximum scores compared with patients with SCAP and HAP (P < 0.001). In an adjusted multivariate logistic regression model, there were no significant differences in odds ratios for hospital mortality between the three pneumonia types. Mortality among the hospital survivors during the 12-month follow-up period was 18% (16/89) in the SCAP group, 35% (18/51) in the HAP group and 41% (7/17) in the VAP group (P = 0.023). CONCLUSION The type of pneumonia (i.e. SCAP, HAP or VAP) had no significant association with hospital mortality, whereas the SCAP patients had the lowest 1-year mortality.
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Affiliation(s)
- J. KARHU
- Department of Anaesthesiology; Division of Intensive Care; Oulu University Hospital; Oulu; Finland
| | - T. I. ALA-KOKKO
- Department of Anaesthesiology; Division of Intensive Care; Oulu University Hospital; Oulu; Finland
| | - P. YLIPALOSAARI
- Department of Infection Control; Oulu University Hospital; Oulu; Finland
| | - P. OHTONEN
- Departments of Anaesthesiology and Surgery; Oulu University Hospital; Oulu; Finland
| | - J. J. LAURILA
- Department of Anaesthesiology; Division of Intensive Care; Oulu University Hospital; Oulu; Finland
| | - H. SYRJÄLÄ
- Department of Infection Control; Oulu University Hospital; Oulu; Finland
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Prowle JR, Echeverri JE, Ligabo EV, Sherry N, Taori GC, Crozier TM, Hart GK, Korman TM, Mayall BC, Johnson PDR, Bellomo R. Acquired bloodstream infection in the intensive care unit: incidence and attributable mortality. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R100. [PMID: 21418635 PMCID: PMC3219371 DOI: 10.1186/cc10114] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 02/25/2011] [Accepted: 03/21/2011] [Indexed: 12/21/2022]
Abstract
INTRODUCTION To estimate the incidence of intensive care unit (ICU)-acquired bloodstream infection (BSI) and its independent effect on hospital mortality. METHODS We retrospectively studied acquisition of BSI during admissions of >72 hours to adult ICUs from two university-affiliated hospitals. We obtained demographics, illness severity and co-morbidity data from ICU databases and microbiological diagnoses from departmental electronic records. We assessed survival at hospital discharge or at 90 days if still hospitalized. RESULTS We identified 6339 ICU admissions, 330 of which were complicated by BSI (5.2%). Median time to first positive culture was 7 days (IQR 5-12). Overall mortality was 23.5%, 41.2% in patients with BSI and 22.5% in those without. Patients who developed BSI had higher illness severity at ICU admission (median APACHE III score: 79 vs. 68, P < 0.001). After controlling for illness severity and baseline demographics by Cox proportional-hazard model, BSI remained independently associated with risk of death (hazard ratio from diagnosis 2.89; 95% confidence interval 2.41-3.46; P < 0.001). However, only 5% of the deaths in this model could be attributed to acquired-BSI, equivalent to an absolute decrease in survival of 1% of the total population. When analyzed by microbiological classification, Candida, Staphylococcus aureus and gram-negative bacilli infections were independently associated with increased risk of death. In a sub-group analysis intravascular catheter associated BSI remained associated with significant risk of death (hazard ratio 2.64; 95% confidence interval 1.44-4.83; P = 0.002). CONCLUSIONS ICU-acquired BSI is associated with greater in-hospital mortality, but complicates only 5% of ICU admissions and its absolute effect on population mortality is limited. These findings have implications for the design and interpretation of clinical trials.
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Affiliation(s)
- John R Prowle
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084, Australia
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Abstract
OBJECTIVES To evaluate quality of life at least 12 months after discharge from the intensive care unit of adult critically ill patients, to evaluate the methodology used to assess long-term quality of life, and to give an overview of factors influencing quality of life. DATA SOURCES EMBASE-PubMed, MEDLINE (OVID), SCI/Web of Science, the Cochrane Library, Google Scholar, and personal files. DATA EXTRACTION Data extraction was performed independently and cross-checked by two reviewers using a predefined data extraction form. Eligible studies were published between 1999 and 2009 and assessed quality of life ≥12 months after intensive care unit discharge by means of the Medical Outcomes Study 36-Item Short Form Health Survey, the RAND 36-Item Health Survey, EuroQol-5D, and/or the Nottingham Health Profile in adult intensive care unit patients. DATA SYNTHESIS Fifty-three articles (10 multicenters) were included, with the majority of studies performed in Europe (68%). The Medical Outcomes Study 36-Item Short Form Health Survey was used in 55%, and the EuroQol-5D, the Nottingham Health Profile, the RAND 36-Item Health Survey, or a combination was used in 21%, 9%, 8%, or 8%, respectively. A response rate of ≥80% was attained in 26 studies (49%). Critically ill patients had a lower quality of life than an age- and gender-matched population, but quality of life tended to improve over years. The worst reductions in quality of life were seen in cases of severe acute respiratory distress syndrome, prolonged mechanical ventilation, severe trauma, and severe sepsis. Study quality criteria, defined as a baseline quality of life assessment, the absence of major exclusion criteria, a description of nonresponders, and a comparison with a reference population were met in only four studies (8%). Results concerning the influence of severity of illness, comorbidity, preadmission quality of life, age, gender, or acquired complications were conflicting. CONCLUSIONS Quality of life differed on diagnostic category but, overall, critically ill patients had a lower quality of life than an age- and gender-matched population. A minority of studies met the predefined methodologic quality criteria. Results concerning the influence of the patients' characteristics and illnesses on long-term quality of life were conflicting.
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Karagozian R, Johannes RS, Sun X, Burakoff R. Increased mortality and length of stay among patients with inflammatory bowel disease and hospital-acquired infections. Clin Gastroenterol Hepatol 2010; 8:961-5. [PMID: 20723618 DOI: 10.1016/j.cgh.2010.07.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Revised: 07/01/2010] [Accepted: 07/23/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Hospitalized patients with inflammatory bowel disease (IBD) could be at increased risk for hospital-acquired infections (HAIs). By using HAI outcome data from Pennsylvania, we examined the influence of HAIs on in-patient mortality and length of stay (LOS) in the hospital among patients with IBD. METHODS Data were generated by linking the Clinical Research Databases from CareFusion (formerly MediQual), which includes all acute care hospitals in Pennsylvania, with publicly reported HAI data from Pennsylvania. The study population included all patients discharged in 2004 with International Classification of Diseases, 9th Clinical Modification codes of 555.x or 556.x (2324 IBD cases from 161 hospitals). Controls were selected using risk-score matching with a 5:1 ratio. Mortality and LOS end points were estimated and corroborated with regression methods. RESULTS Among the IBD patients studied, there were 20 deaths and 22 reported cases of HAI. The mortality from HAI among patients with IBD was 13.6%, compared with 0.9% among controls (P = .0146, Fisher exact test). The odds ratio for mortality was 17.2 (95% confidence interval, 1.7-174.3). The median LOS for patients with IBD and HAI was 22 days, versus 6 days for controls (P < .001, Wilcoxon). Of the 22 cases with HAIs, 15 were urinary tract infections, 5 were blood stream infections, and 2 were from multiple sources. CONCLUSIONS Results from a population-based data set indicate that mortality and LOS are increased among IBD patients who develop HAIs. A majority of the HAIs were from urinary sources. Although HAIs are low-frequency events, increased vigilance to avoid HAI among patients with IBD could improve outcomes.
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Affiliation(s)
- Raffi Karagozian
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Selective decontamination of the digestive tract reduces pneumonia and mortality. Crit Care Res Pract 2010; 2010:501031. [PMID: 20981328 PMCID: PMC2958652 DOI: 10.1155/2010/501031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 09/20/2010] [Indexed: 11/20/2022] Open
Abstract
Selective decontamination of the digestive tract (SDD) has been subject of numerous randomized controlled trials in critically ill patients. Almost all clinical trials showed SDD to prevent pneumonia. Nevertheless, SDD has remained a controversial strategy. One reason for why clinicians remained reluctant to implement SDD into daily practice could be that mortality was reduced in only 2 trials. Another reason could be the heterogeneity of trials of SDD. Indeed, many different prophylactic antimicrobial regimes were tested, and dissimilar diagnostic criteria for pneumonia were applied amongst the trials. This heterogeneity impeded interpretation and comparison of trial results. Two other hampering factors for implementation of SDD have been concerns over the risk of antimicrobial resistance and fear for escalation of costs associated with the use of prophylactic antimicrobials. This paper describes the concept of SDD, summarizes the results of published trials of SDD in mixed medical-surgical intensive care units, and rationalizes the risk of antimicrobial resistance and rise of costs associated with this potentially life-saving preventive strategy.
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Nseir S, Makris D, Mathieu D, Durocher A, Marquette CH. Intensive Care Unit-acquired infection as a side effect of sedation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R30. [PMID: 20226064 PMCID: PMC2887136 DOI: 10.1186/cc8907] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2009] [Revised: 01/03/2010] [Accepted: 03/15/2010] [Indexed: 12/17/2022]
Abstract
Introduction Sedative and analgesic medications are routinely used in mechanically ventilated patients. The aim of this review is to discus epidemiologic data that suggest a relationship between infection and sedation, to review available data for the potential causes and pathophysiology of this relationship, and to identify potential preventive measures. Methods Data for this review were identified through searches of PubMed, and from bibliographies of relevant articles. Results Several epidemiologic studies suggested a link between sedation and ICU-acquired infection. Prolongation of exposure to risk factors for infection, microaspiration, gastrointestinal motility disturbances, microcirculatory effects are main mechanisms by which sedation may favour infection in critically ill patients. Furthermore, experimental evidence coming from studies both in humans and animals suggest that sedatives and analgesics present immunomodulatory properties that might alter the immunologic response to exogenous stimuli. Clinical studies comparing different sedative agents do not provide evidence to recommend the use of a particular agent to reduce ICU-acquired infection rate. However, sedation strategies aiming to reduce the duration of mechanical ventilation, such as daily interruption of sedatives or nursing-implementing sedation protocol, should be promoted. In addition, the use of short acting opioids, propofol, and dexmedetomidine is associated with shorter duration of mechanical ventilation and ICU stay, and might be helpful in reducing ICU-acquired infection rates. Conclusions Prolongation of exposure to risk factors for infection, microaspiration, gastrointestinal motility disturbances, microcirculatory effects, and immunomodulatory effects are main mechanisms by which sedation may favour infection in critically ill patients. Future studies should compare the effect of different sedative agents, and the impact of progressive opioid discontinuation compared with abrupt discontinuation on ICU-acquired infection rates.
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Affiliation(s)
- Saad Nseir
- Intensive Care Unit, Calmette Hospital, University Hospital of Lille, boulevard du Pr Leclercq, Lille cedex, France.
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