1
|
Kruit N, Burrell A, Tian D, Barrett N, Bělohlávek J, Bernard S, Braude D, Buscher H, Chen YS, Donker DW, Finney S, Forrest P, Fowles JA, Hifumi T, Hodgson C, Hutin A, Inoue A, Jung JS, Kruse JM, Lamhaut L, Ming-Hui Lin R, Reis Miranda D, Müller T, Bhagyalakshmi Nanjayya V, Nickson C, Pellegrino V, Plunkett B, Richardson C, Alexander Richardson S, Shekar K, Shinar Z, Singer B, Stub D, Totaro RJ, Vuylsteke A, Yannopoulos D, Zakhary B, Dennis M. Corrigendum to "Expert consensus on training and accreditation for extracorporeal cardiopulmonary resuscitation an international, multidisciplinary modified Delphi Study" [Resuscitation 192 (2023) 109989]. Resuscitation 2024; 194:110046. [PMID: 37996305 DOI: 10.1016/j.resuscitation.2023.110046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Affiliation(s)
- Natalie Kruit
- Department of Perioperative Medicine, Westmead Hospital, Hawksbury Rd, Westmead, NSW 2145, Australia.
| | - Aidan Burrell
- The Alfred Hospital, Melbourne, Victoria, Australia.
| | | | | | - Jan Bělohlávek
- Chair EuroELSO Working Group on ECPR, Deputy Head, 2nd Dept. of Internal Medicine, Cardiovascular Medicine U Nemocnice 2, Prague 2 128 00, Czech Republic.
| | | | - Darren Braude
- Division of Prehospital, Austere and Disaster Medicine, NM, USA.
| | | | | | | | | | - Paul Forrest
- RPAH and Sydney University Medical School, Australia.
| | - Jo-Anne Fowles
- Royal Papworth NHS Foundation Trust, Cambridge Biomedical Campus l Cambridge, UK.
| | - Toru Hifumi
- St. Luke's International Hospital, Tokyo, Japan.
| | | | - Alice Hutin
- Assistance Publique-Hôpitaux de Paris, Paris, France.
| | | | - Jae-Seung Jung
- Korea University Anam Hospital, Seoul, Republic of Korea.
| | - J M Kruse
- Charité - Universitätsmedizin Berlin, Germany.
| | | | - Richard Ming-Hui Lin
- Director of Emergency and Critical Care Services, Lin Shin Hospital, Taichung, Taiwan.
| | | | | | | | | | | | | | | | | | - Kiran Shekar
- The Prince Charles Hospital, Brisbane, QLD, Australia.
| | | | - Ben Singer
- St Bartholomew's Hospital, London, UK London's Air Ambulance, London, UK.
| | - Dion Stub
- The Alfred Hosptial, Victoria, Australia.
| | | | | | | | | | - Mark Dennis
- Royal Prince Alfred Hospital, Faculty of Medicine and Health, University of Sydney, Australia.
| |
Collapse
|
2
|
Kruit N, Burrell A, Tian D, Barrett N, Bělohlávek J, Bernard S, Braude D, Buscher H, Chen YS, Donker DW, Finney S, Forrest P, Fowles JA, Hifumi T, Hodgson C, Hutin A, Inoue A, Jung JS, Kruse JM, Lamhaut L, Ming-Hui Lin R, Reis Miranda D, Müller T, Bhagyalakshmi Nanjayya V, Nickson C, Pellegrino V, Plunkett B, Richardson C, Alexander Richardson S, Shekar K, Shinar Z, Singer B, Stub D, Totaro RJ, Vuylsteke A, Yannopoulos D, Zakhary B, Dennis M. Expert consensus on training and accreditation for extracorporeal cardiopulmonary resuscitation an international, multidisciplinary modified Delphi Study. Resuscitation 2023; 192:109989. [PMID: 37805061 DOI: 10.1016/j.resuscitation.2023.109989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/19/2023] [Accepted: 09/27/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND A multidisciplinary group of stakeholders were used to identify: (1) the core competencies of a training program required to perform in-hospital ECPR initiation (2) additional competencies required to perform pre-hospital ECPR initiation and; (3) the optimal training method and maintenance protocol for delivering an ECPR program. METHODS A modified Delphi process was undertaken utilising two web based survey rounds and one virtual meeting. Experts rated the importance of different aspects of ECPR training, competency and governance on a 9-point Likert scale. A diverse, representative group was targeted. Consensus was achieved when greater than 70% respondents rated a domain as critical (> or = 7 on the 9 point Likert scale). RESULTS 35 international ECPR experts from 9 countries formed the expert panel, with a median number of 14 years of ECMO practice (interquartile range 11-38). Participant response rates were 97% (survey round one), 63% (virtual meeting) and 100% (survey round two). After the second round of the survey, 47 consensus statements were formed outlining a core set of competencies required for ECPR provision. We identified key elements required to safely train and perform ECPR including skill pre-requisites, surrogate skill identification, the importance of competency-based assessment over volume of practice and competency requirements for successful ECPR practice and skill maintenance. CONCLUSIONS We present a series of core competencies, training requirements and ongoing governance protocols to guide safe ECPR implementation. These findings can be used to develop training syllabus and guide minimum standards for competency as the growth of ECPR practitioners continues.
Collapse
Affiliation(s)
- Natalie Kruit
- Department of Perioperative Medicine, Westmead Hospital, Hawksbury Rd, Westmead, NSW 2145, Australia.
| | - Aidan Burrell
- The Alfred Hospital, Melbourne, Victoria, Australia.
| | | | | | - Jan Bělohlávek
- Chair EuroELSO Working Group on ECPR, Deputy Head, 2(nd) Dept. of Internal Medicine, Cardiovascular Medicine U Nemocnice 2, Prague 2 128 00, Czech Republic.
| | | | - Darren Braude
- Division of Prehospital, Austere and Disaster Medicine, NM, United States.
| | | | | | | | | | - Paul Forrest
- RPAH and Sydney University Medical School, Australia.
| | - Jo-Anne Fowles
- Royal Papworth NHS Foundation Trust, Cambridge Biomedical Campus l Cambridge, UK.
| | - Toru Hifumi
- St. Luke's International Hospital, Tokyo, Japan.
| | | | - Alice Hutin
- Assistance Publique-Hôpitaux de Paris, Paris, France.
| | | | - Jae-Seung Jung
- Korea University Anam Hospital, Seoul, Republic of Korea.
| | - J M Kruse
- Charité - Universitätsmedizin Berlin, Germany.
| | | | - Richard Ming-Hui Lin
- Director of Emergency and Critical Care Services, Lin Shin Hospital, Taichung, Taiwan.
| | | | | | | | | | | | | | | | | | - Kiran Shekar
- The Prince Charles Hospital, Brisbane, QLD, Australia.
| | | | - Ben Singer
- St Bartholomew's Hospital, London, UK London's Air Ambulance, London, UK.
| | - Dion Stub
- The Alfred Hosptial, Victoria, Australia.
| | | | | | | | | | - Mark Dennis
- Royal Prince Alfred Hospital, Faculty of Medicine and Health, University of Sydney, Australia.
| |
Collapse
|
3
|
Lorusso R, De Piero ME, Mariani S, Di Mauro M, Folliguet T, Taccone FS, Camporota L, Swol J, Wiedemann D, Belliato M, Broman LM, Vuylsteke A, Kassif Y, Scandroglio AM, Fanelli V, Gaudard P, Ledot S, Barker J, Boeken U, Maier S, Kersten A, Meyns B, Pozzi M, Pedersen FM, Schellongowski P, Kirali K, Barrett N, Riera J, Mueller T, Belohlavek J, Lorusso R, De Piero ME, Mariani S, Di Mauro M, Folliguet T, Taccone FS, Camporota L, Swol J, Wiedemann D, Belliato M, Broman LM, Vuylsteke A, Kassif Y, Scandroglio AM, Fanelli V, Gaudard P, Ledot S, Barker J, Boeken U, Maier S, Kersten A, Meyns B, Pozzi M, Pedersen FM, Schellongowski P, Kirali K, Barrett N, Riera J, Mueller T, Belohlavek J, Lo Coco V, Van der Horst ICC, Van Bussel BCT, Schnabel RM, Delnoij T, Bolotin G, Lorini L, Schmiady MO, Schibilsky D, Kowalewski M, Pinto LF, Silva PE, Kornilov I, Blandino Ortiz A, Vercaemst L, Finney S, Roeleveld PP, Di Nardo M, Hennig F, Antonini MV, Davidson M, Jones TJ, Staudinger T, Mair P, Kilo J, Krapf C, Erbert K, Peer A, Bonaros N, Kotheletner F, Krenner Mag N, Shestakova L, Hermans G, Dauwe D, Meersseman P, Stockman B, Nobile L, Lhereux O, Nrasseurs A, Creuter J, De Backer D, Giglioli S, Michiels G, Foulon P, Raes M, Rodrigus I, Allegaert M, Jorens P, Debeucklare G, Piagnarelli M, Biston P, Peperstraete H, Vandewiele K, Germay O, Vandeweghe D, Havrin S, Bourgeois M, Lagny MG, Alois G, Lavios N, Misset B, Courcelle R, Timmermans PJ, Yilmaz A, Vantomout M, Lehaen J, Jassen A, Guterman H, Strauven M, Lormans P, Verhamme B, Vandewaeter C, Bonte F, Vionne D, Balik M, Blàha J, Lips M, Othal M, Bursa F, Spacek R, Christensen S, Jorgensen V, Sorensen M, Madsen SA, Puss S, Beljantsev A, Saiydoun G, Fiore A, Colson P, Bazalgette F, Capdevila X, Kollen S, Muller L, Obadia JF, Dubien PY, Ajrhourh L, Guinot PG, Zarka J, Besserve P, Malfertheiner MV, Dreier E, Heinze B, Akhyari P, Lichtenberg A, Aubin H, Assman A, Saeed D, Thiele H, Baumgaertel M, Schmitto JD, Ruslan N, Haverich A, Thielmann M, Brenner T, Ruhpawar A, Benk C, Czerny M, Staudacher DL, Beyersdorf F, Kalbhenn J, Henn P, Popov AF, Iuliu T, Muellenbach R, Reyher C, Rolfes C, Lotz G, Sonntagbauer M, Winkels H, Fichte J, Stohr R, Kalverkamp S, Karagiannidis C, Schafer S, Svetlitchny A, Fichte J, Hopf HB, Jarczak D, Groesdonk H, Rommer M, Hirsch J, Kaehny C, Soufleris D, Gavriilidis G, Pontikis K, Kyriakopoulou M, Kyriakoudi A, O'Brien S, Conrick-Martin I, Carton E, Makhoul M, Ben-Ari J, Hadash A, Kogan A, Kassif Lerner R, Abu-Shakra A, Matan M, Balawona A, Kachel E, Altshuler R, Galante O, Fuchs L, Almog Y, Ishay YS, Lichter Y, Gal-oz A, Carmi U, Nini A, Soroksky A, Dekel H, Rozman Z, Tayem E, Ilgiyaev E, Hochman Y, Miltau D, Rapoport A, Eden A, Kompanietz D, Yousif M, Golos M, Grazioli L, Ghitti D, Loforte A, Di Luca D, Baiocchi M, Pacini D, Cappai A, Meani P, Mondino M, Russo CF, Ranucci M, Fina D, Cotza M, Ballotta A, Landoni G, Nardelli P, Fominski EV, Brazzi L, Montrucchio G, Sales G, Simonetti U, Livigni S, Silengo D, Arena G, Sovatzis SS, Degani A, Riccardi M, Milanesi E, Raffa G, Martucci G, Arcadipane A, Panarello G, Chiarini G, Cattaneo S, Puglia C, Benussi S, Foti G, Giani M, Bombino M, Costa MC, Rona R, Avalli L, Donati A, Carozza R, Gasparri F, Carsetti A, Picichè M, Marinello A, Danzi V, Zanin A, Condello I, Fiore F, Moscarelli M, Nasso G, Speziale G, Sandrelli L, Montalto A, Musumeci F, Circelli A, Russo E, Agnoletti V, Rociola R, Milano AD, Pilato E, Comentale G, Montisci A, Alessandri F, Tosi A, Pugliese F, Giordano G, Carelli S, Grieco DL, Dell'Anna AM, Antonelli M, Ramoni E, Zulueta J, Del Giglio M, Petracca S, Bertini P, Guarracino F, De Simone L, Angeletti PM, Forfori F, Taraschi F, Quintiliani VN, Samalavicius R, Jankuviene A, Scupakova N, Urbonas K, Kapturauskas J, Soerensen G, Suwalski P, Linhares Santos L, Marques A, Miranda M, Teixeira S, Salgueiro A, Pereira F, Ketskalo M, Tsarenko S, Shilova A, Afukov I, Popugaev K, Minin S, Shelukhin D, Malceva O, Gleb M, Skopets A, Kornelyuk R, Kulikov A, Okhrimchuk V, Turchaninov A, Shelukhin D, Petrushin M, Sheck A, Mekulov A, Ciryateva S, Urusov D, Gorjup V, Golicnik A, Goslar T, Ferrer R, Martinez-Martinez M, Argudo E, Palmer N, De Pablo Sanchez R, Juan Higuera L, Arnau Blasco L, Marquez JA, Sbraga F, Fuset MP, De Gopegui PR, Claraco LM, De Ayala JA, Peiro M, Ricart P, Martinez S, Chavez F, Fabra M, Sandoval E, Toapanta D, Carraminana A, Tellez A, Ososio J, Milan P, Rodriguez J, Andoni G, Gutierrez C, Perez de la Sota E, Eixeres-Esteve A, Garcia-Maellas MT, Gutierrez-Gutierrez J, Arboleda-Salazar R, Santa Teresa P, Jaspe A, Garrido A, Castaneda G, Alcantara S, Martinez N, Perez M, Villanueva H, Vidal Gonzalez A, Paez J, Santon A, Perez C, Lopez M, Rubio Lopez MI, Gordillo A, Naranjo-Izurieta J, Munoz J, Alcalde I, Onieva F, Gimeno Costa R, Perez F, Madrid I, Gordon M, Albacete Moreno CL, Perez D, Lopez N, Martinenz D, Blanco-Schweizer P, Diez C, Perez D, Prieto A, Renedo G, Bustamante E, Cicuendez R, Citores R, Boado V, Garcia K, Voces R, Domezain M, Nunez Martinez JM, Vicente R, Martin D, Andreu A, Gomez Casal V, Chico I, Menor EM, Vara S, Gamacho J, Perez-Chomon H, Javier Gonzales F, Barrero I, Martin-Villen L, Fernandez E, Mendoza M, Navarro J, Colomina Climent J, Gonzales-Perez A, Muniz-Albaceita G, Amado L, Rodriguez R, Ruiz E, Eiras M, Grins E, Magnus R, Kanetoft M, Eidevald M, Watson P, Vogt PR, Steiger P, Aigner T, Weber A, Grunefelder J, Kunz M, Grapow M, Aymard T, Reser D, Agus G, Consiglio J, Haenggi M, Hansjoerg J, Iten M, Doeble T, Zenklusen U, Bechtold X, Faedda G, Iafrate M, Rohjer A, Bergamaschi L, Maessen J, Reis Miranda D, Endeman H, Gommers D, Meuwese C, Maas J, Van Gijlswijk MJ, Van Berg RN, Candura D, Van der Linden M, Kant M, Van der Heijden JJ, Scholten E, Van Belle-van Haren N, Lagrand WK, Vlaar AP, De Jong S, Cander B, Sargin M, Ugur M, Kaygin MA, Daly K, Agnew N, Head L, Kelly L, Anoma G, Russell C, Aquino V, Scott I, Flemming L, Gillon S, Moore O, Gelandt E, Auzinger G, Patel S, Loveridge R. In-hospital and 6-month outcomes in patients with COVID-19 supported with extracorporeal membrane oxygenation (EuroECMO-COVID): a multicentre, prospective observational study. Lancet Respir Med 2023; 11:151-162. [PMID: 36402148 PMCID: PMC9671669 DOI: 10.1016/s2213-2600(22)00403-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 09/18/2022] [Accepted: 09/23/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been widely used in patients with COVID-19, but uncertainty remains about the determinants of in-hospital mortality and data on post-discharge outcomes are scarce. The aims of this study were to investigate the variables associated with in-hospital outcomes in patients who received ECMO during the first wave of COVID-19 and to describe the status of patients 6 months after ECMO initiation. METHODS EuroECMO-COVID is a prospective, multicentre, observational study developed by the European Extracorporeal Life Support Organization. This study was based on data from patients aged 16 years or older who received ECMO support for refractory COVID-19 during the first wave of the pandemic-from March 1 to Sept 13, 2020-at 133 centres in 21 countries. In-hospital mortality and mortality 6 months after ECMO initiation were the primary outcomes. Mixed-Cox proportional hazards models were used to investigate associations between patient and management-related variables (eg, patient demographics, comorbidities, pre-ECMO status, and ECMO characteristics and complications) and in-hospital deaths. Survival status at 6 months was established through patient contact or institutional charts review. This study is registered with ClinicalTrials.gov, NCT04366921, and is ongoing. FINDINGS Between March 1 and Sept 13, 2020, 1215 patients (942 [78%] men and 267 [22%] women; median age 53 years [IQR 46-60]) were included in the study. Median ECMO duration was 15 days (IQR 8-27). 602 (50%) of 1215 patients died in hospital, and 852 (74%) patients had at least one complication. Multiorgan failure was the leading cause of death (192 [36%] of 528 patients who died with available data). In mixed-Cox analyses, age of 60 years or older, use of inotropes and vasopressors before ECMO initiation, chronic renal failure, and time from intubation to ECMO initiation of 4 days or more were associated with higher in-hospital mortality. 613 patients did not die in hospital, and 547 (95%) of 577 patients for whom data were available were alive at 6 months. 102 (24%) of 431 patients had returned to full-time work at 6 months, and 57 (13%) of 428 patients had returned to part-time work. At 6 months, respiratory rehabilitation was required in 88 (17%) of 522 patients with available data, and the most common residual symptoms included dyspnoea (185 [35%] of 523 patients) and cardiac (52 [10%] of 514 patients) or neurocognitive (66 [13%] of 512 patients) symptoms. INTERPRETATION Patient's age, timing of cannulation (<4 days vs ≥4 days from intubation), and use of inotropes and vasopressors are essential factors to consider when analysing the outcomes of patients receiving ECMO for COVID-19. Despite post-discharge survival being favourable, persisting long-term symptoms suggest that dedicated post-ECMO follow-up programmes are required. FUNDING None.
Collapse
Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, Netherlands.
| | - Maria Elena De Piero
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Silvia Mariani
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Michele Di Mauro
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Thierry Folliguet
- Department of Cardiac Surgery, Assistance Publique–Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - Justyna Swol
- Department of Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University Hospital of Vienna, Vienna, Austria
| | - Mirko Belliato
- Anestesia e Rianimazione II Cardiopolmonare, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Policlinico San Matteo, Pavia, Italy
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Alain Vuylsteke
- ECMO Retrieval Service & Critical Care, Royal Papworth Hospital, NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
| | - Yigal Kassif
- Heart Transplantation Unit, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Ramat Gan, Israel
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vito Fanelli
- Department of Surgical Sciences, Anesthesia and Intensive Care Medicine, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Centre Hospitalier Universitaire Montpellier, Montpellier, France,Le laboratoire de Physiologie et Médecine Expérimentale du Coeur et des Muscles (PhyMedExp), Université de Montpellier, INSERM, CNRS, Montpellier, France
| | - Stephane Ledot
- Intensive Care Unit, Royal Brompton & Harefield hospitals, London, UK
| | - Julian Barker
- Cardiothoracic Critical Care Unit, Whythenshawe Hospital, Manchester, UK
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center University Freiburg, Bad Krozingen, Germany,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alexander Kersten
- Medizinische Klinik, Uniklinik Rheinisch-Westfälische Technische Hochschule, Aachen, Germany
| | - Bart Meyns
- Department of Cardiac Surgery, Universitair Ziekenhuis Leuven Gasthuisberg University Hospital, Leuven, Belgium
| | - Matteo Pozzi
- Department of Cardiac Surgery, Louis Pradel Hospital, Lyon, France
| | - Finn M Pedersen
- Cardiothoracic Intensive Care Unit, University Hospital, Copenhagen, Denmark
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit, Comprehensive Cancer Center, Center of Excellence in Medical Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Kaan Kirali
- Cardiovascular Surgery Department, Kosuyolu High Specialization Education and Research Hospital, Istanbul, Türkiye
| | - Nicholas Barrett
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - Jordi Riera
- Critical Care Department, Val d'Hebron Research Institute, Barcelona, Spain
| | - Thomas Mueller
- Department of Internal Medicine II, University Hospital of Regensburg, Regensburg, Germany
| | - Jan Belohlavek
- 2nd Department of Internal Medicine, Cardiovascular Medicine General Teaching Hospital, Prague, Czech Republic,1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Bunge JJH, Taccone FS, Reis Miranda D. Letter in reply. J Crit Care 2019; 54:268. [PMID: 31648840 DOI: 10.1016/j.jcrc.2019.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 09/11/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Jeroen J H Bunge
- Erasmus MC, University Medical Center Rotterdam, Department of Intensive Care, The Netherlands; Erasmus MC, University Medical Center Rotterdam, Thoraxcenter, Department of Cardiology, The Netherlands.
| | - Fabio Silvio Taccone
- Cliniques Universitaires de Bruxelles, Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Belgium
| | - Dinis Reis Miranda
- Erasmus MC, University Medical Center Rotterdam, Department of Intensive Care, The Netherlands
| |
Collapse
|
5
|
Schmidt M, Schellongowski P, Patroniti N, Taccone FS, Reis Miranda D, Reuter J, Prodanovic H, Pierrot M, Dorget A, Park S, Balik M, Demoule A, Crippa IA, Mercat A, Wohlfarth P, Sonneville R, Combes A. Six-Month Outcome of Immunocompromised Patients with Severe Acute Respiratory Distress Syndrome Rescued by Extracorporeal Membrane Oxygenation. An International Multicenter Retrospective Study. Am J Respir Crit Care Med 2018; 197:1297-1307. [PMID: 29298095 DOI: 10.1164/rccm.201708-1761oc] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Rationale: Because encouraging rates for hospital and long-term survival of immunocompromised patients in ICUs have been described, these patients are more likely to receive invasive therapies, like extracorporeal membrane oxygenation (ECMO).Objectives: To report outcomes of immunocompromised patients treated with ECMO for severe acute respiratory distress syndrome (ARDS) and to identify their pre-ECMO predictors of 6-month mortality and main ECMO-related complications.Methods: Retrospective multicenter study in 10 international ICUs with high volumes of ECMO cases. Immunocompromised patients, defined as having hematological malignancies, active solid tumor, solid-organ transplant, acquired immunodeficiency syndrome, or long-term or high-dose corticosteroid or immunosuppressant use, and severe ECMO-treated ARDS, from 2008 to 2015 were included.Measurements and Main Results: We collected demographics, clinical data, ECMO-related complications, and ICU- and 6 month-outcome data for 203 patients (median Acute Physiology and Chronic Health Evaluation II score, 28 [25th-75th percentile, 20-33]; age, 51 [38-59] yr; PaO2/FiO2, 60 [50-82] mm Hg before ECMO) who fulfilled our inclusion criteria. Six-month survival was only 30%, with a respective median ECMO duration and ICU stay of 8 (5-14) and 25 (16-50) days. Patients with hematological malignancies had significantly poorer outcomes than others (log-rank P = 0.02). ECMO-related major bleeding, cannula infection, and ventilator-associated pneumonia were frequent (36%, 10%, and 50%, respectively). Multivariate analyses retained fewer than 30 days between immunodeficiency diagnosis and ECMO cannulation as being associated with lower 6-month mortality (odds ratio, 0.32 [95% confidence interval, 0.16-0.66]; P = 0.002), and lower platelet count, higher Pco2, age, and driving pressure as independent pre-ECMO predictors of 6-month mortality.Conclusions: Recently diagnosed immunodeficiency is associated with a much better prognosis in ECMO-treated severe ARDS. However, low 6-month survival of our large cohort of immunocompromised patients supports restricting ECMO to patients with realistic oncological/therapeutic prognoses, acceptable functional status, and few pre-ECMO mortality-risk factors.
Collapse
Affiliation(s)
- Matthieu Schmidt
- Sorbonne Universités, UPMC University Paris 06, INSERM UMRS_1166, Institute of Cardiometabolism and Nutrition, Paris, France.,Medical Intensive Care Unit, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
| | - Nicolò Patroniti
- School of Medicine and Surgery, University of Milan-Bicocca, Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme-Université Libre de Bruxelles, Brussels, Belgium
| | - Dinis Reis Miranda
- Department of Intensive Care, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Jean Reuter
- AP-HP, Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Helène Prodanovic
- Sorbonne Universités, UPMC University Paris 06, INSERM, UMRS_1158 Neurophysiologie Respiratoire Expérimentale et Clinique, AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France
| | - Marc Pierrot
- Service de Réanimation Médicale, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Amandine Dorget
- Medical Intensive Care Unit, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Sunghoon Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea; and
| | - Martin Balik
- Department of Anaesthesia and Intensive Care, 1st Medical Faculty, Charles University, General University Hospital, Prague, Czech Republic
| | - Alexandre Demoule
- Sorbonne Universités, UPMC University Paris 06, INSERM, UMRS_1158 Neurophysiologie Respiratoire Expérimentale et Clinique, AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France
| | - Ilaria Alice Crippa
- Department of Intensive Care, Hôpital Erasme-Université Libre de Bruxelles, Brussels, Belgium
| | - Alain Mercat
- Service de Réanimation Médicale, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Philipp Wohlfarth
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
| | - Romain Sonneville
- AP-HP, Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Alain Combes
- Sorbonne Universités, UPMC University Paris 06, INSERM UMRS_1166, Institute of Cardiometabolism and Nutrition, Paris, France.,Medical Intensive Care Unit, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | | |
Collapse
|
6
|
Bunge JJH, Caliskan K, Gommers D, Reis Miranda D. Right ventricular dysfunction during acute respiratory distress syndrome and veno-venous extracorporeal membrane oxygenation. J Thorac Dis 2018; 10:S674-S682. [PMID: 29732186 DOI: 10.21037/jtd.2017.10.75] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Severe ARDS can be complicated by right ventricular (RV) failure. The etiology of RV failure in ARDS is multifactorial. Vascular alterations, hypoxia, hypercapnia and effects of mechanical ventilation may play a role. Echocardiography has an important role in diagnosing RV failure in ARDS patients. Once extracorporeal membrane oxygenation (ECMO) is indicated in these patients, the right ECMO modus needs to be chosen. In this review, the etiology, diagnosis and management of RV failure in ARDS will be briefly outlined. The beneficial effect of veno-venous (VV) ECMO on RV function in these patients will be illustrated. Based on this, we will give recommendations regarding choice of ECMO modus and provide an algorithm for management of RV failure in VV ECMO supported patients.
Collapse
Affiliation(s)
- Jeroen J H Bunge
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Dinis Reis Miranda
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
7
|
Serpa Neto A, Juffermans NP, Hemmes SNT, Barbas CSV, Beiderlinden M, Biehl M, Fernandez-Bustamante A, Futier E, Gajic O, Jaber S, Kozian A, Licker M, Lin WQ, Memtsoudis SG, Miranda DR, Moine P, Paparella D, Ranieri M, Scavonetto F, Schilling T, Selmo G, Severgnini P, Sprung J, Sundar S, Talmor D, Treschan T, Unzueta C, Weingarten TN, Wolthuis EK, Wrigge H, de Abreu MG, Pelosi P, Schultz MJ. Interaction between peri-operative blood transfusion, tidal volume, airway pressure and postoperative ARDS: an individual patient data meta-analysis. Ann Transl Med 2018; 6:23. [PMID: 29430440 DOI: 10.21037/atm.2018.01.16] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Transfusion of blood products and mechanical ventilation with injurious settings are considered risk factors for postoperative lung injury in surgical Patients. Methods A systematic review and individual patient data meta-analysis was done to determine the independent effects of peri-operative transfusion of blood products, intra-operative tidal volume and airway pressure in adult patients undergoing mechanical ventilation for general surgery, as well as their interactions on the occurrence of postoperative acute respiratory distress syndrome (ARDS). Observational studies and randomized trials were identified by a systematic search of MEDLINE, CINAHL, Web of Science, and CENTRAL and screened for inclusion into a meta-analysis. Individual patient data were obtained from the corresponding authors. Patients were stratified according to whether they received transfusion in the peri-operative period [red blood cell concentrates (RBC) and/or fresh frozen plasma (FFP)], tidal volume size [≤7 mL/kg predicted body weight (PBW), 7-10 and >10 mL/kg PBW] and airway pressure level used during surgery (≤15, 15-20 and >20 cmH2O). The primary outcome was development of postoperative ARDS. Results Seventeen investigations were included (3,659 patients). Postoperative ARDS occurred in 40 (7.2%) patients who received at least one blood product compared to 40 patients (2.5%) who did not [adjusted hazard ratio (HR), 2.32; 95% confidence interval (CI), 1.25-4.33; P=0.008]. Incidence of postoperative ARDS was highest in patients ventilated with tidal volumes of >10 mL/kg PBW and having airway pressures of >20 cmH2O receiving both RBC and FFP, and lowest in patients ventilated with tidal volume of ≤7 mL/kg PBW and having airway pressures of ≤15 cmH2O with no transfusion. There was a significant interaction between transfusion and airway pressure level (P=0.002) on the risk of postoperative ARDS. Conclusions Peri-operative transfusion of blood products is associated with an increased risk of postoperative ARDS, which seems more dependent on airway pressure than tidal volume size.
Collapse
Affiliation(s)
- Ary Serpa Neto
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Program of Post-Graduation, Research and Innovation, Faculdade de Medicina do ABC, São Paulo, Brazil.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Nicole P Juffermans
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sabrine N T Hemmes
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Carmen S V Barbas
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Martin Beiderlinden
- Department of Anaesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany.,Department of Anaesthesiology, Marienhospital Osnabrück, Osnabrück, Germany
| | - Michelle Biehl
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Emmanuel Futier
- Department of Anesthesiology and Critical Care Medicine, Estaing University Hospital, Clermont-Ferrand, France
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Samir Jaber
- Department of Critical Care Medicine and Anesthesiology (SAR B), Saint Eloi University Hospital, Montpellier, France
| | - Alf Kozian
- Department of Anesthesiology and Intensive Care Medicine, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Marc Licker
- Department of Anaesthesiology, Pharmacology and Intensive Care, Faculty of Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Wen-Qian Lin
- State Key Laboratory of Oncology of South China, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, USA
| | | | - Pierre Moine
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, USA
| | - Domenico Paparella
- Division of Cardiac Surgery, Department of Emergency and Organ Transplant (D.E.T.O.), University of Bari Aldo Moro, Bari, Italy
| | - Marco Ranieri
- Department of Anesthesia and Intensive Care Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Federica Scavonetto
- Department of Anesthesiology and Anesthesia Clinical Research Unit, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas Schilling
- Department of Anesthesiology and Intensive Care Medicine, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Gabriele Selmo
- Department of Environment, Health and Safety, University of Insubria, Varese, Italy
| | - Paolo Severgnini
- Department of Environment, Health and Safety, University of Insubria, Varese, Italy
| | - Juraj Sprung
- Department of Anesthesiology and Anesthesia Clinical Research Unit, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sugantha Sundar
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | - Tanja Treschan
- Department of Anaesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Carmen Unzueta
- Department of Anaesthesiology and Intensive Care, Hospital de Sant Pau, Barcelona, Spain
| | - Toby N Weingarten
- Department of Anesthesiology and Anesthesia Clinical Research Unit, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Esther K Wolthuis
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Hermann Wrigge
- Department Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino IST University of Genoa, Genoa, Italy
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | |
Collapse
|
8
|
Bougouin W, Marijon E, Planquette B, Karam N, Dumas F, Celermajer D, Jost D, Lamhaut L, Beganton F, Cariou A, Meyer G, Jouven X, Bureau C, Charpentier J, Salem OBH, Guillemet L, Arnaout M, Ferre A, Geri G, Mongardon N, Pène F, Chiche JD, Mira JP, Labro G, Belon F, Luu VP, Chenet J, Besch G, Puyraveau M, Piton G, Capellier G, Martin M, Lascarrou JB, Le Thuaut A, Lacherade JC, Martin-Lefèvre L, Fiancette M, Vinatier I, Lebert C, Bachoumas K, Yehia A, Henry-Laguarrigue M, Colin G, Reignier J, Privat E, Escutnaire J, Dumont C, Baert V, Vilhelm C, Hubert H, Robert-Edan V, Lakhal K, Quartin A, Hobbs B, Cely C, Bell C, Pham T, Schein R, Geng Y, Ng C, Ehrmann S, Gandonnière CS, Boisramé-Helms J, Le Tilly O, De Bretagne IB, Mercier E, Mankikian J, Bretagnol A, Meziani F, Halimi JM, Le Guellec CB, Gaudry S, Hajage D, Tubach F, Pons B, Boulet E, Boyer A, Chevrel G, Lerolle N, Carpentier D, de Prost N, Lautrette A, Mayaux J, Nseir S, Ricard JD, Dreyfuss D, Robert R, Garzotto F, Kipnis E, Tetta C, Ronco C, Schnell D, Aurelie B, Reynaud M, Clec’h C, Benyamina M, Vincent F, Mariat C, Bornstain C, Gloulou O, Boussarsar M, Zelmat SA, Batouche DD, Chaffi B, Mazour F, Benatta N, Fathallah I, Aloui R, Zoubli A, Rouleau S, Kouraichi N, Fathallah I, Kouraichi N, Salem S, Vicaut E, Megarbane B, Ambroise D, Loriot AM, Bourgogne E, Megarbane B, Leroy C, Ghadhoune H, Jihene G, Trabelsi I, Allouche H, Brahmi H, Samet M, Ghord HE, Lebeau R, Laplanche JL, Benturquia N, Cohen Y, Megarbane B, Blel Y, M’rad A, Essafi F, Benabderrahim A, Jouffroy R, Resiere D, Sanchez B, Inamo J, Megarbane B, Morel J, Batouche DD, Zerhouni A, Tabeliouna K, Negadi A, Mentouri Z, Le Gall F, Hanouz JL, Normand H, Khoury A, Sall FS, Legrand M, De Luca A, Pugin A, Pazart L, Vidal C, Leroux F, Khoury A, L’Her E, Marjanovic N, Khoury A, Desmettre T, Terreaux J, Lambert C, Ragey SP, Baboi L, Bazin JE, Koffel C, Dhonneur G, Bouzit Z, Bradai L, Ayed IB, Aissa F, Darmon M, Haouache H, Marechal Y, Biston P, Piagnerelli M, Bortolotti P, Colling D, Colas V, Voisin B, Dewavrin F, Onimus T, Cantier M, Girardie P, Saulnier F, Urbina T, Nguyen Y, Druoton AL, Soudant M, Barraud D, Conrad M, Cravoisy-Popovic A, Nace L, Morisot A, Bollaert PE, Martin R, Bitker L, Richard JC, Brossier D, Goyer I, Marquis C, Lampin M, Duhamel A, Béhal H, Guérot E, Dhaoui T, Godeffroy V, Devouge E, Evrard D, Delepoulle F, Racoussot S, Grandbastien B, Lampin M, Heilbronner C, Roy E, Canet E, Masson A, Hadchouel-Duvergé A, Rigourd V, Delacroix E, Wroblewski I, Pin I, Ego A, Payen V, Debillon T, Millet A, De Montmollin E, Denot J, Berthelot V, Thueux E, Reymond M, De Larrard A, Amblard A, Leger PL, Aoul NT, Lemiale V, Oziel J, Voiriot G, Brule N, Moreau AS, Marhbène T, Sellami S, Jamoussi A, Ayed S, Mhiri E, Slim L, Khelil JB, Besbes M, Neuville M, Chawki S, Hamdi A, Ciroldi M, Cottereau A, Obadia E, Zerbib Y, Andrejak C, Ricome S, Dupont H, Baudin F, Timsit JF, Dureau P, Tanguy A, Arbelot C, Ben HK, Charfeddine A, Granger B, Laporte L, Hermetet C, Regaieg K, Khemakhem R, Sonneville R, Chelly H, Cheikh CM, Mountij H, Rghioui K, Haddad W, Cherkab R, Barrou H, Naima A, bennani OM, Regaieg K, Fayssoil A, Douib A, Samet A, Cungi PJ, Nguyen C, Cotte J, D’aranda E, Meaudre E, Avaro JP, Slaoui MT, Mokline A, Stojkovic T, Rahmani I, Laajili A, Amri H, Gharsallah L, Gasri B, Tlaili S, Hammouda R, Messadi AA, Behin A, Ogna A, Lofaso F, Laforet P, Wahbi K, Prigent H, Duboc D, Orlikowski D, Eymard B, Annane D, Le Guennec L, Cholet C, Bréchot N, Hekimian G, Besset S, Lebreton G, Nieszkowska A, Trouillet JL, Leprince P, Combes A, Luyt CE, Griton M, Sesay M, De Panthou NS, Bienvenu T, Biais M, Nouette-Gaulain K, Fossat G, Baudin F, Coulanges C, Bobet S, Dupont A, Courtes L, Benzekri D, Kamel T, Muller G, Bercault N, Barbier F, Runge I, Skarzynski M, Mathonnet A, Boulain T, Jouan Y, Teixera N, Hassen-Khodja C, Guillon A, Gaborit C, Grammatico-Guillon L, Rebière C, Azoulay E, Misset B, Ruckly S, Garrouste-Orgeas M, Kentish-Barnes N, Duranteau J, Thuong M, Joseph L, Renault A, Lesieur O, Larbi AGS, Viquesnel G, Zuber B, Marque S, Kandelman S, Pichon N, Floccard B, Galon M, Chevret S, Kentish-Barnes N, Seegers V, Legriel S, Jaber S, Lefrant JY, Reuter D, Guisset O, Cracco C, Seguin A, Durand-Gasselin J, Thirion M, Cohen-Solal Z, Foulgoc H, Rogier J, Delobbe E, Schortgen F, Asfar P, Julie BH, Grimaldi D, Fabien G, Anguel N, Sigismond L, Matthieu HL, Gonzalez F, François L, Guitton C, Schenck M, Jean-Marc D, Radermacher P, Kentish-Barnes N, Makunza JN, Nathalie MK, Pierre A, Adolphe KM, Mahieu R, Reydel T, Jamet A, Chudeau N, Huntzinger J, Grange S, Courte A, Lemarie J, Gibot S, Champey J, Dellamonica J, Du Cheyron D, Contou D, Tadié JM, Cour M, Beduneau G, Marchalot A, Guérin L, Jochmans S, Terzi N, Preau S, Brun-Buisson C, Dessap AM, Vedrenne-Cloquet M, Breinig S, Jung C, Brussieux M, Marcoux MO, Durrmeyer X, Blondé R, Angoulvant F, Grasset J, Naudin J, Dauger S, Remy S, Kolev-Descamp K, Demaret J, Monneret G, Javouhey E, Chomton M, Sauthier M, Vallieres E, Jouvet P, Geslain G, Guellec I, Rambaud J, Schmidt M, Schellongowski P, Dorget A, Patroniti N, Taccone FS, Miranda DR, Reuter J, Prodanovic H, Pierrot M, Balik M, Park S, Guérin C, Papazian L, Jean R, Ayzac L, Loundou A, Forel JM, Mezidi M, Aublanc M, Perinel-Ragey S, Lissonde F, Louf-Durier A, Tapponnier R, Yonis H, Coudroy R, Frat JP, Boissier F, Thille AW, Richard F, Le Gullou-Guillemette H, Fahri J, Kouatchet A, Bodet-Contentin L, Garot D, Le Pennec D, Vecellio L, Tavernier E, Dequin PF, Messika J, Martin Y, Maquigneau N, Puechberty C, Stoclin A, Villard S, Dechanet A, De Jong A, Monnin M, Girard M, Chanques G, Molinari N, Decavèle M, Campion S, Ainsouya R, Niérat MC, Raux M, Similowski T, Demoule A, Razazi K, Tchir M, May F, Carteaux G, Pauline RB, Marc A, Bedos JP, Mehrsa K, Mauger-Briche C, Mijon F, Trouiller P, Sztrymf B, Cretallaz P, Mermillod-Blondin R, Savary D, Sedghiani I, Doghri H, Jendoubi A, Hamdi D, Cherif MA, Hechmi YZE, Zouheir J, Persico N, Maltese F, Ferrigno C, Bablon A, Marmillot C, Roch A, Sedghiani I, Papin G, Gainnier M, Argaud L, Christophe A, Souweine B, Goldgran-Toledano D, Marcotte G, Dumenil AS, Carole S, Cecchini J, Tuffet S, Fartoukh M, Roux D, Thyrault M, Armand MD, Chauveau S, Wesner N, Monnier-Cholley L, Bigé N, Ait-Oufella H, Guidet B, Dubée V, Labroca P, Lemarié J, Chiesa G, Laroyenne I, Borrini L, Klotz R, Sy QP, Cristina MC, Paysant J, Fillâtre P, Gacouin A, Revest M, Tattevin P, Flecher E, Le Tulzo Y, Jamme M, Daviaud F, Marin N, Thy M, Duceau B, Ardisson F, Sandrine V, Venot M, Schlemmer B, Zafrani L, Pons S, Styfalova L, Bouadma L, Radjou A, Lebut J, Mourvillier B, Dorent R, Dilly MP, Nataf P, Wolff M, Le Gall A, Bourcier S, Tandjaoui-Lambiotte Y, Das V, Alves M, Bigé N, Kamilia C, Rania A, Baccouch N, Turki O, Ben HC, Bahloul M, Bouaziz M, Dupuis C, Perozziello A, Letheulle J, Valette M, Herrmann-Storck C, Crosby L, Elkoun K, Madeux B, Martino F, Migueres H, Piednoir P, Posch M, Thiery G, Huynh-Ky MT, Bouchard PA, Sarrazin JF, Lellouche F, Nay MA, Lortat-Jacob B, Rozec B, Colnot M, Belin N, Barrot L, Navellou JC, Patry C, Chaignat C, Claveau M, Claude F, Aubron C, Mcquilten Z, Bailey M, Board J, Buhr H, Cartwright B, Dennis M, Forrest P, Hodgson C, Mcilroy D, Murphy D, Murray L, Pellegrino V, Pilcher D, Sheldrake J, Tran H, Vallance S, Cooper J, Bombled C, Vidal C, Margetis D, Amour J, Coart D, Dubois J, Van Herpe T, Mesotten D, Bailly S, Lucet J, Lepape A, L’hériteau F, Aupée M, Bervas C, Boussat S, Berger-Carbonne A, Machut A, Savey A, Tudesq JJ, Valade S, Galicier L, De Bazelaire C, Munoz-Bongrand N, Mignard X, Biard L, Mokart D, Nyunga M, Bruneel F, Rabbat A, Perez P, Meert AP, Benoit D, Mariotte E, Ehooman F, Hamidfar-Roy R, Hourmant Y, Mailloux A, Beurton A, Teboul JL, Girroto V, Laura G, Richard C, Monnet X, Dubée V, Merdji H, Dang J, Preda G, Baudel JL, Desnos C, Zeitouni M, Belaroussi I, Parrot A, Blayau C, Fulgencio JP, Quesnel C, Labbe V, De Chambrun MP, Beloncle F, Merceron S, Fedun Y, Lecomte B, Devaquet J, Puidupin M, Verdière B, Amoura Z, Vuillard C, Xavier J, Bourlier D, David A, Caroline S, David M, Gerald S, Olivier S, Humbert M, Laurent S, Dujardin O, Bouglé A, Ait HN, Salem JE, El-Helali N, Coppere Z, Gibelin A, Taconet C, Djibre M, Maamar A, Colobert E, Fillatre P, Uhel F, Camus C, Moraly J, Dahoumane R, Maury E, Tan BK, Emmanuel V, Pauline M, Laurence P, Philippe P, Zahar JR, Catherine H, Christian P, Karim AB, Mounia H, Laura T, Rasoldier VH, Mager G, Eraldi JP, Gelinotte S, Bougerol F, Dehay J, Rigaud JP, Declercq PL, Michel J, Aissa N, Henard S, Guerci P, Latar I, Levy B, Girerd N, Kimmoun A, Abdallah SB, Nakaa S, Hraiech K, Braiek DB, Adhieb A, M’ghirbi A, Ousji A, Hammouda Z, Abroug F, Sellami W, Hajjej Z, Samoud W, Labbene I, Ferjani M, Medhioub FK, Allela R, Algia NB, Cherif S, Attia D, Herinjatovo A, Francois XL, Bouhouri MA, Slaoui MT, Soufi A, Khaleq K, Hamoudi D, Nsiri A, Harrar R, Maury E, Goursaud S, Gauberti M, Labeyrie PE, Gaberel T, Agin V, Maubert E, Vivien D, Gakuba C, Armel A, Abdou R, Kalouch S, Yaqini K, Chlilek A, Sellami W, Yedder SB, Tonnelier A, Hervé F, Halley G, Frances JL, Moriconi M, Saoli M, Garnero A, Demory D, Arnal JM, Canoville B, Daubin C, Brunet J, Ghezala HB, Snouda S, Ben CI, Kaddour M, Ouanes I, Marzouk M, Haniez F, Jaillet H, Maas H, Andrivet P, Darné C, Viau F, Ghezala HB, Ouanes I, Dangers L, Montlahuc C, Perbet S, Ouanes I, Hamouda Z, Nakee S, Ouanes-Besbes L, Meddeb K, Khedher A, Sma N, Ayachi J, Khelfa M, Fraj N, Lakhal HB, Hammed H, Boukadida R, Hafsa H, Chouchene I, Boussarsar M, Ben BD, Ouanes-Besbes L, Benatti K, Dafir A, Aissaoui W, Elallame W, Haddad W, Cherkab R, Elkettani C, Barrou L, Hamou ZA, Repessé X, Charron C, Aubry A, Paternot A, Maizel J, Slama M, Vieillard-Baron A, Trifi A, Abdellatif S, Fatnassi M, Daly F, Nasri R, Ismail KB, Lakhal SB, Bazalgette F, Daurat A, Roger C, Muller L, Doyen D, Plattier R, Robert A, Hyvernat H, Bernardin G, Jozwiak M, Gimenez J, Mercado P, Depret F, Tilouch N, Mater H, Habiba BSA, Jaoued O, Gharbi R, Hassen MF, Elatrous S, Pasquier P, Vuillemin Q, Schaal JV, Martinez T, Duron S, Trousselard M, Schwartzbrod PE, Baugnon T, Dupic L, Gout CD, De Saint Blanquat L, Séguret S, Le Ficher G, Orliaguet G, Hubert P, Bigé N, Leblanc G, Briand R, Brousse L, Brunet V, Chatelain L, Prat D, Jacobs F, Demars N, Hamzaoui O, Moneger G, Sztrymf B, Duburcq-Gury E, Satre-Buisson L, Duburcq T, Poissy J, Robriquet L, Jourdain M, Sécheresse T, Miquet M, Simond A, Usseglio P, Hamdaoui Y, Boussarsar M, Desailly V, Brun P, Iglesias P, Huet J, Masseran C, Claudon A, Ebeyer C, Truong T, Tesnière A, Mignon A, Gaudry S, Resiere D, Valentino R, Fabre J, Roze B, Ferge JL, Charbatier C, Marie S, Scholsser M, Aitsatou S, Raad M, Cabie A, Mehdaoui H, Cousin C, Rousseau C, Llitjos JF, Alby-Laurent F, Toubiana J, Belaidouni N, Cherruault M, Tamburini J, Bouscary D, Fert S, Delile E, Besnier E, Coquerel D, Nevière R, Richard V, Tamion F, Wei C, Louis H, Margaux S, Eliane A, Sophie O, Kimmoun A, Riad Z, Coroir M, Rémy B, Camille B, Joffre J, Aegerter P, Ilic D, Ginet M, Pignard C, Nguyen P, Mourey G, Samain E, Pili-Floury S, Jouffroy R, Nicolas C, Alvarez JC, Tomasso M, Philippe P, Raphalen JH, Frédéric JB, Vivien B, Pierre C, Baud F, Fredj H, Blel Y, Brahmi N, Ghezala HB, Hanak AS, Malissin I, Poupon J, Risede P, Chevillard L, Megarbane B, Barghouth M, M’rad A, Hmida MB, Thabet H, Liang H, Callebert J, Lagard C, Megarbane B, Habacha S, Chatbri B, Camillerapp C, Labat L, Soichot M, Garçon P, Goury A, Kerdjana L, Voicu S, Deye N, Megarbane B, Armel A, Anas B, Othman M, Moumine S, Kalouch S, Yakini KK, Chlilek A, Hajji A, Louati A, Khaldi A, Borgi A, Ghali N, Bouziri A, Menif K, Ben JN, Armel A, Brochon J, Dumitrescu M, Thévenot S, Saulnier JP, Husseini K, Laland C, Cremniter J, Bousseau A, Castel O, Brémaud-Csizmadia C, Diss M, Portefaix A, Berthiller J, Gillet Y, Aoul NT, Douah A, Addou Z, Youbi H, Moussati M, Belhabiche K, Mir S, Abada S, Amel Z, Aouffen N, Bouzit Z, Grati AH, Dhonneur GF, Boussarsar M, Lau N, Mezhari I, Roucaud N, Le Meur M, Paulet R, Coudray JM, Ghomari WI, Boumlik R, Peigne V, Daban JL, Boutonnet M, Lenoir B, Yassine H, Mohamed CC, Khalid A, Ihssan M, Said E, Said S, Jazia AB, Fatima J, Wafa S, Maha B, Khaoula BA, Sami T, Abdallah Taeib B, Medhioub FK, Rollet-Cohen V, Sachs P, Merchaoui Z, Renolleau S, Oualha M, Eloi M, Jean S, Demoulin M, Valentin C, Guilbert J, Walti H, Carbajal R, Leger PL, Karaca-Altintas Y, Botte A, Labreuche J, Drumez E, Devos P, Bour F, Leclerc F, Ahmed A, khaled M, Louati A, Aida B, Ammar K, Narjess G, Ahmed H, Asma B, Jaballah NB, Leger PL, Pansiot J, Besson V, Palmier B, Baud O, Cauli B, Charriaut-Marlangue C, Mansuy A, Michel F, Le Bel S, Boubnova J, Ughetto F, Ovaert C, Fouilloux V, Paut O, Jacquet-Lagrèze M, Tiebergien N, Hanna N, Evain JN, Baudin F, Courtil-Teyssedre S, Bompard D, Lilot M, Chardonal L, Fellahi JL, Claverie C, Pouessel G, Dorkenoo A, Renaudin JM, Eb M, Deschildre A, Leteurtre S, Yassine H, Kamal B, Adil O, Ouafa A, Mouhamed M, Rachid C, Lahoucine B, Dachraoui F, Nakkaa S, Zaineb H, Mlika D. Proceedings of Réanimation 2017, the French Intensive Care Society International Congress. Ann Intensive Care 2017. [PMCID: PMC5225387 DOI: 10.1186/s13613-016-0223-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
9
|
Neto AS, Hemmes SNT, Barbas CSV, Beiderlinden M, Fernandez-Bustamante A, Futier E, Gajic O, El-Tahan MR, Ghamdi AAA, Günay E, Jaber S, Kokulu S, Kozian A, Licker M, Lin WQ, Maslow AD, Memtsoudis SG, Reis Miranda D, Moine P, Ng T, Paparella D, Ranieri VM, Scavonetto F, Schilling T, Selmo G, Severgnini P, Sprung J, Sundar S, Talmor D, Treschan T, Unzueta C, Weingarten TN, Wolthuis EK, Wrigge H, Amato MBP, Costa ELV, de Abreu MG, Pelosi P, Schultz MJ. Association between driving pressure and development of postoperative pulmonary complications in patients undergoing mechanical ventilation for general anaesthesia: a meta-analysis of individual patient data. Lancet Respir Med 2016; 4:272-80. [PMID: 26947624 DOI: 10.1016/s2213-2600(16)00057-6] [Citation(s) in RCA: 330] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 01/29/2016] [Accepted: 02/01/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Protective mechanical ventilation strategies using low tidal volume or high levels of positive end-expiratory pressure (PEEP) improve outcomes for patients who have had surgery. The role of the driving pressure, which is the difference between the plateau pressure and the level of positive end-expiratory pressure is not known. We investigated the association of tidal volume, the level of PEEP, and driving pressure during intraoperative ventilation with the development of postoperative pulmonary complications. METHODS We did a meta-analysis of individual patient data from randomised controlled trials of protective ventilation during general anesthaesia for surgery published up to July 30, 2015. The main outcome was development of postoperative pulmonary complications (postoperative lung injury, pulmonary infection, or barotrauma). FINDINGS We included data from 17 randomised controlled trials, including 2250 patients. Multivariate analysis suggested that driving pressure was associated with the development of postoperative pulmonary complications (odds ratio [OR] for one unit increase of driving pressure 1·16, 95% CI 1·13-1·19; p<0·0001), whereas we detected no association for tidal volume (1·05, 0·98-1·13; p=0·179). PEEP did not have a large enough effect in univariate analysis to warrant inclusion in the multivariate analysis. In a mediator analysis, driving pressure was the only significant mediator of the effects of protective ventilation on development of pulmonary complications (p=0·027). In two studies that compared low with high PEEP during low tidal volume ventilation, an increase in the level of PEEP that resulted in an increase in driving pressure was associated with more postoperative pulmonary complications (OR 3·11, 95% CI 1·39-6·96; p=0·006). INTERPRETATION In patients having surgery, intraoperative high driving pressure and changes in the level of PEEP that result in an increase of driving pressure are associated with more postoperative pulmonary complications. However, a randomised controlled trial comparing ventilation based on driving pressure with usual care is needed to confirm these findings. FUNDING None.
Collapse
Affiliation(s)
- Ary Serpa Neto
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands; Program of Post-Graduation, Research and Innovation, Faculdade de Medicina do ABC, Santo André, Brazil; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | - Sabrine N T Hemmes
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Carmen S V Barbas
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Martin Beiderlinden
- Department of Anaesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany; Department of Anaesthesiology, Marienhospital Osnabrück, Osnabrück, Germany
| | | | - Emmanuel Futier
- Department of Anesthesiology and Critical Care Medicine, Estaing University Hospital, Clermont-Ferrand, France
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mohamed R El-Tahan
- Department of Cardiothoracic Anaesthesia & Surgical Intensive Care, King Fahd Hospital, University of Dammam, Dammam, Saudi Arabia
| | - Abdulmohsin A Al Ghamdi
- Department of Anesthesiology, King Fahd Hospital, University of Dammam, Dammam, Saudi Arabia
| | - Ersin Günay
- Department of Chest Diseases, Research Unit INSERM U1046, Montpellier, France
| | - Samir Jaber
- Department of Critical Care Medicine and Anesthesiology, Saint Eloi University Hospital, Research Unit INSERM U1046, Montpellier, France
| | - Serdar Kokulu
- Department of Anaesthesiology and Reanimation, Research Unit INSERM U1046, Montpellier, France
| | - Alf Kozian
- Department of Anesthesiology and Intensive Care Medicine, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Marc Licker
- Department of Anaesthesiology, Pharmacology and Intensive Care, Faculty of Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Wen-Qian Lin
- State Key Laboratory of Oncology of South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Andrew D Maslow
- Department of Anesthesiology, The Warren Alpert School of Brown University, Providence, RI, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA
| | - Dinis Reis Miranda
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Pierre Moine
- Department of Anesthesiology, University of Colorado, Aurora, CO, USA
| | - Thomas Ng
- Department of Surgery, The Warren Alpert School of Brown University, Providence, RI, USA
| | - Domenico Paparella
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - V Marco Ranieri
- Department of Anesthesia and Intensive Care Medicine, Rome, Italy; Sapienza University of Rome, Rome, Italy; Policlinico Umberto I Hospital, Rome, Italy
| | - Federica Scavonetto
- Department of Anesthesiology and Anesthesia Clinical Research Unit, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Thomas Schilling
- Department of Anesthesiology and Intensive Care Medicine, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Gabriele Selmo
- Department Biotechnology and Sciences of Life, Azienda Ospedaliera Fondazione Macchi, University of Insubria, Varese, Italy
| | - Paolo Severgnini
- Department Biotechnology and Sciences of Life, Azienda Ospedaliera Fondazione Macchi, University of Insubria, Varese, Italy
| | - Juraj Sprung
- Department of Anesthesiology and Anesthesia Clinical Research Unit, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sugantha Sundar
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Tanja Treschan
- Department of Anaesthesiology, Düsseldorf University Hospital, Heinrich-Heine University, Düsseldorf, Germany
| | - Carmen Unzueta
- Department of Anaesthesiology, Hospital de Sant Pau, Barcelona, Spain
| | - Toby N Weingarten
- Department of Anesthesiology and Anesthesia Clinical Research Unit, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Esther K Wolthuis
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Hermann Wrigge
- Department of Anaesthesiology and Intensive Care Medicine, University of Hospital Leipzig, Leipzig, Germany
| | - Marcelo B P Amato
- Cardio-Pulmonary Department, Pulmonary Division, Heart Institute, University of São Paulo, São Paulo, Brazil
| | - Eduardo L V Costa
- Cardio-Pulmonary Department, Pulmonary Division, Heart Institute, University of São Paulo, São Paulo, Brazil; Research and Education Institute, Hospital Sirio-Libanês, São Paulo, Brazil
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino IST, University of Genoa, Genoa, Italy
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands; Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
10
|
Armstrong E, de Waard MC, de Grooth HJS, Heymans MW, Reis Miranda D, Girbes ARJ, Spijkstra JJ. Using Nursing Activities Score to Assess Nursing Workload on a Medium Care Unit. Anesth Analg 2016; 121:1274-80. [PMID: 26484461 DOI: 10.1213/ane.0000000000000968] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The medium care unit (MCU) or "stepdown" unit is an increasingly important, but understudied care environment. With an aging population and more patients with complex multiple diseases, many patients often require a higher level of inpatient care even when full intensive care is not indicated. However, the nurse-to-patient ratio required on a MCU is neither well defined nor clear whether this ratio should be adjusted per shift. The Nursing Activities Score (NAS) is an effective instrument for measuring nursing workload in the intensive care unit (ICU) but has not been used in an MCU. The aim of this study was to measure the nursing workload per 8-hour shift on an MCU using the NAS and compare it with the NAS from an ICU in the same hospital. We also compared the NAS between groups of patients with different admission sources. METHODS The NAS was prospectively measured per patient per shift for 2 months in a 9-bed tertiary referral university hospital MCU and during a similar period in an ICU in the same hospital. RESULTS The mean NAS per patient did not differ between day (7:30 AM to 4:00 PM) and evening (3:00 PM to 11:30 PM) shifts, but the NAS was significantly lower during the night shift (11:00 PM to 8:00 AM) than during the day (P < 0.0001) and evening (P < 0.0001) shifts. The mean NASs in the ICU for day and night shifts were significantly lower than the scores in the MCU (P = 0.0056 and P < 0.0001, respectively), but NAS during the evening shift did not differ between the ICU and the MCU. The mean NAS for patients admitted to the MCU from the accident and emergency department was significantly higher than for those admitted from the ICU (P = 0.002), recovery (P = 0.002), and general ward (P < 0.0001). Patients on the MCU had a NAS comparable with that of ICU patients. CONCLUSIONS In our university hospital, NAS was higher during the day and evening hours and lower at night. We also found that patients from accident and emergency had a higher NAS than those admitted to the MCU from other locations. NAS in the MCU was not lower than the NAS in the ICU. Because of its ability to discriminate between day and evening workloads and between patients from different sources, the NAS may assist MCU managers in assessing staffing needs.
Collapse
Affiliation(s)
- Elizabeth Armstrong
- From the *Department of Intensive Care, VU University Medical Centre, Amsterdam, The Netherlands; †Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, The Netherlands; and ‡Department of Intensive Care, University Hospital Groningen, Groningen, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
11
|
Reis Miranda D. The University's two vocations: centralizing research and development; decentralizing useful information. Rev Esc Enferm USP 2016; 49 Spec No:1-2. [PMID: 26761685 DOI: 10.1590/s0080-623420150000700001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
12
|
Reis Miranda D, van Thiel R, Brodie D, Bakker J. Right ventricular unloading after initiation of venovenous extracorporeal membrane oxygenation. Am J Respir Crit Care Med 2015; 191:346-8. [PMID: 25635492 DOI: 10.1164/rccm.201408-1404le] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
|
13
|
Pruijsten R, van Thiel R, Hool S, Saeijs M, Verbiest M, Miranda DR. Mobilization of patients on venovenous extracorporeal membrane oxygenation support using an ECMO helmet. Intensive Care Med 2014; 40:1595-7. [DOI: 10.1007/s00134-014-3410-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2014] [Indexed: 11/29/2022]
|
14
|
Reis Miranda D, Dabiri Abkenari L, Nieman K, Dijkshoorn M, Duckers E, Gommers D. Myocardial infarction due to malposition of ECMO cannula. Intensive Care Med 2012; 38:1233-4. [PMID: 22534956 PMCID: PMC3375419 DOI: 10.1007/s00134-012-2583-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2012] [Indexed: 11/26/2022]
Affiliation(s)
- Dinis Reis Miranda
- Department of Intensive Care, Erasmus Medical Centre, Gravendijkwal 230 H-619, 3015 CE Rotterdam, The Netherlands
| | | | - Koen Nieman
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Marcel Dijkshoorn
- Department of Radiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Eric Duckers
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus Medical Centre, Gravendijkwal 230 H-619, 3015 CE Rotterdam, The Netherlands
| |
Collapse
|
15
|
Scohy T, Bikkers I, Reis Miranda D, Kissler J, Geniets B, Saet AV, Bogers A. O-21 Alveolar recruitment strategy and PEEP improves right ventricular outflow impedance in paediatric patients undergoing cardiac surgery for congenital heart disease. J Cardiothorac Vasc Anesth 2011. [DOI: 10.1053/j.jvca.2011.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
16
|
Bikker IG, Leonhardt S, Reis Miranda D, Bakker J, Gommers D. Bedside measurement of changes in lung impedance to monitor alveolar ventilation in dependent and non-dependent parts by electrical impedance tomography during a positive end-expiratory pressure trial in mechanically ventilated intensive care unit patients. Crit Care 2010; 14:R100. [PMID: 20509966 PMCID: PMC2911738 DOI: 10.1186/cc9036] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2009] [Revised: 02/14/2010] [Accepted: 05/30/2010] [Indexed: 12/28/2022]
Abstract
Introduction As it becomes clear that mechanical ventilation can exaggerate lung injury, individual titration of ventilator settings is of special interest. Electrical impedance tomography (EIT) has been proposed as a bedside, regional monitoring tool to guide these settings. In the present study we evaluate the use of ventilation distribution change maps (ΔfEIT maps) in intensive care unit (ICU) patients with or without lung disorders during a standardized decremental positive end-expiratory pressure (PEEP) trial. Methods Functional EIT (fEIT) images and PaO2/FiO2 ratios were obtained at four PEEP levels (15 to 10 to 5 to 0 cm H2O) in 14 ICU patients with or without lung disorders. Patients were pressure-controlled ventilated with constant driving pressure. fEIT images made before each reduction in PEEP were subtracted from those recorded after each PEEP step to evaluate regional increase/decrease in tidal impedance in each EIT pixel (ΔfEIT maps). Results The response of regional tidal impedance to PEEP showed a significant difference from 15 to 10 (P = 0.002) and from 10 to 5 (P = 0.001) between patients with and without lung disorders. Tidal impedance increased only in the non-dependent parts in patients without lung disorders after decreasing PEEP from 15 to 10 cm H2O, whereas it decreased at the other PEEP steps in both groups. Conclusions During a decremental PEEP trial in ICU patients, EIT measurements performed just above the diaphragm clearly visualize improvement and loss of ventilation in dependent and non-dependent parts, at the bedside in the individual patient.
Collapse
Affiliation(s)
- Ido G Bikker
- Department of Intensive Care Medicine, Erasmus MC, 's-Gravendijkwal 230, Rotterdam, 3015 GE, The Netherlands.
| | | | | | | | | |
Collapse
|
17
|
Bikker IG, van Bommel J, Miranda DR, Bakker J, Gommers D. End-expiratory lung volume during mechanical ventilation: a comparison with reference values and the effect of positive end-expiratory pressure in intensive care unit patients with different lung conditions. Crit Care 2008; 12:R145. [PMID: 19021898 PMCID: PMC2646307 DOI: 10.1186/cc7125] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Revised: 10/30/2008] [Accepted: 11/20/2008] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Functional residual capacity (FRC) reference values are obtained from spontaneous breathing patients, and are measured in the sitting or standing position. During mechanical ventilation FRC is determined by the level of positive end-expiratory pressure (PEEP), and it is therefore better to speak of end-expiratory lung volume. Application of higher levels of PEEP leads to increased end-expiratory lung volume as a result of recruitment or further distention of already ventilated alveoli. The aim of this study was to measure end-expiratory lung volume in mechanically ventilated intensive care unit (ICU) patients with different types of lung pathology at different PEEP levels, and to compare them with predicted sitting FRC values, arterial oxygenation, and compliance values. METHODS End-expiratory lung volume measurements were performed at PEEP levels reduced sequentially (15, 10 and then 5 cmH2O) in 45 mechanically ventilated patients divided into three groups according to pulmonary condition: normal lungs (group N), primary lung disorder (group P), and secondary lung disorder (group S). RESULTS In all three groups, end-expiratory lung volume decreased significantly (P < 0.001) while PEEP decreased from 15 to 5 cmH2O, whereas the ratio of arterial oxygen tension to inspired oxygen fraction did not change. At 5 cmH2O PEEP, end-expiratory lung volume was 31, 20, and 17 ml/kg predicted body weight in groups N, P, and S, respectively. These measured values were only 66%, 42%, and 34% of the predicted sitting FRC. A correlation between change in end-expiratory lung volume and change in dynamic compliance was found in group S (P < 0.001; R2 = 0.52), but not in the other groups. CONCLUSIONS End-expiratory lung volume measured at 5 cmH2O PEEP was markedly lower than predicted sitting FRC values in all groups. Only in patients with secondary lung disorders were PEEP-induced changes in end-expiratory lung volume the result of derecruitment. In combination with compliance, end-expiratory lung volume can provide additional information to optimize the ventilator settings.
Collapse
Affiliation(s)
- Ido G Bikker
- Department of Intensive Care Medicine, Erasmus MC, 's Gravendijkwal 230, 3015 CERotterdam, The Netherlands
| | - Jasper van Bommel
- Department of Intensive Care Medicine, Erasmus MC, 's Gravendijkwal 230, 3015 CERotterdam, The Netherlands
| | - Dinis Reis Miranda
- Department of Intensive Care Medicine, Erasmus MC, 's Gravendijkwal 230, 3015 CERotterdam, The Netherlands
| | - Jan Bakker
- Department of Intensive Care Medicine, Erasmus MC, 's Gravendijkwal 230, 3015 CERotterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care Medicine, Erasmus MC, 's Gravendijkwal 230, 3015 CERotterdam, The Netherlands
| |
Collapse
|
18
|
Padilha KG, de Sousa RMC, Queijo AF, Mendes AM, Miranda DR. Nursing Activities Score in the intensive care unit: Analysis of the related factors. Intensive Crit Care Nurs 2008; 24:197-204. [DOI: 10.1016/j.iccn.2007.09.004] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2006] [Revised: 09/10/2007] [Accepted: 09/17/2007] [Indexed: 10/22/2022]
|
19
|
Miranda DR, Gommers D, Papadakos PJ, Lachmann B. Mechanical Ventilation Affects Pulmonary Inflammation in Cardiac Surgery Patients: The Role of the Open-Lung Concept. J Cardiothorac Vasc Anesth 2007; 21:279-84. [PMID: 17418750 DOI: 10.1053/j.jvca.2006.02.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2005] [Indexed: 11/11/2022]
|
20
|
Rivera-Fernández R, Nap R, Vázquez-Mata G, Reis Miranda D. Analysis of physiologic alterations in intensive care unit patients and their relationship with mortality. J Crit Care 2007; 22:120-8. [PMID: 17548023 DOI: 10.1016/j.jcrc.2006.09.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2006] [Revised: 07/29/2006] [Accepted: 09/19/2006] [Indexed: 11/25/2022]
Abstract
PURPOSE To analyze patient physiologic alterations (events) and multiple organ failure during intensive care unit (ICU) stay and examine their relationship with ICU mortality. MATERIAL AND METHODS A total of 17598 consecutive patients were studied for 10 months (1997-1998) in 55 European ICUs (EURICUS-II). Hourly data were collected on critical and noncritical systolic blood pressure, heart rate, oxygen saturation, and urinary events throughout ICU stay. Sepsis-related Organ Failure Assessment (SOFA) score was collected daily (6409 patients). RESULTS SAPS-II was 31.2 +/- 18.4 and ICU mortality 13.9%. There were 3.4 +/- 9.2 noncritical (duration, 3.9 +/- 11.4 hours) and 2 +/- 7.5 critical (3.8 +/- 13.1 hours) systolic blood pressure events per patient. Heart rate, oxygen saturation, and urinary events had similar values. Nonsurvivors had significantly more and longer physiologic alterations vs survivors. Mortality was significantly related to mean daily duration of events and mean and maximum daily SOFA. Discrimination capacity to predict ICU mortality was measured using various models: with SAPS II, area under the receiver operating characteristic curve was 0.80; with APACHE III-classified diagnosis added, 0.84; with mean duration of events/ICU day, 0.91; and with mean and maximum SOFA scores, 0.95. CONCLUSION Routinely gathered ICU data on physiologic variables and multiple organ failure can offer considerable complementary information not provided by usual mortality prediction systems; and their weight in daily care policy decisions may need to be revisited.
Collapse
|
21
|
Reis Miranda D, Klompe L, Mekel J, Struijs A, van Bommel J, Lachmann B, Bogers AJJC, Gommers D. Open lung ventilation does not increase right ventricular outflow impedance: An echo-Doppler study. Crit Care Med 2006; 34:2555-60. [PMID: 16932227 DOI: 10.1097/01.ccm.0000239118.05093.ee] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Ventilation according to the open lung concept (OLC) consists of recruitment maneuvers, followed by low tidal volume and elevated positive end-expiratory pressure (PEEP). Elevated PEEP is associated with an increased right ventricular afterload. We investigated the effect of OLC ventilation on right ventricular outflow impedance during inspiration and expiration in patients after cardiac surgery using transesophageal echo-Doppler. DESIGN A prospective, single-center, crossover, randomized, controlled clinical study. SETTING Cardiothoracic intensive care unit of a university hospital. PATIENTS Twenty-eight patients scheduled for elective cardiac surgery with cardiopulmonary bypass. INTERVENTIONS In the intensive care unit, each patient was ventilated for approximately 30 mins according to both OLC and conventional ventilation. During OLC ventilation, recruitment maneuvers were applied until PaO2/FiO2 was >375 torr (50 kPa); during conventional ventilation no recruitment maneuvers were performed. MEASUREMENTS AND MAIN RESULTS Transesophageal echo-Doppler measurements were performed at end-inspiration and end-expiration in a steady-state condition, 20 mins after initiation of a ventilation strategy. Mean acceleration of flow was determined in the long axis of the pulmonary artery in a transverse axis view. During OLC ventilation, a total PEEP of 14 +/- 4 cm H2O was applied vs. 5 cm H2O during conventional ventilation. Mean acceleration during expiration was comparable between groups. During inspiration, OLC ventilation did not cause a decrease of mean acceleration compared with expiration, whereas this did occur during conventional ventilation. CONCLUSIONS Despite the use of elevated PEEP levels, ventilation according to OLC does not change right ventricular outflow impedance during expiration and decreases right ventricular outflow impedance during inspiration.
Collapse
|
22
|
Miranda DR, Klompe L, Cademartiri F, Haitsma JJ, Palumbo A, Takkenberg JJM, Lachmann B, Bogers AJJC, Gommers D. The effect of open lung ventilation on right ventricular and left ventricular function in lung-lavaged pigs. Crit Care 2006; 10:R86. [PMID: 16764730 PMCID: PMC1550948 DOI: 10.1186/cc4944] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2006] [Revised: 04/18/2006] [Accepted: 05/11/2006] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Ventilation according to the open lung concept (OLC) consists of recruitment maneuvers, followed by low tidal volume and high positive end-expiratory pressure, aiming at minimizing atelectasis. The minimization of atelectasis reduces the right ventricular (RV) afterload, but the increased intrathoracic pressures used by OLC ventilation could increase the RV afterload. We hypothesize that when atelectasis is minimized by OLC ventilation, cardiac function is not affected despite the higher mean airway pressure. METHODS After repeated lung lavage, each pig (n = 10) was conventionally ventilated and was ventilated according to OLC in a randomized cross-over setting. Conventional mechanical ventilation (CMV) consisted of volume-controlled ventilation with 5 cmH2O positive end-expiratory pressure and a tidal volume of 8-10 ml/kg. No recruitment maneuvers were performed. During OLC ventilation, recruitment maneuvers were applied until PaO2/FiO2 > 60 kPa. The peak inspiratory pressure was set to obtain a tidal volume of 6-8 ml/kg. The cardiac output (CO), the RV preload, the contractility and the afterload were measured with a volumetric pulmonary artery catheter. A high-resolution computed tomography scan measured the whole lung density and left ventricular (LV) volumes. RESULTS The RV end-systolic pressure-volume relationship, representing RV afterload, during steady-state OLC ventilation (2.7 +/- 1.2 mmHg/ml) was not significantly different compared with CMV (3.6 +/- 2.5 mmHg/ml). Pulmonary vascular resistance (OLC, 137 +/- 49 dynes/s/cm5 versus CMV, 130 +/- 34 dynes/s/cm5) was comparable between groups. OLC led to a significantly lower amount of atelectasis (13 +/- 2% of the lung area) compared with CMV (52 +/- 3% of the lung area). Atelectasis was not correlated with pulmonary vascular resistance or end-systolic pressure-volume relationship. The LV contractility and afterload during OLC was not significantly different compared with CMV. Compared with baseline, the LV end-diastolic volume (66 +/- 4 ml) decreased significantly during OLC (56 +/- 5 ml) ventilation and not during CMV (61 +/- 3 ml). Also, CO was significantly lower during OLC ventilation (OLC, 4.1 +/- 0.3 l/minute versus CMV, 4.9 +/- 0.3 l/minute). CONCLUSION In this experimental study, OLC resulted in significantly improved lung aeration. Despite the use of elevated airway pressures, no evidence was found for a negative effect of OLC on RV afterload or LV afterload, which might be associated with a loss of hypoxic pulmonary vasoconstriction due to alveolar recruitment. The reductions in the CO and in the mean pulmonary artery pressure were consequences of a reduced preload.
Collapse
Affiliation(s)
| | - Lennart Klompe
- Department of Cardio-Thoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
| | | | - Jack J Haitsma
- Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
| | | | | | - Burkhard Lachmann
- Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
| | - Ad JJC Bogers
- Department of Cardio-Thoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
| |
Collapse
|
23
|
Iapichino G, Mistraletti G, Corbella D, Bassi G, Borotto E, Miranda DR, Morabito A. Scoring system for the selection of high-risk patients in the intensive care unit. Crit Care Med 2006; 34:1039-43. [PMID: 16484895 DOI: 10.1097/01.ccm.0000206286.19444.40] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Patients admitted to the intensive care unit greatly differ in severity and intensity of care. We devised a system for selecting high-risk patients that reduces bias by excluding low-risk patients and patients with an early death irrespective of the treatment. DESIGN A posteriori analysis of a multiple-center prospective observational trial. SETTING A total of 89 units from 12 European countries, with 12,615 patients. INTERVENTION Demographic and clinical data: severity of illness at admission, daily score of nursing workload, length of stay, and hospital mortality. METHODS We enrolled patients with intensive care unit length of stay of >24 hrs. Three groups of high-risk patients were created: a) Severity group, those with Simplified Acute Physiology Score (SAPS II) over the median; b) Intensity-of-care group, patients with >1 day of high level of care (assessed by logistic analysis); and c) MIX group, patients fulfilling both Severity and Intensity-of-care criteria. The groups were included in a logistic regression model (random split-sample design) to identify the characteristics associated with hospital mortality. We compared the outcome prediction of the SAPS II model (unsplit sample) against our model. MAIN RESULTS Out of 8,248 patients, the Severity method selected 3,838 patients, Intensity-of-care selected 4,244, and both methods combined selected 2,662 patients. There were 2,828 low-risk patients. Significant associations with hospital mortality were observed for: age, sites of admission, medical/unscheduled surgical admission, acute physiologic score of SAPS II, and the indicator variable "only Severity," "only Intensity-of-care," or MIX (developmental sample: calibration chi-square test, p = .205; area under the receiver operation characteristic curve, 0.814). Calibration and discrimination were better in our model than with the SAPS II model (unsplit sample). CONCLUSION All three indicator variables select high-risk patients, the Severity/Intensity-of-care MIX being the most robust. These stratification criteria can improve case-mix selection for clinical and organizational studies.
Collapse
Affiliation(s)
- Gaetano Iapichino
- Istituto di Anestesiologia e Rianimazione, Università degli Studi di Milano, Italy
| | | | | | | | | | | | | |
Collapse
|
24
|
Reis Miranda D, Gommers D, Struijs A, Dekker R, Mekel J, Feelders R, Lachmann B, Bogers AJJC. Ventilation according to the open lung concept attenuates pulmonary inflammatory response in cardiac surgery. Eur J Cardiothorac Surg 2005; 28:889-95. [PMID: 16271479 DOI: 10.1016/j.ejcts.2005.10.007] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2005] [Revised: 09/20/2005] [Accepted: 10/03/2005] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Cardiac surgery with cardiopulmonary bypass (CPB) is associated with a systemic inflammatory response, which is correlated with outcome. We hypothesized that ventilation according to the open lung concept (OLC) attenuates cytokine release. METHODS A prospective, single center randomized controlled clinical study containing 62 patients scheduled for elective coronary artery bypass graft and/or valve surgery with cardiopulmonary bypass. Before surgery, patients were randomly assigned to three groups: (1) conventional mechanical ventilation (CV), (2) OLC started after arrival on the ICU (late open lung, LOL), and (3) OLC started directly after intubation (early open lung, EOL). In both OLC groups, recruitment maneuvers were applied until PaO(2)/FiO(2)>50. The CV group received no recruitment maneuvers. Interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor (TNF)-alpha, and interferon (IFN)-gamma were measured preoperatively, immediately after cessation of CPB, and 3h, 5h, 24h, 2, and 3 days after cessation of CPB. RESULTS CPB caused a significant increase of IL-6, IL-8, and IL-10 in all groups. Thereafter, IL-8 decreased significantly more rapidly in both OLC groups compared to CV. IL-10 decreased significantly more rapidly after CPB only in the EOL group, compared with CV. Three hours after cessation of the CPB, IL-10 was already comparable with preoperative levels in the EOL group, but not in the LOL or CV group. IL-6, TNF-alpha, and IFN-gamma did not differ significantly between groups. CONCLUSIONS OLC ventilation leads to an attenuated inflammatory response, presumably by reducing additional lung injury after cardiac surgery. Studies on cytokines after cardiac surgery should take these findings into account.
Collapse
Affiliation(s)
- Dinis Reis Miranda
- Department of Anesthesiology, Erasmus MC, Dr Molewaterplein 40, 3015 DG Rotterdam, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
25
|
Reis Miranda D, Struijs A, Koetsier P, van Thiel R, Schepp R, Hop W, Klein J, Lachmann B, Bogers AJJC, Gommers D. Open lung ventilation improves functional residual capacity after extubation in cardiac surgery*. Crit Care Med 2005; 33:2253-8. [PMID: 16215379 DOI: 10.1097/01.ccm.0000181674.71237.3b] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE After cardiac surgery, functional residual capacity (FRC) after extubation is reduced significantly. We hypothesized that ventilation according to the open lung concept (OLC) attenuates FRC reduction after extubation. DESIGN A prospective, single-center, randomized, controlled clinical study. SETTING Cardiothoracic operating room and intensive care unit of a university hospital. PATIENTS Sixty-nine patients scheduled for elective coronary artery bypass graft and/or valve surgery with cardiopulmonary bypass. INTERVENTIONS Before surgery, patients were randomly assigned to three groups: (1) conventional ventilation (CV); (2) OLC, started after arrival in the intensive care unit (late open lung); and (3) OLC, started directly after intubation (early open lung). In both OLC groups, recruitment maneuvers were applied until Pao2/Fio2 was >375 Torr (50 kPa). No recruitment maneuvers were applied in the CV group. MEASUREMENTS AND MAIN RESULTS FRC was measured preoperatively and 1, 3, and 5 days after extubation. Peripheral hemoglobin saturation (Spo2) was measured daily till the third day after extubation while the patient was breathing room air. Hypoxemia was defined by an Spo2 value < or =90%. Averaged over the 5 postoperative days, FRC was significantly higher in the early open lung group and tended to be higher in the late open lung group, in comparison with the CV group (mean +/- sem: CV, 1.8 +/- 0.1; late open lung,1.9 +/- 0.1; and early open lung, 2.2 +/- 0.1l). In the CV group, 37% of the patients were hypoxic on the third day after extubation, compared with none of the patients in both OLC groups. CONCLUSIONS After cardiac surgery, earlier application of OLC resulted in a significantly higher FRC and fewer episodes of hypoxemia than with CV after extubation.
Collapse
Affiliation(s)
- Dinis Reis Miranda
- Department of Cardio-Thoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
| | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Miranda DR, Mekel J, Klein J, Gommers D. Superior vena cava collapsibility as a gauge of volume status in ventilated septic patients. Intensive Care Med 2004; 30:2282; author reply 2283. [PMID: 15480562 DOI: 10.1007/s00134-004-2473-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2004] [Indexed: 11/30/2022]
|
27
|
Fidler V, Nap R, Miranda DR. The effect of a managerial-based intervention on the occurrence of out-of-range-measurements and mortality in Intensive Care Units. J Crit Care 2004; 19:130-4. [PMID: 15484172 DOI: 10.1016/j.jcrc.2004.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate the effect of an organization-based managerial intervention on performance of intensive care units (ICUs). METHODS AND PARTICIPANTS Prospective multicentre cluster-randomized study with an intervention at the level of ICU staff was carried out. The intervention comprised a set of managerial changes, concerning the nurses' level of skill discretion and participation in decision-making introduced during a period of six months. The ICU-performance was monitored before, during and after the intervention, in terms of mortality and occurrence of out-of-range-measurements (ORMs). The ORMs were defined as a derangement of systolic blood pressure (BP), heart rate (HR), oxygen saturation (SaO2) and urine output (Diur). Data were statistically analyzed by logistic regression with random effects due to ICUs. RESULTS The overall ICU and hospital mortalities were 14% and 20%, the incidence of BP, HR, O2 and Diur ORM was respectively 46%, 38%, 28% and 48%. After adjusting for SAPSII, admission type and age the regression analyses revealed a positive effect of the intervention for all the six outcome variables. CONCLUSIONS The intervention reduced both the ICU and hospital mortalities and the incidences of the out-of-range measurements. Registering ORMs provides a feasible method for evaluating ICU performance and could help to optimize individual patient care.
Collapse
Affiliation(s)
- Vaclav Fidler
- Faculty of Medical Sciences, University of Groningen, The Netherlands.
| | | | | |
Collapse
|
28
|
Iapichino G, Morabito A, Mistraletti G, Ferla L, Radrizzani D, Reis Miranda D. Determinants of post-intensive care mortality in high-level treated critically ill patients. Intensive Care Med 2003; 29:1751-6. [PMID: 12923615 DOI: 10.1007/s00134-003-1915-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2003] [Accepted: 06/23/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assess the predictive ability of preillness and illness variables, impact of care, and discharge variables on the post-intensive care mortality. SETTING AND PATIENTS 5,805 patients treated with high intensity of care in 89 ICUs in 12 European countries (EURICUS-I study) surviving ICU stay. METHODS Case-mix was split in training sample (logistic regression model for post-ICU mortality: discrimination assessed by area under ROC curve) and in testing sample. Time to death was studied by Cox regression model validated with bootstrap sampling on the unsplit case-mix. RESULTS There were 5,805 high-intensity patients discharged to ward and 423 who died in hospital. Significant odds ratios were observed for source of admission, medical/surgical unscheduled admission, each year age, each SAPSII point, each consecutive day in high-intensity treatment, and each NEMS point on the last ICU day. Time to death in ward was significantly shortened by different source of admission; age over 78 years, medical/unscheduled surgical admission; SAPSII score without age, comorbidity and type of admission over 16 points; more than 2 days in high-intensity treatment; all days spent in high treatment; respiratory, cardiovascular, and renal support at discharge; and last ICU day NEMS higher than 27 points CONCLUSIONS Worse outcome is associated with the physiological reserve before admission in the ICU, type of illness, intensity of care required, and the clinical stability and/or the grade of nursing dependence at discharge.
Collapse
Affiliation(s)
- Gaetano Iapichino
- Istituto di Anestesiologia e Rianimazione, Università di Milano, Azienda Ospedaliera-Polo Universitario San Paolo, via A. Di Rudinì 8, 20142 Milan, Italy.
| | | | | | | | | | | |
Collapse
|
29
|
Abstract
OBJECTIVES The instruments used for measuring nursing workload in the intensive care unit (e.g., Therapeutic Intervention Scoring System-28) are based on therapeutic interventions related to severity of illness. Many nursing activities are not necessarily related to severity of illness, and cost-effectiveness studies require the accurate evaluation of nursing activities. The aim of the study was to determine the nursing activities that best describe workload in the intensive care unit and to attribute weights to these activities so that the score describes average time consumption instead of severity of illness. DESIGN To define by consensus a list of nursing activities, to determine the average time consumption of these activities by use of a 1-wk observational cross-sectional study, and to compare these results with those of the Therapeutic Intervention Scoring System-28. SETTING A total of 99 intensive care units in 15 countries. PATIENTS Consecutive admissions to the intensive care units. INTERVENTION Daily recording of nursing activities at a patient level and random multimoment recording of these activities. RESULTS A total of five new items and 14 subitems describing nursing activities in the intensive care unit (e.g., monitoring, care of relatives, administrative tasks) were added to the list of therapeutic interventions in Therapeutic Intervention Scoring System-28. Data from 2,041 patients (6,451 nursing days and 127,951 multimoment recordings) were analyzed. The new activities accounted for 60% of the average nursing time; the new scoring system (Nursing Activities Score) explained 81% of the nursing time (vs. 43% in Therapeutic Intervention Scoring System-28). The weights in the Therapeutic Intervention Scoring System-28 are not derived from the use of nursing time. CONCLUSIONS Our study suggests that the Nursing Activities Score measures the consumption of nursing time in the intensive care unit. These results should be validated in independent databases.
Collapse
|
30
|
Iapichino G, Radrizzani D, Ferla L, Pezzi A, Porta F, Zanforlin G, Miranda DR. Description of trends in the course of illness of critically ill patients. Markers of intensive care organization and performance. Intensive Care Med 2002; 28:985-9. [PMID: 12349820 DOI: 10.1007/s00134-002-1331-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify objective trends of the course of illness that might be used as benchmarks in the auditing of the organization/performance of Intensive Care Units (ICU). DESIGN Retrospective analysis. PATIENTS AND SETTING A group of 12,615 patients and 55,464 patient-days prospectively collected in 89 ICUs of 12 European countries. METHODS The complexity of daily care in the ICU was classified as high (HT) or low (LT), according to six activities registered in NEMS,a daily therapeutic index for ICUs. RESULTS Six trends of clinical course were identified: LT during the whole ICU stay (5,424 patients, mortality 1.8%); HT (3,480 patients, mortality 30.4%); HT followed by LT (2,781 patients, mortality 2.8%); LT followed by HT (197 patients, mortality 39.1%); finally, LT/HT/LT in 298 patients (mortality 10.5%); and HT/LT/HT (mortality 20.1%) in 438 patients. A group of 930 patients had the complexity of treatment increased (mortality 21.1%) and 3,711 patients received both treatments. Low-care before high-care periods had a mean duration of 2.2 +/- 3.5 days, low-care after high-care 2.7 +/- 3.1 days, and between two high-care periods 2.1 +/- 2.2 days. A group of 1,538 'surgical scheduled' patients only received LT, whereas 2,231 received HT (whether or not exclusively). Overall ICU mortality rate was low (3%) and the length of stay short, regardless of diagnosis and complexity of care received. CONCLUSIONS The use of therapeutic indexes help to classify the daily complexity of ICU care. The classification can be used as an indicator of clinical performance and resource utilization.
Collapse
Affiliation(s)
- G Iapichino
- Cattedra di Anestesiologia e Rianimazione dell'Università di Milano, Azienda Ospedaliera--Polo Universitario San Paolo, Milan, Italy.
| | | | | | | | | | | | | |
Collapse
|
31
|
Moreno R, Miranda DR, Matos R, Fevereiro T. Mortality after discharge from intensive care: the impact of organ system failure and nursing workload use at discharge. Intensive Care Med 2001; 27:999-1004. [PMID: 11497159 DOI: 10.1007/s001340100966] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Mortality after ICU discharge accounts for approx. 20-30% of deaths. We examined whether post-ICU discharge mortality is associated with the presence and severity of organ dysfunction/failure just before ICU discharge. PATIENTS AND METHODS The study used the database of the EURICUS-II study, with a total of 4,621 patients, including 2,958 discharged alive to the general wards (post-ICU mortality 8.6%). Over a 4-month period we collected clinical and demographic characteristics, including the Simplified Acute Physiology Score (SAPS II), Nine Equivalents of Nursing Manpower Use Score, and Sequential Organ Failure Assessment (SOFA) score. RESULTS Those who died in the hospital after ICU discharge had a higher SAPS II score, were more frequently nonoperative, admitted from the ward, and had stayed longer in the ICU. Their degree of organ dysfunction/failure was higher (admission, maximum, and delta SOFA scores). They required more nursing workload resources while in the ICU. Both the amount of organ dysfunction/failure (especially cardiovascular, neurological, renal, and respiratory) and the amount of nursing workload that they required on the day before discharge were higher. The presence of residual CNS and renal dysfunction/failure were especially prognostic factors at ICU discharge. Multivariate analysis showed only predischarge organ dysfunction/failure to be important; thus the increased use of nursing workload resources before discharge probably reflects only the underlying organ dysfunction/failure. CONCLUSIONS It is better to delay the discharge of a patient with organ dysfunction/failure from the ICU, unless adequate monitoring and therapeutic resources are available in the ward.
Collapse
Affiliation(s)
- R Moreno
- Unidade de Cuidados Intensivos Polivalente, Hospital de St António dos Capuchos, Lisbon, Portugal.
| | | | | | | |
Collapse
|
32
|
Miranda DR. Improving the cost-effectiveness of coronary artery bypass grafting surgery. Better clinical research or simply better management? Intensive Care Med 2001; 27:461-3. [PMID: 11355112 DOI: 10.1007/s001340100874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
33
|
Iapichino G, Radrizzani D, Bertolini G, Ferla L, Pasetti G, Pezzi A, Porta F, Miranda DR. Daily classification of the level of care. A method to describe clinical course of illness, use of resources and quality of intensive care assistance. Intensive Care Med 2001; 27:131-6. [PMID: 11280624 DOI: 10.1007/s001340000776] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To develop a simple and comparable clinical method able to distinguish between higher and lower complexities of care in the ICU. DESIGN Retrospective analysis. SETTING Database of European ICUs Study I (Euricus-I: including 12,615 patients and 55,464 patient/days), prospectively collected in 89 ICUs of 12 European countries. METHODS AND RESULTS A panel of experts developed the classification of the complexity of care. Six (in addition to monitoring, two levels of respiratory support--R and r--two levels of circulatory support--C and c--and dialysis) out of the nine items of Nine Equivalents of Nursing Manpower use Score (NEMS), a therapeutic index, were utilised. Two levels of care (LOCs) were defined according to a more (HT) and a less complex (LT) combination of common activities of care. The two LOCs were significantly related to mortality: higher in HT and they rose with increasing cumulative number of HT days. HT accounted for 31,976 NEMS days (57.7%) while 23,488 (42.3 %) were LT. Major respiratory and cardiovascular support accounted for about 80 % of the HT days. Respiratory assistance and monitoring were responsible for an equivalent percentage of LT days. The distribution of the clinical classification of LOCs coincided with that of the managerial scores of LOCs in the literature. CONCLUSIONS The managerial instrument described uses simple and reliable clinical data. It is able to distinguish between patients with different severity and outcome, and shows that every additional consecutive day spent in ICU as HT increases the probability of death. Moreover, (1) it suggests the possibility of describing the clinical course of illness by relating the complexity/level of medical care to the available technology and staff; (2) using relevant markers of clinical activity, it might be useful to include in quality control programmes.
Collapse
Affiliation(s)
- G Iapichino
- Servizio di Anestesia e Rianimazione, Ospedale Universitario San Paolo, Milano, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
34
|
Abstract
Nursing costs more than any other element of intensive care. Nurses are allocated exclusively to the ICU, and their use can therefore be accurately monitored. The amount of nursing work in the ICU is intimately associated with the severity of illness of the patients. Consequently, the density of nursing staff in the ICU can be used as a measure of cost, and the Therapeutic Intervention Scoring System (TISS) is a reliable tool for measuring their workload. TISS is therefore often used to compare the costs of alternative courses of care; it covers direct costs of care, but it should not be used as a proxy for total costs in the ICU. The users of TISS should consider the limitations of the scoring system in some aspects of its development, as well as the general nature of the definitions of the items included. The careful enunciation of the more generally defined items has therefore to be considered when it is used in a research project that compares small samples.
Collapse
Affiliation(s)
- D R Miranda
- Health Services Research Unit, University Hospital Groningen, The Netherlands
| |
Collapse
|
35
|
Affiliation(s)
- D R Miranda
- Health Services Research Unit, University Hospital Groningen, The Netherlands
| |
Collapse
|
36
|
Abstract
OBJECTIVE To evaluate the performance of the New Simplified Acute Physiology Score (SAPS II) and the admission Mortality Probability Model (MPM0) in a large independent database, using formal statistical assessment. DESIGN Analysis of the database of a multicenter, multinational, prospective cohort study, EURICUS-I. SETTING Eighty nine intensive care units (ICUs) from 13 European areas. PATIENTS Data of 16,060 patients consecutively admitted to the participating ICUs were collected during a period of 4 months. Following the original SAPS II and MPM0 criteria, the analysis excluded: patients <18 ys of age; readmissions; patients admitted with acute myocardial infarction; burns; and patients in the postoperative period after coronary artery bypass surgery. All patients with a length of stay <8 hrs were excluded from the study to keep comparability between both systems. A total of 10,027 patients were analyzed. INTERVENTIONS Collection of the first 24 hrs' admission data necessary for the calculation of SAPS II and MPM0 and basic demographic statistics. Vital status at discharge from the hospital was registered. MEASUREMENTS AND MAIN RESULTS Despite having a good discriminative capability, as measured by the area under the receiver operating characteristic (ROC) curves (SAPS II: ROC = 0.822 +/- 0.005 SEM; MPM0: ROC = 0.785 +/- 0.006 SEM), both models presented poor calibration, with significant differences between observed and predicted mortality (Hosmer-Lemeshow goodness-of-fit tests H and C, p < .0001). Both SAPS II (predicted risk >40%) and MPM0 (predicted risk >30%) overestimated the risk of death. The evaluation of the uniformity of fit of SAPS II and MPM0 demonstrated large variations across the various subgroups of patients. CONCLUSIONS The original SAPS II and MPM0 models did not accurately predict mortality on an independent large international multicenter ICU patient database. Results of studies utilizing general outcome prediction models without previous validation in the target population should be interpreted with prudence.
Collapse
Affiliation(s)
- R Moreno
- Intensive Care Unit, Hospital de Santo António dos Capuchos, Lisboa, Portugal
| | | | | | | |
Collapse
|
37
|
Abstract
OBJECTIVE To compare the performance of the New Simplified Acute Physiology Score (SAPS II) and the New Admission Mortality Probability Model (MPM II0) within relevant subgroups using formal statistical assessment (uniformity of fit). DESIGN Analysis of the database of a multi-centre, multi-national and prospective cohort study, involving 89 ICUs from 12 European Countries. SETTING Database of EURICUS-I. PATIENTS Data of 16,060 patients consecutively admitted to the ICUs were collected during a period of 4 months. Following the original SAPS II and MPM II0 criteria, the following patients were excluded from the analysis: younger than 18 years of age; readmissions; acute myocardial infarction; burn cases; patients in the post-operative period after coronary artery bypass surgery and patients with a length of stay in the ICU shorter than 8 h, resulting in a total of 10,027 cases. INTERVENTIONS Data necessary for the calculation of SAPS II and MPM II0, basic demographic statistics and vital status on hospital discharge were recorded. Formal evaluation of the performance of the models, comprising discrimination (area under ROC curve), calibration (Hosmer-Lemeshow goodness-of-fit H and C tests) and observed/expected mortality ratios within relevant subgroups. MAIN RESULTS Better predictive accuracy was achieved in elective surgery patients admitted from the operative room/post-anaesthesia room with gastrointestinal, neurological or trauma diagnoses, and younger patients with non-operative neurological, septic or trauma diagnoses. All these characteristics appear to be linked to a lower severity of illness, with both models overestimating mortality in the more severely ill patients. CONCLUSIONS Concerning the performance of the models, very large differences were apparent in relevant subgroups, varying from excellent to almost random predictive accuracy. These differences can explain some of the difficulties of the models to accurately predict mortality when applied to different populations with distinct patient baseline characteristics. This study stresses the importance of evaluating multiple diverse populations (to generate the design set) and of methods to improve the validation set before extrapolations can be made from the validation setting to new independent populations. It also underlines the necessity of a better definition of the patient baseline characteristics in the samples under analysis and the formal statistical evaluation of the application of the models to specific subgroups.
Collapse
Affiliation(s)
- R Moreno
- Intensive Care Unit, Hospital de Santo António dos Capuchos, Lisboa, Portugal.
| | | | | |
Collapse
|
38
|
Iapichino G, Attanasio A, Avalli L, Bassi E, Biffi C, Calappi E, Casiraghi ML, Ferrario P, Guarino A, Langer M, Marcora B, Panozzo M, Reschini G, Rotelli S, Sicignano A, Trivellato A, Vesconi S, Miranda DR. [Daily survey of procedures as markers of resources utilization]. Minerva Anestesiol 1996; 62:289-96. [PMID: 9072711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To assess and to follow along the time-span of ICU stay the process of resources allocation and utilization. DESIGN Prospective study. PATIENTS A cohort of 778 patients consecutively admitted to 7 multipurpose general ICU in the Milano area were enrolled in a survey of the daily performed interventions/procedures. MEASUREMENTS AND MAIN RESULTS The majority of diagnostic procedure/interventions were performed during the first two days. The number and quality of interventions were transferred into points obtaining a score system in non-monetary units. The resource allocation process shows a regular trend in the sub-intensive patients who were only monitorized. On the contrary the 258 patients who were intensively treated and survived show a phase of high resource-consumption (about 30 daily points: roughly twice the score of monitorized patients) then followed by a post-intensive phase with a resource consumption resulting in a daily score absolutely equal to the sub-intensive patients. The intensive patients who die show a significantly higher score than survived patients. Both daily and cumulative scores do not show differences among different type of patients. CONCLUSION The evaluation of the process of resources allocation, even if in non-monetary units enables the knowledge of the trend of ICU costs and allows the elaboration of the appropriate budget mechanism.
Collapse
Affiliation(s)
- G Iapichino
- Servizi di Anestesia e Rianimazione degli Ospedali, IRCCS Maggiore, Milano
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Abstract
OBJECTIVES To validate a simplified version of the Therapeutic Intervention Scoring System, the TISS-28, and to determine the association of TISS-28 with the time spent on scored and nonscored nursing activities. DESIGN Prospective, multicenter study. SETTING Twenty-two adult medical, surgical, and general Dutch intensive care units (ICUs). PATIENTS A total of 903 patients consecutively admitted to the ICUs. INTERVENTIONS TISS-28 was constructed from a random sample of 10,000 records of TISS-76 items. The respective weights were calculated using multivariable regression analysis through the origin; TISS-76 scores were used as predicted values. Cross validation was performed in another random sample of 10,000 records and the scores of TISS-76 were compared with those scores obtained with TISS-28 (r = .96, r2 = .93). Nursing activities in the ICU were inventoried and divided into six categories: a) activities in TISS-28; b) patient care activities not in TISS-28; c) indirect patient care (activities related to but not in direct contact with the patient, such as contact with family, maintaining supplies); d) organizational activities (e.g., meetings, trainee supervision, research); e) personal activities (for the nurse him/herself, such as taking a break, going to the bathroom); f) other. During a 1-month period, TISS-76 and TISS-28 scores were determined daily from the patient's records by independent raters. During a 1-wk period, all of the nurses on duty scored their activities using a method called "work sampling." MEASUREMENTS AND MAIN RESULTS The analysis of validation included 1,820 valid pairs of TISS-76 and TISS-28 records. The mean value of TISS-28 (28.8 +/- 11.1) was higher (p < .00) than that value of TISS-76 (24.2 +/- 10.2). TISS-28 explained 86% of the variation in TISS-76 (r = .93, r2 = .86). "Work sampling" generated 10,079 registrations of nursing activities, of which 5,530 could be matched with TISS-28 records. Samples were taken from medical (19.3%), surgical (19.1%), and general (61.6%) ICUs. Of these samples, 51.1% originated from university hospitals, 35.8% from hospitals with > 500 beds, 7.1% from hospitals with 300 to 500 beds, and 5.8% from hospitals with < 300 beds. Samples were scored in the morning (43.0%), evening (32.9%), and night shifts (24.1%). This sample of work activities was divided into four groups, according to their matched TISS scores (0 to 20, 20 to 35, 35 to 60, and > 60 points). In the successive groups of TISS scores, there was a significant increase in the proportion of time spent on the activities scored with TISS-28. In the lower TISS score group (0 to 20 points), there was a significantly larger proportion of time allocated to patient care activities not in TISS-28. There was no significant difference in the proportion of the time spent when associating indirect patient care and organizational activities with the level of TISS score. There was a significant decrease in the proportion of time spent on personal activities in the successive groups of TISS scores. The mean time spent per shift with personal activities varied between 1 hr and 40 mins (group 0 to 20 points TISS), and 1 hr and 16 mins (group > 60 points TISS). Significantly more time was used for patient care activities during the evening shift than during the day or the night shift. Conversely, nurses spent significantly less time on activities regarding their personal care during the evening shift. The time consumed for the activities of indirect patient care did not differ significantly among the three shifts. A typical nurse was capable of delivering work equal to 46.35 TISS-28 points per shift (one TISS-28 point equals 10.6 mins of each nurse's shift). CONCLUSIONS The simplified TISS-28 explains 86% of the variation in TISS-76 and can therefore replace the original version in the clinical practice in the ICU. Per shift, a typical nurse is capable of delivering nursing activities equal to 46 TISS-28 points.
Collapse
Affiliation(s)
- D R Miranda
- Department of Surgery, University Hospital of Groningen, The Netherlands
| | | | | |
Collapse
|
40
|
|
41
|
Abstract
OBJECTIVES a) to validate the structure of the Sickness Impact Profile scale (SIP) when applied to intensive care patients after discharge from the hospital; b) to explore the influence of age upon the various components of quality of life. DESIGN Prospective study. SETTING Patients admitted to 36 Dutch ICUs. METHODS 6,247 patients out of 13,000 consecutive admissions to the ICUs answered a SIP questionnaire 6 months after discharge from the hospital. The 3,655 returned questionnaire were analyzed after aggregating the respondents into 6 age groups: from group 1: 17-29 up to group 4: > 70 years of age. INTERVENTION Self-administration of SIP one year after discharge, measuring 5 independent categories (IC) and two dimensions: physical (PD) and psychosocial (PSD). RESULTS The total SIP-score oscillated between 5.8 +/- 8.2 (group I) and 10.5 +/- 9.5 (group 4). Group 3 had also a high score (9.4 +/- 11.2). Overall, the quality of life of patients was dominated by dysfunction on the categories composing the physical dimension, with exception of patients with ages between 30 and 50 years, in which dysfunction on the categories composing the psychosocial dimension was dominant. The structure of the SIP in the study was similar to that described to the original instrument. CONCLUSIONS The study validated the use of the SIP QOL-instrument on patients after intensive care. Age influenced consistently the various components of quality of life.
Collapse
Affiliation(s)
- Z M Tian
- Division of Surgical Intensive Care, University Hospital, Groningen, The Netherlands
| | | |
Collapse
|
42
|
Miranda DR. Quality of life after cardiopulmonary resuscitation. Resuscitation 1995. [DOI: 10.1016/0300-9572(95)91003-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
43
|
Abstract
OBJECTIVES This study evaluates the influence of Cardiopulmonary Resuscitation (CPR) on the components of quality of life (QOL) of patients after discharge from the hospital. DESIGN Extracted from a prospective national survey on Dutch intensive care units (ICUs). SETTING Thirty-six ICUs of both university and nonuniversity hospitals, spread throughout the country. METHODS For a period of 6 months, 9,803 consecutive ICU admissions entered the study. Outcome in connection with in-hospital CPR was analyzed by comparing the CPR group (n = 477) with a standardized control group without CPR (n = 500). INTERVENTIONS Activities of daily living were registered at the time of hospital admission. A record was kept of each patient for demographics, severity of illness, length of stay, daily use of manpower and ICU technology, and mortality. Six months after hospital discharge, the QOL of 69 patients in both the CPR and control groups was measured with the Sickness Impact Profile (SIP). RESULTS CPR was performed in 4.8 percent of the patients, mainly from the general ward. These patients were older, had a higher severity of illness, and a higher daily consumption of nursing resources. The QOL did not correlate with severity of illness on admission, length of stay, or consumption of resources in the ICU. On the whole, the SIP scores of both CPR and control groups did not differ much: 11.7 vs 10.7, and circulatory arrest did not appear to impair the self-sufficiency in the study group significantly in comparison with the controls. An increased dysfunction was found in the CPR group of patients concerning their work and their psychosocial functioning. CONCLUSION Patients who have recovered from a circulatory arrest after CPR resuscitation find their capacity for resuming work diminished after discharge from the hospital, while they seem to experience a postponed negative effect on their mental functioning, especially the functions connected with the awareness of their environment.
Collapse
Affiliation(s)
- D R Miranda
- Department of Surgery, University Hospital of Groningen, The Netherlands
| |
Collapse
|
44
|
Miranda DR, Gimbrère J. Cost containment: Europe. The Netherlands. New Horiz 1994; 2:357-63. [PMID: 8087597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
In The Netherlands, 8.3% of the gross national product is allocated to health care. Medical care provided in ICUs consumes approximately 8% of hospital budgets, or approximately 2.5% of the total healthcare budget. The high cost of intensive care medicine in The Netherlands has become a matter of concern during the last decade. A national intensive care study was conducted from 1989 through 1990 to evaluate the effectiveness and organization of ICUs in the country. This study has shown that there is an association between the operational characteristics of ICUs and the hospital in which these units operate. In approximately 50% of ICUs studied, a marked mismatch existed between the provision and the use of resources. Surgical activities in the hospital were the major observed cause for this mismatch, mainly because ICUs were often used instead of the recovery room, which operated only about 8 to 10 hrs/day during working days. In addition to an absence of clearly written policies for the use of the facilities, a lack of sound ICU business organization and management was also documented and may have contributed to the observed misuse of resources and the dissatisfaction and burnout of hospital personnel. In order to improve the use of resources and to establish a controllable program of cost containment in ICUs in The Netherlands, the recommendations made to Dutch authorities were aggregated under two headings: a) the adoption of a quantifiable method for defining levels of ICU care; and b) the enforcement of the professional organization and management of ICUs.
Collapse
Affiliation(s)
- D R Miranda
- Department of Surgery, University Hospital of Groningen, The Netherlands
| | | |
Collapse
|
45
|
Abstract
The economic recession of the last decade brought intensive care systems under the light of cost-effectiveness analysis, making use of several instruments available in medical practice, and others adapted from for-profit enterprises. The present concept of intensive care, particularly its functional and organizational interactions with traditional specialties, is at the brink of an important revaluation. Studies of the cost-effectiveness of therapeutic actions may be grossly biased if they do not consider the complete process of care (before, during, and after treatment), analyzing even its smallest elements.
Collapse
|
46
|
Affiliation(s)
- D R Miranda
- Academisch Ziekenhuis Groningen, Intensive Care Division, The Netherlands
| |
Collapse
|
47
|
Abstract
A hygroscopic condensor humidifier has been tested during high-frequency jet ventilation, in an experimental set up. The influence of various ventilator settings on relative humidity, temperature and water content of the inspiratory and expiratory gases was investigated. The device provides adequate conditioning of the inspired gases with regard to relative humidity, temperature and water content at various ventilator settings.
Collapse
Affiliation(s)
- D F Zandstra
- Institute of Anaesthesiology and Intensive Care, University Hospital Groningen, The Netherlands
| | | | | |
Collapse
|
48
|
Stoutenbeek CP, van Saene HK, Miranda DR, Zandstra DF, Langrehr D. The effect of oropharyngeal decontamination using topical nonabsorbable antibiotics on the incidence of nosocomial respiratory tract infections in multiple trauma patients. J Trauma 1987; 27:357-64. [PMID: 3033259 DOI: 10.1097/00005373-198704000-00003] [Citation(s) in RCA: 160] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The incidence of respiratory tract infections was determined in 59 multiple trauma patients requiring prolonged intensive care (greater than 5 days) and receiving no antibiotic prophylaxis. Early pneumonia (less than 48 hr) with S. aureus, S. pneumoniae, and/or H. influenzae was found in 44% of patients. Secondary colonization of the oropharynx and respiratory tract with ICU-associated Gram-negative bacilli followed by pneumonia occurred in 12 patients (20%). The overall incidence of respiratory tract infections was 59%. In a prospective open trial three prophylactic antibiotic regimens were compared: 17 patients were treated with intestinal decontamination using nonabsorbable antibiotics (polymyxin E 400 mg, tobramycin 320 mg, amphotericin B 2,000 mg/day). No difference in infection rate was found. Twenty-five patients were treated with intestinal and oropharyngeal decontamination using an ointment containing 2% of the same antibiotics. Secondary colonization and infection of the respiratory tract with Gram-negative bacilli was significantly reduced (p less than 0.001). The incidence of early (Gram-positive) infections, however, was unchanged. Another group of 63 patients was treated with systemic antibiotic prophylaxis during the first days in combination with oropharyngeal and intestinal decontamination. The incidence of early pneumonia was significantly reduced (p less than 0.001). Five patients (8%) developed an infection. Superinfections were not observed.
Collapse
|
49
|
Abstract
High-frequency ventilation (HFV) has been used with good results in a variety of clinical situations where conventional ventilation has proved ineffective. However, all of the reports so far have involved the use of a specially purchased specifically designed ventilator which tends to be unfamiliar to most medical and nursing staff responsible for its use. A case where HFV was used in combination with differential lung ventilation in the treatment of unilateral pulmonary atelectasis is described using a Servo 900B as the high-frequency ventilator. It serves to demonstrate that the Servo 900B can be used as an occasional high-frequency ventilator as required, thus avoiding the expense of purchasing a specialized ventilator.
Collapse
|
50
|
Stoutenbeek CP, van Saene HK, Miranda DR, Zandstra DF, Langrehr D. Nosocomial gram-negative pneumonia in critically ill patients. A 3-year experience with a novel therapeutic regimen. Intensive Care Med 1986; 12:419-23. [PMID: 3540063 DOI: 10.1007/bf00254674] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The efficacy of selective decontamination of the oral cavity and GI-tract in the treatment of established gram-negative pneumonia in critically ill patients was evaluated in a prospective open trial. 25 patients with pneumonia caused by Enterobacteriaceae or Pseudomonadaceae were studied. All patients were mechanically ventilated (range 2-60 days). Non-absorbable antibiotics (polymyxin E 100 mg, tobramycin 80 mg, amphotericin B 500 mg) were administered through the nasogastric tube four times a day. The oral cavity was decontaminated with an ointment containing 2% of the same antibiotics, applied to the buccal mucosa four times a day. For systemic therapy a combination of tobramycin (3-6 mg X kg-1) with either cefotaxim (50-100 mg X kg-1) or ceftazidime (100 mg X kg-1) was given both intravenously and by aerosol (50% IV dose/5 ml saline) four times a day. Eradication of pathogens from the respiratory tract was achieved in 24 patients within 9 days (median 5 days). The cure rate was 96%. Two patients had a relapse. Neither recolonization with resistant organisms nor supra-infections were found for the remaining period of mechanical ventilation (up to 60 days), also after systemic/aerosol therapy had been discontinued. Only 3 patients died (12%).
Collapse
|