15 Jun 08
Posted in Admission to ICU at 10:11 by Laci
By M M Levy, J Rapoport, S Lemeshow, D B Chalfin, G Phillips and M Danis
Ann Int Med 2008;148:801-809
Critically ill patients admitted to intensive care units (ICUs) are thought to gain an added survival benefit from management by critical care physicians, but evidence of this benefit is scant.
Objective
To examine the association between hospital mortality in critically ill patients and management by critical care physicians.
Design
Retrospective analysis of a large, prospectively collected database of critically ill patients.
Setting
123 ICUs in 100 U.S. hospitals.
Patients
101 832 critically ill adults.
Measurements
Through use of a random-effects logistic regression, investigators compared hospital mortality between patients cared for entirely by critical care physicians and patients cared for entirely by non–critical care physicians. An expanded Simplified Acute Physiology Score was used to adjust for severity of illness, and a propensity score was used to adjust for differences in the probability of selective referral of patients to critical care physicians.
Results
Patients who received critical care management (CCM) were generally sicker, received more procedures, and had higher hospital mortality rates than those who did not receive CCM. After adjustment for severity of illness and propensity score, hospital mortality rates were higher for patients who received CCM than for those who did not. The difference in adjusted hospital mortality rates was less for patients who were sicker and who were predicted by propensity score to receive CCM.
Limitation
Residual confounders for illness severity and selection biases for CCM might exist that were inadequately assessed or recognized.
Conclusion
In a large sample of ICU patients in the United States, the odds of hospital mortality were higher for patients managed by critical care physicians than those who were not. Additional studies are needed to further evaluate these results and clarify the mechanisms by which they might occur.
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01 Apr 08
Posted in Admission to ICU, ScvO2, Sepsis at 19:23 by Laci
By PA van Beest, JJ Hofstra, MJ Schultz, EC Boerma, PE Spronk and MA Kuiper
Critical Care 2008, 12:R33
Low mixed or central venous saturation (S(c)vO2) can reveal global tissue hypoxia and therefore can predict poor prognosis in critically ill patients. Early goal directed therapy (EGDT), aiming at an ScvO2 ≥ 70%, has been shown to be a valuable strategy in patients with sepsis or septic shock and is incorporated in the Surviving Sepsis Campaign guidelines.
Methods
In this prospective observational multi-center study, we determined central venous pressure (CVP), hematocrit, pH, lactate and ScvO2 or SvO2 in a heterogeneous group of critically ill patients early after admission to the intensive care units (ICUs) in three Dutch hospitals.
Results
Data of 340 acutely admitted critically ill patients were collected. The mean SvO2 value was > 65% and the mean ScvO2 value was > 70%. With mean CVP of 10.3 ± 5.5 mmHg, lactate plasma levels of 3.6 ± 3.6 and acute physiology, age and chronic health evaluation (APACHE II) scores of 21.5 ± 8.3, the in-hospital mortality of the total heterogeneous population was 32.0%. A subgroup of septic patients (n = 125) showed a CVP of 9.8 ± 5.4 mmHg, mean ScvO2 values of 74.0 ± 10.2%, where only 1% in this subgroup revealed a ScvO2 value < 50%, and lactate plasma levels of 2.7 ± 2.2 mmol/l with APACHE II scores 20.9 ± 7.3. Hospital mortality of this subgroup was 26%.
Conclusion
The incidence of low ScvO2 values for acutely admitted critically ill patients is low in Dutch ICUs. This is especially true for patients with sepsis/septic shock.
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06 Nov 07
Posted in Admission to ICU, Critical Care, Mechanical ventilation at 19:05 by Laci
By M J Wildman, C Sanderson, J Groves, B C Reeves, J Ayres, D Harrison, D Young, K Rowan
BMJ 2007;335:xxx-xxx
To determine whether clinicians’ prognoses in patients with severe acute exacerbations of obstructive lung disease admitted to intensive care match observed outcomes in terms of survival.
Design
Prospective cohort study.
Setting
92 intensive care units and three respiratory high dependency units in the United Kingdom.
Participants
832 patients aged 45 years and older with breathlessness, respiratory failure, or change in mental status because of an exacerbation of COPD, asthma, or a combination of the two.
Main outcome measures
Outcome predicted by clinicians. Observed survival at 180 days.
Results
517 patients (62%) survived to 180 days. Clinicians’ prognoses were pessimistic, with a mean predicted survival of 49% at 180 days. For the fifth of patients with the poorest prognosis according to the clinician, the predicted survival rate was 10% and the actual rate was 40%. Information from a database covering 74% of intensive care units in the UK suggested no material difference between units that participated and those that did not. Patients recruited were similar to those not recruited in the same units.
Conclusions
Because decisions on whether to admit patients with COPD or asthma to intensive care for intubation depend on clinicians’ prognoses, some patients who might otherwise survive are probably being denied admission because of unwarranted prognostic pessimism.
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11 Dec 06
Posted in Admission to ICU, Critical Care, Obesity at 15:23 by Laci
By S Peake, J L Moran, D R Ghelani, A J Lloyd, M J Walker
Critical Care Medicine 2006;34:2929-2939
Evaluate the effect of intensive care (ICU) admission body mass index (BMI) on 30-day and 12-month survival in critically ill patients and determine the impact of obesity on outcome.
Design
Prospective, observational cohort study.
Setting
Fourteen-bed medical and surgical ICU of a university-affiliated hospital.
Patients
Four hundred and ninety-three adult patients.
Interventions
None.
Measurements and Main Results
BMI (kg/m2) was calculated from height (m) and measured weight (kg) within 4 hrs of ICU admission, using the PROMED weighing device, or premorbid weight (documented in the previous month) (BMImeasured). Follow-up was for =12 months post-ICU admission. Time to mortality outcome, censored at 30 and 365 days (12-months), was analyzed using a log-normal accelerated failure time regression model. Predictor variables were parameterized as time ratios (TR), where TR <1 is associated with decreased survival time and TR >1 is associated with prolonged survival time. Mean (sd) age and Acute Physiology and Chronic Health Evaluation II score were 62.3 (17.5) years and 20.7(8.4), respectively; 56.0% (285 of 493) of patients were male and 60.6% (299 of 493) medical. ICU admission weight and BMImeasured (available in 433 patients) were 79.1 (22.1) kg and 27.8 (7.0) kg/m2, respectively. In 16.9% (73 of 433) of patients, weight was =100 kg, and in 29.8% (129 of 433), BMImeasured was =30 kg/m2. Raw intensive care, 30-day, and 12-month mortality rates were 15.2% (66 of 433), 22.3% (95 of 433), and 37.3% (159 of 433), respectively. BMImeasured was a significant determinant of mortality at 30 days (TR 1.853, 95% confidence interval 1.053-3.260, p = .032) and 12 months (TR 1.034, 95% confidence interval 1.005-1.063, p = .019). The effect of BMI on 12-month mortality was linear, such that increasing BMI was associated with decreasing mortality.
Conclusions
ICU admission BMI was a determinant of short- to medium-term survival. Obesity was not associated with adverse outcomes and may be protective.
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