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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Posted in Admission to ICU, Critical Care at 15:07 by Laci
By M Garrouste-Orgeas, L Montuclard, J-F Timsit, J Reignier, T Desmettre, P Karoubi et al. for the French ADMISSIONREA study group
Critical Care Medicine 2005;33:750-755
To identify factors associated with granting or refusing intensive care unit (ICU) admission, to analyze ICU characteristics and triage decisions, and to describe mortality in admitted and refused patients.
Design
Observational, prospective, multiple-center study.
Setting
Four university hospitals and seven primary-care hospitals in France.
Interventions
None.
Measurements and Main Results
Age, underlying diseases (McCabe score and Knaus class), dependency, hospital mortality, and ICU characteristics were recorded. The crude ICU refusal rate was 23.8% (137/574), with variations from 7.1% to 63.1%. The reasons for refusal were too well to benefit (76/137, 55.4%), too sick to benefit (51/137, 37.2%), unit too busy (9/137, 6.5%), and refusal by the family (1/137). In logistic regression analyses, two patient-related factors were associated with ICU refusal: dependency (odds ratio [OR], 14.20; 95% confidence interval [CI], 5.27-38.25; p < .0001) and metastatic cancer (OR, 5.82; 95% CI, 2.22-15.28). Other risk factors were organizational, namely, full unit (OR, 3.16; 95% CI, 1.88-5.31), center (OR, 3.81; 95% CI, 2.27-6.39), phone admission (OR, 0.23; 95% CI, 0.14-0.40), and daytime admission (OR, 0.52; 95% CI, 0.32-0.84). The Standardized Mortality Ratio was 1.41 (95% CI, 1.19-1.69) for immediately admitted patients, 1.75 (95% CI, 1.60-1.84) for refused patients, and 1.03 (95% CI, 0.28-1.75) for later-admitted patients.
Conclusions
ICU refusal rates varied greatly across ICUs and were dependent on both patient and organizational factors. Efforts to define ethically optimal ICU admission policies might lead to greater homogeneity in refusal rates, although case-mix variations would be expected to leave an irreducible amount of variation across ICUs.
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