30 Mar 10
Posted in Critical Care, Infection at 21:47 by Laci
By P George and A Morris
Critical Care 2010;14:205
You are director of a large multi-disciplinary ICU. You have recently read that hospital-wide antibiotic stewardship programs have the potential to improve the quality and safety of care, and to reduce the emergence of multi-drug resistant organisms and overall costs. You are considering starting one of these programs in your ICU, but are concerned about the associated infrastructure costs. You are debating whether it is worth bringing the concept forward to your hospital’s administration to consider investing in.
Statement for debate
Antibiotic stewardship programs improve patient outcomes and cost-effectiveness in critically ill patients in the ICU.
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23 Mar 10
Posted in Critical Care, Lactate at 1:04 by Laci
By A Nichol, M Egi, V Pettila, R Bellomo, C French, G Hart et al
Critical Care 2010, 14:R25
Higher lactate concentrations within the normal reference range (“relative hyperlactatemia”) are not considered clinically significant. We tested the hypothesis that relative hyperlactatemia is independently associated with an increased risk of hospital death.
Methods
Retrospective observational study of prospectively obtained intensive care database of 7155 consecutive critically ill patients admitted to the Intensive Care Units (ICUs) of four Australian university hospitals. We assessed the relationship between ICU admission (LacADM), maximal (LacMAX) and time-weighted (LacTW) lactate levels and hospital outcome in all patients and in those patients whose LacADM (n=3964), LacMAX (n=2511) and LacTW (n=4584) lactate was under 2 mmol.L-1 (relative hyperlactatemia).
Results
We obtained 172,723 lactate measurements. Higher LacADM and LacTW concentration within the reference range was independently associated with increased hospital mortality (LacADM: odds ratio (OR) 2.1, 95% confidence interval (CI) 1.3-3.5, P=0.01; LacTW OR 3.7, 95% CI 1.9-7.00, P<0.0001). This significant association was first detectable at lactate concentrations > 0.75 mmol.L-1. Furthermore, in patients whose lactate never exceeded 2 mmol.L-1, higher LacTW remained strongly associated with higher hospital mortality (LacTW OR 4.8, 95% CI 1.8-12.4, P<0.001).
Conclusions
In critically ill patients, relative hyperlactataemia is independently associated with increased hospital mortality. Blood lactate concentrations >0.75 mmol.L-1 can be used by clinicians to identify patients at higher risk of death. The current reference range for lactate in the critically ill may need to be re-assessed.
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15 Jan 10
Posted in Admission to ICU, Critical Care at 0:48 by Laci
By J-L Vincent, S Opal and J Marshall
Crit Care Med 2010;38:283-287
Severity scores such as Acute Physiology and Chronic Health Evaluation II have been advocated as entry criteria for clinical trials and in clinical decision-making. We present ten reasons why we believe this approach is not appropriate and may even be detrimental.
Data sources
Available relevant literature from authors’ personal databases and personal knowledge of past and future clinical trial development.
Data synthesis
Severity scores were not designed for use in individual patients or for therapeutic decision-making for specific interventions. Difficulties with the time window needed to calculate these scores and the need to administer therapies early further limit their use in this context. The complex nature of the scores makes it difficult to use them at the bedside and there is considerable interobserver variability in score calculation. Inclusion of chronic health and age points in severity scores may prevent younger, previously healthy patients, with similar acute physiological dysfunction and therefore total lower severity scores, from trial inclusion or from receiving therapies that may be beneficial.
Conclusions
We believe severity of illness scores are poor surrogates for risk stratification and should not be used as a criterion for patient enrollment into clinical trials or as the basis for individual treatment decisions.
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11 Dec 09
Posted in Critical Care at 1:26 by Laci
By J Preiser
Critical Care 2009, 13:228
In 2008, the interest in metabolic and endocrine issues and their consequences in critically ill patients was high. A large proportion of the research papers related to these issues was related to the metabolism of glucose and its control and to the changes in body composition, including muscular weakness. In Critical Care, original reports from investigations of glucose physiology and clinical data from observational and interventional studies were published. Important reports of the effects of hormone analogues, such as vasopressin and hydrocortisone, and early antioxidants in selected subpopulations were also available in 2008.
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