28-day Ventilator-free Days Research Articles

Correlation of arterial blood gas markers and lactate levels with outcomes in pediatric traumatic brain injury

Background: Various physical markers have been used to predict outcome of traumatic brain injury in children. However, the utility of metabolic alterations for prognostication has been poorly described. Thus, we aim to correlate arterial blood gas markers and lactate levels with outcomes in children with moderate to severe traumatic brain injury. Methods: This is a retrospective cohort study that included all patients <16 years old who presented to the Emergency Department with moderate to severe traumatic brain injury (Glasgow Coma Scale ⩽13). Serial arterial blood gas results and lactate levels in the first five days of admission to a pediatric intensive care unit (PICU) were reviewed. Primary outcome was in-hospital mortality. Secondary outcomes were 28-day ventilator-free and PICU-free days. A stepwise logistic regression analysis in conjunction with receiver operating characteristic analysis were used to identify variables that were associated with in-hospital mortality. Secondary outcomes were analyzed using multiple linear regression. Results: Among the 43 patients analyzed, more than half of the patients (60%) had severe traumatic brain injury (Glasgow Coma Scale 8). Twenty-seven of the 43 (65%) patients underwent neurosurgical intervention and overall mortality was 9/43 (20.9%). The worst base excess and lactate levels of Day 2 of PICU stay were found to be most predictive for mortality with maximal area-under-curve (95% confidence interval) of 0.967 (0.906, 1.000). Worst lactate level on day 2 of PICU stay was also found to be associated with ventilator-free days and PICU-free days. Conclusion: In children with moderate to severe traumatic brain injury, base excess and lactate on Day 2 of PICU stay were predictors of mortality, duration of mechanical ventilation and length of PICU stay.

Use of an evidence-based algorithm for patients with traumatic hemothorax reduces need for additional interventions.

Concerted management of the traumatic hemothorax is ill-defined. Surgical management of specific hemothoraces may be beneficial. A comprehensive strategy to delineate appropriate patients for additional procedures does not exist. We developed an evidence-based algorithm for hemothorax management. We hypothesize that the use of this algorithm will decrease additional interventions. A pre-/post-study was performed on all patients admitted to our trauma service with traumatic hemothorax from August 2010 to September 2013. An evidence-based management algorithm was initiated for the management of retained hemothoraces. Patients with length of stay (LOS) less than 24 hours or admitted during an implementation phase were excluded. Study data included age, Injury Severity Score, Abbreviated Injury Scale chest, mechanism of injury, ventilator days, intensive care unit (ICU) LOS, total hospital LOS, and interventions required. Our primary outcome was number of patients requiring more than 1 intervention. Secondary outcomes were empyema rate, number of patients requiring specific additional interventions, 28-day ventilator-free days, 28-day ICU-free days, hospital LOS, all-cause 6-month readmission rate. Standard statistical analysis was performed for all data. Six hundred forty-two patients (326 pre and 316 post) met the study criteria. There were no demographic differences in either group. The number of patients requiring more than 1 intervention was significantly reduced (49 pre vs. 28 post, p = 0.02). Number of patients requiring VATS decreased (27 pre vs. 10 post, p < 0.01). Number of catheters placed by interventional radiology increased (2 pre vs. 10 post, p = 0.02). Intrapleural thrombolytic use, open thoracotomy, empyema, and 6-month readmission rates were unchanged. The "post" group more ventilator-free days (median, 23.9 vs. 22.5, p = 0.04), but ICU and hospital LOS were unchanged. Using an evidence-based hemothorax algorithm reduced the number of patients requiring additional interventions without increasing complication rates. Defined criteria for surgical intervention allows for more appropriate utilization of resources. Therapeutic study, level IV.

Antithrombin use and 28-day in-hospital mortality among severe-burn patients: an observational nationwide study

BackgroundPrevious studies have suggested that antithrombin may be beneficial for treating coagulopathy in patients with severe burns. However, robust evidence for this idea is lacking. We examined the hypothesis that antithrombin may be effective in treating patients with severe burns.MethodsWe performed propensity score-matched analyses of the nationwide administrative Japanese Diagnosis Procedure Combination inpatient database. We identified patients with severe burns (burn index ≥ 10) who were recorded in the database from 1 July 2010 to 31 March 2013. We compared patients who were administered antithrombin within 2 days of admission (antithrombin group) and those who were not administered antithrombin (control group). The main outcomes were 28-day mortality and ventilator-free days (VFDs).ResultsEligible patients (n = 3223) from 618 hospitals were categorized into either an antithrombin group (n = 152) or control group (n = 3071). Propensity score matching created a matched cohort of 103 pairs with and without antithrombin. Twenty-eight-day mortality was lower in the antithrombin group compared with the control group in propensity-matched analysis (control vs. antithrombin, 47.6 vs. 33.0%; difference, 14.6%; 95% confidence interval [CI] 1.2–28.0). Cox regression analysis showed a significant difference in 28-day in-hospital mortality between the control and antithrombin propensity-matched groups (hazard ratio 0.58; 95% CI 0.37–0.90). There were significantly more VFDs in the antithrombin compared with the control group in propensity score-matched analysis (control vs. antithrombin, 12.6 vs. 16.4 days; difference −3.7; 95% CI −7.2 to −0.12).ConclusionsThis nationwide database study demonstrated that antithrombin use may improve 28-day survival and increase VFDs in patients with severe burns. Further prospective studies are required to confirm these results.

Severity of Inhalation Injury is Predictive of Alterations in Gas Exchange and Worsened Clinical Outcomes.

Inhalation injury (INH) is present in one third of large burn injuries and increases oxygenation and fluid resuscitation requirements, incidences of pulmonary complications, risk for multiple organ dysfunction syndrome (MODS), and overall mortality. Previous studies have demonstrated inconsistent correlation between bronchoscopic evaluation and clinical outcomes. The authors reviewed 161 patients admitted with a diagnosis of INH or underwent diagnostic bronchoscopy for suspected INH over a period of 8.5 years. One hundred one patients had concomitant burn injury and 60 had isolated INH. Seventeen patients had abbreviated injury score (AIS) 0, 81 patients had low-grade injury (AIS 1 and 2), and 63 patients had high-grade injury (AIS 3 and 4). Patients with high-grade INH had worse pulmonary dysfunction, worse oxygenation indices (P = 0.01) and plasma carboxyhemoglobin (COHgb; P < 0.01) on admission, increased fluid requirements (P < 0.01 at 24 hours; P = 0.04 at 48 hours), MODS (P = 0.04), pneumonia (P < 0.01), acute respiratory distress syndrome (P = 0.01 at 48 hours), fewer 28-day ventilator-free days (P < 0.01), greater ventilator dependence (P = 0.03), and longer length of stay (P < 0.01). Multivariate analyses demonstrated increased risk of MODS (P = 0.03), acute respiratory distress syndrome at 48 hours (P < 0.01), pneumonia (P = 0.01), prolonged ventilator dependence (P = 0.03), and a trend toward mortality (P = 0.08) with higher AIS groups. More severe INH correlates with early oxygenation impairments and is associated with more complicated hospitalization, fluid resuscitation requirements, and ventilation demands. Severe INH is associated with and predictive of increased morbidity and mortality.

Implementing a care bundle approach reduces ventilator-associated pneumonia and delays ventilator-associated tracheobronchitis in children: differences according to endotracheal or tracheostomy devices

To reduce ventilator-associated infections (VARI) and improve outcomes for children. This prospective interventional cohort study was conducted in a paediatric intensive care unit (PICU) over three periods: pre-intervention, early post-intervention, and late post-intervention. These children were on mechanical ventilation (MV) for ≥48h. Overall, 312 children (11.9% of whom underwent tracheostomy) and 6187 ventilator-days were assessed. There was a significant reduction in ventilator-associated pneumonia (VAP) among tracheostomized patients (8.16, 3.27, and 0.65 per 1000 tracheostomy ventilation-days before the intervention, after the general bundle implementation, and after the tracheostomy intervention, respectively). The median time from onset of MV to diagnosis of ventilator-associated tracheobronchitis (VAT) increased from 5.5 to 48 days in the late post-intervention period (p=0.004), and was associated with a significant increase in median 28-day ventilator-free days and PICU-free days. Tracheostomy (odds ratio 7.44) and prolonged MV (odds ratio 2.75) were independent variables significantly associated with VARI. A trend towards a reduction in PICU mortality was observed, from 28.4% to 16.6% (relative risk 0.58). The implementation of a care bundle to prevent VARI in children had a different impact on VAP and VAT, diminishing VAP rates and delaying VAT onset, resulting in reduced healthcare resource use. Tracheostomized children were at increased risk of VARI, but preventive measures had a greater impact on them.

Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial.

Noninvasive ventilation (NIV) with a face mask is relatively ineffective at preventing endotracheal intubation in patients with acute respiratory distress syndrome (ARDS). Delivery of NIV with a helmet may be a superior strategy for these patients. To determine whether NIV delivered by helmet improves intubation rate among patients with ARDS. Single-center randomized clinical trial of 83 patients with ARDS requiring NIV delivered by face mask for at least 8 hours while in the medical intensive care unit at the University of Chicago between October 3, 2012, through September 21, 2015. Patients were randomly assigned to continue face mask NIV or switch to a helmet for NIV support for a planned enrollment of 206 patients (103 patients per group). The helmet is a transparent hood that covers the entire head of the patient and has a rubber collar neck seal. Early trial termination resulted in 44 patients randomized to the helmet group and 39 to the face mask group. The primary outcome was the proportion of patients who required endotracheal intubation. Secondary outcomes included 28-day invasive ventilator-free days (ie, days alive without mechanical ventilation), duration of ICU and hospital length of stay, and hospital and 90-day mortality. Eighty-three patients (45% women; median age, 59 years; median Acute Physiology and Chronic Health Evaluation [APACHE] II score, 26) were included in the analysis after the trial was stopped early based on predefined criteria for efficacy. The intubation rate was 61.5% (n = 24) for the face mask group and 18.2% (n = 8) for the helmet group (absolute difference, -43.3%; 95% CI, -62.4% to -24.3%; P < .001). The number of ventilator-free days was significantly higher in the helmet group (28 vs 12.5, P < .001). At 90 days, 15 patients (34.1%) in the helmet group died compared with 22 patients (56.4%) in the face mask group (absolute difference, -22.3%; 95% CI, -43.3 to -1.4; P = .02). Adverse events included 3 interface-related skin ulcers for each group (ie, 7.6% in the face mask group had nose ulcers and 6.8% in the helmet group had neck ulcers). Among patients with ARDS, treatment with helmet NIV resulted in a significant reduction of intubation rates. There was also a statistically significant reduction in 90-day mortality with helmet NIV. Multicenter studies are needed to replicate these findings. clinicaltrials.gov Identifier: NCT01680783.

Failure to Improve the Oxygenation Index Is a Useful Predictor of Therapy Failure in Acute Respiratory Distress Syndrome Clinical Trials

Acute respiratory distress syndrome trials powered for mortality require significant resources, limiting the number of evaluable therapies. Validation of intermediate endpoints would enhance the feasibility of testing novel acute respiratory distress syndrome therapies in pilot studies and potentially reduce the frequency of failed large clinical trials. We sought to determine whether a change in the oxygenation index over the first 7 days of acute respiratory distress syndrome could discriminate between therapies likely or unlikely to show benefit in larger clinical trials. A derivation cohort from three acute respiratory distress syndrome studies was used to estimate the 7-day change in oxygenation index. Receiver operating characteristic curves were used to calculate optimal thresholds and predictability of the change in oxygenation index for 28-day mortality and ventilator-free days. The thresholds were then validated in two cohorts. Then, for each individual acute respiratory distress syndrome study, the threshold 7-day oxygenation index change was tested as an outcome measure and compared with mortality and ventilator-free days as reported in the original study. Medical ICUs. Acute respiratory distress syndrome patients. Various. Change in oxygenation index, 28-day mortality, and ventilator-free days. In the derivation cohort, the mean 7-day oxygenation index improved by 4.2 (± 11.7) in 28-day survivors compared with an increase of 2.4 (± 11.6) in 28-day nonsurvivors (p < 0.001). The mean 7-day oxygenation index decreased by 5.9 (± 8.4) in patients with more than 14 ventilator-free days, compared with a decrease of 1.9 (± 12.4) among those with less than 14 ventilator-free days (p = 0.001). The optimal 7-day oxygenation index threshold for predicting mortality was an increase of 1.71 and for predicting less than 14 ventilator-free days, a decrease of 2.34. When used as a surrogate endpoint, the optimal 7-day oxygenation index change closely approximated mortality and ventilator-free day outcomes in three Acute Respiratory Distress Syndrome Network studies used for the derivation cohort and a distinct study used for validation. The change in oxygenation index was a poor predictor of individual patient outcome. Failure to meet a threshold improvement in the oxygenation index over the first 7 days of therapy can be used to identify therapies unlikely to succeed in subsequent trials powered for mortality and ventilator-free days. By reducing trial time and costs, use of the 7-day oxygenation index change as an intermediate endpoint could increase the number of clinical trials of promising therapies for acute respiratory distress syndrome and reduce the number of large-scale trials of therapies unlikely to be of benefit.

Azithromycin use and outcomes in severe sepsis patients with and without pneumonia

PurposeStudies investigating the association between macrolides and outcomes in both pulmonary and nonpulmonary critically ill patients are limited. We aimed to examine the association between azithromycin use and clinical outcomes in severe sepsis patients with and without pneumonia receiving mechanical ventilation. Materials and MethodsA retrospective cohort of 105 patients admitted to an adult intensive care unit (ICU) with severe sepsis in an urban university hospital were included in the study. Multivariable linear regression was performed to assess the relationship between azithromycin use and the following outcomes: 28-day ICU-free days and 28-day ventilator-free days. ResultsIn univariate analysis, patients receiving azithromycin had nearly 6 more ICU-free days on average than did patients not receiving azithromycin (P = .005). The increased ICU-free days remained in multivariable analysis adjusting for age, sex, race, ICU type, and presence of shock (P = .005). In stratified analysis examining the association of azithromycin use in severe sepsis patients without pneumonia (n = 74), the results were similar to the full cohort. ConclusionAzithromycin was associated with more ICU-free days in severe sepsis patients with and without pneumonia. Further investigations are warranted to better elicit the association of macrolide use on clinical outcomes in severe sepsis patients, especially those without pneumonia.

Enteral Immunomodulatory Diet (Omega-3 Fatty Acid, γ-Linolenic Acid and Antioxidant Supplementation) for Acute Lung Injury and Acute Respiratory Distress Syndrome: An Updated Systematic Review and Meta-Analysis.

Enteral immunomodulatory nutrition is considered as a promising therapy for the treatment of acute lung injury and acute respiratory distress syndrome (ALI/ARDS). However, there are still some divergences, and it is unclear whether this treatment should be recommended for patients with ALI/ARDS. Therefore, we conducted this systematic review and meta-analysis to assess the efficacy and safety of an enteral immunomodulatory diet on the clinical outcomes of ALI/ARDS patients. Methods: We retrieved potentially relevant clinical trials though electronic databases. All trials of enteral immunomodulatory diet for ALI/ARDS were included. Analyses of the overall all-cause mortality, 28-day ventilator-free days and 28-day intensive care unit (ICU) free days were conducted. Results: In total six controlled trials were evaluated. The pooled results did not show a significant reduction in the risk of all-cause mortality (M-H RR (the overall Mantel-Haenszel relative risk), 0.81 (95% CI, 0.50–1.31); p = 0.38; 6 trials, n = 717) in ALI/ARDS patients treated with the immunomodulatory diet. This treatment also did not extend the ventilator-free days and ICU-free days. However, patients with high mortality might benefit from this treatment. Conclusions: The enteral immunomodulatory diet could not reduce the severity of the patients with ALI/ARDS. Whereas, for ALI/ARDS patients with high mortality, this treatment might reduce the all-cause mortality, but its use should be treated with discretion.

CLINICAL NUTRITION WEEK 2015: Long Beach, CA February 14–17, 2015

CLINICAL NUTRITION WEEK 2015: Long Beach, CA February 14–17, 2015

Effect of a selective neutrophil elastase inhibitor on mortality and ventilator-free days in patients with increased extravascular lung water: a post hoc analysis of the PiCCO Pulmonary Edema Study.

BackgroundNeutrophil elastase plays an important role in the development and progression of acute respiratory distress syndrome (ARDS). Although the selective elastase inhibitor, sivelestat, is widely used in Japan for treating ARDS patients, its effectiveness remains controversial. The aim of the current study was to investigate the effects of sivelestat in ARDS patients with evidence of increased extravascular lung water by re-analyzing a large multicenter study database.MethodsA post hoc analysis of the PiCCO Pulmonary Edema Study was conducted. This multicenter prospective cohort study included 23 institutions in Japan. Adult mechanically ventilated ARDS patients with an extravascular lung water index of >10 mL/kg were included and propensity score analyses were performed. The endpoints were 28-day mortality and ventilator-free days (VFDs).ResultsPatients were categorized into sivelestat (n = 87) and control (n = 77) groups, from which 329 inverse probability-weighted group patients (162 vs. 167) were generated. The overall 28-day mortality was 31.1% (51/164). There was no significant difference in 28-day mortality between the study groups (sivelestat vs. control; unmatched: 29.9% vs. 32.5%; difference, −2.6%, 95% confidence interval (CI), −16.8 to 14.2; inverse probability-weighted: 24.7% vs. 29.5%, difference, −4.8%, 95% CI, −14.4 to 9.6). Although administration of sivelestat did not alter the number of ventilator-free days (VFDs) in the unmatched (9.6 vs. 9.7 days; difference, 0.1, 95% CI, −3.0 to 3.1), the inverse probability-weighted analysis identified significantly more VFDs in the sivelestat group than in the control group (10.7 vs. 8.4 days, difference, −2.3, 95% CI, −4.4 to −0.2).ConclusionsAlthough sivelestat did not significantly affect 28-day mortality, this treatment may have the potential to increase VFDs in ARDS patients with increased extravascular lung water. Prospective randomized controlled studies are required to confirm the results of the current study.Electronic supplementary materialThe online version of this article (doi:10.1186/s40560-014-0067-y) contains supplementary material, which is available to authorized users.

Validation of Predictors of Adverse Outcomes in Hospital-Acquired Pneumonia in the ICU*

To validate a set of predictors of adverse outcomes in patients with ICU-acquired pneumonia in relation to clinically relevant assessment at 28 days. Prospective, observational study. Six medical and surgical ICUs of a university hospital. Three hundred thirty-five patients with ICU-acquired pneumonia. None. Development of predictors of adverse outcomes was defined when at least one of the following criteria was present at an evaluation made 72-96 hours after starting treatment: no improvement of PaO2/FIO2, need for intubation due to pneumonia, persistence of fever or hypothermia with purulent respiratory secretions, greater than or equal to 50% increase in radiographic infiltrates, or occurrence of septic shock or multiple organ dysfunction syndrome. We also assessed the inflammatory response by different serum biomarkers. The presence of predictors of adverse outcomes was related to mortality and ventilator-free days at day 28. Sequential Organ Failure Assessment score was evaluated and related to mortality at day 28.One hundred eighty-four (55%) patients had at least one predictor of adverse outcomes. The 28-day mortality was higher for those with versus those without predictors of adverse outcomes (45% vs 19%, p<0.001), and ventilator-free days were lower (median [interquartile range], 0 [0-17] vs 22 [0-28]) for patients with versus patients without predictors of adverse outcomes (p<0.001). The lack of improvement of PaO2/FIO2 and lack of improvement in Sequential Organ Failure Assessment score from day 1 to day 5 were independently associated with 28-day mortality and fewer ventilator-free days. The marginal structural analysis showed an odds ratio of death 2.042 (95% CI, 1.01-4.13; p=0.047) in patients with predictors of adverse outcomes. Patients with predictors of adverse outcomes had higher serum inflammatory response accordingly to biomarkers evaluated. The presence of any predictors of adverse outcomes was associated with mortality and decreased ventilator-free days at day 28. The lack of improvement in the PaO2/FIO2 and Sequential Organ Failure Assessment score was independently associated with mortality in the multivariate analysis.

Association between C-reactive protein levels and outcome in acute lung injury in children

High plasma C-reactive protein (CRP) levels are associated with favorable outcome in adults with acute lung injury (ALI). The association between CRP levels and outcome has not been studied in ALI in children. We performed a historical cohort study in 93 mechanically ventilated children (0-18 years) with ALI. The CRP level within 48 h of disease onset was tested for association with 28-day mortality and ventilator-free days (VFD). Clinical parameters and ventilator settings were evaluated for possible confounding. Fourteen patients died within 28 days. The median (interquartile range) CRP level in nonsurvivors was 126 mg/L (64; 187) compared with 56 mg/L (20; 105) in survivors (p = 0.01). For every 10-mg/L rise in CRP level, the unadjusted odds (95% confidence interval (95% CI)) for mortality increased 8.7% (2.1-15.8%). Cardiovascular organ failure at onset of ALI was the strongest predictor for mortality (odds ratio, 30.5 (6.2-152.5)). After adjustment for cardiovascular organ failure, for every 10-mg/L rise in CRP level, the OR (95% CI) for mortality increased 4.7% (-2.7-12.6%; p = 0.22). Increased CRP levels were associated with a decrease in VFD (ρ = -0.26, p = 0.01). increased plasma CRP levels are not associated with favorable outcome in ALI in children. This is in contrast with findings in adults with ALI.

Low–tidal volume mechanical ventilation in patients with acute respiratory distress syndrome caused by pandemic influenza A/H1N1 infection

PurposeLow–tidal volume (TV) mechanical ventilation is an important manipulation in managing patients with acute respiratory distress syndrome (ARDS). However, there is no definite evidence to support the use of this intervention in patients with viral etiologies. Materials and methodsA retrospective observational study of 104 patients with ARDS caused by pandemic influenza A/H1N1 infection admitted to 28 intensive care units (ICUs) in Korea was performed. Patients were categorized into 3 groups according to the TV they received: TV less than or equal to 7 mL/kg, TV greater than 7 mL/kg but less than or equal to 9 mL/kg, or TV greater than 9 mL/kg. ResultsThe mean age was 55.1 years, and 55.8% were male (n = 58). Patients with TV greater than 9 mL/kg showed higher 28-day ICU mortality than the 2 other groups (vs TV < 7 mL/kg, P = .007 and vs 7 mL/kg < TV ≤ 9 mL/kg, P = .004, respectively). Patients with TV less than or equal to 7 mL/kg required ventilators, ICU admissions, and hospitalizations for fewer days than those with TV greater than 7 mL/kg (11.4 vs 6.1 days for 28-day ventilator-free days, 9.7 vs 4.9 days for 28-day ICU-free days, and 5.2 vs 2.4 days for 28-day hospital-free days, respectively). Tidal volume greater than 9 mL/kg (hazard rate, 2.459; P = .003) and Sequential Organ Failure Assessment score (hazard rate, 1.158; P = .014) were significant predictors of 28-day ICU mortality. ConclusionsLow-TV mechanical ventilation still benefits patients with ARDS caused by viral pneumonia.

The incidence and magnitude of fibrinolytic activation in trauma patients

Trauma is a global disease, with over 2.5 million deaths annually from hemorrhage and coagulopathy. Overt hyperfibrinolysis is rare in trauma, and is associated with massive fatal injuries. Paradoxically, clinical trials suggest a much broader indication for antifibrinolytics. To determine the incidence and magnitude of fibrinolytic activation in trauma patients and its relationship to clot lysis as measured by thromboelastometry. A prospective cohort study of 303 consecutive trauma patients admitted between January 2007 and June 2009 was performed. Blood was drawn on arrival for thromboelastometry (TEM) and coagulation assays. Follow-up was until hospital discharge or death. TEM hyperfibrinolysis was defined as maximum clot lysis of > 15%. Fibrinolytic activation (FA) was determined according to plasmin-antiplasmin (PAP) complex and D-dimer levels. Data were collected on demographics, mechanism, severity of injury, and baseline vital signs. The primary outcome measure was 28-day mortality. The secondary outcome measures were 28-day ventilator-free days and 24-h transfusion requirement. Only 5% of patients had severe fibrinolysis on TEM, but 57% of patients had evidence of 'moderate' fibrinolysis, with PAP complex levels elevated to over twice normal (> 1500 μg L(-1)) without lysis on TEM. TEM detected clot lysis only when PAP complex levels were increased to 30 times normal (P < 0.001) and antiplasmin levels were < 75% of normal. Patients with FA had increased 28-day mortality as compared with those with no FA (12% vs. 1%, P < 0.001), fewer ventilator-free days, and longer hospital stay. FA occurs in the majority of trauma patients, and the magnitude of FA correlates with poor clinical outcome. This was not detected by conventional TEM, which is an insensitive measure of endogenous fibrinolytic activity.

Ambient light levels and critical care outcomes

PurposeGuidelines for the construction of critical care units require windows in room design to ensure a contribution of natural sunlight to ambient lighting. However, few studies have been published with evidence assessing this recommendation. We investigated the association of ambient light levels with clinical outcomes and sedative/analgesic/neuroleptic use in a medical intensive care unit (MICU). MethodsThis is a retrospective, observational study at a tertiary care facility with a 29-bed MICU. First/single MICU admissions between April 19, 2006, and June 30, 2009 (N = 3577), were analyzed with respect to clinical outcomes and sedation use according to MICU room orientation and corresponding light levels. ResultsLight levels were low but varied among the 4 room orientations. There were no significant differences in MICU mortality (north, 14.0%; east, 13.5%; west, 16.2%; south, 15.6%; P = .451), hospital mortality (20.8%, 20.9%, 22.2%, 22.3%; P = .796), 28-day intensive care unit–free days (17.6 ± 10.2, 18.0 ± 10.1, 17.7 ± 10.5, 17.2 ± 10.4; P = .555), 28-day ventilator-free days (16.3 ± 11.1, 16.5 ± 11.1, 15.5 ±11.5, 15.4 ± 11.4; P = .273). No clinically significant differences in intravenous sedative/analgesic use occurred across room orientations. ConclusionsDespite differing ambient light, room orientation was not associated with critical care outcomes or differences in sedative/analgesic/neuroleptic use. Current guidelines positing that windows alone are necessary or sufficient for MICU room light management may require further investigation and consideration.

Decreased mortality resulting from a multicomponent intervention in a tertiary care medical intensive care unit

To evaluate whether a multicomponent intervention, particularly increasing staff, can achieve reductions in patient mortality in an already high-intensity, Leapfrog-compliant medical intensive care unit. Retrospective, observational study. Medical intensive care unit of a tertiary care, academic medical center. A total of 1,263 patients admitted between April 19, 2004 and April 18, 2006 (before the organizational change) were compared with 2,424 patients admitted between September 5, 2006 and September 4, 2008. A multicomponent intervention including the physical move from a 10-bed to a 29-bed medical intensive care unit with larger patient rooms, the initiation of 24-hr critical care specialist coverage in the medical intensive care unit, an increase in the respiratory therapist:patient ratio, and the addition of a clinical pharmacist to the multidisciplinary team. Measurements were made based on mortality in the intensive care unit and in-hospital. Patient comorbidity as measured by the Charlson score did not change after the intervention (2.7 ± 2.7 vs. 2.8 ± 2.6, p = .62), nor did the acuity of illness as measured by the case mix index (3.0 ± 3.7 vs. 3.1 ± 3.8, p = .69). The unadjusted medical intensive care unit mortality decreased from 18.4% to 14.9% (p = .006), as did in-hospital mortality (from 25.8% to 21.7%, p = .005). The reduction in medical intensive care unit mortality was consistent in the multivariable regression with adjustment for multiple possible confounders (odds ratio = 0.74, 95% confidence interval: 0.61-0.91, p = .003), as was the reduction in hospital mortality (odds ratio = 0.74, 95% confidence interval: 0.62-0.88, p = .001). In mechanically ventilated patients, there was an increase in median 28-day ventilator-free days (21, interquartile range 0-25 vs. 22, interquartile range 0-26, p = .04). An increase in median medical intensive care unit (2.4, interquartile range 1.1-5.2 vs. 2.7, interquartile range 1.3-5.9), p = .009) but not hospital (8.3, interquartile range 4.1-17.0 vs. 8.2, interquartile range 4.0-16.8; p = .851) length of stay in days occurred with the intervention. The mean daily dosing of fentanyl and lorazepam decreased after the intervention. A multicomponent reorganization of medical intensive care unit services was associated with important reductions in mortality for medical intensive care unit patients, as well as an increased number of ventilator-free days. Substantial and sustained changes in clinically important outcomes may be obtained from organizational changes.

Right and left heart failure in severe H1N1 influenza A infection

Influenza infection can affect cardiac function. The recent pandemic of H1N1 influenza A provided an opportunity to study echocardiographic findings in critically ill infected patients. We hypothesised that critically ill patients with H1N1 infection would have a higher incidence of right and left heart failure than is seen in unselected populations of patients with septic shock and/or acute respiratory distress syndrome (ARDS). We retrospectively studied all patients admitted to four intensive care units at three hospitals in Salt Lake County, UT, USA, with laboratory-confirmed H1N1 infection in whom a clinical echocardiogram was available. 23 out of 48 patients had qualifying echocardiograms. Right ventricular (RV) dilatation (50-80%) and at least moderate systolic impairment (23%) were common, higher than the range described in general populations with ARDS. Left ventricular systolic dysfunction was present in 17% of patients. No single echocardiographic parameter was associated with 28-day mortality or ventilator-free days to 28 days. Critically ill patients with H1N1 infection frequently exhibit right heart dilatation and failure. RV basal dilatation was extremely common. These patients have less left heart failure than expected on the basis of prior descriptions of influenza myopericarditis or of general populations of septic patients.