Interdisciplinary Intensive Care Unit Research Articles

Wenige Blutkulturproben – wenige Infektionen?

The data of the German hospital nosocomial infection surveillance system (KISS) were used to investigate the association between the frequency of blood cultures (BC) and central venous catheter associated bloodstream infection (CVC-BSI) rates in intensive care units (ICU). A questionnaire on the frequency of BCs taken was sent to all ICUs participating in KISS and univariable and multivariable analyses were performed on the results. A total of 223 ICUs provided data. The median number of BC pairs taken in 2006 was 60 with a huge variation from 3.2 to 680 per 1,000 patient days. The mean primary BSI rate was 0.90 per 1,000 patient days and 0.25 BSIs per 1,000 patient days were caused by coagulase negative Staphylococci (CNS). The mean CVC-BSI rate was 1.40 per 1,000 CVC days. In the univariable analysis the blood culture frequency had a significant influence on the CVC-associated BSI rate, considering either all pathogens (p=0.001) or only the subgroup of CNS-related cases (p=0.019). There was also a significant influence of the BC frequency on the CVC-BSI rate considering all pathogens (p=0.004) as well as the subgroup of CNS (p=0.018). Therefore the BC frequency was a significant factor affecting the incidence of BSI and CVC-BSI. According to the multivariable analysis an increase of the BC frequency of 100 BCs per 1,000 patient days leads to a 1.27-fold higher incidence density of CVC-BSI with a 95% confidence interval (95% CI) of 1.01-1.26. A further significant risk factor for CVC-BSI was the length of stay in the ICU with an adjusted incidence rate ratio (IRR) of 1.25 (95% CI 1.15-1.35). To have the status of an interdisciplinary ICU was a significant protective factor (IRR 0.64; 95% CI 0.45-0.92). If an external benchmarking of ICU CVC-BSI rates is intended an adjustment according to the BC frequency is necessary. The BC frequency itself should be established as a quality indicator in intensive care.

Neurosurgical intensive care unit—essential for good outcomes in neurosurgery?

Neurosurgical intensive care units were increasingly agglomerated in large centralized interdisciplinary intensive care units in the last two decades. In the majority, these centralized interdisciplinary intensive care units were directed and managed by intensivists coming from anaesthesiology. We sought to review the evidence supporting neurosurgical intensive care as a highly specialized discipline resulting in benefits for the treated patients. In general, neurosurgical and neurocritical intensive care has been associated with improved outcomes and reduced mortality rates, reduced length of intensive care stay, improved resource utilisation, decreased in-hospital mortality, and fiscal benefits.

Interdisciplinary Patient Care in the Intensive Care Unit: Focus on the Pharmacist

The field of critical care medicine began to flourish only within the last 40 years, yet it provides some of the best examples of collaborative pharmacy practice models and evidence for the value of pharmacist involvement in interdisciplinary practice. This collaborative approach is fostered by critical care organizations that have elected pharmacists into leadership positions and recognized pharmacists through various honors. There is substantial literature to support the value of the critical care pharmacist as a member of an interdisciplinary intensive care unit (ICU) team, particularly in terms of patient safety. Furthermore, a number of economic investigations have demonstrated cost savings or cost avoidance with pharmacist involvement. As the published evidence supporting pharmacist involvement in patient care activities in the ICU setting has increased, surveys have demonstrated an increase in the percentage of pharmacists performing clinical activities. In addition, substantial support of pharmacists has been provided by other clinicians, safety officers, and administrative personnel who have been involved with the initiation and expansion of critical care pharmacy services in their own institutions. Although there is still room for improvement in the range of pharmacist involvement, particularly with respect to interdisciplinary activities related to education and scholarship, pharmacists have become essential members of interdisciplinary care teams in ICU settings.

The impact of workload on hygiene compliance in nursing

The objective of this research was to clarify whether external factors (e.g. ward capacity, level of nursing intensity) had an influence on nursing staff compliance with hand hygiene guidelines. The study was conducted at a German hospital (450 beds). Quantitative data were collected prospectively in six trial phases (E1-E6) starting in June2007 and ending in May 2008. Included in the study were ten hospital departments: four surgical wards, four internal medicine departments, and two interdisciplinary intensive care units. In six participant observation trials, nursing staff were monitored for the disinfection of hands. Narrative interviews were conducted immediately after the observation with those who did not disinfect their hands in accordance with national guidelines. Observations and interviews were unannounced, taking place at different times. The collected data was analysed on subsequent categorization after summarizing the core statements (content analysis). The statistical relevance of staff compliance to the rate of used ward capacity could be proved using a multifactorial regression model (P=0.011). Workload factors (e.g. maximum ward capacity, severity of patient cases) have an impact on staff compliance with hand hygiene guidelines, even where non-compliance contradicts the personal level of professional training.

Performance of SAPS3, compared with APACHE II and SOFA, to predict hospital mortality in a general ICU in Southern Europe

Simplified Acute Physiology Score (SAPS3) has not been validated in Southern European countries. The purpose of this study was to validate the ability of SAPS3 to predict hospital mortality in adult patients in an interdisciplinary intensive care unit in Southern Europe, compared with Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA). This is a cohort study of 864 patients with a prospective collection of SAPS3 and SOFA variables and retrospective analysis of APACHE II in a mixed intensive care unit at a teaching hospital in Spain throughout 2006. The performance of the systems was determined by examining their discrimination and calibration. The discrimination of SAPS3 was excellent, with an area under the receiver operating characteristic curve of 0.916, similar to APACHE II (area under the receiver operating characteristic curve = 0.893) or SOFA (area under the receiver operating characteristic curve = 0.846). The calibration was good for SAPS3 but insufficient for APACHE II. Hospital death rates were lower than those that were predicted by the models. Our data demonstrate a better calibration of SAPS3 than APACHE II. Calibration was sufficient only for SAPS3. Hospital mortality was lower than predicted by both models. The discrimination of SAPS3 is excellent, and, when it is customized for Southern Europe, SAPS3 accurately predicts mortality risk in our adult mixed-case ICU.

Role of Clinical Ethicists in Making Decisions About Levels of Care in the Intensive Care Unit

Role of Clinical Ethicists in Making Decisions About Levels of Care in the Intensive Care Unit

Angst, Befindlichkeit und Depression: Vergleich zwischen tracheotomierten und intubierten Patienten einer Intensivstation

Research question: This study investigated whether anxiety or depression was different between intubated and tracheotomised patients in a surgical intensive care unit. This study is the first that compares the well-being of intubated vs. tracheotomised patients. Method: 17 intubated patients (7 women and 10 men) and 9 tracheotomised patients (3 women and 6 men) in an interdisciplinary intensive care unit took part in the study which was approved by the local ethics committee. Anxiety and depression were evaluated by the Hospital Anxiety and Depression Scale (HADS), disability was evaluated by a disability scale, vigilance by the Glasgow Coma Scale and the severity of the illness was evaluated by the Simplified Acute Physiology Score (SAPS II). Results: Age, body mass index, vigilance, SAPS II Score, anxiety and depression were not different between intubated and tracheotomised patients. Mean HADS-A was 9.8 (SD=4.7) for the intubated patients and 10 (SD=3.6) for the tracheotomised patients. 47.1% of the intubated patients and 44.4% of the tracheotomised patients had an abnormal HADS-A with a cut-off of more than 10 points. Mean HADS-D was 10.9 (SD=6.1) for the intubated patients and 8.7 (SD=4.5) for the tracheotomised patients. 52.9% of the intubated patients and 44.4% of the tracheotomised patients had an abnormal HADS-D with a cut-off of more than 8 points. HADS-A and HADS-D were not significantly different between intubated and tracheotomised patients. Discussion: Anxiety and depression as measured by the HADS were high in both intubated and tracheotomised patients but there was no difference between the two groups. This is interesting, because tracheotomised patients are predestined for a longer mechanical ventilation period than intubated patients.

Surveillance der Antibiotika-Anwendung und bakterieller Resistenzen auf Intensivstationen in Deutschland

SARI (Surveillance of Antibiotic Use and Bacterial Resistance in Intensive Care Units) provides data on antibiotic use, resistance rates (RR) and resistance densities (RD) in 47 interdisciplinary, medical and surgical intensive care units in Germany. Mean total antibiotic use was 1170 defined daily doses per 1000 patient days (pd). RD of MRSA has remained stable since 2001 in contrast to a continuous increase in the RD of 3rd generation cephalosporins E. coli (4.3 and 1.4, respectively, resistant pathogens/1000 pd in 2007). Local data of antibiotic use and bacterial resistance are important for the antibiotic and quality management of the individual ICUs. Pooled data of antibiotic use and bacterial resistance allow trends and extrapolations for Germany, which are relevant for future strategies.

Invasive candidiasis in the ICU: evidence based and on the edge of evidence

Invasive candidiasis is a common nosocomial infection among critically ill patients, constitutes an important cause of sepsis, and is associated with significant morbidity and mortality. The Infectious Diseases Society of America (IDSA) has created evidence-based guidelines for the management of invasive candidiasis. However, several new antifungal agents with excellent activity against Candida spp. and favourable safety profiles have been introduced successfully in the clinical setting since the IDSA guidelines were published in late 2003. Further, the role of antifungals is not entirely clear in the intensive care unit (ICU) setting. Therefore, this article discusses daily problems in the prophylaxis and treatment of invasive candidasis in interdisciplinary ICUs.

To treat or not to treat – critically ill patients with candiduria

The prevalence of candiduria has increased in patients admitted to intensive care units (ICUs) and it has emerged as a common nosocomial infection among critically ill patients. Generally, urinary candidiasis should be regarded as a risk factor for invasive candidiasis, but not as a disease that needs to be treated on its own. However, decision-making in critically ill patients with candiduria may become a balancing act, because candiduria may be the only indication for invasive candidaemia with significant morbidity and mortality. Of further concern, there is a worldwide increase in the incidence of non-albicans spp. isolated from urine with highly variable susceptibility to fluconazole, which has been the first-line therapy for Candida infections during the last decades. This article discusses everyday problems with urinary candidiasis in interdisciplinary ICUs.

Usefulness of Severity-of-Illness Scores Based on Admission Data Only in Nosocomial Infection Surveillance Systems

Surveillance of nosocomial infection (NI) and the use of reference data for comparison is recommended to improve the quality of patient care. In addition to standardization according to device use, another stratification of reference data according to patients' severity-of-illness scores is often required for benchmarking in intensive care units (ICUs). To determine whether severity-of-illness scores on admission to the ICU are sufficient data for predicting the development of NI. This study was performed in an interdisciplinary ICU at a teaching hospital. Two scores were studied: the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system and the Therapeutic Intervention Scoring System (TISS). The patient's clinical condition was evaluated on admission and reevaluated daily during the period before the development of NI. In addition, we recorded the number of intubations for every patient-day, the age and sex of the patients, and their history of operations. The Fisher exact test and the stepwise multiple logistic regression model were applied to identify significant predictors of NI. During a 12-month period, 270 patients with ICU stays of more than 24 hours were included in the study. Sixty-nine NIs were identified (incidence, 25.6 cases per 100 patients [95% confidence interval, 19.9-32.3]). A mean APACHE II score and a mean TISS score above the median for these scores, duration of ventilation above the median in the period before the development of NI, and patient age were significantly associated with the development of NI; the score data on admission provided a clearly poorer prediction. The APACHE II and TISS scores on admission are not useful predictors for NI in ICUs.

Antibiotic Use in Non–University Regional Acute Care General Hospitals in Southwestern Germany, 2001–2002

A previous study from Germany showed high antibiotic use in university hospitals, particularly in intensive care units (ICU) and hematology-oncology services, but there has been no information about recent antibiotic use in non-university hospitals. In the present study, we collected data from 40 non-university regional general hospitals located in the southwestern part of the country, and analyzed use density in the medical and surgical services of these hospitals. Hospital pharmacy records for the calendar years 2001 and 2002 were evaluated. The number of defined daily doses (DDD, definition according to the WHO/ATC 2001 index) and prescribed daily doses (PDD) per 100 patient days (DDD/100 or PDD/100, respectively) were calculated to compare antibiotic use densities in medical and surgical services. Data for surgery included various subspecialties and gynecology. Antibiotic use in the participating hospitals increased minimally between 2001 and 2002 both in medicine as well as in surgery. Use density in internal medicine (ICU areas excluded) in the year 2002 ranged between 13.5 and 93.7 DDD/100 with a weighted mean of 49.9 DDD/100 (corresponding to 28.6 PDD/100, respectively). Values for surgery were lower with a weighted mean of 43.4 DDD/100 (corresponding to 26.1 PDD/100, range, 10 to 65.4 DDD/100), respectively. Hospital size was not a strong predictor of use density, while large differences were observed between intensive care areas and normal wards. Mean use densities in intensive care areas in 2002 were 105.6 DDD/100 (or 49.7 PDD/100) in medical intensive care units, 116.9 DDD/100 (or 61.2 PDD/100) in surgical intensive care units, and 112.7 DDD/100 (or 66.7 PDD/100) in mixed, interdisciplinary intensive care units. Betalactams made up > 50% of all PDDs, while fluoroquinolones were the second most frequently prescribed drugs (15% of all PDDs). Fluoroquinolones were usually given orally. Overall glycopeptide and aminoglycoside use was < 1 PDD/100. This recent data from a large regional nonuniversity acute care hospital sample confirms that hospital antibiotic use density largely depends on patient care areas and less on hospital size. Surprisingly low use was observed for glycopeptides and aminoglycosides. The data may be useful as a benchmark for further pharmaco-epidemiologic evaluation and focused drug use control interventions.

Pulmonary glutamine production: effects of sepsis and pulmonary infiltrates

To define the role of the lung in the production of glutamine in the critically ill and to determine the effects of the presence of pulmonary infiltrates and the presence and severity of sepsis. Prospective clinical study in a single center; interdisciplinary intensive care unit at a university hospital. Eleven critically ill patients were compared to ten patients prior to cardiac bypass surgery. Fluxes of glutamine and other amino acids were measured. Chest radiography was performed, and APACHE II and multiple-organ failure scores were calculated. Septic patients showed significantly higher glutamine efflux from the lungs than controls. At least one-half of this glutamine is estimated to result from protein breakdown. Severity of illness had no impact on glutamine fluxes. In the presence of pulmonary infiltrates on chest radiographs glutamine efflux did not differ from zero. The lungs produce significant amounts of glutamine in septic patients. Pulmonary infiltrates decrease the glutamine efflux from the lung in septic patients. We suggest that this is caused by uptake of glutamine by white cells in the lung exerting immunological functions.

Adrenocortical hormones in survivors and nonsurvivors of severe sepsis: diverse time course of dehydroepiandrosterone, dehydroepiandrosterone-sulfate, and cortisol.

Activation and suppression of immune responses are crucial events during sepsis. Based on substantial new data, a complex picture of differential immune-enhancing and immunosuppressive actions of adrenocortical steroids is emerging. The adrenal androgen dehydroepiandrosterone and its precursor, dehydroepiandrosterone-sulfate, show a considerable decrease with increasing age and serve as functional antagonists to endogenous glucocorticoids. Therefore, we examined time-dependent changes in dehydroepiandrosterone, dehydroepiandrosterone-sulfate, cortisol, adrenocorticotropin, and inflammatory variables in surviving and nonsurviving patients with severe sepsis. Prospective observational study in consecutive patients. Medical and interdisciplinary intensive care units in two university hospitals and one city hospital. Thirty nonsurgical patients (25 men and 5 women) with severe sepsis (American College of Chest Physicians/Society of Critical Care Medicine criteria); 15 survivors (mean age, 54 +/- 14 yrs; Acute Physiology and Chronic Health Evaluation III score, 59 +/- 35) and 15 nonsurvivors (mean age, 63 +/- 15 yrs; Acute Physiology and Chronic Health Evaluation III score, 67 +/- 24) were included. Hormones were compared individually and between survivors/nonsurvivors by sequential blood drawings from early sepsis till time of recovery/death. None. During early sepsis, cortisol (nmol/L) was not significantly higher in survivors than nonsurvivors (750 +/- 121 vs. 454 +/- 92, p <.08) and decreased in survivors (p <.01) during late sepsis. During early sepsis, dehydroepiandrosterone-sulfate (percentage of age-matched normal levels) was higher in survivors than nonsurvivors (85 +/- 19 vs. 22 +/- 7, p <.01). Dehydroepiandrosterone-sulfate decreased in survivors (p =.0001) but remained low in nonsurvivors during late sepsis. Dehydroepiandrosterone (percentage of age-matched normal levels) was not significantly elevated in survivors compared to nonsurvivors during early sepsis (282 +/- 42 vs. 214 +/- 63, p <.08). Dehydroepiandrosterone decreased in survivors (p <.01) but not in nonsurvivors during late sepsis. Linear regression for dehydroepiandrosterone levels showed a reconstitution of age dependence only in survivors during recovery. Adrenocorticotropin levels did not change. The dehydroepiandrosterone-sulfate/cortisol ratio decreased significantly in both survivors and nonsurvivors, whereas dehydroepiandrosterone/cortisol ratio only decreased in survivors during course of sepsis. During sepsis, adrenal androgens and glucocorticoids show a diverse time-dependent course in survivors and nonsurvivors.

Suppression of interleukin-6 to interleukin-10 ratio in chronic alcoholics: association with postoperative infections.

To investigate the interleukin-6 (IL-6) to interleukin-10 (IL-10) ratio and levels of sE-selectin in patients undergoing elective surgery of the upper digestive tract and to define the differences in the perioperative immune response between chronic alcoholic and non-alcoholic patients. Prospective pilot study. Single center, interdisciplinary intensive care unit (ICU) at a university hospital. The study compared chronic alcoholics ( n=25) and non-alcoholics ( n=20) before and after surgery for resection of upper digestive tract tumors. White blood cell counts, C-reactive protein and circulating levels of sE-selectin, the pro-inflammatory cytokine IL-6 and the inhibitory cytokine IL-10, were obtained at hospital admission, preoperatively, postoperatively at ICU admission and 2 and 4 days later. Rates of postoperative infectious complications including pneumonia and sepsis were determined. sE-selectin only differed between chronic alcoholics and non-alcoholics preoperatively. Compared to non-alcoholics, chronic alcoholic patients showed a fourfold increase in circulating levels of IL-10 ( p<0.01) and a suppression of the IL-6/IL-10 ratio ( p=0.001) immediately after surgery. Coincident with the immune alterations, chronic alcoholics had a prolonged ICU stay ( p<0.01) and a threefold increased rate of wound infections ( p<0.05) and pneumonia ( p<0.01). Lower IL-6/IL-10 ratios were associated with increased rates of infectious complications ( p<0.05). Chronic alcoholics had decreased IL-6/IL-10 ratios at ICU admission and increased rates of infectious complications in the postoperative ICU course. This may indicate immediate postoperative immune suppression before the onset of infections and may help to identify chronic alcoholic patients at risk.

Surveillance of nosocomial infections in ICUs: is postdischarge surveillance indispensable?

To determine how many infections are missed if the postdischarge surveillance (PDS) follow-up of intensive care unit (ICU) patients that is required by the National Nosocomial Infection Surveillance System method is not done. ICU patients were followed up and surveillance results with PDS (gold standard) and without PDS were compared. Surgical or interdisciplinary ICUs in eight German acute-care hospitals. All 1,857 patients within a 6-month period in the participating ICUs (a total of 9,129 ICU-patient-days). Without PDS, 45 urinary tract infections (UTIs) were diagnosed, compared with 53 with PDS; thus, 15% of the UTIs were missed if no postdischarge follow-up was performed. Three nosocomial pneumonias (4%) and one bloodstream infection (8%) also were missed if surveillance was carried out without PDS. A total of 198 nosocomial infections (NIs) were recorded with PDS, compared to 175 NIs without PDS. Approximately 12% of all ICU-associated NIs were missed if no follow-up was done. Since it is very time-consuming to follow patients after their transfer from the ICU, we do not perform a postdischarge follow-up of patients in the course of routine surveillance.

Performance of the score systems Acute Physiology and Chronic Health Evaluation II and III at an interdisciplinary intensive care unit, after customization

Mortality predictions calculated using scoring scales are often not accurate in populations other than those in which the scales were developed because of differences in case-mix. The present study investigates the effect of first-level customization, using a logistic regression technique, on discrimination and calibration of the Acute Physiology and Chronic Health Evaluation (APACHE) II and III scales. Probabilities of hospital death for patients were estimated by applying APACHE II and III and comparing these with observed outcomes. Using the split sample technique, a customized model to predict outcome was developed by logistic regression. The overall goodness-of-fit of the original and the customized models was assessed. Of 3383 consecutive intensive care unit (ICU) admissions over 3 years, 2795 patients could be analyzed, and were split randomly into development and validation samples. The discriminative powers of APACHE II and III were unchanged by customization (areas under the receiver operating characteristic [ROC] curve 0.82 and 0.85, respectively). Hosmer-Lemeshow goodness-of-fit tests showed good calibration for APACHE II, but insufficient calibration for APACHE III. Customization improved calibration for both models, with a good fit for APACHE III as well. However, fit was different for various subgroups. The overall goodness-of-fit of APACHE III mortality prediction was improved significantly by customization, but uniformity of fit in different subgroups was not achieved. Therefore, application of the customized model provides no advantage, because differences in case-mix still limit comparisons of quality of care.

Comparison of Acute Physiology and Chronic Health Evaluations II and III and Simplified Acute Physiology Score II: A prospective cohort study evaluating these methods to predict outcome in a German interdisciplinary intensive care unit

To evaluate the ability of three scoring systems to predict hospital mortality in adult patients of an interdisciplinary intensive care unit in Germany. A prospective cohort study. A mixed medical and surgical intensive care unit at a teaching hospital in Germany. From a total of 3,108 patients, 2,795 patients (89.9%) for Acute Physiology and Chronic Health Evaluation (APACHE) II and 2,661 patients (85.6%) for APACHE III and Simplified Acute Physiology Score (SAPS) II could be enrolled to the study because of defined exclusion criteria. None. Probabilities of hospital death for patients were estimated by applying APACHE II and III and SAPS II and compared with observed outcomes. The overall goodness-of-fit of the three models was assessed. Hospital death rates were equivalent to those predicted by APACHE II but higher than those predicted by APACHE III and SAPS II. Calibration was good for APACHE II. For the other systems, it was insufficient, but better for SAPS II than for APACHE III. The overall correct classification rate, applying a decision criterion of 50%, was 84% for APACHE II and 85% for APACHE III and SAPS II. The areas under the receiver operating characteristic curve were 0.832 for APACHE II and 0.846 for APACHE III and SAPS II. Risk estimates for surgical and medical admissions differed between the three systems. For all systems, risk predictions for diagnostic categories did not fit uniformly across the spectrum of disease categories. Our data more closely resemble those of the APACHE II database, demonstrating a higher degree of overall goodness-of-fit of APACHE II than APACHE III and SAPS II. Although discrimination was slightly better for the two new systems, calibration was good with a close fit for APACHE II only. Hospital mortality was higher than predicted for both new models but was underestimated to a greater degree by APACHE III. Both score systems demonstrated a considerable variation across the spectrum of diagnostic categories, which also differed between the two models.

Intensive care medicine for elderly patients: how applicable are the APACHE III and III score systems?

Scores like APACHE (Acute Physiology And Chronic Health Evaluation) were evaluated for unselected intensive care unit (ICU) admissions. Can they also be used for risk stratification and quality assurance in selected subgroups like elderly patients? Over a 3-year period data of all admissions of a 12 bed interdisciplinary ICU were collected. APACHE II and III scores and probabilities of hospital deaths were compared with observed outcomes. The discriminatory power was evaluated by calculating the areas under the receiver operating characteristic (ROC) curves. Calibration was analyzed with standardized mortality ratios (SMR) and the Hosmer-Lemeshow goodness-of-fit statistic. Of 3382 admissions due to exclusion criteria, 2795 patients were analyzed, 1396 (49.9%) of these were > or = 65 years, mean age 75 (65-99) years. 62.5% were non-operative, 37.5% postoperative admissions, 35% after emergency operations. ICU mortality was 11.7%, hospital mortality 25.1%. The areas under the ROC curves were 0.77 for APACHE II and 0.79 for APACHE III (whole collective 0.83 and 0.85, respectively). The SMR was 1.17 for APACHE II and 1.23 for APACHE III compared with 1.06 and 1.22 for all patients, respectively. Calibration for elderly patients was insufficient for APACHE II (Hosmer-Lemeshow chi-square = 19, p < 0.025) as well as for APACHE III (chi-square = 41, p < 0.001), while it was good for all patients for APACHE II (chi-square = 12, p > 0.1) but not so for APACHE III (chi-square = 48, p < 0.001). APACHE II and III both show good discrimination for elderly patients although a little inferior than for all patients. Both scores can be used for risk stratification of elderly ICU patients. Mortality prognosis is not sufficient for geriatric patients although APACHE II calibrates well for all. Application of these scores for quality assurance in selected subgroups like elderly patients cannot be recommended based on these data.

In Process Citation

Intensive care of the surgical patient is an integral part of the treatment and continuing medical education mission of surgery. Working on the intensive care unit educates surgeons with regard to emergency treatment, pathophysiological thinking, and judging the risks of surgical procedures. The importance of preoperative workup and postoperative care and the diagnosis of postoperative complications are experienced personally and should thus encourage the surgeon to operate nontraumatically and increase their motivation for continuous holistic patient care. This does not mean erecting boundaries or competing with anesthesiologists in surgical intensive care. Rather, the joint aims of surgeons and anesthesiologists should be reinforced. The advantages of close cooperation for successful completion of the mission of patient care and medical education for younger colleagues need to be emphasized. Ideal cooperation between anesthesiologists and surgeons calls for commitment, competence, trust, and personal accord on the part of the persons involved. Under these circumstances, even in hospitals with only one interdisciplinary intensive care unit there should be no problems regarding who takes on official leadership.