Length Of ITU Research Articles

Evaluation of the spontaneous breathing trial in burn intensive care patients

Background The extubation failure rate in our burn patients is 30%. Objective To evaluate the influence of the 30 min spontaneous breathing trial on extubation outcome in burn patients. Methods A prospective, observational study in a burn intensive care unit. All adult patients requiring mechanical ventilation for >24 h and meeting the inclusion criteria underwent a 30 min spontaneous breathing trial (SBT). Extubation was undertaken after a successful SBT. Results Of 49 planned extubations, 9 failed (18%), much lower than the 30% extubation failure rate identified prior to the implementation of the SBT. The duration of ventilation was significantly shorter ( p = 0.04) in the patients who passed a SBT and those who failed extubation were significantly older ( p = 0.003). The logistic regression analysis identified that age independently predicted extubation outcome. Patients who failed extubation, after a successful SBT, had a significantly longer duration of ventilation ( p = 0.0001) and ITU length of stay ( p = 0.001). Conclusions The incidence of extubation failure was much lower and the duration of ventilation significantly shorter in patients who were extubated after a successful SBT. These findings support the use of the SBT in burn patients. Age independently predicts extubation outcome in burn patients who have passed a SBT.

Haemophagocytic Lymphohistiocytosis Post Liver Transplantation.

Haemophagocytic syndromes are rare but often-fatal conditions characterised by an inappropriate and sustained activation of the cellular immune system leading to accumulation of activated macrophages and a cytokine storm. Familial haemophagocytic lymphohistiocytosis (FHLH) is an autosomal recessive condition, which presents in infancy and childhood whereas Reactive Haemophagocytic Lymphohistiocytosis (RHLH) occurs at any age and the genetic contribution remains uncertain. Presentation of RHLH is characterised by a sepsis like syndrome with cytopenia, coagulation and lipid abnormalities. We report on the haematological abnormalities and the clinical course of 37 patients who received liver transplantation and developed RHLH between 1998 and 2003.15/37 patients had been transplanted for acute liver failure(7 drug induced, 7 seronegative hepatitis, 1 Budd Chiari syndrome) and the remaining 22 patients had chronic liver disease(Viral hepatitis 7, Primary bilary cirrhosis 7, Alcohol related liver disease 2, others 7). 34/37 patients presented with thrombocytopenia(< 50x109/l, median 30x109/l), 34/37 were lymphopenic(<1x109/l, median 0.5x109/l), median transfused haemoglobin was 8.3 g/dl, median ferritin was 1294ug/l. Hypertriglyceridemia(>2 mmol/l) and hypofibrinogenemia(<1.5g/l) was noted in 16/37 and 5/37 patients respectively. Median corrected INR was 1.14. Hepatosplenomegaly was a frequent finding in this group but is felt to be associated with the underlying liver disease. 26/37 patients presented within 30 days of transplantation and the remainder developed RHS following either a protracted admission to intensive care or a late complication of transplantation years later(range 33–2737 days). At the time of diagnosis of RHS multiorgan failure was typical with an average 2.4-organ failure.All patients displayed morphological features of RHLH on bone marrow examination, (> 2% macrophages, with tri-lineage histiophagocytosis). Screening for potential infectious triggers revealed contemporaneous positive cytomegalovirus (CMV) serology in 48% (18/37) patients with RHLH compared to annual incidence of CMV post transplant of 4.5% at the same centre. None of these patients received a CMV mismatched organ. Bacterial cultures were positive in 6/18 patients that did not develop CMV.Following PCR amplification and sequencing, one patient was identified as having a single nucleotide base substitution at 272 of exon 2 of PRF1, resulting in an alanine to valine amino acid substitution. This mutation has previously been reported but is felt to be a RFLP.All patients received multiorgan support, targeted anti viral/antibiotic therapy, human immunoglobulin and GM-CSF was reserved for those with severe pancytopenia. In addition all transplant recipients received Tacrolimus and prednisolone. Actuarial one year survival was significantly worse for those who developed RHLH post liver transplant than those that did not (45% vs. 85% p<0.0001; median survival 223 days and 12 month survival 33%). However CMV infection was not associated with length of ITU stay or survival.Our findings suggest that cytopenia post liver transplantation are often associated with RHLH and this population represents a unique group, in whom the histiocyte society criteria for RHLH may not be appropriate and histological diagnosis by bone marrow examination may be required to establish the diagnosis of RHLH. CMV infection is a common trigger of RHLH but is not associated with the poor outcome associated with RHLH.

Early warning tools to identify children at risk of deterioration: a discussion

SC IE N C E P H O TO L IB R A R Y Being able to identify children at risk of clinical deterioration in ward settings and facilitate a timely referral to intensive care is clearly important. Paediatric ‘early warning tools’ to assess risk are beginning to emerge in the UK, based on extensive adult experience with such tools (Buist et al 2002, Goldhill et al 1999, Odell et al 2002, Ridley and Leary 2003, Subbe et al 2001). These tools have the potential to optimise patient outcomes, improve quality of care and reduce the length of ITU stay with its associated costs. However, there is a need for caution in the development of these early warning tools: the paediatric team cannot just modify adult tools without any primary research or audit data on their use in children. In this article we argue that although these tools are likely to be very useful, they must be developed from primary audit and research data as there are key physiological differences between adults and children. Scoring tools need to be validated properly to ensure that they do in fact identify children at risk, and any resultant benefits need to be measured.

Performance monitoring in congenital heart surgery: is it any use?

It is increasingly being accepted that measurement and monitoring should play an important role in modern congenital heart surgery (CHD). We describe the current systems in use, focussing on the two main components of data collection and data analysis. We highlight the complexity of congenital heart defects and the operations used to correct them. The absence of a unified nomenclature for these is probably the main reason for the slow progress in developing CHD databases. Hopefully, the nomenclature recently accepted by the US and European cardiac surgical societies (STS and EACTS) will change this. We emphasize the importance of collecting accurate and validated data. Turning to the analysis phase, even if high quality data is available, assessing performance is a difficult and complex process, where more research is required. Problems arise due to small numbers in many groups of congenital heart operations, the frequent occurrence of multiple procedures and the existence of a wide range of pre-operative risk factors. We suggest that performance measurement based on statistical methods alone should not be taken as a definitive indication of inadequate performance. It is also essential to assess the performance of the whole clinical team rather than individual members since positive outcomes in CHD depend on the ability of a team to co-operate effectively. We stress the need to include confidence intervals in any statistical based measure of performance, and examine the problems associated with league tables. We point out that, with decreasing mortality, other outcome measures such as near misses and/or length of ITU stay may be more useful. We present examples of both beneficial outcomes of performance monitoring as well as some pitfalls. Finally, we suggest that more thought needs to be given to how the results of performance measurement are published, how they are used to improve future clinical practice, and how monitoring systems are evaluated in the medium and long term.

The acquisition of methicillin-resistant Staphylococcus aureus (MRSA) in vascular patients

Objective: the aim of this study was to establish at which point during a hospital admission MRSA acquisition occurs in vascular patients. Method: a consecutive series of 100 patients undergoing arterial surgery were screened for MRSA carriage on admission to hospital, on exit from theatre, on discharge from ITU, weekly whilst an inpatient and on hospital discharge. Screening was with moistened swabs from nose, throat, perineum and open wounds that were pooled for microbiological culture. Results: four patients (4%) screened positive for MRSA on admission to hospital. Of the remaining 96, 16 (17%) acquired MRSA during their hospital stay as follows: exit from theatre, one; exit from ITU, six; on the ward postoperatively, nine. Comparing MRSA acquisition (n=16) with non acquisition (n = 80) the following characteristics were noted, length of stay 16 (4–66) vs 7 (2–50) days (Mann–Whitney p < 0.001); admission to ITU 13/16 vs 46/80 (Fishers chi-squared p = 0.10); length of ITU stay 3 (1–20) vs 3 (1–14) days (Mann–Whitney p = 0.41). Frequent hospital attendance, age, emergency admission, diabetes or renal failure were not commoner in those with MRSA acquisition. Conclusions: these data indicate that 4% of patients undergoing arterial surgery are pre-existing carriers of MRSA. Length of hospital stay is the single most important determinant of MRSA acquisition.Eur J Vasc Endovasc Surg 25, 147–151 (2003)

Interupted sedation reduces ITU length of stay

Interupted sedation reduces ITU length of stay