Medical-surgical ICU Patients Research Articles

Pulmonary embolism in medical-surgical ICU patients

Pulmonary embolism (PE) is a feared complication of critical illness. PE is difficult to diagnose during critical illness due to the nonspecificity of signs and symptoms and low index of suspicion in practice. Our objective was to examine the antecedent characteristics and hospital course of patients who were diagnosed with PE during critical illness in the context of an international trial of thromboprophylaxis ({type:clinical-trial,attrs:{text:NCT00182143,term_id:NCT00182143}}NCT00182143).

Toward Understanding Tight Glycemic Control in the ICU: A Systematic Review and Metaanalysis

Following publication of the Leuven Intensive Insulin Therapy Trial in 2001, tight glycemic control became the standard of care in ICUs around the world. Recent studies suggest that this approach may be flawed. The goal of this systematic review was to determine the benefits and risks of tight glycemic control in ICU patients and to explain the differences in outcomes among reported trials.Prospective, randomized controlled clinical trials (RCTs) that studied the impact of tight glycemic control (blood glucose 80-110 mg/dL) on mortality in ICU patients were identified through a search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews, and a citation review of relevant primary and review articles. Data were abstracted on study design, study size, and patient characteristics, as well as on the mean (or median) and SD of the ICU blood glucose level, mean daily dose of insulin administered, average daily caloric intake, percentage of calories given intravenously (parenteral nutrition), incidence of hypoglycemia, need for dialysis, and 28-day/hospital mortality. Metaanalytic techniques were used to analyze the data; subgroup analysis and metaregression were used to explain differences in the treatment effect.We identified seven RCT studies that included 11,425 patients. Overall, tight glycemic control did not reduce the 28-day mortality (odds ratio [OR] 0.95; 95% CI, 0.87-1.05), the incidence of blood stream infections (OR 1.04; 95% CI, 0.93-1.17), or the requirement for renal replacement therapy (OR 1.01; 95% CI, 0.89-1.13). The incidence of hypoglycemia was significantly higher in patients randomized to tight glycemic control (OR 7.7; 95% CI, 6.0-9.9; P < .001). Metaregression demonstrated a significant relationship between the treatment effect (28-day mortality) and the proportion of calories provided parenterally (P = .005). This suggests that the difference in outcome between the two Leuven Intensive Insulin Therapy Trials and the subsequent trials could be related to the use of parenteral nutrition. When the two Leuven Intensive Insulin Therapy Trials were excluded from the metaanalysis, mortality was lower in the control patients (OR 0.90; 95% CI, 0.81-0.99; P = .04; I(2) = 0%).There is no evidence to support the use of intensive insulin therapy in general medical-surgical ICU patients who are fed according to current guidelines. Tight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients not receiving parenteral nutrition.

Evaluación de la eosinopenia como marcador de infección en pacientes ingresados en una Unidad de Cuidados Intensivos

Introduction To evaluate eosinopenia as an early marker of infection. Design Retrospective cohort study. Patients Medical-surgical ICU patients with high severity scores. Main variables Data on days 1–5: Demographic data, diagnosis, clinical repercussion, mechanical ventilation, clinical development, length of stay, APACHE II, leukocytes, SOFA and lactate. Patients divided into two groups: with and without infection. ROCs (receiver operator characteristic) curves were plotted and best point for discriminative values determined. Results 244 patients were included: 22.5% with infection. 52.9% medical, 22.5% surgical and 24.6% polytrauma patients. APACHE II: 14.9±8.9. In a logistic regression model of infection (dependent variable infection), the independent variables were: APACHE II, SOFA, monocytes and eosinophils. The ROC curve for eosinophils on the first day: area of 0.72; the best cut off value is 10 eosinophils/μl, with sensitivity (S): 64.8% and specificity (Sp): 70.9%. In medical patients, the area under curve is 0.80, with ideal cut off value of 9 eosinophils/μl; in surgical patients is 0.53, with a cut off ideal value of 54. We combined eosinophils and monocytes: a cut-off value of 9 eosinophils/μl in medical patients with >400 monocytes/μl, has: S: 86.7%, Sp: 74.7%, a positive predictive value (PPV) of 40.6% and a negative predictive value (NPV) 96.6%; in postsurgical patients with <400 monocytes/μl and a cut-off value of 54 eosinophils: S: 100%, Sp: 20%, PPV: 52.9% and NPV: 100%. Conclusions In a medical-surgical ICU, the capacity to discriminate infection through examining eosinopenia is not high. It could be useful to rule out infection if we combined eosinopenia with monocytes count.

Inter-Rater Reliability of the 4Ts Scoring System for Diagnosing Heparin-Induced Thrombocytopenia in Critically Ill Patients.

Abstract 3995Poster Board III-931Heparin-induced thrombocytopenia (HIT) is commonly suspected, but rarely confirmed, in the critically ill. The lack of readily available rapid diagnostic tests makes the timely diagnosis of HIT challenging. As a result, when HIT is suspected, heparin is often stopped and an alternative anticoagulant is initiated until diagnostic test results become available. A valid scoring system that accurately predicts the likelihood of HIT would be very valuable since it would allow rapid risk stratification that then might allow treatment to be modified in patients at moderate or high risk of harboring HIT, while other strategies might be employed for those at low risk. The 4Ts scoring system has been proposed as such a classification. 4Ts classifies patients on a 4 component, 8 point linear scale. The final score is assigned to 1 of 3 categories representing low, moderate and hand high pretest probability (scores of 0 to 3, 4 to 5 and 6 or more, respectively). We describe results of a pilot study using the 4Ts scoring system within the PROTECT trial (a 3650 patient randomized controlled trial comparing low molecular weight with unfractionated heparin for primary prevention of venous thromboembolism (VTE) in medical-surgical ICU patients). As per the PROTECT protocol, patients are evaluated for HIT if their platelet count falls more than 50% from their initial platelet count (study day 1), if their platelet count falls to less than 50 × 109/l, if VTE occurs, or if HIT is clinically suspected. As of August 6th, 2009, 2657 patients had been enrolled in PROTECT, of whom 523 (19.7%) met criteria for investigation of HIT (170 due to a platelet count fall; 106 due to a platelet count of less than 50×109/l; 343 due to VTE; and 39 due to clinical suspicion (categories not mutually exclusive)). All suspected cases of HIT are to be evaluated using the serotonin release assay (SRA), with HIT confirmed if the HIT test is positive, or HIT refuted if the SRA is negative. To evaluate the 4Ts score, patients are adjudicated independently by 2 experts blinded to each other's scores (MC, hematologist and DC, intensivist). The adjudication occurs in 2 stages: in Stage 1 the clinical case is reviewed and a 4Ts score assigned, masked to SRA testing; in Stage 2 the presence or absence of HIT is ascribed based on review of the patient's laboratory data. Discordant cases are then discussed and consensus achieved. To August 6th, 2009 100 cases have been adjudicated and consensus achieved. Stage 1 raw agreement on the 4Ts score was poor (raw agreement 47.0%). Stage 1 agreement on risk category (low, moderate or high) was better (77%, weighted kappa 0.36 (0.10 to 0.61) reflecting fair agreement). Discordance was largely due to differences in the timing component of the 4Ts score (raw agreement 77%) and the “other” potential cause of thrombocytopenia component (raw agreement 61%). Agreement for the degree of thrombocytopenia and thrombosis components was excellent (92% and 93%, respectively). We conclude that inter-rater reliability of the 4Ts score in medical-surgical ICU patients is fair overall. Additional calibration work or modification of the scoring system is required if 4Ts is to be widely used to accurately predict HIT in critically ill patients. This poster is p Disclosures:Crowther:Sanofi-Aventis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Leo Pharma: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria, Research Funding; Bayer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; BI: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Artisan Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees.

Neither baseline tests of molecular hypercoagulability nor D-dimer levels predict deep venous thrombosis in critically ill medical-surgical patients

Predicting patients who are harboring asymptomatic deep venous thrombosis (DVT), or who are at particular risk of developing DVT, is a desirable clinical goal since prevention or early treatment of DVT might reduce the risk of fatal pulmonary embolism. Thus validation of simple laboratory tests that reliably predict venous thromboembolism (VTE) would be clinically very important. Tests that might be useful for these applications include markers of hypercoagulability (predicting patients at risk of DVT) and D-dimer (predicting which patients may have acute DVT). In a prospective cohort study we measured a panel of hypercoagulability markers at the time of ICU admission, and six commercial D-dimer assays were performed serially during the ICU stay in medical-surgical ICU patients who were screened for DVT with biweekly lower limb compression ultrasonography. Ultrasonography was also performed at the time of any clinically suspected DVT events. We matched cases with DVT with controls without DVT for length of stay in the ICU to generate receiver operating characteristics (ROC) curves. One hundred ninety-seven patients were enrolled. Blood was collected on a total of 763 occasions (median number of occasions per patient: 3, range 1-21). None of the assays predicted DVT, as indicated by the areas under the ROC curves, that did not differ significantly from 50%. In critically ill patients, neither tests of hypercoagulability nor D-dimer levels predict patients at risk of DVT and thus they should not be used to guide diagnostic testing for DVT.

Comparison of Compression Ultrasound vs Ascending Contrast Venography for Proximal DVT in Medical-Surgical ICU Patients.

Background: Ascending contrast venography is the reference standard for diagnosing DVT. Observational studies suggest that compression ultrasound has 97% sensitivity and 94% specificity for proximal DVT in symptomatic patients. However, in asymptomatic patients, such as those in the medical-surgical ICU, the test properties of ultrasound may be substantially worse. Surveys, observational studies and professional documents show that many intensivists, Research Ethics Boards, and the American College of Radiology have rejected the routine use of venography in the ICU setting.Objective: To compare the results of positive lower limb compression ultrasound with ascending contrast venography in medical-surgical ICU patients.Design: One year longitudinal cohort study.Setting: 15 bed medical-surgical closed ICU in Hamilton, Canada.Methods: We enrolled consecutive patients age >18y with an expected ICU admission >72h. Exclusion criteria were trauma, orthopedic surgery, cardiac surgery, pregnancy or palliative care. Patients underwent bedside lower limb compression ultrasonography by a certified ultrasonographer on ICU admission, twice weekly, and upon clinical suspicion of VTE. Patients with a positive or nondiagnostic ultrasound underwent bilateral lower extremity ascending contrast venography, unless they had pre-specified contraindications: serum creatinine >150 umol/L, pre-existing insulin-requiring diabetes, known or suspected contrast allergy, or contraindications to transport to the Radiology Department. The study radiologist and thrombosis consultant independently interpreted the venograms in duplicate; disagreements were resolved by a third adjudicator.Results: Of 261 patients, lower limb DVT was identified by compression ultrasound in 32 patients (7, 2.7% on ICU admission and 25, 9.6% during the ICU stay). Using the a priori venogram eligibility criteria, 8 of 32 patients (25.0%) with DVT by screening ultrasound were suitable for venography; 7 of the 8 venograms (87.5%) were positive.Conclusions: Venogram eligibility criteria (e.g., low oxygen requirements, hemodynamic stability, and low risk for contrast nephropahthy) designed to safely confirm or refute positive or nondiagnostic screening ultrasound findings resulted in only selected, less seriously ill ICU patients undergoing venography. Concerns about the risk: benefit ratio of research interventions not used in current practice means that in multicenter trials, serial compression ultrasound will be the only safe and feasible method of screening for proximal DVT in the medical-surgical critically ill population.

PROphylaxis for ThromboEmbolism in Critical Care Trial (PROTECT): A Pilot Study.

Rationale: No published randomized trials have compared low molecular weight heparin (LMWH) to unfractionated heparin (UFH) for thromboprophylaxis in medical-surgical ICU patients.Objectives: A) Our Feasibility Objectives were to assess: 1) timely enrollment and complete, blinded study drug administration, 2) LMWH bioaccumulation in renal insufficiency, 3) twice weekly leg ultrasounds, and 4) recruitment rates for a future trial. B) Our Clinical Objectives were to assess 1) the effectiveness of LMWH vs UFH by estimating DVT, and pulmonary embolism (PE) rates, and 2) the safety of LMWH vs UFH regarding bleeding, thrombocytopenia and HIT.Methods: In this prospective randomized stratified concealed blinded multicenter trial, we included patients ≥18 with expected ICU stay ≥72h. We excluded trauma, orthopaedic, cardiac, or neurosurgery, severe hypertension, DVT, PE or hemorrhage within 3 mos, INR >2ULN, PTT >2ULN, platelets <100 x109/L, creatinine clearance <30ml/min, therapeutic anticoagulation, >2 doses of heparin, and palliative care patients. By centralized telephone randomization, we allocated patients to dalteparin 5,000 IU QD SC or UFH 5,000 IU BID SC. All clinicians caring for patients were blinded except the pharmacist. Bilateral leg compression ultrasounds were performed within 48h of ICU admission, twice weekly, on suspicion of DVT, and 7 days post ICU discharge.Results:A) Feasibility Objectives: 1) Timely, complete study drug administration occurred for >99% of scheduled doses; every dose was blinded. 2) No LWMH bioaccumulation was observed as measured by anti-Xa levels when creatinine clearance decreased to <30 ml/min. 3) Ultrasounds were performed without exception. 4) Estimated recruitment for a future trial is 4–5 patients/month/center. B) Clinical Objectives: 1) Effectiveness: Among 128 patients, 11 (8.6 %) had DVT, 2 (1.6 %) had PE. 2) Safety: 6 (4.7 %) had clinically important bleeds, 23 (18 %) had minor bleeds, 4 (3.1%) developed a platelet count <50 x109/L, and 2 (0.8%) had HIT diagnosed by serotonin release assay.Conclusions: DVT rates remain high in medical-surgical ICU patients despite universal heparin thromboprophylaxis. This pilot study suggests that a randomized clinical trial comparing LMWH vs UFH feasible. An adequately powered trial is needed to achieve the clinical objectives.

Thrombocytopenia in medical–surgical ICU patients

Thrombocytopenia in medical–surgical ICU patients

Lowering of Glucose in Critical Care (LOGIC): pilot trial in medical–surgical ICU patients

Lowering of Glucose in Critical Care (LOGIC): pilot trial in medical–surgical ICU patients

Deep venous thrombosis in medical–surgical ICU patients: prevalence, incidence and risk factors

Deep venous thrombosis in medical–surgical ICU patients: prevalence, incidence and risk factors

Percutaneous Tracheostomy Tube Obstruction: Warning

To determine the patency of standard and modified Portex tracheostomy tubes inserted by the percutaneous dilatational technique. Prospective observational study. Medical-surgical ICUs in a tertiary care community hospital. Medical-surgical ICU patients requiring tracheostomy. Consecutive medical-surgical ICU patients requiring tracheostomy were eligible for the study. Percutaneous tracheostomy tubes were inserted using the percutaneous dilatational technique with bronchoscopic guidance. The study population consisted of the following two groups: group 1 (receiving the standard Portex Per-fit percutaneous tracheostomy tube); and group 2 (receiving the modified Portex Per-fit percutaneous tracheostomy tube). Patients underwent daily fiberoptic evaluation to assess tracheostomy tube patency following the first 72 h after the tracheostomy tube placement. Demographic data and clinical signs or symptoms of airway obstruction were recorded. Thirty-seven patients received the standard percutaneous tracheostomy tube (group 1), and 17 patients received the modified percutaneous tracheostomy tube (group 2). Partial tracheostomy tube occlusion (> 25%) was observed in 21 of 37 group 1 patients (57%) and in 1 of 17 group 2 patients (6%; p < 0.005). Fifteen of 37 group 1 patients (41%) and none of the group 2 patients sustained a > or = 40% occlusion of the distal tracheostomy tube opening (p < 0.005). One patient from group 1 had clinical manifestations of tracheostomy tube obstruction. None of the patients in group 2 experienced signs or symptoms of airway obstruction. The standard Portex Per-fit percutaneous tracheostomy tubes used in this study were associated with partial airway obstruction. Modifications of the standard Portex percutaneous tracheostomy tube markedly decreased the airway obstruction. Due to the findings in this study, the authors recommend abandoning the continued use of the Portex Per-fit percutaneous tracheostomy tube in its current configuration and replacing it with the modified tracheostomy tube described in this study.

Posterior Tracheal Wall Perforation During Percutaneous Dilational Tracheostomy: An Investigation Into Its Mechanism and Prevention

Part 1: To describe the complication of posterior tracheal wall injury and perforation associated with the percutaneous dilational tracheostomy (PDT). Part 2: To determine the mechanism of posterior tracheal wall injury during PDT. Prospective observational study. Part 1: Medical-surgical ICU patients requiring tracheostomy. Part 2: Swine and cadaver models. Part 1: Consecutive medical-surgical ICU patients undergoing tracheostomy tube insertion via the percutaneous dilation technique with bronchoscopic guidance were enrolled in the study. Demographic data and complications were recorded. Part 2: Tracheostomy tubes were inserted via the percutaneous dilational technique in the swine model with concomitant bronchoscopic video recording from the proximal and distal airways. Tracheostomy tubes were inserted via the percutaneous dilational technique in the cadaver model followed by anatomic inspection of the airway. Part 1: Seven (29%) of 24 medical-surgical ICU patients sustained complications associated with PDT. Three patients (12.5%) sustained posterior tracheal wall perforations followed by the development of tension pneumothoraces. Part 2: The swine model demonstrated that posterior tracheal wall perforation may occur during PDT when the guiding catheter is withdrawn into the dilating catheters. Five-centimeter posterior tracheal wall mucosal lacerations occurred when the guidewire and the guiding catheter were not properly stabilized during PDT. Percutaneous dilational tracheostomy was associated with a 29% complication rate in this observational study. Of concern was the high rate (12.5%) of posterior tracheal wall perforation. The swine and cadaver models suggest that posterior tracheal wall injury or perforation may occur if the guidewire and guiding catheter are not properly stabilized. To avoid posterior tracheal wall injury, the guidewire and guiding catheter should be firmly stabilized during PDT.

Is intensive care worth it? An assessment of input and outcome for the critically ill.

The high cost of treatment in an ICU is clearly recognized; the ultimate benefit of that care in prolonging meaningful life is not as well quantified. We evaluated 337 mixed medical-surgical ICU patients for severity of illness and intensity of therapy and assessed their survival and quality of life 16 to 20 months after discharge. Mortality was 36.9% for emergency surgical and medical patients and 13.9% for elective surgical patients. A total of 140 patients responded to follow-up; 62.2% of patients not retired or homemakers were working full-time. Quality of life was good using both subjective and objective standards. There were few significant differences between elective surgical and other patients. Survival and life quality were related inversely to severity of illness and cost of treatment. Acute health on ICU admission predicted survival well; chronic health and age were better predictors of life quality.