non-ICU Group Research Articles

The use of combined physiological parameters in the early recognition of the deteriorating acute medical patient

Early warning scores (EWS) are widely used to allow early recognition of the deteriorating patient. We aimed to test their ability to predict major deterioration in medical patients. Two cohorts were prospectively identified who were admitted to an acute medical admissions unit and to the respiratory unit but not admitted to the intensive care unit (ICU): medical-non ICU and respiratory-non ICU groups. Two further cohorts were retrospectively identified that required ICU admission from these units (medical-ICU and respiratory-ICU groups). Discriminant analysis and receiver operating characteristic curves were used to discriminate between groups, and time relationships were analysed. Heart rate (HR) and respiratory rate (RR) were significantly higher--and oxygen saturation (SaO₂) significantly lower--in the medical-ICU group as compared with the medical non-ICU group, and in the respiratory-ICU group as compared with [corrected] the respiratory-non ICU group. Discriminant functions incorporating HR, RR and SaO₂ performed at least as well as existing EWS systems in predicting ICU admission. Commonly used physiological parameters and existing EWS systems are useful at identifying sick patients. The discriminant functions described here appear to have a role in this setting but require validation in future studies.

Antimicrobial Susceptibility Among Bacterial Isolates from ICU and Non-ICU Settings and Different Age Groups: Results from the Tigecycline Evaluation and Surveillance Trial in North America

As part of the tigecycline evaluation and Surveillance trial (T.E.S.T.), isolates were collected from centers in North America. In vitro activity was assessed for isolates collected in 2006 using CLSI guidelines and CLSI or FDA interpretive criteria. Data were analyzed according to intensive care unit (ICU) or non-ICU location and age group (18-64 years and ≥65 years).Rates of mRSA in 2006 were higher among isolates from patients aged ≥65 years (52.0%) than younger patients (48.4%) and from non-iCU settings (48.0%) than from the ICU (45.3%). Rates of vancomycin-resistant E. faecium, multidrug-resistant Acine-tobacter spp. (resistant to levofloxacin and amikacin as well as the carbapenems and/or third generation cephalosporins), and eSbl-producing K. pneumoniae among isolates collected from the ICU were 70.7%, 5.8%, and 16.6%, respectively.Tigecycline, linezolid and vancomycin were active against all isolates of S. aureus, including MRSA, from both settings and the two age groups. Among E. faecium, >95% of isolates were susceptible to linezolid, and tigecycline maintained MIC90s of 0.06-0.12 mg/L. Against Acinetobacter spp., the most active antimicrobials were tigecycline and minocycline irrespective of age group or patient setting (MIC90s 2 and 8 mg/L, respectively). percentage susceptibility of K. pneumoniae was >90% against tigecycline, imipenem, meropenem, cefepime and amikacin for isolates from both age groups and settings. Against eSbl-producing K. pneumoniae, imipenem (88.9%-96.4%) and tigecycline (85.1%-100%) demonstrated the highest rates of activity. Tigecycline demon-strated excellent activity against clinically relevant resistant organisms.

Uso do escore prognóstico APACHE II e ATN-ISS em insuficiência renal aguda tratada dentro e fora da unidade de terapia intensiva

Acute renal failure (ARF) remains highly prevalent with a high rate of morbidity and mortality. of this study was to compare use of the APACHE II scoring prognosis with that of the ATN-ISS to determine whether the APACHE II could be used for patients with ARF outside the ICU. For this purpose, 205 patients with ARF were accompanied in a prospective cohort. Demographic data, preexisting conditions, organ failure and characteristics of ARF were analyzed. The prognostic scores were performed with the assessment of a nephrologist. The mean age was 52 +/- 18 years, 50% were male, 69% were white, 45% were treated in ICU and 55% in other units. Mortality in the ICU group was 85% and in the non-ICU group 18%. Factors that correlated with higher mortality were more prevalent in the ICU group: age, male, hospitalization with ARF, organ failure, sepsis, septic IRA, oliguria and need of dialysis. Overall, the prognostic markers were the same for both the ICU and non-ICU groups. The discrimination with the APACHE II was similar in both, ICU and non-ICU groups and calibration was better in the non-ICU group. The ATN-ISS achieved good discrimination in both the ICU and non-ICU groups, but, regarding calibration, there was a discreet over estimating of mortality in the non-ICU group. The ATN-ISS showed a greater capacity for discrimination than the APACHE II in both the ICU and non-ICU groups. It was concluded that the APACHE II and ATN-ISS scores could be used for stratification of risk in patients with ARF treated outside of the ICU in Brazil.

Herpes simplex virus load in bronchoalveolar lavage fluid is related to poor outcome in critically ill patients

To evaluate the relationship between the HSV-1 and -2 loads in BAL fluid (BALF) and clinical outcome. Retrospective study. The general intensive care unit of the University Hospital Maastricht. Five hundred and twenty-one BALF samples from 462 patients were included. Patients were divided into three groups; (1) patients admitted to the hospital <48 h before lavage (Community), (2) patients admitted to the ICU >48 h before lavage (ICU) and (3) the remaining patients (non-ICU group). No additional interventions were conducted. HSV-1 and HSV-2 loads were determined by real-time polymerase chain reaction (PCR). HSV-1 DNA was detected in 4.3% (4/92) of samples in the community group, 15% (18/121) in the non-ICU group and in 32% (99/308) of the ICU group. In the age group <50 years HSV-1 DNA was less frequently isolated compared to the age group >or=50 years (16/129 (12%) versus 187/376 (25%), respectively, OR = 2.6; P < 0.001). HSV-1 loads of >10(5) genome equivalents (ge)/ml were associated with an increased 14-day in-hospital mortality compared to patients with a HSV-1 load <or=10(5) ge/ml in BALF (41 vs. 20%, respectively, P = 0.001). HSV-1 pneumonia was histologically proven in two patients with a HSV-1 load exceeding 10(5) ge/ml. HSV-1 occurred more in critically ill patients and high loads in BALF were associated with an increased mortality. The higher mortality observed in patients with HSV-1 load >10(5) ge/ml enforces its clinical relevance and necessitates to start randomized medical intervention studies.

Thromboseprophylaxe mit Heparinen bei intensivmedizinisch behandelten Patienten

Venous thromboembolism is a common complication in critically ill patients, resulting in high morbidity and mortality. Most patients treated in intensive care units (ICU) face a high risk of thromboembolic complications. There is a need for well-defined strategies for prevention of thrombosis in ICU patients. Mechanical methods such as compression stockings are frequently used, even though evidence for these measures in ICU patients is limited. Unfractionated heparin (UFH) is still the leading drug for thromboprophylaxis in ICU patients, but pharmacokinetic disadvantages such as low predictability of effect on anticoagulation are relevant, especially in ICU patients. Additionally, there is no sufficient evidence from clinical trials to support subcutaneous or intravenous prophylaxis with UFH. At least equivalent efficacy and safety of subcutaneous low molecular weight heparin (LMWH) compared with subcutaneous UFH have been shown in numerous studies investigating non-ICU high-risk groups. First studies on the use of LMWH in critically ill patients are promising. Some conclusions for safe use of subcutaneous LMWH in ICU patients can be drawn. Intravenous LMWH may be the optimal prophylaxis in most ICU patients, but there is a lack of sufficient data on dosing. Precautions such as monitoring of anticoagulation in patients with renal insufficiency are fundamental if LMWH is given. Further investigations into prevention of venous thromboembolism in ICU patients are urgently needed.