Time Of Intensive Care Unit Admission Research Articles

Mortality among patients admitted to intensive care units during weekday day shifts compared with “off” hours*

To determine whether mortality rates among intensive care unit (ICU) patients differ according to the time of ICU admission, we compared the death rates for patients admitted during weekday day shifts and off hours (from 6:30 pm to 8:29 am the next day for night shifts, from Saturday 1:00 pm to Monday 8:29 am for weekends, and from 8:30 am to 8:29 am the following morning for public holidays). Retrospective cohort study of data collected prospectively from 23 ICUs located in the Paris metropolitan region, France. Between January 2000 and December 2003, 51,643 patients were admitted to these ICUs. Patients were grouped according to their day and time of admission and compared using univariable and multivariable analyses. None. Of the 51,643 patients admitted to ICUs, 33,857 (65.6%) were admitted during off hours. These latter patients were less critically ill than those admitted during day shifts, had fewer failed organs, required fewer support procedures, and their crude in-hospital mortality was lower (20.7 vs. 24.5%, p < .0001). After adjustment for initial disease severity, in-hospital mortality was not higher for off-hours admissions than weekday day admissions and even remained slightly lower (adjusted odds ratio, 0.93; 95% confidence interval, 0.87-0.98). Admission during off hours is common. In our ICUs, off-hours admissions were not associated with higher mortality and might even be associated with a lower death rate.

Detrimental role of delayed antibiotic administration and penicillin-nonsusceptible strains in adult intensive care unit patients with pneumococcal meningitis: The PNEUMOREA prospective multicenter study*

To identify factors associated with mortality and morbidity among adults admitted to intensive care units (ICUs) for pneumococcal meningitis, particularly the impact of delayed antibiotic administration. We conducted a prospective, multicenter, observational study of 156 consecutive adults hospitalized for pneumococcal meningitis. We analyzed parameters associated with 3-month survival. Fifty-six medical and medical-surgical ICUs in France. None. Of the 148 strains isolated, 56 (38%) were nonsusceptible to penicillin G. At 3 months after ICU admission, the mortality rate was 33% (51/156), and 34% of survivors (36/105) had neurologic sequelae. Multivariate analysis identified three variables as independently associated with 3-month mortality: Simplified Acute Physiology Score II (odds ration [OR], 1.12; 95% confidence interval [CI], 1.072-1.153; p = .002); isolation of a nonsusceptible strain (OR, 6.83; 95% CI, 2.94-20.8; p < 10(-4)), and an interval of >3 hrs between hospital admission and administration of antibiotics (OR, 14.12; 95% CI, 3.93-50.9; p < 10(-4)). In contrast, a cerebrospinal fluid leukocyte count >10(3) cells/microL had a protective effect (OR, 0.30; 95% CI, 0.10-0.944; p = 0.04). Independent of severity at the time of ICU admission, isolation of penicillin-nonsusceptible strains and a delay in antibiotic treatment following admission were predictors of mortality among patients with pneumococcal meningitis.

A vertebro-vertebral fistula as a complication of a jugular line

A 13-old female was admitted to the intensive care unit (ICU) because of toxic shock syndrome. On physical examination at the time of ICU admission no bruit was heard during auscultation of the heart. A jugular line was inserted on the right. Shortly after insertion of the line, a computed tomography (CT) scan showed that the tip of the catheter was positioned in the vertebral artery and vein (Figure 1; available at www.jpeds.com). The patient recovered, and after hospital discharge she returned to school and was symptom-free.

Predictors of early recovery of health status after intensive care

To identify factors predictive of good or poor recovery of health status and health-related quality of life (HRQOL) 90 days after admission to an intensive care unit (ICU). Prospective international multicentre study in 19 ICUs participating in the HRQOL substudy of the SAPS 3 project. The EuroQol questionnaire (EQ) was administered to discharged ICU patients 90 days after admission. A question to compare present health status with that 3 months before ICU admission (same/better/worse) was added. Six hundred and eighteen patients who spent >24h in an ICU and survived for 90 days. EQ data and health comparison were available in 559 (90.5%) of them. Patients reported their general level of health to be better (33.8%), the same (31.1%), or worse (35.1%) in comparison with baseline. Recovery was considered to be good for answers "better" or "the same". Regression analysis showed that transplantation surgery [odds ratio (OR) 0.07, 95% confidence interval (CI) 0.01-0.63], coronary artery bypass surgery without valvular repair (OR 0.39, 95% CI 0.17-0.92) and being admitted to the ICU from a ward or other location (OR 0.55, 95% CI 0.31-0.95) predicted good recovery of health. Predictors of poor recovery (all present at the time of ICU admission) were unplanned ICU admission, hypothermia, serum creatinine level >or=2mg/dl, pH<or=7.25 and metastatic cancer. More than 60% of ICU patients report good recovery of their health 90 days after ICU admission, depending on their illness and circumstances of ICU admission.

RISK FACTORS FOR PROLONGED INTENSIVE CARE UNIT STAYS AFTER CARDIOPULMONARY BYPASS

To provide the descriptive clinical information of those patients who experienced intensive care unit (ICU) stays after cardiopulmonary bypass (CPB) surgery. To identify predictive factors associated with mortality and length of stay (LOS) that the medical evidence base are potentially targeted for quality improvement. Methods: A retrospective review was performed using data from pre, intra-, and post-CPB factors undergoing open heart surgery in National Taiwan University Hospital during the year of 2003. All recorded factors using (the guideline you mentioned this morning) were evaluated for possible association with mortality and LOS. A total of 280 patients who had CPB during the study period. Possible predictive factors to the mortality and length of stay in ICU will be derived using logistic and linear regression data analysis. Results: The mortality rates for all study patients was 4.64%, while frequencies of the mortality for infant, child, and adult were 5/105 (4.76%); 3/85 (3.5%); and 5/90 (5.56%). Total hours in intensive care unit (ICU) for all alive patients were 271±2326 hours while there were 156±237.3, 121±166, and 543±4076 hours for infant, child and adult patients. Conclusion: At the time of ICU admission after CPB, clinical criteria are evident that highlight a patient’s risk of mortality and LOS. This study made accessible to quality control.

Medical management of patients with multiple organ dysfunction arising from acute radiation syndrome

The growing risk of accidental and intentional radiation exposure mandates an examination of our current understanding and management of a significant radiation injury. A considerable number of those patients sustaining a significant body exposure will require treatment in an intensive care unit (ICU). This review examines the complex medical management of acute radiation syndrome and the potential role of modern intensive supportive care measures in patients suffering from subsequent multiple organ dysfunction syndrome. As with most radiation preparedness planning, the resource expenditures in the ICU are scenario-driven. In particular, a mass casualty scenario mandates early estimation of prognosis in order to direct resources to patients who are most likely to have a survivable radiation exposure at the time of ICU admission.

Prevalence and Incidence of Arterial and Venous Thrombosis in Critically Ill Patients.

Background: Critically ill patients have multiple risk factors for developing thrombosis, yet little is known about the prevalence and incidence of arterial and venous thrombotic events in this patient population. The development of thrombosis is likely to be frequently unrecognized and thus untreated, which may affect clinical outcomes.Purpose: To document the prevalence and incidence of clinically recognized thrombotic events in critically ill adult patients.Methods: We undertook a retrospective chart review of 208 patients from a cohort of 261 critically ill patients admitted to a medical-surgical intensive care unit (ICU) who were enrolled in a prospective cohort study evaluating the prevalence and incidence of deep vein thrombosis (DVT) using twice weekly ultrasound screening. All other thrombotic events were diagnosed based on clinical suspicion and confirmed by conventional diagnostic tests.Data extraction: We reviewed daily medical records during the patient's ICU admission for signs and symptoms of thrombosis, and abstracted laboratory and radiologic data.Results: At the time of ICU admission, ultrasound screening revealed DVT in 7 of 261 patients (prevalence 2.7%, 95% CI 1.1–5.4%) but only 3 cases (42.9%) were clinically suspected. During the ICU stay, 25 patients developed DVT (incidence 9.6%, 95% CI 6.3–13.8%), but only 3 (12.0%) were clinically suspected. Pulmonary embolism was clinically recognized on admission in 4 of 208 patients (prevalence 1.9%, 95% CI 0.5–4.9%); and was diagnosed in 1 patient during ICU stay (incidence 0.5%, 95% CI 0.0–2.6%). For arterial events, 3 of 208 patients were admitted with ischemic stroke, and 3 developed this complication in the ICU (prevalence and incidence 1.4%, 95% CI 0.3–4.2%). Cardiac troponin I was measured at least once in the first 24 hours of admission in 90% of patients. Elevated cardiac troponin I levels were observed in 69 of 208 patients on admission to ICU (prevalence 33.2%, 95% CI 26.8–40.0%) and 15 patients developed elevations in cardiac troponin I during their ICU stay (incidence 7.2%, 95% CI 4.1–11.6%). A diagnosis of an acute coronary syndrome (ACS) (based on troponin I level, and either ECG changes or initiation of treatment for myocardial ischemia) was made in 54 of 208 patients (prevalence 26.0%, 95% CI 20.1–32.5%). Fifteen patients (7.2%, 95% 4.1–11.6%) had elevated cardiac troponin I levels without any further testing. During the ICU stay, the incidence of ACS was 5.3% (95% CI 2.7–9.3%) and isolated elevated troponin I levels were found in 1.9% (95% CI 0.5–4.9%).Conclusions: Thrombotic events in critically ill patients occurs frequently and may often be unrecognized. Typical diagnostic tests for thromboembolism have not been properly evaluated in the critically ill; moreover, the predictive value for the diagnosis of myocardial infarction has not been determined in these patients. Additional studies evaluating the long term outcome and efficacy of interventions for critically ill patients with thrombotic events is required.

Épidémiologie de l’infection et des états septiques en réanimation Résultats d’une étude de cohorte internationale

Since 1992, epidemiological and clinical studies have classified severe infections into three categories: sepsis, severe sepsis and septic shock. Microbiological documentation is not always provided. We used a different approach, focusing on the infection itself, whether or not it is microbiologically documented or associated with sepsis. In an international prospective cohort study, all patients admitted to the participating units from May 1997 to May 1998 were followed until hospital discharge. Twenty-eight intensive care units (ICU) in eight countries enrolled 14,364 patients. Of these, 6011 stayed in the ICU for less than 24 hours and 8353 for more than 24 hours. Overall, 3034 infectious episodes were recorded at ICU admission (crude incidence rate 21.1%). Among patients hospitalized for more than 24 hours, 1581 infectious episodes occurred in the ICU (crude incidence rate 18.9%), including 713 cases (45%) in patients who were already infected at ICU admission. These rates varied among the ICUs. Respiratory, gastrointestinal, urinary tract and primary bloodstream infections represented about 80% of all infections. Hospital-acquired and Intensive Care Unit-acquired infections were more frequently microbiologically documented than community-acquired infections (71% and 86%, respectively, vs 55%). About 28% of all infections were associated with sepsis, 24% with severe sepsis and 30% with septic shock (18% were not classified). Crude in-hospital mortality rates ranged from 16.9% in uninfected patients to 53.6% in patients who were both infected at the time of ICU admission and subsequently acquired an infection during the ICU stay. The in-hospital mortality rate increased with severity, from 20% for sepsis to 40% for severe sepsis and 60% for septic shock, but also depended on the origin of infection (community vs hospital/ICU). Crude incidence rates of ICU infection were high, varying among ICUs and patient subsets. Thus, vital outcome depends not only on the severity of sepsis but also on the characteristics of the infection.

Prevalence and incidence of severe sepsis in Dutch intensive care units

IntroductionSevere sepsis is a dreaded consequence of infection and necessitates intensive care treatment. Severe sepsis has a profound impact on mortality and on hospital costs, but recent incidence data from The Netherlands are not available. The purpose of the present study was to determine the prevalence and incidence of severe sepsis occurring during the first 24 hours of admission in Dutch intensive care units (ICUs).MethodsForty-seven ICUs in The Netherlands participated in a point prevalence survey and included patients with infection at the time of ICU admission. Clinical symptoms of severe sepsis during the first 24 hours of each patient's ICU stay were recorded and the prevalence of severe sepsis was calculated. Then, the annual incidence of severe sepsis in The Netherlands was estimated, based on the prevalence, the estimated length of stay, and the capacity of the participating ICUs relative to the national intensive care capacity.ResultsThe participating ICUs had 442 beds available for admissions, which was estimated to be 42% of the national ICU capacity. At the time of the survey, 455 patients were currently admitted and 151 were included in the analysis; 134 (29.5%) patients met criteria for severe sepsis. The most common failing organ system was the respiratory system (90%), and most patients were admitted following surgery (37%) and were admitted because of acute infection (62%). The most prevalent source of infection was the lung (47%). The estimated duration of ICU stay for severe sepsis patients was 13.3 ± 1.1 days.ConclusionThe annual number of admissions for severe sepsis in Dutch ICUs was calculated at 8643 ± 929 cases/year, which is 0.054% of the population, 0.61% of hospital admissions and 11% of ICU admissions.

The effects of ICU admission and discharge times on mortality in Finland.

Hospital mortality increases if acutely ill patients are admitted to hospitals on weekends as compared with weekdays. Night discharges may increase mortality in intensive care unit (ICU) patients but the effect of ICU admission time on mortality is not known. We studied the effects of ICU admission and discharge times on mortality and the time of death in critically ill patients. Cohort study using a national ICU database. Eighteen ICUs in university and central hospitals in Finland. Consecutive series of all 23,134 emergency admissions in January 1998-June 2001. None. We defined weekend (as opposed to weekday) from 1600 hours Friday to 2400 hours Sunday and "out-of-office" hours (as opposed to "office hours") from 1600 hours to 0800 hours. Mortality was adjusted for disease severity, intensity of care, and whether restrictions for future care were set. ICU-mortality was 10.9% and hospital mortality 20.7%. Adjusted ICU-mortality was higher for weekend as compared with weekday admissions [odds ratio (OR 1.20) 95% CI 1.01-1.43], but similar for "out-of-office" and "office hour" admissions (OR 0.98, 0.85-1.13). Adjusted risk of ICU death was higher during "out-of-office" hours as compared with office hours (OR 6.89, 5.96-7.96). The time of discharge from ICU to wards was not associated with further hospital mortality. Weekend ICU admissions are associated with increased mortality, and patients in the ICU are at increased risk of dying in evenings and during nighttime. Our findings may have important implications for organization of ICU services.

Risk factors for long intensive care unit stay after cardiopulmonary bypass in children.

To determine whether children who experience longer intensive care unit (ICU) stays after open heart surgery may be identified at admission by clinical criteria. To identify factors associated with longer ICU stays that are potential targets for quality improvement. Tertiary pediatric cardiac surgical center. A retrospective review was performed of pre-, intra-, and postoperative factors for children undergoing open heart surgery. All factors were evaluated for strength of association with length of ICU stay (LOS) using a negative binomial model. After multiple analysis, factors were deemed significant if associated with a LOS with p < .02. A total of 355 pediatric patients who had cardiac surgery with cardiopulmonary bypass in a 1-yr period from April 1999 until March 2000. Children who fell above the 95th percentile for LOS in our institution occupied 30% of bed days and had a three-fold greater mortality. Of all clinical factors considered, those significantly associated with LOS were as follows: preoperative--mechanical ventilation, neonatal status, medical problems, and transfer from abroad; intraoperative--higher operative complexity, increased cardiopulmonary bypass time or ischemic time, and circulatory arrest; and postoperative--delayed sternal closure, sepsis, renal failure, pulmonary hypertension, chylothorax, diaphragm paresis, and arrhythmia. A model combining all factors identified preoperative mechanical ventilation, neonatal status, major medical problems, operative complexity, cardiopulmonary bypass time, and a postoperative complication score as independently associated with LOS (p < .01). At the time of ICU admission after open heart surgery, clinical criteria are evident that highlight a child's risk of longer ICU stay. These pre- and intraoperative factors relate to LOS independent of subsequent postoperative events. Those postoperative complications that are most strongly associated with increased LOS are identified and, therefore, made accessible to quality control.

Risk factors for nosocomial pneumonia in critically ill trauma patients.

To determine risk factors for nosocomial pneumonia in critically ill trauma patients. Prospective cohort study. The trauma intensive care unit (ICU) of a 1500-bed tertiary-care hospital. All critically ill trauma patients (n = 103) admitted consecutively between November 1995 and October 1996. A comparison of data recorded at the time of ICU admission and during the clinical evolution in patients with (n = 23) and without (n = 80) nosocomial pneumonia was made. Data referred mainly to possible risk factors were recorded; they also included factors related to pneumonia etiology and evolutive factors. Predictors of nosocomial pneumonia were assessed by logistic regression analysis. The presence of significant growth on quantitative cultures of the protected specimen brush (> or = 103 colony forming units/mL) was required to accept pneumonia as microbiologically proven, as well as the concurrence of a cohort of clinical and radiologic signs. Twenty-three (22.3%) patients developed nosocomial pneumonia. The mean age of these patients was 41.7 yrs; 18 of them (78.3%) were men. The microorganisms isolated in significant concentrations were Acinetobacter baumanii (ten cases), Staphylococcus aureus (11 cases), Pseudomonas aeruginosa (five cases), Haemophilus influenzae (two cases), and Klebsiella pneumoniae, Citrobacter freundii, Serratia marcescens, Enterococcus spp., Enterobacter spp., coagulase-negative Staphylococcus, and Streptococcus intermedius (one case each one). Risk factors for pneumonia by univariate analysis included nasogastric tube; continuous enteral feeding; prolonged mechanical ventilation (>1 day); use of H2-receptor antagonist, sucralfate, muscle relaxants, corticosteroids, barbiturates, and inotropic agents; positive end-expiratory pressure; intense sedation; re-intubation; tracheotomy; urgent brain computed tomography (CT) scan; craniotomy; iatrogenic event; and hyperventilation. The mortality rate was 43.5% (10 of 23) in the nosocomial pneumonia group and 18.8% in patients without nosocomial pneumonia (p =.02). Also, the mean stay in the ICU, the therapeutic charge (measured with total and mean punctuation of the Therapeutic Intervention Scoring System) and the complications, infectious and noninfectious, of the clinical evolution were significantly more frequent in patients with nosocomial pneumonia than in those without pneumonia (p <.05). In the multivariate analysis, continuous enteral feeding, craniotomy, prolonged mechanical ventilation (>24 hrs), use of positive end-expiratory pressure, and corticotherapy were independent predictors of nosocomial pneumonia. It seems that factors related to the patient's clinical course, rather than variables registered on the first days of ICU admission, are those that would exert an influence on the development of nosocomial pneumonia in critically ill trauma patients. In this way, from our point of view, in our study the main risk factors are the use of prolonged mechanical ventilation (>4 hrs) and positive end-expiratory pressure. At the same time, we can conclude that the reduction of this infection incidence could decrease the mean stay in the ICU, the therapeutic charge, and the prognosis in terms of mortality and morbidity.

Predictive model for survival at the conclusion of a damage control laparotomy

Background: We employed modern statistical and data mining methods to model survival based on preoperative and intraoperative parameters for patients undergoing damage control surgery. Methods: One hundred seventy-four parameters were collected from 68 damage control patients in prehospital, emergency center, operating room, and intensive care unit (ICU) settings. Data were analyzed with logistic regression and data mining. Outcomes were survival and death after the initial operation. Results: Overall mortality was 66.2%. Logistic regression identified pH at initial ICU admission (odds ratio: 4.4) and worst partial thromboplastin time from hospital admission to ICU admission (odds ratio: 9.4) as significant. Data mining selected the same factors, and generated a simple algorithm for patient classification. Model accuracy was 83%. Conclusions: Inability to correct pH at the conclusion of initial damage-control laparotomy and the worst PTT can be predictive of death. These factors may be useful to identify patients with a high risk of mortality.

Measuring for improvement: from Toyota to thoracic surgery

Background. Measuring quality has become a high priority in the era of managed care. Nevertheless, it can be counterproductive to use the same methods for measuring improvement in surgical procedures and processes as we use for measurement in basic research. Techniques of statistical process control have been used for many years to measure process improvement in industry and are now being applied to health care. Methods. Examples of using statistical process control charts to monitor coronary artery bypass grafting mortality, intensive care unit admission time, and length of stay are reviewed. Results. The major advantage of using control chart methodology is that it allows one to determine whether the process being evaluated is in fact stable and to detect when significant or special cause variation occurs. Conclusions. Summary statistics currently provided to purchasers of care and regulatory agencies do not ensure that the processes being evaluated are stable. We need to look at data over time with statistically validated methods such as control charts to better monitor our processes of care and thereby provide accurate statistics.

Vancomycin-resistant enterococci in intensive care units: high frequency of stool carriage during a non-outbreak period.

We aimed to define the epidemiological associations of vancomycin-resistant enterococci (VRE) in intensive care units (ICUs) during a non-outbreak period by examining prevalence, risk factors for colonization, frequency of acquisition, and molecular strain types. A prospective cohort design was followed. Consecutive patient admissions to 2 surgical ICUs at a tertiary care hospital were enrolled. The main outcome measures were results of serial surveillance cultures screened for VRE. Of 290 patients enrolled, 35 (12%) had colonization with VRE on admission. The VRE colonization or infection had been previously detected by clinical cultures in only 4 of these patients. Using logistic regression, VRE colonization at the time of ICU admission was associated with second- and third-generation cephalosporins (odds ratio [OR] = 6.0, P<.0001), length of stay prior to surgical ICU admission (OR = 1.06, P = .001) greater than 1 prior ICU stay (OR = 9.6, P = .002), and a history of solid-organ transplantation (OR = 3.8, P = .021). Eleven (12.8%) of 78 patients with follow-up cultures acquired VRE. By pulsed-field gel electrophoresis, 2 strains predominated, one of which was associated with an overt outbreak on a non-ICU ward near the end of the study period. Colonization was common and usually not recognized by clinical culture. Most patients who had colonization with VRE and were on the surgical ICU acquired VRE prior to surgical ICU entry. Exposure to second- and third-generation cephalosporins, but not vancomycin, was an independent risk factor for colonization. Prospective surveillance of hospitalized patients may yield useful insights about the dissemination of nosocomial VRE beyond what is appreciated by clinical cultures alone.

The impact of a multidisciplinary approach on caring for ventilator-dependent patients.

To determine the clinical and financial outcomes of a highly structured multidisciplinary care model for patients in an intensive care unit (ICU) who require prolonged mechanical ventilation. The structured model outcomes (protocol group) are compared with the preprotocol outcomes. Descriptive study with financial analysis. A twelve-bed medical-surgical ICU in a non-teaching tertiary referral center in Ogden, Utah. During a 54 month period, 469 consecutive intensive care patients requiring mechanical ventilation for longer than 72 hours who did not meet exclusion criteria were studied. A multidisciplinary team was formed to coordinate the care of ventilator-dependent patients. Care was integrated by daily collaborative bedside rounds, monthly meetings, and implementation of numerous guidelines and protocols. Patients were followed from the time of ICU admission until the day of hospital discharge. Patients were assigned APACHE II scores on admission to the ICU, and were divided into eight diagnostic categories. ICU length of stay, hospital length of stay, costs, charges, reimbursement, and in-hospital mortality were measured. Mortality in the preprotocol and protocol group, after adjustment for APACHE II scores, remained statistically unchanged (21-23%). After we implemented the new care model, we demonstrated significant decreases in the mean survivor's ICU length of stay (19.8 days to 14.7 days, P= 0.001), hospital length of stay (34.6 days to 25.9 days, P=0.001), charges (US$102500 to US$78500, P=0.001), and costs (US$71900 to US$58000, P=0.001). Implementation of a structured multidisciplinary care model to care for a heterogeneous population of ventilator-dependent ICU patients was associated with significant reductions in ICU and hospital lengths of stay, charges, and costs. Mortality rates were unaffected.

Acute exacerbations of chronic obstructive pulmonary disease and mechanical ventilation

To review the intensive care unit (ICU) experience of patients admitted with acute exacerbations of chronic obstructive pulmonary disease. Retrospective case series. University teaching hospital. We reviewed the records of 100 consecutive ICU admissions of patients with acute exacerbations of chronic obstructive pulmonary disease over a period of 4.25 yrs. None. Patients were characterized using a computerized prospective database and case note review. Multivariate analysis identified variables predicting ICU and hospital length of stay. The Cox proportional hazards model was used to analyze survival after hospital discharge. Seventy-five patients (24 female and 51 male, mean age 68.5 +/- 7 [SD] yrs) with 100 ICU admissions were identified. Premorbid airway obstruction was severe, with forced expiratory volume in 1 sec (FEV1)/forced vital capacity (FVC) of 0.7 +/- 0.34 L and FEV1/FVC of 39 +/- 16%. Thirty-two percent received home-administered oxygen and 42% were housebound. The pre-ICU admission PaCO2 was 86 +/- 28 torr (11.5 +/- 3.7 kPa), with a pH of 7.24 +/- 0.11 and a PaO2/FIO2 of 190 +/- 66. ICU admission Acute Physiology and Chronic Health Evaluation II score was 18 +/- 5. Forty-three patients were mechanically ventilated for a median of 4 days (range 0.08 to 30). Tracheostomy, in seven patients, was maintained for 21 +/- 7 days. Ventilation time and tracheostomy frequency predicted length of ICU stay (median 3 days; range 1 to 40) and hospital stay (17 days; 4 to 97), respectively. ICU and hospital case-fatality rates were 1% and 11%. Out-of-hospital (24-month) probability of survival was predicted by plasma albumin concentration at the time of ICU admission; this probability of survival was .64 at an albumin concentration of 38 g/L. ICU admission of severely ill chronic obstructive pulmonary disease patients results in acceptable outcomes. Survival of < or =2 yrs is not affected by mechanical ventilation or tracheostomy requirement.

Procoagulant activity in patients with isolated severe head trauma

To determine the degree of regional and systemic coagulation activation soon after isolated severe head injury. Prospective, controlled clinical study. The emergency room and intensive care unit (ICU) of a trauma center in a university hospital serving a population of 5 million people. Twenty-four trauma victims: 20 patients with isolated severe head injury (head trauma group, Glasgow Coma Score of < or =8) and four patients with isolated bone fracture (control group). Insertion of central venous, i.e. superior caval vein, jugular bulb, and arterial catheters for blood sampling. Central venous (i.e., superior caval vein) global coagulation variables (i.e., prothrombin time, activated partial thromboplastin time, fibrinogen concentration, antithrombin III activity, and platelet count) and central venous and jugular bulb activation coagulation and fibrinolysis variables (i.e., prothrombin fragment F1+2, thrombin-antithrombin III complex, soluble fibrin, and D-dimer concentration) were measured soon after trauma (<6 hrs) and 3 hrs later. When compared with the control group patients, upon ICU admission, fibrinogen concentration (p < .005) and platelet count (p < .025) were significantly decreased in the head trauma group. Thrombin-antithrombin III complex (p < .025), prothrombin fragment F1+2 (p < .025), and D-dimer (p < .005) concentrations measured at the time of ICU admission were significantly higher in the head trauma group than in the control group. Only in the head trauma group were soluble fibrin concentrations increased above the normal range; thrombin-antithrombin III complex and the prothrombin fragment F1+2 were found to be significantly higher in cerebrovenous blood than in central venous blood (p < .025). There was no cerebrocentral venous difference in the concentrations of soluble fibrin or D-dimer in either group. Within 6 hrs after severe isolated head trauma, systemic procoagulant overflow from the traumatized cerebral microvasculature proceeds to the thrombin level and is then inhibited by antithrombin III. Regional and systemic hypercoagulability and increased D-dimer concentrations appear to be common among head trauma patients. Increased procoagulant and consecutive fibrinolytic turnover may, therefore, spark disseminated intravascular coagulation in this patient group.

Severe Pancreatitis

To determine factors associated with mortality in patients with severe pancreatitis. Retrospective review. University tertiary referral center intensive care unit (ICU). Thirty patients admitted to the ICU with the primary diagnosis of pancreatitis from 1986 to 1995. Survival vs nonsurvival. Twenty-seven patients were transferred from another institution. At the time of ICU admission, subsequent death was not associated with the following: systolic blood pressure, pulse rate, hemoglobin level, leukocyte count, platelet count, or serum calcium concentration. The patients who died during the study were older at admission (age [mean+/-SD] of those who lived, 47+/-17 years; age of those who died, 64+/-8 years; P=.01) and their serum creatinine concentrations were higher (creatinine concentrations [mean +/-SD] of those who lived, 150+/-90 micromol/L [1.7+/-1.0 mg/dL]; creatinine concentrations of those who died, 410+/-250 micromol/L [4.6+/-2.8 mg/dL]; P=.001). Clinical events not associated with mortality included respiratory failure, insulin use, positive blood cultures, positive pancreatic cultures, and abdominal surgery for pancreatitis and infected pancreatic necrosis. Death was associated with the use of inotropic and/or vasopressor support (P=.05) and renal failure (creatinine, >170 micromol/L[>2.0 mg/dL]) at any time during the ICU stay (P=.01). Patients with renal failure were no older than the patients without, but were admitted later after the onset of pancreatitis (mean+/-SD, 5.9+/-7.2 days vs 1.5+/-1.1 days; P=.03; median, 2 days vs 1 days). After hospital transfer to a teritiary referral center, only older age, use of inotropic and/or vasopressor support, and evidence of renal malfunction are associated with death. Prompt recognition of severe pancreatitis, especially in older patients, aggressive hemodynamic management, and/or earlier transfer to a tertiary care center may diminish the incidence of renal failure and mortality in severe pancreatitis.

Acute renal failure in intensive care units--causes, outcome, and prognostic factors of hospital mortality; a prospective, multicenter study. French Study Group on Acute Renal Failure.

To assess the causes, the prognostic factors, and the outcome of patients with severe acute renal failure. Prospective, multicenter study. Twenty French multidisciplinary intensive care units (ICUs). All patients with severe acute renal failure were prospectively enrolled in the study for a 6-month period. Severe acute renal failure was defined by the following criteria: a) a serum creatinine concentration of > or = 3.5 mg/dL ( > or = 310 mumol/L) and/or a blood urea nitrogen concentration of > or = 100 mg/dL ( > or = 36 mmol/L); or b) an increase in blood urea nitrogen or serum creatinine concentration, such that the concentration is 100% above the baseline value in patients with previous chronic renal insufficiency (serum creatinine concentration of > 1.8 mg/dL [ > 150 mumol/L]), excluding those patients with a basal serum creatinine concentration of > 3.4 mg/dL ( > 300 mumol/L). None. Age, sex, previous health status and preexisting organ dysfunction, and type and origin of acute renal failure were recorded. The Simplified Acute Physiology Score, the Acute Physiology and Chronic Health Evaluation (APACHE II) score, and the number of Organ System Failures were calculated on ICU day 1 and at the time of inclusion in the study. Prognostic factors were determined by univariate methods and stepwise logistic regression analysis. There were 360 patients in the study; 217 patients were admitted to the study at the time of ICU admission and 143 patients were admitted to the study after ICU admission. Only 41% of these patients were in good health 3 months before ICU entry. The reason for admission was medical in 78% of cases. The type of acute renal failure was prerenal (n = 16), renal (n = 282), or postrenal (n = 17). Renal replacement therapy was used in 174 patients. Two hundred ten (58%) patients died during the hospital stay. Using stepwide logistic regression, seven variables were predictive of death. These variables were advanced age, altered previous health status, hospitalization before ICU admission, delayed occurrence of acute renal failure, sepsis, oliguria, and severity of illness as assessed at the time of study inclusion by Simplified Acute Physiology Score, APACHE II, or Organ System Failure. The hospital mortality rate of patients with severe acute renal failure in patients requiring intensive care remains high. In order to compare patient groups in further trials concerning acute renal failure, recorded characteristics of the population should include age, previous health status, disease characteristics (initial or delayed acute renal failure, oliguria, sepsis), and the severity of the illness as assessed by physiologic scoring systems recorded at the time of study inclusion.