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1.
Pierre?Kalfon Karine?Baumstarck Philippe?Estagnasie Marie-Agnès?Geantot Audrey?Berric Georges?Simon Bernard?Floccard Thomas?Signouret Mohamed?Boucekine Mélanie?Fromentin Martine?Nyunga Achille?Sossou Marion?Venot René?Robert Arnaud?Follin Juliette?Audibert Anne?Renault Ma?té?Garrouste-Orgeas Olivier?Collange Quentin?Levrat Isabelle?Villard Didier?Thevenin Julien?Pottecher René-Gilles?Patrigeon Nathalie?Revel Coralie?Vigne Elie?Azoulay Olivier?Mimoz Pascal?Auquier 《Intensive care medicine》2017,43(12):1829-1840
Purpose
Critically ill patients are exposed to stressful conditions and experience several discomforts. The primary objective was to assess whether a tailored multicomponent program is effective for reducing self-perceived discomfort.Methods
In a cluster-randomized two-arm parallel trial, 34 French adult intensive care units (ICUs) without planned interventions to reduce discomfort were randomized, 17 to the arm including a 6-month period of program implementation followed by a 6-month period without the program (experimental group), and 17 to the arm with an inversed sequence (control group). The tailored multicomponent program consisted of assessment of ICU-related self-perceived discomforts, immediate and monthly feedback to healthcare teams, and site-specific tailored interventions. The primary outcome was the overall discomfort score derived from the 16-item IPREA questionnaire (0, minimal, 100, maximal overall discomfort) and the secondary outcomes were the discomfort scores of each IPREA item. IPREA was administered on the day of ICU discharge with a considered timeframe from the ICU admission until ICU discharge.Results
During a 1-month assessment period, 398 and 360 patients were included in the experimental group and the control group, respectively. The difference (experimental minus control) of the overall discomfort score between groups was ? 7.00 (95% CI ? 9.89 to ? 4.11, p < 0.001). After adjustment (age, gender, ICU duration, mechanical ventilation duration, and type of admission), the program effect was still positive for the overall discomfort score (difference ? 6.35, SE 1.23, p < 0.001) and for 12 out of 16 items.Conclusions
This tailored multicomponent program decreased self-perceived discomfort in adult critically ill patients. Trial Registration: Clinicaltrials.gov Identifier NCT02442934.2.
Objective
The aim of the present study was (1) to determine the prevalence of intensive care unit (ICU) admissions due to an adverse drug reaction (ADR), and (2) to compare affected patients with patients admitted to the ICU for the treatment of deliberate self-poisoning using medical drugs.Design
Prospective observational cohort study.Setting
Fourteen bed medical ICU including an integrated intermediate care (IMC) section at a tertiary referral center.Patients
A total of 1,554 patients admitted on 1 January 2003 to 31 December 2003.Results
Ninety-nine patients were admitted to the ICU with a diagnosis of ADR (6.4% of all admissions), 269 admissions (17.3%) were caused by deliberate self-poisoning. Patients admitted for treatment of ADR had a significantly higher age, a longer treatment duration in the ICU, a higher SAPS II score, and a higher 6-month mortality than those with deliberate self-poisoning. Most patients (71.7%) suffering from ADR required advanced supportive care in the ICU while the majority of patients (90.7%) with deliberate self-poisoning could be sufficiently treated in the IMC area. All diagnostic and therapeutic procedures in the ICU except mechanical ventilation were significantly more often performed in patients with ADR.Conclusions
This study provides further evidence that ADR is a frequent cause of admission to medical ICUs resulting in a considerable use of ICU capacities. In the present setting patients with ADR required longer and more intense medical treatment in the ICU than those with deliberate self-poisoning.3.
Purpose
Hospital funding for the intensive care unit (ICU) stays in France is made of reimbursement of a fixed amount based on the diagnosis-related group (DRG) of the patients and of extra funding for each day spent in the ICU. These tariffs are updated annually. We measured the impact of these updates on the theoretical income of our ICU.Patients and Methods
DRG and length of stay of the patients hospitalized during 2011 in a 12-bed ICU were extracted. We computed the theoretical reimbursement for these patients with the tariffs from 2011 to 2016.Results
592 ICU stays, classified in 237 DRGs, were analyzed. The theoretical income decreased from € 8,416,260.14 in 2011 to € 7,809,709.15 in 2016 (–7.21%). This reduction was explained by lower tariffs for the different DRGs (mean evolution–4.6%) and a diminution of the extra funding (–1.6%).Conclusion
These results are based on a small number of ICU stays but are significant because of the high number of DRGs analyzed.This simulation gives an estimate of the economic impact on the French ICUs for the update of the reimbursement rates during the last six years. Productivity gains are necessary to face the tariff evolution and should preferably be obtained by the reduction of the costs.4.
Elie Azoulay Jean-Marie Forel Isabelle Vinatier Romain Truillet Anne Renault Sandrine Valade Samir Jaber Jacques Durand-Gasselin Carole Schwebel Hughes Georges Sybille Merceron Alain Cariou Myriam Moussa Sami Hraiech Laurent Argaud Marc Leone J. Randall Curtis Nancy Kentish-Barnes Elisabeth Jouve Laurent Papazian 《Intensive care medicine》2018,44(11):1879-1887
Purpose
Relatives of intensive care unit (ICU) patients suffer emotional distress that impairs their ability to acquire the information they need from the staff. We sought to evaluate whether providing relatives with a list of important questions was associated with better comprehension on day 5.Methods
Randomized, parallel-group trial. Relatives of mechanically ventilated patients were included from 14 hospitals belonging to the FAMIREA study group in France. A validated list of 21 questions was handed to the relatives immediately after randomization. The primary endpoint was comprehension on day 5. Secondary endpoints were satisfaction (Critical Care Family Needs Inventory, CCFNI) and symptoms of anxiety and depression (Hospital Anxiety and Depression Scale, HADS).Results
Of 394 randomized relatives, 302 underwent the day-5 assessment of all outcomes. Day-5 family comprehension was adequate in 68 (44.2%) and 75 (50.7%) intervention and control group relatives (P?=?0.30), respectively. Over the first five ICU days, median number of family–staff meetings/patient was 6 [3–9], median total meeting time was 72.5 [35–110] min, and relatives asked a median of 20 [8–33] questions including 11 [6–13] from the list, with no between-group difference. Satisfaction and anxiety/depression symptoms were not significantly different between groups. The only variable significantly associated with better day-5 comprehension by multivariable analysis was a higher total number of questions asked before day 5.Conclusions
Providing relatives with a list of questions did not improve day-5 comprehension, secondary endpoints, or information time. Further research is needed to help families obtain the information they need.Trial registration
ClinicalTrials.gov Identifier: NCT02410538.5.
Introduction
Extubation failure has been associated with poor intensive care unit (ICU) and hospital outcomes in tertiary care medical centers. Given the large proportion of critical care delivered in the community setting, our purpose was to determine the impact of extubation failure on patient outcomes in a community hospital ICU.Methods
A retrospective cohort study was performed using data gathered in a 16-bed medical/surgical ICU in a community hospital. During 30 months, all patients with acute respiratory failure admitted to the ICU were included in the source population if they were mechanically ventilated by endotracheal tube for more than 12 hours. Extubation failure was defined as reinstitution of mechanical ventilation within 72 hours (n = 60), and the control cohort included patients who were successfully extubated at 72 hours (n = 93).Results
The primary outcome was total ICU length of stay after the initial extubation. Secondary outcomes were total hospital length of stay after the initial extubation, ICU mortality, hospital mortality, and total hospital cost. Patient groups were similar in terms of age, sex, and severity of illness, as assessed using admission Acute Physiology and Chronic Health Evaluation II score (P > 0.05). Both ICU (1.0 versus 10 days; P < 0.01) and hospital length of stay (6.0 versus 17 days; P < 0.01) after initial extubation were significantly longer in reintubated patients. ICU mortality was significantly higher in patients who failed extubation (odds ratio = 12.2, 95% confidence interval [CI] = 1.5–101; P < 0.05), but there was no significant difference in hospital mortality (odds ratio = 2.1, 95% CI = 0.8–5.4; P < 0.15). Total hospital costs (estimated from direct and indirect charges) were significantly increased by a mean of US$33,926 (95% CI = US$22,573–45,280; P < 0.01).Conclusion
Extubation failure in a community hospital is univariately associated with prolonged inpatient care and significantly increased cost. Corroborating data from tertiary care centers, these adverse outcomes highlight the importance of accurate predictors of extubation outcome.6.
Karlsson S Varpula M Ruokonen E Pettilä V Parviainen I Ala-Kokko TI Kolho E Rintala EM 《Intensive care medicine》2007,33(3):435-443
Objective
To determine the incidence and outcome of severe sepsis in the adult Finnish population and to evaluate how treatment guidelines in severe sepsis are applied in clinical practice.Study design
A prospective study in 24 closed multidisciplinary ICUs in 21 hospitals (4 university and 17 tertiary hospitals) in Finland.Patients
All 4,500 consecutive ICU admission episodes were screened for severe sepsis during a 4-month period (1 November 2004 – 28 February 2005). The referral population was 3,743,225.Results
The severe sepsis criteria were fulfilled in 470 patients, who had472 septic episodes. The incidence of severe sepsis in the ICUs in Finland was 0.38/1000 in the adult population (95% confidence interval 0.34–0.41). The mean ICU length of stay was 8.2?±?8.1?days. ICU, hospital, and 1-year mortality rates were 15.5%, 28.3%, and 40.9%, respectively. Respiratory failure requiring ventilation support was the most common organ failure (86.2%); septic shock was present in 77% and acute renal failure in 20.6% of cases. Activated protein C was given to only 15 of the 55 patients with indication (27%) and low-dose corticosteroids to 150 of 366 (41%) patients with septic shock.Conclusions
This prospective study found the incidence of ICU-treated severe sepsis in Finland to be 0.38 per 1,000 of the population. The ICU and hospital mortalities were also lower than earlier reported in United States or Australia. Evidence-based sepsis therapies were not used as often as recommended.7.
Purpose
This systematic review assessed if outcomes in adult intensive care units (ICUs) are related to hospital and ICU patient volume.Methods
A systematic search strategy was used to identify studies reporting on volume–outcome relationship in adult ICU patients till November 2010. Inclusion of articles was established through a predetermined protocol. Two reviewers assessed studies independently and data extraction was performed using standardized data extraction forms.Results
A total of 254 articles were screened. Of these 25 were relevant to this study. After further evaluation a total of 13 studies including 596,259 patients across 1,068 ICUs met the inclusion criteria and were reviewed. All were observational cohort studies. Four of the studies included all admissions to ICU, five included mechanically ventilated patients, two reported on patients admitted with sepsis and one study each reported on patients admitted with medical diagnoses and post cardiac arrest patients admitted to ICU, respectively. There was a wide variability in the quantitative definition of volume and classification of hospitals and ICUs on this basis. Methodological heterogeneity amongst the studies precluded a formal meta-analysis. A trend towards favourable outcomes for high volume centres was observed in all studies. Risk-adjusted mortality rates revealed a survival advantage for a specific group of patients in high volume centres in ten studies but no significant difference in outcomes was evident in three studies.Conclusions
The results indicate that outcomes of certain subsets of ICU patients—especially those on mechanical ventilation, high-risk patients, and patients with severe sepsis—are better in high volume centres within the constraints of risk adjustments.8.
Hans?Flaatten Dylan?W.?De?Lange Alessandro?Morandi Finn?H.?Andersen Antonio?Artigas Guido?Bertolini Ariane?Boumendil Maurizio?Cecconi Steffen?Christensen Loredana?Faraldi Jesper?Fj?lner Christian?Jung Brian?Marsh Rui?Moreno Sandra?Oeyen Christina?Agwald??hman Bernardo?Bollen?Pinto Ivo?W.?Soliman Wojciech?Szczeklik Andreas?Valentin Ximena?Watson Tilemachos?Zaferidis Bertrand?Guidet 《Intensive care medicine》2017,43(12):1820-1828
Purpose
Very old critical ill patients are a rapid expanding group in the ICU. Indications for admission, triage criteria and level of care are frequently discussed for such patients. However, most relevant outcome studies in this group frequently find an increased mortality and a reduced quality of life in survivors. The main objective was to study the impact of frailty compared with other variables with regards to short-term outcome in the very old ICU population.Methods
A transnational prospective cohort study from October 2016 to May 2017 with 30 days follow-up was set up by the European Society of Intensive Care Medicine. In total 311 ICUs from 21 European countries participated. The ICUs included the first consecutive 20 very old (≥ 80 years) patients admitted to the ICU within a 3-month inclusion period. Frailty, SOFA score and therapeutic procedures were registered, in addition to limitations of care. For measurement of frailty the Clinical Frailty Scale was used at ICU admission. The main outcomes were ICU and 30-day mortality and survival at 30 days.Results
A total of 5021 patients with a median age of 84 years (IQR 81–86 years) were included in the final analysis, 2404 (47.9%) were women. Admission was classified as acute in 4215 (83.9%) of the patients. Overall ICU and 30-day mortality rates were 22.1% and 32.6%. During ICU stay 23.8% of the patients did not receive specific ICU procedures: ventilation, vasoactive drugs or renal replacement therapy. Frailty (values ≥ 5) was found in 43.1% and was independently related to 30-day survival (HR 1.54; 95% CI 1.38–1.73) for frail versus non-frail.Conclusions
Among very old patients (≥ 80 years) admitted to the ICU, the consecutive classes in Clinical Frailty Scale were inversely associated with short-term survival. The scale had a very low number of missing data. These findings provide support to add frailty to the clinical assessment in this patient group.Trial registration
ClinicalTrials.gov (ID: NCT03134807).9.
Etienne Gayat Alexa Hollinger Alain Cariou Nicolas Deye Antoine Vieillard-Baron Samir Jaber Benjamin G. Chousterman Qin Lu Pierre François Laterre Xavier Monnet Michael Darmon Marc Leone Bertrand Guidet Romain Sonneville Jean-Yves Lefrant Marie-Céline Fournier Matthieu Resche-Rigon Alexandre Mebazaa Matthieu Legrand On behalf of FROG-ICU investigators 《Intensive care medicine》2018,44(5):598-605
10.
Background
In December 2007, the European Society of Intensive Care Medicine established a Task Force to develop standard operating procedures (SOPs) for operating intensive care units (ICU) during an influenza epidemic or mass disaster.Purpose
To provide direction for health care professionals in the preparation and management of emergency ICU situations during an influenza epidemic or mass disaster, standardize activities, and promote coordination and communication among the medical teams.Methods
Based on a literature review and contributions of content experts, a list of essential categories for managing emergency situations in the ICU were identified. Based on three cycles of a modified Delphi process, consensus was achieved regarding the categories. A primary author along with an expert group drafted SOPs for each category.Results
Based on the Delphi cycles, the following key topics were found to be important for emergency preparedness: triage, infrastructure, essential equipment, manpower, protection of staff and patients, medical procedures, hospital policy, coordination and collaboration with interface units, registration and reporting, administrative policies and education.Conclusions
The draft SOPs serve as benchmarks for emergency preparedness and response of ICUs to emergencies or outbreak of pandemics.11.
Purpose
Patients in the intensive care unit (ICU) are often transfused with red blood cells (RBC). During storage, the RBCs and storage medium undergo changes, which may have clinical consequences. Several trials now have assessed these consequences, and we reviewed the present evidence on the effects of shorter versus longer storage time of transfused RBCs on outcomes in ICU patients.Methods
We conducted a systematic review with meta-analyses and trial sequential analyses (TSA) of randomised clinical trials including adult ICU patients transfused with fresher versus older or standard issue blood.Results
We included seven trials with a total of 18,283 randomised ICU patients; two trials of 7504 patients were judged to have low risk of bias. We observed no effects of fresher versus older blood on death (relative risk 1.04, 95% confidence interval (CI) 0.97–1.11; 7349 patients; TSA-adjusted CI 0.93–1.15), adverse events (1.26, 0.76–2.09; 7332 patients; TSA-adjusted CI 0.16–9.87) or post-transfusion infections (1.07, 0.96–1.20; 7332 patients; TSA-adjusted CI 0.90–1.27). The results were unchanged by including trials with high risk of bias. TSA confirmed the results and the required information size was reached for mortality for a relative risk change of 20%.Conclusions
We may be able to reject a clinically meaningful effect of RBC storage time on mortality in transfused adult ICU patients as our trial sequential analyses reject a 10% relative risk change in death when comparing fresher versus older blood for transfusion.12.
Niels Van Regenmortel Walter Verbrugghe Ella Roelant Tim Van den Wyngaert Philippe G. Jorens 《Intensive care medicine》2018,44(4):409-417
Purpose
Research on intravenous fluid therapy and its side effects, volume, sodium, and chloride overload, has focused almost exclusively on the resuscitation setting. We aimed to quantify all fluid sources in the ICU and assess fluid creep, the hidden and unintentional volume administered as a vehicle for medication or electrolytes.Methods
We precisely recorded the volume, sodium, and chloride burdens imposed by every fluid source administered to 14,654 patients during the cumulative 103,098 days they resided in our 45-bed tertiary ICU and simulated the impact of important strategic fluid choices on patients’ chloride burdens. In septic patients, we assessed the impact of the different fluid sources on cumulative fluid balance, an established marker of morbidity.Results
Maintenance and replacement fluids accounted for 24.7% of the mean daily total fluid volume, thereby far exceeding resuscitation fluids (6.5%) and were the most important sources of sodium and chloride. Fluid creep represented a striking 32.6% of the mean daily total fluid volume [median 645 mL (IQR 308–1039 mL)]. Chloride levels can be more effectively reduced by adopting a hypotonic maintenance strategy [a daily difference in chloride burden of 30.8 mmol (95% CI 30.5–31.1)] than a balanced resuscitation strategy [daily difference 3.0 mmol (95% CI 2.9–3.1)]. In septic patients, non-resuscitation fluids had a larger absolute impact on cumulative fluid balance than did resuscitation fluids.Conclusions
Inadvertent daily volume, sodium, and chloride loading should be avoided when prescribing maintenance fluids in view of the vast amounts of fluid creep. This is especially important when adopting an isotonic maintenance strategy.13.
Development of an ICU discharge instrument predicting psychological morbidity: a multinational study
A. Milton A. Schandl I. W. Soliman K. Meijers M. van den Boogaard I. M. Larsson C. Brorsson U. Östberg M. Oxenbøll-Collet J. Savilampi S. Paskins M. Bottai P. V. Sackey 《Intensive care medicine》2018,44(12):2038-2047
Purpose
To develop an instrument for use at ICU discharge for prediction of psychological problems in ICU survivors.Methods
Multinational, prospective cohort study in ten general ICUs in secondary and tertiary care hospitals in Sweden, Denmark and the Netherlands. Adult patients with an ICU stay?≥?12 h were eligible for inclusion. Patients in need of neurointensive care, with documented cognitive impairment, unable to communicate in the local language, without a home address or with more than one limitation of therapy were excluded. Primary outcome was psychological morbidity 3 months after ICU discharge, defined as Hospital Anxiety and Depression Scale (HADS) subscale score?≥?11 or Post-traumatic Stress Symptoms Checklist-14 (PTSS-14) part B score?>?45.Results
A total of 572 patients were included and 78% of patients alive at follow-up responded to questionnaires. Twenty percent were classified as having psychological problems post-ICU. Of 18 potential risk factors, four were included in the final prediction model after multivariable logistic regression analysis: symptoms of depression [odds ratio (OR) 1.29, 95% confidence interval (CI) 1.10–1.50], traumatic memories (OR 1.44, 95% CI 1.13–1.82), lack of social support (OR 3.28, 95% CI 1.47–7.32) and age (age-dependent OR, peak risk at age 49–65 years). The area under the receiver operating characteristics curve (AUC) for the instrument was 0.76 (95% CI 0.70–0.81).Conclusions
We developed an instrument to predict individual patients’ risk for psychological problems 3 months post-ICU, http://www.imm.ki.se/biostatistics/calculators/psychmorb/. The instrument can be used for triage of patients for psychological ICU follow-up.Trial registration
The study was registered at clinicaltrials.gov, NCT02679157.14.
Purpose
To review the salient features of the diagnosis and management of the most common skin and soft tissue infections (SSTI). This review focuses on severe SSTIs that require care in an intensive care unit (ICU), including toxic shock syndrome, myonecrosis/gas gangrene, and necrotizing fasciitis.Methods
Guidelines, expert opinion, and local institutional policies were reviewed.Results
Severe SSTIs are common and their management complex due to regional variation in predominant pathogens and antimicrobial resistance patterns, as well as variations in host immune responses. Unique aspects of care for SSTIs in the ICU are discussed, including the role of prosthetic devices, risk factors for bacteremia, and the need for surgical consultation. SSTI mimetics, the role of dermatologic consultation, and the unique features of SSTIs in immunocompromised hosts are also described.Conclusions
We provide recommendations for clinicians regarding optimal SSTI management in the ICU setting.15.
Vanessa Chaves Barreto Ferreira de Lima Ana Luiza Bierrenbach Gizelton Pereira Alencar Ana Lucia Andrade Luciano Cesar Pontes Azevedo 《Intensive care medicine》2018,44(7):1090-1096
Purpose
To describe long-term mortality and hospital readmissions of patients admitted to Brazilian intensive care units (ICU).Methods
Retrospective cohort study of adult patients admitted to Brazilian hospitals affiliated to the Public Healthcare System from 10 state capitals. ICU patients were paired to non-ICU patients by frequency matching (ratio 1:2), according to postal code and admission semester. Hospitalization records were linked through deterministic linkage to national mortality data. Primary outcome was mortality up to 1 year. Other outcomes were mortality and readmissions at 30 and 90 days and 3 years. Multiple Cox regressions were used adjusting for age, sex, cancer diagnosis, type of hospital, and surgical status.Results
We included 324,594 patients (108,302 ICU and 216,292 non-ICU). ICU patients had increased hospital length of stay [9 (5–17) vs. 3 (1–6) days, p?<?0.001] and mortality (18.5 vs. 3.6%, p?<?0.001) versus non-ICU patients. One year after discharge, ICU patients were more frequently readmitted to hospital (25.4 vs. 17.4%, p?<?0.001) and to ICU (31.4 vs. 7.3%, p?<?0.001) than controls. Mortality up to 1 year was also higher for ICU patients (14.3 vs. 3.9%, p?<?0.001). A significant interaction between surgical status and mortality was found, with adjusted hazard ratios (HRs) up to 1 year of 2.7 [95% confidence interval (CI) 2.5–2.9] for surgical patients, and 3.4 (95%CI 3.3–3.5) for medical patients. The risk for death and readmission diminished over time up to 3 years.Conclusions
In a public healthcare system of a developing country, ICU patients have excessive long-term mortality and frequent readmissions. The ICU burden tended to reduce over time after hospital discharge.16.
Endotracheal tubes positioning detection in adult portable chest radiography for intensive care unit
Sheng Chen Min Zhang Liping Yao Wentao Xu 《International journal of computer assisted radiology and surgery》2016,11(11):2049-2057
Purpose
To present an automated method for detecting endotracheal (ET) tubes and marking their tips in portable chest radiography (CXR) for intensive care units (ICUs).Methods
In this method, the lung region is first estimated and then the spine is detected between the right lung and the left lung. Because medical tubes are inserted into the body through the throat, the region of interest (ROI) is obtained across the spine. A seed point is determined in the cervical region of the ROI, and then the line path is selected from the seed point. In order to detect ET tubes, the ICU CXR image is preprocessed by contrast-limited adaptive histogram equalization. Then, a feature-based threshold method is applied to the line path to determine the tip location. A comparison to the method by use of Hough transform is also presented. The distance (error) between the detected locations and the locations annotated by a radiologist is used to evaluate the detection precision for the tip location.Results
The proposed method is evaluated using 44 images with ET tubes and 43 images without ET tubes. The discriminant performance for detecting the existence of ET tubes in this study was 95 %, and the average of detection error for the tip location was approximately 2.5 mm.Conclusions
The proposed method could be useful for detecting malpositioned ET tubes in ICU CXRs.17.
Bertrand?Guidet Hans?Flaatten Ariane?Boumendil Alessandro?Morandi Finn?H.?Andersen Antonio?Artigas Guido?Bertolini Maurizio?Cecconi Steffen?Christensen Loredana?Faraldi Jesper?Fj?lner Christian?Jung Brian?Marsh Rui?Moreno Sandra?Oeyen Christina?Agwald??hman Bernardo?Bollen?Pinto Ivo?W.?Soliman Wojciech?Szczeklik Andreas?Valentin Ximena?Watson Tilemachos?Zafeiridis Dylan?W.?De?Lange 《Intensive care medicine》2018,44(7):1027-1038
Purpose
To document and analyse the decision to withhold or withdraw life-sustaining treatment (LST) in a population of very old patients admitted to the ICU.Methods
This prospective study included intensive care patients aged?≥?80 years in 309 ICUs from 21 European countries with 30-day mortality follow-up.Results
LST limitation was identified in 1356/5021 (27.2%) of patients: 15% had a withholding decision and 12.2% a withdrawal decision (including those with a previous withholding decision). Patients with LST limitation were older, more frail, more severely ill and less frequently electively admitted. Patients with withdrawal of LST were more frequently male and had a longer ICU length of stay. The ICU and 30-day mortality were, respectively, 29.1 and 53.1% in the withholding group and 82.2% and 93.1% in the withdrawal group. LST was less frequently limited in eastern and southern European countries than in northern Europe. The patient-independent factors associated with LST limitation were: acute ICU admission (OR 5.77, 95% CI 4.32–7.7), Clinical Frailty Scale (CFS) score (OR 2.08, 95% CI 1.78–2.42), increased age (each 5 years of increase in age had a OR of 1.22 (95% CI 1.12–1.34) and SOFA score [OR of 1.07 (95% CI 1.05–1.09 per point)]. The frequency of LST limitation was higher in countries with high GDP and was lower in religious countries.Conclusions
The most important patient variables associated with the instigation of LST limitation were acute admission, frailty, age, admission SOFA score and country.Trial registration
ClinicalTrials.gov (ID: NTC03134807).18.
Marie O. Collet Jesús Caballero Romain Sonneville Fernando A. Bozza Peter Nydahl Anna Schandl Hilden Wøien Giuseppe Citerio Mark van den Boogaard Johanna Hästbacka Matthias Haenggi Kirsten Colpaert Louise Rose Marija Barbateskovic Theis Lange Aksel Jensen Martin B. Krog Ingrid Egerod Helle L. Nibro Jørn Wetterslev Anders Perner the AID-ICU cohort study co-authors 《Intensive care medicine》2018,44(7):1081-1089
Purpose
We assessed the prevalence and variables associated with haloperidol use for delirium in ICU patients and explored any associations of haloperidol use with 90-day mortality.Methods
All acutely admitted, adult ICU patients were screened during a 2-week inception period. We followed the patient throughout their ICU stay and assessed 90-day mortality. We assessed patients and their variables in the first 24 and 72 h in ICU and studied their association together with that of ICU characteristics with haloperidol use.Results
We included 1260 patients from 99 ICUs in 13 countries. Delirium occurred in 314/1260 patients [25% (95% confidence interval 23–27)] of whom 145 received haloperidol [46% (41–52)]. Other interventions for delirium were benzodiazepines in 36% (31–42), dexmedetomidine in 21% (17–26), quetiapine in 19% (14–23) and olanzapine in 9% (6–12) of the patients with delirium. In the first 24 h in the ICU, all subtypes of delirium [hyperactive, adjusted odds ratio (aOR) 29.7 (12.9–74.5); mixed 10.0 (5.0–20.2); hypoactive 3.0 (1.2–6.7)] and circulatory support 2.7 (1.7–4.3) were associated with haloperidol use. At 72 h after ICU admission, circulatory support remained associated with subsequent use of haloperidol, aOR 2.6 (1.1–6.9). Haloperidol use within 0–24 h and within 0–72 h of ICU admission was not associated with 90-day mortality [aOR 1.2 (0.5–2.5); p?=?0.66] and [aOR 1.9 (1.0–3.9); p?=?0.07], respectively.Conclusions
In our study, haloperidol was the main pharmacological agent used for delirium in adult patients regardless of delirium subtype. Benzodiazepines, other anti-psychotics and dexmedetomidine were other frequently used agents. Haloperidol use was not statistically significantly associated with increased 90-day mortality.19.
Lara Hessels Niels Koopmans Antonio W. Gomes Neto Meint Volbeda Jacqueline Koeze Annemieke Oude Lansink-Hartgring Stephan J. Bakker Heleen M. Oudemans-van Straaten Maarten W. Nijsten 《Intensive care medicine》2018,44(10):1699-1708
Purpose
Patients with reduced muscle mass have a worse outcome, but muscle mass is difficult to quantify in the ICU. Urinary creatinine excretion (UCE) reflects muscle mass, but has not been studied in critically ill patients. We evaluated the relation of baseline UCE with short-term and long-term mortality in patients admitted to our ICU.Methods
Patients who stayed ≥?24 h in the ICU with UCE measured within 3 days of admission were included. We excluded patients who developed acute kidney injury stage 3 during the first week of ICU stay. As muscle mass is considerably higher in men than women, we used sex-stratified UCE quintiles. We assessed the relation of UCE with both in-hospital mortality and long-term mortality.Results
From 37,283 patients, 6151 patients with 11,198 UCE measurements were included. Mean UCE was 54% higher in males compared to females. In-hospital mortality was 17%, while at 5-year follow-up, 1299 (25%) patients had died. After adjustment for age, sex, estimated glomerular filtration rate, body mass index, reason for admission and disease severity, patients in the lowest UCE quintile had an increased in-hospital mortality compared to the patients in the highest UCE quintile (OR 2.56, 95% CI 1.96–3.34). For long-term mortality, the highest risk was also observed for patients in the lowest UCE quintile (HR 2.32, 95% CI 1.89–2.85), independent of confounders.Conclusions
In ICU patients without severe renal dysfunction, low urinary creatinine excretion is associated with short-term and long-term mortality, independent of age, sex, renal function and disease characteristics, underscoring the role of muscle mass as risk factor for mortality and UCE as relevant biomarker.20.
Catherina Lueck Michael Stadler Christian Koenecke Marius M. Hoeper Elke Dammann Andrea Schneider Jan T. Kielstein Arnold Ganser Matthias Eder Gernot Beutel 《Intensive care medicine》2018,44(9):1483-1492