Outcomes and prognostic factors in patients with head and neck cancer and severe acute illnesses

Objectives To evaluate the outcomes of patients with head and neck cancer and severe acute illnesses, and to identify characteristics associated with hospital mortality. Design Cohort study. Setting Ten-bed medical–surgical oncologic intensive care unit (ICU). Patients Consecutive patients admitted to the ICU over a 68-month period. Interventions None. Measurements and results Demographic, clinical and cancer-related data were collected. Multivariate logistic regression analysis was performed to identify predictive factors of hospital mortality. One hundred and twenty-one patients aged 63.3 ± 14.7 years were enrolled in the study. The main sites of primary tumor were oral cavity (30%), larynx (25%), pharynx (14%) and thyroid (9%). The main reasons for ICU admission were sepsis (37%) and acute respiratory failure (20%). The mean SAPS II score was 49.6 ± 17.8 points, and during ICU stay 100 (83%) patients received mechanical ventilation, 70 (58%), vasopressors, and 12 (10%), dialysis. The ICU, hospital and 6-month mortality rates were 39%, 56% and 72%, respectively. A performance status ≥ 2 [odds ratio (OR) = 5.17 (95% confidence interval, CI = 1.84–14.53)], advanced cancer (TNM stage IV) [OR = 3.80 (95% CI = 1.28–11.28)], and the number of organ failures [OR=2.87 (95% CI=1.83–4.50)] were associated with increased mortality in multivariate analysis. Conclusions In conjunction with clinical judgment and taking into consideration the patient's preferences and values, the knowledge of these outcome predictors may be useful in helping physicians to identify patients who might benefit from the intensive care and to improve discussions on patients' prognosis. This work was performed at the Intensive Care Unit, Instituto Nacional de Cancer, Rio de Janeiro, Brazil. This study is original and was not previously submitted to another primary scientific journal. Preliminary data were presented as a poster at the 2005 American Head & Neck Society Annual Meeting in Boca Raton, FL, USA, and at the 9th Congress of the World Federation of Intensive and Critical Care Medicine in Buenos Aires, Argentina, 27–31 August 2005. Financial support: Institutional departmental funds Conflicts of interest: None     

Incidence,risk factors and consequences of ICU delirium

Objective Delirium in the critically ill is reported in 11–80% of patients. We estimated the incidence of delirium using a validated scale in a large cohort of ICU patients and determined the associated risk factors and outcomes. Design and setting Prospective study in a 16-bed medical-surgical intensive care unit (ICU). Patients 820 consecutive patients admitted to ICU for more than 24 h. Interventions Tools used were: the Intensive Care Delirium Screening Checklist for delirium, Richmond Agitation and Sedation Scale for sedation, and Numerical Rating Scale for pain. Risk factors were evaluated with univariate and multivariate analysis, and factors influencing mortality were determined using Cox regression. Results Delirium occurred in 31.8% of 764 patients. Risk of delirium was independently associated with a history of hypertension (OR 1.88, 95% CI 1.3–2.6), alcoholism (2.03, 1.2–3.2), and severity of illness (1.25, 1.03–1.07 per 5-point increment in APACHE II score) but not with age or corticosteroid use. Sedatives and analgesics increased the risk of delirium when used to induce coma (OR 3.2, 95% CI 1.5–6.8), and not otherwise. Delirium was linked to longer ICU stay (11.5 ± 11.5 vs. 4.4 ± 3.9 days), longer hospital stay (18.2 ± 15.7 vs. 13.2 ± 19.4 days), higher ICU mortality (19.7% vs. 10.3%), and higher hospital mortality (26.7% vs. 21.4%). Conclusion Delirium is associated with a history of hypertension and alcoholism, higher APACHE II score, and with clinical effects of sedative and analgesic drugs. This article is discussed in the editorial available at:     

Incidence, risk factors, and outcome of aspiration pneumonitis in ICU overdose patients

Objective To assess the incidence and outcome of clinically significant aspiration pneumonitis in intensive care unit (ICU) overdose patients and to identify its predisposing factors.Design Retrospective cohort study.Setting Medical ICU of an academic tertiary care hospital.Patients A total of 273 consecutive overdose admissions.Measurements and results Clinically significant aspiration pneumonitis was defined as the occurrence of respiratory dysfunction in a patient with a localised infiltrate on chest X-ray within 72 h of admission. In our cohort we identified 47 patients (17%) with aspiration pneumonitis. Importantly, aspiration pneumonitis was associated with a higher incidence of cardiac arrest (6.4 vs 0.9%; p = 0.037) and an increased duration of both ICU stay and overall hospital stay [respectively: median 1 (interquartile range 1–3) vs 1 (1–2), p = 0.025; and median 2 (1–7) vs 1 (1–3), p < 0.001]. In multivariate logistic regression analysis, Glasgow Coma Scale (GCS) score [odds ratio (OR) for each point of GCS 0.8; 95% confidence interval (CI) 0.7–0.9; p = 0.001], ingestion of opiates (OR 4.5; 95% CI 1.7–11.6; p = 0.002), and white blood cell count (WBC) (OR for each increase in WBC of 10⁹/l 1.05; 95% CI 1.0–1.19; p = 0.049) were identified as independent risk factors.Conclusions Clinically relevant aspiration pneumonitis is a frequent complication in overdose patients admitted to the ICU. Moreover, aspiration pneumonitis is associated with a higher incidence of cardiac arrest and increased ICU and total in-hospital stay.     

A Bayesian decision-support system for diagnosing ventilator-associated pneumonia

Objective To determine the diagnostic performance of a Bayesian Decision-Support System (BDSS) for ventilator-associated pneumonia (VAP). Design A previously developed BDSS, automatically obtaining patient data from patient information systems, provides likelihood predictions of VAP. In a prospectively studied cohort of 872 ICU patients, VAP was diagnosed by two infectious-disease specialists using a decision tree (reference diagnosis). After internal validation daily BDSS predictions were compared with the reference diagnosis. For data analysis two approaches were pursued: using BDSS predictions (a) for all 9422 patient days, and (b) only for the 238 days with presumed respiratory tract infections (RTI) according to the responsible physicians. Measurements and results 157 (66%) of 238 days with presumed RTI fulfilled criteria for VAP. In approach (a), median daily BDSS likelihood predictions for days with and without VAP were 77% [Interquartile range (IQR) = 56–91%] and 14% [IQR 5–42%, p < 0.001, Mann–Whitney U-test (MWU)], respectively. In receiver operating characteristics (ROC) analysis, optimal BDSS cut-off point for VAP was 46%, and with this cut-off point positive predictive value (PPV) and negative predictive value (NPV) were 6.1 and 99.6%, respectively [AUC = 0.857 (95% CI 0.827–0.888)]. In approach (b), optimal cut-off for VAP was 78%, and with this cut-off point PPV and NPV were 86 and 66%, respectively [AUC = 0.846 (95% CI 0.794–0.899)]. Conclusions As compared with the reference diagnosis, the BDSS had good test characteristics for diagnosing VAP, and might become a useful tool for assisting ICU physicians, both for routinely daily assessment and in patients clinically suspected of having VAP. Empirical validation of its performance is now warranted. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Excess ICU mortality attributable to ventilator-associated pneumonia: The role of early vs late onset

Objective To determine the impact of ventilator-associated pneumonia (VAP) on ICU mortality, and whether it is related to time of onset of pneumonia. Design Prospective cohort study. Setting 16-bed medical-surgical ICU at a university-affiliated hospital. Patients and measurements From 2002 to 2003, we recorded patients receiving mechanical ventilation for > 72 h. Patients developing an infection other than VAP were excluded. Patients definitively diagnosed with VAP (n = 40) were cases and patients free of any infection acquired during ICU stay (n = 61) were controls. The VAP-attributed mortality was defined as the difference between observed mortality and predicted mortality (SAPS II) on admission. Results Mechanical ventilation was longer in VAP patients (25 ± 20 vs 11 ± 9 days; p < 0.001), as was ICU stay (33 ± 23 vs 14 ± 12 days; p < 0.001). In the non-VAP group, no difference was found between observed and predicted mortality (27.9 vs 27.4%; p > 0.2). In the VAP group, observed mortality was 45% and predicted mortality 26.5% (p < 0.001), with attributable mortality 18.5%, and relative risk (RR) 1.7 (95% CI 1.12–23.17). No difference was observed between observed and predicted mortality in early-onset VAP (27.3 vs 25.8%; p > 0.20); in late-onset VAP, observed mortality was higher (51.7 vs 26.7%; p < 0.01) with attributable mortality of 25% and an RR 1.9 (95% CI 1.26–2.63). Empiric antibiotic treatment was appropriate in 77.5% of episodes. No differences in mortality were related to treatment appropriateness. Conclusions In mechanically ventilated patients, VAP is associated with excess mortality, mostly restricted to late-onset VAP and despite appropriate antibiotic treatment.     

After-hours admissions are not associated with increased risk-adjusted mortality in pediatric intensive care

Objective To examine the influence of time of admission on risk-adjusted mortality and length of stay for nonelective patients admitted to a pediatric intensive care unit (ICU) without 24-h per day in-house intensivist coverage. Design Data analyzed came from a comprehensive, prospectively collected ICU database. Setting A 12-bed pediatric ICU located in a university-affiliated tertiary referral children's hospital. Patients Subjects consisted of 4,456 consecutive nonelective patients admitted over a 10-year period (1997–2006). Interventions None. Measurements and results Patients were categorized according to time of admission to the ICU as either in-hours (0800–1800 Monday–Friday and 0800–1200 on weekends), when an intensivist is present in the ICU, or after-hours (all other times), when intensivists attend only on an as-needed basis. Multivariate logistic regression was used to assess the effect of time of admission on outcome after adjustment for severity of illness using the Paediatric Index of Mortality (PIM). Patients admitted after hours had a lower risk-adjusted mortality than those admitted during normal working hours, with an odds ratio for death of 0.712 (95% confidence interval 0.518–0.980, p = 0.037). Length of stay was also significantly shorter for patients admitted after hours (44.05 h vs. 50.0 h, p = 0.001). Conclusions A lack of in-house intensivist presence is not associated with any increase in mortality or length of stay for patients admitted to our pediatric ICU; on the contrary, after-hours admission in this cohort was associated with a decreased risk-adjusted mortality and a shorter length of stay.     

Ultrasonographic identification and semiquantitative assessment of unloculated pleural effusions in critically ill patients by residents after a focused training

Purpose

Chest ultrasonography is currently a required element to achieve competence in general critical care ultrasound (GCCUS) which should be part of the training of every intensivist. We sought to assess the ability of resident novices in ultrasonography to identify and quantify unloculated pleural effusions in ICU patients after a limited training program.

Methods

A total of 147 patients (mean age, 62 ± 17 years; simplified acute physiology score II, 35 ± 15; 78 % ventilated) with a suspected pleural effusion underwent a thoracic ultrasonography performed successively by a recently trained resident novice in ultrasound and by an experienced intensivist with expertise in GCCUS, considered as reference. Ultrasonographic examinations were performed randomly and independently. In the presence of a pleural effusion, the maximal interpleural distance was measured at the thoracic base.

Results

Residents performed a mean of 15 ± 9 examinations. Agreement between residents and experienced intensivists for the diagnosis of left- and right-sided pleural effusions was good to excellent [kappa 0.74 (95 % CI 0.63–0.85) and 0.86 (95 % CI 0.78–0.94), respectively)]. Agreement for the measurement of left and right maximal interpleural distance was excellent (intraclass concordance coefficient, 0.86 [95 % CI 0.77–0.91] and 0.85 [95 % CI 0.75–0.90], respectively). Mean bias for left and right interpleural distance was ?0.3 mm (95 % CI ?2.4, 1.8 mm) and ?1.2 mm (95 % CI ?3.4, 1.1 mm), respectively.

Conclusions

After a focused training program, resident novices in ultrasound identify and quantify unloculated pleural effusions in ICU patients using chest ultrasonography with a good agreement with experts.     

Validation of the SAPS 3 admission prognostic model in patients with cancer in need of intensive care

Objectives To validate the SAPS 3 admission prognostic model in patients with cancer admitted to the intensive care unit (ICU).Design Cohort study.Setting Ten-bed medical–surgical oncologic ICU.Patients and participants Nine hundred and fifty-two consecutive patients admitted over a 3-year period.Interventions None.Measurements and results Data were prospectively collected at admission of ICU. SAPS II and SAPS 3 scores with respective estimated mortality rates were calculated. Discrimination was assessed by area under receiver operating characteristic (AUROC) curves and calibration by Hosmer–Lemeshow goodness-of-fit test. The mean age was 58.3 ± 23.1 years; there were 471 (49%) scheduled surgical, 348 (37%) medical and 133 (14%) emergency surgical patients. ICU and hospital mortality rates were 24.6% and 33.5%, respectively. The mean SAPS 3 and SAPS II scores were 52.3 ± 18.5 points and 35.3 ± 20.7 points, respectively. All prognostic models showed excellent discrimination (AUROC ≥ 0.8). The calibration of SAPS II was poor (p < 0.001). However, the calibration of standard SAPS 3 and its customized equation for Central and South American (CSA) countries were appropriate (p > 0.05). SAPS II and standard SAPS 3 prognostic models tended somewhat to underestimate the observed mortality (SMR > 1). However, when the customized equation was used, the estimated mortality was closer to the observed mortality [SMR = 0.95 (95% CI = 0.84–1.07)]. Similar results were observed when scheduled surgical patients were excluded.Conclusions The SAPS 3 admission prognostic model at ICU admission, in particular its customized equation for CSA, was accurate in our cohort of critically ill patients with cancer.This work was performed at the Intensive Care Unit, Instituto Nacional de Cancer, Rio de Janeiro, Brazil. Financial support: institutional departmental funds. Conflicts of interest: none.     

Atrial fibrillation in trauma patients requiring intensive care

Objectives To evaluate the incidence and risk factors of atrial fibrillation (AF) in trauma patients. Design and setting Prospective observational study in a surgical intensive care unit (ICU). Patients All trauma patients admitted in the surgical ICU except those who had AF at admission. Measurements and results AF occurred in 16/293 patients (5.5%). AF patients were older, had a higher number of regions traumatized, and received more fluid therapy, transfusion products, and catecholamines. They more frequently experienced systemic inflammatory response syndrome, sepsis, shock, and acute renal failure and had higher scores of severity (Simplified Acute Physiology Score, SAPS II; Injury Severity Score). ICU length of stay and resources use were also increased. ICU and hospital mortality rates were twice higher in AF patients whereas standardized mortality ratio (observed/expected mortality by SAPS II) was similar in the two groups. We found five independent risk factors of developing AF: catecholamine use (OR = 5.7, 95% CI 1.7–19.1), SAPS II of 30 or higher (OR = 11.6, 95% CI 1.3–103.0), three or more regions traumatized (OR = 6.2, 95% CI 1.8–21.4), age 40 years or higher (OR = 6.3, CI 1.4–28.7), and systemic inflammatory response syndrome (OR = 4.4, 95% CI 1.2–16.1). Conclusions In addition to age and catecholamine use, inflammation and severity of injury may be involved in the development of AF in trauma patients. Our results suggest that AF could rather be a marker of a higher severity of illness without major effect on mortality. This article is discussed in the editorial available at: .     

Workplace NO and NO2 during combined treatment of infants with nasal CPAP and NO

Objective To determine the workplace concentrations of NO and NO₂ in and around a paediatric incubator during inhaled NO (iNO) treatment and during an accidental emptying of NO cylinders into room air.Design We simulated iNO–nasal CPAP treatment in order to assess the impact on the occupational environment. Furthermore, two full NO cylinders for therapy, 1,000 ppm, 20 litres, 150 bar and 400 ppm, 10 litres, 150 bar, were emptied as rapidly as possible into an intensive care unit (ICU) room.Setting University hospital ICU.Measurements and results To correctly gauge the contribution from iNO–CPAP we constructed a system measuring breathing zone and room ventilation inlet-outlet values during a 10-ppm iNO treatment of a simulated infant. Maximal breathing zone values were 17.9 ± 7.0 (mean ± 95% CI) ppb for NO and 25.2 ± 4.8 ppb for NO_2. If room inlet values were subtracted, the contributions to breathing zone values emanating from iNO–CPAP were 14.8 ± 4.6 ppb for NO and 14.6 ± 4.6 ppb for NO₂. At the ventilation outlet the maximal contributions were 4.2 ± 2.9 ppb NO and 9.6 ± 4.3 ppb NO₂. During rapid total release of a gas cylinder in the ICU room, simulating an accident, we found transient NO levels comparable to the high therapeutic dosing range, but only low NO₂ levels.Conclusions Neither 8-h time-weighted average (TWA) nor 15 min short-term exposure limits (STEL) were exceeded during normal operation or during a simulated accident. The contribution of nitrogen oxides from treatment to workplace air were minor compared to those from ambient air.     

Junctional ectopic tachycardia after surgery for congenital heart disease in children

Objective To determine incidence, predictors and outcome [intensive care unit (ICU) mortality and length of stay (LOS)] after postoperative junctional ectopic tachycardia (JET) in an unselected paediatric population. Design Patients with JET (n = 89) were compared with non-JET controls (n = 178) in a nested case–control study. Setting Tertiary ICU at Skejby Sygehus, Aarhus University Hospital, Denmark. Patients The patient records of all children (n = 874) who underwent corrective cardiac surgery on cardio-pulmonary bypass (CPB) between 1998 and 2005 were reviewed for postoperative JET. Methods and results The association between JET and its potential predictors was examined with multivariate conditional regression analyses. The overall incidence of JET was 10.2%. CPB duration > 90 min [adjusted odds ratio (OR) 2.6; 95% confidence interval (CI) 1.1–6.5], high inotropic requirements (adjusted OR 2.6; CI 1.2–5.9) and high postoperative levels of creatine kinase (CK)-MB (adjusted OR 3.1; CI 1.3–7.1) were associated with an increased risk of JET. ICU mortality was higher for patients with JET (13.5%; CI 7.2–22.4%) than for controls (1.7%; CI 0.3–4.8%), and LOS in ICU was 3 times higher in JET patients (median 2 vs. 7 days, p < 0.001). Conclusions JET occurred in approximately 10% of children following cardiac surgery and was associated with higher mortality and longer ICU stay. Risk factors included high inotropic requirements after surgery and extensive myocardial injury in terms of high CK-MB values and longer CPB duration.     

Mean glucose level is not an independent risk factor for mortality in mixed ICU patients

Objective To find out if there is an association between hyperglycaemia and mortality in mixed ICU patients. Design and setting Retrospective cohort study over a 2-year period at the medical ICU of a university hospital. Measurements Admission glucose, maximum and mean glucose, length of stay, mortality, insulin therapy and Apache-II score. Results In 1085 consecutive patients, ICU- and hospital mortality were 20 and 25%, respectively. The total number of blood glucose measurements was 10.012. Admission glucose was 7.9 ± 4.5 mmol/l (mean ± SD), mean glucose 7.5 ± 2.9 and maximum glucose 10.0 ± 5.4 mmol/l. Median ICU length of stay (LOS) was 3.0 days (range 2.0–6.0 days, IQR), and hospital LOS was 16 days (range 7–32 days). In 28% of patients insulin treatment was started. Median Apache-II score was 13. 68% of patients were mechanically ventilated. Univariate analysis showed an association with ICU mortality for mean glucose (non-survivors 8.6 ± 4.3 vs 7.2 ± 2.4 survivors), maximum glucose (11.7 ± 5.9 vs 9.6 ± 5.2, non-survivors vs survivors, respectively), use of insulin (mortality 29 vs 17% in patients not using insulin) and age (61 vs 55.7 years). Gender and a history of diabetes mellitus were not associated with mortality. In a multivariate model, the Apache-II score was the only variable associated with mortality independent of other variables, including mean blood glucose. Conclusion In this retrospective study mean glucose level was not an independent risk factor for mortality in mixed ICU patients.     

Validation of a skills assessment scoring system for transesophageal echocardiographic monitoring of hemodynamics

Objective Transesophageal echocardiography (TEE) is increasingly used in hemodynamic monitoring in the intensive care unit. This paper describes and validates a scoring system for assessing competence in TEE performed by intensivists for this indication. Design Prospective study over an 18-month period. Settings Two medical intensive care units. Methods The scoring system is used to assess four aspects of TEE: quality of the views (score out of 14); semiquantitative evaluation of respiratory variations in the superior vena cava, valve regurgitation, size of the right ventricle (score out of 10); accuracy of measurement of velocity-time integrals for pulmonary and aortic flow, peak velocity of the E and A waves of mitral flow, left ventricular fractional area change (score out of 8); summary and proposed treatment (score out of 8). The scoring system was validated by using it to assess intensivists after 1 month (M1), 3 months (M3) and 6 months (M6) of training. TEE was done on a mechanically ventilated, hypotensive patient and scored by comparing the intensivist's examination with that of the expert examiner. The intensivists were divided into two groups of theoretical expertise at the start of training. Results Nineteen intensivists were evaluated. The scores at M1 for level 0 (no experience in echocardiography) and level 1 (previous experience) were, respectively, 18.5 ± 4 and 24.7 ± 5. The scores at M1, M3, and M6 were, respectively, 20.4 ± 5, 30.4 ± 5 and 35.7 ± 3. At M6, the intensivists had performed TEE 29 ± 10 times. Conclusion The scoring system was discriminatory and sensitive to change, and could be used as a tool to assess an intensivist's mastery of TEE. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users. This article is discussed in the editorial available at: .     

Predictors of early recovery of health status after intensive care

Objective 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).Design and setting Prospective international multicentre study in 19 ICUs participating in the HRQOL substudy of the SAPS 3 project.Intervention 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.Patients Six hundred and eighteen patients who spent > 24 h in an ICU and survived for 90 days. EQ data and health comparison were available in 559 (90.5%) of them.Measurements and results 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 ≥ 2 mg/dl, pH ≤ 7.25 and metastatic cancer.Conclusions 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.Electronic supplementary material Supplementary material is available in the online version of this article at and is accessible for authorized users.The authors wrote this article on behalf of the SAPS 3 Investigators.     

Treatment of severe acute respiratory distress syndrome: role of extracorporeal gas exchange

Objective To evaluate the effect of extracorporeal gas exchange (ECMO) on mortality of patients referred with severe acute respiratory distress syndrome (ARDS).Design and setting Prospective observational study in a university hospital ICU.Patients 150 patients with severe ARDS.Interventions Multimodal treatment with and without ECMO.Measurements and main results We treated 118 patients (78.7%) conservatively and 32 patients with ECMO. Patients in the ECMO group presented with significantly more severe disease (lung injury score 3.8 ± 0.3 vs. 3.3 ± 0.4; SOFA score 52 ± 14 vs. 43 ± 12; and SAPS score 14 ± 3.3 vs. 10 ± 3.5). Mortality in ECMO-treated patients tended to be higher than that with conservative treatment (46.9% vs. 28.8%, p = 0.059). Multivariate logistic regression analyses with backward selection excluded ECMO as predictor of mortality (p = 0.79). Independent predictors of mortality were age (odds ratio 1.044, 95% confidence interval 1.014–1.075, p = 0.004), mean pulmonary artery pressure (1.082, 1.026–1.141, p = 0.036), sequential organ failure assessment score (1.148, 1.018–1.294, p = 0.024), and days of mechanical ventilation prior to referral (1.064, 1.008–1.123, p = 0.025).Conclusion ECMO treatment does not predict mortality in patients with most severe ARDS.     

Should dialysis be offered to cancer patients with acute kidney injury?

Objectives Cancer patients are at high risk for acute kidney injury (AKI), which is associated with high mortality when renal replacement therapy is required. Because physicians might be reluctant to offer dialysis to patients with malignancies, we sought to appraise outcomes in critically ill cancer patients (mainly with hematological malignancies) who received renal replacement therapy for AKI complicating cancer management. Design Cohort study including consecutive patients who received renal replacement therapy for AKI complicating cancer management, over a 42-month period. Their mortality was compared with that of non-cancer patients who received renal replacement therapy in the same center over the same study period (control group). Setting A 12-bed medical intensive care unit in a university hospital. Results 94 critically-ill cancer patients met the inclusion criteria. Median SAPS II was 53 (IQR 40–75) and median Logistic Organ Dysfunction score was 7 (IQR 5–10). The etiology of AKI was multiple in most patients (248 identified factors in 93 patients). Hospital mortality was 51.1%. Two variables were independently associated with hospital mortality: the severity of associated organ failures at ICU admission (OR, 1.33; 95% CI, 1.11–1.59; per point) and renal function deterioration after ICU admission (OR, 5.42; 95% CI, 1.62–18.11). Characteristics of the malignancy were not associated with hospital mortality. The presence of cancer had no detectable influence on hospital mortality after adjustment for gender, age, acute severity as assessed by the SAPS II score, and chronic health status [OR 1.2, 95% CI 0.63–2.27; p = 0.57]. Conclusion ICU admission should be considered in selected critically ill cancer patients with AKI requiring renal replacement therapy.     

Epidemiology of sepsis in Germany: results from a national prospective multicenter study

Objective To determine the prevalence and mortality of ICU patients with severe sepsis in Germany, with consideration of hospital size. Design Prospective, observational, cross-sectional 1-day point-prevalence study. Setting 454 ICUs from a representative nationwide sample of 310 hospitals stratified by size. Data were collected via 1-day on-site audits by trained external study physicians. Visits were randomly distributed over 1 year (2003). Patients Inflammatory response of all ICU patients was assessed using the ACCP/SCCM consensus conference criteria. Patients with severe sepsis were followed up after 3 months for hospital mortality and length of ICU stay. Measurements and results Main outcome measures were prevalence and mortality. A total of 3,877 patients were screened. Prevalence was 12.4% (95% CI, 10.9–13.8%) for sepsis and 11.0% (95% CI, 9.7–12.2%) for severe sepsis including septic shock. The ICU and hospital mortality of patients with severe sepsis was 48.4 and 55.2%, respectively, without significant differences between hospital size. Prevalence and mean length of ICU stay of patients with severe sepsis were significantly higher in larger hospitals and universities (≤ 200 beds: 6% and 11.5 days, universities: 19% and 19.2 days, respectively). Conclusions The expected number of newly diagnosed cases with severe sepsis in Germany amounts to 76–110 per 100,000 adult inhabitants. To allow better comparison between countries, future epidemiological studies should use standardized study methodologies with respect to sepsis definitions, hospital size, and daily and monthly variability. The named authors wrote this article on behalf of the German Competence Network Sepsis (SepNet) C. Engel and F. M. Brunkhorst contributed equally to this work     

Influence of an acute increase in systemic vascular resistance on transpulmonary thermodilution-derived parameters in critically ill patients

Objective The transpulmonary thermodilution technique enables measurement of cardiac index (CI), intrathoracic blood volume (ITBV), global end-diastolic volume (GEDV), and extravascular lung water (EVLW). In this study, we analyzed the robustness of this technique during an acute increase in systemic vascular resistance (SVR). Design Prospective, clinical study. Setting Surgical intensive care unit in a university hospital. Patients and methods Twenty-four mechanically ventilated septic shock patients, who for clinical indications underwent extended hemodynamic monitoring by transpulmonary thermodilution and continuously received norepinephrine. Interventions and main results After baseline measurements, mean arterial pressure was increased briefly by increasing norepinephrine dosage and hemodynamic measurements were repeated before a control measurement was obtained. At each time point, 15 cc of 0.9% saline (< 8 °C) was administered by central venous injection in triplicate. Fluid status and respirator adjustments were kept constant. ANOVA with an all-pairwise comparison method was used for statistical analysis. Heart rate, central venous pressure, and EVLW remained constant throughout, while SVR significantly changed from 551 ± 106 to 746 ± 91 dyn*s*cm⁻⁵ and again to 566 ± 138 dyn*s*cm⁻⁵ (p < 0.05). However, CI and central blood volumes showed a reversible significant increase, i.e., ITBV went from 816 ± 203 to 867 ± 195 ml/m² and then to 821 ± 205 ml/m² and GEDV from 703 ± 178 to 747 ± 175 ml/m² and finally to 704 ± 170 ml/m², respectively. In eight patients, 2-D echocardiography was applied and revealed a reversible increase in left-ventricular end-diastolic area. Conclusion An acute increase in SVR by increasing norepinephrine dosage results in a reversible increase in central blood volumes (ITBV, GEDV) as measured by transpulmonary thermodilution and supported by echocardiography. This work was presented in part at the 19th annual meeting of the European Society of Intensive Care Medicine, 24–27 September 2006, Barcelona. Samir Sakka has received fees from Pulsion Medical Systems AG, Munich, Germany, for giving lectures.     

Urinary biomarker of oxidative stress correlating with outcome in critically septic patients

Objective To determine whether urinary 8-hydroxy-2′-deoxyguanosine (8-OHdG), an in vivo parameter of oxidative stress, is correlated with the outcome of critically septic patients. Design and setting Clinical outcome study in an adult medical intensive care unit (ICU). Patients 85 consecutive septic patients (59 men, 26 women). Measurements and results Patient characteristics and the clinical course were examined. Urinary 8-OHdG was analyzed using isotope-dilution liquid chromatography with tandem mass spectrometry (LC/MS/MS). ICU mortality was 25.9% (22/85) and hospital mortality 38.8% (33/85). Survivors' APACHE II scores on days 1 and 3 and the difference between them differed significantly from those of nonsurvivors (day 1, 21.0 ± 7.1 vs. 25.9 ± 8.0; day 3, 15.0 ± 5.8 vs. 23.2 ± 8.3; difference, 6.0 ± 5.5 vs. 1.7 ± 6.6). Urinary 8-OHdG was significantly lower in survivors than in nonsurvivors on day 1 (1.8 ± 2.4 vs. 3.0 ± 2.4). The area under receiver operating characteristic curve analysis for the association between day 1 urinary 8-OHdG and ICU mortality was 0.71. The comparison performed upon discharge from hospital revealed similar results. Conclusions This is a preliminary study. Excretion of urinary 8-OHdG, as measured using isotope-dilution LC/MS/MS, and the APACHE II score were correlated with the outcome of critically septic patients in medical ICU.     

Impact of piperacillin resistance on the outcome of Pseudomonas ventilator-associated pneumonia

Background The impact of antibiotic resistance on the outcome of infections due to Gram-negative bacilli, especially Pseudomonas, remains highly controversial.Study objective, design, and patients We evaluated the impact of piperacillin resistance on the outcomes of Pseudomonas aeruginosa ventilator-associated pneumonia (VAP) for patients who had received appropriate empiric antibiotics before enrollment in the PNEUMA trial, a multicenter randomized study comparing 8 vs 15 days of antibiotics.Results Despite similar characteristics at intensive care unit (ICU) admission, patients infected with piperacillin-resistant Pseudomonas strains were more acutely ill at VAP onset and had a higher 28-day mortality rate (37 vs 19%; P = 0.04) than those with piperacillin-susceptible Pseudomonas VAP. Factors associated with 28-day mortality retained by multivariable analysis were: age (OR: 1.07; 95% CI: 1.03–1.12); female gender (OR: 4.00; 95% CI: 1.41–11.11); severe underlying comorbidities (OR: 2.73; 95% CI: 1.02–7.33); and SOFA score (OR: 1.17; 95% CI: 1.03–1.32), but piperacillin resistance did not reach statistical significance (OR: 2.00; 95% CI: 0.72–5.61). The VAP recurrence rates, either superinfection or relapse, and durations of mechanical ventilation and ICU stay did not differ as a function of Pseudomonas-resistance status.Conclusions For patients with Pseudomonas VAP benefiting from appropriate empiric antibiotics, piperacillin resistance was associated with increased disease severity at VAP onset and higher 28-day crude mortality; however, after controlling for confounders, piperacillin-resistance was no longer significantly associated with 28-day mortality. The VAP recurrence rates and durations of ICU stay and mechanical ventilation did not differ for susceptible and resistant strains.