59 740例住院糖尿病患者病死率及其危险因素

目的了解住院糖尿病患者的病死率,分析死亡相关因素。方法回顾分析1998~2009年北京某医院内分泌科住院糖尿病患者的资料,并分析不同性别、住院次数、住院时间以及糖尿病类型的病死率。结果59740例住院糖尿病患者中,死亡1283例,总体病死率为2.1%（男性2.2%,女性2.0%）。死亡组患者的人均住院次数和住院时间均大于存活组患者。不同类型的糖尿病患者的病死率也存在较明显差异。其中急性并发症糖尿病患者病死率2.8%,其次是2型糖尿病患者的病死率2.4%,病死率最低的是1型糖尿病患者（1.1%）。结论住院次数、住院时间及糖尿病类型反映患者病情严重程度,是住院糖尿病患者病死相关因素。     

The longer patients are in hospital before Intensive Care admission the higher their mortality

Objective To explore the relationship between hospital mortality and time spent by patients on hospital wards before admission to the intensive care unit (ICU).Design Observational study of prospectively collected data.Setting Participating intensive care units within the North East Thames Regional Database.Patients and participants Patients, 7,190, admitted to ICU from the hospital wards of 24 hospitals.Interventions None.Measurements and results Of ICU admissions from the wards, 40.1% were in hospital for more than 3 days and 11.7% for more than 15 days. ICU patients who died in hospital were in-patients longer (p=0.001) before admission (median 3 days; interquartile range 1–9) than those discharged alive (median 2 days; interquartile range 1–5). Hospital mortality increased significantly (p<0.0001) in relation to time on hospital wards before ICU: 47.1% (standardised mortality ratio 1.09) for patients in hospital 0–3 days before ICU admission up to 67.2% (standardised mortality ratio 1.39) for patients on the wards for more than 15 days before ICU. Length of stay before ICU admission was an independent predictor of hospital mortality (odds ratio per day 1.019; 95% confidence interval 1.014–1.024). There were significant differences (p<0.001) in patient age, APACHE II score and predicted mortality in relation to time on wards before ICU admission.Conclusions Mortality was high among patients admitted from the wards to ICU; many were inpatients for days or weeks before admission. The longer these patients were in hospital before ICU admission, the higher their mortality. Patients with delayed admission differed in some respects compared to those admitted earlier.Electronic Supplementary Material Supplementary material is available in the online version of this article at Preliminary analysis of this data was presented in abstract at the Intensive Care Society (UK) State of the Art Scientific Meeting in London, December 2001.     

Antipsychotic use and diagnosis of delirium in the intensive care unit

ABSTRACT: INTRODUCTION: Delirium is an independent risk factor for prolonged hospital length of stay (LOS) and increased mortality. Several antipsychotics have been studied for the treatment of intensive care unit (ICU) delirium that has led to a high variability in prescribing patterns for these medications. We hypothesize that in clinical practice the documentation of delirium is lower than the incidence of delirium reported in prospective clinical trials. The objective of this study was to document the incidence of delirium diagnosed in ICU patients and to describe the utilization of antipsychotics in the ICU. METHODS: This was a retrospective, observational, cohort study conducted at 71 United States academic medical centers that reported data to the University Health System Consortium Clinical Database/Resource Manager. It included all patients 18 years of age and older admitted to the hospital between 1 January 2010 and 30 June 2010 with at least one day in the ICU. RESULTS: Delirium was diagnosed in 6% (10,034 of 164,996) of hospitalizations with an ICU admission. Antipsychotics were administered to 11% (17,764 of 164,996) of patients. Of the antipsychotics studied, the most frequently used were haloperidol (62%; n = 10,958) and quetiapine (31%; n = 5,448). Delirium was associated with increased ICU LOS (5 vs. 3 days, P < 0.001) and hospital LOS (11 vs. 6 days, P < 0.001), but not in-hospital mortality (8% vs. 9%, P = 0.419). Antipsychotic exposure was associated with increased ICU LOS (8 vs. 3 days, P < 0.001), hospital LOS (14 vs. 5 days, P < 0.001) and mortality (12% vs. 8%, P < 0.001). Of patients with antipsychotic exposure in the ICU, absence of a documented mental disorder (32%, n = 5,760) was associated with increased ICU LOS (9 vs. 7 days, P < 0.001), hospital LOS (16 vs. 13 days, P < 0.001) and in-hospital mortality (19% vs. 9%, P < 0.001) compared to patients with a documented mental disorder (68%, n = 12,004). CONCLUSIONS: The incidence of documented delirium in ICU patients is lower than that documented in previous prospective studies with active screening. Antipsychotics are administered to 1 in every 10 ICU patients. When administration occurs in the absence of a documented mental disorder, antipsychotic use is associated with an even higher ICU and hospital LOS, as well as in-hospital mortality.     

Are readmissions to the intensive care unit a useful measure of hospital performance?

BACKGROUND: Although patients readmitted to intensive care units (ICUs) typically have poor outcomes, ICU readmission rates have not been studied as a measure of hospital performance. OBJECTIVES: To determine variation in ICU readmission rates across hospitals and associations of readmission rates with other ICU-based measures of hospital performance. RESEARCH DESIGN: Observational cohort study. SUBJECTS: One hundred three thousand nine hundred eighty four consecutive ICU patients who were admitted to twenty eight hospitals who were then transferred to a hospital ward in those 28 hospitals. MEASURES: Predicted risk of in-hospital death and ICU length of stay (LOS) were determined by a validated method based on age, ICU admission source, diagnosis, comorbidity, and physiologic abnormalities. Severity-adjusted mortality rates, LOS, and readmission rates were determined for each hospital. RESULTS: One or more ICU readmissions occurred in 5.8% patients who were initially classified as postoperative and in 6.4% patients who were initially classified as nonoperative. In-hospital mortality rate was 24.7% in patients who were readmitted as compared with 4.0% in other patients (P < 0.001). After adjusting for predicted risk of death, the odds of death remained 7.5 times higher (OR 7.5, 95% CI, 6.8-8.3). Readmitted patients also had longer (P < 0.001) ICU LOS (5.2 vs. 3.7 days) and hospital LOS (29.3 vs. 11.7 days). Severity-adjusted readmission rates varied across hospitals from 4.2% to 7.6%. Readmission rates were not correlated with severity-adjusted hospital mortality, ICU LOS, or hospital LOS. CONCLUSIONS: ICU patients who were subsequently readmitted have a higher risk of death and longer LOS after adjusting for severity of illness. However, readmission rates were not associated with severity-adjusted mortality or LOS. Those data indicate that ICU readmission may capture other aspects of hospital performance and may be complementary to these measures.     

Length of stay as a source of bias in comparing performance in VA and private sector facilities: lessons learned from a regional evaluation of intensive care outcomes

OBJECTIVES: Compare intensive care unit (ICU) mortality and length of stay (LOS) in a VA hospital and private sector hospitals and examine the impact of hospital utilization on mortality comparisons. RESEARCH DESIGN: Retrospective cohort study. SUBJECTS: Consecutive ICU admissions to a VA hospital (n = 1,142) and 27 private sector hospitals (n = 51,249) serving the same health care market in 1994 to 1995. MEASURES: Mortality and ICU LOS were adjusted for severity of illness using a validated method that considers physiologic data from the first 24 hours of ICU admission. Mortality comparisons were made using two different multivariable techniques. RESULTS: Unadjusted in-hospital mortality was higher in VA patients (14.5% vs. 12.0%; P = 0.01), as was hospital (28.3 vs. 11.3 days; P <0.001) and ICU (4.3 vs. 3.9 days; P <0.001) LOS. Using logistic regression to adjust for severity, the odds of death was similar in VA patients, relative to private sector patients (OR 1.16, 95% CI 0.93-1.44; P = 0.18). However, a higher proportion of VA deaths occurred after 21 hospital days (33% vs. 13%; P <0.001). Using proportional hazards regression and censoring patients at hospital discharge, the risk for death was lower in VA patients (hazard ratio 0.70; 95% CI 0.59-0.82; P <0.001). After adjusting for severity, differences in ICU LOS were no longer significant (P = 0.19). CONCLUSIONS: Severity-adjusted mortality in ICU patients was lower in a VA hospital than in private sector hospitals in the same health care market, based on proportional hazards regression. This finding differed from logistic regression analysis, in which mortality was similar, suggesting that comparisons of hospital mortality between systems with different hospital utilization patterns may be biased if LOS is not considered. If generalizable to other markets, our findings further suggest that ICU outcomes are at least similar in VA hospitals.     

Association between pre-intensive care unit (ICU) hospital length of stay and ICU outcomes in a resource-limited setting

Background Previous studies demonstrated higher mortality for patients with a longer pre-intensive care unit (ICU) hospital length of stay (LOS), in well-resourced settings. Objectives The study aimed to determine the association between pre-ICU hospital LOS and ICU outcomes in a resource-limited setting. We hypothesised that longer pre-ICU hospital LOS would be associated with higher ICU mortality. Methods This was a retrospective cohort study measuring the association between pre-ICU hospital LOS and ICU outcomes using data extracted from a regional hospital ICU in KwaZulu-Natal, South Africa. Consecutive ICU admissions of all patients (medical and surgical) older than 18 years were included during the study period September 2014 to August 2018. A corrected sample size of 2 040 patients was identified. Multivariable logistic regression was used to assess the primary outcome of ICU mortality, and multivariable Cox proportional hazard regression was used for the secondary outcome of ICU LOS. Results The median pre-ICU hospital LOS was 1 day (interquartile range (IQR) 0 - 2 days). The median length of ICU stay was 2.4 days (IQR 1.1 - 4.8 days) and the observed ICU mortality was 16% (n=327/2 040). Pre-ICU hospital LOS was not associated with ICU mortality in the unadjusted (odds ratio (OR) 1.00; 95% confidence interval (CI) 0.98 - 1.02; p=0.68; n=2 040) and fully adjusted logistic regression models (OR 1.00; 95% CI 0.98 - 1.03; p=0.90; n=1 981) using a complete case analysis for missing patient-level covariates. In Cox proportional hazard models, there was no association between pre-ICU hospital LOS and ICU LOS (hazard ratio 1.00; 95% CI 0.98 - 1.03; p=0.72; n=1 967), including when stratified by admission source. Conclusion Pre-ICU hospital LOS was not associated with either ICU mortality or ICU LOS in a resource-limited setting. Future studies should aim to include multicentre data and evaluate long-term outcomes. Contributions of the study The study was conducted in a resource-limited setting and found no association between prolonged LOS pre-ICU and patient outcomes. Several potential explanations for this observation have been explored. This important subject is pertinent to the appropriate use of limited resources and encourages future studies to evaluate this association and to consider longer-term outcomes (e.g. 30-day mortality) in future findings.     

Nursing home patients in the intensive care unit: Risk factors for mortality

OBJECTIVE: To determine intensive care unit (ICU) admission characteristics predictive of mortality among older nursing home residents. DESIGN: Retrospective cohort study. SETTING: A 725-bed teaching nursing home and two teaching-hospital ICUs. PATIENTS: One hundred twenty-three nursing home residents > or =75 yrs admitted to the ICU between July 1, 1999, and September 30, 2003. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Characteristics of nursing home residents admitted to the ICU were identified by medical record review at the nursing home and the hospital. Additionally, the minimum data set was used to calculate preadmission functional status using the Activities of Daily Living-Long Form (ADL-L) and cognitive status with the Cognitive Performance Scale (CPS). Our primary outcomes were hospital mortality and mortality within 90 days of ICU admission. The nursing home residents admitted to the ICU were old (87.7 +/- 5.4 yrs) with impaired cognition (CPS 2.8 +/- 1.7, range 0-6, where 6 = most impaired) and moderately dependent function (ADL-L 14.5 +/- 9.4, range 0-28, where 28 = total dependence). Of the 123 patients, 33 (27%) died in the hospital, whereas 90 (73%) survived to hospital discharge. Acute Physiology and Chronic Health Evaluation (APACHE) III score was independently associated with significantly increased odds of hospital mortality (adjusted odds ratio 1.04; 95% confidence interval 1.02, 1.07). Among the 90 patients who survived to return to the nursing home, 34 (37.8%) died within 90 days. Cox regression demonstrated that higher APACHE III score (adjusted risk ratio 1.02; 95% confidence interval 1.01, 1.04) and increasing functional dependency before ICU admission (adjusted risk ratio 1.6; 95% confidence interval 1.05, 2.57, per ADL-L quartile) were independently associated with increased mortality rate within 90 days. CONCLUSIONS: Among vulnerable elderly nursing home residents, higher APACHE III score is independently associated with increased hospital mortality rate and mortality within 90 days. Among hospital survivors, impaired functional status is independently associated with increased mortality rate within 90 days.     

High cost of trauma care in the elderly

Trauma in the elderly is a significant public health problem in terms of morbidity, mortality, and expenditure of health care resources. We compared injury severity score, length of stay, hospital charges, and mortality rate in a group of 60 elderly patients and a group of 60 younger patients admitted to our hospital. The older group had an average hospital stay that was more than four days longer, at an average hospital charge of $15,769.55, and their mortality rate was 15% versus 0% among the younger group. Despite early and aggressive care, the elderly continue to pose an important problem for trauma centers in terms of both length of stay and cost.     

Attributable cost of catheter-associated bloodstream infections among intensive care patients in a nonteaching hospital

OBJECTIVE: To determine the attributable cost and length of stay of intensive care unit (ICU)-acquired, catheter-associated bloodstream infections from a hospital-based cost perspective, after adjusting for potential confounders. DESIGN: Patients admitted to the ICU between January 19, 1998, and July 31, 2000, were observed prospectively for the occurrence of catheter-associated bloodstream infections. Hospital costs were obtained from the hospital cost accounting database. SETTING: The medical and surgical ICUs at a 500-bed suburban, tertiary care hospital. PATIENTS: Patients requiring central venous catheterization while in the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We measured occurrence of catheter-associated bloodstream infection, in-hospital mortality rate, total ICU and hospital lengths of stay, and total hospital costs. Catheter-associated bloodstream infection occurred in 41 of 1,132 patients (3.6 cases per 1000 catheter days). Patients with catheter-associated bloodstream infection had significantly higher unadjusted ICU length of stay (median, 24 vs. 5 days; p < .001), hospital length of stay (median, 45 vs. 11 days; p < .001), mortality rate (21 [51%] vs. 301 [28%], p = .001), and total hospital costs (83,544 dollars vs. 23,803 dollars, p < .001). Controlling for other factors that may affect costs and lengths of stay, catheter-associated bloodstream infections resulted in an attributable cost of 11,971 dollars (95% confidence interval, 6,732 dollars-18,352 dollars), ICU length of stay of 2.41 days (95% confidence interval, 0.08-3.09 days), and hospital length of stay of 7.54 days (95% confidence interval, 3.99-11.09 days). CONCLUSIONS: Patients with catheter-associated bloodstream infection had significantly longer ICU and hospital lengths of stay, with higher unadjusted total mortality rate and hospital cost compared with uninfected patients. After adjusting for underlying severity of illness, the attributable cost of catheter-associated bloodstream infection was approximately 11,971 dollars.     

Hospital volume and mortality for mechanical ventilation of medical and surgical patients: a population-based analysis using administrative data

OBJECTIVE: In an effort to improve efficiency and quality of care, regionalization of adult critical care services, similar to trauma and neonatal intensive care, has been suggested. However, there is little research to understand if hospitals with higher patient volumes have better outcomes. Our objective is to determine whether hospital volume is associated with improved survival for medical or surgical patients receiving mechanical ventilation. DESIGN: Population-based retrospective cohort study. SETTING: Province of Ontario, Canada. PATIENTS: A total of 13,846 medical and 6,373 surgical patients receiving mechanical ventilation for greater than two consecutive days between 1998 and 2000. INTERVENTIONS: None. MEASUREMENTS: Odds ratio for death within 30 days of initiation of mechanical ventilation was calculated in relation to hospital volume of ventilation. Estimates were adjusted for patient demographics, diagnoses, and urgency status; hospital region and rural location; and accounted for clustering within hospitals. MAIN RESULTS: There was no effect of volume on mortality for surgical patients. After adjustment for clustering, among medical patients, the lowest-volume category (<100 episodes/yr) had a nonsignificant increase in mortality, with an odds ratio (95% confidence interval) of 1.13 (0.87-1.47) compared with the highest-volume category (> or =700 episodes/yr). A post hoc analysis revealed that within the lowest-volume category, the proportion of patients transferred to larger hospitals was 81% for hospitals with <20 episodes/yr and only 32% for hospitals with 20-99 episodes/yr, with odds ratios (95% confidence interval) for mortality of 0.74 (0.49-1.12) and 1.18 (0.90-1.54), respectively, compared with the highest-volume category. CONCLUSIONS: For surgical patients requiring mechanical ventilation for >2 days, hospital volume had no effect on mortality. For medical patients, higher mortality may occur in a subgroup of low-volume hospitals that do not routinely transfer their patients to larger-volume facilities. This finding needs further investigation in a larger-sized study.     

Effect of interhospital transfer on resource utilization and outcomes at a tertiary care referral center

OBJECTIVE: Mortality and length of stay are two outcome variables commonly used as benchmarks in rating the performance of medical centers. Acceptance of transfer patients has been shown to affect both outcomes and the costs of health care. Our objective was to compare observed and predicted lengths of stay, observed and predicted mortality, and resource consumption between patients directly admitted and those transferred to the intensive care unit (ICU) of a large academic medical center. DESIGN: Observational cohort study. SETTING: Mixed medical/surgical ICU of a university hospital. PATIENTS: A total of 4,569 consecutive patients admitted to a tertiary care ICU from April 1, 1997, to March 30, 2000. INTERVENTIONS: None. MEASUREMENTS: Acute Physiology and Chronic Health Evaluation (APACHE) III score, actual and predicted ICU and hospital lengths of stay, actual and predicted ICU and hospital mortality, and costs per admission. MAIN RESULTS: Crude comparison of directly admitted and transfer patients revealed that transfer patients had significantly higher APACHE III scores (mean, 60.5 vs. 49.7, p < .001), ICU mortality (14% vs. 8%, p < .001), and hospital mortality (22% vs. 14%, p < .001). Transfer patients also had longer ICU lengths of stay (mean, 6.0 vs. 3.8 days, p < .001) and hospital lengths of stay (mean, 20 vs. 15.9 days, p < .001). Stratified by disease severity using the APACHE III model, there was no difference in either ICU or hospital mortality between the two populations. However, in the transfer group with the lowest predicted mortality of 0-20%, ICU and hospital lengths of stay were significantly higher. In crude cost analysis, transfer patients' costs were $9,600 higher per ICU admission compared with nontransfer patients (95% confidence interval, $6,000-$13,400). Risk stratification revealed that the higher per-patient cost was entirely confined to the transfer patients with the lowest predicted mortality. CONCLUSIONS: Patients transferred to a tertiary care ICU are generally more severely ill and consume more resources. However, they have similar adjusted mortality outcomes when compared with directly admitted patients. The difference in resource consumption is mainly attributable to the group of patients in the lowest predicted risk bracket.     

The clinical significance of Candida colonization of respiratory tract secretions in critically ill patients

PURPOSE: Clinical uncertainty exists regarding the significance of colonization confined to respiratory tract secretions with Candida sp in critically ill patients. Our objectives were to describe such colonization, its associated risk factors, and to examine the clinical outcomes in patients with a clinical suspicion of ventilator-associated pneumonia with isolated Candida colonization compared to those without. MATERIALS AND METHODS: In a retrospective analysis of the Canadian ventilator-associated pneumonia study, patients were divided into 2 groups according to the isolated presence or absence of Candida in the respiratory tract enrollment culture. We compared length of mechanical ventilation, intensive care unit and hospital stay, and mortality outcomes between groups. We used multiple logistic regression analysis to determine factors independently associated with Candida colonization and hospital mortality. RESULTS: Of the 639 eligible patients, 114 (17.8%) were colonized with Candida in the enrollment culture. A multivariate analysis identified female sex (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.02-2.65), number of comorbidities (OR, 1.35; 95% CI, 1.08-1.71), worsening or persistent infiltrate at randomization (OR, 1.92; 95% CI, 1.09-1.38), antibiotics started within 3 days of randomization (OR, 3.16; 95% CI, 1.71-5.83), and on antibiotics at randomization but all started more than 3 days before randomization (OR, 3.04; 95% CI, 1.68-5.50) as variables associated with Candida respiratory tract colonization. A significant increase in median hospital stay (59.9 vs 38.6 days, P = .006) and hospital mortality (34.2% vs 21.0%, P = .003) was observed in patients with Candida colonization. In a multivariate model, Candida colonization of the respiratory tract was independently associated with hospital mortality (OR, 2.47; 95% CI, 1.39-4.37). CONCLUSION: Respiratory tract Candida colonization is associated with worse clinical outcomes and is independently associated with increased hospital mortality. However, it is unclear whether Candida colonization is causally related to poor outcomes or whether it is a marker for increased morbidity and mortality.     

The effect of blood storage duration on in-hospital mortality: a randomized controlled pilot feasibility trial

BACKGROUND: Whether the duration of storage of blood has an impact on patient outcomes remains controversial. The objective was to determine feasibility of a comparative effectiveness trial to evaluate duration of storage of blood before transfusion on in‐hospital mortality. STUDY DESIGN AND METHODS: A single‐center randomized controlled trial was performed at an acute care hospital in Canada between June and December 2010, involving consecutive hospitalized patients needing blood transfusion. Patients (n = 910) were randomly assigned in a 1:2 ratio to receive freshest available versus standard‐issue (oldest available) blood. Four feasibility criteria were measured: proportion of eligible patients randomized, contrast in age of blood between treatment groups, real‐time data acquisition, and trial impact on blood outdating. In‐hospital mortality was also reported. RESULTS: A total of 1075 of 1129 patients (95.2%) were eligible and 910 of 1075 (84.7%) were randomized: 309 received freshest available blood (1157 units), and 601 received standard‐age blood (2369 units). Contrast in mean age of the oldest blood transfused between groups was 14.6 days: 12.0 (standard deviation [SD], 6.8) days in the fresh arm and 26.6 (SD, 7.8) days in the standard arm. Weekly recruitment and event reporting were achieved for all patients. The blood outdate rate was 0.10%. In‐hospital mortality was 10.5%: 35 deaths (11.3%) in the fresh arm and 61 deaths (10.1%) in the standard arm (odds ratio, 1.13; 95% confidence interval [CI], 0.73, 1.76). CONCLUSION: It is feasible to conduct a large comparative effectiveness trial comparing the effect of freshest available versus standard‐issue blood on in‐hospital mortality. The wide CI around the estimate for in‐hospital mortality supports the need for a large trial.     

整体护理在老年慢性心力衰竭患者中的临床应用

目的探讨整体护理在老年慢性心力衰竭患者中的临床应用,以提供适合老年患者的最佳护理。方法94例老年慢性心力衰竭患者随机分为观察组（60例）和对照组（34例）,观察组实施整体护理,对照组则进行常规护理,出院后定期随访,观察180d内慢性心衰复发再人院率、2次以上再入院率、病死率、护理服务满意度。结果180d内再入院率和2次以上再入院率观察组分别为32．0％和10．8％,对照组分别为58．2％和32．5％,两组比较差异有显著性意义（P〈0．05）;观察组的病死率、护理服务满意度分别为7．8％、91．2％,对照组分别为12．4％和52．6％（P〈0．05）。结论整体护理在老年慢性心力衰竭患者中的临床应用,更有利于老年慢性心力衰竭患者的治疗与康复,有助于减少慢性心衰的复发,提高患者的生活质量。     

小儿粘连性肠梗阻手术时机的选择

目的 探讨小儿粘连性肠梗阻治疗中手术时机的选择。方法 回顾性分析我院自1990年1月至2002年10月收治的187例小儿粘连性肠梗阻病例，结合献资料讨论其手术时机的选择问题。结果 非手术治疗小儿粘连性肠梗阻104例。手术治疗83例，急症手术56例，其中肠切除15例(26．8％)，死亡2例(3．6％)，平均住院11天；非手术治疗无效转手术治疗27例，其中肠切除10例(37．0％)，死亡2例(7．4％)，平均住院20天。结论 小儿粘连性肠梗阻非手术治疗无效应及时手术治疗。     

The association of nicotine replacement therapy with mortality in a medical intensive care unit

OBJECTIVE: Smokers admitted to the intensive care unit may receive nicotine replacement therapy to prevent withdrawal. However, the safety of nicotine replacement in the critically ill has not been studied. The objective of this study was to determine the impact of nicotine replacement on the outcome of critically ill patients. DESIGN: Retrospective, case-control. SETTING: The medical intensive care unit of a tertiary academic hospital. PATIENTS: Patients who were active smokers at admission to the intensive care unit were included in the study. Those who received nicotine replacement therapy were considered as cases, and those who did not receive nicotine replacement were considered as controls. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: For each of the 90 cases, one control smoker who did not receive nicotine replacement therapy was selected based on the severity of illness and then age. Outcome was measured by hospital mortality and 28-day intensive care unit-free days, defined as the number of days spent outside of intensive care or without mechanical ventilation by a living patient following admission to intensive care. The mean mortality rate predicted by the Acute Physiology and Chronic Health Evaluation III was 9.2% for the cases compared with 10.3% for the controls (p = .7127). The observed hospital mortality rate was 20% in the cases vs. 7% in the control group (p = .0085). When adjusted for the severity of illness and invasive mechanical ventilation, nicotine replacement therapy was independently associated with increased mortality (odds ratio, 24.6; 95% confidence interval, 3.6-167.6; p = .0011). The mean (sd) 28-day intensive care unit-free days were 20.7 (10.5) in the case group compared with 23.4 (7.1) in the control group (p = .0488). CONCLUSIONS: Our study shows that nicotine replacement therapy is associated with increased hospital mortality in critically ill patients. However, because of the limitations of the study, a future study based on a better case-control design is warranted.     

Weekend and weeknight admissions have the same outcome of weekday admissions to an intensive care unit with onsite intensivist coverage

OBJECTIVE: Several reports have indicated increased mortality for weekend and nighttime admissions to the intensive care unit. This increase has been attributed to differences in staffing levels. The impact of onsite 24-hr/7-day intensivist staffing on weekend and weeknight outcomes has not been examined before. The objective of this study was to determine whether weekend and nighttime admissions compromise patient outcome in an intensive care unit staffed by an onsite intensivist 24 hrs a day and 7 days a week. DESIGN: Cohort study. Setting: Tertiary care medical-surgical intensive care unit staffed 24 hrs/7 days by onsite consultant intensivists with predominantly North American Critical Care Board certifications. PATIENTS: We included all emergency admissions over 4 yrs (March 1999 to February 2003) from a prospectively collected intensive care unit database. Admissions were grouped into weekday, weeknight, and weekend admissions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Predicted mortality rates were calculated using Mortality Probability Models II0 and II24. The primary outcome was hospital mortality. Standardized mortality ratios were calculated. Secondary end points included intensive care unit mortality, duration of mechanical ventilation, intensive care unit length of stay, and the need for renal replacement therapy, tracheostomy, and pulmonary artery catheter during the intensive care unit course. A total of 2,093 admissions were included in the study, of which 31% were admitted on weekdays, 35% on weeknights, and 34% on weekends. The three groups were similar in baseline characteristics. There was no significant difference in hospital mortality rates among the three time periods (36%, 36%, and 37%, respectively, p=.90). There were also no significant differences in any of the secondary end points. CONCLUSIONS: In an intensive care unit staffed by onsite certified intensivists 24 hrs/7 days, we found no compromise in the care of patients admitted during weekends and weeknights. These findings suggest that such coverage helps in ensuring consistency of care and therefore represents a potentially improved model for intensive care unit practice.     

Subglottic Secretion Drainage for Preventing Ventilator Associated Pneumonia: A Meta-analysis

Objective:Ventilator associated pneumonia(VAP) has been shown to be associated with significant morbidity and mortality(Chastre and Fagon,2002;klompas,2007) among mechanically ventilated patients in the intensive care unit(ICU),with the incidence ranging from 9%to 21%;crude mortality ranges from 25%to 50%.A meta- analysis of published studies was undertaken to combine information regarding the effect of subglottic secretion drainage(SSD) on the incidence of ventilated associated pneumonia in adult ICU patients.Methods:Reports of studies on SSD were identified by searching the PUBMED,EMBASE,and COCHRANCE LIBRARY databases(December 30,2010).Randomized trials of SSD compared to usual care in adult mechanically ventilated ICU patients were included in this meta-analysis.Results:Ten RCTs with 2,314 patients were identified.SSD significantly reduced the incidence of VAP[relative risk(RR) = 0.52,95%confidence interval(CI):0.42- 0.64,P 0.000 01].When SSD was compared with the control groups,the overall RR for ICU mortality was 1.00(95%CI,0.84- 1.19) and for hospital mortality was 0.95(95%CI,0.80- 1.13).Overall,the subglottic drainage effect on the days of mechanical ventilation was-1.52 days(95%CI,-2.94 to-0.11) and on the ICU length of stay(LOS) was-0.81days(95%CI,-2.33 to-0.7).Conclusions:In this meta-analysis,when an endotracheal tube(ETT) with SSD was compared with an ETT without SSD,there was a highly significant reduction in the VAP rate of approximately 50%.Time on mechanical ventilation(MV) and the ICU LOS may be reduced,but no reduction in ICU or hospital mortality has been observed in published trials.     

Resuscitation of critically ill patients based on the results of gastric tonometry: a prospective, randomized, controlled trial

OBJECTIVE: To determine whether additional therapy aimed at correcting low gastric intramucosal pH (pHi) improves outcome in conventionally resuscitated, critically ill patients. DESIGN: Prospective, randomized, controlled study. SETTING: General intensive care unit (ICU) of a university teaching hospital. PATIENTS: A total of 210 adult patients, with a median Acute Physiology and Chronic Health Evaluation II score of 24 (range, 8-51). INTERVENTIONS: All patients were resuscitated according to standard guidelines. After resuscitation, those patients in the intervention group with a pHi of <7.35 were treated with additional colloid and then dobutamine (5 microg/kg/min then 10 microg/kg min) until 24 hrs after enrollment. MEASUREMENTS AND MAIN RESULTS: There were no significant differences (p > .05) in ICU mortality (39.6% in the control group vs. 38.5% in the intervention group), hospital mortality (45.3% in the control group vs. 42.3% in the intervention group), and 30-day mortality (43.7% in the control group vs. 40.2 in the intervention group); survival curves; median modified maximal multiorgan dysfunction score (10 points in the control group vs. 13 points in the intervention group); median modified duration of ICU stay (12 days in the control group vs. 11.5 days in the intervention group); or median modified duration of hospital stay (60 days in the control group vs. 42 days in the intervention group). A subgroup analysis of those patients with gastric mucosal pH of > or =7.35 at admission revealed no difference in ICU mortality (10.3% in the control group vs. 14.8% in the intervention group), hospital mortality (13.8% in the control group vs. 29.6% in the intervention group), or 30-day mortality (10.3% in the control group vs. 26.9% in the intervention group). CONCLUSIONS: The routine use of treatment titrated against pHi in the management of critically ill patients cannot be supported. Failure to improve outcome may be caused by an inability to produce a clinically significant change in pHi or because pHi is simply a marker of disease rather than a factor in the pathogenesis of multiorgan failure.     

Hospital mortality and resource use in subgroups of the Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) trial

OBJECTIVE: To compare differences in hospital mortality and resource use in adult severe sepsis subjects randomized to receive drotrecogin alfa (activated) (DrotAA) or placebo in the PROWESS trial. DESIGN: Retrospective, cross-sectional, blinded follow-up of subjects enrolled in a previous randomized, controlled trial. SETTING: One hundred sixty-four tertiary care institutions in 11 countries. PARTICIPANTS: The 1,690 subjects with severe sepsis enrolled and treated with study drug in PROWESS, of whom 1,220 were alive at 28 days (the end of the original PROWESS follow-up). INTERVENTIONS: DrotAA (n = 850), 24 microg/kg/hr for 96 hrs, or placebo (n = 840). MEASUREMENTS AND MAIN RESULTS: New follow-up data through hospital discharge were merged with existing 28-day follow-up data. Hospital mortality was calculated for designated subgroups. Intensive care unit and hospital length of stay and Simplified Therapeutic Intervention Scoring System-28 (TISS-28) scores were calculated overall and in designated subgroups. Hospital discharge location was recorded. The 95% confidence interval of most subgroups contained the relative risk estimate for overall 28-day and hospital mortality. Median hospital length of stay and intensive care unit length of stay were similar in both treatment groups: 16 vs. 17 days (p = .22) and 9 vs. 9 days (p = .7) for placebo vs. DrotAA. No significant difference in TISS-28 scores was observed between treatment groups overall or in subgroups of disease severity. In subjects for whom discharge destination was reported, 42.8% of placebo subjects and 46.8% of DrotAA subjects (two thirds of survivors in each group) were discharged directly to home. CONCLUSIONS: Reduction in hospital mortality with DrotAA in most of the subgroups of PROWESS is consistent with the reduction in 28-day and hospital mortality observed in the overall PROWESS population. Additional survivors created with DrotAA treatment did not increase per-patient resource use or intensive care unit or hospital length of stay.