Relationship between height and outcomes among critically ill adults: a cohort study

Purpose

Many diagnostic and therapeutic interventions for critically ill adult patients are not performed according to patient size, but are standardized for an idealized 174-cm man (ideal body weight 70 kg). This study aims to determine whether critically ill patients with heights significantly different from a standardized patient have higher hospital mortality or greater resource utilization.

Methods

Retrospective cohort study of consecutive patients admitted to 210 intensive care units (ICUs) in the United Kingdom participating in the Intensive Care National Audit and Research Centre’s Case Mix Programme Database from April 1, 2009, to March 31, 2015. Primary outcome was hospital mortality, adjusted for age, comorbid disease, severity of illness, socioeconomic status and body mass index, using hierarchical modeling to account for clustering by ICU. Data were stratified by sex, and the effect of height was modeled continuously using restricted cubic splines.

Results

The cohort included 233,308 men and 184,070 women, with overall hospital mortality of 22.5% and 20.6%, respectively. After adjustment for potential confounders, hospital mortality decreased with increasing height; predicted mortality (holding all other covariates at their mean value) decreased from 24.1 to 17.1% for women and from 29.2 to 21.0% for men across the range of heights. Similar patterns were observed for ICU mortality and several additional secondary outcomes.

Conclusions

Short stature may be a risk factor for mortality in critically ill patients. Further work is needed to determine which unmeasured patient characteristics and processes of care may contribute to the increased risk observed.

     

Bioavailability of fondaparinux to critically ill patients

Introduction

Venous thromboembolism is a common problem in the intensive care unit (ICU). To decrease its incidence, prophylactic pharmacologic interventions are part of the ICU routine. However, common ICU conditions may impair the bioavailability of subcutaneously administered agents. The present study evaluates the bioavailability of prophylactic subcutaneous fondaparinux to critically ill patients.

Purpose

The purpose of the study was to evaluate vasopressor effect on the bioavailability of subcutaneously administered fondaparinux.

Materials and Methods

A 2-center, prospective, observational study was performed. Forty patients were enrolled and divided into 2 groups depending on their vasopressor requirements. All subjects were critically ill patients admitted to a medical ICU for an anticipated stay of more than 72 hours.

Interventions

All patients received subcutaneous fondaparinux 2.5 mg/d, and serum anti-Xa factor was serially assessed during the first 100 hours of medical ICU stay.

Results

Therapeutic anti–factor Xa levels among patients receiving vasopressors were observed. In hemodynamically normal patients, subtherapeutic concentrations were detected during the first 48 hours of fondaparinux administration.

Conclusions

Vasopressor therapy does not appear to affect fondaparinux bioavailability or to reduce anti–factor Xa levels. Subtherapeutic concentrations were detected during the first 48 hours of fondaparinux administration in hemodynamically stable patients. The clinical significance of reduced levels during the first 2 days of fondaparinux administration remains unknown.     

Elevated asymmetric dimethylarginine levels predict short- and long-term mortality risk in critically ill patients

Objective

Serum concentrations of asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase, may contribute to endothelial dysfunction and organ failure in sepsis. We aimed at investigating ADMA levels as a potential diagnostic or prognostic biomarker in critically ill patients.

Methods

Two hundred fifty-five patients (164 with sepsis, 91 without sepsis) were studied prospectively upon admission to the medical intensive care unit (ICU) and on day 7, in comparison to 78 healthy controls. ADMA serum concentrations were correlated with clinical data and extensive laboratory parameters. Patients’ survival was followed up for up to 3 years.

Results

ADMA serum levels were significantly elevated in critically ill patients at admission compared to controls. ADMA levels did not differ between patients with or without sepsis, but were closely related to hepatic and renal dysfunction, metabolism and clinical scores of disease severity. ADMA levels further increased during the first week of ICU treatment. ADMA serum levels at admission were an independent prognostic biomarker in critically ill patients not only for short-term mortality at the ICU, but also for unfavorable long-term survival.

Conclusion

Serum ADMA concentrations are significantly elevated in critically ill patients, associated with organ failure and related to short- and long-term mortality risk.     

Stress hyperglycemia may not be harmful in critically ill patients with sepsis

Background

Stress hyperglycemia (SH) is commonly seen in critically ill patients. It has been shown to be associated with adverse outcomes in some groups of patients. The effects of SH on critically ill patients with sepsis have not been well studied. We aimed to evaluate the effects of SH in critically ill patients with sepsis.

Methods

In this retrospective study, patients with sepsis admitted to intensive care unit (ICU) over a 5-year period were included.

Results

Of 297 patients, 204 (68.7%) had SH during the study period. The mean blood glucose level in patients with SH was 8.7 mmol/L compared with 5.9 mmol/L in those without SH (P < .05). There were no statistically significant differences in age; sex; sepsis severity; cardiovascular, respiratory, and renal comorbidities; requirement of mechanical ventilation; inotropes; and Acute Physiology, Age, and Chronic Health Evaluation III and Simplified Acute Physiology 2 scores on ICU admission. Intensive care unit mortality was significantly lower in patients who had SH. The median duration of ICU and hospital length of stay was longer in patients with SH. On logistic regression analysis, the presence of SH was associated with reduced ICU mortality. Subgroup analysis revealed SH to be protective in patients with septic shock.

Conclusion

Stress hyperglycemia may not be harmful in critically ill patients with sepsis. Patients with SH had lower ICU mortality.     

Cytomegalovirus infection in critically ill patients: a systematic review

Introduction

The precise role of cytomegalovirus (CMV) infection in contributing to outcomes in critically ill immunocompetent patients has not been fully defined.

Methods

Studies in which critically ill immunocompetent adults were monitored for CMV infection in the intensive care unit (ICU) were reviewed.

Results

CMV infection occurs in 0 to 36% of critically ill patients, mostly between 4 and 12 days after ICU admission. Potential risk factors for CMV infection include sepsis, requirement of mechanical ventilation, and transfusions. Prolonged mechanical ventilation (21 to 39 days vs. 13 to 24 days) and duration of ICU stay (33 to 69 days vs. 22 to 48 days) correlated significantly with a higher risk of CMV infection. Mortality rates in patients with CMV infection were higher in some but not all studies. Whether CMV produces febrile syndrome or end-organ disease directly in these patients is not known.

Conclusions

CMV infection frequently occurs in critically ill immunocompetent patients and may be associated with poor outcomes. Further studies are warranted to identify subsets of patients who are likely to develop CMV infection and to determine the impact of antiviral agents on clinically meaningful outcomes in these patients.     

Expedited admission of patients decreases duration of mechanical ventilation and shortens ICU stay

Background

To determine if expedited admission (<2 hours) of critically ill patients requiring intubation and mechanical ventilation from the emergency department (ED) to the intensive care unit (ICU) decreases ICU and hospital length of stay.

Methods

Patients with respiratory failure that required intubation and mechanical ventilation who were admitted to the hospital between June 2004 and May 2006 were retrospectively identified from the Project IMPACT database. Patients were divided into 2 groups based on ED length of stay: expedited (<2 hours) or nonexpedited (>2 hours).

Results

The expedited (n = 12) and nonexpedited (n = 66) groups were comparable in demographics, medical conditions, and disease severity. Mean duration of mechanical ventilation was significantly shorter in the expedited group (28.4 hours vs 67.9 hours; P = .0431), as was mean ICU length of stay (2.4 days vs 4.9 days; P = .0209). Length of hospital stay tended to be shorter for the patients in the expedited group (6.8 days vs 8.9 days; P = .0609).

Conclusions

Expedited admission (<2 hours) of critically ill patients requiring intubation and mechanical ventilation from the ED to the ICU was associated with shorter durations of mechanical ventilation and ICU length of stay, suggesting that prompt ICU admission results in improved use of resources.     

The impact of frailty on intensive care unit outcomes: a systematic review and meta-analysis

Purpose

Functional status and chronic health status are important baseline characteristics of critically ill patients. The assessment of frailty on admission to the intensive care unit (ICU) may provide objective, prognostic information on baseline health. To determine the impact of frailty on the outcome of critically ill patients, we performed a systematic review and meta-analysis comparing clinical outcomes in frail and non-frail patients admitted to ICU.

Methods

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PubMed, CINAHL, and Clinicaltrials.gov. All study designs with the exception of narrative reviews, case reports, and editorials were included. Included studies assessed frailty in patients greater than 18 years of age admitted to an ICU and compared outcomes between fit and frail patients. Two reviewers independently applied eligibility criteria, assessed quality, and extracted data. The primary outcomes were hospital and long-term mortality. We also determined the prevalence of frailty, the impact on other patient-centered outcomes such as discharge disposition, and health service utilization such as length of stay.

Results

Ten observational studies enrolling a total of 3030 patients (927 frail and 2103 fit patients) were included. The overall quality of studies was moderate. Frailty was associated with higher hospital mortality [relative risk (RR) 1.71; 95% CI 1.43, 2.05; p < 0.00001; I ² = 32%] and long-term mortality (RR 1.53; 95% CI 1.40, 1.68; p < 0.00001; I ² = 0%). The pooled prevalence of frailty was 30% (95% CI 29–32%). Frail patients were less likely to be discharged home than fit patients (RR 0.59; 95% CI 0.49, 0.71; p < 0.00001; I ² = 12%).

Conclusions

Frailty is common in patients admitted to ICU and is associated with worsened outcomes. Identification of this previously unrecognized and vulnerable ICU population should act as the impetus for investigating and implementing appropriate care plans for critically ill frail patients. Registration: PROSPERO (ID: CRD42016053910).

     

Quantifying off-hour emergency physician coverage of in-hospital codes: a survey of community emergency departments

Background

Community emergency physicians (EPs) are often required to respond to unstable patients outside of their department during off-hours.

Objective

The primary objective of this study was to describe the critical care responsibility of community EPs outside of their departments.

Methods

A one-page survey was mailed to emergency department (ED) directors of 10 states and Washington, DC.

Results

Three hundred forty of 1169 surveys were returned. The median (interquartile range [IQR]) number of hospital and intensive care unit (ICU) beds was 145 (IQR 60–242) and 11 (IQR 6–20), respectively. Median ED annual volume and ICU admission percentage was reported to be 25 K (IQR 14–40) and 5% (IQR 2–10), respectively. Seventy-six percent of reporting institutions require EPs to leave their department and respond to medical codes on the floors after hours. In 57% of institutions, the EP was the only physician required to respond. In addition, 48% of EPs must respond to unstable patients in the ICUs after hours. Hospitals in which EPs were required to respond to medical codes and unstable ICU patients were more likely to have fewer hospital beds (137 vs. 275; p < 0.001), fewer ICU beds (12 vs. 27; p < 0.001), and have a smaller ED annual volume (24 K vs. 39 K; p < 0.001).

Conclusions

Many community EPs are responsible for covering critically ill patients outside of their ED. Further investigation is required to determine the impact on patient care.     

The effect of diaries written by relatives for intensive care patients on posttraumatic stress (DRIP study): protocol for a randomized controlled trial and mixed methods study

Background

Critically ill patients and their relatives have complex needs for support during their stay in the intensive care unit (ICU) and the post-ICU rehabilitation period. Diaries written by nurses have proven beneficial for patients and relatives, preventing post-traumatic stress, anxiety and depression and helping patients and families find meaning. Actively involving relatives in writing a diary for critically ill patients is a new approach to helping relatives and patients cope; however, research is limited.The aim of this study is to test the hypothesis that a diary written by a close relative of a critically ill patient will reduce the risk of developing symptoms of post-traumatic stress disorder (PTSD) in the patient and relatives at 3 months post-ICU. Furthermore, the aim is to explore the perceptions and use of the diary and describe the diary content and structure.

Method

The intervention consists of a hard-cover notebook that will be given to a close relative to write a diary for the critically ill patient while in the ICU. Guidance will be offered by ICU nurses on how to author the diary. The effect of the intervention will be tested in a two-arm, single-blind, randomized controlled trial, which aims to include 100 patient/relative pairs in each group. The primary outcome studied is symptoms of post-traumatic stress (PTSS-14). Secondary outcomes are scores on anxiety and depression (HADS) and the Medical Outcomes Study Questionnaire Short Form 36 (SF-36). The narrative structure and content of the diary as well as its use will be explored in two qualitative studies.

Discussion

The results of this study will inform ICU nurses about the effects, strengths and limitations of prompting relatives to author a diary for the patient. This will allow the diary intervention to be tailored to the individual needs of patients and relatives.

Trial registration

NCT02357680. Registered September 3, 2015.

     

Early intervention on the outcomes in critically ill cancer patients admitted to intensive care units

Purpose

To determine whether earlier intervention was associated with decreased mortality in critically ill cancer patients admitted to an intensive care unit (ICU).

Methods

A retrospective observational study was performed of 199 critically ill cancer patients admitted to the ICU from the general ward between January 2010 and December 2010. A logistic regression model was used to adjust for potential confounding factors in the association between time to intervention and in-hospital mortality.

Results

In-hospital mortality was 52?%, with a median Simplified Acute Physiology Score 3 (SAPS 3) of 80 [interquartile range (IQR) 67–93], and a median Sequential Organ Failure Assessment (SOFA) score of 8 (IQR 5–11). Median time from physiological derangement to intervention (time to intervention) prior to ICU admission was 1.5 (IQR 0.6–4.3)?h. Median time to intervention was significantly shorter in survivors than in non-survivors (0.9 vs. 3.0?h; p?p?2/FiO₂ ratio. Even after adjusting for potential confounding factors, time to intervention was still significantly associated with hospital mortality (adjusted odds ratio 1.445, 95?% confidence interval 1.217–1.717).

Conclusions

Early intervention before ICU admission was independently associated with decreased in-hospital mortality in critically ill cancer patients admitted to the ICU.     

Intensivists: don't quit your day job...yet!

Citation

Levy MM, Rapoport J, Lemeshow S, Chalfin DB, Phillips G, and Danis M: Association between Critical Care Physician Management and Patient Mortality in the Intensive Care Unit. Ann Intern Med 2008 Jun 3, 148(11): 801-9 [1].

Background

Critically ill patients admitted to intensive care units (ICUs) are thought to gain an added survival benefit from management by critical care physicians, but evidence of this benefit is scant.

Methods

Objective

To examine the association between hospital mortality in critically ill patients and management by critical care physicians.

Design

Retrospective analysis of a large, prospectively collected database of critically ill patients.

Setting

123 ICUs in 100 U.S. hospitals.

Subjects

101,832 critically ill adults.

Intervention

None.

Outcomes

Through use of a random-effects logistic regression, investigators compared hospital mortality between patients cared for entirely by critical care physicians and patients cared for entirely by non-critical care physicians. An expanded Simplified Acute Physiology Score was used to adjust for severity of illness, and a propensity score was used to adjust for differences in the probability of selective referral of patients to critical care physicians.

Results

Patients who received critical care management (CCM) were generally sicker, received more procedures, and had higher hospital mortality rates than those who did not receive CCM. After adjustment for severity of illness and propensity score, hospital mortality rates were higher for patients who received CCM than for those who did not. The difference in adjusted hospital mortality rates was less for patients who were sicker and who were predicted by propensity score to receive CCM. Residual confounders for illness severity and selection biases for CCM might exist that were inadequately assessed or recognized.

Conclusion

In a large sample of ICU patients in the United States, the odds of hospital mortality were higher for patients managed by critical care physicians than those who were not. Additional studies are needed to further evaluate these results and clarify the mechanisms by which they might occur.     

Invasive pulmonary aspergillosis is a frequent complication of critically ill H1N1 patients: a retrospective study

Purpose

Despite their controversial role, corticosteroids (CS) are frequently administered to patients with H1N1 virus infection with severe respiratory failure secondary to viral pneumonia. We hypothesized that invasive pulmonary aspergillosis (IPA) is a frequent complication in critically ill patients with H1N1 virus infection and that CS may contribute to this complication.

Methods

We retrospectively selected all adult patients with confirmed H1N1 virus infection admitted to the intensive care unit (ICU) of two tertiary care hospitals from September 2009 to March 2011. Differences in baseline factors, risk factors, and outcome parameters were studied between patients with and without IPA.

Results

Of 40 critically ill patients with confirmed H1N1, 9 (23?%) developed IPA 3?days after ICU admission. Five patients had proven and four had probable IPA. Significantly more IPA patients received CS within 7?days before ICU admission (78 versus 23?%, p?=?0.002). IPA patients also received significantly higher doses of CS before ICU admission [hydrocortisone equivalent 800 (360–2,635) versus 0 (0–0)?mg, p?=?0.005]. On multivariate analysis, use of CS before ICU admission was independently associated with IPA [odds ratio (OR) 14.4 (2.0–101.6), p?=?0.007].

Conclusions

IPA was diagnosed in 23?% of critically ill patients with H1N1 virus infection after a median of 3?days after ICU admission. Our data suggest that use of CS 7?days before ICU admission is an independent risk factor for fungal superinfection. These findings may have consequences for clinical practice as they point out the need for increased awareness of IPA, especially in those critically ill H1N1 patients already receiving CS.     

A Risk Prediction Model for Invasive Fungal Disease in Critically Ill Patients in the Intensive Care Unit

Purpose

Developing a risk prediction model for invasive fungal disease based on an analysis of the disease-related risk factors in critically ill patients in the intensive care unit (ICU) to diagnose the invasive fungal disease in the early stages and determine the time of initiating early antifungal treatment.

Serum adiponectin upon admission to the intensive care unit may predict mortality in critically ill patients

Purpose

Adiponectin has been proposed as an important regulator of glucose metabolism influencing obesity and insulin resistance, which are important risk factors for the outcome of critically ill patients. Moreover, experimental models of inflammation suggest protective anti-inflammatory properties of adiponectin. We therefore investigated the potential pathogenic role and prognostic value of circulating adiponectin levels in critical illness.

Materials and methods

One hundred seventy critically ill patients (122 with sepsis and 48 without sepsis) were prospectively studied at admission to the medical intensive care unit (ICU) and compared with 60 healthy controls. Patients' survival was followed for approximately 3 years.

Results

Adiponectin serum concentrations did not differ between healthy controls and critically ill patients, neither in patients with nor in patients without sepsis. However, patients with decompensated liver cirrhosis had significantly elevated serum adiponectin levels. Likewise to non-critically ill subjects, ICU patients with preexisting diabetes or obesity displayed significantly reduced circulating adiponectin. Inflammatory cytokines did not correlate with serum adiponectin. Interestingly, low adiponectin levels at ICU admission were an independent positive predictor of short-term and overall survival.

Conclusions

Although serum concentrations did not differ in critically ill patients from controls, low adiponectin levels at admission to ICU have been identified as an independent predictor of survival.     

Pronounced elevation in circulating calcitonin in critical care patients is related to the severity of illness and survival

Objective

To study circulating levels of calcitonin in critically ill patients in relation to the severity of illness and survival.

Design

Cross-sectional and prospective.

Setting

The ICU in Gävle hospital, a secondary non-teaching hospital.

Patients

37 consecutive ICU patients.

Measurements and results

Serum calcium and immunoreactive calcitonin (iCT) were measured and the Apache II and the Multiple Organ Failure (MOF) scores were recorded during the first 24 h in the ICU. Patients were followed for hospital survival. Profound increase in circulating iCT was seen (mean 591, median 184, range 8–3445 pg/ml) in the studied sample and only 11% of the patients showed normal levels (<40 pg/ml). iCT was higher in septic than non-septic patients (p<0.004) and was correlated to two indices of severity of illness (r=0.50,p<0.006 versus the Apache II score andp=0.55,p<0.003 versus the MOF score). Furthermore, iCT was correlated to the length of stay in the intensive care unit (r=0.56,p<0.001) and was elevated in the patients who did not survive when compared to survivors (p<0.03). iCT was not significantly related to the degree of serum calcium (mean 2.22±0.15 SD mmol/l). Gel chromatography in a fast protein liquid chromatography (FPLC) system of serum from 4 patients with elevated iCT disclosed that a majority of the measured CT was not due to monomeric CT, but high molecular CT.

Conclusions

Pronounced elevations in circulating iCT were seen during the first 24 h critically ill patients. As the major part of the iCT consisted of high molecular weight CT this would not induce hypocalcemia. Rather, the elevated iCT would be regarded as a part of the metabolic responses to illness.     

Improved short- and long-term outcome of allogeneic stem cell recipients admitted to the intensive care unit: a retrospective longitudinal analysis of 942 patients

Purpose

Intensive care unit (ICU) admission of allogeneic hematopoietic stem cell transplant (HSCT) recipients is associated with relatively poor outcome. Since longitudinal data on this topic remains scarce, we analyzed reasons for ICU admission as well as short- and long-term outcome of critically ill HSCT recipients.

Methods

A total of 942 consecutive adult patients were transplanted at Hannover Medical School from 2000 to 2013. Of those, 330 patients were at least admitted once to the ICU and included in this retrospective study. To analyze time-dependent improvements, we separately compared patient characteristics as well as reasons and outcome of ICU admission for the periods 2000–2006 and 2007–2013.

Results

The main reasons for ICU admission were acute respiratory failure (ARF) in 35%, severe sepsis/septic shock in 23%, and cardiac problems in 18%. ICU admission was clearly associated with shortened survival (p?<?0.001), but survival of ICU patients after hospital discharge reached 44% up to 5 years and was comparable to that of non-ICU HSCT patients. When ICU admission periods were compared, patients were older (48 vs. 52 years; p?<?0.005) and the percentage of ARF as leading cause for ICU admission decreased from 43% in the first to 30% in the second period. Over time ICU and hospital survival improved from 44 to 60% (p?<?0.01) and from 26 to 43% (p?<?0.01), respectively. The 1- and 3-year survival rate after ICU admission increased significantly from 14 to 32% and from 11 to 23% (p?<?0.01).

Conclusions

Besides ARF and septic shock, cardiac events were especially a major reason for ICU admission. Both short- and long-term survival of critically ill HSCT patients has improved significantly in recent years, and survival of HSCT recipients discharged from hospital is not significantly affected by a former ICU stay.

     

Vitamin?D status in critically ill children

Background

Hypovitaminosis?D is an independent risk factor for cardiovascular disease, muscle weakness, impaired metabolism, immune dysfunction, and compromised lung function. Hypovitaminosis?D is common in critically ill adults and has been associated with adverse outcomes. The prevalence of hypovitaminosis?D and its significance in critically ill children are unclear.

Methods

We performed a prospective study to determine the prevalence of hypovitaminosis?D in 316 critically ill children, and examined its association with physiological and biochemical variables, length of pediatric intensive care unit (PICU) stay, and hospital mortality.

Results

The prevalence of hypovitaminosis?D [25(OH)D₃ <50?nmol/L] was 34.5?%. Hypovitaminosis?D was more common in postoperative cardiac patients than in general medical ICU patients (40.5 versus 22.6?%, p?=?0.002), and the cardiac patients had a higher inotrope score [2.5 (1.9–3.3) versus 1.4 (1.1–1.9), p?=?0.006]. Additionally, ionized calcium within the first 24?h was lower in patients with 25(OH)D₃ <50?nmol/L [1.07 (0.99–1.14)?mmol/L] compared with patients with normal vitamin?D₃ [1.17 (1.14–1.19)?mmol/L, p?=?0.02]. Hypovitaminosis?D was not associated with longer PICU stay or increased hospital mortality.

Conclusions

Hypovitaminosis?D is common in critically ill children, and is associated with higher inotropes in the postoperative cardiac population, but not with PICU length of stay or hospital survival.     

Association between weight change and clinical outcomes in critically ill patients

Purpose

Body weight fluctuates daily throughout a patient’s stay in the intensive care unit (ICU) due to a variety of factors, including fluid balance, nutritional status, type of acute illness, and presence of comorbidities. This study investigated the association between change in body weight and clinical outcomes in critically ill patients during short-term hospitalization in the ICU.

Methods

All patients admitted to the Gyeongsang National University hospital between January 2010 and December 2011 who met the inclusion criteria of age 18 or above and ICU hospitalization for at least 2 days were prospectively enrolled in this study. Body weight was measured at admission and daily thereafter using a bed scale. Univariate and multivariate linear and logistic regression analyses were performed to evaluate factors associated with mortality and the association between changes in body weight and clinical outcomes, including duration of mechanical ventilation (MV) use, length of ICU stay, and ICU mortality.

Results

Of the 140 patients examined, 33 died during ICU hospitalization, yielding an ICU mortality rate of 23.6%. Non-survivors experienced higher rates of severe sepsis and septic shock and greater weight gain than survivors on days 2, 3, 4, 5, and 6 of ICU hospitalization (P < .05). Increase of body weight on days 2 through 7 on ICU admission was correlated with the longer stay of ICU, and increase on days 3 through 7 on ICU admission was correlated with the prolonged use of mechanical ventilation. Increase of body weight on days 3 through 5 on ICU admission was associated with ICU mortality.

Conclusions

Increase in body weight of critically ill patients may be correlated with duration of mechanical ventilation use and longer stay of ICU hospitalization and be associated with ICU mortality.     

An open-labelled randomized controlled trial comparing costs and clinical outcomes of open endotracheal suctioning with closed endotracheal suctioning in mechanically ventilated medical intensive care patients

Purpose

Closed endotracheal suctioning (CES) may impact ventilator-associated pneumonia (VAP) risk by reducing environmental contamination. In developing countries where resource limitations constrain the provision of optimal bed space for critically ill patients, CES assumes greater importance.

Materials and Methods

In this prospective, open-labeled, randomized controlled trial spanning 10 months, we compared CES with open endotracheal suctioning (OES) in mechanically ventilated patients admitted to the medical intensive care unit (ICU) of a university-affiliated teaching hospital. Patients were followed up from ICU admission to death or discharge from hospital. Primary outcome was incidence of VAP. Secondary outcomes included mortality, cost, and length of stay.

Results

Two hundred patients were recruited, 100 in each arm. The incidence of VAP was 23.5%. Closed endotracheal suctioning was associated with a trend to a reduced incidence of VAP (odds ratio, 1.86; 95% confidence interval, 0.91-3.83; P = .067). A significant benefit was, however, observed with CES for late-onset VAP (P = .03). Mortality and duration of ICU and hospital stay were similar in the 2 groups. The cost of suction catheters and gloves was significantly higher with CES (Rs 272 [US $5.81] vs Rs 138 [US $2.94], P < .0001). Nine patients need to be treated with CES to prevent 1 VAP (95% confidence interval, −0.7 to 22).

Conclusions

In the ICU setting in a developing country, CES may be advantageous in reducing the incidence of VAP, particularly late-onset VAP. These results mandate further studies in this setting before specific guidelines regarding the routine use of CES are proposed.