Bloodless intensive care: a case series and review of Jehovah's Witnesses in ICU

The objective of this study was to assess the outcome of Jehovah's Witness (JW) patients admitted to a major Australasian ICU and to review the literature regarding the management of critically ill Jehovah's Witness patients. All Jehovah's Witness patients admitted to the ICU between January 1999 and September 2003 were identified from a prospective database. Their ICU mortality, APACHE II scores, APACHE II risk of death and ICU length of stay were compared to the general ICU population. Twenty-one (0.24%) out of 8869 patients (excluding re-admissions) admitted to the ICU over this period were Jehovah's Witness patients. Their mean APACHE II score was 14.1 (+/- 7.0), the mean APACHE II risk of death was 21.2% (+/- 16.6), and the mean nadir haemoglobin (Hb) was 80.2 g/l (+/- 36.4). Four out of 21 Jehovah's Witness patients died in ICU compared to 782 out of 8848 non- Jehovah's Witness patients (19.0% vs 8.8%, P = 0.10, chi square). The median ICU length of stay in both groups was two days (P = 0.64, Wilcoxon rank sum). The lowest Hb recorded in a survivor was 23 g/l. Jehovah's Witness patients appear to be an uncommon patient population in a major Australasian ICU but are not over-represented when compared with their prevalence in the community. Despite similar severity of illness scores and predicted mortality to those in the general ICU population, there was a trend towards higher mortality in Jehovah's Witness patients.     

中度急性胰腺炎临床特征分析

目的探讨中度急性胰腺炎的临床特征。方法回顾性分析2013年1月至12月,青海省交通医院普通外科收治的103例急性胰腺炎（acute pancreatitis,AP）患者临床资料,根据国际AP专题研讨会最新修订的诊断和分类标准（2012年,美国亚特兰大）诊断为轻度急性胰腺炎（mildacutepancreatitis,MAP）61例、中度急性胰腺炎（moderately severe acute pancreatitis,MSAP）25例、重度急性胰腺炎（severe acute pancreatitis,SAP）17例,对比三组患者一般资料、局部并发症发生此例、器官功能衰竭发生比例、入住ICU比例和天数、干预措施、住院天数、病死率。结果三组患者性别、年龄和病因学情况差异均无统计学意义,但MSAP组APACHEⅡ评分显著高于MAP组,同时低于SAP组（均P〈0．05）。MAP、MSAP和SAP三组出现局部并发症的比例分别为0、92．0％（23125）和76．5％（13／17）（P〈0．05）。MAP组无器官功能表竭发生,MSAP组5例出现一过性（〈48h）器官功能表竭,SAP组均出观特续性（〉48h）器官功能衰竭,SAP组器官功能衰竭比例显著高于MSAP组（P〈0．05）。MAP组无入住ICU病例,均无需介入、内镜或外科干预,无死亡病例。MSAP组入住ICU此例、ICU时间、住院时间和病死率显著低于SAP组（P〈0．05）。结论中度急性胰腺炎为有别于轻度和重度急性胰腺炎的独立类型,伴有局部并发症或一过性（48h内）器官功能表竭,但病死率较低,预后明显好于重度急性胰腺炎。     

Impact of ventilator-associated pneumonia in patients with severe head injury

BACKGROUND: The impact of ventilator-associated pneumonia (VAP) on outcome seems to vary depending on the critically ill patients we analyze. Our objective, therefore, has been to evaluate the influence of VAP on the mortality and morbidity in patients with severe head injury (Glasgow Coma Scale score 相似文献   

Pregnancy-related admissions to the intensive care unit

We conducted a retrospective review of obstetric patients admitted to the intensive care unit at Al-Ain hospital during period January 1(st) 1997 to December 31(st) 2002, in order to identify the indications for admission and the outcome. A total of 60 patients were admitted during the six years. The frequency of admission was 2.6 per 1000 deliveries and obstetric patients represented 2.4% of all ICU admissions. Admission was planned in 11 patients (18%) and unplanned in 49 (82%). The mean (+/-SD) duration of stay in ICU was 1.6+/-1.5 days. The leading indications for admission were haemorrhage (28.4%) and preeclampsia/eclampsia (25%). Of the 60 admissions, 47 (78.4%) followed surgery. The mean APACHE II score was 5.0+/-3.0. Twenty-two patients (37%) had blood transfusions, and only two (3.3%) required ventilation. Of the 60 patients only 28 (46.7%) were deemed to have severe illness necessitating intensive care; the remaining 32 patients were suitable for high dependency care. The mean APACHE II score and duration of stay were significantly higher in these patients. There were two deaths, representing 3.3% of obstetric intensive care unit admissions. Our findings highlight the need for establishing a high dependency unit to avoid unnecessary admission to the intensive care unit and to ensure proper management.     

Need for maternal critical care in obstetrics: a population-based analysis

The purpose of this study was to note potential obstetric risk factors leading to maternal intensive care and to estimate the frequency, costs and outcomes of management. In a cross-sectional study of intensive care admissions in Kuopio from March 1993 to October 2000, 22 consecutive obstetric patients admitted to a mixed medical-surgical intensive care unit were followed. We recorded demographics, admitting diagnoses, APACHE II score, clinical outcomes and treatment costs. The overall need for maternal intensive care was 0.9 per 1000 deliveries during the study period. The mean age (+/-SD) of the patients was 31.7 (+/-6.6) years and the APACHE II score 10.8 (+/-6.2). The most common admission diagnoses were obstetric haemorrhage (73%) and pre-eclampsia-related complications (32%). The duration of ICU stay was 5.8 days (range 1-31) and one of the 21 patients died in the intensive care unit (4.5%). The total cost of intensive care was in the order of USD 5000 per patient. Very few obstetric patients develop complications requiring intensive care. Although several risk factors associated with maternal intensive care were documented, most cases occurred in low-risk women, which implies that the risk is relevant to all pregnancies. Long-term morbidity was rare, and collectively the outcome of intensive care was good. Further research is needed to determine effective approaches in prevention, such as uterine artery embolization.     

Acute respiratory distress syndrome in the trauma intensive care unit: Morbid but not mortal

HYPOTHESIS: The diagnosis of acute respiratory distress syndrome (ARDS) carries significant additional morbidity and mortality among critically injured patients. DESIGN: Retrospective case-control study using a prospectively maintained ARDS database. SETTING: Surgical intensive care unit (ICU) in an academic county hospital. PATIENTS: All trauma patients admitted to the ICU from January 1, 2000, to December 31, 2003, who developed ARDS as defined by (1) acute onset, (2) a partial pressure of arterial oxygen-fraction of inspired oxygen ratio of 200 or less, (3) bilateral pulmonary infiltrates on chest radiographs, and (4) absence of left-sided heart failure. Each patient with ARDS was matched with 2 control patients without ARDS on the basis of sex, age (+/-5 years), mechanism of injury (blunt or penetrating), Injury Severity Score (+/-3), and chest Abbreviated Injury Score (+/-1). MAIN OUTCOME MEASURES: Mortality, hospital charges, hospital and ICU lengths of stay, and complications (defined as pneumonia, deep venous thrombosis, pulmonary embolism, acute renal failure, and disseminated intravascular coagulopathy). RESULTS: Of 2042 trauma ICU admissions, 216 patients (10.6%) met criteria for ARDS. We identified 432 similarly injured control patients. Compared with controls, trauma patients with ARDS had more complications (43.1% vs 9.5%), longer hospital (32.2 vs 17.9 days) and ICU (22.1 vs 8.4 days) lengths of stay, and higher hospital charges (267,037 dollars vs 136,680 dollars) (P < .01 for all), but mortality was similar (27.8% vs 25.0%, P = .48). CONCLUSION: Although ARDS is associated with increased morbidity, hospital and ICU length of stay, and costs, it does not increase overall mortality among critically ill trauma patients.     

The acute physiology and chronic health evaluation III outcome prediction in patients admitted to the intensive care unit after pneumonectomy

PURPOSE: The Acute Physiology and Chronic Health Evaluation (APACHE) III prognostic system has not been previously validated in patients admitted to the intensive care unit (ICU) after pneumonectomy. The purpose of this study was to determine if the APACHE III predicts hospital mortality after pneumonectomy. METHODS: A retrospective review of all adult patients admitted to a single thoracic surgical intensive care unit after pneumonectomy between October 1994 and December 2004. Patient demographics, ICU admission day APACHE III score, actual and predicted hospital mortality, and length of hospital and ICU stay data were collected. Data on preoperative pulmonary function tests and smoking habits were also collected. Univariate statistical methods and logistic regression were used. The performance of the APACHE III prognostic system was assessed by the Hosmer-Lemeshow statistic for calibration and area under receiver operating characteristic curve (AUC) for discrimination. RESULTS: There were 417 pneumonectomies performed during the study period, of which 281 patients were admitted to the ICU. The mean age was 61.1 years, and 67.2% were men; 88.2% were smokers with a median of 40.0 (interquartile range, 18-62) pack-years of tobacco use. The mean APACHE III score on the day of ICU admission was 37.7 (+/- standard deviation 17.8), and the mean predicted hospital mortality rate was 6.4% (+/-10.4). The median (and interquartile range) lengths of ICU and hospital stay were 1.7 (0.9-3.1) and 9.0 (7.0-17.0) days, respectively. The observed ICU and hospital mortality rates were 4.6% (13/281 patients) and 8.2% (23/281), respectively. The standardized ICU and hospital mortality ratios with their 95% confidence intervals (CIs) were 1.55 (0.71-2.39) and 1.27 (0.75-1.78), respectively. There were significant differences in the mean APACHE III score (p < 0.001) and the predicted mortality rate (p < .001) between survivors and nonsurvivors. In predicting mortality, the AUC of APACHE III prediction was 0.801 (95% CI, 0.711-0.891), and the Hosmer-Lemeshow statistic was 9.898 with a p value of 0.272. Diffusion capacity of the lung for carbon monoxide (DLCO) and percentage predicted DLCO were higher in survivors, but the addition of either of these variables to a logistic regression model did not improve APACHE III mortality prediction. CONCLUSIONS: In patients admitted to the ICU after pneumonectomy, the APACHE III discriminates moderately well between survivors and nonsurvivors. The calibration of the model appears to be good, although the low number of deaths limits the power of the calibration analysis. The use of APACHE III data in outcomes research involving patients who have undergone pneumonectomy is acceptable.     

Post-traumatic stress disorder-related symptoms after intensive care

AIM: To determine the incidence of Post Traumatic Stress Disorder (PTSD) related symptoms in a population of intensive care unit (ICU) admitted patients and the relationship between PTSD-related symptoms and memories of ICU. METHODS: Adults consecutively admitted to an ICU of a University hospital during 1 year, who stayed in the ICU at least 3 days, were prospectively studied. A questionnaire (ICU memory tool) was administered to 84 patients 1 week after ICU discharge and to 63 of them after 3 months. Past medical history and clinical variables present during ICU stay were collected. RESULTS: At the 1st interview, 5 patients (5.9%) did not remember to have been in ICU. Of the remaining 79 patients (males 59.5%, median age 69 years, SAPS II 34, APACHE II 14 and ICU stay 5 days), 4 reported intrusive memories and none panic attacks. The Impact of Events Scale (IES), available in 3 of them, scored in medium/high levels. Only the median number of factual memories reported by the patients with and without intrusive memories was significantly different (4 interquartile range 2-5 vs 8 interquartile range 6-10; p=0.002). The patients with intrusive memories at the 1st interview did not report them at the 2nd interview. Two patients not having panic or intrusive memories at the 1st interview reported PTSD-related symptoms after 3 months. CONCLUSIONS: In a general ICU population, few patients (5%) have PTSD-related symptoms and those who present those symptoms report less factual memories of ICU stay.     

Assessment of outcome over a 10-year period of patients admitted to a multidisciplinary adult intensive care unit with haematological and solid tumours

The risk factors for time to mortality, censored at 30 days, of patients admitted to an adult teaching hospital ICU with haematological and solid malignancies were assessed in a retrospective cohort study. Patients, demographics and daily ICU patient data, from admission to day 8, were identified from a prospective computerized database and casenote review in consecutive admissions to ICU with haematological and solid tumours over a 10-year period (1989-99). The cohort, 108 ICU admissions in 89 patients was of mean age (+/-SD) 55+/-14 years; 43% were female. Patient diagnoses were leukaemia (35%), lymphoma (38%) and solid tumours (27%). Median time from hospital to ICU admission was five days (range 0-67). On ICU admission, 50% had septic shock and first day APACHE II score was 28+/-9. Forty-six per cent of patients were ventilated. ICU and 30-day mortality were 39% and 54% respectively. Multivariate Cox model predictors (P<0.05), using only ICU admission day data were: Charlson comorbidity index (CCI), time to ICU admission (days) and mechanical ventilation. For daily data (admission through day 8), predictors were: cohort effect (2nd vs 1st five-year period); CCI; time to ICU admission (days); APACHE II score and mechanical ventilation. Outcomes were considered appropriate for severity of illness and demonstrated improvement over time. Ventilation was an independent outcome determinant. Controlling for other factors, mortality has improved over time (1st vs 2nd five year period). Analysis restricted to admission data alone may be insensitive to particular covariate effects.     

免疫调控营养对重症急性胰腺炎的治疗作用

目的 探讨免疫调控营养对重症急性胰腺炎(SAP)患者的治疗作用.方法 前瞻性分析2008年2月至2009年10月华中科技大学同济医学院附属协和医院收治的80例SAP患者的临床资料.将80例SAP患者按照配对的方法分为常规营养组(CN组)和免疫调控营养组(IRN组),每组40例.CN组接受分阶段营养支持,而IRN组则在常规营养治疗基础上联合应用ω-3多不饱和脂肪酸(ω-3 PUFA)和谷氨酰胺.评估两组患者在治疗第1、4、7、10、14天的APACHEⅡ评分,比较两组患者住院期间肺部感染、腹腔感染、脓毒血症发生率,手术干预率,ICU时间,住院时间和病死率的差异.采用t检验和χ2检验分析检测数据.结果 IRN组患者APACHEⅡ评分在治疗的第4、7天分别为(15.3±1.8)、(9.0±1.8)分,明显低于CN组的(20.0±2.7)、(13.3±2.4)分,两组比较,差异有统计学意义(t=3.3,2.8,P<0.05),IRN组在第10、14天仍低于CN组,但两组比较,差异无统计学意义(t=0.7,0.6,P>0.05).IRN组肺部感染、腹腔感染发生率和手术干预率分别为18%(7/40)、13%(5/40)和5%(2/40),显著低于CN组的38%(15/40)、33%(13/40)和20%(8/40),两组比较,差异有统计学意义(χ2=4.0,4.6,4.1,P<0.05).IRN组脓毒血症发生率为5%(2/40),低于CN组的8%(3/40),但两组比较,差异无统计学意义(χ2=0.0,P>0.05).IRN组的ICU时间和住院时间分别为(5.4±1.6)、(38.6±9.3)d,而CN组分别为(7.8±2.8)、(43.1±11.6)d,两组比较,差异有统计学意义(t=2.7,3.7,P<0.05).IRN组和CN组病死率分别为5%(2/40)和8%(3/40),两组比较,差异无统计学意义(χ2=0.0,P>0.05).结论 在SAP患者营养支持中添加ω-3PUFA及谷氨酰胺可调控SAP早期过度炎症反应,有效减少严重感染的发生,降低手术率,缩短ICU时间及住院时间,对SAP具有积极的治疗作用.     

Severity scoring for prognostication in patients with severe acute pancreatitis: comparative analysis of the Ranson score and the APACHE III score

BACKGROUND: Despite a paucity of validation, the Ranson score is still the most popular method for gauging the severity of pancreatitis. HYPOTHESES: The Ranson score more accurately predicts outcomes in patients with severe acute pancreatitis (SAP) when compared with APACHE (Acute Physiology and Chronic Health Evaluation) III scores, and the individual components of the Ranson score differ in their capacities to predict outcome in patients with SAP. METHODS: Patients admitted with SAP to a university surgical intensive care unit (ICU) were studied prospectively. Each component and the total Ranson score were recorded. Also recorded were the APACHE II and III scores. These Ranson variables were compared using univariate analysis of variance for mortality, need for operative debridement, and need for an ICU stay for longer than 7 days. Significant variables were then analyzed by a multivariate analysis of variance to assess independent predictors of mortality, the need for debridement, and prolonged length of stay. Data are given as the mean +/- SEM. RESULTS: Seventy-six patients (21.1% mortality), aged 61.8 +/- 1.9 years, were studied. The mean APACHE III score was 48.2 +/- 3.3, and the mean ICU stay was 10.4 +/- 2.1 days. The number of positive Ranson variables was significantly higher in nonsurvivors compared with survivors (5.6 +/- 0.5 vs 3.4 +/- 0.2; P<.001), as were the APACHE III score (76.9 +/- 9.9 vs 40.5 +/- 2.5; P<.001) and ICU stay (24.9 +/- 7.5 vs 76.5 +/- 1.9 days; P =.002). Ranson variables that predicted mortality included values for blood urea nitrogen, calcium, base deficit, and fluid sequestration. CONCLUSIONS: The Ranson score remains a valid predictor of outcomes in patients with SAP, and individual Ranson variables determined 48 hours after hospital admission predicted adverse outcomes more accurately than early Ranson variables in patients with SAP.     

Perioperative medical management and outcome following thymectomy for myasthenia gravis

PURPOSE: To describe the evolution of the perioperative management of myasthenia gravis (MG) patients undergoing thymectomy and to question the need for systematic postoperative ventilation. CLINICAL FEATURES: We collected data retrospectively from 36 consecutive MG patients who underwent thymectomy over a 21-yr period, via transthoracic, -cervical or -sternal incisions (n=5, n=7, n=24, respectively). From 1980 to 1993, a balanced anesthetic technique (n=24) included various inhalational agents with opiates and myorelaxants (in eight cases); 22 patients were admitted to the intensive care unit (ICU). Since 1994, i.v. propofol was combined with epidural bupivacaine and sufentanil (n=12); all patients were admitted to the postanesthesia care unit. Short-term postoperative ventilation (median time four hours, range from three to 48 hr) was required in eight patients who had longer hospital stay (median stay=12 days, range (8-28) vs five days (4-15) for patients with early extubation, P <0.05) but similar clinical improvement six months after thymectomy. Postoperative ventilatory support was required more frequently when a balanced anesthetic technique was used (odds ratio=4.2 (1.1-9.7), P=0.03) and particularly when myorelaxants were given (odds ratio=13.9 (2.1-89.8), P=0.009). Leventhal's scoring system had low sensitivity (22.2%) and positive predictive values (25%). CONCLUSIONS: Our data show that the severity of MG failed to predict the need for postoperative ventilation. A combined anesthetic technique was a safe and cost-effective alternative to balanced anesthesia as it provided optimal operating conditions and resulted in fewer admissions in ICU and shorter hospital stays.     

Outcome from intensive care. I. A 5-year study of 1308 patients: methodology and patient population

During a 5-year period, from 1979 to 1983, demographic and disease-related data were collected prospectively on 1308 adult patients from 1555 admissions to a multidisciplinary intensive care unit (ICU) in a Danish university hospital. The patients were followed during the stay in ICU, the ensuing hospital stay, and up to 8 years after discharge from hospital. The male: female ratio was 1:1. One-third of the patients were admitted from medical wards, two-thirds were surgical patients (including gynaecological and obstetric patients). Median age was 60 years, and 25% of the patients were aged 70 years and older. Median length of stay in ICU was 2 days, and the median length of the ensuing hospital stay was 10 days. Respiratory diseases (43%) and cardiovascular diseases (16%) were the most common primary indications for ICU admission; increasing age was associated with more frequent cardiovascular diseases. Six-hundred and twenty-three (48%) patients needed mechanical ventilation; of these 373 were on mechanical ventilation for more than 24 h. Increasing age was associated with a more frequent need for mechanical support. Cancer was diagnosed in 290 patients prior to ICU admission. In 41% the cancer originated from the digestive tract. Cancer was more frequent in surgical patients than in medical patients. The APACHE- and TISS-systems were simultaneously applied to a representative sample of 216 consecutive admissions. The average APACHE score was 14.9 +/- 8.2 and the average TISS score 28.3 +/- 11.1 points. The ICU patients presented in this paper do not differ much from ICU patients in other outcome studies.     

Prolonged rehospitalizations following renal transplantation: causes, risk factors, and outcomes

BACKGROUND: Although some studies have described rehospitalization after transplantation, few have focused on risk factors and consequences of prolonged hospital stay. Our goal was to determine the causes, risk factors, and outcomes of prolonged rehospitalizations after renal transplantation. PATIENTS AND METHODS: In this retrospective study, 574 randomly selected rehospitalization records of kidney transplant recipients were reviewed from 1994 to 2006. Admissions were divided into group 1, prolonged stay (length of stay >14 days, n=149), and group II, short stay (length of stay 62% of all hospital costs; however, they comprised only 26% of the patients. High-risk kidney transplant recipients for prolonged hospitalizations should be closely observed for infections and graft rejection.     

重症急性胰腺炎并发细菌性肝脓肿的诊断与治疗（附11例报告）

目的 探讨重症急性胰腺炎（SAP）并发细菌性肝脓肿（PLA）的临床特点、治疗方案及预后转归,以期为临床诊疗提供借鉴。方法 回顾性分析南京大学医学院附属金陵医院2015年1月至2021年6月连续住院的SAP病人中并发PLA的临床资料。结果 在住院的3285例SAP中并发11例PLA（发生率为0.33%）,其中死亡3例（病死率为27.3%）。PLA中8例发生于SAP病程晚期（10周后）,所有病例均明确为胆源性病因,且伴有糖尿病病史,10例在病程中伴多器官功能障碍（90.9%）、7例伴腹腔出血（63.6%）、7例伴消化道瘘（63.6%）等胰外并发症,7例接受了胆囊穿刺引流（63.6%）等胆道干预措施。PLA发生部位右叶多于左叶（9例vs.2例）,多发高于单发（7例 vs. 4例）。在8例细菌学培养结果中6例为肺炎克雷伯菌（75.0%）。3例病人单独应用抗生素治疗,余8例在确诊PLA后中位天数3.5（1~27）d予CT引导下经肝穿刺脓肿引流。结论 PLA是SAP晚期罕见的并发症,病死率高,主要继发于胆源性胰腺炎合并糖尿病史的病人,肺炎克雷伯杆菌为其主要病原菌。     

Acute respiratory failure secondary to chronic obstructive pulmonary disease treated in the intensive care unit: a long term follow up study

BACKGROUND: Traditionally, patients with acute respiratory failure due to chronic obstructive pulmonary disease (COPD) admitted to the intensive care unit (ICU) are believed to have a poor outcome. A study was undertaken to explore both hospital and long term outcome in this group and to identify clinical predictors. METHODS: A retrospective review was carried out of consecutive admissions to a tertiary referral ICU over a 6 year period. This group was then followed prospectively for a minimum of 3 years following ICU admission. RESULTS: A total of 74 patients were admitted to the ICU with acute respiratory failure due to COPD during the study period. Mean forced expiratory volume in 1 second (FEV1) was 0.74 (0.34) l. Eighty five per cent of the group underwent invasive mechanical ventilation for a median of 2 days (range 1-17). The median duration of stay in the ICU was 3 days (range 2-17). Survival to hospital discharge was 79.7%. Admission arterial carbon dioxide tension (PaCO2) and APACHE II score were independent predictors of hospital mortality on multiple regression analysis. Mortality at 6 months, 1, 2, and 3 years was 40.5%, 48.6%, 58.1%, and 63.5%, respectively. There were no independent predictors of mortality in the long term. CONCLUSIONS: Despite the need for invasive mechanical ventilation in most of the study group, good early survival was observed. Mortality in the long term was significant but acceptable, given the degree of chronic respiratory impairment of the group.     

Multi-variate analysis of burns patients in the Singapore General Hospital Burns Centre (2003-2005)

The Burns Centre at the Singapore General Hospital (SGH) serves as a tertiary referral centre for burns management for Singapore's 4 million residents as well as the Southeast Asia region. Our study is a multivariate analysis of all burns patients admitted between 2003 and 2005. A total of 482 patients were admitted during this period with an average annual admission of 161. This represents a low incidence of 0.04 per 1000 admissions for the Singapore population. 13.3% of the study population were children, which is lower than previous studies. The mean age at admission was 35 years old and the male:female ratio was 1.9:1. We found a significant difference in age between the local and foreign patients, with the latter being younger. Our study demonstrated a 7.3% increase in cases of occupational burns. The bulk of our patients (57.3%) were directly admitted from SGH's Accident and Emergency Department. The patient characteristics of the various referral sources were found to be very different. GP referrals had significantly lower TBSA while overseas patients had significantly higher TBSA and longer length of stay. The mean and median time to admission was 3.05 days (+/-6.26) and 0 (0-60) day, respectively and the mean and median time to surgery was 7.33 days (+/-8.18) and 5 (0-22) days, respectively. The most common cause of burns was due to scalding. The mean extent of burn (TBSA) was 13.5% (+/-18.0), with significant correlation with the social background. Length of stay was dependent on the need for surgery. The overall mortality rate in this study population was 4.5%, with inhalation injury the main aetiological factor. In addition, the mean duration of the first surgery that patients undergo was significantly longer than that of the second one. This information will be useful for estimating operation times in the future. Finally, Acinetobacter baumannii was the most common bacteria in wound cultures. There is a need for periodic reviews of wound cultures in burns patients in order to modify the preventive and therapeutic strategies against these bacteria.     

Candidemia after cardiac surgery in the intensive care unit: an observational study

Candidemia is a well-recognized complication of hospital stay, especially in critically ill patients. There is not a general consensus that predictors for candidemia in cardiosurgical intensive care unit (cICU) are different from a general ICU and it has been reported that cardiopulmonary bypass time is a specific risk factor in the cICU. We performed a prospective study to evaluate the main predictors for candidemia in patients admitted to the cICU. Included patients were adults admitted between July 2005 and December 2007 with an ICU-length of stay (ICU-LOS) ≥48 hours after cardiac surgery. Exclusion criteria were solid organ or bone marrow transplants, previous diagnosis of candidemia or other invasive infections and ICU stay before surgery. A multiple regression analysis was performed to identify the risk factors. Among 1955 patients admitted to the cICU, 345 were enrolled. Only 26 patients (1.3%) had candidemia after an ICU-LOS of 20 days (inter-quartile range, IQR 8-49 days). Total parenteral nutrition [odds ratio (OR)=9.56; confidence interval (CI)=1.741-52.534], severe sepsis (OR=4.20; CI=1.292-13.667), simplified acute physiology score II (OR=1.16; CI=1.052-1.278) and ICU-LOS >20 days (OR=6.38; CI=1.971-20.660) were independent predictors of candidemia. Patients undergoing cardiac surgery developed candidemia late after cICU admission and the independent predictors were similar to the general ICU.     

Early versus late tracheostomy in patients with severe traumatic head injury

BACKGROUND AND PURPOSE: A majority of patients with severe traumatic brain injury (TBI) need ventilatory support and require endotracheal intubation. There has been substantial debate regarding the timing of tracheostomy. We reviewed our data to determine the impact of early tracheostomy on our resources. STUDY DESIGN: Retrospective review of a consecutive series of patients with severe TBI treated at a Level II trauma center. METHOD: All 55 patients admitted to the surgical intensive care unit (ICU) with severe TBI from January, 2002 through September, 2005 were reviewed through the trauma registry. The inclusion criteria were severe TBI with a Glasgow Coma Scale (GCS) score < or = eight points at the time of admission and expected survival for longer than three days. All of these patients required mechanical ventilation and subsequently underwent tracheostomy. According to the timing of tracheostomy, subjects were classified as early group (< or = 7 days; N = 27) or late group (> 7 days; N = 28). The Wilcoxon rank sum test, the log-rank test, and Fisher exact tests were used to compare these groups. RESULT: The average time of the tracheostomy procedure was 5.5 +/- 1.8 (SD) days in the early group and 11.0 +/- 4.3 days in the late group. There were no significant differences between the groups in terms of age, proportion of female sex, GCS, Injury Severity Score, or need for blood transfusion. However, patients in the early group had a significantly shorter stay in the ICU than patients in the late group (19.0 +/- 7.7 vs. 25.8 +/- 11.8 days; P = 0.008). There was no difference between the groups in ventilator days (15.7 +/- 6.0 vs. 20.0 +/- 16.0 days; p = 0.57). There were no significant differences between the groups regarding overall mortality (15% vs. 4%; p = 0.19), incidence of pneumonia prior to tracheostomy (41% vs. 50%; p = 0.59), median total hospital length of stay (24 days vs. 28 days; p = 0.42), discharged to rehabilitation (74% vs. 82%; p = 0.53), or median total hospital cost (292,329 dollars vs. 332,601 dollars; p = 0.26). CONCLUSION: Early tracheostomy was beneficial, resulting in a shorter ICU stay.