Clinical assessment of hemodynamic values in two surgical intensive care units. Effects on therapy

A prospective study of 126 surgical patients from two institutions was undertaken to assess the impact of pulmonary artery catheterization in surgical intensive care units. Before catheterization, surgical residents were asked to predict pulmonary artery wedge pressure, cardiac output, systemic vascular resistance, and plan of therapy. After catheterization, each chart was reviewed by a panel of intensive care specialists and a general surgeon. Correct classification for the hemodynamic variables ranged from 47% to 55%. Catheterization results prompted a major change in therapy in 50% of patients. The data suggest that hemodynamic variables obtained from pulmonary artery catheterization improve the accuracy of bedside evaluation and lead to alteration in therapy, particularly in patients whose pulmonary artery wedge pressure predictions were poor.     

Pharmaceutical use and antibiotic therapy in intensive care units

The present study has involved a sample of 750 medical or medical/surgical intensive care units. The aim was to identify the variations of antibiotic (AB) use, measured in monetary terms, and to sort out explicative variables accounting for the corresponding expense. Activity and expense data have been recorded for 1997. "Second intention" antibiotics have been defined as follows: imipenem, ceftazidime, cefpirome, cefepime, piperacillin/tazobactam, amikacin, isepamicin, vancomycin and teicoplanin. Only 60 evaluable sheets have been sent back. They include data about 28,000 admissions and 183,960 hospital days. The results are presented as means +/- standard deviation (SD) and the variability has been considered to be important if the ratio SD/mean was > 1. Nosocomial infections (NI) surveillance, antibiotic advisory board and restriction of use for some molecules were present in 95%, 67% and 78% of units, respectively. The units usually had 10 beds (range: 6-24) and the mean activity was 468 +/- 184 admissions/year and 3,066 +/- 1,454 hospital days/year. Mean duration of hospitalisation (MDH) was 6.9 +/- 2.7 days and mean omega score 114 +/- 61. Mean age of patients was 56.5 years, IGS II score 35.7 +/- 7; 29 +/- 16% of patients were mechanically ventilated for more than 48 hours and mortality rate was 17 +/- 7%. The mean number of bacterial isolates per unit was 369 +/- 323: Staphylococcus sp. 30% [including 25% of meticillin-resistant Staphylococcus aureus (MRSA)]; enterobacteria 30% (including 14% of cefotaxime-resistant isolates); Pseudomonas sp. 14% (including 40% of ticarcillin R isolates); other 26%. Pharmaceutical expense was 834 +/- 364 FF per day of hospitalisation, including 536 +/- 273 FF for drugs. Antibiotics accounted for 32% of the expense and second intention molecules for nearly 50% of antibiotic expense. More than 80% of antibiotic expense was accounted for by only 10 molecules. The mean cost/hospital day for the most expensive antibiotic, whatever the molecule ranking first, was 27 FF, for the second and third ones 18 and 14 FF. The expense for the tenth molecule was only 3 FF. There was a correlation between antibiotic expense and number of beds, number of hospital days, MDH, omega score, number of patients mechanically ventilated for more than 48 hours, mortality, number of bacterial isolates and incidence of NI. Molecules thought to be active against MRSA and ticarcillin-resistant Pseudomonas sp. accounted for 7 and 20% of total antibiotic expense, as compared to 7.5 and 4.6%, respectively, of bacterial isolates. As a conclusion, in this sample of 60 intensive care units, differences were shown for the cost of antibiotics, but the variability was low, without major discrepancies. Ten molecules accounted for 83% of total antibiotic expense. The financial impact of molecules against ticarcillin-resistant Pseudomonas sp is high.     

Intensive care units in surgery

The reasons why intensive care units have become essential are examined. The purpose of such units is to modify the organization of hospital assistance according to the concept of progressive treatment in line with the gravity of the disease concerned. Monitoring techniques as a function of the patient's gravity are outlined and the use of electronic processing as a valuable contribution to the surgeon in providing him with a complete and speedy physiological profile of the seriously ill patient is recommended. Finally, the cost of intensive care units is examined and to keep it down careful attention must be paid to the type of pathology admitted to such units. In spite of this by no means negligible factor, institution of such units is still recommended as quickly as possible, their organization being moulded to the situation in question.     

Cost analysis of blood purification in intensive care units: continuous versus intermittent hemodiafiltration

BACKGROUND: We implemented a program for continuous renal replacement therapies (CRRT) in intensive care units (ICU) based on the cooperative work of dialysis and ICU personnel. Our aim was to report the main details of this program and compare its cost with that of intermittent hemodiafiltration (IHDF). METHODS: The study referred to 181 ICU patients with renal failure. We considered the costs of both technical devices and assisting personnel. CRRT was performed as continuous veno-venous hemodiafiltration (CVVHDF) (24 hr daily); dialysis and ICU nurses shared surveillance. Only dialysis nurses performed IHDF (as acetate-free biofiltration, 4 hr daily) in the ICU. RESULTS: The daily cost of CRRT was Euro 276.70; of which 79% was for devices and 21% was for human resources. Nurse surveillance required 141 min per day, ICU nurses supplied 55% (77 min) and dialysis nurses 45% (64 min). On average, CRRT surveillance required less than 1 min/nurse/hr for both dialysis and ICU nurses. The daily cost of 4-hr IHDF sessions of was Euro 247.83, of which 44% was for technical devices and 56% was for human resources. CONCLUSIONS: The cooperation between dialysis and ICUs improved the use of human resources and allowed us to supply CRRT to all critically ill patients with acute renal failure. The expenditure for CRRT was 12% higher than that for IHDF, due to the cost of technical devices.     

Reevaluation of current transfusion practices in patients in surgical intensive care units.

Widespread interest in the complications associated with packed red blood cell (PRBC) transfusions has led to the scrutiny of traditional transfusion practices. Recently, attempts have been made to define more clearly the indications for PRBC transfusions in patients, particularly those who are critically ill. At present, however, transfusions continue to be ordered based on a hemoglobin level less than 10 g/dL. We report herein the impact on oxygen consumption of PRBC transfusions administered for a hemoglobin concentration less than 10 g/dL in 30 surgical intensive care unit patients who were euvolemic and hemodynamically stable. For the group as a whole, transfusion had a negligible effect on oxygen consumption. Fifty-eight percent of all such transfusions failed to change oxygen consumption by greater than 10% and could therefore be considered of questionable benefit.     

强化胰岛素治疗对外科重症患者预后的影响

目的 探讨不同血糖控制水平对外科重症患者炎症反应及预后的影响。方法 将188例术后入加强治疗病房（ICU）的APACH Ⅱ〉10分的重症患者随机分为血糖严格控制组（4．4～6．1mmol／L,n=75）、控制组（6．7～8．3mmol／L,n=75）和对照组（10．0～11．1mmol／L,n=38）。使用计算机程序化血糖管理方案控制血糖至目标水平,记录各组术后第1、4、7天血清C反应蛋白（CRP）,呼吸机使用天数、感染发生率、术后红细胞输注量、住ICU费用、住ICU天数、住院病死率等。结果 两血糖控制组红细胞输注及感染发生率均低于对照组（P〈0．05）。与对照组相比,严格控制组呼吸机使用天数及住ICU天数明显缩短（P〈0．05）。在住院病死率、住ICU费用方面,严格控制组与其他两组比较,亦有降低（P〉0．05）。低血糖发生率（〈3．3mmol／L）,严格控制组仍明显高于其他两组（P〈0．05）。结论 应激后控制血糖于正常可能更有利于改善外科重症患者预后,减少住ICU天数与费用。对于确定最佳的目标血糖,还需进一步的相关研究。     

Early tracheostomy versus late tracheostomy in the surgical intensive care unit

BACKGROUND: This study's purpose was to determine if early tracheostomy (ET) of severely injured patients reduces days of ventilatory support, the frequency of ventilator-associated pneumonia (VAP), and surgical intensive care unit (SICU) length of stay (LOS). METHODS: This 2-year retrospective review included 185 SICU patients with acute injuries requiring mechanical ventilation and tracheostomy. ET was defined as 7 days or less, and late tracheostomy (LT) as more than 7 days. RESULTS: The incidence of VAP was significantly higher in the LT group, relative to the ET group (42.3% vs. 27.2%, respectively; P <.05). Acute Physiology and Chronic Health Evaluation II scores, hospital and SICU LOS, and the number of ventilator days were significantly higher in the LT group. CONCLUSIONS: In patients who required prolonged mechanical ventilation, there was significant decreased incidence of VAP, less ventilator time, and lower ICU LOS when tracheostomy was performed within 7 days after admission to the SICU.