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

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

Subsyndromal delirium in the ICU: evidence for a disease spectrum

Objective ICU delirium is common and adverse. The Intensive Care Delirium Screening Checklist (ICDSC) score ranges from 0 to 8, with a score of 4 or higher indicating clinical delirium. We investigated whether lower (subsyndromal) values affect outcome. Patients 600 patients were evaluated with the ICDSC every 8 h. Measurements and results Of 558 assessed patients 537 noncomatose patients were divided into three groups: no delirium (score = 0; n = 169, 31.5%), subsyndromal delirium (score = 1–3; n = 179, 33.3%), and clinical delirium (score ≥ 4; n = 189, 35.2%). ICU mortality rates were 2.4%, 10.6%, and 15.9% in these three groups, respectively. Post-ICU mortality was significantly greater in the clinical delirium vs. no delirium groups (hazard ratio = 1.67) after adjusting for age, APACHE II score, and medication-induced coma. Relative ICU length of stay was: no delirium < subsyndromal delirium < clinical delirium and hospital LOS: no delirium < subsyndromal delirium ≈ clinical delirium. Patients with no delirium were more likely to be discharged home and less likely to need convalescence or long-term care than those with subsyndromal delirium or clinical delirium. ICDSC score increments higher than 4/8 were not associated with a change in mortality or LOS. Conclusions Clinical delirium is common, important and adverse in the critically ill. A graded diagnostic scale permits detection of a category of subsyndromal delirium which occurs in many ICU patients, and which is associated with adverse outcome. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users. This study was partly funded by the FRSQ (Fonds de Recherche en Santé du Québec, Réseau respiratoire). An erratum to this article can be found at     

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

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

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

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

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

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

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

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

Internal jugular venous catheter-related bacteremia according to central and posterior accesses

Background Although there are many studies about central venous catheter-related infection, we have not found any analysis of the incidence of internal jugular venous catheter-related bacteremia associated with different accesses. Objective The objective of this study was to test whether the position of the internal jugular venous catheter, central or posterior, influences the incidence of bacteremia. Design A cohort study. Setting A 12-bed polyvalent medical–surgical intensive care unit (ICU). Patients Patients admitted to ICU between 1 May 2000 and 30 April 2004 who received one or more internal jugular venous catheters. Measurements and results A total of 1,483 patients were admitted to the polyvalent ICU, of whom 1,311 underwent central venous catheterization. A total of 547 patients received 684 internal jugular venous catheters, 169 by posterior and 515 by central access. There were no significant differences between central and posterior access patients in sex, age, APACHE II (14.1 ± 5.0 vs. 13.9 ± 5.2, p = 0.40), diagnosis, order of catheter insertion, use of mechanical ventilation, use of antimicrobials, use of total parenteral nutrition or use of pulmonary artery catheter. We found a higher incidence of internal jugular venous catheter-related bacteremia with central (4.8 per 1000 catheter-day) than with posterior (1.2 per 1000 catheter-day) access (odds ratio 3.9; 95% confidence interval 1.1–infinite; p = 0.03). Conclusion Posterior access has a lower incidence of internal jugular venous catheter-related bacteremia than central access in non-severely ill patients (according to the low APACHE II score values of the study patients). Competing interests: none declared     

Focused training for goal-oriented hand-held echocardiography performed by noncardiologist residents in the intensive care unit

Objective We sought to evaluate the efficacy of a limited training dedicated to residents without knowledge in ultrasound for performing goal-oriented echocardiography in ICU patients. Design Prospective pilot observational study. Setting Medical-surgical ICU of a teaching hospital. Patients 61 consecutive adult ICU patients (SAPS II score: 38 ± 17; 46 ventilated patients) requiring a transthoracic echocardiography were studied. Interventions After a curriculum including a 3-h training course and 5 h of hands-on training, one of four noncardiologist residents and an intensivist experienced in ultrasound subsequently performed hand-held echocardiography (HHE), independently and in random order. Assessable “rule in, rule out” clinical questions were purposely limited to easily identifiable conditions by the sole use of two-dimensional imaging. Measurements and results When compared with residents, the experienced intensivist performed shorter examinations (4 ± 1 vs. 11 ± 4 min: p < 0.0001) and had significantly less unsolved clinical questions [3 (0.8%) vs. 27 (7.4%) of 366 clinical questions: p < 0.0001]. When addressed, clinical questions were adequately appraised by residents: left ventricular systolic dysfunction [Kappa: 0.76 ± 0.09 (95% CI: 0.59–0.93)], left ventricular dilatation [Kappa: 0.66 ± 0.12 (95% CI: 0.43–0.90)], right ventricular dilatation [Kappa: 0.71 ± 0.12 (95% CI: 0.46–0.95)], pericardial effusion [Kappa: 0.68 ± 0.18 (95 CI: 0.33–1.03)], and pleural effusion [Kappa: 0.71 ± 0.09 (95% CI: 0.53–0.88)]. The only case of tamponade was accurately diagnosed by the resident. Conclusions Limited training of noncardiologist ICU residents without previous knowledge in ultrasound appears feasible and efficient to address simple clinical questions using point-of-care echography. Influence of the learning curve on diagnostic accuracy and potential therapeutic impact remain to be determined.     

Gastric feed intolerance is not increased in critically ill patients with type II diabetes mellitus

Objective To examine the occurrence of feed intolerance in critically ill patients with previously diagnosed type II diabetes mellitus (DM) who received prolonged gastric feeding. Design and setting Retrospective study in a level 3 mixed ICU. Patients All mechanically ventilated, enterally fed patients (n = 649), with (n = 118) and without type II DM (n = 531) admitted between January 2003 and July 2005. Interventions Patients with at least 72 h of gastric feeding were identified by review of case notes and ICU charts. The proportion that developed feed intolerance was determined. All patient received insulin therapy. Results The proportion of patients requiring gastric feeding for at least 72 h was similar between patients with and without DM (42%, 50/118, vs. 42%, 222/531). Data from patients with DM were also compared with a group of 50 patients matched for age, sex and APACHE II score, selected from the total non-diabetic group. The occurrence of feed intolerance (DM 52% vs. matched non-DM 50% vs. unselected non-diabetic 58%) and the time taken to develop feed intolerance (DM 62.6 ± 43.8 h vs. matched non-DM 45.3 ± 54.6 vs. unselected non-diabetic 50.6 ± 59.5) were similar amongst the three groups. Feed intolerance was associated with a greater use of morphine/midazolam and vasopressor support, a lower feeding rate and a longer ICU length of stay. Conclusions In critically ill patients who require prolonged enteral nutrition, a prior history of DM type II does not appear to be a further risk factor for feed intolerance. This research was supported by the National Health and Medical Research Council of Australia An erratum to this article can be found at     

Adult congenital heart disease: intensive care management and outcome prediction

Objective Improved patient survival and increasingly complex surgery have expanded the requirement for specialist care for patients with adult congenital heart disease (ACHD). Despite the recent publications of management guidelines for ACHD, data concerning optimal patterns of care in the peri-operative/critical care period of this challenging population are sparse. The aims of the current study were to therefore to determine the pattern of intensive care unit (ICU) management, resource utilisation and predictors of mortality in critically ill ACHD patients. Design, setting and patients Data were collected prospectively for patients with ACHD stratified for complexity of disease admitted to the ICU of a tertiary cardiothoracic centre (1997–2002). Multivariate analysis of pre-operative indices as predictors of mortality was performed. Of 342 ACHD admissions (total mortality 4.4%, simple 0%, moderate/complex 10.6%), the requirement for specialist investigations and interventions was high, reflected in ICU admission costs per patient (simple $5391 ± 130, moderate $13218 ± 261, complex $30074 ± 689). Standard severity of illness scoring systems did not accurately predict mortality; however, abnormal pre-operative thyroid function (p = 0.0048), creatinine (p = 0.0032) and bilirubin (p = 0.0021) were highly predictive of mortality. Conclusions Peri-operative mortality in patients with ACHD is low overall but varies with disease complexity. Such patients have a high requirement for specialist ICU investigation/intervention. Although standard severity of illness scoring is unhelpful, simple pre-operative parameters may predict peri-operative mortality. These findings reflect the requirement for specialist care, and have implications for planning service provision, training and operative consent in ACHD patients.     

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

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

De-escalation therapy rates are significantly higher by bronchoalveolar lavage than by tracheal aspirate

Objective To assess outcomes with de-escalation therapy in ventilator-associated pneumonia (VAP). Design Prospective observational study. Setting Multidisciplinary intensive care unit. Patients and participants VAP was diagnosed by positive quantitative cultures of both tracheal aspirate and bronchoalveolar lavage (BAL) and treated appropriately for all significant isolates of tracheal aspirate and BAL in 143 patients who were assigned to de-escalation therapy by BAL or tracheal aspirate. Interventions None. Measurements and results Antibiotic therapy was de-escalated in 58 patients (40.5%), who had decreased mortality at day 15 (5.1% vs. 31.7%) and day 28 (12% vs. 43.5%) and shorter intensive care unit (17.2 ± 1.2 vs. 22.7 ± 6.3 days) and hospital (23.7 ± 2.8 vs. 29.8 ± 11.1 days) stay (p < 0.05). Of the 81 patients assigned to tracheal aspirate, the 17 (21%) who achieved de-escalation of therapy had reduced 15-day mortality (5.8% vs. 34.3%), reduced 28-day mortality (11.6% vs. 45.3%), and shorter intensive care unit (17.2 ± 1.6 vs. 22.4 ± 6.4 days) and hospital (23.1 ± 4.4 vs. 29.9 ± 11.1 days) stay (p < 0.05). Of the 62 patients assigned to BAL, the 41 (66.1%) who achieved de-escalation of therapy had decreased 15-day mortality (4.8% vs. 23.8%), decreased 28-day mortality (12.1% vs. 38%), and shorter intensive care unit (17.2 ± 1.1 vs. 23.2 ± 6 days) and hospital (23.8 ± 2.4 vs. 29.8 ± 11.4 days) stay (p < 0.05). Conclusions For patients with VAP who have had appropriate treatment and shown a favorable clinical response, mortality and duration of stay can be further improved by de-escalation therapy.     

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

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

Elimination of daily routine chest radiographs in a mixed medical–surgical intensive care unit

Objective To determine the impact of elimination of daily routine chest radiographs (CXRs) in a mixed medical–surgical intensive care unit (ICU) on utility of on demand CXRs, length of stay (LOS) in ICU, readmission rate, and mortality rate. Design and setting Prospective, nonrandomized, controlled study in a 28-bed ICU. Analysis included data of all admitted ICU patients during 5 months before and after elimination of daily routine CXRs. Results Before elimination, 2457 daily routine CXRs and 1437 on demand CXRs were obtained from 754 patients. After elimination, 1267 CXRs were obtained from 622 patients. The ratio of CXRs/patient day decreased from 1.1 ± 0.3 to 0.6 ± 0.4 (p < 0.05). Elimination did not result in a change in utility and timing of on demand CXRs. The absolute diagnostic and therapeutic value of on demand CXRs increased with elimination of daily routine CXRs: before intervention, 147 unexpected predefined abnormalities were found (10.2% of all on demand CXRs in 15.9% of all patients), of which 57 (3.9%) in 6.4% of all patients led to a change in therapy. After intervention, 156 unexpected predefined abnormalities were found (11.6%; p < 0.05), of which 61 (4.8%) in 9.5% of all patients (p < 0.05) led to a change in therapy. The LOS in ICU, readmission rate and ICU, and hospital mortality rate were not influenced by the change in strategy. Conclusions Elimination of daily routine CXRs reduced the number of CXRs in a mixed medical–surgical ICU, while not affecting readmission rate and ICU and hospital mortality rates. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users     

Junctional ectopic tachycardia after surgery for congenital heart disease in children

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

Occurrence of delirium is severely underestimated in the ICU during daily care

Objective  Delirium is associated with prolonged intensive care unit (ICU) stay and higher mortality. Therefore, the recognition of delirium is important. We investigated whether intensivists and ICU nurses could clinically identify the presence of delirium in ICU patients during daily care. Methods  All ICU patients in a 3-month period who stayed for more than 48 h were screened daily for delirium by attending intensivists and ICU nurses. Patients were screened independently for delirium by a trained group of ICU nurses who were not involved in the daily care of the patients under study. The Confusion Assessment Method for the ICU (CAM-ICU) was used as a validated screening instrument for delirium. Values are expressed as median and interquartile range (IQR; P25–P75). Results  During the study period, 46 patients (30 male, 16 female), median age 73 years (IQR = 64–80), with an ICU stay of 6 days (range 4–11) were evaluated. CAM-ICU scores were obtained during 425 patient days. Considering the CAM-ICU as the reference standard, delirium occurred in 50% of the patients with a duration of 3 days (range 1–9). Days with delirium were poorly recognized by doctors (sensitivity 28.0%; specificity 100%) and ICU nurses (sensitivity 34.8%; specificity 98.3%). Recognition did not differ between hypoactive or active status of the patients involved. Conclusion  Delirium is severely under recognized in the ICU by intensivists and ICU nurses in daily care. More attention should be paid to the implementation of a validated delirium-screening instrument during daily ICU care. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Goal-directed fluid management reduces vasopressor and catecholamine use in cardiac surgery patients

Objective We examined whether guiding therapy by an algorithm based on optimizing the global end-diastolic volume index (GEDVI) reduces the need for vasopressor and inotropic support and helps to shorten ICU stay in cardiac surgery patients. Design and setting Single-center clinical study with a historical control group at an university hospital. Patients Forty cardiac bypass surgery patients were included prospectively and compared with a control group. Interventions In the goal-directed therapy (GDT) group hemodynamic management was guided by an algorithm based on GEDVI. Hemodynamic goals were: GEDVI above 640 ml/m², cardiac index above 2.5 l/min/m², and mean arterial pressure above 70 mmHg. The control group was treated at the discretion of the attending physician based on central venous pressure, mean arterial pressure, and clinical evaluation. Results In the GDT group duration of catecholamine and vasopressor dependence was shorter (187 ± 70 vs. 1458 ± 197 min), and fewer vasopressors (0.73 ± 0.32 vs. 6.67 ± 1.21 mg) and catecholamines (0.01 ± 0.01 vs. 0.83 ± 0.27 mg) were administered. They received more colloids (6918 ± 242 vs. 5514 ± 171 ml). Duration of mechanical ventilation (12.6 ± 3.6 vs. 15.4 ± 4.3 h) and time until achieving status of fit for ICU discharge (25 ± 13 vs. 33 ± 17 h) was shorter in the GDT group. Conclusions Guiding therapy by an algorithm based on GEDVI leads to a shortened and reduced need for vasopressors, catecholamines, mechanical ventilation, and ICU therapy in patients undergoing cardiac surgery. Electronic supplementary material Supplementary material is available in the online version of this article at and is accessible for authorized users.     

Management of blood glucose in the critically ill in Australia and New Zealand: a practice survey and inception cohort study

Objective To document current management of blood glucose in Australian and New Zealand intensive care units (ICUs) and to investigate the association between insulin administration, blood glucose concentration and hospital outcome.Design and setting Practice survey and inception cohort study in closed multi-disciplinary ICUs in Australia and New Zealand.Patients Twenty-nine ICU directors and 939 consecutive admissions to 29 ICUs during a 2-week period.Measurement and results Data collected included unit approaches to blood glucose management, patient characteristics, blood glucose concentrations, insulin administration and patient outcomes. Ten percent of the ICU directors reported using an intensive insulin regimen in all their patients. In 861 patients (91.7%) blood glucose concentration was greater than 6.1 mmol/l, 287 (31.1%) received insulin, and the median blood glucose concentration triggering insulin administration was 11.5 (IQR 9.4–14) mmol/l. Univariate analysis demonstrated that non-survivors had a higher maximum daily blood glucose concentration (12 mmol/l, 9.4–14.8, vs. 9.5, 7.6–12.2) and were more likely to receive insulin (47% vs. 28%). Multiple logistic regression analysis showed age (OR per 5-year decrease 0.93, 95% CI 0.87–1.00) and APACHE II (OR per point decrease 0.87, 95% CI 0.84–0.90) to be independently associated with hospital mortality. After controlling for age and APACHE II both daily highest blood glucose (OR 0.95, 95% CI 0.90–1.00) and administration of insulin (OR 0.62, 95% CI 0.39–1.00) were independently associated when added to the model alone; neither was independently associated when they were simultaneously included in the model.Conclusion Few Australian and New Zealand ICUs have adopted intensive insulin therapy. In this study, insulin administration and highest daily blood glucose concentration could not be separated in their association with hospital mortality.Electronic supplementary material The electronic reference of this article is . The online full-text version of this article includes electronic supplementary material. This material is available to authorised users and can be accessed by means of the ESM button beneath the abstract or in the structured full-text article. To cite or link to this article you can use the above reference.     

Intensive care unit acquired infection and organ failure

Objective To assess the temporal relationship between ICU-acquired infection (IAI) and the prevalence and severity of organ dysfunction or failure (OD/F). Design and setting Observational, single center study in a mixed intensive care unit of a university hospital. Patients We analyzed 1,191 patients hospitalized for more than 2 days during a 2-year observation period: 845 did not acquire IAI, 306 of whom had infection on admission (IOA); 346 did acquire IAI, 125 of whom had IOA. Measurements and results The SOFA score was calculated daily, both SOFAmax, the sum of the worst OD/F during the ICU stay, and SOFApreinf, the sum of the worst OD/F existing before the occurrence of the first IAI. The SAPS II and SOFA score of the first 24 h were significantly higher in patients with than in those without IAI. SOFApreinf of IAI patients was also higher than the SOFAmax of patients without IAI both in patients with (12.1 ± 4.6 vs. 8.9 ± 4.7) and those without IOA (9.2 ± 4.0 vs. 6.7 ± 3.5). SOFApreinf represented 85.7% of the value of SOFAmax in patients with IAI. SOFApreinf increased significantly with the occurrence of sepsis, severe sepsis, or septic shock during ICU stay. Severe sepsis and septic shock during ICU stay as well as SOFApreinf were part of the factors associated with hospital mortality. Conclusions IAI is significantly associated with hospital mortality; however, its contribution to OD/F is minor. Moreover, severity of IAI seems to be related to previous health status. This article is discussed in the editorial available at: .     

Acute disseminated encephalomyelitisin the intensive care unit:clinical features and outcome of 20 adults

Objective Because acute disseminated encephalomyelitis (ADEM) is a rare disease in adults admitted to the intensive care unit (ICU), we describe its characteristics and patient outcomes. Design and setting A retrospective (2000–2006), observational, multicenter study was conducted in seven medical ICUs. Clinical, biological and neuroimaging features of patients diagnosed with ADEM were evaluated. Functional prognosis was graded using the modified Rankin (mR) scale. Interventions None. Measurements and results At ICU admission, the 20 patients' median (25th–75th percentile) Glasgow coma score (GCS) was 7 (4–13), temperature 39 (38–39) °C. Six (30%) patients had seizures, 17 (85%) had a motor deficit and 14 (70%) required mechanical ventilation. Fifteen (75%) patients had cerebrospinal fluid pleocytocis. All patients had white-matter lesions on their magnetic resonance images. All patients received high-dose steroids. Five (25%) patients died. Fourteen (70%) patients were able to walk without assistance (mR ≤ 3) at follow-up [7 (3–9) months]. Compared to the latter, patients who died or were severely disabled at the follow-up evaluation [6 (30%) patients, mR > 3] had significantly lower GCS (4 (3–4) vs. 12 (7–13), p = 0.002) and more frequent seizures [4 (67%) vs. 2 (14%), p = 0.02] at admission. Conclusions Unlike previous reports, our results showed that ADEM requiring ICU admission is a severe disease causing high mortality, and 35% of the patients had persistent functional sequelae. Intensivists should be aware of ADEM's clinical features to initiate appropriate immunomodulating therapy. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.