Disposition of instilled versus nebulized tobramycin and imipenem in ventilated intensive care unit (ICU) patients

BACKGROUND: Delivery of antibiotics to the lower respiratory tract could potentially achieve antimicrobial bronchial drug concentrations without toxicity. AIM: To assess bronchial and serum concentrations of imipenem or tobramycin obtained by nebulization or instillation in critically ill mechanically ventilated patients. METHODS: Prospective randomized open trial. Eighteen patients ventilated for more than 48 h were included. Two doses of imipenem/cilastatin (1000/500 mg) separated by 8 h, or two doses of tobramycin 200 mg separated by 12 h were randomly nebulized or instilled into the tracheal tube. Five bronchoaspirates (two bronchoscopic, three blind) and five blood samples were collected on a timed schedule after the second dose. Respiratory and serum samples were analysed by HPLC, and a subset of blood samples was also evaluated by enzyme-immunoassay. RESULTS: When instilled, imipenem/cilastatin obtained higher concentrations in respiratory secretions than when nebulized (P=0.022, 1 h after the last dose; P=0.029, 2 h after the last dose). Tobramycin showed equally high concentrations when nebulized or instilled. Instillation of tobramycin may result in significant accumulation in patients with renal failure. CONCLUSIONS: High bronchial concentrations of imipenem could only be achieved by instillation, whereas tobramycin seems suitable for both modes of administration. Instillation of these antibiotics is a safe procedure that achieves high drug concentrations in respiratory secretions.     

ICU与非ICU MRSA医院感染患者特征分析

目的探讨耐甲氧西林金葡菌(MRSA)医院感染患者的临床特征,为制订有效的MRSA感染控制方案提供参考和依据。方法采用前瞻性调查方法,对2011年1—6月MRSA医院感染患者的临床资料进行调查分析。结果重症监护病房(ICU)MRSA医院感染率高于非ICU,两者差异有统计学意义(P<0.05);ICU MRSA感染以下呼吸道感染(61.1%)和血流感染(27.8%)为主,而非ICU以皮肤软组织感染(66.7%)为主,不同科室MRSA感染疾病谱存在差异(P<0.05);ICU和非ICU MRSA感染患者在年龄、基础疾病、侵袭性操作、手术、疾病转归等方面差异均存在统计学意义(P<0.05)。结论 ICU和非ICU MRSA感染存在差异,应采取针对性的控制措施。     

A systematic review and meta-analysis of propofol versus midazolam sedation in adult intensive care (ICU) patients

PurposeCompare outcomes of adult patients admitted to ICU- length of ICU stay, length of mechanical ventilation (MV), and time until extubation- according to the use of propofol versus midazolam.MethodsWe searched MEDLINE, EMBASE, LILACS, and Cochrane databases to retrieve RCTs that compared propofol and midazolam used as sedatives in adult ICU patients. We applied a random-effects, meta-analytic model in all calculations. We applied the Cochrane collaboration tool and GRADE. We separated patients into two groups: acute surgical patients (hospitalization up to 24 h) and critically-ill patients (hospitalization over 24 h and whose articles mostly mix surgical, medical and trauma patients).ResultsGlobally, propofol was associated with a reduced MV time of 4.46 h (MD: -4.46 [95% CI -7.51 to −1.42] p = 0.004, I2 = 63%, 6 studies) and extubation time of 7.95 h (MD: -7.95 [95% CI -9.86 to −6.03] p < 0.00001, I2 = 98%, 16 studies). Acute surgical patients sedation with propofol compared to midazolam was associated with a reduced ICU stay of 5.07 h (MD: -5.07 [95% CI -8.68 to −1.45] p = 0.006, I2 = 41%, 5 studies), MV time of 4.28 h (MD: −4.28; [95% CI -4.62 to −3.94] p < 0.0001, I2 = 0%, 3 studies), extubation time of 1.92 h (MD: −1.92; [95% CI -2.71 to −1.13] p = 0.00001, I2 = 89%, 9 studies). In critically-ill patients sedation with propofol compared to midazolam was associated with a reduced extubation time of 32.68 h (MD: -32.68 [95% CI -48.37 to −16.98] p = 0.0001, I2 = 97%, 9 studies). GRADE was very low for all outcomes.ConclusionsSedation with propofol compared to midazolam is associated with improved clinical outcomes in ICU, with reduced ICU stay MV time and extubation time in acute surgical patients and reduced extubation time in critically-ill patients.     

Sepsis in European intensive care units: results of the SOAP study

OBJECTIVE: To better define the incidence of sepsis and the characteristics of critically ill patients in European intensive care units. DESIGN: Cohort, multiple-center, observational study. SETTING: One hundred and ninety-eight intensive care units in 24 European countries. PATIENTS: All new adult admissions to a participating intensive care unit between May 1 and 15, 2002. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic data, comorbid diseases, and clinical and laboratory data were collected prospectively. Patients were followed up until death, until hospital discharge, or for 60 days. Of 3,147 adult patients, with a median age of 64 yrs, 1,177 (37.4%) had sepsis; 777 (24.7%) of these patients had sepsis on admission. In patients with sepsis, the lung was the most common site of infection (68%), followed by the abdomen (22%). Cultures were positive in 60% of the patients with sepsis. The most common organisms were Staphylococcus aureus (30%, including 14% methicillin-resistant), Pseudomonas species (14%), and Escherichia coli (13%). Pseudomonas species was the only microorganism independently associated with increased mortality rates. Patients with sepsis had more severe organ dysfunction, longer intensive care unit and hospital lengths of stay, and higher mortality rate than patients without sepsis. In patients with sepsis, age, positive fluid balance, septic shock, cancer, and medical admission were the important prognostic variables for intensive care unit mortality. There was considerable variation between countries, with a strong correlation between the frequency of sepsis and the intensive care unit mortality rates in each of these countries. CONCLUSIONS: This large pan-European study documents the high frequency of sepsis in critically ill patients and shows a close relationship between the proportion of patients with sepsis and the intensive care unit mortality in the various countries. In addition to age, a positive fluid balance was among the strongest prognostic factors for death. Patients with intensive care unit acquired sepsis have a worse outcome despite similar severity scores on intensive care unit admission.     

Early tracheotomy versus prolonged endotracheal intubation in unselected severely ill ICU patients

Objective  Although several advantages are attributed to tracheotomy in ICU patients requiring mechanical ventilation (MV), true benefits and the optimal timing of tracheotomy remain controversial. In this study, we compared early tracheotomy (ET) with prolonged intubation (PI) in severely ill patients requiring prolonged MV. Design  Prospective, randomized study. Setting  Twenty-five medical and surgical ICUs in France. Patients  Patients expected to require MV > 7 days. Measurements and results  Patients were randomised to either (open or percutaneous) ET within 4 days or PI. The primary end-point was 28-day mortality. Secondary end-points were: the incidence of ICU-acquired pneumonia, number of d1-d28 ventilator-free days, time spent in the ICU, 60-day mortality, number of septic episodes, amount of sedation, comfort and laryngeal and tracheal complications. A sample size of 470 patients was considered necessary to obtain a reduction from 45 to 32% in 28-day mortality. After 30 months, 123 patients had been included (ET = 61, PI = 62) in 25 centres and the study was prematurely closed. All group characteristics were similar upon admission to ICU. No difference was found between the two groups for any of the primary or secondary end-points. Greater comfort was the sole benefit afforded by tracheotomy after subjective self-assessment by patients. Conclusions  The trial did not demonstrate any major benefit of tracheotomy in a general population of ICU patients, as suggested in a previous meta-analysis, but was underpowered to draw any firm conclusions. The potential advantage of ET may be restricted to selected groups of patients. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users. This article is discussed in the editorial available at: doi:     

Video versus direct laryngoscopy on successful first-pass endotracheal intubation in ICU patients

BACKGROUND: Airway management in intensive care unit (ICU) patients is challenging. The aim of this study was to compare the rate of successful first-pass intubation in the ICU by using the direct laryngoscopy (DL) and that by using the video laryngoscopy (VL).METHODS: A randomized, non-blinded trial comparing first-pass success rate of intubation between VL and DL was performed. Patients were recruited in the period from August 2014 to August 2016. All physicians working at ICU received hands-on training in the use of the video and direct laryngoscope. The primary outcome measure was the first-pass intubation success.RESULTS: A total of 163 ICU patients underwent intubation during the study period (81 patients in VL group and 82 in DL group). The rate of successful first-pass intubation was not significantly different between the VL and the DL group (67.9% vs. 69.5%, P=0.824). Moreover, the overall intubation success and total number of attempts to achieve intubation success did not differ between the two groups. In patients with successful first-pass intubation, the median duration of the intubation procedure did not differ between the two groups. The Cormack-Lehane grades and the percentage of glottic opening score were similar, and no significant differences were found between the two groups. There were no statistical differences between the VL and the DL group in intubation complications (all P>0.05).CONCLUSION: Among ICU patients requiring intubation, there was no significant difference in the rate of successful first-pass intubation between VL and DL.     

Changes in treatments and outcomes among elderly patients with out-of-hospital cardiac arrest between 2002 and 2012: A post hoc analysis of the SOS-KANTO 2002 and 2012

BackgroundLittle is known about recent changes in pre- and in-hospital treatments and outcomes for elderly patients with out-of-hospital cardiac arrest (OHCA).MethodsWe compared data collected for the SOS-KANTO study in 2002 and 2012. We included patients aged ≥65 years who experienced OHCA of cardiac aetiology. The primary endpoint was favourable neurological outcomes 1 month after cardiac arrest.ResultsA total of 8,964 (2002 vs. 2012: 3,544 vs. 5,420) patients were eligible for the current analysis. The proportion of pre-hospital return of spontaneous circulation (ROSC) increased significantly (3.8 vs. 5.6%, p < 0.001). Among patients achieving ROSC, the proportion of advanced in-hospital treatments (i.e. extracorporeal membrane oxygenation, therapeutic hypothermia, and/or percutaneous coronary angiogram/intervention) provided increased significantly in 2012 (1.2 vs. 5.5%, p < 0.001; 2.6 vs. 15.1%, p < 0.001; 4.9 vs. 16.5%, p < 0.001; respectively). The proportion of favourable neurological outcomes at 1 month increased significantly in 2012 (1.6 vs. 2.7%, p = 0.001). A logistic regression analysis that did not consider advanced in-hospital treatments showed a significantly higher rate of favourable neurological outcomes in the 2012 group than that in the 2002 group (OR, 2.2; 95% CI, 1.4–3.5). However, this difference was no longer observed in the second regression model that accounted for advanced in-hospital treatments (OR, 1.6; 95% CI, 0.9–2.9).ConclusionThere was an increased proportion of aggressive treatment, both pre- and in-hospital, for elderly patients with cardiogenic OHCA in the Kanto area, Japan. Favourable neurological outcomes improved significantly over 10 years.     

Eight-hour versus 12-h shifts in an ICU: Comparison of nursing responses and patient outcomes

IntroductionControversy remains about the impact of 12-h shift patterns on staff satisfaction and health and on patient outcomes. Consequently, the objective of the study was to investigate the effect on nurses and patients of 8-h rostering compared with 12-h rostering.MethodsWe conducted a two-phase survey. Intensive care nurses completed a purposefully designed 49-item questionnaire, which included open- and closed-ended questions. Phase 1 was conducted during 2015, while the 8-h shift pattern was in place. Data for phase 2 were collected in 2017, approximately 6 months after the trial of 12-h shifts began. We extracted data from the hospital's adverse event register to compare patient outcomes between the two phases.ResultsA total of 152/193 (78.8%) surveys were returned in phase 1. In phase 2, the response rate was 114/188 (60.6%). The proportion of nurses satisfied with the roster increased 3-fold after the introduction of 12-h shifts; risk ratios 3.36 (95% confidence intervals 2.62 to 4.28). Communication with all levels of senior staff improved, and the number of hours of professional development leave increased with the 12-h roster phase 1, 358 h versus 538 h in phase 2 (p = <0.0001). Most respondents believed that 12-h shifts would be beneficial for their health, and this belief was validated by official leave records; there was a reduction of 69 days for sick leave and 216 days for family leave. Adverse outcomes for patients were similar in the two periods.ConclusionTwelve-hour shifts are popular with ICU nurses, days lost to sick and family leave are reduced, and patient outcomes are not compromised.     

Cooling strategies for patients with severe cerebral insult in ICU (Part 2)

Critically ill patients who have sustained a severe cerebral insult will be actively cooled should they develop an elevated body core temperature. Patients who require therapeutic hypothermia for neuroprotection may require the same cooling strategies. A literature review suggested limited evidence to support cooling strategies currently used within one intensive care unit. An experimental approach was used to examine the effects of paracetamol and four external cooling strategies on patients with severe cerebral insult It is suggested that paracetamol is effective in reducing body core temperature and that fans may not. However, data obtained from the study of the four external cooling strategies were inconclusive.     

A review of cooling patients with severe cerebral insult in ICU (Part 1)

A review of the literature was undertaken to determine the existence of any evidence to support cooling strategies used in the ICU. The focus of the review was to examine previous findings on the specific problems of cooling patients with severe cerebral insult. Cooling methods that use external physical cooling strategies as well as the effects of antipyretics and vasoactive drugs were examined. Overall, it would appear that conclusions for practice remain unclear. The findings led to the implementation of a pilot study, the findings of which will be discussed in Part 2.     

Comparison of different pain scoring systems in critically ill patients in a general ICU

Background

Pain in critically ill patients in the intensive care unit (ICU) is common. However, pain assessment in critically ill patients often is complicated because these patients are unable to communicate effectively. Therefore, we designed a study (a) to determine the inter-rater reliability of the Numerical Rating Scale (NRS) and the Behavioral Pain Scale (BPS), (b) to compare pain scores of different observers and the patient, and (c) to compare NRS, BPS, and the Visual Analog Scale (VAS) for measuring pain in patients in the ICU.

Methods

We performed a prospective observational study in 113 non-paralyzed critically ill patients. The attending nurses, two researchers, and the patient (when possible) obtained 371 independent observation series of NRS, BPS, and VAS. Data analyses were performed on the sample size of patients (n = 113).

Results

Inter-rater reliability of the NRS and BPS proved to be adequate (kappa = 0.71 and 0.67, respectively). The level of agreement within one scale point between NRS rated by the patient and NRS scored by attending nurses was 73%. However, high patient scores (NRS ≥4) were underestimated by nurses (patients 33% versus nurses 18%). In responsive patients, a high correlation between NRS and VAS was found (r_s = 0.84, P < 0.001). In ventilated patients, a moderate positive correlation was found between the NRS and the BPS (r_s = 0.55, P < 0.001). However, whereas 6% of the observations were NRS of greater than or equal to 4, BPS scores were all very low (median 3.0, range 3.0 to 5.0).

Conclusion

The different scales show a high reliability, but observer-based evaluation often underestimates the pain, particularly in the case of high NRS values (≥4) rated by the patient. Therefore, whenever this is possible, ICU patients should rate their pain. In unresponsive patients, primarily the attending nurse involved in daily care should score the patient's pain. In ventilated patients, the BPS should be used only in conjunction with the NRS nurse to measure pain levels in the absence of painful stimuli.     

重症监护室中风患者早期康复治疗的价值

目的 探讨早期康复治疗在重症监护室(ICU)的实施及对急性脑卒中患者功能的影响.方法 对ICU中风患者在监护下生命体征相对稳定时实施早期康复治疗,并评定患者治疗前后脑损伤程度及运动功能的恢复情况.结果 治疗组患者在实施康复治疗后Glasgow昏迷量表(GCS)与对照组比有明显恢复(P<0.001), 而对照组改善不明显.肢体运动功能简式Fugl-Mayer评估(FMA)治疗组和对照组在治疗前后都有明显提高,治疗组在治疗后上肢运动功能改善明显优于对照组(P<0.05).结论 ICU中风患者虽然预后不良,但早期康复干预,对患者功能有促进作用,减少各种并发症,具有康复的潜力和价值.     

Early versus late parenteral nutrition in ICU patients: cost analysis of the EPaNIC trial

ABSTRACT: INTRODUCTION: The EPaNIC randomized controlled multicentre trial showed that postponing initiation of parenteral nutrition (PN) in ICU-patients to beyond the first week (Late-PN) enhanced recovery, as compared with Early-PN. This was mediated by fewer infections, accelerated recovery from organ failure and reduced duration of hospitalization. Now, the trial's preplanned cost analysis (N = 4640) from the Belgian healthcare payers' perspective is reported. METHODS: Cost data were retrieved from individual patient invoices. Undiscounted total healthcare costs were calculated for the index hospital stay. A cost tree based on acquisition of new infections and on prolonged length-of-stay was constructed. Contribution of 8 cost categories to total hospitalization costs was analyzed. The origin of drug costs was clarified in detail through the Anatomical Therapeutic Chemical (ATC) classification system. The potential impact of Early-PN on total hospitalization costs in other healthcare systems was explored in a sensitivity analysis. RESULTS: ICU-patients developing new infection (24.4%) were responsible for 42.7% of total costs, while ICU-patients staying beyond one week (24.3%) accounted for 43.3% of total costs. Pharmacy-related costs represented 30% of total hospitalization costs and were increased by Early-PN (+608.00 EUR/patient, p = 0.01). Notably, costs for ATC-J (anti-infective agents) (+227.00 EUR/patient, p = 0.02) and ATC-B (comprising PN) (+220.00 EUR/patient, p = 0.006) drugs were increased by Early-PN. Sensitivity analysis revealed a mean total cost increase of 1,210.00 EUR/patient (p = 0.02) by Early-PN, when incorporating the full PN costs. CONCLUSIONS: The increased costs by Early-PN were mainly pharmacy-related and explained by higher expenditures for PN and anti-infective agents. The use of Early-PN in critically ill patients can thus not be recommended for both clinical (no benefit) and cost-related reasons. TRIAL REGISTRATION: ClinicalTrials.gov NCT00512122.