A one-year mortality study of the most acutely ill patients in a medical-surgical intensive care unit: toward developing a model for selection of recipients of intensive care

This study over a 1-year period of time in a medical-surgical ICU in a large metropolitan teaching hospital was conducted to determine the mortality rate among a select group of acutely ill patients. By operational definition the acutely ill patients included in this study were those who were admitted to the medical-surgical ICU and treated with at least two out of three of the following: MA-1 ventilator, flow-directed balloon-tipped catheter, and vasopressor(s). Of 158 patients in the study, 117 died during hospitalization. The personnel in this oversubscribed unit were constantly faced with the decision of who should and who should not be admitted and who should be transferred out. Statistics on intensive care management are converted into daily costs for intensive care for those who did and did not survive. Model building is discussed as a process necessary in determining who shall receive intensive care and who shall not. The basic premise for conducting the study was that decisions regarding who shall receive care that is expensive and in limited supply should be based on facts to the extent that they can be elucidated.     

Outcome of patients having dermatomyositis admitted to the intensive care unit

Patients having systemic rheumatic diseases constitute a small percentage of admissions to the medical intensive care units (ICUs). Dermatomyositis (DM) is one of the rheumatic diseases that have secondary complications that may lead to a critical illness requiring hospitalization in the ICU. Herein, we present the features, clinical course, and outcome of critically ill patients having DM who were admitted to the ICU. The medical records of six DM patients admitted to the ICU in a large tertiary hospital in a 12-year period were reviewed. The mean age of patients at time of admission to the ICU was 38 (range 16–37). Mean disease duration from diagnosis to admission to the ICU was 1.6 years (range 1 month–8 years), while the main reason for admission to the ICU was acute respiratory failure. Two of six patients died during the hospitalization. The main causes of death were respiratory complications and sepsis. The outcome of DM patients admitted to the ICU was generally not different from the outcome of other patients hospitalized in the ICU. The main reason for hospitalization was acute respiratory failure. As there are many reasons for respiratory failure in DM, an early diagnosis and aggressive appropriate treatment may help to further reduce the mortality in these patients.     

Impact of a comprehensive supportive care team on management of hopelessly ill patients with multiple organ failure

We developed a supportive care team for hopelessly ill patients in an urban emergency/trauma hospital. The team includes a clinical nurse specialist and a faculty physician as well as a chaplain and social worker. The supportive care team provides an alternative to intensive care or conventional ward management of hopelessly ill patients and concentrates on the physical and psychosocial comfort needs of patients and their families. We describe our experience with 20 hopelessly ill patients with multiple organ failure vs a similar group treated before the development of the supportive care team. Although there was no difference in mortality (100 percent), the length of stay in the medical ICU for patients with multiple organ failure decreased by 12 days to 6 days. Additionally, there were 50 percent fewer therapeutic interventions provided by the supportive care team vs intensive care or conventional ward treatment of multiple organ failure patients. We describe the methods that the supportive care team uses in an attempt to meet the physical and psychosocial comfort needs of hopelessly ill multiple organ failure patients and their families. This multidisciplinary approach to the care of the hopelessly ill may have applications in other institutions facing the ethical, medical, and administrative challenges raised by these patients.     

Nonphysician clinicians in the ICU

Until very recently the medical care of the patient in the intensive care unit (ICU) was provided primarily by physicians. Many of these physicians were specifically trained as intensivists to manage the critically ill and provide minute to minute titration of care to improve the outcomes of these patients. However there has been a change in the delivery of critical care in many centers with the addition of NPCs (nonphysician clinicians) to the team. A 1998 article in JAMA listed 10 nonphysician disciplines that will affect the demand for physicians in the future; this article focuses on only two of these disciplines: physician assistants (PAs) and acute care nurse practitioners (ACNPs). A driving force for the addition of these NPCs to the ICU team is the downsizing of resident programs. This article explores the utilization of NPCs in the ICU, including the perceived advantages and potential controversies associated with these practitioners.     

An evolving role for endobronchial ultrasonography in the intensive care unit

Endobronchial ultrasound (EBUS) bronchoscopy is an established minimally-invasive modality for visualization, characterization, and guidance of sampling of paratracheal and parabronchial structures and tissues. In the intensive care unit (ICU), rapidly obtaining an accurate diagnosis is paramount to the management of critically ill patients. In some instances, diagnosing and confirming terminal illness in a critically ill patient provides needed closure for patients and their loved ones. Currently available data on feasibility, safety, and yield of EBUS bronchoscopy in critically ill patients is based on single center experiences. These data suggest that in select ICU patients convex and radial probe-EBUS bronchoscopy can serve as useful tools in the evaluation of mediastinal lymphadenopathy, central airway obstruction, pulmonary embolism, and peripheral lung lesions. Barriers to the use of EBUS bronchoscopy in the ICU include: (I) requirement for dedicated equipment, prolonged procedure time, and bronchoscopy team expertise that may not be available; (II) applicability to a limited number of patients and conditions in the ICU; and (III) technical difficulty related to the relatively large outer diameter of the convex probe-EBUS bronchoscope and an increased risk for adverse cardiopulmonary consequences due to intermittent obstruction of the artificial airway. While the prospects for EBUS bronchoscopy in critically ill patients appear promising, judicious patient selection in combination with bronchoscopy team expertise are of utmost importance when considering performance of EBUS bronchoscopy in the ICU setting.     

Sensory-perceptual alterations: delirium in the intensive care unit

The delirium that is commonly associated with admission to an intensive care setting (intensive care unit [ICU] psychosis) may be terrifying to the patient, but may go undetected by the nurse. Our current understanding of this delirium is discussed according to incidence, defining characteristics, and etiologic or contributing factors such as predisposing patient factors, pharmacologic agents, and environmental factors. We examine several episodes of delirium that were recounted retrospectively by patients who were discharged from a surgical ICU. These episodes of delirium are examined with reference to sensory-perceptual, perceptual or sensory alterations. We discuss nursing interventions that help to prevent or lessen the impact of delirium before an ICU admission, during the ICU course, and after discharge from the ICU.     

Pulmonary function testing in the intensive care unit

A number of tests of pulmonary function have been successfully developed for use in the intensive care unit. When performed in the ICU on critically ill patients, many of the traditional laboratory-based tests will have different clinical implications than when performed in ambulatory patients, for example vital capacity measurement. Also, the clinical questions posed in the ICU are often different, such that estimates of lung water may be clinically more useful than more traditional measures, such as the flow-volume loop. There is a need for further research to identify the clinical utility of these measurements. As the understanding of ARDS and MOF improves, new therapies may be developed which will require sensitive methods in order that they can be evaluated accurately. Similarly, the potential for new methods of respiratory support such as jet ventilation, extracorporeal techniques and lung transplantation reinforce the need for the pulmonary physician to be able to make an accurate assessment of respiratory function on the intensive care unit.     

Sedation and analgesia in the mechanically ventilated patient

Sedation and analgesia are important components of care for the mechanically ventilated patient in the intensive care unit (ICU). An understanding of commonly used medications is essential to formulate a sedation plan for individual patients. The specific physiological changes that a critically ill patient undergoes can have direct effects on the pharmacology of drugs, potentially leading to interpatient differences in response. Objective assessments of pain, sedation, and agitation have been validated for use in the ICU for assessment and titration of medications. An evidence-based strategy for administering these drugs can lead to improvements in short- and long-term outcomes for patients. In this article, we review advances in the field of ICU sedation to provide an up-to-date perspective on management of the mechanically ventilated ICU patient.     

A 2015 Update on Ventilator-Associated Pneumonia: New Insights on Its Prevention,Diagnosis, and Treatment

Ventilator-associated pneumonia (VAP), an infection of the lower respiratory tract which occurs in association with mechanical ventilation, is one of the most common causes of nosocomial infection in the intensive care unit (ICU). VAP causes significant morbidity and mortality in critically ill patients including increased duration of mechanical ventilation, ICU stay and hospitalization. Current knowledge for its prevention, diagnosis and management is therefore important clinically and is the basis for this review. We discuss recent changes in VAP surveillance nomenclature incorporating ventilator-associated conditions and ventilator-associated events, terms recently proposed by the Centers for Disease Control. To the extent possible, we rely predominantly on data from randomized control trials (RCTs) and meta-analyses.     

Cost considerations in sedation, analgesia, and neuromuscular blockade in the intensive care unit

Sedation of critically ill patients is a costly endeavor. Costs of commonly used intensive care unit (ICU) sedatives range from pennies to more than $500 per day. Although the agents account for some of this expense, complications related to the use of these drugs in the ICU produce even greater costs. Prolongation of mechanical ventilation and length of stay are some of the common complications resulting from non-ideal use of these drugs. Sedative agents also impair neurological evaluation in many critically ill patients, which may mask detection of acute delirium resulting from intercurrent illness or intracranial catastrophes and can lead to excessive diagnostic testing. Opiates may result in gastrointestinal dysfunction with resulting malnutrition and perhaps bacterial translocation and sepsis. Neuromuscular blocking agents may cause prolonged paralysis and disability in critically ill patients who receive them. Simple dosing strategies based on pharmacological principles may decrease the incidence of these costly problems.     

Klinisch relevante pharmakokinetische Arzneimittelinteraktionen in der Intensivmedizin

Critically ill patients in the intensive care unit (ICU) are predisposed to pharmacokinetic drug interactions because of the complexity of the drug regimens received in the intensive care setting. Drugs may affect the absorption, distribution, metabolism and/or elimination of an object drug and consequently alter the intended pharmacologic response and potentially lead to an adverse event. The paper presents an overview of pharmacokinetic drug-drug interactions which can occur with commonly used drugs in the ICU and outlines the underlying types and mechanisms.     

Nursing interventions for children with a parent in the intensive care unit

Hospitalization of a family member in an intensive care unit is a stressful event for the entire family. Nurses should be concerned not only with the hospitalized patient but with the family, as a unit. Attention is often focused on the patient and to a lesser extent on the spouse. The needs of the children may be neglected. To reduce the long-term negative effects of the crisis event on the life of the child, appropriate interventions should be made at the time of the crisis. It is important for nurses to recall emotional and cognitive phases of growth and development when counseling parents. This information is used to help the nonhospitalized parent identify the needs of the child. The nurse can act as a resource person for this parent in planning strategies that will prevent or alleviate problems for the child.     

Upon-admission adrenal steroidogenesis is adapted to the degree of illness in intensive care unit patients

Adrenal function was studied in 2 groups of intensive care unit (ICU) patients with varying degrees of illness, as determined by Acute Physiological and Chronic Health Evaluation (APACHE). The 15 seriously ill patients with high APACHE scores (greater than or equal to 25) had elevated Therapeutic Intervention Scores and increased mortality compared to the 15 ill patients (APACHE, less than or equal to 10; 67% vs. 27%). Plasma cortisol, aldosterone, and androstenedione concentrations were increased in the ICU patients compared to those in normal subjects (n = 23), being greater in the seriously ill patients. Plasma dehydroepiandrosterone sulfate (DHEAS) concentrations were low in both groups of ICU patients. The ratios of aldosterone or androstenedione to cortisol were not altered, whereas the DHEAS to cortisol ratios were reduced in the ICU patients. ACTH injection elicited increases in plasma cortisol, aldosterone, and androstenedione concentrations in both groups of ICU patients, and the ratios of aldosterone and androstenedione to cortisol did not change. In the seriously ill patients, plasma DHEAS increased, so that the DHEAS to cortisol ratio did not change, whereas in less ill patients plasma DHEAS did not increase, so that the DHEAS to cortisol ratio was reduced. In this study of patients admitted to an ICU, impairment of adrenal steroid secretion appears to be specific for DHEAS. Although plasma cortisol was elevated in ill patients proportional to the degree of illness, the contribution of the concomitant decrease in DHEAS to this increase is not clear.     

Therapy insight: the effect of tight glycemic control in acute illness

Hyperglycemia commonly occurs in patients who are acutely ill, in a variety of clinical situations. Generally, moderate hyperglycemia in critically ill patients was thought to be beneficial; however, the degree of hyperglycemia on admission and the duration of hyperglycemia during critical illness are now recognized markers of adverse outcome. The use of insulin therapy to maintain normoglycemia for at least a few days improves survival and reduces morbidity in patients who are in a surgical intensive care unit (ICU), as shown by a large, randomized, controlled study. These results were recently confirmed by two studies--a randomized, controlled study of patients in a medical ICU, and a prospective, observational study of a heterogeneous patient population admitted to a mixed medical and surgical ICU. Results of multicenter trials that investigated tight blood-glucose control in critically ill patients are, however, still lacking. While we await those multicenter results, the current evidence favors the control of blood glucose levels in the ICU. Indeed, the studies showed that many lives are saved with this intervention, despite an increased incidence of hypoglycemia. Prevention of glucose toxicity by strict glycemic control (but also other metabolic and nonmetabolic effects of insulin) contribute to these clinical benefits.     

Use of contrast echocardiography in intensive care and at the emergency room

Bedside echocardiography in emergency room (ER) or in intensive care unit (ICU) is an important tool for managing critically ill patients, to obtain a timely accurate diagnosis and to immediately stratify the risk to the patient's life. It may also render invasive monitoring unnecessary. In these patients, contrast echocardiography may improve quality of imaging and also may provide additional information, especially regarding myocardial perfusion in those with suspected coronary artery disease. This article focuses on the principle of contrast echocardiography and the clinical information that can be obtained according to the most frequent presentations in ER and ICU.     

Effect of intensive care unit organizational model and structure on outcomes in patients with acute lung injury

RATIONALE: Prior studies supported an association between intensive care unit (ICU) organizational model or staffing patterns and outcome in critically ill patients. OBJECTIVES: To examine the association of closed versus open models with patient mortality across adult ICUs in King County (WA). METHODS: Cohort study of patients with acute lung injury (ALI). MEASUREMENTS AND MAIN RESULTS: ICU structure, organization, and patient care practices were assessed using self-administered mail questionnaires completed by the medical director and nurse manager. We defined closed ICUs as units that required patient transfer to or mandatory patient comanagement by an intensivist and open ICUs as those relying on other organizational models. Outcomes were obtained from the King County Lung Injury Project, a population-based cohort of patients with ALI. The main endpoint was hospital mortality. Of 24 eligible ICUs, 13 ICUs were designated closed and 11 open. Complete survey data were available for 23 (96%) ICUs. Higher physician and nurse availability was reported in closed versus open ICUs. A total of 684 of 1,075 (63%) of patients with ALI were cared for in closed ICUs. After adjusting for potential confounders, patients with ALI cared for in closed ICUs had reduced hospital mortality (adjusted odds ratio, 0.68; 95% confidence interval, 0.53, 0.89; P = 0.004). Consultation by a pulmonologist in open ICUs was not associated with improved mortality (adjusted odds ratio, 0.94; 95% confidence interval, 0.74, 1.20; P = 0.62). These findings were robust for varying assumptions about the study population definition. CONCLUSIONS: Patients with ALI cared for in a closed-model ICU have reduced mortality. These data support recommendations to implement structured intensive care in the United States.     

Outcome of patients with scleroderma admitted to intensive care unit. A report of nine cases

OBJECTIVE: Patients with systemic rheumatic disease constitute a small percentage of admissions to the medical intensive care units (ICUs). Systemic sclerosis (SSc) is one of the rheumatic diseases that together with secondary complications may lead to a critical illness requiring hospitalization in the ICU. We present the features, clinical course and outcome of critically ill patients with scleroderma that were admitted to the ICU. METHODS: The medical records of nine patients with diagnosis of scleroderma (8 female, 1 male), admitted to the intensive care unit of Sheba Medical Center during the 11-year interval between 1991 and 2002, were reviewed. RESULTS: The mean age of the patients at the time of admission to the ICU was 48 +/- 13 [SD] years.The mean duration of SSc from diagnosis to the ICU admission was 8 +/- 8 years. Six patients had diffuse SSc, two patients had limited SSc and one patient had juvenile diffuse morphea. The main reasons for admission to the ICU were: infection/ septic syndrome (n = 4), scleroderma renal crisis (SRC) with pulmonary congestion (n = 2), acute renal failure associated with diffuse alveolar hemorrhage namely scleroderma- pulmonary - renal syndrome (SPRS) (n = 1), iatrogenic pericardial tamponade (n = 1), mesenteric ischemia (n = 1). The patients had high severity illness score (mean APACHE II 25 +/- 3). Eight out of nine patients (89%) that were admitted to the ICU died during the hospitalization, six (66.6%) of them died in the ICU. Septic complications as the main cause of death were determined in five patients (62.5%), while four of them had pneumonia and acute respiratory failure along with underlying severe pulmonary fibrosis. Lungs and kidneys were the most common severely affected organs by SSc in our patients. CONCLUSION: The outcome of scleroderma patients admitted to the ICU was extremely poor. Infectious complication was the most common cause of death in our patients. Although infections are treatable, the high mortality rate for this group of patients was dependent on the severity of the underlying visceral organ involvement, particularly severe pulmonary fibrosis. The severity of this involvement is a poor outcome predictor. An early diagnosis and an appropriate treatment of such complications may help to reduce the mortality in scleroderma patients.     

Plasma B-type natriuretic peptide in predicting outcomes of elective coronary artery bypass surgery

The risks of surgery and its clinical outcome are of great importance for both patients and physicians when choosing coronary artery bypass (CABG) surgery for coronary artery disease. The purpose of the current study was to clarify the relationship between serum B-type natriuretic peptide (BNP) and patient clinical outcome. Seventy-six eligible patients who underwent CABG were enrolled into the prospective study. Venous blood samples were drawn for serum BNP and N-terminal (NT)-proBNP levels measurement on preoperative Day 1, postoperative Day 1, and postoperative Day 7. Clinical end points were: (1) intensive care unit (ICU) stay longer than 4 days postoperatively and/or hospital stay longer than 13 days postoperatively; (2) major complications and poor outcomes. Patients who had prolonged ICU stay and hospitalization had significantly higher postoperative Day 1 BNP and postoperative Day 1 NT-proBNP level (p = 0.02 and 0.005, respectively). Age was significantly older in patients with prolonged ICU stay and hospitalization than those without prolonged ICU stay and hospitalization (p = 0.03). Serum creatinine level was also significantly increased in patients with prolonged ICU stay and hospitalization (p = 0.009). However, age was the only remaining factor that correlated with prolonged ICU stay and hospitalization in the multivariate logistic regression model. These results suggest that research using BNP and NT-proBNP for predicting ICU stay and hospitalization in patients who have undergone CABG must adjust risk factors to present a more appropriate estimation of its clinical outcome.