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1.
Raj Kumar Mani Amit Kumar Mandal Sabyasachi Bal Yash Javeri Rakesh Kumar Deepak Kumar Nama Praveen Pandey Tara Rawat Navneet Singh Hemant Tewari Rajiv Uttam 《Intensive care medicine》2009,35(10):1713-1719
Background
There is a paucity of data on end-of-life decisions (EOLD) for patients in Indian intensive care units (ICUs).Objective
To document the end-of-life and full-support (FS) decisions among patients dying in an ICU, to compare the respective patient characteristics and to describe the process of decision-making.Design
Retrospective, observational.Patients
Consecutive patients admitted to a 12-bed closed medical-surgical ICU.Exclusions
Patients with EOLD discharged home or transferred to another hospital.Measurements and results
Demographic profile, APACHE IV at 24 h, ICU outcome, type of limitation, disease category, pre-admission functional status, reasons for EOLD, interventions and therapies within 3 days of death, time to EOLD, time to death after EOLD and ICU length of stay. Out of 88 deaths among 830 admissions, 49% were preceded by EOLD. Of these 58% had withholding of treatment, 35% had do-not-resuscitate orders (DNR) and 7% had a withdrawal decision. Mean age and APACHE IV scores were similar between EOLD and FS groups. Functional dependence before hospitalization favored EOLD. Patients receiving EOLD as opposed to FS had longer stays. Fifty-three percent of limitations were decided during the first week of ICU stay well before the time of death. Escalation of therapy within 3 days of death was less frequent in the EOLD group.Conclusions
Despite societal and legal barriers, half the patients dying in the ICU received a decision to limit therapy mostly as withholding or DNR orders. These decisions evolved early in the course of stay and resulted in significant reduction of therapeutic burdens. 相似文献2.
Jon Pérez-Bárcena Pedro Marsé Arturo Zabalegui-Pérez Esther Corral Rubén Herrán-Monge María Gero-Escapa Mercedes Cervera Juan Antonio Llompart-Pou Ignacio Ayestarán Joan Maria Raurich Antonio Oliver Antonio Buño Abelardo García de Lorenzo Guiem Frontera 《Intensive care medicine》2014,40(4):539-547
Purpose
To evaluate the effect of the intravenous (i.v.) l-alanyl-l-glutamine dipeptide supplementation during 5 days on clinical outcome in trauma patients admitted to the intensive care unit (ICU).Methods
This was a prospective, randomized, double-blind, multicenter trial. Glutamine was not given as a component of nutrition but as an extra infusion. The primary outcome variable was the number of new infections within the first 14 days.Results
We included 142 patients. There were no differences between groups in baseline characteristics. Up to 62 % of the patients in the placebo group and 63 % in the treatment group presented confirmed infections (p = 0.86). ICU length of stay was 14 days in both groups (p = 0.54). Hospital length of stay was 27 days in the placebo group and 29 in the treatment group (p = 0.88). ICU mortality was 4.2 % in both groups (p = 1). Sixty percent of the patients presented low glutamine levels before randomization. At the end of the treatment (6th day), 48 % of the patients maintained low glutamine levels (39 % of treated patients vs. 57 % in the placebo group). Patients with low glutamine levels at day 6 had more number of infections (58.8 vs. 80.9 %; p = 0.032) and longer ICU (9 vs. 20 days; p < 0.01) and hospital length of stay (24 vs. 41 days; p = 0.01).Conclusions
There was no benefit with i.v. l-alanyl-l-glutamine dipeptide supplementation (0.5 g/kg body weight/day of the dipeptide) during 5 days in trauma patients admitted to the ICU. The i.v. glutamine supplementation was not enough to normalize the plasma glutamine levels in all patients. Low plasma glutamine levels at day 6 were associated with a worse outcome. 相似文献3.
Azoulay E Garrouste M Goldgran-Toledano D Adrie C Max A Vesin A Francais A Zahar JR Cohen Y Allaouchiche B Schlemmer B Timsit JF 《Intensive care medicine》2012,38(7):1169-1176
Objective
End-of-life decisions are based on objective and subjective criteria. Previous studies identified substantial subjective biases during end-of-life decision-making. We evaluated whether in-ICU patient’s birthday influenced management decisions.Design
We used a case–control design in which patients spending their birthday in the ICU (cases) were matched to controls on center, gender, age, severity, type of admission, and length of ICU stay before birthday.Setting
12 ICUs in French hospitals.Patients
The cases and controls were patients with ICU admissions >48?h over a 10-year period.Interventions
None.Measurements and main results
Compared with the 1,042 controls, the 223 cases were more often trauma patients and received a larger number and longer durations of life-sustaining interventions. This increased intensity of life support occurred after, but not before, the birthday. The cases had longer ICU stay lengths. ICU and hospital mortality were not different between the two groups. End-of-life decisions were made in 22% and 24% of cases and controls, respectively. However, these decisions were made later in the cases than in the controls (18 [5–33] versus 9 [3–19]?days).Conclusions
Our finding that patients who spent their birthday in the ICU received a higher intensity of life-sustaining care and had longer ICU stays but did not have significantly different mortality rates compared with the controls suggests the use of nonbeneficial interventions. Staff members caring for patients whose birthdays fall during the ICU stay should be aware that this feature can bias end-of-life decisions, leading to an inappropriate level of care. 相似文献4.
Johan Mårtensson Max Bell Anders Oldner Shengyuan Xu Per Venge Claes-Roland Martling 《Intensive care medicine》2010,36(8):1333-1340
Purpose
To study the impact of inflammation/sepsis on the concentrations of neutrophil gelatinase-associated lipocalin (NGAL) in plasma and urine in adult intensive care unit (ICU) patients and to estimate the predictive properties of NGAL in plasma and urine for early detection of acute kidney injury (AKI) in patients with septic shock.Methods
Sixty-five patients admitted to the general ICU at the Karolinska University Hospital Solna, Sweden, with normal plasma creatinine were assessed for eligibility. Twenty-seven patients with systemic inflammatory response syndrome (SIRS), severe sepsis, or septic shock without AKI and 18 patients with septic shock and concomitant AKI were included in the final analysis. Plasma and urine were analyzed twice daily for plasma NGAL (pNGAL), C-reactive protein (CRP), procalcitonin, myeloperoxidase, plasma cystatin C, plasma creatinine, urine NGAL (uNGAL), urine cystatin C, and urine α1-microglobulin.Results
Of the 45 patients, 40 had elevated peak levels of pNGAL. Peak levels of pNGAL were not significantly different between septic shock patients with and without AKI. Peak levels of uNGAL were below the upper reference limit in all but four patients without AKI. uNGAL was a good predictor (area under ROC 0.86) whereas pNGAL was a poor predictor (area under ROC 0.67) for AKI within the next 12 h in patients with septic shock.Conclusions
pNGAL is raised in patients with SIRS, severe sepsis, and septic shock and should be used with caution as a marker of AKI in ICU patients with septic shock. uNGAL is more useful in predicting AKI as the levels are not elevated in septic patients without AKI. 相似文献5.
Iris Pelieu Juliette Djadi-Prat Silla M. Consoli Alain Cariou Bertrand Guidet Cécile You-Harada Virginie Paget Guillaume Héraud Claire Lefur Adeline Massin Marlène Hennequin Pierre Durieux Jean-Yves Fagon Christophe Faisy 《Intensive care medicine》2013,39(7):1214-1220
Purpose
To determine whether organizational culture is associated with preventability assessment of reported adverse events (AE) in intensive care units (ICU).Design
Blind review of time randomly distributed case notes written in the form of structured abstracts by the nurses who participated in recently implemented morbidity and mortality conferences from December 2006 to June 2010 in a 18-bed ICU in France. Ninety-five abstracts summarizing the discussions of 95 AE involving 95 patients were reviewed by two external blinded pairs (each comprised of one senior intensivist and one psychologist).Methods
A score for each organizational culture style was determined, with the highest scorer being considered the dominant style present in the abstract.Results
Reliability of the classification and quantification of culture traits between pairs was very good or good for 13 dimensions and moderate for two others. The two pairs deemed 32/95 and 43/95 of AE preventable (κ = 0.59). Concordance was very good (κ = 0.85) between the external pairs for evaluation of the dominant culture style. The Cochran–Armitage trend test indicated an increasing trend for change of the dominant organizational culture style over time: the team-satisfaction-oriented culture took a leading role (p = 0.02), while the people-security-oriented culture decreased dramatically (p < 0.001). The task-security-oriented culture was significantly associated with a preventable judgment, while the people-security-oriented culture was significantly associated with an unpreventable judgment (p < 0.001).Conclusions
This study demonstrated a strong relationship between preventability assessment of AE reported by caregivers and their organizational culture in the ICU. 相似文献6.
Matthieu Schmidt Robert B. Banzett Mathieu Raux Capucine Morélot-Panzini Laurence Dangers Thomas Similowski Alexandre Demoule 《Intensive care medicine》2014,40(1):1-10
Background
Intensive care unit (ICU) patients are exposed to many sources of discomfort. Although increasing attention is being given to the detection and treatment of pain, very little is given to the detection and treatment of dyspnea (defined as “breathing discomfort”).Methods
Published information on the prevalence, mechanisms, and potential negative impacts of dyspnea in mechanically ventilated patients are reviewed. The most appropriate tools to detect and quantify dyspnea in ICU patients are also assessed.Results/Conclusions
Growing evidence suggests that dyspnea is a frequent issue in mechanically ventilated ICU patients, is highly associated with anxiety and pain, and is improved in many patients by altering the ventilator settings.Conclusions
Future studies are needed to better delineate the impact of dyspnea in the ICU and to define diagnostic, monitoring and therapeutic protocols. 相似文献7.
Purpose
To quantify the error in evaluating recovery from acute kidney injury (AKI) with estimated GFR (eGFR) in relation to ICU stay.Methods
Secondary analysis performed on the database of the EPaNIC trial. In a cohort of patients who developed AKI during ICU stay we compared eGFR with measured creatinine clearance (Clcr) at ICU discharge. Recovery of kidney function was assessed by comparison with baseline eGFR and the accuracy of eGFR to detect “potential CKD status” defined by Clcr was quantified. The same analysis was performed in subgroups with different ICU stay. Multivariate regression was performed to determine independent predictors of the eGFR–Clcr difference.Results
A total of 757 patients were included. The bias (limits of agreement (LOA)) between eGFR and Clcr at ICU discharge related to ICU stay, increasing from +1.3 (?37.4/+40) ml/min/1.73 m2 in patients with short stay to +34.7 (?54.4/+123.8) ml/min/1.73 m2 in patients with ICU stay of more than 14 days. This resulted in a significantly different incidence of complete recovery with the two evaluation methods and reduced sensitivity to detect “potential CKD status” with eGFR in patients with prolonged ICU stay. Independent predictors of the bias included creatinine excretion on the last day in ICU, baseline eGFR, ICU stay, gender, and age.Conclusion
Compared to Clcr, discharge eGFR results in overestimation of renal recovery in patients with prolonged ICU stay and in reduced accuracy of “CKD staging”. Since age, gender and race do not change during ICU stay the same conclusion can be drawn with regard to plasma creatinine. 相似文献8.
9.
Charles L. Sprung Marion Danis Gaetano Iapichino Antonio Artigas Jozef Kesecioglu Rui Moreno Anne Lippert J. Randall Curtis Paula Meale Simon L. Cohen Mitchell M. Levy Robert D. Truog 《Intensive care medicine》2013,39(11):1916-1924
Rationale
Intensive care unit (ICU) resources are limited in many hospitals. Patients with little likelihood of surviving are often admitted to ICUs. Others who might benefit from ICU are not admitted.Objective
To provide an updated consensus statement on the principles and recommendations for the triage of patients for ICU beds.Design
The previous Society of Critical Care Medicine (SCCM) consensus statement was used to develop drafts of general and specific principles and recommendations. Investigators and consultants were sent the statements and responded with their agreement or disagreement.Setting
The Eldicus project (triage decision making for the elderly in European intensive care units).Participants
Eldicus investigators, consultants, and experts consisting of intensivists, users of ICU services, ethicists, administrators, and public policy officials.Interventions
Consensus development was used to grade the statements and recommendations.Measurements and main results
Consensus was defined as 80 % agreement or more. Consensus was obtained for 54 (87 %) of 62 statements including all (19) general principles, 31 (86 %) of the specific principles, and 10 (71 %) of the recommendations. Inconsistencies in responses were noted for ICU admission and discharge. Despite agreement for guidelines applying to individual patients and an objective triage score, there was no agreement for a survival cutoff for triage, not even for a chance of survival of 0.1 %.Conclusions
Consensus was reached for most general and specific ICU triage principles and recommendations. Further debate and discussion should help resolve the remaining discrepancies. 相似文献10.
11.
Sébastien Roques Antoine Parrot Armelle Lavole Pierre-Yves Ancel Valérie Gounant Michel Djibre Muriel Fartoukh 《Intensive care medicine》2009,35(12):2044-2050
Background
Intensive care unit (ICU) admission of patients with lung cancer remains debated because of the poor short-term prognosis. However, ICU admission of such patients should also be assessed on the possibility to administer specific anticancer treatment and the long-term outcome thereafter.Objectives
To identify predictive factors of hospital and 6-month mortality in critically ill lung-cancer patients.Design and setting
Retrospective study conducted in the ICU of a university hospital.Patients
One hundred five consecutive lung-cancer patients included between 1 January 1997 and 31 December 2006.Interventions
None.Results
Of the 105 patients (mean age 64.8 years), 87 (83%) had a non-small cell lung cancer (NSCLC). Extensive disease was diagnosed in 85 patients (83%) (NSCLC stages IIIB and IV or disseminated small cell lung cancer). The main reasons for ICU admission were acute respiratory failure (59%) and/or hemoptysis (45%). Forty-three patients (41%) needed mechanical ventilation (MV). The ICU, hospital and 6-month mortality rates were 43, 54 and 73%, respectively. A performance status (PS) ≥2 [odds ratio OR = 3.6 (95% confidence interval CI (1.5–8.7)] and acute respiratory failure [OR = 3.5 (95% CI (1.5–8.4)] predicted hospital mortality. In a multivariate Cox model, the cancer progression [hazard ratio HR = 6.1 (95% CI 2.2–17)] and the need for MV [HR = 3.6 (95% CI 1.35–9.4)] were independently associated with 6-month mortality. Two-thirds of the ICU survivors were able to receive anticancer treatment.Conclusions
ICU admission should be considered in selected patients with lung cancer (PS <2, no cancer disease progression). 相似文献12.
Kathryn Puxty Philip McLoone Tara Quasim John Kinsella David Morrison 《Intensive care medicine》2014,40(10):1409-1428
Purpose
One in seven patients admitted to intensive care units (ICU) has a cancer diagnosis but evidence on their expected outcomes after admission has not been synthesised.Methods
Systematic literature review of solid cancer adult patients admitted to ICU from 2000 onwards using EMBASE and MEDLINE electronic databases.Results
There were 48 papers identified that reported survival in ICU patients with solid cancers. ICU mortality was reported in 35 studies comprising a total sample of 25,339 patients and ranging from 4.5 to 85 %. The average mortality of the distribution of reported mortality rates within ICU was 31.2 % (95 % CI 24.0–39.0 %). Hospital mortality was reported in 31 studies across a total sample of 74,061 patients. The average hospital mortality was 38.2 % (33.8–42.7 %) and ranged from 4.6 to 76.8 %. Poorer physiological score, invasive mechanical ventilation and poor functional status were associated with higher mortality.Conclusions
Several factors have been associated with poor survival in ICU cancer patients; however, primary research is still needed to describe outcomes in cancer patients with sufficient case mix and treatment details to be of prognostic value to clinicians. 相似文献13.
14.
Cristiane Ritter Aline S Miranda Vinícius Renê Giombelli Cristiane D Tomasi Clarissa M Comim Antonio Lucio Teixeira João Quevedo Felipe Dal-Pizzol 《Critical care (London, England)》2012,16(6):1-6
Introduction
Because of its relevance to the functioning of the central nervous system, brain-derived neurotrophic factor (BDNF) has been implicated in the pathogenesis of different neuropsychiatric diseases. Whether the BDNF level can be a marker of brain dysfunction and thus predict mortality in critically ill patients is not known. Thus we aimed to determine whether the plasma levels of BDNF are associated with morbidity and mortality in critically ill patients.Methods
Healthy volunteers (n = 40) and consecutive patients older than 18 years (n = 76) admitted for more than 24 hours in an Intensive Care Unit (ICU) in a University hospital between July and October 2010 were included in the present study. First blood samples were collected within 12 hours of enrollment (D0), and a second sample, 48 hours after (D2) for determination of plasma BDNF levels. The relation between BDNF levels and mortality was the primary outcome. The secondary outcomes were the relation between BDNF levels and delirium and coma-free days (DCFD) and ICU and hospital length of stay (LOS).Results
Admission plasma levels of BDNF were higher in ICU patients when compared with healthy volunteers (1,536 (962) versus 6,565 (2,838) pg/ml). The mean BDNF D2 was significantly lower in nonsurvivor patients (5,865 (2,662) versus 6,741 (2,356) pg/ml). After adjusting for covariates, BDNF levels, the need for mechanical ventilation, and sepsis were associated with mortality. Even in patients without clinically detectable brain dysfunction, lower BDNF D2 levels were associated with mortality. BDNF D2 had a mild correlation to DCFD (r = 0.44), but not to ICU and hospital LOS. In addition, plasma BDNF did not correlate to different plasma cytokines and platelets levels.Conclusions
The plasma levels of BDNF were independently associated with mortality, even in the absence of clinically detectable brain dysfunction. 相似文献15.
D. Pittet M.D. M.S. B. Thiévent R. P. Wenzel N. Li G. Gurman P. M. Suter 《Intensive care medicine》1993,19(5):265-272
Objective
To determine admission characteristics associated with the outcome of septicemia in critically ill patients and more specifically assess the prognostic value of pre-existing co-morbidities.Design
5 year-retrospective cohort study.Setting
Surgical Intensive Care Unit (ICU-20 beds) in a 1600 bed-tertiary care center.Patients
Among 5457 patients admitted to the ICU between 1984 and 1988, 176 (3.2%) met prospectively-defined criteria for blood culture-proven septicemia (8.77 per 1000 patient-days). Overall septicemic patients had a 5-fold increased risk of death compared to non-septicemic patients (relative risk 5.03, 95% confidence intervals 4.17–6.07,p<0.0001), and this estimate persisted after stratification according to age, sex, primary diagnosis and conditions of admission to the ICU (emergency/elective).Results
Prognostic factors recorded on admission to ICU that were associated with mortality from septicemia among 173 patients were older age, higher admission Apache II score, gastrointestinal surgery, ultimately and rapidly fatal diseases and the number of co-morbidities in addition to the principal diagnosis (active smoking, alcohol abuse, non-cured malignancy, diabetes mellitus, splenectomy, recent antibiotic therapy, major surgery, or major cardiac event). In the multivariate analysis with logistic regression procedures, Apache II and co-morbidities were identified as the two independent predictors of mortality.Conclusions
Pre-existing co-morbidities assessed at the admission to the ICU significantly improved the prediction of mortality from septicemia compared to Apache II score alone. 相似文献16.
Ulrike Holzinger Reinhard Kitzberger Andja Bojic Marlene Wewalka Wolfgang Miehsler Thomas Staudinger Christian Madl 《Intensive care medicine》2009,35(9):1614-1618
Objective
To compare the success rate of correct jejunal placement of a new self-advancing jejunal tube with the gold standard, the endoscopic guided technique, in a comparative intensive care unit (ICU) patient population.Design
Prospective, randomized study.Setting
Two medical ICUs at a university hospital.Patients
Forty-two mechanically ventilated patients with persisting intolerance of intragastric enteral nutrition despite prokinetic therapy.Methods
Patients were randomly assigned to receive an unguided self-advancing jejunal feeding tube (Tiger Tube?) or an endoscopic guided jejunal tube (Freka® Trelumina). Primary outcome measure was the success rate of correct jejunal placement after 24 h.Results
Correct jejunal tube placement was reached in all 21 patients using the endoscopic guided technique whereas the unguided self-advancing jejunal tube could be placed successfully in 14 out of 21 patients (100% versus 67%; P = 0.0086). In the remaining seven patients, successful endoscopic jejunal tube placement was performed subsequently. Duration of tube placement was longer in the unguided self-advancing tube group (20 ± 12 min versus 597 ± 260 min; P < 0.0001). Secondary outcome parameters (complication rate, number of attempts, days in correct position with accurate functional capability, days with high gastric residual volume, length of ICU stay, ICU mortality) were not statistically different between the two groups. No potentially relevant parameter predicting the failure of correct jejunal placement of the self-advancing tube could be identified.Conclusions
Success rate of correct jejunal placement of the new unguided self-advancing tube was significantly lower than the success rate of the endoscopic guided technique. 相似文献17.
Franco Valenza Lorella Fagnani Silvia Coppola Sara Froio Francesca Sacconi Cecilia Tedesco Micol Maffioletti Marta Pizzocri Valentina Salice Maria Luisa Ranzi Cristina Marenghi Luciano Gattinoni 《Critical care (London, England)》2009,13(3):R102-8
Introduction
The aim of this observational study was to investigate the prevalence of endotoxemia after surgery and its association with ICU length of stay.Methods
102 patients admitted to a university ICU after surgery were recruited. Within four hours of admission, functional data were collected and APACHE II severity score calculated. Arterial blood samples were taken and endotoxemia was measured by chemiluminescence (Endotoxin Activity (EA)). Patients were stratified according to their endotoxin levels (low, intermediate and high) and according to their surgical procedures. Differences between endotoxin levels were assessed by ANOVA, accepting P < 0.05 as significant. Data are expressed as mean ± SD.Results
EA levels were low in 68 (66%) patients, intermediate in 17 (17%) and high in 17 (17%). Age (61 ± 17 years) and APACHE II score 8.3 ± 3.7 (P = 0.542) were not significantly different in the three EA groups. Functional parameters on admission were similar between EA groups: white blood cells 11093 ± 4605 cells/mm3 (P = 0.385), heart rate 76 ± 16 bpm (P = 0.898), mean arterial pressure 88.8 ± 13.6 mmHg (P = 0.576), lactate 1.18 ± 0.77 mmol/L (P = 0.370), PaO2/FiO2 383 ± 109 mmHg (P = 0.474). Patients with high levels of EA were characterized by longer length of stay in the ICU: 1.9 ± 3.0 days in the low EA group, 1.8 ± 1.4 days in intermediate and 5.2 ± 7.8 days in high group (P = 0.038).Conclusions
17% of our patients were characterized by high levels of endotoxemia as assessed by EA assay, despite their low level of complexity on admission. High levels of endotoxin were associated with a longer ICU length of stay. 相似文献18.
Gastric versus post-pyloric feeding: a systematic review 总被引:3,自引:1,他引:2
19.
Virginie Lemiale Florence Dumas Nicolas Mongardon Olivier Giovanetti Julien Charpentier Jean-Daniel Chiche Pierre Carli Jean-Paul Mira Jerry Nolan Alain Cariou 《Intensive care medicine》2013,39(11):1972-1980
Objective
Brain injury is well established as a cause of early mortality after out-of-hospital cardiac arrest (OHCA), but postresuscitation shock also contributes to these deaths. This study aims to describe the respective incidence, risk factors, and relation to mortality of post-cardiac arrest (CA) shock and brain injury.Design
Retrospective analysis of an observational cohort.Setting
24-bed medical intensive care unit (ICU) in a French university hospital.Patients
All consecutive patients admitted following OHCA were considered for analysis. Post-CA shock was defined as a need for infusion of vasoactive drugs after resuscitation. Death related to brain injury included brain death and care withdrawal for poor neurological evolution.Intervention
None.Measurements and main results
Between 2000 and 2009, 1,152 patients were admitted after OHCA. Post-CA shock occurred in 789 (68 %) patients. Independent factors associated with its onset were high blood lactate and creatinine levels at ICU admission. During the ICU stay, 269 (34.8 %) patients died from post-CA shock and 499 (65.2 %) from neurological injury. Age, raised blood lactate and creatinine values, and time from collapse to restoration of spontaneous circulation increased the risk of ICU mortality from both shock and brain injury, whereas a shockable rhythm was associated with reduced risk of death from these causes. Finally, bystander cardiopulmonary resuscitation (CPR) decreased the risk of death from neurological injury.Conclusions
Brain injury accounts for the majority of deaths, but post-CA shock affects more than two-thirds of OHCA patients. Mortality from post-CA shock and brain injury share similar risk factors, which are related to the quality of the rescue process. 相似文献20.
J.-C. Devaud M. M. Berger A. Pannatier P. Marques-Vidal L. Tappy N. Rodondi R. Chiolero P. Voirol 《Intensive care medicine》2012,38(12):1990-1998