A prospective, randomized trial of continuous lateral rotation (“kinetic therapy”) in patients with cardiogenic shock

Background

Continuous lateral rotation [“Kinetic therapy” (KT)] has been shown to reduce complications and to shorten hospital stay in trauma patients. Data in non-surgical patients is inconclusive. Retrospective data suggest a beneficial effect of KT in patients with cardiogenic shock (CS) requiring ventilator therapy. KT, however, has not been tested prospectively in those patients.

Methods

A prospective, randomized, open-label trial was performed to compare KT using oscillating beds (TryaDyne Proventa, KCI) with standard care (SC). Patients with cardiogenic shock requiring ventilator therapy for more than 24?h were included. Primary endpoint was the occurrence of hospital-acquired pneumonia. Secondary endpoints were the occurrence of pressure ulcers during the hospital stay and 1-year all-cause mortality.

Results

Forty-five patients were randomized to KT, and 44 to SC. All patients required at least one inotropic agent and one vasopressor for circulatory assistance. The groups were comparable in the etiology of heart disease, in the use of revascularization procedures, the use of balloon counterpulsation, and APACHE-II score (33?±?5 vs. 33?±?4) and SOFA score (11?±?1 vs. 11?±?1) at inclusion; however, more patients in SC were subject to resuscitation before inclusion. Hospital-acquired pneumonia occurred in 10 patients in KT and 28 patients in SC (p?<?0.001); pressure ulcers were seen in 10 versus 2 patients (p?<?0.001). Hospital mortality tended to be lower in KT, and 1-year all-cause mortality was 41?% in KT and 66?% in SC (p?=?0.028).

Conclusion

The use of KT reduces rates of pneumonia and pressure ulcers as compared to SC. Moreover, in this study, patients with KT had a better outcome. The study suggests that KT should be used in patients with cardiogenic shock requiring ventilator therapy for a prolonged time.     

Do pressure ulcers influence length of hospital stay in surgical cardiothoracic patients? A prospective evaluation

Aim and objective. The aim and objective of this study was to determine whether the occurrence of pressure ulcers following cardiothoracic surgery increases the length of hospitalisation. Background. Literature suggests that a pressure ulcer extends the length of hospital stay. The impact of pressure ulcers on length of hospital stay after cardiothoracic surgery is yet undetermined. Design. Prospective follow‐up study. Methods. Two hundred and four patients admitted for elective cardiothoracic surgery and with an intensive care unit stay of >48 hours were included in a prospective cohort study. The course of the skin condition in relation to pressure ulcers was monitored during their stay in a teaching hospital. Length of hospital stay was compared between the group with and without pressure ulcers. Results. Hospital stay for cardiothoracic patients with and without pressure ulcers did not differ significantly (p = 0·23). Patients that developed pressure ulcers had a median hospital stay of 13 days (interquartile range: 9–19) vs. 12 days (interquartile range: 7–15) for patients without pressure ulcers. However, we observed that length of stay in the intensive care unit was significantly (p = 0·005) longer for patients with pressure ulcers. This was not associated with the occurrence of complications. However, the occurrence of pressure ulcers was significantly correlated with length of intensive care support in postoperative care. Conclusion. Non‐complicated pressure ulcers in postsurgery patients do not significantly increase the length of total hospital stay. Relevance to clinical practice. Health professionals need to recognise that patients who have undergone major surgery (such as cardiothoracic surgery) are prone to develop pressure ulcers. Despite the fact that pressure ulcers do not necessarily extend hospital stay, monitoring the skin condition remains of crucial importance for prevention and early detection as well as treatment of pressure ulcers and to minimise patient discomfort. Moreover, as pressure ulcers often originate in the operating room, prevention in the operating room should receive more attention.     

Does noninvasive positive pressure ventilation improve outcome in acute hypoxemic respiratory failure? A systematic review

CONTEXT: The results of studies on noninvasive positive pressure ventilation (NPPV) for acute hypoxemic respiratory failure unrelated to cardiogenic pulmonary edema have been inconsistent. OBJECTIVE: To assess the effect of NPPV on the rate of endotracheal intubation, intensive care unit and hospital length of stay, and mortality for patients with acute hypoxemic respiratory failure not due to cardiogenic pulmonary edema. DATA SOURCE: We searched the databases of MEDLINE (1980 to October 2003) and EMBASE (1990 to October 2003). Additional data sources included the Cochrane Library, personal files, abstract proceedings, reference lists of selected articles, and expert contact. STUDY SELECTION: We included studies if a) the design was a randomized controlled trial; b) patients had acute hypoxemic respiratory failure not due to cardiogenic pulmonary edema; c) the interventions compared noninvasive ventilation and standard therapy with standard therapy alone; and d) outcomes included need for endotracheal intubation, length of intensive care unit or hospital stay, or intensive care unit or hospital survival. DATA EXTRACTION: In duplicate and independently, we abstracted data to evaluate methodological quality and results. DATA SYNTHESIS: The addition of NPPV to standard care in the setting of acute hypoxemic respiratory failure reduced the rate of endotracheal intubation (absolute risk reduction 23%, 95% confidence interval 10-35%), ICU length of stay (absolute reduction 2 days, 95% confidence interval 1-3 days), and ICU mortality (absolute risk reduction 17%, 95% confidence interval 8-26%). However, trial results were significantly heterogeneous. CONCLUSION: Randomized trials suggest that patients with acute hypoxemic respiratory failure are less likely to require endotracheal intubation when NPPV is added to standard therapy. However, the effect on mortality is less clear, and the heterogeneity found among studies suggests that effectiveness varies among different populations. As a result, the literature does not support the routine use of NPPV in all patients with acute hypoxemic respiratory failure.     

Kinetic therapy in critically III patients: Combined results based on meta-analysis

Several investigators have independently studied kinetic therapy (KT) using continuous postural oscillation in medical, surgical, and neurologic intensive care units (ICUs). These studies were designed to determine if KT would reduce complications associated with immobilization of ICU patients and reduce costs by decreasing hospital stay. The results based on the six randomized studies varied with reports of significant and nonsignificant differences between KT tables (Roto Rest bed, KCI, San Antonio, TX) and conventional hospital beds. The inconsistencies could be due in part to insufficient sample sizes of each study, which ranged from 30 to 100 patients. The present report presents the results of meta-analysis, which tests the statistical significance of differences between treatment groups by combining six independent studies with a total sample size of 419 patients. The analysis indicates that the incidences of pneumonia and atelectasis were significantly reduced by KT tables (P < .002 and P < .03, respectively). The number of hours intubated and the length of ICU stay were also significant (P < .04 and P < .02, respectively). However, KT did not appear to have a statistically significant effect on adult respiratory distress syndrome, pressure ulcers, embolisms, mortality, or length of hospital stay.     

Results of the use of intraaortic balloon counterpulsation in patients with perioperative myocardial infarct]

The results of complex intensive therapy of cardiogenic shock have been studied in 17 patients with acute myocardial infarction developed as a complication of reconstructive surgery for ischemic heart disease. Complex therapy of cardiogenic shock included the use of intraaortic balloon contrapulsation, adrenomimetic agents, controlled lung ventilation and other intensive care procedures. 11 patients (64.7%) recovered from cardiogenic shock, 4 of them survived and were discharged from hospital. In 6 patients (35.3%) the combined use of adrenomimetics and intraaortic balloon contrapulsation had no effect. The results of intensive care procedures were shown to depend on the size of perioperative myocardial infarction, which affected the severity of hemodynamic disturbances and duration and efficacy of complex intensive therapy of cardiogenic shock. The use of intraaortic balloon contrapulsation in cardiogenic shock resistant to adrenomimetic agents led to temporary hemodynamic stabilization without improving the prognosis.     

The longer patients are in hospital before Intensive Care admission the higher their mortality

Objective To explore the relationship between hospital mortality and time spent by patients on hospital wards before admission to the intensive care unit (ICU).Design Observational study of prospectively collected data.Setting Participating intensive care units within the North East Thames Regional Database.Patients and participants Patients, 7,190, admitted to ICU from the hospital wards of 24 hospitals.Interventions None.Measurements and results Of ICU admissions from the wards, 40.1% were in hospital for more than 3 days and 11.7% for more than 15 days. ICU patients who died in hospital were in-patients longer (p=0.001) before admission (median 3 days; interquartile range 1–9) than those discharged alive (median 2 days; interquartile range 1–5). Hospital mortality increased significantly (p<0.0001) in relation to time on hospital wards before ICU: 47.1% (standardised mortality ratio 1.09) for patients in hospital 0–3 days before ICU admission up to 67.2% (standardised mortality ratio 1.39) for patients on the wards for more than 15 days before ICU. Length of stay before ICU admission was an independent predictor of hospital mortality (odds ratio per day 1.019; 95% confidence interval 1.014–1.024). There were significant differences (p<0.001) in patient age, APACHE II score and predicted mortality in relation to time on wards before ICU admission.Conclusions Mortality was high among patients admitted from the wards to ICU; many were inpatients for days or weeks before admission. The longer these patients were in hospital before ICU admission, the higher their mortality. Patients with delayed admission differed in some respects compared to those admitted earlier.Electronic Supplementary Material Supplementary material is available in the online version of this article at Preliminary analysis of this data was presented in abstract at the Intensive Care Society (UK) State of the Art Scientific Meeting in London, December 2001.     

Noninvasive positive-pressure ventilation in patients with milder chronic obstructive pulmonary disease exacerbations: a randomized controlled trial

OBJECTIVES: To determine the effect of the addition of noninvasive positive-pressure ventilation (NPPV) to standard medical therapy on length of hospital stay among patients presenting with mild exacerbations of chronic obstructive pulmonary disease (COPD) requiring hospitalization. DESIGN: Randomized controlled unblinded study with concealed allocation. SETTING: Respiratory ward of a single-center, academic, tertiary-care hospital. PARTICIPANTS: Patients with a prior history of COPD who presented with a recent onset of shortness of breath and a pH of > 7.30 were eligible for inclusion in the study. INTERVENTIONS: NPPV daily for 3 days for intervals of 8, 6, and 4 hours, respectively, plus standard therapy, versus standard therapy alone. MEASUREMENTS: Borg dyspnea index at baseline, 1 hour, and daily. Length of hospital stay, endotracheal intubation, hospital survival. RESULTS: We found that NPPV was generally poorly tolerated, with only 12 of 25 patients wearing it for the prescribed 3 days. With the exception of a decrease in dyspnea at 1 hour and 2 days, significant between-group differences were not seen for any measured variable. CONCLUSIONS: The effectiveness and cost-effectiveness of the addition of NPPV to standard therapy in milder COPD exacerbations remains unclear. P(aCO(2)) related to this increased WOB that requires intervention with some form of assisted ventilation. All patients developing an exacerbation of COPD that requires hospitalization have an increased WOB and, we hypothesize, potentially develop some degree of associated respiratory muscle fatigue. We further hypothesize that adding intermittent NPPV during the initial days of hospital stay would afford respiratory muscle rest for patients with milder COPD exacerbations and that this rest would allow these patients to recover more quickly and to be discharged home earlier. The objective of this trial was to determine whether the addition of NPPV to standard therapy during the first 3 days of admission in milder COPD exacerbations could decrease length of hospital stay.     

Simultaneous care: a model approach to the perceived conflict between investigational therapy and palliative care

Clinical trials of investigational therapy in patients with advanced cancer may not pay sufficient attention to quality of life (QOL) and supportive care issues, resulting in an adverse impact on the quality of care (QOC). We hypothesized that the simultaneous delivery of investigational therapy and a structured program of supportive care would result in measurable improvements in predefined outcomes without adverse events for patients, caregivers, or the physician/patient interaction. This report describes the findings of a trial designed to test the feasibility and initial results of such an approach. Forty-four patients accrued to Phase I or Phase II investigational therapy trials were simultaneously enrolled into a defined home care program focused on supportive care needs of the patient and family, as well as assessment of the toxicities of investigational therapy. These 44 patients constitute the Simultaneous Care (SC) cohort. Twenty patients receiving investigational therapy and the standard supportive care measures available through the Cancer Center served as a control group, designated the Usual Care (UC) cohort. We measured QOL using baseline and monthly assessments of the Functional Assessment of Cancer Therapy (FACT-G) instrument. This instrument measures four domains of well-being: physical, emotional, functional, and social/family. We prospectively defined QOC as: the percentage of hospice referrals; hospice length of stay; and number of cycles of chemotherapy administered. A summary score for the four FACT domains at each time point for each patient was calculated (FACT 4). The FACT 4 scores of the SC group improved compared to the UC group but did not reach a significant difference. Individual scores reflected a wide range of psychometric variability. A statistically significant difference in referral to hospice was seen in the SC group (35/44) compared to the UC group (8/15) (P = 0.034). The median length of stay in hospice was the same for both cohorts but the mean stay was greater in the SC cohort (54 days) compared to the UC cohort (37 days). The mean number of chemotherapy cycles was not different between SC and UC (P = 0.25). The self-reported acceptance by patients, caregivers, physicians and Cancer Center support staff was qualitatively excellent. Patients with advanced cancer at the time of enrollment onto investigational therapy should have made an explicit transition to palliative care goals but often have not. In the current health care environment, patients with advanced cancer without curative potential may be forced by their health provider or health insurer to choose between disease-directed therapy (including investigational therapy) or structured best supportive care programs. In this emerging era of targeted therapies, SC provides an approach designed to optimize palliative care goals while supporting the clinical research mission of offering patients with advanced cancer new and potentially better therapeutic interventions. SC is a system of care that enhances patient choice by allowing patients and families to have concurrent access to two beneficial options. SC may enhance coordination of care and facilitate patients' explicit transition from curative intent to palliative intent. In order to validate this approach, a randomized comparative trial evaluating SC has been initiated.     

Microvascular response in patients with cardiogenic shock

OBJECTIVE: To examine the mechanisms contributing to decreased microvascular blood flow in cardiogenic shock by comparing patients with cardiogenic shock with critically ill controls and with patients with septic shock. DESIGN: Prospective, consecutive entry of patients meeting the criteria for septic shock, cardiogenic shock, and critical illness without coexisting infection or shock. SETTING: University hospital, medical intensive care unit, coronary care unit, and respiratory care unit. PATIENTS: Eight patients with cardiogenic shock secondary to acute myocardial infarction, six critically ill controls, and six patients with septic shock. MEASUREMENTS AND MAIN RESULTS: Forearm blood flow was measured at rest and during reactive hyperemia by venous air plethysmography. Red cell deformability was determined by filtration. Leukocyte aggregation was detected by the leukergy test. Neutrophil CD11b/CD18 expression and soluble intercellular adhesion molecule-1 levels were also measured. In cardiogenic shock, forearm arterial resistance was significantly increased at rest and during reactive hyperemia compared with controls and patients with septic shock. The response to reactive hyperemia was attenuated in cardiogenic and septic shock patients, as measured by the absolute change in forearm blood flow from baseline, which was significantly less as compared with controls (p < .01). The percent change in forearm blood flow during reactive hyperemia compared with forearm blood flow at rest was significantly lower in cardiogenic shock (60+/-10) and in septic shock (50+/-11) compared with controls at baseline (145+/-20; p < .01). Red cell deformability was significantly decreased in cardiogenic shock (1.2+/-0.2 mL/min; p < .05) and septic shock (1.1+/-0.2 mL/min; p < .05), compared with controls (1.8+/-0.1 mL/min). Neutrophil CD11b/CD18 expression, leukergy, and serum intercellular adhesion molecule-1 levels in cardiogenic shock patients were not significantly different from controls. CONCLUSION: These data suggest that the response to reactive hyperemia is attenuated in cardiogenic shock. This appears to reflect increased vasoconstriction and an impaired capacity for vasodilation. Decreased erythrocyte deformability may also be important in limiting systemic microvascular flow. However, evidence supporting a role for neutrophil-endothelial cell interactions was not observed.     

Extrapyramidal effects of acute organophosphate poisoning

Background: There is limited information on extrapyramidal symptoms in acute organophosphate (OP) poisoning. We describe the course and outcome of severely poisoned patients who develop extrapyramidal manifestations. Methods: In this prospective observational study, spanning 8 months (Apr–Nov 2013) adult patients (>18 years) admitted with OP poisoning were enrolled. Patients on anti-psychotic therapy, those refusing consent or presenting with co-ingestions were excluded. Treatment included atropine and supportive care (e.g. ventilation and inotropes as indicated); oximes were not administered. The presence of rigidity, tremors, dystonia and chorea were assessed daily till discharge using modifications of the Unified Parkinson’s Disease rating scale and the Tremor rating scale. The presence of extrapyramidal manifestations was correlated with length of ventilation and hospital stay and mortality. Results: Of the 77 patients admitted with OP poisoning, 32 were enrolled; 17 (53.1%) developed extrapyramidal manifestations which included rigidity (94.1%), tremors (58.8%) and dystonia (58.8%). None developed chorea. The median (inter-quartile range) time of symptom onset was 8 (5–11) days; extrapyramidal features resolved in 11 (6–17) days. The median duration of intensive care stay in patients not developing extrapyramidal symptoms was 6 (2–8) days, indicating that most of these patients had recovered even before symptom onset in patients who developed extrapyramidal manifestations. Overall, 27/32 (84%) were ventilated. Hospital mortality was 6.25% (2/32). When compared with patients not developing extrapyramidal signs, those with extrapyramidal manifestations had significantly prolonged ventilation (5 versus 16 median days; p?=?0.001) and hospitalization (8 versus 21 days; p?<?0.001), reduced ventilator-free days (23 versus 12 days; p?=?0.023) and increased infections (p?=?0.03). The need for ventilation and mortality were not significantly different (p?>?0.6). Extrapyramidal symptoms were not observed in non-OP poisoned patients with prolonged ICU stay. Conclusion: In this small series of acute OP poisoning, extrapyramidal manifestations were common after 1 week of intensive care but self-limiting. They are significantly associated with longer duration of ventilation and hospital stay.     

Effect of kinetic therapy on pulmonary complications.

BACKGROUND: Optimal turning of critically ill patients is not well established. Kinetic therapy (systematic mechanical rotation of patients with 40 degree turns) may improve pulmonary function more than the improvement in function achieved via the standard of care (turning patients every 2 hours). OBJECTIVE: To determine (1) if patients receiving mechanical ventilation who tolerate kinetic therapy have better pulmonary function than do patients treated with standard turning and (2) the cost-effectiveness of kinetic therapy. METHODS: A prospective, randomized, multicenter study including 234 medical, surgical, and trauma patients (137 control patients, 97 patients receiving kinetic therapy). RESULTS: Kinetic therapy significantly decreased the occurrence of ventilator-associated pneumonia and lobar atelectasis. The risk of pneumonia developing was lower (P = .002) in patients receiving kinetic therapy than in the control patients. The risk of lobar atelectasis developing was decreased (P = .02) for the patients receiving kinetic therapy. Lengths of stay in the intensive care unit and in the hospital did not differ between the groups. Charges for intensive care were less in the kinetic therapy group (81,700 dollars) than in the control group (84,958 dollars), but not significantly less. Twenty-one patients did not tolerate kinetic therapy and were not included in the analysis. CONCLUSION: Kinetic therapy helps prevent ventilator-associated pneumonia and lobar atelectasis in critically ill patients. Costs to rent the bed may be offset by the potential cost reduction associated with kinetic therapy.     

Should timing be considered before abandoning convalescent plasma in covid-19? Results from the Turkish experience

IntroductionsResults with convalescent plasma therapy in coronavirus disease 2019 (COVID-19) have been contradictory. Timing seems to be an important factor for COVID-19 convalescent plasma(CCP) to be effective. Aim of this study is to compare disease outcomes in hospitalized COVID-19 patients who were treated with CCP within first three or seven days of symptoms to patients with symptoms longer than seven days.Material and methodsA multicenter retrospective study was conducted to evaluate disease outcomes in hospitalized COVID-19 patients who received CCP in addition to standard of care (SOC) approach. Patients were subgrouped according to time of CCP administration; within three days of symptoms, seven days of symptoms and after seven days of symptoms. A control group was formed from age, gender and comorbidity matched hospitalized patients who received SOC treatments without CCP. Length of hospital stay, rates of anti-inflammatory treatment initiation, intensive care unit (ICU) admission and mortality was set as outcome measures.ResultsA total of 223 patients were enrolled in this study, 113 patients received CCP (38 within three days, 63 within seven days, 50 after seven days of symptom onset). Rate of anti-inflammatory treatment initiation was significantly lower (38.1 % vs 62.7 %, p = 0.002, relative risk, 0.60,73; 95 % confidence interval [CI], 0.42 to 0.85) and length of hospital stay was significantly shorter (median(IQR) 8(4) days vs 9.5(5.25) days, p = 0.0025) in patients who received CCP within seven days of symptom onset when compared to SOC group.ConclusionCCP therapy may provide better outcomes when applied within seven days of symptoms.     

Use of flexible intermediate and intensive care to reduce multiple transfers of patients.

OBJECTIVE: To test an alternative flexible approach to traditional fixed intermediate and intensive care to minimize transfers of patients. METHODS: Patients admitted to a 28-bed nursing unit with intermediate care potential and a 12-bed intensive care unit at a 300-bed teaching community hospital were studied. The group included 524 patients with a discharge diagnosis code for mechanical ventilation. During eight 3-week cycles, 1073 transfers of patients were tabulated. A plan-do-study-act method was used to improve weaning from mechanical ventilation and reduce the number of inappropriate days in intensive care. Admissions and transfers to the 2 units for all patients during the eight 3-week cycles were compared over time. Length of stay and mortality were noted for all patients treated with conventional and noninvasive ventilation. RESULTS: Direct admissions to the flexible intermediate unit increased with no overall change in admissions to the intensive care unit. Fewer patients needed conventional ventilation, and more in both units were treated with noninvasive ventilation. The median number of transfers per patient treated with mechanical ventilation decreased from 1.94 to 1.20. Length of stay and mortality also decreased among such patients. Some cost savings were attributable to the decrease in the number of transfers. Transfers out of the hospital directly from the intensive care unit increased from 2.24% to 4.43%. CONCLUSIONS: In a community teaching hospital, flexible care policies decreased the number of in-hospital transfers of patients treated with mechanical ventilation.     

Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: a nine-hospital study of surgical patients

BACKGROUND: Health care organizations face pressures from patients to improve the quality of care and clinical outcomes, as well as pressures from managed care to do so more efficiently. Coordination, the management of task interdependencies, is one way that health care organizations have attempted to meet these conflicting demands. OBJECTIVES: The objectives of this study were to introduce the concept of relational coordination and to determine its impact on the quality of care, postoperative pain and functioning, and the length of stay for patients undergoing an elective surgical procedure. Relational coordination comprises frequent, timely, accurate communication, as well as problem-solving, shared goals, shared knowledge, and mutual respect among health care providers. RESEARCH DESIGN: Relational coordination was measured by a cross-sectional questionnaire of health care providers. Quality of care was measured by a cross-sectional postoperative questionnaire of total hip and knee arthroplasty patients. On the same questionnaire, postoperative pain and functioning were measured by the WOMAC osteoarthritis instrument. Length of stay was measured from individual patient hospital records. SUBJECTS: The subjects for this study were 338 care providers and 878 patients who completed questionnaires from 9 hospitals in Boston, MA, New York, NY, and Dallas, TX, between July and December 1997. MEASURES: Quality of care, postoperative pain and functioning, and length of acute hospital stay. RESULTS: Relational coordination varied significantly between sites, ranging from 3.86 to 4.22 (P <0.001). Quality of care was significantly improved by relational coordination (P <0.001) and each of its dimensions. Postoperative pain was significantly reduced by relational coordination (P = 0.041), whereas postoperative functioning was significantly improved by several dimensions of relational coordination, including the frequency of communication (P = 0.044), the strength of shared goals (P = 0.035), and the degree of mutual respect (P = 0.030) among care providers. Length of stay was significantly shortened (53.77%, P <0.001) by relational coordination and each of its dimensions. CONCLUSIONS: Relational coordination across health care providers is associated with improved quality of care, reduced postoperative pain, and decreased lengths of hospital stay for patients undergoing total joint arthroplasty. These findings support the design of formal practices to strengthen communication and relationships among key caregivers on surgical units.     

Prospective evaluation of pulmonary edema

OBJECTIVES: To describe the clinical profile and hospital outcome of successive unselected patients with pulmonary edema hospitalized in an internal medicine department. DESIGN: Prospective, consecutive, unsolicited patients diagnosed with pulmonary edema. SETTING: An internal medicine department in a 900 tertiary care center. PATIENTS: A total of 150 consecutive unselected patients (90 males, 60 females; median age, 75 yrs). RESULTS: Ischemic heart disease, hypertension, various valvular lesions and diabetes mellitus were present in 85%, 70%, 53%, and 52% of patients, respectively. Acute myocardial infarction at admission was observed in 15% of patients. The most common precipitating factors associated with the development of pulmonary edema included: high blood pressure (29%), rapid atrial fibrillation (29%,) unstable angina pectoris (25%), infection (18%), and acute myocardial infarction (15%). Twenty-two patients (15%) were mechanically ventilated. Eighteen patients (12%) died while in the hospital, and the cause of death was cardiac pump failure in 82%. The median hospital stay was 10 days. Predictors for increase rate of in-hospital mortality included: diabetes (p<.05), orthopnea (p<.05), echocardiographic finding of moderate-to-severely depressed global left ventricular systolic function (p<.001), acute myocardial infarction during hospital stay (p<.001), hypotension/shock (p<.05), and the need for mechanical ventilation (p<.001). CONCLUSIONS: Most patients with pulmonary edema in the internal medicine department are elderly, having ischemic heart disease, hypertension, diabetes, and a previous history of pulmonary edema. The overall mortality is high (in-hospital, 12%) and the predictors associated with high in-hospital mortality are related to left ventricular myocardial function. The long median hospital stay (10 days) and the need for many cardiovascular drugs, impose a considerable cost in the management and health care of these patients.     

Predictive value of SYNTAX score II for clinical outcomes in cardiogenic shock underwent primary percutaneous coronary intervention; a pilot study

SYNTAX Score II (SSII) connects clinical variables with coronary anatomy. We investigated the prognostic value of SSII in patients with ST segment elevated myocardial infarction (STEMI) complicated with cardiogenic shock treated with primary percutaneous coronary intervention (PPCI). In this retrospective analysis, we evaluated the in-hospital prognostic impact of SSII on 492 patients with STEMI complicated with cardiogenic shock treated with PPCI. Patients were stratified by tertiles of SSII, in-hospital clinical outcomes were compared between those groups. In-hospital univariate analysis revealed higher rates of in-hospital death for patients with SSII in tertile 3, as compared to patients with SSII in tertile 1 (OR 17.4, 95% CI 10.0–30.2, p?<?0.001). After adjustment for confounding baseline variables, SSII in tertile 3 was associated with 6.2-fold hazard of in-hospital death (OR 6.2, 95% CI 2.6–14.1, p?<?0.001). SSII in patients with STEMI complicated with cardiogenic shock treated with PPCI provide an independent prognostic marker of in-hospital outcomes. Our data suggests SSII to be a simple, feasible and clinically applicable tool for rapid risk stratification in patients with STEMI complicated with cardiogenic shock treated with PPCI.     

Effectiveness of nursing-led inpatient care for patients with post-acute health care needs: secondary data analysis from a programme of randomized controlled trials

OBJECTIVES: To determine whether transfer to a nursing-led inpatient unit (NLIU) prior to discharge from hospital can improve clinical outcome and reduce length of stay and readmission rate for medically stable post-acute patients assessed as requiring inpatient care. METHOD: Retrospective secondary data analysis of individual patient data (n=471) from a programme of three, purposefully replicated, pragmatic randomized controlled trials. Patients were referred to the NLIU by their consultant (attending doctor/surgeon) for nursing-led subacute/post-acute care and randomly allocated to a treatment group for planned transfer to the NLIU for the remainder of their hospital stay or to a control group for traditional consultant-led care in acute wards. Outcome measures were physical function (Barthel Index), length of stay, discharge destination, mortality, psychological well-being (General Health Questionnaire-12), health-related distress (Nottingham Health Profile Distress Index), incidence of complications and readmission within 7, 28, 90 and 180 days. RESULTS: Patients allocated to the NLIU showed greater improvement in physical function (P<0.001) and were more likely to be discharged to live independently in the community than controls [odds ratio (OR)=0.42, P=0.001] although they spent longer in hospital (P= 0.003). They showed greater improvement in psychological well-being (P = 0.001) and health-related distress (P =0.025) and a lower incidence of pressure ulcers (OR=0.33, P=0.011). CONCLUSION: Transfer to a NLIU can have a beneficial effect on outcomes of care for post-acute patients with complex health and social needs although length of stay is longer. This study strengthens the evidence of effectiveness of the NLIU model of care and provides evidence of effectiveness of post-acute and subacute models of care.     

Procalcitonin-guided therapy in intensive care unit patients with severe sepsis and septic shock – a systematic review and meta-analysis

Introduction

Procalcitonin (PCT) algorithms for antibiotic treatment decisions have been studied in adult patients from primary care, emergency department, and intensive care unit (ICU) settings, suggesting that procalcitonin-guided therapy may reduce antibiotic exposure without increasing the mortality rate. However, information on the efficacy and safety of this approach in the most vulnerable population of critically ill patients with severe sepsis and septic shock is missing.

Method

Two reviewers independently performed a systematic search in PubMed, Embase, ISI Web of Knowledge, BioMed Central, ScienceDirect, Cochrane Central Register of Controlled Trials, http://www.ClinicalTrials.gov and http://www.ISRCTN.org.Eligible studies had to be randomized controlled clinical trials or cohort studies which compare procalcitonin-guided therapy with standard care in severe sepsis patients and report at least one of the following outcomes: hospital mortality, 28-day mortality, duration of antimicrobial therapy, length of stay in the intensive care unit or length of hospital stay. Disagreements about inclusion of studies and judgment of bias were solved by consensus.

Results

Finally seven studies comprising a total of 1,075 patients with severe sepsis or septic shock were included in the meta-analysis.Both hospital mortality (RR [relative risk]: 0.91, 95%CI [confidence interval]: 0.61; 1.36) and 28-day mortality (RR: 1.02, 95%CI: 0.85; 1.23) were not different between procalcitonin-guided therapy and standard treatment groups.Duration of antimicrobial therapy was significantly reduced in favor of procalcitonin-guided therapy (HR [hazard ratio]: 1.27, 95%CI: 1.01; 1.53). Combined estimates of the length of stay in the ICU and in hospital did not differ between groups.

Conclusion

Procalcitonin-guided therapy is a helpful approach to guide antibiotic therapy and surgical interventions without a beneficial effect on mortality. The major benefit of PCT-guided therapy consists of a shorter duration of antibiotic treatment compared to standard care.Trials are needed to investigate the effect of PCT-guided therapy on mortality, length of ICU and in-hospital stay in severe sepsis patients.