The epidemiology of acute respiratory failure in critically ill patients(*)

STUDY OBJECTIVES: To describe the risk factors for the development of and mortality resulting from acute respiratory failure (ARF) in a large patient population. DESIGN: A substudy of a prospective, multicenter, observational cohort study, which was designed to validate the sequential organ failure assessment score. SETTING: Forty ICUs in 16 countries. PATIENTS: All critically ill patients who were admitted to one of the participating ICUs during a 1-month period were observed until the end of their hospital course. MEASUREMENTS AND RESULTS: Of the 1,449 patients who were enrolled into the study, 458 (32%) were admitted to an ICU with ARF, as defined by a PaO(2)/fraction of inspired oxygen ratio of < 200 mm Hg and the need for respiratory support. Patients who presented with ARF were older than the other patients (63 vs 57 years, respectively; p < 0.001) and more commonly had an infection (47% vs 20%, respectively; p < 0.001). The length of ICU stay was longer (6 vs 4 days, respectively; p < 0.001) and the ICU mortality rate was more than double (34% vs 16%, respectively; p < 0.001) in ARF patients compared to non-ARF patients. Of the 991 patients who were admitted to an ICU without ARF, 352 (35%) developed ARF later during the ICU stay. The independent risk factors for the development of ARF were infection developing in the ICU (odds ratio [OR], 7.59; 95% confidence interval [CI], 5.08 to 11.33) or present on ICU admission (OR, 2.3; 95% CI, 1.68 to 3.16), the presence of neurologic failure on ICU admission (OR, 2.73; 95% CI, 1.90 to 3.91), and older age (OR, 1.70; 95% CI, 1.30 to 2.22). Of all 810 patients with ARF, 253 (31%) died. The independent risk factors for death were multiple organ failure following ICU admission, history of hematologic malignancy, chronic renal failure or liver cirrhosis, the presence of circulatory shock on ICU admission, the presence of infection, and older age. CONCLUSIONS: The present study stresses that ARF is common in the ICU (56% of all patients) and that a number of extrapulmonary factors are related to the risk of development of ARF and to mortality rate in these patients.     

The quality of Intensive Care nursing before,during, and after the introduction of nurses without ICU-training

OBJECTIVE: The forecasted shortage of nurses specialized in intensive care seriously threatens the service level in the intensive care units (ICUs). This problem might partly be solved by introducing nurses without ICU experience who can provide basic nursing care to relieve the workload of the ICU nurses. This prospective controlled study was set up to determine whether such an introduction causes a significant shift in the quality of care. DESIGN: A prospective observational study was conducted to measure possible changes in the quality of care by examining the number of predefined nursing errors per patient with an observational instrument, the Critical Nursing Situation Index (CNSI). The CNSI was randomly applied during a preassessment period, an intervention period, and a postassessment period. During the intervention period, 16 full time equivalent nurses were employed with the assignment to assist the ICU nurses with basic care activities for 6 months. SETTING: The study was conducted in a 30-bed ICU at the Academic Medical Center in Amsterdam. ANALYSIS: The effect of the employment of nurses was expressed as the difference in the incidence of CNSI scores between the preassessment period and the intervention period on the basis of the relative risk ratios. The results of the comparison between the preassessment and the postassessment period were used to express the consistency of the measure. RESULTS: The researchers completed 600 CNSI observations in 256 patients in 162 days. Overall incidence rates during the preassessment (13%; 1539/12 222) and postassessment (14%; 1554/11 327) period were comparable, whereas the intervention period showed a diminished overall incidence of 9% (1019/11 395). The overall relative risk (95% CL) was 0.70 (0.56/0.86), indicating a significant risk reduction during the intervention period. CONCLUSION: The employment of nurses without ICU training improved the quality of care. This positive effect was primarily explained by the increase in available nursing time.     

Empathy of intensive care nurses and critical care family needs assessment.

In this study we explored the relationship between the empathy of intensive care unit (ICU) nurses and their ability to assess accurately the perceived needs of family members of patients hospitalized in ICU settings. Thirty family needs were studied by using Molter's 1983 revision of the Critical Care Family Needs Inventory (CCFNI). Data consisted of 92 pairs of CCFNI responses obtained from 92 family members of ICU patients and 60 ICU nurses providing direct care for these patients. Multiple regression analysis was performed to determine the extent to which empathy and nursing experience contribute to accurate assessment of the needs of ICU family members. The more emphatic ICU nurses were, the greater their ability to assess ICU family members' needs accurately on six of the needs studied (p less than or equal to 0.05). Length of nursing experience negatively affected the nurse's ability to assess three of the ICU family members' needs accurately (p less than 0.05).     

Noninvasive vs conventional mechanical ventilation in acute respiratory failure: a multicenter, randomized controlled trial

STUDY OBJECTIVE: Noninvasive mechanical ventilation (NIMV) is beneficial for patients with acute respiratory failure (ARF) when added to medical treatment. However, its role as an alternative to conventional mechanical ventilation (CMV) remains controversial. Our aim was to compare the efficacy and resource consumption of NIMV against CMV in patients with ARF. DESIGN: A randomized, multicenter, controlled trial. SETTING: Seven multipurpose ICUs. PATIENTS: Sixty-four patients with ARF from various causes who fulfilled criteria for mechanical ventilation. INTERVENTION: The noninvasive group received ventilation through a face mask in pressure-support mode plus positive end-expiratory pressure; the conventional group received ventilation through a tracheal tube. MEASUREMENTS AND RESULTS: Avoidance of intubation, mortality, and consumption of resources were the outcome variables. Thirty-one patients were assigned to the noninvasive group, and 33 were assigned to the conventional group. In the noninvasive group, 58% patients were intubated, vs 100% in the conventional group (relative risk reduction, 43%; p < 0.001). Stratification by type of ARF gave similar results. In the ICU, death occurred in 23% and 39% (p = 0.09) and complications occurred in 52% and 70% (p = 0.07) in the noninvasive and conventional groups, respectively. There were no differences in length of stay. The Therapeutic Intervention Score System-28, but not the direct nursing activity time, was lower in the noninvasive group during the first 3 days. CONCLUSIONS: NIMV reduces the need for intubation and therapeutic intervention in patients with ARF from different causes. There is a nonsignificant trend of reduction in ICUs and hospital mortality together with fewer complications during ICU stay.     

Acute renal failure after allogeneic myeloablative stem cell transplantation: retrospective analysis of incidence, risk factors and survival

Acute renal failure (ARF) is an important complication after stem cell transplantation (SCT). We retrospectively analysed ARF in 363 recipients of allogeneic myeloablative SCT to identify incidence, risk factors, associated post-transplantation complications and mortality of ARF. ARF was graded as grade 0 (no ARF) to grade 3 (need for dialysis) according to creatinine, estimated glomerular filtration rate and need for dialysis. The incidence of severe renal failure (grades 2 and 3 combined) was 49.6% (180 of 363 patients). Hypertension present at SCT was identified as a risk factor for ARF (P=0.003). Despite this, survival of these patients was not different compared to patients without hypertension. Admission to the intensive care unit (ICU) was a post-transplantation complication significantly associated with ARF (P<0.001). Survival rate was highest in patients with ARF grade 0-1 and lowest in patients with grade 3 (P<0.001). However, after correction for complications associated with high mortality (admission to the ICU, thrombotic thrombocytopenic purpura, sinusoidal occlusion syndrome (SOS) and acute graft-versus-host disease) the significant difference in survival disappeared, showing that ARF without co-morbid conditions has a good prognosis, and ARF with co-morbid conditions has a poor prognosis. This poor prognosis is due to the presence of co-morbid conditions rather than development of ARF itself.     

A prospective, multicenter study of the epidemiology, management, and outcome of severe acute renal failure in a "closed" ICU system

The safety and effectiveness of "closed" intensive care units (ICUs) are highly controversial. The epidemiology and outcome of acute renal failure (ARF) requiring replacement therapy (severe ARF) within a "closed" ICU system are unknown. Accordingly, we performed a prospective 3-mo multicenter observational study of all Nephrology Units and ICUs in the State of Victoria (all "closed" ICUs), Australia, and focused on the epidemiology, treatment, and outcome of patients with severe ARF. We collected demographic, clinical, and outcome data using standardized case report forms. Nineteen ward patients and 116 adult ICU patients had severe ARF (13.4 cases/100, 000 adults/yr). Among the ICU patients with severe ARF, 37 had impaired baseline renal function, 91 needed ventilation, and 95 needed vasoactive drugs. Intensivists controlled patient care in all cases. Continuous renal replacement therapy (CRRT) was used in 111 of the ICU patients. Nephrological opinion was sought in only 30 cases. Predicted mortality was 59.6%. Actual mortality was 49.2%. Only 11 ICU survivors were dialysis dependent at hospital discharge. In the state of Victoria, Australia, intensivists manage severe ARF within a "closed" ICU system. Renal replacement is typically continuous and outcomes compare favorably with those predicted by illness severity scores. Our findings support the safety and efficacy of a "closed" ICU model of care.     

Outcome of coal worker's pneumoconiosis with acute respiratory failure

STUDY OBJECTIVE: To investigate the clinical features and prognosis of patients with coal worker's pneumoconiosis (CWP) requiring invasive mechanical ventilation (MV) in the ICU for their first episode of acute respiratory failure (ARF), with special attention to the prognostic implication of radiographic progressive massive fibrosis (PMF). DESIGN: Retrospective study. SETTING: A 16-bed medical ICU at a community hospital. PATIENTS AND METHODS: We reviewed 53 patients with CWP and ARF requiring invasive MV in the ICU for the first time between August 1998 and March 2002. RESULTS: Of the 53 patients with CWP, 28 patients (53%) with PMF had their first ARF at a younger age than those without PMF (69.1 +/- 7.9 years vs 74.8 +/- 7.2 years, p = 0.008 [mean +/- SD]). Pneumonia (49%) was the most common cause of ARF. The mean APACHE (acute physiology and chronic health evaluation) II score was 26.0 +/- 9.9, and the mean ICU stay was 14.7 +/- 16.1 days. Twenty-one patients (40%) were weaned successfully in the ICU, with mean ventilator time of 17.0 +/- 25.1 days. The ICU and in-hospital mortality rates were 40% and 43%, respectively. The median survivals for all patients and the ICU survivors were 2.6 months and 14.3 months, respectively. Multivariate analysis showed the following risk (or protective) factors for the ICU mortality: PaCO(2) > 45 mm Hg at the time of intubation (adjusted odds ratio [OR], 0.04; 95% confidence interval [CI], 0.003 to 0.44), PaO(2)/fraction of inspired oxygen ratio < 200 mm Hg at the time of intubation (OR, 8.78; 95% CI, 1.36 to 56.48), and APACHE II score >or= 25 (OR, 11.99; 95% CI, 1.49 to 96.78). PMF was not associated with the ICU mortality (OR, 1.18; 95% CI, 0.20 to 7.10). CONCLUSIONS: Radiographic PMF was not associated with the ICU mortality in patients with CWP and ARF receiving invasive MV in the ICU. Although a substantial proportion of them could be weaned from the ventilator and discharged from the hospital, their long-term prognosis was poor.     

10 Comparison of Four Prognostic Indexes in Severe Acute Renal Failure

Background Several prognostic indexes and models are in use for acute renal failure (ARF) patients in intensive care units (ICU). Some were designed on general ICU populations (like APACHE II) and some were made specifically for ICU patients with ARF. The purpose of our prospective clinical study was to compare APACHE II and three ARF‐specific prognostic indexes in their ability to discriminate survivors and non‐survivors among critically ill ARF patients requiring dialysis. Methods Forty‐four critically ill patients with ARF requiring dialysis were included. Patients with chronic renal insufficiency (creatinine > 200 µmol/L), transplanted kidney or urinary tract obstruction were excluded. Four prognostic indexes were measured at the time of first dialysis: APACHE II score (0–71), Cleveland Clinic Foundation (CCF) score (0–20), predicted mortality by Mehta and by Liano model. Primary end‐points were ICU survival and recovery of renal function. Results Patients were 65 ± 5 years old, 75% were male, 50% recovered renal function (22/44). Mean APACHE II score was 21.9 ± 6.5, CCF score was 9.2 ± 2.5, predicted mortality by Mehta model was 64 ± 5% and by Liano model 47 ± 20%. Patients that recovered renal function and those that died in ARF did not differ significantly in any of the prognostic indexes measured. Intensive Care Unit survival data was available for 32 patients, this group was not significantly different in prognostic indexes from the group for which ICU survival data was not available. Intensive Care Unit mortality was 75% (24/32). There was significant difference in APACHE II value in ICU survivors and non‐survivors (16.6 ± 6.1 vs. 23.4 ± 6.5, P = 0.015), but no difference in the other three indexes. Conclusions Only the APACHE II values measured at first dialysis were significantly different between ICU survivors and non‐survivors, whereas other three prognostic indexes were not.     

Continuous arteriovenous hemofiltration in the elderly patients

The outcome of continuous arteriovenous hemofiltration (CAVH) treatment was evaluated in fifty one critically ill elderly with acute renal failure (ARF). They were admitted into our University Hospital's intensive-care units (ICU) during January 1987 and December 1990. Mean age (± SD) was 70.7 ± 5 (range 65–84) years. Elderly patients (>65 years old) comprised 44% of the ICU-ARF patients. The causes of ARF were cardiac surgery (41%), medical (31%), aneurysm of the resection of abdominal aorta (20%), and general surgery (8%). In the majority of the patients ARF was complicated by multiple organ failure. A survival of 60% was obtained with CAVH treatment. The highest survival rate (69%) was noted among cardiac surgery ARF patients, while the lowest survival (25%) was seen among patients with ARF following aneurysm of the resection of abdominal aorta. From the results of this study we conclude that CAVH serves a benificial role if it is considered in the management of ARF in the elderly intensive care patients with multiple organ failure.     

The characteristics and outcomes of patients with idiopathic pulmonary fibrosis admitted to the ICU with acute respiratory failure

BackgroundTo date, studies have provided conflicting results regarding the outcomes of patients with Idiopathic Pulmonary Fibrosis (IPF) admitted to the ICU with acute respiratory failure (ARF).ObjectiveTo understand the characteristics and outcomes of these patients.MethodsRetrospective study using a large single-center ICU database. We identified 48 unique patients with IPF admitted for ARF from 2001-2012.ResultsThe most common causes of ARF were IPF exacerbation and pneumonia. The overall hospital mortality rate was 43.8% and was 56.7% in those who required invasive mechanical ventilation (IMV). In patients requiring IMV for IPF exacerbation, the mortality rate was 81.3%. In multiple regression analysis, the presence of diabetes mellitus was associated with decreased mortality whereas the need for IMV was associated with increased mortality.ConclusionsAlthough the overall mortality rate for IPF patients with ARF has improved, the need for IMV due to IPF exacerbations is associated with increased mortality.     

Touch: a nursing strategy in the intensive care unit

In this article findings are reported from a qualitative study that examined touch from the perspective of intensive care (ICU) nurses. In-depth interviews with eight experienced ICU nurses and participant observation were used to collect data. Three distinct kinds of touch were identified, as well as normative patterns of touch among ICU nurses. The findings indicate that an understanding of touch is predicated on knowledge about the structural components of touch and the contextual variables and conditions that determine norms of touching. Touch is described as a multipurpose nursing strategy in the ICU. A need was identified to study a wider range of potential therapeutic and nontherapeutic touch meanings for nurses and patients than has previously been reported.     

Time course of expiratory flow limitation in COPD patients during acute respiratory failure requiring mechanical ventilation

STUDY OBJECTIVES: (1) To determine the incidence of expiratory flow limitation (FL) at ICU admission, at the time of extubation, and at ICU discharge in intubated patients with COPD receiving mechanical ventilation for acute respiratory failure (ARF); and (2) to assess the feasibility of inspiratory capacity (IC) as an indication of pulmonary dynamic hyperinflation in this setting. DESIGN: Prospective, observational pilot study with physiologic measurements performed at ICU admission and during the weaning process driven by the clinician. A 60-min T-tube trial was initiated once criteria for weaning were present. The decision to extubate or reventilate patients was made by the clinician at the end of this session. Assessment of failure or success of T-tube trials was performed independently. SETTING: A 25-bed ICU of a tertiary teaching university hospital. PATIENTS: Over a 13-month period, 25 intubated patients with COPD receiving mechanical ventilation for ARF were included. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: At ICU admission, FL assessed by the negative expiratory pressure test was measured under passive ventilatory conditions at the baseline ventilatory settings, on zero end-expiratory pressure, and in a semirecumbent position. During weaning, FL, respiratory pattern, and IC were measured during T-tube trials, before extubation, 1 h after extubation, and at ICU discharge. At ICU admission, 24 of 25 patients presented FL with, on average, 73 +/- 22% of the tidal volume. Ten patients were unavailable for follow-up due to death (n = 6) unplanned extubation (n = 3), or refusal (n = 1), so that only 15 patients completed the whole protocol (all 15 patients were extubated). For these 15 patients, the incidence of FL was 93% at ICU admission, 47% before extubation, and 40% at ICU discharge. IC was significantly greater at ICU discharge than before extubation (36 +/- 11% predicted vs 44 +/- 12% predicted, p < 0.01) and in successful T-tube trials compared with unsuccessful T-tube trials (38 +/- 13% predicted vs 24 +/- 8% predicted, p < 0.01). CONCLUSIONS: The incidence of expiratory FL is high in patients with COPD receiving mechanical ventilation, and is reduced during aggressive therapy when the patient is placed on mechanical ventilatory support and the time that weaning begins during the ICU stay. IC was lower in patients in whom weaning was unsuccessful. Further large-scale studies are required to confirm these preliminary results.     

Evaluation of a practice guideline for noninvasive positive-pressure ventilation for acute respiratory failure

OBJECTIVES: Clinical practice guidelines have been devised to change practitioner performance and to improve the process and outcomes of care. The objective of this study was to determine whether adherence to a practice guideline on noninvasive positive-pressure ventilation (NPPV) for the treatment of patients with acute respiratory failure (ARF) would change clinician behavior and resource utilization, and improve NPPV utilization and patient outcomes. DESIGN: Using a multidisciplinary team, we developed, implemented, and evaluated an NPPV practice guideline for ARF. Before and after guideline implementation, we recorded the incidence of endotracheal intubation (ETI) and mortality. Secondary outcomes were technological settings (ie, NPPV settings and duration) and NPPV administration (ie, cardiopulmonary monitoring, transfer to and time spent in the ICU, and pulmonary consultation). PARTICIPANTS: We enrolled 189 patients, 91 in the preguideline phase and 98 in the postguideline phase. Patients were similar in the both phases with respect to diagnoses at hospital admission and severity of illness. RESULTS: Of patients receiving NPPV for ARF, 67.3% fulfilled the guideline eligibility criteria in the postguideline phase compared to 62.6% in the preguideline phase (p = 0.543). Compared to the preguideline phase, more patients in the postguideline phase were transferred to the ICU (14.7% vs 33.7%, respectively; p = 0.003), spent more time in the ICU (30.9% vs 62.4%, respectively; p < 0.0001), and had consultation by a pulmonary physician (28.4% vs 49.0%, respectively; p = 0.004). There were no changes in technological settings. Guideline implementation was associated with improved cardiopulmonary monitoring. Nursing and respiratory therapist flow sheets were well-utilized during the guideline phase. There were no differences in ETI rates and mortality rates before and after guideline implementation. CONCLUSION: In this before-after study, we found that a multidisciplinary guideline for the use of NPPV for the treatment of patients with ARF was associated with changes in the process of care, with greater NPPV utilization in the ICU, and with increased pulmonary consultation, without any significant changes in the outcomes of care (ie, ETI and mortality rates).     

老年重症患者的人性化护理与精细化管理

目的探讨精细化管理的人性化护理在ICU老年重症患者中应用的意义。方法通过对2004年5月-2008年12月期间第三军医大学三院创伤中心ICU369例ICU老年重症患者的监测和人性化护理进行回顾性分析总结。结果369例病例中,358例患者均安全转出ICU,认真的护理评估、严密的病情观察、积极采取护理及预防措施,可以降低老年重症患者护理并发症、减少ICU住院天数以及提高老年患者的生活质量。结论精细化管理的人性化护理在ICU老年重症患者的治疗、并发症的预防,以及康复中具有重要的作用。     

The prognosis of acute respiratory failure in critically ill cancer patients

Acute respiratory failure (ARF) in patients with cancer is frequently a fatal event. To identify factors associated with survival of cancer patients admitted to an intensive care unit (ICU) for ARF, we conducted a prospective 5-year observational study in a medical ICU in a teaching hospital in Paris, France. The patients were 203 cancer patients with ARF mainly due to infectious pneumonia (58%), but also noninfectious pneumonia (9%), congestive heart failure (12%), and no identifiable cause (21%). We measured clinical characteristics and ICU and hospital mortality rates.ICU mortality was 44.8% and hospital mortality was 47.8%. Noninvasive mechanical ventilation was used in 79 (39%) patients and conventional mechanical ventilation in 114 (56%), the mortality rates being 48.1% and 75.4%, respectively. Among the 14 patients with late noninvasive mechanical ventilation failure (>48 hours), only 1 survived. The mortality rate was 100% in the 19 noncardiac patients in whom conventional mechanical ventilation was started after 72 hours. By multivariable analysis, factors associated with increased mortality were documented invasive aspergillosis (odds ratio [OR], 2.13; 95% confidence intervals [CI], 1.05-14.74), no definite diagnosis (OR, 3.85; 95% CI, 1.26-11.70), vasopressors (OR, 3.19; 95% CI, 1.28-7.95), first-line conventional mechanical ventilation (OR, 8.75; 95% CI, 2.35-35.24), conventional mechanical ventilation after noninvasive mechanical ventilation failure (OR, 17.46; 95% CI, 5.04-60.52), and late noninvasive mechanical ventilation failure (OR, 10.64; 95% CI, 1.05-107.83). Hospital mortality was lower in patients with cardiac pulmonary edema (OR, 0.16; 95% CI, 0.03-0.72).Survival gains achieved in critically ill cancer patients in recent years extend to patients requiring ventilatory assistance. The impact of conventional mechanical ventilation on survival depends on the time from ICU admission to conventional mechanical ventilation and on the patient's response to noninvasive mechanical ventilation.     

"One more thing to think about…" Cognitive burden experienced by intensive care unit nurses when implementing a tight glucose control protocol

Critically ill patients require intensive nursing care. Intensive care unit (ICU) nurses, who care for these physiologically unstable patients, are continuously occupied with the integration of assessments, monitoring, and interventions that are responsive to a patient's evolving state. Since 2005, numerous evidenced-based clinical protocols have been implemented in the critical care unit. Individually, each may not appear to be burdensome but, collectively, these clinical protocols add to the cognitive work of ICU nurses. While nurses are central to the successful implementation of these protocols, little is written about the cognitive burden imposed on them by the addition of these clinical protocols. This article explores the impact of clinical protocols on the cognitive burden of ICU nurses, using a tight glucose control (TGC) protocol as an exemplar case. Research from management, ergonomics, systems engineering, and nursing is used to build the concept of cognitive burden. Future research can build upon this understanding to facilitate successful implementation of clinical protocols.     

Acute renal failure in the intensive care unit

Acute renal failure (ARF) is a common complication in critically ill patients, with ARF requiring renal replacement therapy (RRT) developing in approximately 5 to 10% of intensive care unit (ICU) patients. Epidemiological studies have demonstrated that ARF is an independent risk factor for mortality. Interventions to prevent the development of ARF are currently limited to a small number of settings, primarily radiocontrast nephropathy and rhabdomyolysis. There are no effective pharmacological agents for the treatment of established ARF. Renal replacement therapy remains the primary treatment for patients with severe ARF; however, the data guiding selection of modality of RRT and the optimal timing of initiation and dose of therapy are inconclusive. This review focuses on the epidemiology and diagnostic approach to ARF in the ICU and summarizes our current understanding of therapeutic approaches including RRT.     

Diagnostic accuracy of the Bedside Lung Ultrasound in Emergency protocol for the diagnosis of acute respiratory failure in spontaneously breathing patients

Objective:

Bedside lung ultrasound (LUS) is a noninvasive, readily available imaging modality that can complement clinical evaluation. The Bedside Lung Ultrasound in Emergency (BLUE) protocol has demonstrated a high diagnostic accuracy in patients with acute respiratory failure (ARF). Recently, bedside LUS has been added to the medical training program of our ICU. The aim of this study was to investigate the accuracy of LUS based on the BLUE protocol, when performed by physicians who are not ultrasound experts, to guide the diagnosis of ARF.

Methods:

Over a one-year period, all spontaneously breathing adult patients consecutively admitted to the ICU for ARF were prospectively included. After training, 4 non-ultrasound experts performed LUS within 20 minutes of patient admission. They were blinded to patient medical history. LUS diagnosis was compared with the final clinical diagnosis made by the ICU team before patients were discharged from the ICU (gold standard).

Results:

Thirty-seven patients were included in the analysis (mean age, 73.2 ± 14.7 years; APACHE II, 19.2 ± 7.3). LUS diagnosis had a good agreement with the final diagnosis in 84% of patients (overall kappa, 0.81). The most common etiologies for ARF were pneumonia (n = 17) and hemodynamic lung edema (n = 15). The sensitivity and specificity of LUS as measured against the final diagnosis were, respectively, 88% and 90% for pneumonia and 86% and 87% for hemodynamic lung edema.

Conclusions:

LUS based on the BLUE protocol was reproducible by physicians who are not ultrasound experts and accurate for the diagnosis of pneumonia and hemodynamic lung edema.     

Feasibility and inter-rater reliability of the ICU Mobility Scale

Objectives

The objectives of this study were to develop a scale for measuring the highest level of mobility in adult ICU patients and to assess its feasibility and inter-rater reliability.

Background

Growing evidence supports the feasibility, safety and efficacy of early mobilization in the intensive care unit (ICU). However, there are no adequately validated tools to quickly, easily, and reliably describe the mobility milestones of adult patients in ICU. Identifying or developing such a tool is a priority for evaluating mobility and rehabilitation activities for research and clinical care purposes.

Methods

This study was performed at two ICUs in Australia. Thirty ICU nursing, and physiotherapy staff assessed the feasibility of the ‘ICU Mobility Scale’ (IMS) using a 10-item questionnaire. The inter-rater reliability of the IMS was assessed by 2 junior physical therapists, 2 senior physical therapists, and 16 nursing staff in 100 consecutive medical, surgical or trauma ICU patients.

Results

An 11 point IMS scale was developed based on multidisciplinary input. Participating clinicians reported that the scale was clear, with 95% of respondents reporting that it took <1 min to complete. The junior and senior physical therapists showed the highest inter-rater reliability with a weighted Kappa (95% confidence interval) of 0.83 (0.76–0.90), while the senior physical therapists and nurses and the junior physical therapists and nurses had a weighted Kappa of 0.72 (0.61–0.83) and 0.69 (0.56–0.81) respectively.

Conclusion

The IMS is a feasible tool with strong inter-rater reliability for measuring the maximum level of mobility of adult patients in the ICU.     

Objektive, quantitative Messung des therapeutisch-pflegerischen Aufwandes für die Beatmungsbehandlung in der internistischen Intensivmedizin

Mechanical ventilation as the key procedure in the management of respiratory failure is considered to consume a significant amount of intensive care resources. Scoring systems have gained an important role for objectively assessing resource use, quality control and stratification of study populations in intensive care medicine. The aim of our study was the objective and quantitative measurement of the therapeutic as well as the nursing workload for mechanical ventilation due to respiratory failure in medical intensive care medicine employing the simplified Therapeutic Intervention Scoring System (TISS)-28. Particularly we focused our attention on the technique of non-invasive ventilation (NIV). Therefore the TISS-28 scores were determined on each ICU day in 80 mechanically ventilated patients in a medical ICU (844 ICU days determined in total). 40 patients were on NIV and 40 patients were on conventional mechanical ventilation following endotracheal intubation, respectively. In addition in all patients the APACHE II score was determined on the first ICU day for assessment of severity of illness. Study inclusion of the NIV patients was performed in a consecutive manner, whereas the conventionally ventilated patients were included in the study based on the criterion of equivalence of disease severity compared to the NIV patients (APACHE II matching). Furthermore the number of nurses available for the ICU patients assessed by the scoring systems were counted per shift and per day, respectively, in order to obtain information concerning the number of TISS-28 scoring points, which can be managed by one critical care nurse per shift. Overall 21 218 TISS-28 scoring points were counted on the 844 ICU days for the 80 patients on mechanical ventilation. A mean value of 25.1 TISS-28 points per ICU day was calculated for each patient. Each nurse was capable of delivering care equal to 51.6 TISS-28 scoring points/d in her shift. This almost exactly matches with the nursing workload required for 2 patients on mechanical ventilation due to respiratory failure. Finally, 1 TISS-28 point/d equals a value of 9.3 min of workload in each nurse’s shift. Using NIV the mean TISS-28 score (24.1 points/d) was only slightly lower compared to conventional invasive ventilation (25.8 points/d). However, the duration of ventilation was much shorter in the NIV group (mean 5.1 days; ICU stay 8.2 days) compared to the conventional ventila tion group (mean 10.4 days; ICU stay 12.9 days). Therefore – based on scoring results – the overall nursing workload in the NIV group (7905 TISS points) was much lower compared to the overall nursing workload required for the ICU treatment of an identical number of patients in the conventional ventilation group (13 313 TISS-28 points). In conclusion, our study demonstrates that the easily and quickly accessible TISS-28 scoring system is a sophisticated instrument for the objective assessmentof therapeutic as well as nursing workload for mechanical ventilation in medical intensive care medicine. Knowledge ofsuch data is becoming increasingly important because decisions concerning resource allocation, nursing capacities as well as numbers of ICU beds are increasingly based on objective measurements like TISS-28.