Prognostic factors,clinical course,and hospital outcome of patients with chronic obstructive pulmonary disease admitted to an intensive care unit for acute respiratory failure

OBJECTIVE: To describe prognostic factors, clinical course, and hospital outcome of patients with chronic obstructive pulmonary disease admitted to an intensive care unit for acute respiratory failure. DESIGN: Analysis of prospectively collected data. SETTING: A multidisciplinary intensive care unit of an inner-city university hospital. PATIENTS: Patients with chronic obstructive pulmonary disease admitted to an intensive care unit for acute respiratory failure from August 1995 through July 1998. MEASUREMENTS AND MAIN RESULTS: Data were obtained concerning demographics, arterial blood gas, Acute Physiology and Chronic Health Evaluation (APACHE) II score, sepsis, mechanical ventilation, organ failure, complications, and hospital mortality rate. Fifty-nine percent of patients were male, 63% white, and 36% African-American; the mean age was 63.1 +/- 8.9 yrs. Noninvasive mechanical ventilation was tried in 40% of patients and was successful in 54% of them. Invasive mechanical ventilation was required in 61% of the 250 admissions. Sepsis developed in 31% of patients, nonpulmonary organ failure in 20%, pneumothorax in 3%, and acute respiratory distress syndrome in 2%. Multiple organ failure developed in 31% of patients with sepsis compared with 3% without sepsis (p <.0001). Predicted and observed hospital mortality rates were 30% and 15%, respectively. Differences in age and arterial carbon dioxide and oxygen tensions between survivors and nonsurvivors were not significant. Arterial pH was lower in nonsurvivors than in survivors (7.21 vs. 7.25, p =.0408). The APACHE II-predicted mortality rate (p =.0001; odds ratio, 1.046; 95% confidence interval, 1.022-1.070) and number of organ failures (p <.0001; odds ratio, 5.524; 95% confidence interval, 3.041-10.031) were independent predictors of hospital outcome; invasive mechanical ventilation was not an independent predictor. CONCLUSIONS: Physiologic abnormalities at admission to an intensive care unit and development of nonrespiratory organ failure are important predictors of hospital outcome for critically ill patients with chronic obstructive pulmonary disease who have acute respiratory failure. Improved outcome would require prevention and appropriate treatment of sepsis and multiple organ failure.     

Complicated acute myocardial infarction requiring mechanical ventilation in the intensive care unit: prognostic factors of clinical outcome in a series of 157 patients

OBJECTIVE: To determine prognostic factors associated with death in patients with complicated acute myocardial infarction requiring mechanical ventilation. DESIGN: Retrospective chart-based analysis. SETTING: A 22-bed medical intensive care unit in a university hospital. PATIENTS: A total of 157 consecutive patients with acute myocardial infarction requiring endotracheal intubation and mechanical ventilation admitted to an intensive care unit during a 6-yr period. INTERVENTIONS: Coronary reperfusion strategy within 12 hrs following symptom onset. MEASUREMENTS AND MAIN RESULTS: Clinical characteristics at admission of survivors (n = 77) and nonsurvivors (n = 80) were similar regarding demographics, medical history, and Glasgow Coma Scale score. Twenty-eight-day intensive care unit mortality rate was 51%. The following criteria were higher for nonsurvivors: Simplified Acute Severity Score II, 79 +/- 18 vs. 64 +/- 17 (p <.0001); Acute Physiology and Chronic Health Evaluation (APACHE) II, 33 +/- 13 vs. 25 +/- 6 (p <.0001); incidence of cardiogenic shock (p =.0085) and failing organs (p <.0001); coronary artery disease extension (p =.045); and delay between symptom onset and coronary reperfusion (p =.0348). Nonsurvivors also had higher serum urea and creatinine and lower urine output, arterial pH, and left ventricular ejection fraction (p <.05). Mortality rate was higher in patients with PaO2/FiO2 ratio <200 than in patients with PaO2/FiO2 ratio >200 at admission (log-rank, 5.016; p =.0251). By multivariate analysis, only three factors were independently associated with death: APACHE II >29 (odds ratio, 1.132; 95% confidence interval, 1.013-1.265, p =.0287), serum creatinine >180 micromol/L (odds ratio, 6.151; 95% confidence interval, 1.446-26.166, p =.0139), and initial left ventricular ejection fraction <0.4 (odds ratio, 1.121; 95% confidence interval, 1.049-1.347, p =.0316). Overall, good discrimination was achieved for the risk score model (c-index, 0.852). CONCLUSIONS: We confirmed the high mortality rate of patients admitted to an intensive care unit with acute myocardial infarction requiring mechanical ventilation. In these patients, the main risk factors for death found, namely high APACHE II, early development of acute renal failure, and low resting left ventricular function, reflected the severity of the myocardial infarction.     

Association of pulmonary artery catheter use with in-hospital mortality

OBJECTIVE: To determine the association of pulmonary artery catheter (PAC) use with in-hospital mortality. DESIGN: Prospective, observational study. SETTING: The medical intensive care units (MICU) of two teaching hospitals. METHODS: The study included 751 adults who were admitted to the MICU, excluding those who stayed for <24 hrs. Demographics and the worst Acute Physiology and Chronic Health Evaluation (APACHE) II score within the first 24 hrs of MICU admission were obtained. Daily logistic organ dysfunction system (LODS) scores were calculated. The associations of in-hospital mortality with the admission source, admission disease category, APACHE II scores, the worst LODS scores, mechanical ventilation, and PAC use were determined using chi-square, Mann-Whitney U, and multiple logistic regression analysis tests. p Values < 0.05 were considered significant. RESULTS: Mean patient age was 52.6 +/- 17.1 yrs; 425 (57%) were male; 464 (62%) were African-American, 275 (37%) Caucasian, 6 (1%) Asian, and 6 (1%) Hispanic. PAC was used in 119/751 (16%). The median APACHE II and worst LODS scores were 19 and 4, respectively. The in-hospital mortality rate was 159/751 (21%). The median APACHE II score for survivors was 17.5, compared with 28.0 for nonsurvivors (p <.0001). The worst median LODS score was 4 for survivors, compared with 11 for nonsurvivors (p <.0001). Sixty-four (54%) of the 119 patients with PAC died, compared with 95 (15%) of the 632 without PAC (p <.0001). Multiple logistic regression analysis showed that higher APACHE II-predicted mortality rate (p =.0088) and worst daily LODS score (p <.0001) were associated with increased mortality. The admission source, admission disease category, PAC use, and mechanical ventilation were not associated with in-hospital mortality. CONCLUSIONS: This study could not detect an association between PAC use and mortality. The APACHE II-predicted mortality rate and the development of multiple organ dysfunction were the main determinants of poor outcome in critically ill patients admitted to MICU.     

Factors associated with withdrawal of mechanical ventilation in a neurology/neurosurgery intensive care unit

OBJECTIVE: The objective of this study was to identify factors associated with the decision to withdraw mechanical ventilation from patients in a neurology/neurosurgery intensive care unit. Specifically, the following factors were considered: the severity of the neurologic illness, the healthcare delivery system, and social factors. DESIGN: Retrospective analysis of prospectively collected clinical database. SETTING: Neurology/neurosurgery intensive care unit of a large academic tertiary care hospital. PATIENTS: Patients were 2,109 nonelective admissions to the neurology/neurosurgery intensive care unit who received mechanical ventilation over a period of 82 months. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The average age was 56 +/- 19.7 yrs, 53% were male, and 81% were functionally normal before admission. The median Glasgow Coma Scale score was 14, the average Acute Physiology and Chronic Health Evaluation II severity of illness score was 13.5 +/- 8.3, and probability of death was 18.2 +/- 22.0%. Mechanical ventilation was withdrawn from 284 (13.5%). Factors that were independently associated with withdrawal of mechanical ventilation were as follows: more severe neurologic injury [admission Glasgow Coma Scale score (odds ratio 0.86/point, confidence interval 0.82-0.90), diagnosis of subarachnoid hemorrhage (odds ratio 2.44, confidence interval 1.50-3.99), or ischemic stroke (odds ratio 1.72, confidence interval 1.13-2.60)], older age (odds ratio 1.04/yr, confidence interval 1.03-1.05), and higher Acute Physiology and Chronic Health Evaluation II probability of death (odds ratio 1.03/%, confidence interval 1.02-1.04). Mechanical ventilation was less likely to be withdrawn if patients were African-American (odds ratio 0.50, confidence interval 0.36-0.68) or had undergone surgery (odds ratio 0.44, confidence interval 0.2- 0.67). Marital status, premorbid functional status, clinical service (neurology vs. neurosurgery), attending status (private vs. academic), and type of health insurance were not associated with decisions to withdraw mechanical ventilation. CONCLUSIONS: We conclude that decisions to withdraw mechanical ventilation in the neurology/neurosurgery intensive care unit are based primarily on the severity of the acute neurologic condition and age but not on characteristics of the healthcare delivery system. Care is less likely to be withdrawn from African-American patients or those who had surgery.     

Characteristics and outcomes of cancer patients requiring mechanical ventilatory support for >24 hrs

OBJECTIVES: To describe the characteristics of a large cohort of cancer patients receiving mechanical ventilation for >24 hrs and to identify clinical features predictive of in-hospital death. DESIGN: Prospective cohort study. SETTING: Ten-bed oncologic medical-surgical intensive care unit. PATIENTS: A total of 463 consecutive patients were included over a 45-month period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data were collected on the day of admission to the intensive care unit. The intensive care unit and hospital mortality rates were 50% and 64%, respectively. There were 359 (78%) patients with solid tumors and 104 (22%) with hematologic malignancies; 35 (8%) patients had leukopenia. Sepsis (63%), coma (15%), invasion or compression by tumor (11%), pulmonary embolism (7%), and cardiopulmonary arrest (6%) were the main reasons for mechanical ventilation. The independent unfavorable risk factors for mortality were older age (odds ratio, 3.09; 95% confidence interval, 1.61-5.93, for patients 40-70 yrs old, and odds ratio, 9.26; 95% confidence interval, 4.16-20.58, for patients >70 yrs old); performance status 3-4 (odds ratio, 2.51; 95% confidence interval, 1.40-4.51); cancer recurrence/progression (odds ratio, 3.43; 95% confidence interval, 1.81-6.53); Pao2/Fio2 ratio <150 (odds ratio, 2.64; 95% confidence interval, 1.40-4.99); Sequential Organ Failure Assessment score (excluding respiratory domain, each 4 points; odds ratio, 2.34; 95% confidence interval, 1.70-3.24); and airway/pulmonary invasion or compression by tumor as a reason for mechanical ventilation (odds ratio, 5.73; 95% confidence interval, 1.92-17.08). CONCLUSIONS: Severity of acute organ failures, poor performance status, cancer status, and older age were the main determinants of mortality. The appropriate use of such easily available clinical characteristics may avoid forgoing intensive care for patients with a chance of survival.     

Six-month survival of patients with acute lung injury: prospective cohort study

OBJECTIVE: Both short- and long-term outcome studies in acute lung injury (ALI) performed thus far were conducted before the implementation of recent advances in mechanical ventilation and supportive care and/or in the context of clinical trials with restricted inclusion criteria. We sought to determine the outcome of consecutive acute lung injury patients after the implementation of these interventions. DESIGN: Prospective cohort study. SETTING: Three intensive care units of two tertiary care hospitals. PATIENTS: Patients with acute lung injury treated from October 2005 to May 2006, excluding those with no research authorization or do-not-resuscitate order. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The investigators collected detailed information about comorbidities, severity of pulmonary and nonpulmonary organ failures, complications, respiratory support, and other interventions. The main outcome measure was mortality 6 months after the onset of acute lung injury. From 142 patients enrolled over a 6-month period, 24 (17%) died in the intensive care unit, 38 (27%) in the hospital, and 55 (39%) by the end of the 6-month follow-up. Median (interquartile range) intensive care unit length of stay, duration of mechanical ventilation, and number of day 28 ventilator-free days were 7.1 (3.6-11.3), 5.7 (2.6-10.3), and, 19.0 (0-24.2) days. Multiple logistic regression analysis identified underlying Charlson comorbidity score (odds ratio 3.11, 95% confidence interval 2.01-5.05) for each point increase, transfer admission from the floor or outside hospital (odds ratio 3.75, 95% confidence interval 1.41-10.99), day 3 cardiovascular failure (odds ratio 3.30, 95% confidence interval 1.19-9.92), and day 3 Pao2/Fio2 (odds ratio 0.94, 95% confidence interval 0.88-0.99) as significant predictors of 6-month mortality. CONCLUSIONS: With the implementation of recent advances in mechanical ventilation and supportive care, premorbid condition is the most important determinant of acute lung injury survival.     

Tracheostomy does not improve the outcome of patients requiring prolonged mechanical ventilation: a propensity analysis

OBJECTIVE: To examine the association between the performance of a tracheostomy and intensive care unit and postintensive care unit mortality, controlling for treatment selection bias and confounding variables. DESIGN: Prospective, observational, cohort study. SETTING: Twelve French medical or surgical intensive care units. PATIENTS: Unselected patients requiring mechanical ventilation for > or =48 hrs enrolled between 1997 and 2004. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two models of propensity scores for tracheostomy were built using multivariate logistic regression. After matching on these propensity scores, the association of tracheostomy with outcomes was assessed using multivariate conditional logistic regression. Results obtained with the two models were compared. Of the 2,186 patients included, 177 (8.1%) received a tracheostomy. Both models led to similar results. Tracheostomy did not improve intensive care unit survival (model 1: odds ratio, 0.94; 95% confidence interval, 0.63-1.39; p = .74; model 2: odds ratio, 1.12; 95% confidence interval, 0.75-1.67; p = .59). There was no difference whether tracheostomy was performed early (within 7 days of ventilation) or late (after 7 days of ventilation). In patients discharged free from mechanical ventilation, tracheostomy was associated with increased postintensive care unit mortality when the tracheostomy tube was left in place (model 1: odds ratio, 3.73; 95% confidence interval, 1.41-9.83; p = .008; model 2: odds ratio, 4.63; 95% confidence interval, 1.68-12.72, p = .003). CONCLUSIONS: Tracheostomy does not seem to reduce intensive care unit mortality when performed in unselected patients but may represent a burden after intensive care unit discharge.     

Prognosis factors and outcome of community-acquired pneumonia needing mechanical ventilation

PURPOSE: To evaluate the variables associated with mortality of patients with community-acquired pneumonia who require mechanical ventilation and to determine the attributable morbidity and intensive care unit (ICU) mortality of community-acquired pneumonia. MATERIAL AND METHODS: Retrospective cohort study carried out in 361 ICUs from 20 countries including 124 patients who required mechanical ventilation on the first day of admission to the hospital due to acute respiratory failure secondary to severe community-acquired pneumonia. To assess the factors associated with outcome, a forward stepwise logistic regression analysis was performed, and to determine the attributable mortality of community-acquired pneumonia, a matched study design was used. RESULTS: We found 3 independent variables significantly associated with death in patients with community-acquired pneumonia requiring mechanical ventilation: simplified acute physiological score greater than 45 (odds ratio, 5.5 [95% confidence interval, 1.7-12.3]), shock (odds ratio, 5.7 [95% confidence interval, 1.7-10.1]), and acute renal failure (odds ratio, 3.0 [95% confidence interval, 1.1-4.0]). There was no statistically significant difference in ICU mortality among patients with or without community-acquired pneumonia (32% vs 35%; P=.59). CONCLUSIONS: Community-acquired pneumonia needing mechanical ventilation is not a disease associated with higher mortality. The main determinants of patient outcome were initial severity of illness and the development of shock and/or acute renal failure.     

Effect of critical illness polyneuropathy on the withdrawal from mechanical ventilation and the length of stay in septic patients

OBJECTIVES: No previous study has demonstrated whether critical illness polyneuropathy itself lengthens mechanical ventilation or whether this prolonged duration of ventilatory support is explained by concomitant risk factors for weaning failure. Our objectives were to evaluate the impact of critical illness polyneuropathy on the length of mechanical ventilation after controlling for coexisting risk factors for weaning failure and to assess the impact of critical illness polyneuropathy on the length of the stay in a cohort of septic patients. DESIGN: Prospective cohort study. SETTING: Intensive care unit of a tertiary hospital. PATIENTS: All patients with severe sepsis or septic shock who required mechanical ventilation for > or =7 days who were considered ready to discontinue mechanical ventilation. INTERVENTIONS: Patients underwent a neurophysiologic evaluation at onset of weaning from mechanical ventilation. MEASUREMENTS AND MAIN RESULTS: Sixty-four critically ill septic patients were enrolled, and 34 developed critical illness polyneuropathy (53.1%; 95% confidence interval, 40.2-65.7%). Length of mechanical ventilation was significantly higher in patients who had developed critical illness polyneuropathy (median 34 days vs. 14 days, p < .001). The duration of the weaning period was also significantly greater in patients with critical illness polyneuropathy (median 15 days vs. 2 days, p < .001) even though factors suspected to influence the weaning process did not differ between these two groups. Multiple logistic regression analysis indicated that critical illness polyneuropathy was the only risk factor independently associated with weaning failure (odds ratio, 15.4; 95% confidence interval, 4.55, 52.3; p < .001). Lengths of intensive care unit and hospital stays were significantly higher in patients with critical illness polyneuropathy. CONCLUSIONS: In critically ill septic patients, critical illness polyneuropathy significantly increases the duration of mechanical ventilation and prolongs the lengths of intensive care unit and hospital stays.     

Outcome of patients with end-stage renal disease admitted to the intensive care unit

OBJECTIVES: To describe the clinical course of patients with end-stage renal disease (ESRD) admitted to the intensive care unit (ICU) and to compare the performance of Acute Physiology and Chronic Health Evaluation (APACHE) III and Sequential Organ Failure Assessment (SOFA) in predicting their outcome. PATIENTS AND METHODS: This retrospective cohort study consisted of patients with ESRD admitted to 3 ICUs between January 1, 1997, and November 30, 2002. Data on demographics, APACHE III score, SOFA score, development of sepsis and organ failure, use of mechanical ventilation, and mortality were collected. RESULTS: Of the 476 patients with ESRD who underwent dialysis during the study period, 93 (20%) required admission to the ICU. The most common ICU admission diagnosis was gastrointestinal bleeding. The first day median (Interquartile range) APACHE III score, SOFA score, and APACHE III predicted hospital mortality rate were 64 (47-79), 6 (5-8), and 12.9% (4.2%-30.8%), respectively. The observed ICU, hospital, and 30-day mortality rates were 9%, 16%, and 22%, respectively. Nonrenal organ failure developed in 48 patients (52%) and sepsis in 15 patients (16%). Mechanical ventilation was required In 26 patients (28%). The area under the receiver operating characteristic curve for the first-day APACHE III probability of hospital death in predicting 30-day mortality was 0.78 (95% confidence interval, 0.68-0.86) compared with 0.66 (95% confidence interval, 0.55-0.76) for the SOFA score (P = .16). CONCLUSIONS: The observed hospital mortality of patients with ESRD admitted to the ICU is relatively low. There is no statistically significant difference in the performance of APACHE III and SOFA prognostic models in discriminating between 30-day survivors and nonsurvivors.     

Six-year mortality and quality of life in critically ill patients with chronic obstructive pulmonary disease

OBJECTIVE: To study the mortality and quality of life (QOL) of survivors at 6 yrs after intensive care unit (ICU) admission for chronic obstructive pulmonary disease. DESIGN: Prospective, multiple-center cohort study. SETTING: A total of 86 ICUs throughout Spain. PATIENTS: Patients in the Project for the Epidemiological Analysis of Critical Care Patients (PAEEC) project with chronic obstructive pulmonary disease were included. MEASUREMENTS AND MAIN RESULTS: The sample comprised 742 patients; 508 of them were admitted for acute exacerbation of chronic obstructive pulmonary disease, and 379 of these required intermittent positive-pressure ventilation. The mean age of the patients was 65.2 +/- 9.89 yrs, Acute Physiology and Chronic Health Evaluation (APACHE) III score was 66.6 +/- 21.04; preadmission QOL questionnaire score was 7 +/- 4.82 points, and hospital mortality was 31.8%. At 6 yrs, 32.2% had died after hospital discharge, 21.6% could not be traced, and 107 patients were alive (18.3% of the 582 followed-up patients). QOL of survivors was worse than preadmission (6.55 +/- 5.6 vs. 4.92 +/- 4.5 points, p < .05), but 72% of patients were self-sufficient. Among the 379 patients admitted to the ICU for acute chronic obstructive pulmonary disease exacerbation and requiring intermittent positive-pressure ventilation, 36.7% died in the hospital; at 6 yrs after hospital discharge, 31.4% had died, 18.7% could not be traced, and 50 patients (16.2% of followed-up patients) were alive. Multivariate analysis with logistic regression showed that the mortality at 6 yrs was related to age (odds ratio, 1.046; 95% confidence interval, 1.023-1.071), APACHE III score (odds ratio, 1.013; 95% confidence interval, 1.001-1.024), and preadmission QOL score (odds ratio, 1.139; 95% confidence interval, 1.078-1.204). CONCLUSION: The 6-yr mortality of patients with chronic obstructive pulmonary disease requiring ICU admission is high. Mortality is mainly influenced by pre-ICU admission QOL. At 6 yrs, at least 15% are alive; survivors have a worse QOL compared with pre-ICU admission, although three quarters of them are self-sufficient.     

Despite variation in volume, Veterans Affairs hospitals show consistent outcomes among patients with non-postoperative mechanical ventilation*

OBJECTIVE:: To assess the relationship between volume of nonoperative mechanically ventilated patients receiving care in a specific Veterans Health Administration hospital and their mortality. DESIGN:: Retrospective cohort study. SETTING:: One-hundred nineteen Veterans Health Administration medical centers. PATIENTS:: We identified 5,131 hospitalizations involving mechanically ventilated patients in an intensive care unit during 2009, who did not receive surgery. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: We extracted demographic and clinical data from the VA Inpatient Evaluation Center. For each hospital, we defined volume as the total number of nonsurgical admissions receiving mechanical ventilation in an intensive care unit during 2009. We examined the hospital contribution to 30-day mortality using multilevel logistic regression models with a random intercept for each hospital. We quantified the extent of interhospital variation in 30-day mortality using the intraclass correlation coefficient and median odds ratio. We used generalized estimating equations to examine the relationship between volume and 30-day mortality and risk-adjusted all models using a patient-level prognostic score derived from clinical data representing the risk of death conditional on treatment at a high-volume hospital. Mean age for the sample was 65 (SD 11) yrs, 97% were men, and 60% were white. The median VA hospital cared for 40 (interquartile range 19-62) mechanically ventilated patients in 2009. Crude 30-day mortality for these patients was 36.9%. After reliability and risk adjustment to the median patient, adjusted hospital-level mortality varied from 33.5% to 40.6%. The intraclass correlation coefficient for the hospital-level variation was 0.6% (95% confidence interval 0.1, 3.4%), with a median odds ratio of 1.15 (95% confidence interval 1.06, 1.38). The relationship between hospital volume of mechanically ventilated and 30-day mortality was not statistically significant: each 50-patient increase in volume was associated with a nonsignificant 2% decrease in the odds of death within 30 days (odds ratio 0.98, 95% confidence interval 0.87-1.10). CONCLUSIONS:: Veterans Health Administration hospitals caring for lower volumes of mechanically ventilated patients do not have worse mortality. Mechanisms underlying this finding are unclear, but, if elucidated, may offer other integrated health systems ways to overcome the disadvantages of small-volume centers in achieving good outcomes.     

The association of nicotine replacement therapy with mortality in a medical intensive care unit

OBJECTIVE: Smokers admitted to the intensive care unit may receive nicotine replacement therapy to prevent withdrawal. However, the safety of nicotine replacement in the critically ill has not been studied. The objective of this study was to determine the impact of nicotine replacement on the outcome of critically ill patients. DESIGN: Retrospective, case-control. SETTING: The medical intensive care unit of a tertiary academic hospital. PATIENTS: Patients who were active smokers at admission to the intensive care unit were included in the study. Those who received nicotine replacement therapy were considered as cases, and those who did not receive nicotine replacement were considered as controls. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: For each of the 90 cases, one control smoker who did not receive nicotine replacement therapy was selected based on the severity of illness and then age. Outcome was measured by hospital mortality and 28-day intensive care unit-free days, defined as the number of days spent outside of intensive care or without mechanical ventilation by a living patient following admission to intensive care. The mean mortality rate predicted by the Acute Physiology and Chronic Health Evaluation III was 9.2% for the cases compared with 10.3% for the controls (p = .7127). The observed hospital mortality rate was 20% in the cases vs. 7% in the control group (p = .0085). When adjusted for the severity of illness and invasive mechanical ventilation, nicotine replacement therapy was independently associated with increased mortality (odds ratio, 24.6; 95% confidence interval, 3.6-167.6; p = .0011). The mean (sd) 28-day intensive care unit-free days were 20.7 (10.5) in the case group compared with 23.4 (7.1) in the control group (p = .0488). CONCLUSIONS: Our study shows that nicotine replacement therapy is associated with increased hospital mortality in critically ill patients. However, because of the limitations of the study, a future study based on a better case-control design is warranted.     

Prognostic factors in obstetric patients admitted to an Indian intensive care unit

OBJECTIVES: Obstetric patients form a significant proportion of intensive care unit admissions in countries like India, where maternal mortality is high (440 per 100,000 deliveries). We studied the diseases requiring intensive care and prognostic factors in obstetric patients. DESIGN: Retrospective chart review. Acute Physiology and Chronic Health Evaluation (APACHE) II data were prospectively collected. SETTING: Multidisciplinary intensive care unit of a public hospital in Mumbai, India. PATIENTS: Women admitted during pregnancy or 6 wks post-partum during a 5-yr study period (1997-2001). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Four hundred fifty-three obstetric patients (age 25.5 +/- 4.6 yrs [mean +/- SD], mean gestational age 31 wks) were admitted (548 intensive care unit admissions per 100,000 deliveries), 138 with single organ failure and 152 with multiple organ failure. Ninety-eight women died (mortality rate 21.6%). Mortality was comparable in antepartum (n = 216) and postpartum (n = 247) admissions but increased with increasing number of organs affected. There were 236 fetal deaths (52%), of which 104 occurred before hospital admission. Median APACHE II score was 16 (interquartile range, 10-24), and standardized mortality ratio (observed deaths/predicted deaths) was 0.78. Compared with pregnant patients admitted with obstetric disorders (n = 313), those with medical diseases (n = 140) had significantly lower APACHE II scores (median 14 vs. 17) but higher observed mortality rate (28.6% vs. 18.5%; odds ratio, 1.76; 95% confidence interval, 1.08-2.87) and standardized mortality ratio (1.09 vs. 0.66). On multivariate analysis, increased mortality rate was associated with acute cardiovascular (odds ratio, 5.8), nervous system (odds ratio, 4.73) and respiratory (odds ratio, 12.9) failure, disseminated intravascular coagulation (odds ratio, 2.4), viral hepatitis (odds ratio, 5.8), intracranial hemorrhage (odds ratio, 5.4), absence of prenatal care (odds ratio, 1.94), and >24 hrs interval between onset of acute symptoms and intensive care unit admission (odds ratio, 2.3). CONCLUSIONS: Multiple organ failure is common in obstetric patients; mortality rate increases with increasing organ failure. APACHE II scores overpredict mortality rate. Standardized mortality ratio is lower in obstetric disorders than in medical disorders. Lack of prenatal care and delay in intensive care unit referral adversely affect outcome and are easily preventable.     

Clinician predictions of intensive care unit mortality

OBJECTIVE: Predicting outcomes for critically ill patients is an important aspect of discussions with families in the intensive care unit. Our objective was to evaluate clinical intensive care unit survival predictions and their consequences for mechanically ventilated patients. DESIGN: Prospective cohort study. SETTING: Fifteen tertiary care centers. PATIENTS: Consecutive mechanically ventilated patients > or = 18 yrs of age with expected intensive care unit stay > or = 72 hrs. INTERVENTIONS: We recorded baseline characteristics at intensive care unit admission. Daily we measured multiple organ dysfunction score (MODS), use of advanced life support, patient preferences for life support, and intensivist and bedside intensive care unit nurse estimated probability of intensive care unit survival. MEASUREMENTS AND MAIN RESULTS: The 851 patients were aged 61.2 (+/- 17.6, mean + SD) yrs with an Acute Physiology and Chronic Health Evaluation (APACHE) II score of 21.7 (+/- 8.6). Three hundred and four patients (35.7%) died in the intensive care unit, and 341 (40.1%) were assessed by a physician at least once to have a < 10% intensive care unit survival probability. Independent predictors of intensive care unit mortality were baseline APACHE II score (hazard ratio, 1.16; 95% confidence interval, 1.08-1.24, for a 5-point increase) and daily factors such as MODS (hazard ratio, 2.50; 95% confidence interval, 2.06-3.04, for a 5-point increase), use of inotropes or vasopressors (hazard ratio, 2.14; 95% confidence interval, 1.66-2.77), dialysis (hazard ratio, 0.51; 95% confidence interval, 0.35-0.75), patient preference to limit life support (hazard ratio, 10.22; 95% confidence interval, 7.38-14.16), and physician but not nurse prediction of < 10% survival. The impact of physician estimates of < 10% intensive care unit survival was greater for patients without vs. those with preferences to limit life support (p < .001) and for patients with less vs. more severe organ dysfunction (p < .001). Mechanical ventilation, inotropes or vasopressors, and dialysis were withdrawn more often when physicians predicted < 10% probability of intensive care unit survival (all ps < .001). CONCLUSIONS: Physician estimates of intensive care unit survival < 10% are associated with subsequent life support limitation and more powerfully predict intensive care unit mortality than illness severity, evolving or resolving organ dysfunction, and use of inotropes or vasopressors.     

Severity of illness and risk of death associated with pulmonary artery catheter use

OBJECTIVE: To examine the association between the use of the pulmonary artery catheter and mortality rate in critically ill patients with a higher vs. a lower severity of illness. DESIGN: Observational cohort study. SETTING: A tertiary care university teaching hospital from March 1988 to March 1998. PATIENTS: A total of 7,310 critically ill adult patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The main outcome measure was hospital mortality rate, controlled by multivariable logistic regression within four patient groups based on severity of illness. Cutoffs for severity of illness were chosen based on Acute Physiology and Chronic Health Evaluation (APACHE) II score 25th percentiles. Logistic regression analysis demonstrated no increased risk of death associated with exposure to the pulmonary artery catheter in the population as a whole. The associated odds ratio of hospital death for the entire cohort was 1.05 (95% confidence interval, 0.92-1.21). Subgroup analysis of severity of illness revealed the highest risk of death to be associated with the lowest APACHE II score quartile vs. a decreased associated mortality rate with the highest APACHE II score quartile after adjustment with multivariable logistic regression (APACHE II <18: odds ratio, 2.47, 95% confidence interval, 1.27-4.81; APACHE II 18-24: odds ratio, 1.64, 95% confidence interval, 1.24-2.17; APACHE II 25-31: odds ratio, 1.00, 95% confidence interval, 0.80-1.24; APACHE II >31: odds ratio, 0.80, 95% confidence interval, 0.64-1.00). CONCLUSIONS: The use of the pulmonary artery catheter may decrease mortality rate in the most severely ill while increasing it in a population with a lower severity of illness. These findings underscore the necessity of examining the effect of severity of illness in future randomized controlled trials.     

Prediction and timing of tracheostomy in patients with infratentorial lesions requiring mechanical ventilatory support

OBJECTIVES: To determine the frequency and predictors of successful extubations and tracheostomy in patients with infratentorial lesions requiring mechanical ventilation and to determine the optimal time for tracheostomy based on probability of successful extubation and in-hospital survival according to the duration of translaryngeal intubation. DESIGN: Retrospective chart review. SETTINGS: A neurocritical care unit at a university hospital. PATIENTS: A total of 69 patients with infratentorial lesions who were mechanically ventilated during their intensive care unit stay. MEASUREMENTS AND MAIN RESULTS: Of the 69 patients who were mechanically ventilated, 23 (33%) were successfully extubated. In logistic regression analysis, both the presence of a Glasgow Coma Scale score >7 at time of intubation (odds ratio, 4.8; 95% confidence interval, 1.2-21.7) and the absence of brainstem deficits (odds ratio, 4.3; 95% confidence interval, 1.3-16.7), were independently associated with successful extubation. After extubation, 11 patients were reintubated; seven were reintubated within the same day because of poor control over secretions, airway spasm, or hypoventilation. Tracheostomy was performed in 23 (33%) patients, of whom 19 were successfully weaned off mechanical ventilatory support over a mean period of 3.7+/-4.0 days after tracheostomy. Patients undergoing tracheostomy had a significantly longer intensive care unit stay (19.1+/-9.0 vs. 8.7+/-6.6 days, p < .01) and total hospital stay (34.8+/-18.7 vs. 20.1+/-9.9 days, p < .01) compared with patients who were successfully extubated. The probability of successful extubation or death before extubation or tracheostomy was 67% on the day of intubation, which decreased to 5.8% after translaryngeal intubation for >8 days. CONCLUSIONS: An aggressive policy toward tracheostomy is justified based on the low frequency of successful extubations and high frequency of extubation failures and tracheostomies in patients with infratentorial lesions. The decision regarding tracheostomy should be made on day 8 of mechanical ventilatory support because of the low probability of subsequent extubation or in-hospital death.     

Duration of mechanical ventilation in an adult intensive care unit after introduction of sedation and pain scales

BACKGROUND: Sedation and analgesia scales promote a less-distressing experience in the intensive care unit and minimize complications for patients receiving mechanical ventilation. OBJECTIVES: To evaluate outcomes before and after introduction of scales for sedation and analgesia in a general intensive care unit. METHOD: A before-and-after design was used to evaluate introduction of the Richmond Agitation-Sedation Scale and the Behavioral Pain Scale for patients receiving mechanical ventilation. Data were collected for 6 months before and 6 months after training in and introduction of the scales. RESULTS: A total of 769 patients received mechanical ventilation for at least 6 hours (369 patients before and 400 patients after implementation). Age, scores on the Acute Physiology and Chronic Health Evaluation (APACHE) II, and diagnostic groups were similar in the 2 groups, but the after group had more men than did the before group. Duration of mechanical ventilation did not change significantly after the scales were introduced (median, 24 vs 28 hours). For patients who received mechanical ventilation for 96 hours or longer (24%), mechanical ventilation lasted longer after implementation of the scales (P=.03). Length of stay in the intensive care unit was similar in the 2 groups (P= .18), but patients received sedatives for longer after implementation (P=.01). By logistic regression analysis, APACHE II score (P<.001) and diagnostic group (P<.001) were independent predictors of mechanical ventilation lasting 96 hours or longer. CONCLUSION: Sedation and analgesia scales did not reduce duration of ventilation in an Australian intensive care unit.     

Red blood cell transfusion and ventilator-associated pneumonia: A potential link?

OBJECTIVE: To determine the relationship between packed red blood cell transfusion practice and the development of ventilator-associated pneumonia (VAP). DESIGN: Secondary analysis of a multicentered, prospective observational study of transfusion practice in intensive care units in the United States. SETTING: A total of 284 intensive care units in the United States were studied from August 2000 to April 2001. PATIENTS: Patients without pneumonia at intensive care unit admission and who then required at least 48 hrs of mechanical ventilation were considered at risk for VAP. MEASUREMENTS AND MAIN RESULTS: VAP was diagnosed based on prospectively defined clinical criteria and represented the primary study end point. Late-onset VAP (VAP arising after > or =5 days of mechanical ventilation) represented a secondary end point. Transfusions given during the intensive care unit stay and before the onset of VAP were tracked prospectively. Of 4,892 subjects in the original cohort, 1,518 received mechanical ventilation of > or =48 hrs and did not have preexisting pneumonia. VAP was diagnosed in 311 (20.5%) patients. Multivariate analysis revealed that transfusion independently increased the risk for VAP (odds ratio, 1.89; 95% confidence interval [CI], 1.33-2.68). Other factors increasing the risk for VAP included male sex (odds ratio, 1.54; 95% CI, 1.15-2.07), admission after trauma (odds ratio, 1.68; 95% CI, 1.15-2.47), use of continuous sedation (odds ratio, 1.43; 95% CI, 1.07-1.92), and type of nutritional support (e.g., early enteral nutrition: odds ratio, 2.65; 95% CI, 1.93-3.63; total parenteral nutrition: odds ratio, 3.27; 95% CI, 2.24-4.75). The effect of transfusion on late-onset VAP was more pronounced (odds ratio, 2.16; 95% CI, 1.27-3.66) and demonstrated a positive dose-response relationship (p =.0223 for trend test). CONCLUSIONS: Transfusion of packed red blood cells increases the risk of developing VAP. Avoiding the unnecessary use of packed red blood cell transfusions may decrease the occurrence of VAP.     

Outcome of patients with liver cirrhosis admitted to a specialty liver intensive care unit in India

Purpose

The study aimed to describe the clinical outcome of patients with liver cirrhosis admitted to intensive care unit (ICU) and to compare the performance of Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) in predicting mortality.

Methods

In this prospective study of patients with cirrhosis admitted to the ICU, demographic data, APACHE II score, SOFA score, presence of acute renal failure (ARF), need for organ support, and mortality were collected.

Results

The observed mortality in ICU and at 30 days among 104 patients was 42.3% (95% confidence interval [CI], 32.7%-52.0%) and 56.7% (95% CI, 47.0%-66.4%), respectively. Area under the receiver operating characteristic curve for first-day APACHE II in predicting 30-day mortality was 0.90 (95% CI, 0.83-0.96) and 0.93 (95% CI, 0.88-0.98) for SOFA score (P = .24). On multivariate analysis, ARF (adjusted odds ratio, 7.7; 95% CI, 1.09-54.64) and mechanical ventilation (adjusted odds ratio, 277.6; 95% CI, 12.83-6004.94) were significantly associated with mortality.

Conclusions

Presence of ARF and need for mechanical ventilation are associated with high mortality in patients with liver cirrhosis admitted to the ICU. Acute Physiology and Chronic Health Evaluation II and SOFA are good prognostic models in predicting 30-day mortality and do not differ in performance.