Assessment of peri-extubation pain by visual analogue scale in the adult intensive care unit: a prospective observational study

Objective This prospective observational study was undertaken in order to assess pain experienced by intensive care unit patients at the time of extubation and to identify factors associated with pain of at least moderate intensity.Design Prospective observational study.Setting Intensive care unit at a university hospital.Patients During a 1-year period the presence, severity and clinical predictors of orofacial and/or chest pain among patients undergoing removal of endotracheal tubes was assessed.Measurements and results Pain was evaluated using a visual analogue scale (VAS). Of 332 extubated patients, 203 could be evaluated. During the peri-extubation period, pain was significantly associated with a SAPS II score more than 36 (p=0.03) and duration of mechanical ventilation (MV) of 6 days or more (p=0.002), whereas intubation in the operating room was associated with less pain (p=0.001). Pain of at least moderate intensity (VAS score >30 mm) was reported by 73% of patients and pain of severe intensity (VAS score >50 mm) was reported by 45% of patients. MV duration of 6 days or more was the only independent risk factor for pain of at least moderate intensity (OR 2.4, 95% CI 1.03–5.4, p=0.04). We also observed that pain had resolved 1 h after extubation in the majority of patients.Conclusion Our results suggest that, in intensive care unit patients, peri-extubation pain is frequent and should be considered for treatment, especially in patients with longer intubation.Presented, in part, at XXXI^e Congrès de la Société de réanimation de langue française, January 16, 2003, CNIT, Paris-la-Défense     

Complications of care in a pediatric intensive care unit: A prospective study

Objectives (a) To examine the frequency, type, and severity of complications occurring in a pediatric intensive care unit; (b) to identify populations at risk; and (c) to study the impact of complications on morbidity and mortality.Design Prospective survey.Setting Pediatric intensive care unit (PICU) of a university-affiliated hospital.Patients 1035consecutive admissions over an 18-month period.Results 115 complications occurred during 83 (8.0%) admissions, for 2.7 complications per 100 PICU-days; 48 (42%) complications were major, 45 (39%) moderate, and 22 (19%) minor. Sixty complications (52%) were ventilator-related, 14 were drug-related, 13 procedure-related, 24 infectious, and 22 involved invasive devices (18 vascular catheters). Human error was involved in 41 (36%) cases, 21 of which were major (18%). Treatments included reintubation <24 h (28), intravenous antimicrobials (24), and invasive bedside procedures (14). Cardiopulmonary resuscitation was required in 6 patients. Thirteen patients with complications died (15.7%); 2 deaths were directly due to complications.Patients with complications were younger, had longer lengths of stay, and had a higher mortality. Length of stay was a positive risk factor for complication risk (odds ratio=1.09, 95% confidence interval: 1.05 to 1.13;p=0.0001); other patient characteristics had no predictive effect. Kaplan-Meier estimates showed that the most severe complications occurred early in the PICU stay. The best indicators of patient mortality were number of complications (odds ratio=2.96, 95% confidence interval 1.72 to 5.08;p=0.0001), and mortality risk derived from the Pediatric Risk of Mortality Score (odds ratio=1.08, 95% confidence interval 1.06 to 1.10;p=0.0001). Mortality was correlated with increasing severity of complications.Conclusion Complications have a significant impact on patient care. Patients may be at increased risk earlier in their PICU course, when the number of interventions may be greatest. Complications may increase patient mortality and predict patient death better than other patient variables.     

Toward less sedation in the intensive care unit: a prospective observational study

Purpose

Excessive sedation is associated with prolonged mechanical ventilation and longer intensive care unit (ICU) and hospital stays. We evaluated the feasibility of using minimal sedation in the ICU.

Methods

Prospective observational study in a university hospital 34-bed medico-surgical department of intensive care. All adult patients who stayed in the ICU for more than 12 hours over a 2-month period were included. Intensive care unit admission diagnoses, severity scores, use of sedatives and/or opiates, duration of mechanical ventilation, length of ICU stay, and 28-day mortality were recorded for each patient.

Results

Of the 335 patients (median age, 61 years) admitted during the study period, 142 (42%) received some sedation, most commonly with midazolam and propofol. Sedative agents were administered predominantly for short periods of time (only 10% of patients received sedation for >24 hours). One hundred fifty-five patients (46%) received mechanical ventilation, generating 15?240 hours of mechanical ventilation, of these, only 2993 (20%) hours were accompanied by a continuous sedative infusion. Self-extubation occurred in 6 patients, but only 1 needed reintubation.

Conclusions

In a mixed medical-surgical ICU, minimal use of continuous sedation seems feasible without apparent adverse effects.     

Opening the doors of the intensive care unit to cancer patients: A current perspective

The introduction of new treatments for cancer and advances in the intensive care of critically ill cancer patients has improved the prognosis and survival. In recent years, the classical intensive care unit(ICU) admission comorbidity criteria used for this group of patients have been discouraged since the risk factors for death that have been studied, mainly the number and severity of organic failures, allow us to understand the determinants of the prognosis inside the ICU. However, the availability of intensive care resources is dissimilar by country, and these differences are known to alter the indications for admission to critical care setting. Three to five days of ICU management is warranted before making a final decision(ICU trial) to consider keep down intensive management of critically ill cancer patients. Nowadays, taking into account only the diagnosis of cancer to consider ICU admission of patients who need full-supporting management is no longer justified.     

A prospective study of fever in the intensive care unit

Objective: To determine the epidemiology of fever on the intensive care unit (ICU). Design: Prospective, observational study. Setting: Nine-bed general ICU in a 500-bed tertiary care inner city institution. Patients: 100 consecutive admissions of 93 patients over a 4-month period between July and October 1996. Interventions: All patients were seen and examined by one investigator within 24 h of ICU admission. Patients were followed up on a daily basis throughout their ICU stay, and all clinical and laboratory data were recorded during the admission. Measurements and results: Fever (core temperature ≥ 38.4 °C) was present in 70 % of admissions, and it was caused by infective and non-infective processes in approximately equal number. Most fevers occurred early in the course of the admission, within the first 1–2 days, and most lasted less than 5 days. The median Acute Physiology and Chronic Health Evaluation (APACHE) II score was 15 ( ± 0.6). The 70 episodes associated with fever at any time were associated with a significantly higher APACHE II score on admission than the afebrile episodes (15.8 ± 6.1 vs 12.1 ± 6.7, p = 0.04). The most common cause of non-infective fever was in the group designated post-operative fever (n = 34). All the patients in the post-operative fever group were febrile on day 0 or day 1; their mean admission APACHE score was 12.4 ( ± 4.4) compared to 15.9 ( ± 7.1) for the remaining patients (p = 0.01). Fever alone was not associated with a higher mortality: 26/70 (37 %) of febrile patients died, compared to 8/30 (27 %) of afebrile patients, (χ ² = 1.23, p = 0.38). Prolonged fever ( > 5 days) occurred in 16 patients. In 13 cases, fever was due to infection, and in the remaining 3 both infective and non-infective processes occurred concurrently. The mortality in the group with prolonged fever was 62.5 % (10/16) compared to 29.6 % (16/54) in patients with fever of less than 5 days' duration, a highly significant difference (p < 0.0001). Conclusions: Fever is a common event on the intensive care unit. It usually occurs early in the course, is frequently non-infective and is often benign. Prolonged fever is associated with a poor outcome. Post-operative fever is a well-recognised but poorly defined syndrome which requires further study. Received: 29 December 1998 Final revision received: 16 March 1999 Accepted: 14 April 1999     

143例ICU老年创伤患者的流行病学分析

目的探讨单中心老年创伤重症患者流行病学特点,为临床救治提供参考。 方法回顾性分析2017年1月至2018年6月陆军军医大学大坪医院重症医学科（ICU）收治的65岁以上老年创伤患者143例,分析患者性别、年龄、致伤机制、损伤严重程度评分（ISS）、并发症、住院时间等资料。采用Mann-Whitney检验比较ISS评分、急性生理与慢性健康评分（APACHE Ⅱ评分）、ICU时间、住院时间在不同受伤机制和不同年龄之间的差异,使用Pearson χ²检验比较年龄分层计数、基础疾病分类计数、好转出院例数在不同受伤机制和不同年龄之间的差异,应用Logistic回归分析法分析并发症发生的危险因素。 结果所有创伤患者中,男性患者71例（49.65%,71/143）,女性72例（50.34%,72/143）;年龄65~99岁,平均年龄（78±1）岁;多发伤43例（30.07%,43/143）,单部位伤100例（69.93%,100/143）。跌倒伤是首位致伤原因90例（62.94%,90/143）,其次为车祸伤40例（27.97%,40/143）。跌倒伤ISS［9（9,9）分vs 22（16,27）分,Z=7.574,P<0.001］、APACHE II评分［15（14,17）分vs 17（15,21）分,P=0.001］均较低,住ICU时间［2（1,3）d vs 8（1,16）d,Z=4.407,P<0.001］和住院时间［（16（12,22.25）d vs 30（19,49）d,Z=4.779,P<0.001）］较非跌倒伤更短,好转出院率比较差异无统计学意义（P>0.05）。≥80岁患者与<80岁患者比较,APACHE Ⅱ评分明显升高［16（15,20）分vs 14（15,18）分,Z=2.093,P=0.036）］,住ICU的时间更长［3（1,10）d vs 1（1,7.5）d,Z=2.013,P=0.044］。APACHE Ⅱ评分是并发症发生的危险因素（OR=1.771,P=0.01）。 结论老年患者入住ICU的主要原因是跌倒伤,其次是车祸伤。除年龄外,APACHE Ⅱ评分高时,住ICU时间更长和并发症发生率更高。     

Outcome of early intensive care unit patients readmitted in the same hospitalization

Purpose

The aim of the study was to evaluate factors associated with early readmission to the intensive care unit (ICU) during the same hospitalization and factors associated with adverse outcomes.

Patients and Methods

Among 25 717 admissions, 378 (1.5%) patients were quickly readmitted within 3 days; of these, 374 patients for whom complete medical records were available for review were included. This was a prospective observational study for a 2-year period, with an additional 1-year follow-up.

Results

Respiratory (118 [31.6%]) and cardiovascular (91 [24.3%]) causes accounted for most readmissions. Need for mechanical ventilation during the second ICU stay was the variable most significantly associated with increased mortality (P < .001). Comparing the 2 study periods, we observed a decreased mortality rate (31.3 vs 19.5%; P = .018).

Conclusion

Patients with respiratory and cardiovascular diseases are at greatest risk for early ICU readmission. Better patient assessment and knowledge of factors associated with early readmission may contribute to reduced mortality.     

Predicting mortality in intensive care unit patients infected with Klebsiella pneumoniae: A retrospective cohort study

IntroductionAlthough several models to predict intensive care unit (ICU) mortality are available, their performance decreases in certain subpopulations because specific factors are not included. Moreover, these models often involve complex techniques and are not applicable in low-resource settings. We developed a prediction model and simplified risk score to predict 14-day mortality in ICU patients infected with Klebsiella pneumoniae.MethodologyA retrospective cohort study was conducted using data of ICU patients infected with Klebsiella pneumoniae at the largest tertiary hospital in Northern Vietnam during 2016–2018. Logistic regression was used to develop our prediction model. Model performance was assessed by calibration (area under the receiver operating characteristic curve-AUC) and discrimination (Hosmer-Lemeshow goodness-of-fit test). A simplified risk score was also constructed.ResultsTwo hundred forty-nine patients were included, with an overall 14-day mortality of 28.9%. The final prediction model comprised six predictors: age, referral route, SOFA score, central venous catheter, intracerebral haemorrhage surgery and absence of adjunctive therapy. The model showed high predictive accuracy (AUC = 0.83; p-value Hosmer-Lemeshow test = 0.92). The risk score has a range of 0–12 corresponding to mortality risk 0–100%, which produced similar predictive performance as the original model.ConclusionsThe developed prediction model and risk score provide an objective quantitative estimation of individual 14-day mortality in ICU patients infected with Klebsiella pneumoniae. The tool is highly applicable in practice to help facilitate patient stratification and management, evaluation of further interventions and allocation of resources and care, especially in low-resource settings where electronic systems to support complex models are missing.     

Reconsidering the transfer of patients from the intensive care unit to the ward: a case study approach

Evidence indicates that the poorly managed transfer of a patient from the intensive care unit (ICU) to the ward can lead to physical and psychological complications for the patient, and often require ICU readmission and rehospitalization. Reviewing this patient transfer process to improve the quality of care would be a positive step towards enhancing patients' recovery and providing skills to staff. The aim of this paper is to review case studies of transferring ICU patients to general wards in order to identify the shortcomings of this process. A literature review was conducted to evaluate current practices in the ICU transfer process. The results of this paper have clinical implications, suggest approaches to improve support for patients and their carers, and provide strategies to improve the transfer procedure.     

Cross-validation of the Care Dependency Scale in intensive care unit (ICU-CDS)

ObjectivesThe Care Dependency Scale is a theory-based, comprehensive tool widely used in low-intensity care settings to evaluate patients’ dependency. This study aimed to test the psychometric properties of the Care Dependency Scale in intensive care units.Research methodology/designA multicentre cross-sectional validation study was conducted. Exploratory factor analysis and confirmatory factor analysis were performed using a Maximum Likelihood robust estimator with Geomin oblique rotation.SettingAdult patients admitted to intensive care units of four Italian hospitals.ResultsThe sample included 453 patients (mean age = 68 years, 62% male). The exploratory factor analysis, conducted on a subsample of 227 patients, revealed a two-factor structure (Physical care dependency and Psychosocial care dependency) with good fit indexes. The confirmatory factor analysis was conducted on another subsample of 226 patients and a second-order factor was specified. The model tested yielded adequate fit indexes. Concurrent and known-groups validity, and reliability, were also adequate.ConclusionThe Care Dependency Scale is a multidimensional, valid and reliable tool able to assess the care dependency of critically ill patients. It can help to distinguish between physical and psychosocial needs and to create a base for patient-customised and holistic care.     

Adverse drug reactions and deliberate self-poisoning as cause of admission to the intensive care unit: a 1-year prospective observational cohort study

Objective

The aim of the present study was (1) to determine the prevalence of intensive care unit (ICU) admissions due to an adverse drug reaction (ADR), and (2) to compare affected patients with patients admitted to the ICU for the treatment of deliberate self-poisoning using medical drugs.

Design

Prospective observational cohort study.

Setting

Fourteen bed medical ICU including an integrated intermediate care (IMC) section at a tertiary referral center.

Patients

A total of 1,554 patients admitted on 1 January 2003 to 31 December 2003.

Results

Ninety-nine patients were admitted to the ICU with a diagnosis of ADR (6.4% of all admissions), 269 admissions (17.3%) were caused by deliberate self-poisoning. Patients admitted for treatment of ADR had a significantly higher age, a longer treatment duration in the ICU, a higher SAPS II score, and a higher 6-month mortality than those with deliberate self-poisoning. Most patients (71.7%) suffering from ADR required advanced supportive care in the ICU while the majority of patients (90.7%) with deliberate self-poisoning could be sufficiently treated in the IMC area. All diagnostic and therapeutic procedures in the ICU except mechanical ventilation were significantly more often performed in patients with ADR.

Conclusions

This study provides further evidence that ADR is a frequent cause of admission to medical ICUs resulting in a considerable use of ICU capacities. In the present setting patients with ADR required longer and more intense medical treatment in the ICU than those with deliberate self-poisoning.

     

Colonization and infection in surgical intensive care patients —a prospective study

Nosocomial infections are a major problem in intensive care patients. Thirty-nine patients, requiring intensive care for 5 days or more (mean 15.8 days) were prospectively investigated, to determine the relation between colonisation and nosocomial infection. Thrice weekly, cultures from the oropharynx, respiratory and digestive tract were obtained. Colonization with aerobic gram-negative microorganisms of the oropharynx, respiratory and digestive tract significantly increased during the stay in the Intensive Care Unit. In 29 patients (74%) 78 nosocomial infections were diagnosed. The most frequent nosocomial infections were pneumonia (26 patients, 66.6%), catheterrelated bacteraemia (11 patients, 28.2%), and wound infections (7 patients, 17.9%). In 59 instances (75.6%), colonization with the same potential pathogenic microorganism preceeded the nosocomial infection. The overall mortality was 25.6% (10 patients), bacteraemia with aerobic gram-negative microorganisms being the cause of death in 7 patients.     

Exercise is feasible in patients receiving vasoactive medication in a cardiac surgical intensive care unit: A prospective observational study

BackgroundPatients may require vasoactive medication after cardiac surgery. The effect and safety profile of exercise on haemodynamic parameters in these patients is unclear.ObjectivesThe objective of this study was to measure the effect of upright positioning and low-level exercise on haemodynamic parameters in patients after cardiac surgery who were receiving vasoactive therapy and to determine the incidence of adverse events.MethodsThis was a prospective, single-centre, observational study conducted in an adult intensive care unit of a tertiary, cardiothoracic university–affiliated hospital in Australia. The Flotrac-Vigileo™ system was used to measure haemodynamic changes, including cardiac output, cardiac index, and stroke volume. Normally distributed variables are presented as n (%) and mean (standard deviation), and non-normally distributed variables are presented as median [interquartile range].ResultsThere were a total of 20 participants: 16 (80%) male, with a mean age of 65.9 (10.6) years. Upright positioning caused significant increases (p = 0.018) in the mean arterial pressure (MAP), with MAP readings increasing from baseline (supine), from 72.31 (11.91) mmHg to 77.44 (9.55) mmHg when back in supine. There were no clinically significant changes in cardiac output, heart rate, stroke volume, or cardiac index with upright positioning. The incidence of adverse events was low (5%). The adverse event was transient hypotension of low severity.ConclusionsLow-level exercise in patients after cardiac surgery receiving vasoactive medication was well tolerated with a low incidence of adverse events and led to significant increases in MAP. Upright positioning and low-level exercise appeared safe and feasible in this patient cohort.