The 350th issues of the Critical Care Reviews Newsletter brings you the best critical care research and open access articles from across the medical literature during the last week. “The highlights of this week’s edition are medium term results for major randomised controlled trials TRICS (6 month outcomes after restrictive or liberal transfusion for cardiac surgery) & CULPRIT-SHOCK (1 year outcomes after PCI strategies in cardiogenic shock); systematic reviews and meta analyses on industry sponsorship and research outcome & Impella 5.0 in cardiogenic shock; and observational studies on the global epidemiology and outcomes of acute kidney injury & outcome of allogeneic stem cell recipients admitted to the intensive care unit. The fourth universal definition of myocardial infarction was also published this weekend. In addition, there are excellent narrative reviews on perioperative management of severe traumatic brain injury, advanced modes of mechanical ventilation & palliative care in intensive care units; a series of editorials on conflict of interest; and commentaries on mechanisms behind cardiac troponin elevations & nutritional epidemiologic research.”
The full text of the newsletter can be accessed via this link.
Category: 08 August 2018
Assessment of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit: A Multicenter Population-Based Cohort Study
This article by Stelfox et al was published in JAMA internal medicine in August 2018.
Importance: The safety of discharging adult patients recovering from critical illness directly home from the intensive care unit (ICU) is unknown.
Objective: To compare the health care utilization and clinical outcomes for ICU patients discharged directly home from the ICU with those of patients discharged home via the hospital ward.
Design, Setting, and Participants: Retrospective population-based cohort study of adult patients admitted to the ICU of 9 medical-surgical hospitals from January 1, 2014, to January 1, 2016, with 1-year follow-up after hospital discharge. All adult ICU patients were discharged home alive from hospital, and the propensity score matched cohort (1:1) was based on patient characteristics, therapies received in the ICU, and hospital characteristics.
Exposures: Patient disposition on discharge from the ICU: directly home vs home via the hospital ward.
Main Outcomes and Measures: The primary outcome was readmission to the hospital within 30 days of hospital discharge. The secondary outcomes were emergency department visit within 30 days and death within 1 year.
Results: Among the 6732 patients included in the study, 2826 (42%) were female; median age, 56 years (interquartile range, 41-67 years); 922 (14%) were discharged directly home, with significant variation found between hospitals (range, 4.4%-44.0%). Compared with patients discharged home via the hospital ward, patients discharged directly home were younger (median age 47 vs 57 years; P < .001), more likely to be admitted with a diagnosis of overdose, substance withdrawal, seizures, or metabolic coma (32% [295] vs 10% [594]; P < .001), to have a lower severity of acute illness on ICU admission (median APACHE II score 15 vs 18; P < .001), and receive less than 48 hours of invasive mechanical ventilation (42% [389] vs 34% [1984]; P < .001). In the propensity score matched cohort (n = 1632), patients discharged directly home had similar length of ICU stay (median, 3.1 days vs 3.0 days; P = .42) but significantly shorter length of hospital stay (median, 3.3 days vs 9.2 days; P < .001) compared with patients discharged home via the hospital ward. There were no significant differences between patients discharged directly home or home via the hospital ward for readmission to the hospital (10% [n = 81] vs 11% [n = 92]; hazard ratio [HR], 0.88; 95% CI, 0.64-1.20) or emergency department visit (25% [n = 200] vs 26% [n = 212]; HR, 0.94; 95% CI, 0.81-1.09) within 30 days of hospital discharge. Four percent of patients in both groups died within 1 year of hospital discharge (n = 31 and n = 34 in the discharged directly home and discharged home via the hospital ward groups, respectively) (HR, 0.90; 95% CI, 0.60-1.35).
Conclusions and Relevance: The discharge of select adult patients directly home from the ICU is common, and it is not associated with increased health care utilization or increased mortality.
To access the full text of this article via the journal’s homepage you require a personal subscription to the journal. Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.
A Comparison of the Quick Sequential (Sepsis-Related) Organ Failure Assessment Score and the National Early Warning Score in Non-ICU Patients With/Without Infection
This research by Redfern and colleagues was published in Critical Care Medicine in August 2018.
Objectives: The Sepsis-3 task force recommended the quick Sequential (Sepsis-Related) Organ Failure Assessment score for identifying patients with suspected infection who are at greater risk of poor outcomes, but many hospitals already use the National Early Warning Score to identify high-risk patients, irrespective of diagnosis. We sought to compare the performance of quick Sequential (Sepsis-Related) Organ Failure Assessment and National Early Warning Score in hospitalized, non-ICU patients with and without an infection.
Design: Retrospective cohort study. Setting: Large U.K. General Hospital.
Patients: Adults hospitalized between January 1, 2010, and February 1, 2016.
Measurement and main results: We applied the quick Sequential (Sepsis-Related) Organ Failure Assessment score and National Early Warning Score to 5,435,344 vital signs sets (241,996 hospital admissions). Patients were categorized as having no infection, primary infection, or secondary infection using International Classification of Diseases, 10th Edition codes. National Early Warning Score was significantly better at discriminating in-hospital mortality, irrespective of infection status (no infection, National Early Warning Score 0.831 [0.825-0.838] vs quick Sequential [Sepsis-Related] Organ Failure Assessment 0.688 [0.680-0.695]; primary infection, National Early Warning Score 0.805 [0.799-0.812] vs quick Sequential [Sepsis-Related] Organ Failure Assessment 0.677 [0.670-0.685]). Similarly, National Early Warning Score performed significantly better in all patient groups (all admissions, emergency medicine admissions, and emergency surgery admissions) for all outcomes studied. Overall, quick Sequential (Sepsis-Related) Organ Failure Assessment performed no better, and often worse, in admissions with infection than without.
Conclusions: The National Early Warning Score outperforms the quick Sequential (Sepsis-Related) Organ Failure Assessment score, irrespective of infection status. These findings suggest that quick Sequential (Sepsis-Related) Organ Failure Assessment should be re-evaluated as the system of choice for identifying non-ICU patients with suspected infection who are at greater risk of poor outcome.
To access the full text of this article via the journal’s homepage you require a personal subscription to the journal. Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.
Time-limited trial of intensive care treatment: an overview of current literature
This article by Vink and others was published in the August 2018 issue of Intensive Care Medicine.
In critically ill patients, it is frequently challenging to identify who will benefit from admission to the intensive care unit and life-sustaining interventions when the chances of a meaningful outcome are unclear. In addition, the acute illness not only affects the patients but also family members or surrogates who often are overwhelmed and unable to make thoughtful decisions. In these circumstances, a time-limited trial (TLT) of intensive care treatment can be helpful. A TLT is an agreement to initiate all necessary treatments or treatments with clearly delineated limitations for a certain period of time to gain a more realistic understanding of the patient’s chances of a meaningful recovery or to ascertain the patient’s wishes and values. In this article, we discuss current research on different aspects of TLTs in the intensive care unit. We propose how and when to use TLTs, discuss how much time should be taken for a TLT, give an overview of the potential impact of TLTs on healthcare resources, describe ethical challenges concerning TLTs, and discuss how to evaluate a TLT.
To access the full text of this article via the journal’s homepage you require a personal subscription to the journal. Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.
Reassessing access to intensive care using an estimate of the population incidence of critical illness
The article by Garland and colleagues was published in the journal Critical Care in August 2018.
Background: The consistently observed male predominance of patients in intensive care units (ICUs) has raised concerns about gender-based disparities in ICU access. Comparing rates of ICU admission requires choosing a normalizing factor (denominator), and the denominator usually used to compare such rates between subpopulations is the size of those subpopulations. However, the appropriate denominator is the number of people whose medical condition warranted ICU care. We devised an estimate of the number of critically ill people in the general population, and used it to compare rates of ICU admission by gender and income.
Methods: This population-based, retrospective analysis included all adults in the Canadian province of Manitoba, 2004-2015. We created an estimate for the number of critically ill people who warrant ICU care, and used it as the denominator to generate critical illness-normalized rates of ICU admission. These were compared to the usual population-normalized rates of ICU care.
Results: Men outnumbered women in ICUs for all age groups; population-normalized male female rate ratios significantly exceed 0 for every age group, ranging from 1.15 to 2.10. Using critical-illness normalized rates, this male predominance largely disappeared; critically ill men and women aged 45-74 years were admitted in equivalent proportions (critical-illness normalized rate ratios 0.96-1.01). While population-normalized rates of ICU care were higher in lower income strata (p < 0.001), the gradient for critical illness-based rates was reversed (p < 0.001).
Conclusions: Across a 30-year adult age span, the male predominance of ICU patients was accounted for by higher estimated rates of critical illness among men. People in lower income strata had lower critical-illness normalized rates of ICU admission. Our methods highlight that correct inferences about access to healthcare require calculating rates using denominators appropriate for this purpose.
The full text of this article is freely available via this link.
Critical Care Reviews Newsletter 349 19th August 2018
The 349th Critical Care Reviews Newsletter brings you the best critical care research and open access articles from across the medical literature during the last week. “The highlights of this week’s edition are a randomised controlled trial on dopamine for acute heart failure (ROPA-DOP); a systematic review and meta-analysis on red cell transfusion thresholds in cardiac surgery; and observational studies on hypoxaemia in the ICU & the association of frailty with short-term outcomes, organ support and resource use. The latest SCCM guideline on pain, agitation/sedation, delirium, immobility, and sleep disruption was published this week, as were narrative reviews on difficult tracheal intubation, feeding intolerance & airway and ventilation management during CPR and after successful resuscitation.“
The full text of the newsletter can be accessed via this link.
Ten-year trends in intensive care admissions for respiratory infections in the elderly
This article by Laporte and colleagues was published in Annals of Intensive Care August issue.
Background: The consequences of the ageing population concerning ICU hospitalisation need to be adequately described. We believe that this discussion should be disease specific. A focus on respiratory infections is of particular interest, because it is strongly associated with old age. Our objective was to assess trends in demographics over a decade among elderly patients admitted to the ICU for acute respiratory infections.
Methods: A cross-sectional study was performed between 2006 and 2015 based on hospital discharge databases in one French region (2.5 million inhabitants). Patients with acute respiratory infection were selected according to the specific ICD-10 diagnosis codes recorded, including acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and community-acquired pneumonia (CAP). We also identified comorbid conditions based on any significant ICD-10 secondary diagnoses adapted from the Charlson and Elixhauser indexes.
Results: A total of 98,381 hospital stays for acute respiratory infection were identified among the 3,856,785 stays over the 10-year period. The number of patients 75 y/o and younger increased 1.6-fold from 2006 to 2015, whereas the numbers of patients aged 85-89 and ≥ 90 y/o increased by 2.5- and 2.1-fold, respectively. Both CAP and AECOPD hospitalisations significantly increased for all age groups over the decade. ICU hospitalisations for respiratory infection increased 2.7-fold from 2006 to 2015 (p = 0.0002). The greatest increases in the use of ICU resources were for the 85-89 and ≥ 90 y/o groups, which corresponded to increases of 3.3- and 5.8-fold. Indeed, the proportion of patients hospitalized for respiratory infection in ICU that were elderly clearly grew during the decade: 11.3% were ≥ 85 y/o in 2006 versus 16.4% in 2015 (p < 0.0001). This increase in ICU hospitalisation rate of ageing patients was not associated with significant changes in the level of care or ICU mortality except for patients ≥ 90 y/o (for whom ICU mortality dropped from 40.9 to 22.3%, p = 0.03).
Conclusion: We observed a substantial increase in acute respiratory infection diagnoses associated with hospitalisation between 2006 and 2015, with a growing demand for critical care services. Both the absolute number and the percentage of elderly patient ICU admissions increased over the last decade, with the greatest increases being observed for patients 85 years and older.
The full text of this article is freely available via this link.
Effect of procalcitonin-guided antibiotic treatment on clinical outcomes in intensive care unit patients with infection and sepsis patients: a patient-level meta-analysis of randomized trials
The secondary research was published in the journal Critical Care in August 2018 by Wirz and others.
Background: The clinical utility of serum procalcitonin levels in guiding antibiotic treatment decisions in patients with sepsis remains unclear. This patient-level meta-analysis based on 11 randomized trials investigates the impact of procalcitonin-guided antibiotic therapy on mortality in intensive care unit (ICU) patients with infection, both overall and stratified according to sepsis definition, severity, and type of infection.
Methods: For this meta-analysis focusing on procalcitonin-guided antibiotic management in critically ill patients with sepsis of any type, in February 2018 we updated the database of a previous individual patient data meta-analysis which was limited to patients with respiratory infections only. We used individual patient data from 11 trials that randomly assigned patients to receive antibiotics based on procalcitonin levels (the “procalcitonin-guided” group) or the current standard of care (the “controls”). The primary endpoint was mortality within 30 days. Secondary endpoints were duration of antibiotic treatment and length of stay.
Results: Mortality in the 2252 procalcitonin-guided patients was significantly lower compared with the 2230 control group patients (21.1% vs 23.7%; adjusted odds ratio 0.89, 95% confidence interval (CI) 0.8 to 0.99; p = 0.03). These effects on mortality persisted in a subgroup of patients meeting the sepsis 3 definition and based on the severity of sepsis (assessed on the basis of the Sequential Organ Failure Assessment (SOFA) score, occurrence of septic shock or renal failure, and need for vasopressor or ventilatory support) and on the type of infection (respiratory, urinary tract, abdominal, skin, or central nervous system), with interaction for each analysis being > 0.05. Procalcitonin guidance also facilitated earlier discontinuation of antibiotics, with a reduction in treatment duration (9.3 vs 10.4 days; adjusted coefficient -1.19 days, 95% CI -1.73 to -0.66; p < 0.001).
Conclusion: Procalcitonin-guided antibiotic treatment in ICU patients with infection and sepsis patients results in improved survival and lower antibiotic treatment duration.
The full text of this article is freely available via this link.
Interprofessional Collaborative Practice in the Medical Intensive Care Unit: a Survey of Caregivers’ Perspectives.
This article was published in Journal of General Internal Medicine in August 2018 by Chen and colleagues.
Background: Research on caregivers, defined as designated family members or support persons, in the medical intensive care unit (MICU) has primarily focused on their emotional needs and experiences, thus leaving a gap in knowledge related to their perceptions of team dynamics.
Objective: To examine caregivers’ perceptions of team interactions and competencies for interprofessional collaborative practice (IPCP) and overall satisfaction with the MICU team.
Methods: The Support Person Jefferson Teamwork Observation Guide (JTOG)™ was administered to a convenience sample of caregivers in the MICU at a large urban academic medical center between May 2016 and December 2016.
Results: One hundred sixty-one JTOG surveys were completed. Caregivers agreed on the importance of healthcare professionals working together as a team to provide patient care (3.97 out of 4.0 on Likert response scale where 1 is “Not at all important” and 4 is ‘Extremely important”) and were satisfied with the MICU team (3.74 out of 4.0), positively evaluating the four core competencies for IPCP (3.55 for values/ethics, 3.58 for interprofessional communication, 3.61 for roles/responsibilities, and 3.64 for teams/teamwork) and the patient/family-centeredness sub-competency (3.58 out of 4.0). There was a strong positive correlation between caregivers’ Global JTOG scores and overall satisfaction with the MICU team (r = 0.596, p < 0.01). Caregivers’ comments about factors that affected their experience focused on aspects of interprofessional communication and patient/family-centeredness.
Conclusion: Findings underscore the importance of interprofessional communication and providing patient/family-centered care. Assessing caregivers’ perceptions of IPCP can provide a critical lens into team functioning and, thus, be used to identify teams’ strengths as well as opportunities for improvement.
To access the full text of this article via the journal’s homepage you require a personal subscription to the journal. Some articles may be available freely without a password. Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.
Critical Care Reviews Newsletter 348 12th August 2018
The 348th Critical Care Reviews Newsletter, brings you the best critical care research and open access articles from across the medical literature during the last week. “The highlights of this week’s edition are randomised controlled trials on terlipressin versus noradrenaline for AKI in acute-on-chronic liver failure, restricted fluid bolus volume in early paediatric septic shock & early CPAP in acute respiratory failure in children with impa
ired immunity; systematic reviews and meta analyses on complications and failures of central vascular access devices & laryngeal injury and upper airway symptoms after intubation during critical care; and guidelines and position statements on steroid therapy for sepsis, disorders of consciousness & spinal motion restriction in trauma.”
The full text of the newsletter can be accessed via this link.
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