Angelo Pezzi

The Eldicus prospective, observational study of triage decision making in European intensive care units. Part II: intensive care benefit for the elderly.

Rationale:Life and death triage decisions are made daily by intensive care unit physicians. Admission to an intensive care unit is denied when intensive care unit resources are constrained, especially for the elderly. Objective:To determine the effect of intensive care unit triage decisions on mortality and intensive care unit benefit, specifically for elderly patients. Design:Prospective, observational study of triage decisions from September 2003 until March 2005. Setting:Eleven intensive care units in seven European countries. Patients:All patients >18 yrs with an explicit request for intensive care unit admission. Interventions:Admission or rejection to intensive care unit. Measurements and Main Results:Demographic, clinical, hospital, physiologic variables, and 28-day mortality were obtained on consecutive patients. There were 8,472 triages in 6,796 patients, 5,602 (82%) were accepted to the intensive care unit, 1,194 (18%) rejected; 3,795 (49%) were ≥65 yrs. Refusal rate increased with increasing patient age (18–44: 11%; 45–64: 15%; 65–74: 18%; 75–84: 23%; >84: 36%). Mortality was higher for older patients (18–44: 11%; 45–64: 21%; 65–74: 29%; 75–84: 37%; >84: 48%). Differences between mortalities of accepted vs. rejected patients, however, were greatest for older patients (18–44: 10.2% vs. 12.5%; 45–64: 21.2% vs. 22.3%; 65–74: 27.9% vs. 34.6%; 75–84: 35.5% vs. 40.4%; >84: 41.5% vs. 58.5%). Logistic regression showed a greater mortality reduction for accepted vs. rejected patients corrected for disease severity for elderly patients (age >65 [odds ratio 0.65, 95% confidence interval 0.55–0.78, p < .0001]) than younger patients (age <65 [odds ratio 0.74, 95% confidence interval 0.57–0.97, p = .01]). Conclusions:Despite the fact that elderly patients have more intensive care unit rejections than younger patients and have a higher mortality when admitted, the mortality benefit appears greater for the elderly. Physicians should consider changing their intensive care unit triage practices for the elderly. (Crit Care Med 2012; 40:132–138)

The Eldicus prospective, observational study of triage decision making in European intensive care units: Part I—European Intensive Care Admission Triage Scores*

Objective:Life and death triage decisions are made daily by intensive care unit physicians. Scoring systems have been developed for prognosticating intensive care unit mortality but none for intensive care unit triage. The objective of this study was to develop an intensive care unit triage decision rule based on 28-day mortality rates of admitted and refused patients. Design:Prospective, observational study of triage decisions from September 2003 until March 2005. Setting:Eleven intensive care units in seven European countries. Patients:All patients >18 yrs with a request for intensive care unit admission. Interventions:Admission or rejection to an intensive care unit. Measurements and Main Results:Clinical, laboratory, and physiological variables and data from severity scores were collected. Separate scores for accepted and rejected patients with 28-day mortality end point were built. Values for variables were grouped into categories determined by the locally weighted least squares graphical method applied to the logit of the mortality and by univariate logistic regressions for reducing candidates for the score. Multivariate logistic regression was used to construct the final score. Cutoff values for 99.5% specificity were determined. Of 6796 patients, 5602 were admitted and 1194 rejected. The initial refusal score included age, diagnosis, systolic blood pressure, pulse, respirations, creatinine, bilirubin, PaO2, bicarbonate, albumin, use of vasopressors, Glasgow Coma Scale score, Karnofsky Scale, operative status and chronic disorder, and the initial refusal receiver operating characteristics were area under the curve 0.77 (95% confidence interval 0.76–0.79). The final triage score included age, diagnosis, creatinine, white blood cells, platelets, albumin, use of vasopressors, Glasgow Coma Scale score, Karnofsky Scale, operative status and chronic disorder, and the final score receiver operating characteristics were area under the curve 0.83 (95% confidence interval 0.80–0.86). Patients with initial refusal scores >173.5 or final triage scores = 0 should be rejected. Conclusions:The initial refusal score and final triage score provide objective data for rejecting patients that will die even if admitted to the intensive care unit and survive if refused intensive care unit admission. (Crit Care Med 2012; 40:125–131)

Diaphragm ultrasound as indicator of respiratory effort in critically ill patients undergoing assisted mechanical ventilation: a pilot clinical study

IntroductionPressure-support ventilation, is widely used in critically ill patients; however, the relative contribution of patient’s effort during assisted breathing is difficult to measure in clinical conditions. Aim of the present study was to evaluate the performance of ultrasonographic indices of diaphragm contractile activity (respiratory excursion and thickening) in comparison to traditional indices of inspiratory muscle effort during assisted mechanical ventilation.MethodConsecutive patients admitted to the ICU after major elective surgery who met criteria for a spontaneous breathing trial with pressure support ventilation were enrolled. Patients with airflow obstruction or after thoracic/gastric/esophageal surgery were excluded. Variable levels of inspiratory muscle effort were achieved by delivery of different levels of ventilatory assistance by random application of pressure support (0, 5 and 15 cmH2O). The right hemidiaphragm was evaluated by B- and M-mode ultrasonography to record respiratory excursion and thickening. Airway, gastric and oesophageal pressures, and airflow were recorded to calculate indices of respiratory effort (diaphragm and esophageal pressure–time product).Results25 patients were enrolled. With increasing levels of pressure support, parallel reductions were found between diaphragm thickening and both diaphragm and esophageal pressure–time product (respectively, R = 0.701, p < 0.001 and R = 0.801, p < 0.001) during tidal breathing. No correlation was found between either diaphragm or esophageal pressure–time product and diaphragm excursion (respectively, R = −0.081, p = 0.506 and R = 0.003, p = 0.981), nor was diaphragm excursion correlated to diaphragm thickening (R = 0.093, p = 0.450) during tidal breathing.ConclusionsIn patients undergoing in assisted mechanical ventilation, diaphragm thickening is a reliable indicator of respiratory effort, whereas diaphragm excursion should not be used to quantitatively assess diaphragm contractile activity.

Implications of ICU triage decisions on patient mortality: a cost-effectiveness analysis

IntroductionIntensive care is generally regarded as expensive, and as a result beds are limited. This has raised serious questions about rationing when there are insufficient beds for all those referred. However, the evidence for the cost effectiveness of intensive care is weak and the work that does exist usually assumes that those who are not admitted do not survive, which is not always the case. Randomised studies of the effectiveness of intensive care are difficult to justify on ethical grounds; therefore, this observational study examined the cost effectiveness of ICU admission by comparing patients who were accepted into ICU after ICU triage to those who were not accepted, while attempting to adjust such comparison for confounding factors.MethodsThis multi-centre observational cohort study involved 11 hospitals in 7 EU countries and was designed to assess the cost effectiveness of admission to intensive care after ICU triage. A total of 7,659 consecutive patients referred to the intensive care unit (ICU) were divided into those accepted for admission and those not accepted. The two groups were compared in terms of cost and mortality using multilevel regression models to account for differences across centres, and after adjusting for age, Karnofsky score and indication for ICU admission. The analyses were also stratified by categories of Simplified Acute Physiology Score (SAPS) II predicted mortality (< 5%, 5% to 40% and >40%). Cost effectiveness was evaluated as cost per life saved and cost per life-year saved.ResultsAdmission to ICU produced a relative reduction in mortality risk, expressed as odds ratio, of 0.70 (0.52 to 0.94) at 28 days. When stratified by predicted mortality, the odds ratio was 1.49 (0.79 to 2.81), 0.7 (0.51 to 0.97) and 0.55 (0.37 to 0.83) for <5%, 5% to 40% and >40% predicted mortality, respectively. Average cost per life saved for all patients was

Daily classification of the level of care. A method to describe clinical course of illness, use of resources and quality of intensive care assistance

103,771 (€82,358) and cost per life-year saved was

Liver rupture after cardiopulmonary resuscitation (CPR) and thrombolysis.

7,065 (€5,607). These figures decreased substantially for patients with predicted mortality higher than 40%,

Intensive care unit patients with lower respiratory tract nosocomial infections: The ENIRRIs project

60,046 (€47,656) and

Reasons for refusal of admission to intensive care and impact on mortality

4,088 (€3,244), respectively. Results were very similar when considering three-month mortality. Sensitivity analyses performed to assess the robustness of the results provided findings similar to the main analyses.ConclusionsNot only does ICU appear to produce an improvement in survival, but the cost per life saved falls for patients with greater severity of illness. This suggests that intensive care is similarly cost effective to other therapies that are generally regarded as essential.

Direct Cost Analysis of Intensive Care Unit Stay in Four European Countries: Applying a Standardized Costing Methodology

Objective: To develop a simple and comparable clinical method able to distinguish between higher and lower complexities of care in the ICU. Design: Retrospective analysis. Setting: Database of European ICUs Study I (Euricus-I: including 12,615 patients and 55,464 patient/days), prospectively collected in 89 ICUs of 12 European countries. Methods and results: A panel of experts developed the classification of the complexity of care. Six (in addition to monitoring, two levels of respiratory support – R and r – two levels of circulatory support – C and c – and dialysis) out of the nine items of Nine Equivalents of Nursing Manpower use Score (NEMS), a therapeutic index, were utilised. Two levels of care (LOCs) were defined according to a more (HT) and a less complex (LT) combination of common activities of care. The two LOCs were significantly related to mortality: higher in HT and they rose with increasing cumulative number of HT days. HT accounted for 31,976 NEMS days (57.7%) while 23,488 (42.3%) were LT. Major respiratory and cardiovascular support accounted for about 80% of the HT days. Respiratory assistance and monitoring were responsible for an equivalent percentage of LT days. The distribution of the clinical classification of LOCs coincided with that of the managerial scores of LOCs in the literature. Conclusions: The managerial instrument described uses simple and reliable clinical data. It is able to distinguish between patients with different severity and outcome, and shows that every additional consecutive day spent in ICU as HT increases the probability of death. Moreover, (1) it suggests the possibility of describing the clinical course of illness by relating the complexity/level of medical care to the available technology and staff; (2) using relevant markers of clinical activity, it might be useful to include in quality control programmes.

Sedation in the critically ill ventilated patient: possible role of enteral drugs

Sir: It is well known that external cardiac massage (ECM) can cause serious visceral injuries [1]. Haemorrhagic complications may occur after cardiopulmonary resuscitation (CPR) and thrombolytic therapy [2, 3]. For this reason, CPR is considered by some authors to be a relative contraindication to thrombolysis independent of its duration [4], but others consider it a contraindication only if the rescue manoeuvers last more than 10 min [5]. The following report may help to define this open question. A male, 50 years old, affected by arterial hypertension, arrived in the hospital with high frequency, low voltage ventricular fibrillation. After several defibrillations and ECM for about 30 min along with standard intravenous therapy (lidocaine, adrenaline, bretylium tosylate, MgSO4), we observed stable cardiac electrical activity with left anterior hemiblock and right bundle branch block morphology and a 20±mm ST upward displacement in D1, aVL and from V1 to V6. 2D echocardiography showed marked hypocinesia of the cardiac apex and of interventricular septum. Then, a thrombolytic therapy (tissue-plasminogen activator) was administered followed by lidocaine 100 mg i. v. bolus, heparin 5000 IU bolus and 1000 IU/h infusion. Within 5 min of thrombolytic therapy the electrocardiographic signs of myocardical injury had almost disappeared. Arterial blood pressure (ABP) became measurable and sinus tachycardia (120 bpm) with several premature atrial and ventricular complexes appeared. Tachyarrhythmias were controlled by atenolol 2.5 mg i. v. bolus and lidocaine 1 mg/kg per h as a continuous infusion. Low ABP was treated with titrated dopamine infusion. Later on, we found ABP 90/50 mmHg, stable sinus rhythm (heart rate 90/min) with fewer premature beats. Nevertheless the patient was in postanoxic coma (Glasgow Coma Scale score = 4) and ventilated: expiratory flowrate VE 10.8 l/min, positive end-expiratory pressure (PEEP) 5 cmH2O, arterial oxygen tension/fractional inspired oxygen (PaO2/ FIO2) ratio 135, arterial carbondioxide tension (PaCO2) 36 mmHg, pH 7.41. Serum creatinine and urea were 97.2 mmol/l and 6.1 mmol/l, respectively. Two hours after admission to the emergency room, the patient was transferred to the intensive care unit Ventilatory assistance and dopamine (10 mg/kg per min) and lidocaine (1 mg/kg per h) treatment were continued. In the following 8 h, acceptable haemodynamic parameters were maintained. Small boluses of atenolol were given to an overall dose of 12.5 mg. In this phase we observed an improvement in blood gases (PaO2/FIO2 ratio 247, VE 12.5 l/min, PEEP 5 cmH2O, PaCO2 33 mmHg, pH 7.43), and the patient was kept sedated with fentanyl 0.01 mg/kg/min continuous infusion. At 20 h after hospital admission, acute circulatory failure (ABP 70/40 mmHg, heart rate 120/min, central venous pressure 7 mmHg, pulmonary artery wedge pressure 9 mmHg, pulmonary artery pressure 22 mmHg, cardiac index 2.19 l/m2, systemic vascular resistances 807 dyne/s per cm±5) was detected. We infused 2000 ml saline solution and 2 units of blood within 2 h because of suspected a haemorrage despite a haemoglobin of 10.7 g/dl. This intervention was ineffective as haemoglobin further decreased (9.1 g/dl), although melaena and/or gastrorrhagia had been excluded. 2D echocardiography showed a light septum hypocinesia, good global contractility and a widening of the thoracic aorta, suggesting a traumatic injury. The sudden worsening of clinical conditions precluded any surgical approach and the patient died within 30 min. Haemoperitoneum of about 2 l (due to laceration of the liver capsule coupled with left lobe intraparenchymal haematomas) and osteochondral joint fractures of the 4th, 5th and 6th right ribs were found at autopsy. No evidence of a ruptured aortic aneurysm was detected. This is a case of a patient with an acute myocardial infarction complicated by cardiac arrest managed with CPR and thrombolytic treatment. Recovery was, however, associated with a transitory low output state as well as severe hypoxia, which was probably produced by pulmonary edema secondary to acute myocardial dysfunction and/or prolonged ECM. Both improved during the immediate clinical course. We emphasize the efficacy of thrombolysis for reperfusion and to improve haemodynamics after myocardial infarction. However, at 20th h after hospital admission, the patient entered into irreversible shock, likely to be due to a haemorrage. At post-mortem examination, 2 l of blood was found in the abdomen due to rupture of the liver likely to have been caused by fractured ribs. We cannot exclude the possibility that some of the drugs (fentanyl, lidocaine), and particularly atenolol, given to reduce myocardial oxygen consumption and to counteract the proarrythmic effects of sympathetic activation, could have potentiated the low output condition and induced low systemic vascular resistance. In conclusion, this case report demonstrates the risks of administering thrombolytic therapy when CPR lasts more than 15±20 min. We therefore suggest that more than 10 min of CPR, even in expert hands, could be a contraindication to thrombolytic therapy due to the high risk of visceral injures. However, in a resuscitated (even with less 10 min of CPR) patient treated for thrombolysis who develops low blood pressure and tachycardia, the possibility of visceral injuries should be taken very seriously and cannot be excluded on the basis of a 2D transthoracic echocardiogram. On the other hand, in this kind of situation, acute percutaneous transluminal coronary angioplasty must be considered the best option, if available.