Brian H. Cuthbertson

Hydrocortisone therapy for patients with septic shock.

BACKGROUND Hydrocortisone is widely used in patients with septic shock even though a survival benefit has been reported only in patients who remained hypotensive after fluid and vasopressor resuscitation and whose plasma cortisol levels did not rise appropriately after the administration of corticotropin. METHODS In this multicenter, randomized, double-blind, placebo-controlled trial, we assigned 251 patients to receive 50 mg of intravenous hydrocortisone and 248 patients to receive placebo every 6 hours for 5 days; the dose was then tapered during a 6-day period. At 28 days, the primary outcome was death among patients who did not have a response to a corticotropin test. RESULTS Of the 499 patients in the study, 233 (46.7%) did not have a response to corticotropin (125 in the hydrocortisone group and 108 in the placebo group). At 28 days, there was no significant difference in mortality between patients in the two study groups who did not have a response to corticotropin (39.2% in the hydrocortisone group and 36.1% in the placebo group, P=0.69) or between those who had a response to corticotropin (28.8% in the hydrocortisone group and 28.7% in the placebo group, P=1.00). At 28 days, 86 of 251 patients in the hydrocortisone group (34.3%) and 78 of 248 patients in the placebo group (31.5%) had died (P=0.51). In the hydrocortisone group, shock was reversed more quickly than in the placebo group. However, there were more episodes of superinfection, including new sepsis and septic shock. CONCLUSIONS Hydrocortisone did not improve survival or reversal of shock in patients with septic shock, either overall or in patients who did not have a response to corticotropin, although hydrocortisone hastened reversal of shock in patients in whom shock was reversed. (ClinicalTrials.gov number, NCT00147004.)

High-frequency oscillation for acute respiratory distress syndrome.

BACKGROUND Patients with the acute respiratory distress syndrome (ARDS) require mechanical ventilation to maintain arterial oxygenation, but this treatment may produce secondary lung injury. High-frequency oscillatory ventilation (HFOV) may reduce this secondary damage. METHODS In a multicenter study, we randomly assigned adults requiring mechanical ventilation for ARDS to undergo either HFOV with a Novalung R100 ventilator (Metran) or usual ventilatory care. All the patients had a ratio of the partial pressure of arterial oxygen (PaO) to the fraction of inspired oxygen (FiO) of 200 mm Hg (26.7 kPa) or less and an expected duration of ventilation of at least 2 days. The primary outcome was all-cause mortality 30 days after randomization. RESULTS There was no significant between-group difference in the primary outcome, which occurred in 166 of 398 patients (41.7%) in the HFOV group and 163 of 397 patients (41.1%) in the conventional-ventilation group (P=0.85 by the chi-square test). After adjustment for study center, sex, score on the Acute Physiology and Chronic Health Evaluation (APACHE) II, and the initial PaO:FiO ratio, the odds ratio for survival in the conventional-ventilation group was 1.03 (95% confidence interval, 0.75 to 1.40; P=0.87 by logistic regression). CONCLUSIONS The use of HFOV had no significant effect on 30-day mortality in patients undergoing mechanical ventilation for ARDS. (Funded by the National Institute for Health Research Health Technology Assessment Programme; OSCAR Current Controlled Trials number, ISRCTN10416500.).

The PRaCTICaL study of nurse led, intensive care follow-up programmes for improving long term outcomes from critical illness: a pragmatic randomised controlled trial

Objectives To test the hypothesis that nurse led follow-up programmes are effective and cost effective in improving quality of life after discharge from intensive care. Design A pragmatic, non-blinded, multicentre, randomised controlled trial. Setting Three UK hospitals (two teaching hospitals and one district general hospital). Participants 286 patients aged ≥18 years were recruited after discharge from intensive care between September 2006 and October 2007. Intervention Nurse led intensive care follow-up programmes versus standard care. Main outcome measure(s) Health related quality of life (measured with the SF-36 questionnaire) at 12 months after randomisation. A cost effectiveness analysis was also performed. Results 286 patients were recruited and 192 completed one year follow-up. At 12 months, there was no evidence of a difference in the SF-36 physical component score (mean 42.0 (SD 10.6) v 40.8 (SD 11.9), effect size 1.1 (95% CI −1.9 to 4.2), P=0.46) or the SF-36 mental component score (effect size 0.4 (−3.0 to 3.7), P=0.83). There were no statistically significant differences in secondary outcomes or subgroup analyses. Follow-up programmes were significantly more costly than standard care and are unlikely to be considered cost effective. Conclusions A nurse led intensive care follow-up programme showed no evidence of being effective or cost effective in improving patients’ quality of life in the year after discharge from intensive care. Further work should focus on the roles of early physical rehabilitation, delirium, cognitive dysfunction, and relatives in recovery from critical illness. Intensive care units should review their follow-up programmes in light of these results. Trial registration ISRCTN 24294750

Quality of life in the five years after intensive care: a cohort study

IntroductionData on quality of life beyond 2 years after intensive care discharge are limited and we aimed to explore this area further. Our objective was to quantify quality of life and health utilities in the 5 years after intensive care discharge.MethodsA prospective longitudinal cohort study in a University Hospital in the UK. Quality of life was assessed from the period before ICU admission until 5 years and quality adjusted life years calculated.Results300 level 3 intensive care patients of median age 60.5 years and median length of stay 6.7 days, were recruited. Physical quality of life fell to 3 months (P = 0.003), rose back to pre-morbid levels at 12 months then fell again from 2.5 to 5 years after intensive care (P = 0.002). Mean physical scores were below the population norm at all time points but the mean mental scores after 6 months were similar to those population norms. The utility value measured using the EuroQOL-5D quality of life assessment tool (EQ-5D) at 5 years was 0.677. During the five years after intensive care unit, the cumulative quality adjusted life years were significantly lower than that expected for the general population (P < 0.001).ConclusionsIntensive care unit admission is associated with a high mortality, a poor physical quality of life and a low quality adjusted life years gained compared to the general population for 5 years after discharge. In this group, critical illness associated with ICU admission should be treated as a life time diagnosis with associated excess mortality, morbidity and the requirement for ongoing health care support.

Developing a team performance framework for the intensive care unit

Objective:There is a growing literature on the relationship between teamwork and patient outcomes in intensive care, providing new insights into the skills required for effective team performance. The purpose of this review is to consolidate the most robust findings from this research into an intensive care unit (ICU) team performance framework. Data Sources:Studies investigating teamwork within the ICU using PubMed, Science Direct, and Web of Knowledge databases. Study Selection:Studies investigating the relationship between aspects of teamwork and ICU outcomes, or studies testing factors that are found to influence team working in the ICU. Data Extraction:Teamwork behaviors associated with patient or staff-related outcomes in the ICU were identified. Data Synthesis:Teamwork behaviors were grouped according to the team process categories of “team communication,” “team leadership,” “team coordination,” and “team decision making.” A prototype framework explaining the team performance in the ICU was developed using these categories. The purpose of the framework is to consolidate the existing ICU teamwork literature and to guide the development and testing of interventions for improving teamwork. Conclusions:Effective teamwork is shown as crucial for providing optimal patient care in the ICU. In particular, team leadership seems vital for guiding the way in which ICU team members interact and coordinate with others.

Quality of life before and after intensive care

Quality of life is often thought to be poor before and after intensive care unit admission. The aim of this study was to investigate changes in quality of life before and after intensive care. A prospective cohort study of 300 consecutive patients admitted to intensive care was performed in a Scottish Teaching Hospital. Quality of life was assessed premorbidly and 3, 6 and 12 months after intensive care admission for surviving patients using SF‐36 as well as EQ‐5D scores at 12 months. The median value for age was 60.5 years and for APACHE II score, 18. The mean length of stay was 6.7 days. SF‐36 physical component scores decreased from premorbid values at 3 months (p = 0.05) and then returned to premorbid values at 12 months (p < 0.001). The mean physical scores were below the population norm at all time points but the mean mental scores were similar or higher than these population norms. Patients who died after intensive care discharge had lower quality of life scores than did survivors (all p < 0.01). Poor premorbid quality of life was demonstrated and appears to reduce after ICU discharge. For survivors there was a slow increase in physical quality of life to premorbid levels by the end of the first year but these remained lower than in the general population. ICU patients experience a considerable longer‐term burden of ill health.

Communication skills and error in the intensive care unit.

Purpose of reviewPoor communication in critical care teams has been frequently shown as a contributing factor to adverse events. There is now a strong emphasis on identifying the communication skills that can contribute to, or protect against, preventable medical errors. This review considers communication research recently conducted in the intensive care unit and other acute domains. Recent findingsError studies in the intensive care unit have shown good communication to be crucial for ensuring patient safety. Interventions to improve communication in the intensive care unit have resulted in reduced reports of adverse events, and simulated emergency scenarios have shown effective communication to be correlated with improved technical performance. In other medical domains where communication is crucial for safety, the relationship between communication skills and error has been examined more closely, with highly detailed teamwork assessment tools being developed. SummaryCritical care teams perform many activities where effective communication is crucial for ensuring patient safety and reducing susceptibility to error. To develop valid team training and assessment tools for improving teamwork in the intensive care unit there is a requirement to better understand and identify the specific communication skills important for safety during the provision of intensive care medicine.

Effect of selective decontamination on antimicrobial resistance in intensive care units: a systematic review and meta-analysis.

BACKGROUND Many meta-analyses have shown reductions in infection rates and mortality associated with the use of selective digestive decontamination (SDD) or selective oropharyngeal decontamination (SOD) in intensive care units (ICUs). These interventions have not been widely implemented because of concerns that their use could lead to the development of antimicrobial resistance in pathogens. We aimed to assess the effect of SDD and SOD on antimicrobial resistance rates in patients in ICUs. METHODS We did a systematic review of the effect of SDD and SOD on the rates of colonisation or infection with antimicrobial-resistant pathogens in patients who were critically ill. We searched for studies using Medline, Embase, and Cochrane databases, with no limits by language, date of publication, study design, or study quality. We included all studies of selective decontamination that involved prophylactic application of topical non-absorbable antimicrobials to the stomach or oropharynx of patients in ICUs, with or without additional systemic antimicrobials. We excluded studies of interventions that used only antiseptic or biocide agents such as chlorhexidine, unless antimicrobials were also included in the regimen. We used the Mantel-Haenszel model with random effects to calculate pooled odds ratios. FINDINGS We analysed 64 unique studies of SDD and SOD in ICUs, of which 47 were randomised controlled trials and 35 included data for the detection of antimicrobial resistance. When comparing data for patients in intervention groups (those who received SDD or SOD) versus data for those in control groups (who received no intervention), we identified no difference in the prevalence of colonisation or infection with Gram-positive antimicrobial-resistant pathogens of interest, including meticillin-resistant Staphylococcus aureus (odds ratio 1·46, 95% CI 0·90-2·37) and vancomycin-resistant enterococci (0·63, 0·39-1·02). Among Gram-negative bacilli, we detected no difference in aminoglycoside-resistance (0·73, 0·51-1·05) or fluoroquinolone-resistance (0·52, 0·16-1·68), but we did detect a reduction in polymyxin-resistant Gram-negative bacilli (0·58, 0·46-0·72) and third-generation cephalosporin-resistant Gram-negative bacilli (0·33, 0·20-0·52) in recipients of selective decontamination compared with those who received no intervention. INTERPRETATION We detected no relation between the use of SDD or SOD and the development of antimicrobial-resistance in pathogens in patients in the ICU, suggesting that the perceived risk of long-term harm related to selective decontamination cannot be justified by available data. However, our study indicates that the effect of decontamination on ICU-level antimicrobial resistance rates is understudied. We recommend that future research includes a non-crossover, cluster randomised controlled trial to assess long-term ICU-level changes in resistance rates. FUNDING None.

Predicting death and readmission after intensive care discharge.

BACKGROUND Despite initial recovery from critical illness, many patients deteriorate after discharge from the intensive care unit (ICU). We examined prospectively collected data in an attempt to identify patients at risk of readmission or death after intensive care discharge. METHODS This was a secondary analysis of clinical audit data from patients discharged alive from a mixed medical and surgical (non-cardiac) ICU. RESULTS Four hundred and seventy-five patients (11.2%) died in hospital after discharge from the ICU. Increasing age, time in hospital before intensive care admission, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and discharge Therapeutic Intervention Scoring System (TISS) score were independent risk factors for death after intensive care discharge. Three hundred and eighty-five patients (8.8%) were readmitted to intensive care during the same hospital admission. Increasing age, time in hospital before intensive care, APACHE II score, and discharge to a high dependency unit were independent risk factors for readmission. One hundred and forty-three patients (3.3%) were readmitted within 48 h of intensive care discharge. APACHE II scores and discharge to a high dependency or other ICU were independent risk factors for early readmission. The overall discriminant ability of our models was moderate with only marginal benefit over the APACHE II scores alone. CONCLUSIONS We identified risk factors associated with death and readmission to intensive care. It was not possible to produce a definitive model based on these risk factors for predicting death or readmission in an individual patient.

Can physiological variables and early warning scoring systems allow early recognition of the deteriorating surgical patient

Objective:Early warning scoring systems are widely used in clinical practice to allow early recognition of the deteriorating patient, but they lack validation. We aimed to test the ability of physiologic variables, either alone or in existing early scoring systems, to predict major deterioration in a patient’s condition and attempt to derive functions with superior accuracy. Design:A comparative cohort study. Setting:A teaching hospital in Scotland. Patients:Two cohorts of general surgical high-dependency patients. The cohorts are a group of surgical high-dependency care patients who did not require intensive care admission and another group of patients who did require admission. Interventions:None. Measurements and Main Results:Prospective physiologic data on consecutive surgical high-dependency unit patients were collected and compared with physiologic data on patients admitted to the intensive care unit from the same surgical high-dependency units. Data were quality checked and summarized, and discriminant analysis and receiver operator curves were used to discriminate between the groups. There were significant physiologic differences between groups with regard to heart rate (p < .001, area under the receiver operating characteristic curve [AUC] 0.7), respiratory rate (p < .001, AUC 0.71), and oxygen saturation (p < .001, AUC 0.78) across time points. This was not present for systolic blood pressure or temperature. Existing early warning scoring systems had good discriminatory power (AUC 0.83–0.86). We derived discriminant functions, which have a high predictive ability to determine differences between groups (p < .0001, AUC 0.86–0.90). We found that heart rate and respiratory rate could detect differences between groups at 6 and 8 hrs before ICU admission, but oxygen saturation and the discriminant function 2 could detect differences 48 hrs before ICU admission. Conclusions:Some commonly used physiologic variables have reasonable power in determining the difference between patients requiring intensive care unit admission, but others are poor. Existing early warning scores have comparatively good discriminatory power. We have derived functions with excellent predictive power in this derivation cohort.