Cooper Dj

Predicting Survival after Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Failure. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) Score

RATIONALEnIncreasing use of extracorporeal membrane oxygenation (ECMO) for acute respiratory failure may increase resource requirements and hospital costs. Better prediction of survival in these patients may improve resource use, allow risk-adjusted comparison of center-specific outcomes, and help clinicians to target patients most likely to benefit from ECMO.nnnOBJECTIVESnTo create a model for predicting hospital survival at initiation of ECMO for respiratory failure.nnnMETHODSnAdult patients with severe acute respiratory failure treated by ECMO from 2000 to 2012 were extracted from the Extracorporeal Life Support Organization (ELSO) international registry. Multivariable logistic regression was used to create the Respiratory ECMO Survival Prediction (RESP) score using bootstrapping methodology with internal and external validation.nnnMEASUREMENTS AND MAIN RESULTSnOf the 2,355 patients included in the study, 1,338 patients (57%) were discharged alive from hospital. The RESP score was developed using pre-ECMO variables independently associated with hospital survival on logistic regression, which included age, immunocompromised status, duration of mechanical ventilation before ECMO, diagnosis, central nervous system dysfunction, acute associated nonpulmonary infection, neuromuscular blockade agents or nitric oxide use, bicarbonate infusion, cardiac arrest, PaCO2, and peak inspiratory pressure. The receiver operating characteristics curve analysis of the RESP score was c = 0.74 (95% confidence interval, 0.72-0.76). External validation, performed on 140 patients, exhibited excellent discrimination (c = 0.92; 95% confidence interval, 0.89-0.97).nnnCONCLUSIONSnThe RESP score is a relevant and validated tool to predict survival for patients receiving ECMO for respiratory failure.

The impact of disability in survivors of critical illness

PurposeTo use the World Health Organisation’s International Classification of Functioning to measure disability following critical illness using patient-reported outcomes.MethodsA prospective, multicentre cohort study conducted in five metropolitan intensive care units (ICU). Participants were adults who had been admitted to the ICU, received more than 24xa0h of mechanical ventilation and survived to hospital discharge. The primary outcome was measurement of disability using the World Health Organisation’s Disability Assessment Schedule 2.0. The secondary outcomes included the limitation of activities and changes to health-related quality of life comparing survivors with and without disability at 6xa0months after ICU.ResultsWe followed 262 patients to 6xa0months, with a mean age of 59xa0±xa016xa0years, and of whom 175 (67%) were men. Moderate or severe disability was reported in 65 of 262 (25%). Predictors of disability included a history of anxiety/depression [odds ratio (OR) 1.65 (95% confidence interval (CI) 1.22, 2.23), Pxa0=xa00.001]; being separated or divorced [OR 2.87 (CI 1.35, 6.08), Pxa0=xa00.006]; increased duration of mechanical ventilation [OR 1.04 (CI 1.01, 1.08), Pxa0=xa00.03 per day]; and not being discharged to home from the acute hospital [OR 1.96 (CI 1.01, 3.70) Pxa0=xa00.04]. Moderate or severe disability at 6xa0months was associated with limitation in activities, e.g. not returning to work or studies due to health (Pxa0<xa00.002), and reduced health-related quality of life (Pxa0<xa00.001).ConclusionDisability measured using patient-reported outcomes was prevalent at 6xa0months after critical illness in survivors and was associated with reduced health-related quality of life. Predictors of moderate or severe disability included a prior history of anxiety or depression, separation or divorce and a longer duration of mechanical ventilation.Trial registration: NCT02225938.

Hypothermia for Intracranial Hypertension after Traumatic Brain Injury.

n engl j med nejm.org 1 From the Centre for Clinical Brain Sciences (P.J.D.A.), Department of Anaesthesia, Critical Care, and Pain Medicine (H.L.S., B.A.H., C.G.B., J.K.J.R.), and Centre for Population Health Sciences (A.R., G.D.M.), University of Edinburgh, and Critical Care, Western General Hospital, NHS Lothian (B.A.H., J.K.J.R.) — all in Edinburgh. Address reprint requests to Dr. Andrews at Ward 20, Intensive Care Unit, Western General Hospital, Crewe Rd., Edinburgh EH4 2XU, United Kingdom, or at p . andrews@ ed . ac . uk.

Trends in severe traumatic brain injury in Victoria, 2006-2014

Objective: To describe the incidence and causes of hospitalisation for severe traumatic brain injury (TBI) in Victoria over a 9‐year period.

Erratum to: The impact of disability in survivors of critical illness

In the Results section, under the subheading “Return to work or usual activities”, the second sentence should read.

Craniectomy for Traumatic Intracranial Hypertension.

To the Editor: In the Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intracranial Pressure (RESCUEicp) trial reported by Hutchinson and others (Sept. 22 issue),1 mortality among patients with severe traumatic brain injury (TBI) and refractory intracranial hypertension who underwent decompressive craniectomy was lower than that among patients who received medical care. However, at 6 months, patients in the surgical group were more likely to have severe disability (as assessed with the use of the Extended Glasgow Outcome Scale [GOS-E]2) than patients in the medical group. At 12 months, a higher percentage of patients in the surgical group than in the medical group had a favorable outcome. Although most patients in the surgical group underwent a bifrontal decompressive craniectomy (63%), an analysis according to the type of surgery (i.e., bifrontal or unilateral craniectomy) was not performed. This analysis would be helpful given that in the United States, unilateral decompressive craniectomy is a more common surgical decompression procedure than bifrontal decompressive craniectomy. This trial included children as young as 10 years of age. Since among patients with severe TBI, school-aged children generally tend to have better outcomes than adults,3,4 these patients perhaps should be assessed with a pediatric version of the GOS-E in a separate subgroup analysis.5