Dan Roberts

Initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock.

OBJECTIVEnOur goal was to determine the impact of the initiation of inappropriate antimicrobial therapy on survival to hospital discharge of patients with septic shock.nnnMETHODSnThe appropriateness of initial antimicrobial therapy, the clinical infection site, and relevant pathogens were retrospectively determined for 5,715 patients with septic shock in three countries.nnnRESULTSnTherapy with appropriate antimicrobial agents was initiated in 80.1% of cases. Overall, the survival rate was 43.7%. There were marked differences in the distribution of comorbidities, clinical infections, and pathogens in patients who received appropriate and inappropriate initial antimicrobial therapy (p < 0.0001 for each). The survival rates after appropriate and inappropriate initial therapy were 52.0% and 10.3%, respectively (odds ratio [OR], 9.45; 95% CI, 7.74 to 11.54; p < 0.0001). Similar differences in survival were seen in all major epidemiologic, clinical, and organism subgroups. The decrease in survival with inappropriate initial therapy ranged from 2.3-fold for pneumococcal infection to 17.6-fold with primary bacteremia. After adjustment for acute physiology and chronic health evaluation II score, comorbidities, hospital site, and other potential risk factors, the inappropriateness of initial antimicrobial therapy remained most highly associated with risk of death (OR, 8.99; 95% CI, 6.60 to 12.23).nnnCONCLUSIONSnInappropriate initial antimicrobial therapy for septic shock occurs in about 20% of patients and is associated with a fivefold reduction in survival. Efforts to increase the frequency of the appropriateness of initial antimicrobial therapy must be central to efforts to reduce the mortality of patients with septic shock.

Twenty-four-hour intensivist presence: a pilot study of effects on intensive care unit patients, families, doctors, and nurses.

RATIONALEnAround-the-clock intensivist presence in intensive care units (ICUs) has been promoted as necessary to optimize outcomes. Little data have addressed how it affects the multiple stakeholders in such care.nnnOBJECTIVESnTo assess effects of around-the-clock intensivist presence on intensivists, patients, families, housestaff, and nurses.nnnMETHODSnThis 32-week, crossover pilot trial of two intensivist staffing models, performed in two Canadian ICUs, alternated 8-week blocks of two staffing models: the standard model, where one intensivist worked for 7 days, taking night call from home; and the shift work model, where one intensivist worked 7 day shifts, while other intensivists remained in the ICU at night.nnnMEASUREMENTS AND MAIN RESULTSnSurveys scaled from 0-100 points assessed outcomes for 24 intensivists (primary outcome: burnout); 119 families (satisfaction); 74 nurses (satisfaction with collaboration and communications, role conflict); and 34 housestaff (autonomy, supervision, and learning opportunities). Outcomes for 501 patients included mortality, length of stay, and resource use. Intensivists doing shift work experienced less burnout (-6.9 points; P = 0.04). Adjusted hospital mortality (odds ratio, 1.22; P = 0.44), ICU length of stay (-6 h; P = 0.46), and family satisfaction (0.9 points; P = 0.79) did not differ between staffing models. Under shift work staffing, nurses reported more role conflict (9 points; P < 0.001), whereas nighttime housestaff reported less autonomy, more supervision, but no difference in learning opportunities.nnnCONCLUSIONSnShiftwork staffing was better for intensivists and most were receptive once they had experienced it. Although there were no evident negative outcomes for patients or families, further evaluation is needed to clarify how around-the-clock intensivist staffing influences the various stakeholders in ICU care, given power considerations in this study. Clinical trial registered with www.clinicaltrials.gov (NCT 01146691).

EFFECT OF INDOMETHACIN ON ARTERIAL OXYGENATION IN CRITICALLY ILL PATIENTS WITH SEVERE BACTERIAL PNEUMONIA

The effect of indomethacin (1 mg/kg) on gas exchange was studied in ten patients with hypoxaemic respiratory failure precipitated by bacterial pneumonia. Mean arterial oxygen tension (PaO2) improved significantly (79 +/- 16 mm Hg to 98 +/- 20 mm Hg) but the response varied between patients: five showed substantial responses (27-42 mm Hg), three lesser responses (7-9 mm Hg), and two no response. Similar changes were found in the alveolar-arterial oxygen gradient and the ratio of PaO2 to fractional inspired oxygen concentration. In two responders studied further, PaO2 had fallen to baseline values 4-6 h later and a repeat indomethacin challenge again increased PaO2 by greater than 25 mm Hg with concomitant changes in pulmonary shunt. There were no significant changes in the other gas-exchange or haemodynamic variables measured and there was no clear reason for the variability in response to indomethacin. These results suggest a role for products of the cyclo-oxygenase pathway of arachidonic acid metabolism in the pathogenesis of hypoxaemia in patients with severe bacterial pneumonia.

Outcomes of Chronic Dialysis Patients Admitted to the Intensive Care Unit

Admission rates and outcomes of patients who have ESRD and are admitted to an intensive care unit (ICU) are not well defined. We conducted a historical cohort study using a prospective regional ICU database that captured all 11 adult ICUs in Winnipeg, Canada. Between 2000 and 2006, there were 34,965 total admissions to the ICU, 1173 (3.4%) of which were patients with ESRD. The main admission diagnoses among patients with ESRD were cardiac disease (31%), sepsis (15%), and arrest (10%). Compared with other patients in the ICU, those with ESRD were significantly younger but had more diabetes, peripheral arterial disease, and higher APACHE II (Acute Physiology and Chronic Health Evaluation II) scores; mean length of stay in the ICU was similar, however, between these two groups. Restricting the analysis to first admissions to the ICU, unadjusted in-hospital mortality was higher for patients with ESRD (16 versus 11%; P < 0.0001), but this difference did not persist after adjustment for baseline illness severity. In conclusion, although ESRD associates with increased mortality among patients who are admitted to the ICU, this effect is mostly a result of comorbidity.

Control of blood gas measurements in intensive-care units

The frequency of blood gas measurement in two adult intensive-care units was assessed for 7 months before and 12 months after introduction of a protocol of indications for such investigation. Demographic, diagnostic, outcome, and intervention data were collected prospectively. There were no differences in demographic characteristics, severity or type of illness, survival, or frequency of arterial or pulmonary artery catheter use between the two observation periods, but the frequency of blood gas analysis fell by 44% (p less than 0.001) after the protocol was introduced.

Acute kidney injury in critically ill patients infected with 2009 pandemic influenza A(H1N1): report from a Canadian Province.

n n Backgroundn 2009 pandemic influenza A(H1N1) has led to a global increase in severe respiratory illness. Little is known about kidney outcomes and dialytic requirements in critically ill patients infected with pandemic H1N1.n n n Study Designn Prospective observational study.n n n Setting & Participantsn 50 patients with pandemic H1N1 admitted to any of 7 intensive care units in Manitoba, Canada, were prospectively followed.n n n Outcome & Measurementsn Outcomes were kidney injury and kidney failure defined using RIFLE (risk, injury, failure, loss, end-stage disease) criteria or need for dialysis therapy.n n n Resultsn The pandemic H1N1 group was composed of 50 critically ill patients with pandemic H1N1 with severe respiratory syndrome (47 confirmed cases, 3 probable). Kidney injury, kidney failure, and need for dialysis occurred in 66.7%, 66%, and 11% of patients, respectively. Mortality was 16%. Kidney failure was associated with increased death (OR, 11.29; 95% CI, 1.29-98.9), whereas the need for dialysis was associated with an increase in length of stay (RR, 2.38; 95% CI, 2.13-25.75).n n n Limitationsn Small population studied from single Canadian province; thus, limited generalizability.n n n Conclusionsn In critically ill patients with pandemic H1N1, kidney injury, kidney failure, and the need for dialysis are common and associated with an increase in mortality and length of intensive care unit stay.n n

Long-term outcomes of end-stage renal disease patients admitted to the ICU

BACKGROUNDnEnd-stage renal disease (ESRD) patients admitted to the intensive care unit (ICU) have poor survival and high rates of readmission; however, little evidence exists on long-term outcomes. We set out to investigate the long-term (6 and 12 months) survival of ESRD patients admitted to the ICU and whether differential survival could be explained by dialysis modality and vascular access.nnnMETHODSnWe compared the admission characteristics, outcomes and readmission rates of 619 ESRD [95 peritoneal dialysis (PD), 334 hemodialysis with a catheter (HD CVC), 190 hemodialysis with an AV fistula (HD AVF)] patients admitted to 11 ICUs in Winnipeg, Manitoba, Canada. Parametric and nonparametric tests were used as appropriate to determine differences in baseline characteristics. Multivariable Cox and logistic regression was used to assess outcomes between the groups.nnnRESULTSnThe 6- and 12-month crude survival was 62 and 52%, respectively. In a univariate model, modality and vascular access were associated with an increased hazard ratio (HR) of death [PD HR 1.60 95% confidence interval (CI) 1.20-2.13, HD CVC HR 1.55 95% CI 1.25-1.93] compared to patients on HD with an AVF. In three different multivariate adjusted models, this association persisted with HRs for death of 1.63-1.75 for PD and 1.50-1.58 for HD CVC.nnnCONCLUSIONSnOverall long-term survival of ESRD patients after admission to the ICU is poor. Being on PD or being dialyzed with a catheter was independently associated with an increased mortality.

The Role of Functional Status in Discharge to Assisted Care Facilities and In-Hospital Death Among Dialysis Patients

BACKGROUNDnFunctional status is an important component in the assessment of hospitalized patients. We set out to determine the scope, severity, and prognostic significance of impaired functional status in acutely hospitalized dialysis patients.nnnSTUDY DESIGNnRetrospective cohort study.nnnSETTING & PARTICIPANTSn1,286 hospitalized dialysis patients admitted and discharged from 1 of 11 area hospitals in Manitoba, Canada, from September 2003 to September 2010 with an activity of daily living (ADL) assessment within 24 hours of admission.nnnPREDICTORnThe 12-point ADL score assesses 6 domains (bathing, toileting, dressing, incontinence, feeding, and transferring) and scores them as independent or supervision only (score, 0), partial assistance (1), and full assistance (2). Thus, higher score indicates worse functional status. Parametric and nonparametric tests were used as appropriate to determine differences in baseline characteristics.nnnOUTCOMESnMultivariable logistic regression and Cox proportional hazards assessed the association between functional status, in-hospital death, and discharge to an assisted care facility.nnnRESULTSnDuring the study period, 250 (19.4%) and 72 (5.6%) patients experienced the outcomes of in-hospital death or discharge to an assisted care facility. Abnormalities in functional status were present in >70% of the cohort. ADL score within 24 hours of admission combined with age differentiated risks of death and discharge to an assisted care facility home, ranging from 4.8%-46.6% and 0.6%-17.8%, respectively. After adjustment, ORs of death and discharge to an assisted care facility were 1.16 (95% CI, 1.11-1.22; P < 0.001; C statistic = 0.79) and 1.25 (95% CI, 1.14-1.36; P < 0.001; C statistic = 0.91) per 1-point increase in ADL score, respectively. Findings were consistent after accounting for the competing outcomes of in-hospital death or discharge to an assisted care facility versus discharge to home.nnnLIMITATIONSnA 1-time measurement of ADLs could not differentiate temporary from long-term deterioration in functional status.nnnCONCLUSIONSnImpaired functional status is common at the time of admission in the dialysis population. A single ADL score measurement at admission combined with age is highly predictive of poor outcomes in the hospitalized dialysis population.

End-stage renal disease status and critical illness in the elderly.

BACKGROUND AND OBJECTIVESnElderly patients (> 65 years old) are a rapidly growing demographic in the ESRD and intensive care unit (ICU) populations, yet the effect of ESRD status on critical illness in elderly patients remains unknown. Reliable estimates of prognosis would help to inform care and management of this frail and vulnerable population.nnnDESIGN, SETTING, PARTICIPANTS, & MEASUREMENTSnThe effect of ESRD status on survival and readmission rates was examined in a retrospective cohort of 14,650 elderly patients (>65 years old) admitted to 11 ICUs in Winnipeg, Manitoba, Canada between 2000 and 2006. Logistic regression models were used to adjust odds of mortality and readmission to ICU for baseline case mix and illness severity.nnnRESULTSnElderly ESRD patients had twofold higher crude in-hospital mortality (22% versus 13%, P < 0.0001) and readmission rate (6.4 versus 2.7%, P = 0.001). After adjustment for illness severity alone or illness severity and case mix, the odds ratio for mortality decreased to 0.85 (95% CI: 0.57 to 1.25) and 0.82 (95% CI: 0.55 to 1.23), respectively. In contrast, ESRD status remained significantly associated with readmission to ICU after adjustment for other risk factors (OR 2.06 [95% CI: 1.32, 3.22]).nnnCONCLUSIONSnIllness severity on admission, rather than ESRD status per se, appears to be the main driver of in-hospital mortality in elderly patients. However, ESRD status is an independent risk factor for early and late readmission, suggesting that this population might benefit from alternative strategies for ICU discharge.

HIGH RATES OF MORTALITY AND TECHNIQUE FAILURE IN PERITONEAL DIALYSIS PATIENTS AFTER CRITICAL ILLNESS

♦ Introduction: Little is known regarding the causes and outcomes of peritoneal dialysis (PD) patients admitted to the intensive care unit (ICU). We explored the outcomes of technique failure and mortality in a cohort of PD patients admitted to the ICU. ♦ Methods: Using a provincial database of 990 incident PD patients followed from January 1997 to June 2009, we identified 90 (9%) who were admitted to the ICU. Parametric and nonparametric tests were used as appropriate to determine differences in baseline characteristics. The Cox proportional hazards and competing risk methods were used to investigate associations. ♦ Results: Compared with other patients, those admitted to the ICU had been on PD longer (p < 0.0001) and were more often on continuous ambulatory PD (74.2% vs 25.8%, p = 0.016). Cardiac problems were the most common admitting diagnosis (50%), followed by sepsis (23%), with peritonitis accounting for 69% of the sepsis admissions. The 1-year mortality was 53.3%, with 12% alive and converted to hemodialysis, and one third remaining alive on PD. In multivariate Cox modeling, age [hazard ratio (HR): 1.01; 95% confidence interval (CI): 0.99 to 1.03], white blood cell count (HR: 1.02; 95% CI: 1.00 to 1.04), temperature (HR: 0.75; 95% CI: 0.61 to 0.92), and peritonitis (1.64; 95% CI: 1.21 to 2.22) at admission to the ICU were associated with the composite outcome of technique failure or death. In a competing risk analysis, the risk for death was 30%, and for technique failure, 36% at 1 year. ♦ Conclusions: Patients on PD have high rates of death and technique failure after admission to the ICU.