Gabriel M. Gurman

Survival of critically ill patients hospitalized in and out of intensive care units under paucity of intensive care unit beds

Objective:The demand for intensive care beds far exceeds their availability in many European countries. Consequently, many critically ill patients occupy hospital beds outside intensive care units, throughout the hospital. The outcome of patients who fit intensive care unit admission criteria but are hospitalized in regular wards needs to be assessed for policy implications. The object was to screen entire hospital patient populations for critically ill patients and compare their 30-day survival in and out of the intensive care unit. Design:Screening teams visited every hospital ward on four selected days in five acute care Israeli hospitals. The teams listed all patients fitting a priori developed study criteria. One-month data for each patient were abstracted from the medical records. Setting:Five acute care Israeli hospitals. Patients:All patients fitting a priori developed study criteria. Interventions:None. Measurements and Main Results:Survival in and out of the intensive care unit was compared for screened patients from the day a patient first met study criteria. Cox multivariate models were constructed to adjust survival comparisons for various confounding factors. The effect of intensive care unit vs. other departments was estimated separately for the first 3 days after deterioration and for the remaining follow-up time. Results showed that 5.5% of adult hospitalized patients were critically ill (736 of 13,415). Of these, 27% were admitted to intensive care units, 24% to specialized care units, and 49% to regular departments. Admission to an intensive care unit was associated with better survival during the first 3 days of deterioration, after we adjusted for age and severity of illness (p = .018). There was no additional survival advantage for intensive care unit patients (p = .9) during the remaining follow-up time. Conclusions:The early survival advantage in the intensive care unit suggests a window of critical opportunity for these patients. Under economic constraints and dearth of intensive care unit beds, increasing the turnover of patients in the intensive care unit, thus exposing more needy patients to the early benefit of treatment in the intensive care unit, may be advantageous.

Ketamine Attenuates the Interleukin-6 Response After Cardiopulmonary Bypass

Cardiopulmonary bypass (CPB) has been proposed as a model for studying the inflammatory cascade associated with the systemic inflammatory response syndrome.Serum interleukin-6 (IL-6) concentration seems to be a good indicator of activation of the inflammatory cascade and predictor of subsequent organ dysfunction and death. Prolonged increases of circulating IL-6 are associated with morbidity and mortality after cardiac operations. In the present study, we compared the effects of adding ketamine 0.25 mg/kg to general anesthesia on serum IL-6 levels during and after elective coronary artery bypass grafting (CABG). Thirty-one patients undergoing elective CABG were randomized to one of two groups and prospectively studied in a double-blind manner. The patients received either ketamine 0.25 mg/kg or a similar volume of isotonic sodium chloride solution in addition to large-dose fentanyl anesthesia. Blood samples for analysis of serum IL-6 levels were drawn before the operation; after CPB; 4, 24, and 48 h after surgery; and daily for 6 days beginning the third day postoperatively. Ketamine suppressed the serum IL-6 response immediately after CPB and 4, 24, and 48 h postoperatively (P < 0.05). During the first 7 days after surgery, the serum IL-6 levels in the ketamine group were significantly lower than those in the control group (P < 0.05). On Day 8 after surgery, IL-6 levels were no different from baseline values in both groups. A single dose of ketamine 0.25 mg/kg administered before CPB suppresses the increase of serum IL-6 during and after CABG. Implications: In this randomized, double-blind, prospective study of patients during and after coronary artery bypass surgery, we examined whether small-dose ketamine added to general anesthesia before cardiopulmonary bypass suppresses the increase of the serum interleukin-6 (IL-6) concentration. Serum IL-6 levels correlate with the patients clinical course during and after coronary artery bypass. Ketamine suppresses the increase of serum IL-6 during and after coronary artery bypass surgery. (Anesth Analg 1998;87:266-71)

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)

Insertion of the endotracheal tube, laryngeal mask airway and oesophageal–tracheal Combitube ® . A 6-month comparative prospective study of acquisition and retention skills by medical students

Objective: To assess the ability of medical students to learn and retain skills of airway manipulation for insertion of the endotracheal tube, the laryngeal mask airway (Laryngeal Mask Company, Henley‐on‐Thames, UK) and the oesophageal‐tracheal Combitube® (Kendall‐Sheridan Catheter Corp., Argyle, NY, USA). Methods: A 6‐month prospective study was conducted among fifth‐year medical students attending a 3‐week clerkship in the Division of Anesthesiology and Critical Care Medicine in the Soroka Medical Center. All the students viewed a demonstration of insertion technique for the endotracheal tube, the laryngeal mask airway and the Combitube®, followed by formal teaching in a mannikin. At the end of the program, the insertion skills were demonstrated in the mannikin, the success rate on the first attempt was registered and the students were requested to assess (by questionnaire) their ability to execute airway manipulation (phase 1). Six months later, the students were requested to repeat the insertion technique, and a similar re‐evaluation applied (phase 2). Results: The success rate, during the first phase, at first attempts was 100% for the laryngeal mask airway and the Combitube®, compared to 57.4% for the endotracheal tube (P < 0.02), and 92.6%, 96.2% and 62.9% (P < 0.02) respectively for the second phase of the study. Conclusion: Learning and retention skills of medical students, in a mannikin, are more accentuated with the laryngeal mask airway and the Combitube® than seen with an endotracheal tube.

A history of neuraxial administration of local analgesics and opioids.

The history of intrathecal and epidural anaesthesia is in parallel with the development of general anaesthesia. As ether anaesthesia (1846) is considered the first modern anaesthetic since its use by Morton 157 yr ago, so Bier made history by using cocaine for intrathecal anaesthesia in 1898. The first published report on opioids for intrathecal anaesthesia belongs to a Romanian surgeon, Racoviceanu-Pitesti, who presented his experience at Paris in 1901. It was almost a century before the opioids were used for epidural analgesia. Behar and his colleagues published the first report on the epidural use of morphine for the treatment of pain in The Lancet in 1979. Epidural and intrathecal opioids are today part of a routine regimen for intra- and postoperative analgesia. Over the last 30 yr, the use of epidural opioids has became a standard for analgesia in labour and delivery, and for the management of chronic pain. Finally, epidural opioids have been shown to have a pre-emptive effect, when used before major surgery. We present the evolution of neuraxial anaesthesia and the history of intrathecal and epidural administration of opioids.

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

Cannulation of big arteries in critically ill patients.

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

Predictors of recommendation and acceptance of intrapartum epidural analgesia.

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

The anaesthetic management of patients with congenital insensitivity to pain with anhidrosis

60,046 (€47,656) and