Graeme J. Duke

Renal support in critically ill patients: low-dose dopamine or low-dose dobutamine?

Objective: Low‐dose dopamine has been used in critically ill patients to minimize renal dysfunction without sufficient data to support its use. The aim of this study was to determine whether low‐dose dopamine improves renal function, and whether dobutamine, a nondopaminergic inotrope, improves renal function. Design: Prospective, randomized, double‐blind trial. Patients: Twenty‐three patients at risk for renal dysfunction were entered into the study. Five patients were later withdrawn. Study data for the remaining 18 patients were: mean age 55 yrs; mean Acute Physiology and Chronic Health Evaluation (APACHE) II score of 18; mean weight 71 kg). The following conditions were present: mechanical ventilation (n = 17 [inverse‐ratio ventilation, n = 6]); inotrope administration (n = 11); sepsis (n = 13); and adult respiratory distress syndrome or multiple organ failure syndrome (n = 9). Interventions: The study patients were administered dopamine (200 &mgr;g/min), dobutamine (175 &mgr;g/min), and placebo (5% dextrose) over 5 hrs each in a randomized order. Ventilator settings, fluid management, and preexisting inotropic support were not altered during the study. Measurements and Main Results: Systemic hemodynamic values and indices of renal function (4‐hr urine volume, fractional excretion of sodium, and creatinine clearance) were measured during the last 4 hrs of each infusion. Dopamine produced a diuresis (145 ± 148 mL/ hr) compared with placebo (90 ± 44 mL/hr; p < .01) without a change in creatinine clearance. Conversely, dobutamine caused a significant increase in creatinine clearance (97 ± 54 mL/ min) compared with placebo (79 ± 38 mL/min; p < .01), without an increase in urine output. Conclusions: In stable critically ill patients, dopamine acted primarily as a diuretic and did not improve creatinine clearance. Dobutamine improved creatinine clearance without a significant change in urine output. (Crit Care Med 1994; 22:1919–1925)

The role of the medical emergency team in end-of-life care : a multicenter, prospective, observational study

Objective:To investigate the role of medical emergency teams in end-of-life care planning. Design:One month prospective audit of medical emergency team calls. Setting:Seven university-affiliated hospitals in Australia, Canada, and Sweden. Patients:Five hundred eighteen patients who received a medical emergency team call over 1 month. Interventions:None. Measurements and Main Results:There were 652 medical emergency team calls in 518 patients, with multiple calls in 99 (19.1%) patients. There were 161 (31.1%) patients with limitations of medical therapy during the study period. The limitation of medical therapy was instituted in 105 (20.3%) and 56 (10.8%) patients before and after the medical emergency team call, respectively. In 78 patients who died with a limitation of medical therapy in place, the last medical emergency team review was on the day of death in 29.5% of patients, and within 2 days in another 28.2%.Compared with patients who did not have a limitation of medical therapy, those with a limitation of medical therapy were older (80 vs. 66 yrs; p < .001), less likely to be male (44.1% vs. 55.7%; p = .014), more likely to be medical admissions (70.8% vs. 51.3%; p < .001), and less likely to be admitted from home (74.5% vs. 92.2%, p < .001). In addition, those with a limitation of medical therapy were less likely to be discharged home (22.4% vs. 63.6%; p < .001) and more likely to die in hospital (48.4% vs. 12.3%; p < .001). There was a trend for increased likelihood of calls associated with limitations of medical therapy to occur out of hours (51.0% vs. 43.8%, p = .089). Conclusions:Issues around end-of-life care and limitations of medical therapy arose in approximately one-third of calls, suggesting a mismatch between patient needs for end-of-life care and resources at participating hospitals. These calls frequently occur in elderly medical patients and out of hours. Many such patients do not return home, and half die in hospital. There is a need for improved advanced care planning in our hospitals, and to confirm our findings in other organizations.

The Timing of Discharge from the Intensive Care Unit and Subsequent Mortality. A Prospective, Multicenter Study

RATIONALE Previous studies suggested an association between after-hours intensive care unit (ICU) discharge and increased hospital mortality. Their retrospective design and lack of correction for patient factors present at the time of discharge make this association problematic. OBJECTIVES To determine factors independently associated with mortality after ICU discharge. METHODS This was a prospective, multicenter, binational observational study involving 40 ICUs in Australia and New Zealand. Participants were consecutive adult patients discharged alive from the ICU between September 2009 and February 2010. MEASUREMENTS AND MAIN RESULTS We studied 10,211 patients discharged alive from the ICU. Median age was 63 years (interquartile range, 49-74), 6,224 (61%) were male, 5,707 (56%) required mechanical ventilation, and their median Acute Physiology and Chronic Health Evaluation III risk of death was 9% (interquartile range, 3-25%). A total of 8,539 (83.6%) patients were discharged in-hours (06:00-18:00) and 1,672 (16.4%) after-hours (18:00-06:00). Of these, 408 (4.8%) and 124 (7.4%), respectively, subsequently died in hospital (P < 0.001). After risk adjustment for markers of illness severity at time of ICU discharge including limitations of medical therapy (LOMT) orders, the time of discharge was no longer a significant predictor of mortality. The presence of a LOMT order was the strongest predictor of death (odds ratio, 35.4; 95% confidence interval, 27.5-45.6). CONCLUSIONS In this large, prospective, multicenter, binational observational study, we found that patient status at ICU discharge, particularly the presence of LOMT orders, was the chief predictor of hospital survival. In contrast to previous studies, the timing of discharge did not have an independent association with mortality.

Is ED length of stay before ICU admission related to patient mortality

Objective:  To describe and identify the relationship between ED length of stay (LOS) and mortality after ICU admission.

Validation of the hospital outcome prediction equation (HOPE) model for monitoring clinical performance

Background: The aim of this study was to validate a risk‐adjusted hospital outcome prediction equation (HOPE) using a statewide administrative dataset.

Outcomes of older people receiving intensive care in Victoria.

Objective: To assess trends in service use and outcome of critically ill older people (aged ≥ 65 years) admitted to an intensive care unit (ICU).

Readmissions to Intensive Care: A Prospective Multicenter Study in Australia and New Zealand*

Objectives: To determine factors independently associated with readmission to ICU and the independent association of readmission with subsequent mortality. Design: Prospective multicenter observational study. Setting: Forty ICUs in Australia and New Zealand. Patients: Consecutive adult patients discharged alive from ICU to hospital wards between September 2009 and February 2010. Interventions: Measurement of hospital mortality. Measurements and Main Results: We studied 10,210 patients and 674 readmissions. The median age was 63 years (interquartile range, 49–74), and 6,224 (61%) were male. The majority of readmissions were unplanned (84.1%) but only deemed preventable in a minority (8.9%) of cases. Time to first readmission was shorter for unplanned than planned readmission (3.2 vs 6.9 d; p < 0.001). Primary diagnosis changed between admission and readmission in the majority of patients (60.2%) irrespective of planned (58.2%) or unplanned (60.6%) status. Using recurrent event analysis incorporating patient frailty, we found no association between readmissions and hospital survival (hazard ratios: first readmission 0.88, second readmission 0.90, third readmission 0.44; p > 0.05). In contrast, age (hazard ratio, 1.03), a medical diagnosis (hazard ratio, 1.43), inotrope use (hazard ratio, 3.47), and treatment limitation order (hazard ratio, 17.8) were all independently associated with outcome. Conclusions: In this large prospective study, readmission to ICU was not an independent risk factor for mortality.