H. Michael Marsh

Prevention of Infection in Critically Ill Patients by Selective Decontamination of the Digestive Tract

OBJECTIVE To determine whether selective decontamination of the digestive tract using oral and nonabsorbable antimicrobial agents and parenteral cefotaxime prevents infection in critically ill patients. DESIGN Randomized, controlled trial without blinding. SETTING Surgical trauma and medical intensive care units in a tertiary referral hospital. PATIENTS One hundred fifty patients admitted to surgical trauma and medical intensive care units during a 3-year interval, whose condition suggested a prolonged stay (greater than 3 days). INTERVENTION Patients were randomly allocated to an experimental group (n = 75) that received cefotaxime, 1 g intravenously every 8 hours for the first 3 days only, and oral, nonabsorbable antibiotics (gentamicin, polymyxin, and nystatin by oral paste and oral liquid) for the entire stay in the intensive care unit. Control patients (n = 75) received usual care. MEASUREMENTS The number of infections, total hospital days, and deaths, as well as the number of days in intensive care unit, were recorded. RESULTS Control patients experienced more infections (36 compared with 12, P = 0.04), including bacteremias (14 compared with 4, P = 0.05) and pulmonary infections (14 compared with 4, P = 0.03). Although total hospital days, days in intensive care, and the overall death rate all were lower in the treatment group, these differences were not statistically significant. Clinically important complications of selective decontamination of the digestive tract were not encountered. CONCLUSIONS Selective decontamination of the digestive tract decreases subsequent infection rates, especially by gram-negative bacilli, in selected patients during long-term stays in the intensive care unit.

Fundamental considerations in pacing of the diaphragm for chronic ventilatory insufficiency: A multi-center study

Records were reviewed of 477 patients who had diaphragm pacemakers implanted for treatment of chronic hypoventilation. Three groups were established for comparison. (1) Center group: 165 patients operated on in six medical centers participating in a cooperative study; (2) Noncenter group, sufficient data available: 203 patients operated on by surgeons with experience limited to a few cases; (3) Nonstudy group, minimal data available: 109 patients operated on as in group 2; vital statistics only were contributed. The protocol for data gathering was comprised of 154 major variables. Basic data on age, sex, diagnosis and etiology were analyzed for homogenicity of data among the groups. A comprehensive analysis of the pacing methods, complication and results fom the Center group yielded information on the early experience with diaphragm pacing important to its future application.

Assessment of Prediction of Mortality by Using the APACHE II Scoring System in Intensive-Care Units

Some investigators have suggested that information on quality of care in intensive-care units (ICUs) may be inferred from mortality rates. Specifically, the ratio of actual to predicted hospital mortality (A/P) has been proposed as a valid measure for comparing ICU outcomes when predicted mortality has been derived from data collected during the first 24 hours of ICU therapy with use of a severity scoring tool, APACHE II (acute physiology and chronic health evaluation). We present a comparison of mortality ratios (A/P) in four ICUs under common management, in two hospitals within a single institution. Significant differences in A/P were detected for nonoperative patients (0.99 versus 0.67;P = 0.014) between the two hospitals. This variation was traced to uneven representation of a subset of patients who had chronic health problems related to diseases that necessitated admission to the hematology-oncology or hepatology service. No differences in A/P were seen between the two hospitals for operative patients or for nonoperative patients on services other than hematology-oncology or hepatology. Thus, differences in A/P detected by using the APACHE II system not only may reside in operational factors within the ICU organization but also may be related to weaknesses in the APACHE II model to measure factors intrinsic to the disease process in some patients. We suggest that case-mix must be examined in detail before concluding that differences in A/P are caused by differences in quality of care.