Johannes H. Rommes

The prognostic value of blood lactate levels relative to that of vital signs in the pre-hospital setting: a pilot study.

IntroductionA limitation of pre-hospital monitoring is that vital signs often do not change until a patient is in a critical stage. Blood lactate levels are suggested as a more sensitive parameter to evaluate a patients condition. The aim of this pilot study was to find presumptive evidence for a relation between pre-hospital lactate levels and in-hospital mortality, corrected for vital sign abnormalities.MethodsIn this prospective observational study (n = 124), patients who required urgent ambulance dispatching and had a systolic blood pressure below 100 mmHg, a respiratory rate less than 10 or more than 29 breaths/minute, or a Glasgow Coma Scale (GCS) below 14 were enrolled. Nurses from Emergency Medical Services measured capillary or venous lactate levels using a hand-held device on arrival at the scene (T1) and just before or on arrival at the emergency department (T2). The primary outcome measured was in-hospital mortality.ResultsThe average (standard deviation) time from T1 to T2 was 27 (10) minutes. Non-survivors (n = 32, 26%) had significantly higher lactate levels than survivors at T1 (5.3 vs 3.7 mmol/L) and at T2 (5.4 vs 3.2 mmol/L). Mortality was significantly higher in patients with lactate levels of 3.5 mmol/L or higher compared with those with lactate levels below 3.5 mmol/L (T1: 41 vs 12% and T2: 47 vs 15%). Also in the absence of hypotension, mortality was higher in those with higher lactate levels. In a multivariable Cox proportional hazard analysis including systolic blood pressure, heart rate, GCS (all at T1) and delta lactate level (from T1 to T2), only delta lactate level (hazard ratio (HR) = 0.20, 95% confidence interval (CI) = 0.05 to 0.76, p = 0.018) and GCS (HR = 0.93, 95% CI = 0.88 to 0.99, p = 0.022) were significant independent predictors of in-hospital mortality.ConclusionsIn a cohort of patients that required urgent ambulance dispatching, pre-hospital blood lactate levels were associated with in-hospital mortality and provided prognostic information superior to that provided by the patients vital signs. There is potential for early detection of occult shock and pre-hospital resuscitation guided by lactate measurement. However, external validation is required before widespread implementation of lactate measurement in the out-of-hospital setting.

The Impact of Severe Sepsis on Health-Related Quality of Life: A Long-Term Follow-Up Study

BACKGROUND:Severe sepsis is frequently complicated by organ failure and accompanied by high mortality. Patients surviving severe sepsis can have impaired health-related quality of life (HRQOL). The time course of changes in HRQOL in severe sepsis survivors after discharge from the intensive care unit (ICU) and during a general ward stay have not been studied. METHODS:We performed a long-term prospective study in a medical-surgical ICU. Patients with severe sepsis (n = 170) admitted for >48 h were included in the study. We used the Short-form 36 to evaluate the HRQOL of severe sepsis patients before ICU and hospital stay and at 3 and 6 mo after ICU discharge. Furthermore, we compared the results for ICU admission and 6 mo after ICU discharge with those of an age-matched general Dutch population. RESULTS:At 6 mo after ICU discharge, 95 patients could be evaluated (eight patients were lost to follow-up, 67 died). HRQOL showed a multidimensional decline during the ICU stay and gradual improvement over the 6 mo after ICU discharge for the social functioning, vitality, role-emotional, and mental health dimensions. However, 6 mo after ICU discharge, scores for the physical functioning, role-physical, and general health dimensions were still significantly lower than preadmission values. Physical and Mental Component Scores changed significantly over time. In particular, the Mental Component Score showed a small decline at ICU discharge but recovered rapidly, and at 6 mo after ICU discharge had improved to near normal values. In addition, Short-form 36 scores were lower than those in a matched general population in six of the eight dimensions, with the exception of social functioning and bodily pain. Interestingly, the preadmission HRQOL in surviving patients was already lower in three of the eight dimensions (role-physical, mental health, and vitality) when compared with the general population. CONCLUSIONS:Severe sepsis patients demonstrate a sharp decline of HRQOL during ICU stay and a gradual improvement during the 6 mo after ICU discharge. Recovery begins after ICU discharge to the general ward. Nevertheless, recovery is incomplete in the physical functioning, role-physical, and general health dimensions at 6 mo after ICU discharge compared with preadmission status.

Limitations and practicalities of CAM-ICU implementation, a delirium scoring system, in a Dutch intensive care unit.

BACKGROUND Delirium is a frequently missed diagnosis in the intensive care unit (ICU). Implementation of the Confusion Assessment Method for the ICU (CAM-ICU) may improve recognition of delirium. However, the ICU team may be reluctant to adopt daily assessment by a screening tool. This report focusses on the obstacles and barriers encountered with respect to organisational context and prevailing opinions and attitudes when implementing the CAM-ICU in daily practice in a Dutch ICU. METHODS A structured implementation process was set up comprising four phases: (1) assessing the current situation to understand behaviour towards delirium; (2) the identification of barriers to the implementation of the CAM-ICU; (3) preparation of the ICU team for a change in attitude; and (4) evaluation of the effects of implementation. RESULTS Phase 1 demonstrated that there was no delirium protocol available; it was left to the attending physicians when and how to diagnose delirium in each individual patient. In addition, nurses acted on delirium in a non-structured way; nurses thought implementation of the CAM-ICU would be very time-consuming and would not add to their ability in recognising delirium. In Phase 2, several barriers to implementation were addressed. Firstly, all nurses had to be convinced that delirium is an important problem and, secondly, logistics had to be put in place, for example, picture cards at every bedside, communication between daily nurses and a delirium working group had to be improved. In Phase 3, 10 nurses were educated to perform the CAM-ICU through several training sessions which included videos to illustrate different delirium states; these trained nurses educated all other nurses. A check box in the daily records was introduced to denote whether the CAM-ICU had been performed. In Phase 4, after a training period and 2 months of actual routine bedside CAM-ICU performance, evaluation demonstrated that frequency of assessments on un-sedated patients had increased from 38% to 95% per nursing shift. A short survey amongst the ICU nurses also showed that awareness of delirium and appreciation of the clinical problem had markedly increased. CONCLUSION Implementation of the CAM-ICU in daily critical care is feasible. A structural training programme is probably helpful for success of implementation.

Prognostic Value of Blood Lactate Levels : Does the Clinical Diagnosis at Admission Matter?

BACKGROUND Hyperlactatemia and its reduction after admission in the intensive care unit (ICU) have been related to survival. Because it is unknown whether this equally applies to different groups of critically ill patients, we compared the prognostic value of repeated lactate levels (a) in septic patients versus patients with hemorrhage or other conditions generally associated with low-oxygen transport (LT) (b) in hemodynamically stable versus unstable patients. METHODS In this prospective observational two-center study (n = 394 patients), blood lactate levels at admission to the ICU (Lac(T0)) and the reduction of lactate levels from T = 0 to T = 12 hours (DeltaLac(T0-12)) and from T = 12 to T = 24 hours (DeltaLac(T12-24)), were related to in-hospital mortality. RESULTS Reduction of lactate was associated with a lower mortality only in the sepsis group (DeltaLac(T0-12): hazard ratio [HR] 0.34, p = 0.004 and DeltaLac(T12-24): HR 0.24, p = 0.003), but not in the LT group (DeltaLac(T0-12); HR 0.78, p = 0.52 and DeltaLac(T12-24); HR 1.30, p = 0.61). The prognostic values of Lac(T0), DeltaLac(T0-12), and DeltaLac(T12-24) were similar in hemodynamically stable and unstable patients (p = 0.43). CONCLUSIONS Regardless of the hemodynamic status, lactate reduction during the first 24 hours of ICU stay is associated with improved outcome only in septic patients, but not in patients with hemorrhage or other conditions generally associated with LT. We hypothesize that in this particular group a reduction in lactate is not associated with improved outcome due to irreversible damage at ICU admission.

Off hour admission to an intensivist-led ICU is not associated with increased mortality.

IntroductionCaring for the critically ill is a 24-hour-a-day responsibility, but not all resources and staff are available during off hours. We evaluated whether intensive care unit (ICU) admission during off hours affects hospital mortality.MethodsThis retrospective multicentre cohort study was carried out in three non-academic teaching hospitals in the Netherlands. All consecutive patients admitted to the three ICUs between 2004 and 2007 were included in the study, except for patients who did not fulfil APACHE II criteria (readmissions, burns, cardiac surgery, younger than 16 years, length of stay less than 8 hours). Data were collected prospectively in the ICU databases. Hospital mortality was the primary endpoint of the study. Off hours was defined as the interval between 10 pm and 8 am during weekdays and between 6 pm and 9 am during weekends. Intensivists, with no responsibilities outside the ICU, were present in the ICU during daytime and available for either consultation or assistance on site during off hours. Residents were available 24 hours a day 7 days a week in two and fellows in one of the ICUs.ResultsA total of 6725 patients were included in the study, 4553 (67.7%) admitted during daytime and 2172 (32.3%) admitted during off hours. Baseline characteristics of patients admitted during daytime were significantly different from those of patients admitted during off hours. Hospital mortality was 767 (16.8%) in patients admitted during daytime and 469 (21.6%) in patients admitted during off hours (P < 0.001, unadjusted odds ratio 1.36, 95%CI 1.20–1.55). Standardized mortality ratios were similar for patients admitted during off hours and patients admitted during daytime. In a logistic regression model APACHE II expected mortality, age and admission type were all significant confounders but off-hours admission was not significantly associated with a higher mortality (P = 0.121, adjusted odds ratio 1.125, 95%CI 0.969–1.306).ConclusionsThe increased mortality after ICU admission during off hours is explained by a higher illness severity in patients admitted during off hours.

Lactate measurements in critically ill patients with a hand-held analyser

Objective: To compare a recently introduced hand-held lactate analyser to a reference point of care analyser (POCI) and the hospital laboratory in a critical care setting. Setting: 10-bed surgical/medical intensive care unit in a teaching hospital. Patients and methods: In 39 critically ill patients, 50 convenience measurement cycles consisting of three paired measurements at 30-min intervals were carried out with a hand-held analyser, reference POCI and hospital laboratory using arterial blood samples. Duplicate measurements with the hand-held analyser were done in 129 blood samples. Results: Lactate levels ranged from 1.1 to 21.0 mmol/l. Regression analysis of the hand-held analyser and laboratory showed a slope of 1.01, bias of –0.38 mmol/l, R2 = 0.97 and mean error of 14.9 %. Reference POCI versus laboratory: slope = 1.07, bias = –0.29 mmol/l, R2 = 0.98 and mean error of 6.4 %. Hand-held analyser versus reference POCI: slope = 0.90, bias = 0.09 mmol/l and R2 = 0.92. The hand-held analyser showed acceptable precision. Conclusion: The hand-held lactate analyser can reliably measure arterial blood lactate levels in critically ill patients.

The practice of and documentation on withholding and withdrawing life support: a retrospective study in two Dutch intensive care units.

OBJECTIVE:We determined how often life support was withheld or withdrawn in patients who died in the intensive care unit (ICU) or early after ICU discharge and evaluated documentation on decisions regarding these changes in life support orders. METHODS:This was a retrospective study in a university hospital and a general teaching hospital. Charts of patients who died during ICU stay or within 7 days after ICU discharge in 2005 were reviewed. RESULTS:Of 2578 admitted patients, 356 patients (14%) died either in the ICU or within 7 days after ICU discharge. For 9 patients data were missing, leaving 347 patients for analysis. Seventy-seven patients (22%) died with full life support, 85 (25%) died while treatment was being withheld, and 185 (53%) patients died while treatment was being withdrawn. One or more changes in life support orders were noted in 266 patients (77%). Only 8% of the patients were recorded to be incapacitated at the time of the change. Patients’ preferences regarding life support were documented in less than one-quarter of cases. In approximately one third of cases, it was not documented which member(s) of the ICU team were involved in an end-of-life decision. In the documented cases, end-of-life decisions were made along with the patient (7%) or with the patient’s representatives (59%). CONCLUSION:ICU nonsurvivors and patients who die shortly after ICU discharge predominantly die with orders to withhold or withdraw life support. Documentation on the decisions to forgo full life support is poor.

Health-related quality of life in critically ill patients: How to score and what is the clinical impact?

Purpose of reviewTraditionally, the assessment of critical care has focused largely on mortality. However, in the last few years, there is more attention on the quality of survival. Health-related quality of life (HRQOL) is an important issue for both patients and family. The purpose of this review is to describe HRQOL scoring in critically ill patients and to discuss the clinical impact on HRQOL. Recent findingsStudies on the effect of critical illness on HRQOL show contradicting results. Several studies found that HRQOL at the time of discharge from hospital was impaired and that a gradual improvement occurred during follow-up, in some cases to preadmission hospital levels. Others show a full recovery to preadmission HRQOL. SummaryIn this article, we reviewed the methods and description of measurement instruments used in critically ill patients. The most recently used instruments to measure HRQOL, how to score HRQOL before ICU admission and the impact of critical illness on HRQOL are discussed. Assessment of HRQOL can improve the answers given by critical care physicians and nurses about the prospects of their patients. To get insights in these issues regarding the impact of ICU treatment, we should incorporate not only short-term outcomes, for example length of stay and mortality, but also HRQOL.

Cardiac Arrest Following an Iatrogenic 3, 4-Diaminopyridine Intoxication in a Patient with Lambert-Eaton Myasthenic Syndrome

Syndromes with impaired neuromuscular transmission are frequently treated with pyridine derivates. 3,4-diaminopyridine is thought to have fewer side effects than the commonly used, but less potent, 4-aminopyridine. We describe a patient with an initially unrecognized iatrogenic intoxication with 3,4-diaminopyridine. Except for a life threatening arrhythmia, symptoms were similar to a 4-aminopyridine intoxication. The patient made a full recovery with symptomatic treatment and withdrawal of the drug.

The effect of acute kidney injury on long-term health-related quality of life : a prospective follow-up study

IntroductionAcute kidney injury (AKI) is a serious complication in critically ill patients admitted to the Intensive Care Unit (ICU). We hypothesized that ICU survivors with AKI would have a worse health-related quality of life (HRQOL) outcome than ICU survivors without AKI.MethodsWe performed a long-term prospective observational study. Patients admitted for > 48 hours in a medical-surgical ICU were included and divided in two groups: patients who fulfilled RIFLE criteria for AKI and patients without AKI. We used the Short-Form 36 to evaluate HRQOL before admission (by proxy within 48 hours after admission of the patient), at ICU discharge, hospital discharge, 3 and 6 months following ICU discharge (all by patients). Recovery in HRQOL from ICU-admission onwards was assessed using linear mixed modelling.ResultsBetween September 2000 and January 2007 all admissions were screened for study participation. We included a total of 749 patients. At six months after ICU discharge 73 patients with AKI and 325 patients without AKI could be evaluated. In survivors with and without AKI, the pre-admission HRQOL (by proxy) and at six months after ICU discharge was significantly lower compared with an age matched general population. Most SF-36 dimensions changed significantly over time from ICU discharge. Change over time of HRQOL between the different AKI Rifle classes (Risk, Injury, Failure) showed no significant differences. At ICU discharge, scores were lowest in the group with AKI compared with the group without AKI for the physical functioning, role-physical and general health dimensions. However, there were almost no differences in HRQOL between both groups at six months.ConclusionsThe pre-admission HRQOL (by proxy) of AKI survivors was significantly lower in two dimensions compared with the age matched general population. Six months after ICU discharge survivors with and without AKI showed an almost similar HRQOL. However, compared with the general population with a similar age, HRQOL was poorer in both groups.