Paolo Merlani

Continuous Positive Airway Pressure Versus Noninvasive Pressure Support Ventilation to Treat Atelectasis After Cardiac Surgery

Atelectasis is common after cardiac surgery and may result in impaired gas exchange. Continuous positive airway pressure (CPAP) is often used to prevent or treat postoperative atelectasis. We hypothesized that noninvasive pressure support ventilation (NIPSV) by increasing tidal volume could improve the evolution of atelectasis more than CPAP. One-hundred-fifty patients admitted to our surgical intensive care unit (SICU) with a Radiological Atelectasis Score ≥2 after cardiac surgery were randomly assigned to receive either CPAP or NIPSV four times a day for 30 min. Positive end-expiratory pressure was set at 5 cm H2O in both groups. In the NIPSV group, pressure support was set to provide a tidal volume of 8–10 mL/kg. At SICU discharge, we observed an improvement of the Radiological Atelectasis Score in 60% of the patients with NIPSV versus 40% of those receiving CPAP (P = 0.02). There was no difference in oxygenation (Pao2/fraction of inspired oxygen at SICU discharge: 280 ± 38 in the CPAP group versus 301 ± 40 in the NIPSV group), pulmonary function tests, or length of stay. Minor complications, such as gastric distensions, were similar in the two groups. NIPSV was superior to CPAP regarding the improvement of atelectasis based on radiological score but did not confer any additional clinical benefit, raising the question of its usefulness for altering outcome.

Quality improvement report: Linking guideline to regular feedback to increase appropriate requests for clinical tests: blood gas analysis in intensive care.

Abstract Problem: Need to decrease the number of requests for arterial blood gas analysis and increase their appropriateness to reduce the amount of blood drawn from patients, the time wasted by nurses, and the related cost. Design: Assessment of the impact of a multifaceted intervention aimed at changing requests for arterial blood gas analysis in a before and after study. Background and setting: Twenty bed surgical intensive care unit of a tertiary university affiliated hospital, receiving 1500 patients per year. Key measures for improvement: Number of tests per patient day, proportion of tests complying with current guideline, and safety indicators (mortality, incident rate, length of stay). Comparison of three 10 month periods corresponding to baseline, pilot (first version of the guideline), and consolidated (second version of the guideline) periods from March 1997 to August 1999. Strategies for change: Multifaceted intervention combining a new guideline developed by a multidisciplinary group, educational sessions, and monthly feedback about adherence to the guideline and use of blood gas analysis. Effects of change: Substantial decrease in the number of tests per patient day (from 8.2 to 4.8; P<0.0001), associated with increased adherence to the guideline (from 53% to 80%, P<0.0001). No significant variation of safety indicators. Lessons learnt: A multifaceted intervention can substantially decrease the number of requests for arterial blood gas analysis and increase their appropriateness without affecting patient safety.

Burnout in ICU caregivers: a multicenter study of factors associated to centers.

RATIONALE The stressful work environment of ICUs can lead to burnout. Burnout can impact on the welfare and performance of caregivers, and may lead them to resign their job. The shortage of ICU caregivers is becoming a real threat for health care leaders. OBJECTIVES To investigate the factors associated with burnout on a national level in order to determine potential important factors. METHODS Prospective, multicenter, observational survey of all caregivers from 74 of the 92 Swiss ICUs, measuring the prevalence of burnout among the caregivers and the pre-specified center-, patient- and caregiver-related factors influencing its prevalence. MEASUREMENTS AND MAIN RESULTS Out of the 4322 questionnaires distributed from March 2006 to April 2007, 3052 (71%) were returned, with a response rate of 72% by center, 69% from nurse-assistants, 73% from nurses and 69% from physicians. A high proportion of female nurses among the team was associated with a decreased individual risk of high burnout (OR 0.98, 95% CI:0.97-0.99 for every %). The caregiver-related factors associated with a high risk of burnout were being a nurse-assistant, being a male, having no children and being under 40 years old. CONCLUSIONS The findings of this study seem to open a new frontier concerning burnout in ICUs, highlighting the importance of team composition. Our results should be confirmed in a prospective multicenter, multinational study. Whether our results can be exported to other medical settings where team-working is pivotal remains to be investigated.

Low apolipoprotein A-I level at intensive care unit admission and systemic inflammatory response syndrome exacerbation

ObjectiveExamine whether a low serum level of apolipoprotein A-I at intensive care unit (ICU) admission is associated with a further increase of the number of systemic inflammatory response syndrome (SIRS) criteria. DesignProspective observational study. SettingA 20-bed, university-affiliated, surgical ICU. PatientsPatients admitted after major surgery, multiple trauma, or acute pancreatitis without septic shock. InterventionsWe defined as the SIRS Exacerb group patients who presented a further increase of the number of SIRS criteria during their ICU stay or, in the presence of four SIRS criteria at ICU admission, those who presented a further aggravation of organ failure. Other patients were attributed to the SIRS No Exacerb group. From day 1 to 6, we measured apolipoprotein A-I, high-density lipoprotein and total cholesterol, triglycerides, C-reactive protein, procalcitonin, serum amyloid A, interleukin 6, interleukin-1 receptor antagonist, albumin, and other nutrition-linked variables. We looked at laboratory values or factors present at ICU admission according to the two groups. Measurements and Main ResultsFrom 63 patients analyzed, 29 (46%) were assigned to the SIRS Exacerb group. Age, sex, and SAPS II and SIRS scores at ICU admission did not differ between the groups. Patients in the SIRS Exacerb group presented more often a septic event (5/29 vs. 0/34, p = .02), had a higher hospital mortality (6/29 vs. 0/34, p = .007), and had a longer ICU stay (p = .0023). At admission, inflammatory variables such as the C-reactive protein, serum amyloid A, interleukin 6, interleukin-1 receptor antagonist plasma levels, and other lipid or nutrition-linked variables were similar between the two groups. Apolipoprotein A-I levels were lower in the SIRS Exacerb group (median [interquartile range]: 68 [56–81] vs. 84 [69–94] mg/dL, p = .028). ConclusionA low serum level of apolipoprotein A-I at ICU admission is associated with an increase of the number of SIRS criteria during the ICU stay.

Long‐term outcome of elderly patients requiring intensive care admission for abdominal pathologies: survival and quality of life*

Background:  Medical developments have allowed the management of patients aged over 70 years with severe abdominal pathologies requiring intensive care unit (ICU) admission. These patients require enhanced life support and present a high ICU mortality. We investigated the outcome and quality of life (QOL) of elderly patients 2 years after their ICU stay for abdominal pathologies.

Delayed matrix metalloproteinase inhibition reduces intracerebral hemorrhage after embolic stroke in rats

Hemorrhagic transformation (HT) and brain edema are life-threatening complications of recombinant tissue plasminogen activator (rt-PA)-induced reperfusion after ischemic stroke. The risk of HT limits the therapeutic window for reperfusion to 3 h after stroke onset. Pre-treatment with matrix metalloproteinase (MMP) inhibitors reduces HT and cerebral edema in experimental stroke. However, whether a delayed therapeutic intervention would be beneficial is unknown. In this study, 215 male Sprague-Dawley rats were subjected to embolic stroke and 75 rats were included in the final analysis. The animals were treated with the MMP inhibitor p-aminobenzoyl-gly-pro-D-leu-D-ala-hydroxamate before or after 3 or 6 h of ischemia. Animals were monitored for reperfusion and received rt-PA 6 h after ischemia onset. The results at 24 h showed that MMP inhibition 3 h after ischemia significantly decreased the degree of brain edema (17% of hemispheric enlargement in the treated group versus 24% in controls, P=0.018), reduced the risk (OR=0.163; 95% CI: 0.029 to 0.953) and gravity (0.09 versus 0.19 mg of parenchymal hemoglobin, P=0.02) of intracerebral hemorrhage, and improved neurological outcome (20% of the treated animals had a slight deficit; all of the controls had a bad outcome, P<0.05). Delaying MMP inhibition to 6 h after ischemia restricted the beneficial role of the treatment to a reduction in the risk of parenchymal hemorrhage (OR=0.242; 95% CI: 0.060 to 0.989). Our results confirm the involvement of MMPs in HT and support the possibility of extending the therapeutic window for thrombolysis in stroke by administering a broad-spectrum MMP inhibitor after the onset of ischemia.

Point of care and central laboratory determinations of the aPTT are not interchangeable in surgical intensive care patients

PurposeThe objective of the study was to compare a bedside whole blood activated partial thromboplastin time (aPTT) performed by a point of care (POC) apparatus (CoaguCheck® Pro) in surgical intensive care (SIC) patients with a conventional aPTT obtained from the central laboratory.MethodsThe prospective concomitant measurements of the two aPTT were performed in 233 samples from 46 consecutive patients admitted after cardiovascular or major abdominal surgery.ResultsInter-operator, inter-instrument and inter-cartridge variability of the new device measured in three healthy volunteers and in nine patients in stable condition (controls) was low (F test: P=0.86). The agreement by Bland and Altman between POC and central laboratory aPTT (−20.2 ± 18.8 sec) was not satisfactory. The agreement between POC and central laboratory aPTT in patients after surgery was worst (−17 ±33.1 sec). Heparin treatment or timing of blood sampling after intensive care admission (< 48 hrvs > 48 hr) did not influence the agreement. The correlation between POC or central laboratory aPTT and anti-factor Xa activity was poor (r2 0.077 and 0.181 respectively). The test which correlated the best to heparin doses was anti-factor Xa activity (r2 0.714).ConclusionPOC aPTT and central laboratory aPTT showed a poor agreement in SIC patients admitted after surgery, although in healthy volunteers or in control patients, this agreement was better. The best test to monitor heparin treatment in this setting was anti-factor Xa activity.RésuméObjectifComparer le temps de céphaline activé (TCA) du sang total réalisé au chevet du malade (CDM), au moyen d’un CoaguCheck® Pro, avec le TCA traditionnel obtenu d’un laboratoire central, pour des patients aux soins intensifs chirurgicaux (SIC).MéthodeLes mesures prospectives concomitantes des deux TCA ont été faites pour 233 échantillons prélevés auprès de 46 patients successifs admis aux SIC après une opération cardiovasculaire ou abdominale majeure.RésultatsLa variabilité interopérateurs, interinstruments et interéprouvettes du nouvel appareil étudié auprès de trois volontaires en bonne santé et neuf patients de condition stable (témoins) a été faible (Test F: P = 0,86). Le test de concordance de Bland et Altman entre le TCA (− 20,2 ± 18,8 s) réalisé au CDM ou en laboratoire n’était pas satisfaisant. Ce même test réalisé chez des patients après l’opération a été pire (− 17 ± 33,1 sec). Le traitement à l’héparine ou la chronologie de l’échantillonnage prélevé après l’arrivée aux soins intensifs (< 48 h vs > 48 h) n’a pas eu d’effet sur la concordance. Il n’existait qu’une très faible corrélation entre le TCA fait au CDM ou en laboratoire et l’activité de l’antifacteur Xa (r2 0,077 et 0,181 respectivement). Le test le mieux corrélé aux doses d’héparine a été l’activité de l’antifacteur Xa (r2 0,714).ConclusionLe TCA fait au CDM et le TCA du laboratoire central n’ont affiché qu’une faible concordance chez des patients des SIC admis après l’intervention, même si cette concordance a été meilleure pour des patients témoins et des volontaires en bonne santé. Dans ces circonstances, le meilleur test pour suivre le traitement avec héparine a été l’activité de l’antifacteur Xa.

From the ICU to the ward: cross-checking of the physician’s transfer report by intensive care nurses

ObjectiveTo assess whether cross-checking of the physician ICU transfer report by ICU nurses may reduce transfer report errors.DesignProspective, observational study with random selection (according to patient registration code) of ICU transfer reports.SettingEight-bed multidisciplinary intensive care unit of a teaching hospital.Patients and participantsICU transfer reports of 123 patients were randomly selected at discharge from the ICU between November 2006 and February 2007.InterventionsPhysician ICU transfer reports were cross-checked by nurses using defined review criteria. Inter-rater agreement (between nurses and the head of ICU) was assessed by κ-values, and was excellent overall (0.9). All intercepted errors (100%) were consequently corrected by the interns.Measurements and resultsOut of 123 transfer reports, 76 (62%) were affected by at least one error. Among 305 intercepted errors, 247 were prescription errors (26% of all prescriptions), 45 involved proposed procedures, and 13 were deficient in updating diagnoses. Most of the errors (248/305, 81%) were classified as simple, 43 (14%) as serious, or 14 (5%) as critical. Thirty-five (28%) transfer reports were considered potentially harmful (i.e., affected by at least one critical/serious error). In a multivariate model, only the number of medications included in the transfer report was associated with the occurrence of at least one critical/serious error.ConclusionsErrors in ICU transfer reports are frequent and may be potentially harmful. ICU nurses may help to effectively and accurately intercept those inaccuracies, and therefore reduce the exportation of errors from the ICU to the ward.

Who should consent for research in adult intensive care? Preferences of patients and their relatives: a pilot study

Introduction: Research in intensive care is necessary for the continuing advancement of patient care. In research, informed consent is considered essential for patient protection. In intensive care, the modalities of informed consent are currently being debated by both lawyers and the medical community. The preferences of patients and their relatives regarding informed consent for research in intensive care have never been assessed. The aim of this study was to investigate these preferences. Methods: A pilot study conducted via a questionnaire mailed to patients and relatives who had experienced intensive care. Results: 52/400 patient–relative pairs completed the questionnaire fully. If the patient was imagined to be conscious, 75% of patients and 77% of relatives believed the patient should be the person who should consent. If the patient was imagined to be unconscious, 72% of patients and 67% of relatives thought that a relative should be asked to consent. The majority of responders thought that at least two persons should consent. Their answers were concordant in 61–80% of cases, depending on the question. Patients (25%) and relatives (30%) did not feel free in their decision to participate in a study. The majority of patients and relatives wanted to consent by writing, indifferently with or without a witness. Conclusion: Patients are willing to decide on their own participation in a study. If they lose their capacity to decide for themselves, in the great majority of cases, they would agree to delegate the decision to a relative.

The Short-term Prognosis of Cardiogenic Shock Can Be Determined Using Hemodynamic Variables: A Retrospective Cohort Study*

Objectives:Few reports address the relationship between hemodynamic variables and the cardiogenic shock outcome in critically ill patients. The present study aimed to investigate the association between hemodynamic variables and early cardiogenic shock mortality in critically ill patients. Design:Retrospective, single-center cohort study. Setting:Tertiary academic hospital’s 36-bed multidisciplinary intensive care. Patients:Initial presentation with cardiogenic shock. Measurements and Main Results:The authors retrospectively analyzed medical information and the hemodynamic variables (recorded during the first 24 hr following admission to the ICU) of patients with cardiogenic shock. For all the patients, the Simplified Acute Physiology Score II, cardiac index, cardiac power index, and continuous hemodynamic values following the first 24 hours of admission were reviewed. Mortality within 28 days was the primary endpoint. All the variables were then compared with survival and nonsurvival status and those variables with a significant association in the univariate analysis were entered into a multivariate logistic regression model. Seventy-one patients were included. Among them, 26 (37%) died within 28 days after ICU admission and were classified as “nonsurvivors.” The minimum value for diastolic arterial blood pressure during the first 24 hours was independently associated with the 28-day mortality in the univariate and multivariate analyses model. This model performed better than the model using the Simplified Acute Physiology Score II, even when assessing the effect of inotrope and vasoactive treatments at 24, 48, and 72 hours. Conclusions:In the first 24 hours of an ICU admission, the minimum diastolic arterial blood pressure was a hemodynamic variable that was independently associated with 28-day mortality in cardiogenic shock patients.