Richard Johnston

Quality of life measures before and one year after admission to an intensive care unit.

OBJECTIVE To assess outcome of patients admitted to an intensive care unit (ICU), using a prospective 1-yr follow-up, with special emphasis on various quality of life measures before and after admission to the ICU. DESIGN Prospective comparison of quality of life before and 1 yr after admission to the ICU. SETTING Eleven-bed adult medical/surgical ICU. PATIENTS All patients admitted to the ICU over a 1-yr period were eligible for inclusion in this study. Repeat admissions were enrolled only on first admission. Patients < 17 yrs of age and those patients who died within 24 hrs of admission were excluded. INTERVENTIONS Quality of life measures were collected before and 6 and 12 months after ICU admission. MEASUREMENTS AND MAIN RESULTS The following data were collected: duration of ICU and hospital stay; ICU, hospital, 6- and 12-month mortality; quality of life (level of activity, activities of daily living, perceived health, support, and outlook on life) and place of residence at baseline and 12 months after ICU admission. There were 504 patients who met the study criteria; age 55 +/- 20 yrs (median 59), 229 female and 275 male. Mean ICU length of stay was 4.3 +/- 7.4 days. Hospital length of stay was 31 +/- 41 days. Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 14 +/- 7. Cumulative mortality: ICU 5.4%, hospital 13.5%, 6 month 20.6%, and 12 month 25%. One year quality of life questionnaires were completed for 293 patients. Relative to baseline, there was a decrease in the level of activity and activities of daily living at 12 months (p < .01). Perceived health status increased over the year for patients > or = 75 yrs of age (p < .01). There was no difference in the level of support from family or friends, or outlook on life, at 12 months. At 1 yr, 262 (89%) patients were living at home. CONCLUSION Patients admitted to intensive care tend to have a decrease in the level of activity and activities of daily living 1 yr after their ICU stay, although in the very elderly, perceived health status increases. As well, the majority (89%) of patients return home.

One-year outcome of elderly and young patients admitted to intensive care units

ObjectiveTo compare the outcome of patients over and under age 65 admitted to two intensive care units (ICUs). DesignProspective, two-center study. Convenience sample of all admissions to two adult ICUs for a 1-yr period, with a 1-yr follow-up. SettingAdult multidisciplinary closed ICUs. PatientsAll patients (n = 1,040) admitted to two ICUs during a 1-yr period were entered into the study, except patients with self-induced poisoning. Of these patients, 145 patients were lost to follow-up. InterventionsAdmission statistics on all patients included demographic, case mix, and severity data. Variables associated with intensive care unit outcomes at discharge (length of stay, mortality) and at 1 yr from admission (mortality, functional capacity, health attitudes) were analyzed. Vital status was confirmed from both Alberta Vital Statistics and Alberta Health. Follow-up interviews were conducted with all available survivors. ResultsThe elderly group (>65yrs) comprised 46% of patients studied. Both age groups (>65 yrs and <65 yrs) had comparable demographics and illness severity measures. Although ICU and 1-yr mortality rates differed between groups (16% of >65 yrs vs. 12.9% of <65 yrs ICU mortality and 49% of ≥65 yrs vs. 31% of <65 yrs 1-yr mortality), age was not a major contributor to the variance in outcome. At 1 yr, 65% of patients admitted to the study were alive. Follow-up interviews were conducted with 75% of survivors. Assessment of activities of daily living showed that the elderly patients were similar to younger patients. The elderly demonstrated more positive health attitudes than younger survivors. Functional capacity was significantly associated with health attitudes of younger patients, but not for older survivors. ConclusionsAge does not have an important impact on outcome from critical illness, which is most strongly predicted by severity of illness, length of stay, prior ICU admission and respiratory failure. Satisfaction with personal health should not be inferred from the functional status of elderly survivors of intensive care. (Crit Care Med 1993; 21:687–691).

Air insufflation technique of enteral tube insertion: a randomized, controlled trial.

OBJECTIVE To test air insufflation as an adjunct to placement of enteral feeding tubes. DESIGN Prospective, randomized study. SETTING Intensive care unit in a tertiary hospital. SUBJECTS Sixty-four consecutive patients requiring enteral nutrition, in whom a decision to insert a nasoenteral feeding tube was made. INTERVENTIONS A 12-Fr feeding tube was inserted to the level of the fundus of the stomach. A 60-mL syringe was used to pump 500 mL of air into the stomach. The tube was then advanced. An abdominal flat plate was obtained within 2 hrs of completion of the procedure and the tube position noted. If the tube was not in the duodenum, the patient was placed on a promotility agent and a repeat radiograph was performed the next day. The technique varied from our control technique only by the instillation of air. MEASUREMENTS AND MAIN RESULTS Using the study technique, 21 of 32 tubes were successfully placed, as seen on the initial radiograph, in our study patients compared with only 12 of 34 tubes in our control patients (p< .02). In addition, the success rate at 24 hrs was 25 of 32 vs. 16 of 34 (p< .02). Only 3 of 21 tubes placed in the antrum, body, or fundus of the stomach advanced to the duodenum the following day, compared with 5 of 12 tubes initially placed in the pylorus (p< .075). No complications were noted. CONCLUSION Instilling air into the stomach may facilitate the ability to get the feeding tube to the level of the pylorus, at which point it is more likely to advance into the duodenum and beyond.

A randomized clinical trial comparing ranitidine and antacids in critically ill patients

In a randomized trial of gastric pH control for stress ulcer prophylaxis, 200 mg/day ranitidine iv was compared to antacids in 86 patients admitted to an ICU. Six (15%) patients receiving ranitidine and six (13%) given antacids failed to maintain >50% of the hourly gastric pH measurements at or above 4. Increasing the ranitidine dosage to 300 mg/day did not provide additional control. One patient in the antacid group developed an overt upper GI bleed secondary to endoscopically proven erosive disease. We conclude that iv ranitidine in a dosage of 200 mg/day is as effective as antacids in reducing gastric acidity and preventing stress ulcer disease in critically ill patients.

Sedation for Colonoscopy: A Double-Blind Comparison of Diazepam/Meperidine, Midazolam/Fentanyl and Propofol/Fentanyl Combinations

Rate of recovery and incidence of complications were compared among three intravenous sedation techniques for colonoscopy. Sixty patients were randomized to receive diazepam and meperidine, midazolam and fentanyl, or propofol and fentanyl with a continuous infusion of propofol. Patients were sedated to a standard end-point using a double-blinded technique. There were no differences in rate of recovery or incidence of minor side effects among the three groups. The techniques were equally effective in providing sedation and analgesia for colonoscopy. All groups developed significant oxygen desaturation measured by continuous pulse oximetry. Over 20% of patients required supplemental oxygen due to persistent desaturation below 85% following administration of sedatives. The authors conclude that oxygen should be administered to all patients undergoing colonoscopy.

Cerebrospinal fluid myelin basic protein as a prognostic marker in patients with head injury.

Despite increasing interest in identifying biochemical and serologic markers to judge the severity of closed head injury in comatose patients, clinical variables remain the most readily available methods for assessing prognosis. In a series of 35 severely head-injured comatose patients, the cerebrospinal fluid (CSF) level of myelin basic protein (MBP) was analyzed by radio-immunoassay. MBP levels during the first week after injury were significantly correlated with the Glasgow outcome score at 7 days (p < .005), 3 months (p < .005), and 6 months (p < .05) postinjury. Measurement of CSF MBP appears to be a useful laboratory adjunct to clinical assessment, for judging the outcome of severely head-injured patients.

Spironolactone-induced agranulocytosis

Agranulocytosis associated with spironolactone administration is described in a 57-year-old man. Four days after initiation of spironolactone, leukocyte counts decreased from 8.2 to 2.3 × 109/L with 6% neutrophils. Spironolactone, domperidone, and prochlorperazine were discontinued. Domperidone and prochlorperazine were reintroduced and there was concomitant improvement of the leukocyte and neutrophil counts. Substitution of triamterene for spironolactone was not associated with recurrent leukopenia. The potential association of spironolactone with granulocytopenia warrants increased awareness of this rare but serious adverse drug reaction.

Unrelenting hypoxemia and fatal myocardial infarction resulting from paradoxical embolization through an atrial septal defect

This report describes such an occurrence wherein persistent hypoxemia was followed by paradoxical emboli which obstructed the coronary vasculature and resulted in myocardial infarction, and ultimately death

Noncardiogenic pulmonary edema during intrabiliary infusion of mono-octanoin.

Mono-octanoin (glycerol-1-mono-octanoate) is a medium-chain diglyceride used to dissolve gallstones. We describe a patient in whom noncardiogenic pulmonary edema developed during intrabiliary infusion of monooctanoin. The temporal sequence suggests that the drug infusion initiated the lung injury.