Stephen M. Pastores

Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: Consensus statements from an international task force by the American College of Critical Care Medicine

Objective:To develop consensus statements for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients. Participants:A multidisciplinary, multispecialty task force of experts in critical care medicine was convened from the membership of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. In addition, international experts in endocrinology were invited to participate. Design/Methods:The task force members reviewed published literature and provided expert opinion from which the consensus was derived. The consensus statements were developed using a modified Delphi methodology. The strength of each recommendation was quantified using the Modified GRADE system, which classifies recommendations as strong (grade 1) or weak (grade 2) and the quality of evidence as high (grade A), moderate (grade B), or low (grade C) based on factors that include the study design, the consistency of the results, and the directness of the evidence. Results:The task force coined the term critical illness–related corticosteroid insufficiency to describe the dysfunction of the hypothalamic-pituitary-adrenal axis that occurs during critical illness. Critical illness–related corticosteroid insufficiency is caused by adrenal insufficiency together with tissue corticosteroid resistance and is characterized by an exaggerated and protracted proinflammatory response. Critical illness–related corticosteroid insufficiency should be suspected in hypotensive patients who have responded poorly to fluids and vasopressor agents, particularly in the setting of sepsis. At this time, the diagnosis of tissue corticosteroid resistance remains problematic. Adrenal insufficiency in critically ill patients is best made by a delta total serum cortisol of <9 &mgr;g/dL after adrenocorticotrophic hormone (250 &mgr;g) administration or a random total cortisol of <10 &mgr;g/dL. The benefit of treatment with glucocorticoids at this time seems to be limited to patients with vasopressor-dependent septic shock and patients with early severe acute respiratory distress syndrome (Pao2/Fio2 of <200 and within 14 days of onset). The adrenocorticotrophic hormone stimulation test should not be used to identify those patients with septic shock or acute respiratory distress syndrome who should receive glucocorticoids. Hydrocortisone in a dose of 200 mg/day in four divided doses or as a continuous infusion in a dose of 240 mg/day (10 mg/hr) for ≥7 days is recommended for septic shock. Methylprednisolone in a dose of 1 mg·kg−1·day−1 for ≥14 days is recommended in patients with severe early acute respiratory distress syndrome. Glucocorticoids should be weaned and not stopped abruptly. Reinstitution of treatment should be considered with recurrence of signs of sepsis, hypotension, or worsening oxygenation. Dexamethasone is not recommended to treat critical illness–related corticosteroid insufficiency. The role of glucocorticoids in the management of patients with community-acquired pneumonia, liver failure, pancreatitis, those undergoing cardiac surgery, and other groups of critically ill patients requires further investigation. Conclusion:Evidence-linked consensus statements with regard to the diagnosis and management of corticosteroid deficiency in critically ill patients have been developed by a multidisciplinary, multispecialty task force.

Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs.

Objectives:To analyze the evolving role, patterns of use, and costs of critical care medicine in the United States from 2000 to 2005. Design:Retrospective study of data from the Hospital Cost Report Information System (Centers for Medicare and Medicaid Services, Baltimore, Maryland). Setting:Nonfederal, acute care hospitals with critical care medicine beds in the United States. Subjects:None. Interventions:None. Measurements and Main Results:We analyzed hospital and critical care medicine beds, bed types, days, occupancy rates, payer mix (Medicare and Medicaid), and costs. Critical care medicine costs were compared with national cost indexes. Between 2000 and 2005, the total number of U.S. hospitals with critical care medicine beds decreased by 12.2% (from 3,586 to 3,150). Although the number of hospital beds decreased by 4.2% (from 655,785 to 628,409), both hospital days and occupancy rates increased by 5.1% (from 145.1 to 152.5 million) and 13.7% (from 59% to 67%), respectively. Critical care medicine beds increased by 6.5% (from 88,252 to 93,955), days by 10.6% (from 21.0 to 23.2 million), and occupancy rates by 4.5% (from 65% to 68%). The majority (90%) of critical care medicine beds were classified as intensive care, premature/neonatal, and coronary care unit beds. The percentage of critical care medicine days used by Medicare decreased by 3.8% (from 37.9% to 36.5%) compared with an increase of 15.5% (from 14.5% to 16.8%) by Medicaid. From 2000 to 2005, critical care medicine costs per day increased by 30.4% (from

Critical care medicine in the United States 1985-2000: An analysis of bed numbers, use, and costs

2698 to

Intensive care of the cancer patient: recent achievements and remaining challenges

3518). Although annual critical care medicine costs increased by 44.2% (from

Prevalence and Mortality of Acute Lung Injury and ARDS After Lung Resection

56.6 to

Changes in critical care beds and occupancy in the United States 1985–2000: Differences attributable to hospital size

81.7 billion), the proportion of hospital costs and national health expenditures allocated to critical care medicine decreased by 1.6% and 1.8%, respectively. However, the proportion of the gross domestic product used by critical care medicine increased by 13.7%. In 2005, critical care medicine costs represented 13.4% of hospital costs, 4.1% of national health expenditures, and 0.66% of the gross domestic product. Conclusions:Critical care medicine continues to grow in a shrinking U.S. hospital system. The critical care medicine payer mix is evolving, with Medicaid increasing in its percentage of critical care medicine use. Critical care medicine is more cost controlled than other healthcare indexes, but is still using an increasing percentage of the gross domestic product. Our updated and comprehensive critical care medicine use and cost analysis provides a contemporary benchmark for the strategic planning of critical care medicine services within the U.S. healthcare system.

Structure, process, and annual ICU mortality across 69 centers: United States critical illness and injury trials group critical illness outcomes study

Objective:To establish a database that permits description and analysis of the evolving role, patterns of use, and costs of critical care medicine (CCM) in the United States from 1985 to 2000. Design:Retrospective study combining data from federal (Hospital Cost Report Information System, Center for Medicare and Medicaid Services, Baltimore, MD) and private (Hospital Statistics, American Hospital Association, Chicago, IL) databases to analyze U.S. hospitals, hospital and CCM beds, and occupancy. CCM costs were calculated by the Russell equation and compared with national health care and financial indexes. Setting:Nonfederal, acute care hospitals with CCM units in the United States. Subjects:None. Interventions:None. Measurements and Main Results:We analyzed hospitals with CCM units and focused on hospital and CCM beds, CCM occupancy, and CCM costs. CCM costs were compared with national cost indexes. Between 1985 and 2000, the total number of U.S. hospitals decreased by 8.9% (6,032 to 5,494) and acute care hospitals offering CCM decreased by 13.7% (4,150 to 3,581). The total number of beds in hospitals with CCM units decreased by 26.4% (889,600 to 654,400). In contrast, CCM beds increased by 26.2% (69,300 to 87,400). CCM occupancy was constant at 65%. CCM bed costs per day increased by 126% (

Premortem clinical diagnoses and postmortem autopsy findings: discrepancies in critically ill cancer patients

1,185 to

The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units.

2,674). Although CCM costs increased by 190.4% (

Review of A Large Clinical Series: Intrahospital Transport of Critically Ill Patients: Outcomes, Timing, and Patterns

19.1 billion to