Thomas Staudinger

Outcome and prognostic factors in critically ill cancer patients admitted to the intensive care unit

Objective: To assess survival in cancer patients admitted to an intensive care unit (ICU) with respect to the nature of malignancy, cause of ICU admittance, and course during ICU stay as well as to evaluate the prognostic value of the Acute Physiology and Chronic Health Evaluation (APACHE) III score. Design: Retrospective cohort study. Setting: ICU at a university cancer referral center. Patients: A total of 414 cancer patients admitted to the ICU during a period of 66 months. Interventions: None. Measurements: Charts of the patients were analyzed with respect to underlying disease, cause of admission, APACHE III score, need and duration of mechanical ventilation, neutropenia and development of septic shock, as well as ICU survival and survival after discharge. Mortality data were compared with two control groups: 1362 patients admitted to our ICU suffering from diseases other than cancer and 2,776 cancer patients not admitted to the ICU. Main Results: ICU survival was 53%, and 1‐yr survival was 23%. The 1‐yr mortality rate was significantly lower in both control groups. Patients admitted after bone marrow transplantation had the highest mortality. In a multivariate analysis, prognosis was negatively influenced by respiratory insufficiency, the need of mechanical ventilation, and development of septic shock during the ICU stay. Admission after cardiopulmonary resuscitation yielded high ICU mortality but a relatively good long‐term prognosis. Admission after surgery and as a result of acute hemorrhage was associated with a good prognosis. Age, neutropenia, and underlying disease did not influence outcome significantly. Admission APACHE III scores were significantly higher in nonsurvivors but failed to predict individual outcome satisfactorily. All patients with APACHE III scores of >80 died at the ICU. Conclusion: A combination of factors must be taken into account to estimate a critically ill cancer patients prognosis in the ICU. The APACHE III scoring system alone should not be used to make decisions about therapy prolongation. Admission to the ICU worsens the prognosis of a cancer patient substantially; however, as ICU mortality is 47%, comparable with severely ill noncancer patients, general reluctance to admit cancer patients to an ICU does not seem to be justified.

Attributable mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomised prevention studies

BACKGROUND Estimating attributable mortality of ventilator-associated pneumonia has been hampered by confounding factors, small sample sizes, and the difficulty of doing relevant subgroup analyses. We estimated the attributable mortality using the individual original patient data of published randomised trials of ventilator-associated pneumonia prevention. METHODS We identified relevant studies through systematic review. We analysed individual patient data in a one-stage meta-analytical approach (in which we defined attributable mortality as the ratio between the relative risk reductions [RRR] of mortality and ventilator-associated pneumonia) and in competing risk analyses. Predefined subgroups included surgical, trauma, and medical patients, and patients with different categories of severity of illness scores. FINDINGS Individual patient data were available for 6284 patients from 24 trials. The overall attributable mortality was 13%, with higher mortality rates in surgical patients and patients with mid-range severity scores at admission (ie, acute physiology and chronic health evaluation score [APACHE] 20-29 and simplified acute physiology score [SAPS 2] 35-58). Attributable mortality was close to zero in trauma, medical patients, and patients with low or high severity of illness scores. Competing risk analyses could be done for 5162 patients from 19 studies, and the overall daily hazard for intensive care unit (ICU) mortality after ventilator-associated pneumonia was 1·13 (95% CI 0·98-1·31). The overall daily risk of discharge after ventilator-associated pneumonia was 0·74 (0·68-0·80), leading to an overall cumulative risk for dying in the ICU of 2·20 (1·91-2·54). Highest cumulative risks for dying from ventilator-associated pneumonia were noted for surgical patients (2·97, 95% CI 2·24-3·94) and patients with mid-range severity scores at admission (ie, cumulative risks of 2·49 [1·81-3·44] for patients with APACHE scores of 20-29 and 2·72 [1·95-3·78] for those with SAPS 2 scores of 35-58). INTERPRETATION The overall attributable mortality of ventilator-associated pneumonia is 13%, with higher rates for surgical patients and patients with a mid-range severity score at admission. Attributable mortality is mainly caused by prolonged exposure to the risk of dying due to increased length of ICU stay. FUNDING None.

Comparison of a conventional tracheal airway with the Combitube in an urban emergency medical services system run by physicians

This prospective randomised study was performed to compare the use of the Esophageal-Tracheal Combitube(R) (ETC; Tyco Healthcare, Mansfield, MA; http://www.combitube.org) with a conventional tracheal airway (ETA) for airway management by experienced physicians of the Emergency Medical Services System of the City of Vienna in the prehospital setting. Access to the patients head, time of arrival of the ambulance, ease of insertion, time of insertion, potential substitution by the alternate airway, efficacy of adrenaline (epinephrine) administered via the airway, survival to the intensive care unit (ICU) ward and survival to discharge from the hospital were evaluated. One hundred and seventy-two non-traumatic cardiac arrest patients (131 males, 41 females) were enrolled in this study during a 12 months period. In 83 patients (48.3%), the conventional ETA (group 1) was used for the initial intubation attempt which was successful in 78 patients (94%). The remaining five patients of group 1 could not be intubated with an ETA, but were successfully managed with the ETC. Eighty-nine patients (51.7%) were intubated with the ETC (group 2) as first choice (79 in oesophageal position (89%); eight in tracheal position: (9%)), which was successful in 87 (98%) patients. The remaining two patients in group 2 (2%) were successfully managed with the ETA. Success of intubation and ventilation with ETC was comparable to the ETA. Recorded time of insertion was shorter with the ETC versus ETA (P<0.05). The Combitube worked well in cases of difficult access to the patients head and in bleeding and vomiting patients. Both devices served as successful substitutes for each other. Adrenaline (epinephrine) applied via ETC with a 10-fold dosage was as effective as via the conventional ETA. To our knowledge this is the first study using physicians comparing ETC and ETA in the prehospital setting.

Emergency intubation with the combitube®: Comparison with the endotracheal airway

STUDY OBJECTIVE To evaluate the safety and effectiveness of the Combitude as used by ICU nurses under medical supervision compared with endotracheal airway established by ICU physicians during CPR. DESIGN Prospective study of ICU patients over a seven-month period. SETTING Medical ICU. PARTICIPANTS Thirty-seven patients suffering from cardiac arrest. INTERVENTIONS Emergency intubation with either the Combitube by nurses or the endotracheal airway by physicians and subsequent mechanical ventilation. MEASUREMENTS AND MAIN RESULTS Evaluation of blood gases after 20 minutes of mechanical ventilation. Intubation time was shorter for the Combitube (P < .001). Blood gases for each device showed comparable results; PaO2 was slightly higher during ventilation with the Combitube (P < .001). CONCLUSION The Combitube as used by ICU nurses was as effective as establishment of the endotracheal airway by intensivists during CPR. The Combitube may be used whenever endotracheal intubation cannot be performed immediately.

Evaluation of Seldinger technique Emergency cricothyroidotomy versus standard surgical cricothyroidotomy in 200 cadavers

Background: Percutaneous cricothyroidotomy is a lifesaving procedure for airway obstruction in trauma victims who need airway establishment and cannot be intubated or in whom intubation has failed. Methods: The purpose of this study was to examine whether there is a training effect using Seldinger technique emergency cricothyroidotomy (group 1; Arndt Emergency Cricothyroidotomy Catheter Set; Cook Critical Care, Bloomington, IN) versus standard surgical cricothyroidotomy (group 2). Twenty emergency physicians performed five cricothyroidotomies with each method in a total of 200 human cadavers, comparing efficacy and safety (speed, success rate, and injuries). Results: Seven attempts in group 1 and six in group 2 had to be aborted. Time intervals from the start of the procedure to location of the cricothyroid membrane were not significantly different between the groups. However, time to tracheal puncture (P < 0.01) and time to first ventilation (P < 0.001) were significantly longer in group 2. No time effect could be observed in both groups. The airway was accurately placed into the trachea through the cricothyroid membrane in 88.2% (82 of 93) of the cadavers in group 1 and in 84.0% (79 of 94) in group 2 (not significant). No injuries were observed in group 1, whereas there were six punctures of the thyroid vessels in group 2 (P < 0.05). Conclusions: With respect to time needed for the procedure, the participants performed Seldinger technique emergency cricothyroidotomy significantly faster as compared with standard surgical cricothyroidotomy. Even if no training effect had been observed, the authors believe that it is important to train residents in different methods of cricothyroidotomy in cadavers in addition to training in mannequins to achieve a higher level of efficacy in real-life situations. The shorter time to first ventilation and the fact that no injuries could be observed favor the Seldinger technique.

Prognostic factors for intensive care unit admission, intensive care outcome, and post-intensive care survival in patients with de novo acute myeloid leukemia: a single center experience

Background Acute myeloid leukemia is a life-threatening disease associated with high mortality rates. A substantial number of patients require intensive care. This investigation analyzes risk factors predicting admission to the intensive care unit in patients with acute myeloid leukemia eligible for induction chemotherapy, the outcome of these patients, and prognostic factors predicting their survival. Design and Methods A total of 406 consecutive patients with de novo acute myeloid leukemia (15–89 years) were analyzed retrospectively. Markers recorded at the time of diagnosis included karyotype, fibrinogen, C-reactive protein, and Charlson comorbidity index. In patients requiring critical care, the value of the Simplified Acute Physiology Score II, the need for mechanical ventilation, and vasopressor support were recorded at the time of intensive care unit admission. The independent prognostic relevance of the parameters was tested by multivariate analysis. Results Sixty-two patients (15.3%) required intensive care, primarily due to respiratory failure (50.0%) or life-threatening bleeding (22.6%). Independent risk factors predicting intensive care unit admission were lower fibrinogen concentration, the presence of an infection, and comorbidity. The survival rate was 45%, with the Simplified Acute Physiology Score II being the only independent prognostic parameter (P<0.05). Survival was inferior in intensive care patients compared to patients not admitted to an intensive care unit. However, no difference between intensive care and non-intensive care patients was found concerning continuous complete remission at 6 years or survival at 6 years in patients who survived the first 30 days after diagnosis (non-intensive care patients: 28%; intensive care patients: 20%, P>0.05). Conclusions Ongoing infections, low fibrinogen and comorbidity are predictive for intensive care unit admission in acute myeloid leukemia. Although admission was a risk factor for survival, continuous complete remission and survival of patients alive at day 30 were similar in patients who were admitted or not admitted to an intensive care unit.

Comparison of prone positioning and continuous rotation of patients with adult respiratory distress syndrome: results of a pilot study.

ObjectiveTo compare prone positioning and continuous rotational therapy with respect to oxygenation and hemodynamics in patients suffering from adult respiratory distress syndrome (ARDS). DesignRandomized, prospective pilot study. SettingIntensive care unit at a university hospital. PatientsTwenty-six mechanically ventilated patients with ARDS from nontraumatic causes. InterventionsTwelve patients were turned prone (group 1), 14 patients underwent continuous axial rotation from one lateral position to the other with a maximum angle of 124 degrees in specially designed beds (group 2). All patients had received inhaled nitric oxide (NO) therapy before positioning. Measurements and Main Results Gas exchange and hemodynamics were assessed using a pulmonary artery catheter. In both groups, an improvement in Pao2/Fio2-ratio and intrapulmonary shunt fraction occurred after initiation of NO as well as during the first 72 hrs of positioning therapy. During the study period, seven patients died in group 1 and nine patients in group 2 (p = NS). Comparing the areas under the curve during the first 72 hrs, no significant differences with respect to Pao2/Fio2-ratio, Paco2, positive end-expiratory and peak inspiratory pressure levels, intrapulmonary shunt fraction, the alveolar-arterial oxygen difference, and oxygen delivery and consumption, as well as cardiac index, pulmonary and arterial blood pressures, and pulmonary arterial occlusion pressure could be detected between the groups. Prone positioning was tolerated well, continuous rotational therapy had to be modified according to hemodynamic instability in three patients. ConclusionsIn severe lung injury, continuous rotational therapy seems to exert effects comparable to prone positioning and could serve as alternative when prone positioning seems inadvisable.

Influence of prothrombin complex concentrates on plasma coagulation in critically ill patients

Objective: To evaluate thrombogenicity of prothrombin complex concentrates (PCCs) in critically ill patients.¶Design: Prospective clinical study.¶Setting: Medical intensive care unit at a university hospital.¶Patients: 16 consecutive patients suffering from acquired deficiencies of coagulation factors and with either overt bleeding from any site or a planned invasive procedure.¶Interventions: 2000 factor IX units of PCCs intravenously.¶Measurements and results: Prothrombin time (PT), activated partial prothrombin time, fibrinogen, platelet count, plasma levels of coagulation factors II, V, VII, VIII, IX, X, antithrombin, protein C, thrombin-antithrombin complex (TAT), prothrombin fragment F1+2, and the fibrin degradation product D-dimer were measured prior to and 1, 3, and 24 h after administration of PCCs. PT as well as coagulation factors II, VII, IX, and X, TAT, and F1+2 showed a significant increase after administration of PCCs. All other parameters remained unchanged.¶Conclusions: Administration of PCCs induces thrombin generation. No evidence for induction of disseminated intravascular coagulation in biochemical terms could be found. When rapid correction of acquired coagulation factor disturbances is warranted, the use of PCCs seems reasonable, but the elevated risk of intravascular thrombus formation should be kept in mind.

Experiences with severe P. falciparum malaria in the intensive care unit

Objective: To review the clinical profiles and therapies instituted for patients with severe malaria admitted to an ICU.¶Design: Retrospective study.¶Setting: Internal ICU of a tertiary care centre.¶Patients and participants: Between January, 1992, and February, 1999, 104 patients with malaria were admitted to the General Hospital of Vienna. Sixty-nine patients suffered from Plasmodium falciparum malaria (66 %), seven of these were admitted to the ICU.¶Measurement and results: Seven patients were admitted to the ICU, of whom three died (4 % in hospital case-fatality rate). Four patients required mechanical ventilation because of respiratory insufficiency and adult respiratory distress syndrome (ARDS), of whom three died. Three patients were treated with inhaled nitric oxide (NO) and kinetic therapy; one patient required extracorporeal veno-venous oxygenation. All patients who died required haemofiltration because of acute renal failure.¶Conclusion: As P. falciparum is a potentially life-threatening disease, reliable criteria for ICU admission should be defined and risk factors identified. Early ICU monitoring should be attempted, especially under the following conditions: (1) lack of clinical response to anti-malarial treatment within 48 h and/or (2) any signs of neurological disturbance (hypoglycaemia excluded). Prospective multicentre trials and guidelines for supportive intensive care are urgently needed.

Comparison of Mucosal Pressures Induced by Cuffs of Different Airway Devices

Background:High pressures exerted by balloons and cuffs of conventional endotracheal tubes, the Combitube® (Tyco Healthcare Nellcor Mallinckrodt, Pleasanton, CA), the EasyTube® (Teleflex Ruesch, Kernen, Germany), the Laryngeal Mask Airway ™ (LMA North America, San Diego, CA), the Intubating Laryngeal Mask Airway ™ (Fastrach®; LMA North America), the ProSeal ™ (LMA North America), and the Laryngeal Tube (LT; VBM Medizintechnik, Sulz, Germany) may traumatize the pharyngeal mucosa. The aim of this study was to compare pressures exerted on the pharyngeal, tracheal, and esophageal mucosa by different devices designed for securing the patient’s airways. Methods:Nineteen fresh cadavers were included. To measure mucosal pressures, microchip sensors were fixed on the anterior, lateral, and posterior surfaces of the proximal balloon and the distal cuff of the investigated devices. Depending on the respective airway device, the cuff volume was increased in 10-ml increments at the proximal balloon starting from 0 to a maximum of 100 ml, and in 2-ml increments at the distal cuff starting from 0 up to 12 ml. Results:Tracheal mucosal pressures were significantly higher using the Combitube® compared with the endotracheal tube and the EasyTube®. Maximal esophageal pressures were significantly higher using the EasyTube® compared with the Combitube®. Using cuff volumes according to the manufacturers’ guidelines, we found the highest pharyngeal pressures with the Intubating Laryngeal Mask Airway ™ versus all other devices. At maximal volumes, the Laryngeal Mask Airway ™, the Intubating Laryngeal Mask Airway ™, and the ProSeal ™ induced significantly higher pharyngeal pressures compared with all other devices. Using a pharyngeal cuff volume of 40 ml, the Intubating Laryngeal Mask Airway ™ followed by the Laryngeal Mask Airway ™ exerted significantly higher pressures compared with the other devices. Conclusions:Although some devices exhibit a somewhat higher mucosal pressure when compared with others, the authors believe that the observed differences of the cuff pressures do not suggest a clinically relevant danger, because the investigated devices, except the endotracheal tubes, are not intended for prolonged use.