Intensive care of patients with the acquired immunodeficiency syndrome. Outcome and changing patterns of utilization

Eighty-two patients with the acquired immunodeficiency syndrome (AIDS) were admitted to the intensive care units (ICUs) at San Francisco General Hospital (SFGH) between March 1981 and December 1985. Of these patients, 69% died in the hospital, as did 87% of patients who required mechanical ventilation because of Pneumocystis carinii pneumonia and respiratory failure. Although the number of hospital admissions of patients with AIDS has increased steadily since the fourth quarter of 1982 (12 admissions) through the fourth quarter of 1985 (158 admissions), the number of admissions to the ICUs peaked at 17 in the second quarter of 1984 and decreased steadily, averaging 5 per quarter in 1985. This decrease was not explained by a reduction in the number of patients with P. carinii pneumonia or an improvement in their treatment. A survey of physicians at SFGH indicated that physicians are aware of the poor prognosis of patients with AIDS with P. carinii pneumonia and respiratory failure, believe that mechanical ventilation is infrequently indicated for this condition, and have become increasingly likely to discuss issues of resuscitation with their patients with AIDS. Therefore, possible explanations for this trend in ICU utilization include changing physician attitudes, in addition to more effective patient counseling and increased availability of hospital and community-based support services that provide alternatives to terminal intensive care.     

Concurrent bacterial lung infection in patients with AIDS, PCP, and respiratory failure.

STUDY OBJECTIVES: To determine and compare the incidence of concurrent bacterial lung infection in intubated and nonintubated patients with the acquired immunodeficiency syndrome (AIDS) and Pneumocystis carinii pneumonia (PCP) requiring medical intensive care unit (MICU) admission for support of their respiratory function. DESIGN: Retrospective review of medical records. SETTING: A large university hospital and AIDS treatment center. PATIENTS: All AIDS/PCP patients admitted to the MICU for support of oxygenation and/or ventilation between 1985 and 1989. Survival was defined as discharge from the hospital; nonsurvival was defined as death any time during the hospitalization. Patients with acute spinal cord injury (SCI) were used as controls to determine the incidence of nosocomial pneumonia in ICU patients of similar age without AIDS. MEASUREMENTS AND RESULTS: Twenty-nine AIDS/PCP patients met study criteria; eight (28 percent) were survivors and 21 (72 percent) were nonsurvivors. There was no significant difference in duration of intubation or duration of ICU stay between survivors and nonsurvivors with or without intubation. The incidence of bacterial concurrent lung infection (CLI) in AIDS/PCP patients overall was 7 percent and in intubated AIDS/PCP patients it was 10 percent. There was no statistically significant difference in the incidence of bacterial CLI between the survivors and nonsurvivors or between intubated and nonintubated patients with AIDS/PCP. The incidence of nosocomial pneumonia in SCI overall was 17 percent and in intubated SCI patients it was 30 percent. CONCLUSIONS: The incidence of bacterial lung infections in our retrospective study of AIDS patients with PCP is remarkably less than in the general ICU population with respiratory failure and in our control patients with SCI, although the differences did not attain statistical significance. This finding may be related to antimicrobial therapy directed against P carinii. Endotracheal intubation in patients with AIDS and PCP, who were undergoing appropriate antimicrobial therapy, did not result in a significantly higher incidence of bacterial lung infections than in those who were not intubated. There was no significant difference in the incidence of bacterial lung infections between those AIDS/PCP patients who survived episodes of severe respiratory failure and those who did not. Endotracheal intubation should not be delayed or withheld from this patient population due to concerns of pulmonary bacterial superinfection.     

Multisystem organ failure predicts mortality of ICU patients with acute respiratory failure secondary to AIDS-related PCP.

OBJECTIVE: To evaluate the ability of a variety of scoring systems to predict mortality of patients admitted to an intensive care unit (ICU) with acute respiratory failure (ARF) secondary to AIDS-related Pneumocystis carinii pneumonia (PCP). METHODS: All patients with AIDS-related PCP admitted to ICU at St. Paul's Hospital between January 1, 1985 and April 1, 1991 were reviewed. For each case, the following scores were calculated from data obtained within 24 h of ICU admission: acute physiology and chronic health evaluation II (APACHE II); acute lung injury score; AIDS score as described by Justice and Feinstein; and modified multisystem organ failure (MSOF) score. The serum lactate dehydrogenase (LDH) level was also recorded when obtained within 24 h of ICU admission. RESULTS: A total of 52 ICU admissions in 51 patients were studied. Overall mortality was 65 percent. Mortality increased with increasing MSOF (p < 0.05) score and LDH (p < 0.05). Based on receiver operating characteristic (ROC) curves, the MSOF score and the LDH were found to be good predictors of mortality. Multivariate logistic regression showed that the MSOF score was the only independent predictor of mortality (p < 0.05). The AIDS score, APACHE II, and the acute lung injury score were not significantly associated with mortality. Addition of the serum LDH level improved the performance of both the MSOF and AIDS scores, though the AIDS score plus LDH performed no better than the LDH alone. Of all the scores tested, the MSOF plus LDH level was the best (p < 0.005) predictor of mortality. CONCLUSIONS: The modified MSOF score and the serum LDH level are the best predictors of mortality of patients admitted to ICU with ARF secondary to AIDS-related PCP. The performance of the MSOF score was enhanced when the LDH level was added. The AIDS score, APACHE II, and the acute lung injury score were not found to be useful in this group of critically ill patients.     

Determinants of short- and long-term outcome in patients with respiratory failure caused by AIDS-related Pneumocystis carinii pneumonia

OBJECTIVES: To determine (1) predictors of in-hospital mortality and long-term survival in patients with acute respiratory failure (ARF) caused by acquired immunodeficiency syndrome-related Pneumocystis carinii pneumonia (PCP) and (2) long-term survival for patients with ARF relative to those without ARF. METHODS: A retrospective medical chart review was conducted of all cases of PCP-related ARF for which the patient was admitted to the intensive care unit of a single tertiary care institution between 1991 and 1996. Data were extracted regarding physiologic scores, relevant laboratory values, and duration of previous maximal therapy with combined anti-PCP agents and corticosteroids at entry to the intensive care unit. Duration of survival was determined by Kaplan-Meier methods from date of first hospital admission and compared for patients with and without ARF. RESULTS: There were 41 admissions to the intensive care unit among 39 patients, with 56.4% in-hospital mortality. Higher physiologic scores (Acute Physiology and Chronic Health Evaluation II [APACHE II], Acute Lung Injury, and modified Multisystem Organ Failure scores) were predictive of in-hospital mortality. Duration of previous maximal therapy also predicted in-hospital mortality (45% for patients with <5 days of previous maximal therapy vs 88% for those with > or =5 days of previous maximal therapy; P = .03). Combining physiologic scores and duration of previous maximal therapy enhanced prediction of in-hospital mortality. There was no difference in long-term survival between patients with PCP with ARF and those without ARF (P = .80), and baseline characteristics did not predict long-term survival. CONCLUSIONS: In-hospital mortality of patients with acquired immunodeficiency syndrome-related PCP and ARF is predicted by duration of previous maximal therapy and physiologic scores, and their combination enhances predictive accuracy. Long-term survival of patients with ARF caused by PCP is comparable to that of patients with PCP who do not develop ARF, and determinants of in-hospital mortality do not predict long-term survival.     

Factors predicting survival for HIV-infected patients with respiratory failure

BACKGROUND: Despite improved treatment modalities, the mortality of HIV infected patients admitted to the intensive care unit with respiratory failure remains high. To help ICU physicians in advising HIV infected patients whether to undergo mechanical ventilation, we retrospectively investigated prognostic factors predicting hospital outcome for HIV-infected patients, admitted to a medical intensive care unit with respiratory failure before the era of highly-active anti-retroviral therapy. METHODS: A retrospective chart review was carried out of all HIV-infected patients with respiratory failure admitted to the medical ICU of a Dutch University Hospital between 1991 and 1997. RESULTS: In the six year period, 29 HIV-infected patients were admitted to the ICU for respiratory failure. Mechanical ventilation, CD4 cell count, APACHE II score, APACHE III score, ARDS and length of ICU stay all differed significantly between survivors and non-survivors. However, a multivariate analysis only showed the need for mechanical ventilation as an independent risk factor for mortality. The only combination of factors able to accurately predict mortality for the individual patient was the development of ARDS and the requirement of mechanical ventilation. CONCLUSIONS: The combination of mechanical ventilation and ARDS accurately predicts hospital outcome in HIV-infected patients presenting with respiratory failure before the HAART era.     

Outcomes of patients with haematological malignancies admitted to intensive care unit. A comparative review of allogeneic haematopoietic stem cell transplantation data

The outcomes of 55 consecutive haemato-oncology patients admitted to the intensive care unit (ICU) were retrospectively analysed. Twenty-eight patients were admitted following haemopoietic stem cell transplantation (HSCT). Thirty-nine patients were admitted with respiratory failure, and all patients required respiratory support. Seventeen patients survived to be discharged from ICU, with an actuarial 1-year survival of 18%. Overall survival between patients who received intensive chemotherapy and those who underwent allogeneic HSCT was not significantly different (19% vs. 10%, P = 0.19). None of the nine myeloablative HSCT recipients survived (median survival: 9 d). Six of the 15 reduced-intensity conditioned HSCT recipients survived beyond 1 year (median survival: 1050 d, range: 438-1437).     

Impact of HAART advent on admission patterns and survival in HIV-infected patients admitted to an intensive care unit

BACKGROUND: Several studies found increased survival times and decreased hospitalization rates since the introduction of highly active antiretroviral therapy (HAART). OBJECTIVE: To examine the impact of HAART on admission patterns and survival of HIV-infected patients admitted to an intensive care unit (ICU). DESIGN: Prospective observational cohort study. SETTING AND SUBJECTS: All HIV-infected patients admitted from 1 January 1995 to 30 June 1999, to an infectious diseases ICU located in Paris. MAIN OUTCOME MEASURES: ICU utilization and admission patterns, and survival. RESULTS: A total of 426 HIV-related admissions were included. Sepsis increased from 16.3% to 22.6% from the pre- to the post-HAART era, whereas AIDS-related admissions decreased from 57.7% to 37% (P < 0.05). No significant difference in ICU utilization was found. In both periods, half of the patients were not on antiretroviral treatment at ICU admission. In-ICU mortality was 23%, without significant difference between the study periods. By multivariable analysis, in-ICU mortality was significantly associated with SAPS II > 40, Omega score > 75 and mechanical ventilation; and long-term survival with admission in the HAART era and AIDS at ICU admission. Cumulative survival rates after ICU discharge were 85.3% and 70.8% after 12 and 24 months, respectively. CONCLUSIONS: HAART had little impact on ICU utilization by HIV-infected patients. After the introduction of HAART AIDS-related conditions decreased and sepsis increased as reasons for ICU admission. Whereas ICU survival was dependent on usual prognostic markers, long-term survival was clearly dependent on HIV disease stage and HAART availability. In both study periods, at least a half of the HIV infected patients were not on anti-retroviral treatment at the time of ICU admission.     

Trends in mortality among AIDS patients in Amsterdam, 1982-1988

In this study we evaluated the survival of 515 AIDS patients diagnosed in Amsterdam between 1982 and 1988 and followed-up until April 1990. Non-resident patients survived for a shorter period than resident patients (median survival time 10 versus 16 months). Residents had a 1-, 2- and 3-year survival of 56.1, 33.0 and 17.2%, respectively. Heterosexual intravenous drug users tended to have a better survival than homosexual men, although this was not significant. The survival time was longer for AIDS patients less than 30 years of age at diagnosis and varied for the different clinical manifestations leading to AIDS diagnosis. We calculated the 1- and 2-year survival probability by year of diagnosis for patients initially presenting with a Pneumocystis carinii pneumonia (PCP). The 1-year survival improved greatly in 1986 and continued to rise in the following years. The 2-year survival was similar in 1986 and 1987 (26.8 versus 28.2%) but increased in 1988 (38.9%). We conclude that besides better clinical experience and diagnostic methods, this improvement in prognosis could be explained by the start of secondary prophylaxis for PCP in 1985 and the introduction of zidovudine therapy in 1987.     

Survival following mechanical ventilation for Pneumocystis carinii pneumonia in patients with the acquired immunodeficiency syndrome: a different perspective

PURPOSE: Pulmonary infection is a frequent cause of morbidity and mortality in patients with acquired immunodeficiency syndrome (AIDS), and Pneumocystis carinii pneumonia (PCP) is the predominant infection in these patients. In those patients who experience progression to respiratory failure from PCP, the reported mortality rate has been between 87% to 100%. This, in addition to the ultimately fatal outcome of patients with AIDS, has led many physicians to question the advisability of instituting mechanical support for respiratory failure in the setting of PCP. It had been our impression that the outcome of patients on our service was not as poor as was generally reported. We therefore undertook a retrospective analysis of our clinical experience. PATIENTS AND METHODS: We reviewed the clinical course of patients admitted to our service between December 1984 and June 1988 who required intubation and mechanical ventilation for PCP or presumed PCP. RESULTS: Thirty-three cases were identified with 18 survivors (54.5%) and 15 non-survivors (45.5%). Twenty-five of the 33 patients were intubated for their first episode of PCP, with 16 survivors (64%), whereas the remaining eight patients were intubated for their second episode of PCP, with two survivors (25%). We were not able to identify any parameters that predicted survival, although the serum lactate dehydrogenase level was useful in following the response to treatment. CONCLUSION: It is our belief that there is a reasonable chance of survival for patients requiring mechanical ventilation for PCP. We question the wisdom of avoiding intubation and mechanical ventilation altogether in patients with PCP due to the presumption of fatality in this clinical situation.     

Improved survival in patients with AIDS, Pneumocystis carinii pneumonia, and severe respiratory failure

Pneumocystis carinii pneumonia (PCP) causing acute respiratory failure (ARF) in patients with acquired immunodeficiency syndrome (AIDS) has been reported in several studies to have a mortality of 84 to 100 percent. A recent report found a 42 percent survival rate. We followed 58 patients with AIDS who required positive pressure ventilation and identified 33 patients with PCP and ARF who had a PaO2/FIo2 level less than 150 mmHg. We report the survival of 12 of these 33 (36 percent). The mean duration of survival after discharge from the hospital was 7.9 +/- 1.8 months, which is an improvement over previous reports. These data suggest that we should reevaluate the reported recommendations that patients with AIDS, PCP and ARF should not receive intensive care or mechanical ventilation.     

Intensive care unit experience of haemopoietic stem cell transplant patients

Background: Previous research at our institution (1988–1998) established an intensive care unit (ICU) and hospital mortality between 70% and 80% in haemopoietic stem cell transplant (HSCT) patients requiring ICU admission. Aims: This study explored mortality in a more contemporary cohort while comparing outcomes to published literature and our previous experience. Methods: Retrospective chart review of HSCT patients admitted to ICU between December 1998 and June 2008. Results: Of 146 admissions, 53% were male, with a mean age of 44 years, an Acute Physiologic and Chronic Health Evaluation II score of 28 and Sepsis Organ Failure Assessment score of 11. Fifty‐six per cent had graft versus host disease (GVHD), with respiratory failure (67%) being the most common admission diagnosis. All but one received mechanical ventilation. The ICU and hospital mortality were 42% (72% 1988–1998 cohort) and 64% (82% 1998–1998 cohort) respectively. The 6‐ and 12‐month survivals were 29% and 24% respectively for the 1998–2008 cohort. Dying in ICU was independently predicted by fungal infection (P= 0.02) and early onset of organ failure (P < 0.001), while GVHD (P= 0.04) predicted survival. Mortality at 12 months was independently predicted by the acute physiology score (P= 0.002), increasing number of organ failures (P= 0.001), and cytomegalovirus positive serology (P= 0.005), while blood stream infection (P= 0.003), an antibiotic change on admission to the ICU (P= 0.007) and a diagnosis of non‐Hodgkin lymphoma (P= 0.02) predicted survival. Conclusion: Our study found that acute admission of HSCT patients to the ICU is associated with improved survival compared to our previous experience, with organ failure progression a strong predictor of ICU outcome, and specific disease characteristics contributing to long‐term survival.     

Sequential organ failure predicts mortality of patients with a haematological malignancy needing intensive care

OBJECTIVES: Poor survival of patients with a haematological malignancy admitted to the intensive care unit (ICU) prompts for proper admission triage and prediction of ICU treatment failure and long-term mortality. We therefore tried to find predictors of the latter outcomes. METHODS: A retrospective analysis of charts and a prospective follow-up study were done, of haemato-oncological patients, admitted to our ICU in a 7-year period with a follow-up until 2 yr thereafter. Clinical parameters during the first four consecutive days were taken to calculate the simplified acute physiology (SAPS II) and the sequential organ failure assessment (SOFA) scores, of proven predictive value in general ICU populations. RESULTS: From a total of 58 patients (n = 47 with acute myelogenous leukaemia or non-Hodgkin lymphoma), admitted into ICU mostly because of respiratory insufficiency, sepsis, shock or combinations, 36 patients had died during their stay in the ICU. Of ICU survivors (n = 22), 20 patients died during follow-up so that the 1-year survival rate was only 12%. The SAPS II and particularly the SOFA scores were of high predictive value for ICU and long-term mortality. CONCLUSIONS: Patients with life-threatening complications of haematological malignancy admitted to ICU ran a high risk for death in the ICU and on the long-term, and the risk can be well predicted by SOFA. The latter may help us to decide on intensive care in individual cases, in order to avoid potentially futile care for patients with a SOFA score of 15 or higher.     

Improved survival with highly active antiretroviral therapy in HIV-infected patients with severe Pneumocystis carinii pneumonia

BACKGROUND: Although the incidence of pneumonia (PCP) has declined, mortality of patients who require intensive care for this disease remains high. Highly active antiretroviral therapy (HAART) might alter the course of PCP either via effects on the immune system or through anti- actions; however, HAART has not been studied in patients acutely ill with PCP. OBJECTIVE: To assess the effects of HAART on outcome of patients admitted to the intensive care unit (ICU) with PCP. DESIGN AND SETTING: Retrospective cohort study carried out at a University-affiliated county hospital. PARTICIPANTS: Fifty-eight HIV-infected adults with PCP admitted to an ICU from 1996 to 2001. MEASUREMENTS: A standardized chart review was performed to collect information on demographic variables, hospital course, and use of antiretroviral therapy. Outcome measured was death while in the ICU or hospital. RESULTS: A total of 20.7% of patients were either receiving HAART or were started on therapy while hospitalized. Mortality in this group was 25%, whereas mortality in those not receiving therapy was 63% (P = 0.03). Multiple logistic regression analyses adjusting for potential confounders showed that HAART started either before or during hospitalization was associated with a lower mortality [odds ratio (OR), 0.14; 95% confidence interval (95% CI), 0.02-0.84; = 0.03). The need for mechanical ventilation and/or development of a pneumothorax (OR, 20.9; 95% CI, 1.9-227.2; = 0.01) and delayed ICU admission (OR, 9.7; 95% CI, 2.2-42.1; = 0.002) were associated with increased mortality. CONCLUSIONS: Use of HAART is an independent predictor of decreased mortality in severe PCP and may represent a potential therapy to improve outcome in this disease.     

Clinical outcomes and need for intensive care after non-ST-segment-elevation myocardial infarction

BackgroundThe decision on whether non-ST-segment elevation myocardial infarction (NSTEMI) patients should be admitted to intensive care units (ICU) takes into account several factors including hospital routines. The Acute Coronary Treatment and Intervention Outcomes Network (ACTION) ICU score was developed to predict complications requiring ICU care post-NSTEMI.MethodsWe described patient characteristics and clinical outcomes of 1263 NSTEMI patients admitted to a private hospital in Sao Paulo, Brazil, from 2014 to 2018. We also aimed to retrospectively identify NSTEMI patients who might not have needed to be admitted to the ICU based on the ACTION ICU risk score. We defined complications requiring ICU care post-NSTEMI as cardiac arrest, cardiogenic shock, stroke, re-infarction, death, heart block requiring pacemaker placement, respiratory failure, or sepsis.ResultsMean age was 62.3 years and 35.8% were female. A total of 94.6% of NSTEMI patients were admitted to the ICU. Most NSTEMI patients (91.9%) underwent coronary angiography. Percutaneous coronary intervention was performed in 47.1% and coronary artery bypass graft surgery in 10.3%. Complications requiring ICU care occurred in 62 patients (4.9%). In-hospital mortality rate was 1.3%. Overall, 70.4% had an ACTION ICU score ≤ 5. The C-statistics for the ACTION risk score to predict complications was 0.55 (95% confidence interval 0.47–0.63).ConclusionsComplications requiring ICU care were infrequent in a cohort of NSTEMI patients who were routinely admitted to the ICU over a 4-year period. The ACTION risk score had low accuracy in the prediction of complications requiring ICU care in our population.     

Reappraisal of the aetiology and prognostic factors of severe acute respiratory failure in HIV patients.

The introduction of highly active antiretroviral therapy with protease inhibitors in 1996 has changed the morbidity and mortality of acquired immune deficiency syndrome patients. Therefore, the aetiologies and prognostic factors of human immunodeficiency virus (HIV)-infected patients with life-threatening respiratory failure requiring intensive care unit (ICU) admission need to be reassessed. From 1993 to 1998, we prospectively evaluated 57 HIV patients (mean+/-SEM age 36.5+/-1.3 yrs) admitted to the ICU showing pulmonary infiltrates and acute respiratory failure. A total of 21 and 30 patients were diagnosed as having Pneumocystis carinii and bacterial pneumonia, respectively, of whom 13 and eight died during their ICU stay (p=0.01). Both groups of patients had similar age, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and severity in respiratory failure. The number of cases with bacterial pneumonia admitted to ICU decreased after 1996 (p=0.05). Logistic regression analysis showed that (APACHE) II score >17, serum albumin level <25 g.(-1), and diagnosis of P. carinii pneumonia were the only factors at entry associated with ICU mortality (p=0.02). Patients with bacterial pneumonia are less frequently admitted to the intensive care unit after the introduction of highly active antiretroviral therapy with protease inhibitors in 1996. Compared to the previous series, it was observed that the few Pneumocystis carinii pneumonia patients that need intensive care still have a bad prognosis.     

Pneumocystis jiroveci pneumonia in patients with AIDS in the inner city: a persistent and deadly opportunistic infection

Highly active antiretroviral therapy (HAART) has decreased the morbidity and mortality of opportunistic infections including Pneumocystis jiroveci pneumonia (PCP) among HIV-infected individuals. We performed a hospital-based retrospective cohort study among a population of medically underserved inner city persons living in Atlanta, Georgia, diagnosed with confirmed PCP to compare the epidemiology and outcomes of PCP during 2 defined periods: 1990 to 1995, or pre-HAART period, and 1996 to 2001, or HAART period. A total of 488 patients were available for analysis. The overall mortality rate was 47% during the pre-HAART era compared with 37% during the HAART era (P = 0.02). However, among those patients that required medical intensive care unit admission and mechanical ventilation, the mortality rate was particularly high, with over 80% of patients dying as a result of their episode of PCP during both periods. PCP was the initial presentation of HIV infection in 39.3% in the pre-HAART period with a mortality rate of 52%, in contrast with 37% in the HAART period, with a mortality rate of 45%, respectively (P = NS). Only 30.7% in the pre-HAART period and 31.1% of patients in the HAART period were receiving PCP prophylaxis. The overall risk of death, when we combined both groups in the analysis, was higher for those patients who did not take PCP prophylaxis, those who smoked tobacco, and those who were admitted to the medical intensive care unit and required mechanical ventilatory support. Our findings suggest that despite the availability of HAART, PCP continues to cause a significant burden of disease among inner-city HIV-infected populations.     

Outcomes of intensive care unit care in adults with cystic fibrosis

Cystic fibrosis (CF) causes progressive respiratory failure and death in more than 90% of patients. Mechanical ventilation has been discouraged in CF because of poor outcomes, but improved survival and the availability of lung transplantation have increased the indications for care of CF patients in the intensive care unit (ICU). We studied the outcomes of all CF patients admitted to the University of North Carolina Hospitals Medical ICU from January 1990 through December 1998. Seventy-six patients, ranging in ages from 17 to 45 yr (mean: 27 yr), and of whom 53% were female, had 136 admissions for exacerbations of CF with respiratory failure (RF, n = 65), hemoptysis (n = 33), antibiotic desensitization (n = 30), pneumothorax (n = 3), or other reasons (n = 5). Eighty-six percent of the patients with hemoptysis and all of those with desensitization and pneumothorax were alive 1 yr after ICU discharge. Of the 42 patients with RF, 37 (88%) required assisted ventilation. Twenty-three (55%) of the patients with RF survived to ICU discharge and 19 (45%) died. Seventeen (40%) of the patients with RF received lung transplants and 14 were alive 1 yr later. Without transplantation, three (7%) of the patients with RF were alive and three (7%) were dead 1 yr later. Sex, body mass index, and respiratory bacteria did not correlate with survival. We conclude that ICU care for adults with CF who have reversible complications is appropriate and effective. Ventilatory support is appropriate for some transplant candidates.     

Characteristics and outcome of patients with active pulmonary tuberculosis requiring intensive care.

Severe tuberculosis (TB) requiring intensive care unit (ICU) care is rare but commonly known to be of markedly bad prognosis. The present study aimed to describe this condition and to determine the mortality rate and risk factors associated with mortality. Patients with confirmed TB admitted to ICU between 1990 and 2001 were retrospectively identified and enrolled. Clinical, radiological and bacteriological data at admission and during hospital stay were recorded. A multivariate analysis was performed to identify the predictive factors for mortality. A total of 58 TB patients (12 females, mean age 48 yrs) admitted to ICU were included. Mean Acute Physiology and Chronic Health Evaluation (APACHE) II score at admission was 13.1+/-5.6 and 22 of 58 (37.9%) patients required mechanical ventilation. The in-hospital mortality was 15 of 58 (25.9%); 13 (22.4%) patients died in the ICU. The mean survival of patients who died was 53.6 days (range 1-229), with 50% of the patients dying within the first 32 days. The factors independently associated with mortality were: acute renal failure, need for mechanical ventilation, chronic pancreatitis, sepsis, acute respiratory distress syndrome, and nosocomial pneumonia. These data indicate a high mortality of patients with tuberculosis requiring intensive care unit care and identifies new independently associated risk factors.     

SARS in the intensive care unit

Approximately 20% of patients with severe acute respiratory syndrome (SARS) develop respiratory failure that requires admission to an intensive care unit (ICU). Old age, comorbidity, and elevated lactate dehydrogenase on hospital admission are associated with increased risk for ICU admission. ICU admission usually is late and occurs 8 to 10 days after symptom onset. Acute respiratory distress syndrome occurs in almost all admitted patients and most require mechanical ventilation. ICU admission is associated with significant morbidity, particularly an apparent increase in the incidence of barotrauma and nosocomial sepsis. Long-term mortality for patients admitted to the ICU ranges from 30% to 50%. Many procedures in ICUs pose a high risk for transmission of SARS coronavirus to health care workers. Contact and airborne infection isolation precautions, in addition to standard precautions, should be applied when caring for patients with SARS. Ensuring staff safety is important to maintain staff morale and delivery of adequate services.