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 carinii pneumonia and respiratory failure in AIDS. Improved outcomes and increased use of intensive care units

To determine whether the outcome of intensive care for patients with AIDS, Pneumocystis carinii pneumonia (PCP), and respiratory failure has changed, we studied patients admitted to the intensive care units an San Francisco General Hospital from 1981 to 1988. We compared the course of patients with PCP and respiratory failure admitted to the intensive care unit from 1986 to 1988 with a similar cohort hospitalized from 1981 to 1985. The hospital survival rate for the 35 patients in the 1986 to 1988 cohort was 40%, compared with 14% for the 42 patients in the 1981 to 1985 cohort (p less than 0.01). Age, episode of PCP, time since AIDS diagnosis, anti-PCP therapy, and important clinical variables were similar in both cohorts. Corticosteroids were used commonly in the recent era. Patients who received steroids had an in-hospital survival rate of 46%, compared with 22% for those who did not receive steroids (p = NS). In a stepwise logistic regression model, ICU care in the recent era and higher serum albumin at the time of ICU admission were the only variables significantly associated with survival. The hospital survival of patients with PCP and respiratory failure has improved. The improvement could not be explained by patient selection or by better anti-PCP therapy. The apparent beneficial effect of corticosteroids deserves further study. The improvement in ICU outcome was reflected in increased ICU utilization by patients with AIDS, PCP, and respiratory failure.     

The role of new therapies for severe community-acquired pneumonia

PURPOSE OF REVIEW: Community-acquired pneumonia (CAP) is associated with significant morbidity and mortality and is the most common cause of death from infectious diseases. CAP patients requiring intensive care unit (ICU) admission carry the highest mortality rates. This paper aims to review the current literature regarding epidemiology, risk factors, severity criteria and reasons for admitting the hospitalized patient to the ICU, and the empiric and specific antibiotic therapeutic regimens employed. RECENT FINDINGS: Multiple sets of clinical practice guidelines have been published in the past few years addressing the treatment of CAP. The guidelines all agree that CAP patients admitted to the hospital represent a major concern, and appropriate empiric therapy should be instituted to improve clinical outcomes. SUMMARY: The cost, morbidity and mortality of CAP patients requiring ICU admission remain unacceptably high. These are heterogeneous groups of patients, so it is important to use risk-stratification based on clinical parameters and prediction tools. Appropriate antibiotic therapy is an important component in the management of both groups of patients. In particular, it is essential to administer an appropriate antimicrobial agent from the initiation of therapy, so that the risks of treatment failure and the morbidity of CAP may be minimized.     

Impact of a comprehensive supportive care team on management of hopelessly ill patients with multiple organ failure

We developed a supportive care team for hopelessly ill patients in an urban emergency/trauma hospital. The team includes a clinical nurse specialist and a faculty physician as well as a chaplain and social worker. The supportive care team provides an alternative to intensive care or conventional ward management of hopelessly ill patients and concentrates on the physical and psychosocial comfort needs of patients and their families. We describe our experience with 20 hopelessly ill patients with multiple organ failure vs a similar group treated before the development of the supportive care team. Although there was no difference in mortality (100 percent), the length of stay in the medical ICU for patients with multiple organ failure decreased by 12 days to 6 days. Additionally, there were 50 percent fewer therapeutic interventions provided by the supportive care team vs intensive care or conventional ward treatment of multiple organ failure patients. We describe the methods that the supportive care team uses in an attempt to meet the physical and psychosocial comfort needs of hopelessly ill multiple organ failure patients and their families. This multidisciplinary approach to the care of the hopelessly ill may have applications in other institutions facing the ethical, medical, and administrative challenges raised by these patients.     

Special Considerations in Critical Care of the Congenital Heart Disease Patient

Outcomes of congenital heart disease have improved markedly over the past 20 years, with survival to adulthood now close to 90%. The mean age of admission to an intensive care unit (ICU) is 40 years. The incidence of hospital and critical care admissions have increased significantly as a consequence of this improved survival. Intensivists are now confronted with the management not only of complex adult congenital heart disease (ACHD) lesions from a cardiac perspective, but also of extracardiac organ consequences of years of abnormal circulation after surgical or palliative correction. Kidney and liver dysfunction and respiratory and hematologic abnormalities are very common in this population. ACHD patients can present to the ICU for a vast number of reasons, classified in this review as medical noncardiac, medical cardiac, and surgical. Community/hospital–acquired infections, cerebrovascular accidents, and respiratory failure, alongside arrhythmias and heart failure, are responsible for medical admissions. Surgical admissions include postoperative management after correction or palliation, but also medical optimisation and work-up for advanced therapies. ICU management of this large heterogeneous group requires a thorough understanding of the pathophysiology in order to apply conventional adult critical care modalities; left ventricular or right ventricular dysfunction, pulmonary hypertension, intracardiac, extracardiac, and palliative surgical shunts can be present and require additional consideration. This review focuses on the pathophysiology, long-term sequelae, and different treatment modalities to supply a framework for the ICU physician caring for these patients. Successful outcome, especially in complex lesions, depends on early involvement of specialised ACHD centres.     

Outcome of patients with scleroderma admitted to intensive care unit. A report of nine cases

OBJECTIVE: Patients with systemic rheumatic disease constitute a small percentage of admissions to the medical intensive care units (ICUs). Systemic sclerosis (SSc) is one of the rheumatic diseases that together with secondary complications may lead to a critical illness requiring hospitalization in the ICU. We present the features, clinical course and outcome of critically ill patients with scleroderma that were admitted to the ICU. METHODS: The medical records of nine patients with diagnosis of scleroderma (8 female, 1 male), admitted to the intensive care unit of Sheba Medical Center during the 11-year interval between 1991 and 2002, were reviewed. RESULTS: The mean age of the patients at the time of admission to the ICU was 48 +/- 13 [SD] years.The mean duration of SSc from diagnosis to the ICU admission was 8 +/- 8 years. Six patients had diffuse SSc, two patients had limited SSc and one patient had juvenile diffuse morphea. The main reasons for admission to the ICU were: infection/ septic syndrome (n = 4), scleroderma renal crisis (SRC) with pulmonary congestion (n = 2), acute renal failure associated with diffuse alveolar hemorrhage namely scleroderma- pulmonary - renal syndrome (SPRS) (n = 1), iatrogenic pericardial tamponade (n = 1), mesenteric ischemia (n = 1). The patients had high severity illness score (mean APACHE II 25 +/- 3). Eight out of nine patients (89%) that were admitted to the ICU died during the hospitalization, six (66.6%) of them died in the ICU. Septic complications as the main cause of death were determined in five patients (62.5%), while four of them had pneumonia and acute respiratory failure along with underlying severe pulmonary fibrosis. Lungs and kidneys were the most common severely affected organs by SSc in our patients. CONCLUSION: The outcome of scleroderma patients admitted to the ICU was extremely poor. Infectious complication was the most common cause of death in our patients. Although infections are treatable, the high mortality rate for this group of patients was dependent on the severity of the underlying visceral organ involvement, particularly severe pulmonary fibrosis. The severity of this involvement is a poor outcome predictor. An early diagnosis and an appropriate treatment of such complications may help to reduce the mortality in scleroderma patients.     

Dramatic improvement in hypoxemic respiratory failure after patent foramen ovale closure in a patient with obesity hypoventilation syndrome

We report a case of a patient with pulmonary hypertension who presented with acute hypoxemic respiratory failure. The patient had continued refractory hypoxemia despite a prolonged ICU admission that included ventilatory support, and empiric therapy for pulmonary embolism and pneumonia. Transthoracic echocardiography (TTE) revealed a patent foramen ovale (PFO), which after percutaneous closure resulted in profound improvement in hypoxemia and clinical status.     

Outcome predictors of cirrhosis patients admitted to the intensive care unit

OBJECTIVE: To evaluate outcome predictors of patients with cirrhosis admitted to an intensive care unit (ICU). METHODS: One hundred and twenty-nine consecutive patients with cirrhosis admitted to the ICU at a tertiary care transplant centre in Saudi Arabia between March 1999 and December 2000 were entered prospectively in an ICU database. Liver transplantation patients and readmissions to the ICU were excluded. The following data were documented: demographic features, severity of illness measures, parameters of organ failure, presence of gastrointestinal bleeding, and sepsis. The need for mechanical ventilation, renal replacement therapy and pulmonary artery catheter placement was recorded. The primary endpoint was hospital outcome. RESULTS: Cirrhotic patients admitted to the ICU had high hospital mortality (73.6%). However, the actual mortality was not significantly different from the predicted mortality using prediction systems. There was an association between the number of organs failing and mortality. Coma and acute renal failure emerged as independent predictors of mortality. All patients who were monitored with pulmonary artery catheterisation in this study died. Patients requiring mechanical ventilation and renal replacement therapy had very high mortalities (84% and 89%, respectively). All 13 cirrhotic patients admitted to ICU immediately post-cardiac arrest in this study died. CONCLUSIONS: Cirrhotic patients admitted to ICU have a poor prognosis, especially when admitted with coma, acute renal failure or post-cardiac arrest. The consistently poor prognosis associated with certain ICU interventions should raise new awareness regarding limitations of medical therapy. These mortality statistics compel a critical re-examination of uniformly aggressive life support for the critically ill cirrhotic patient, a percentage of whom will not benefit from invasive measures.     

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.     

Continuous arteriovenous hemofiltration in the elderly patients

The outcome of continuous arteriovenous hemofiltration (CAVH) treatment was evaluated in fifty one critically ill elderly with acute renal failure (ARF). They were admitted into our University Hospital's intensive-care units (ICU) during January 1987 and December 1990. Mean age (± SD) was 70.7 ± 5 (range 65–84) years. Elderly patients (>65 years old) comprised 44% of the ICU-ARF patients. The causes of ARF were cardiac surgery (41%), medical (31%), aneurysm of the resection of abdominal aorta (20%), and general surgery (8%). In the majority of the patients ARF was complicated by multiple organ failure. A survival of 60% was obtained with CAVH treatment. The highest survival rate (69%) was noted among cardiac surgery ARF patients, while the lowest survival (25%) was seen among patients with ARF following aneurysm of the resection of abdominal aorta. From the results of this study we conclude that CAVH serves a benificial role if it is considered in the management of ARF in the elderly intensive care patients with multiple organ failure.     

Allocation of patients with liver cirrhosis and organ failure to intensive care: Systematic review and a proposal for clinical practice

AIM: To propose an allocation system of patients with liver cirrhosis to intensive care unit(ICU), and developed a decision tool for clinical practice. METHODS: A systematic review of the literature was performed in Pub Med, MEDLINE and EMBASE databases. The search includes studies on hospitalized patients with cirrhosis and organ failure, or acute on chronic liver failure and/or intensive care therapy. RESULTS: The initial search identified 660 potentially relevant articles. Ultimately, five articles were selected; two cohort studies and three reviews were found eligible. The literature on this topic is scarce and no studies specifically address allocation of patients with liver cirrhosis to ICU. Throughout the literature, there is consensus that selection criteria for ICU admission should be developed and validated for this group of patients and multidisciplinary approach is mandatory. Based on current available data we developed an algorithm, to determine if a patient is candidate to intensive care if needed, based on three scoring systems: premorbid Child-Pugh Score, Model of End stage Liver Disease score and the liver specific Sequential Organ Failure Assessment score.CONCLUSION: There are no established systems for allocation of patients with liver cirrhosis to the ICU and no evidence-based recommendations can be made.     

Considerations in Critical-Care and Anesthetic Management of Adult Patients Living With Fontan Circulation

The Fontan procedure is a staged palliation for various complex congenital cardiac lesions, including tricuspid atresia, pulmonary atresia, hypoplastic left heart syndrome, and double-inlet left ventricle, all of which involve a functional single-ventricle physiology. The complexity of the patients’ original anatomy combined with the anatomic and physiologic consequences of the Fontan circulation creates challenges. Teens and adults living with Fontan palliation will need perioperative support for noncardiac surgery, peripartum management for labour and delivery, interventions related to their structural heart disease, electrophysiology procedures, pacemakers, cardioversions, cardiac surgery, transplantation, and advanced mechanical support. This review focuses on the anesthetic and intensive care unit (ICU) management of these patients during their perioperative journey, with an emphasis on the continuity of preintervention planning, referral pathways, and postintervention ICU management. Requests for recipes and doses of medications are frequent; however, as in normal anesthesia and ICU practice, the method of anesthesia and dosing are dependent on the presenting medical/surgical conditions and the underlying anatomy and physiologic reserve. A patient with Fontan palliation in their early 20s attending school full-time with a cavopulmonary connection is likely to have more reserve than a patient in their late 40s with an atriopulmonary Fontan at home waiting for a heart transplant. Each case will require an anesthetic and critical care plan tailored to the situation. The critical care environment is a natural extension of the anesthetic management of a patient, with complex considerations for a patient with Fontan palliation.     

综合医院危重症患者1735例死亡危险因素分析

目的探讨综合医院危重症患者死亡的危险因素,以提高诊治质量。方法回顾性分析2005年至2010年重症监护病房收治的1735例患者,其中198例于重症监护病房（ICU）死亡,135例出ICU后死亡,对198例患者各年龄段进行统计学分析,并调查疾病分布特点;对比ICU内、外器官功能衰竭数与死亡率,检验各种危险因素对死亡的影响。结果老年组死亡率明显高于非老年组,差异有统计学意义（P〈0.01）。随年龄增长,死亡率呈增高趋势;发生功能障碍器官数与死亡率密切相关,功能障碍器官数越多,死亡率越高;当有5个或5个以上器官发生功能障碍时,死亡率接近100%。当衰竭器官数≤3个时,ICU内死亡率明显低于ICU外死亡率（P〈0.01）。从器官功能障碍分布来看,心血管系统功能障碍发生率高达51.8%,死亡率却低;致死性最高的功能障碍器官是：血液（59.3%）、肾（58.7%）;ICU内、外致死的障碍功能器官不同。结论降低危重症患者死亡率首先要降低≥60岁老年人的死亡率,明确原发病和受损器官,积极控制疾病向多器官功能衰竭的发展,保护重要脏器功能在危重症患者治疗中占重要地位。     

Bronchoscopy in intubated and non-intubated intensive care unit patients with respiratory failure

Bronchoscopy is one of the important tool for the pulmonary and critical care physicians to diagnose and treat various pulmonary conditions. It is increasingly being used by the intensivist due to its safety and portability. The utilization of bronchoscopy in the intensive care unit (ICU) has made the diagnosis and treatment of many conditions more feasible to intensivists. Sedation, topical or intravenous, usually helps better tolerate the procedure. However, the risks and benefits of bronchoscopy should be carefully considered in critically ill patients. The hypoxic patients in ICU pose a challenge as hypoxemia is one of the known complications of bronchoscopy, and this risk is exacerbated in patients with hypoxic respiratory failure. Bronchoscopy is relatively contraindicated in patients with severe hypoxemia and coagulopathy. However, bronchoscopy in hypoxic patients can have diagnostic as well as therapeutic implications. In patients with hypoxic respiratory failure, the use of non-invasive ventilation (NIV) during bronchoscopy has been shown to reduce the risk of intubation. On the other hand, bronchoscopy in mechanically ventilated patients is not contraindicated and has been widely used. Staying focused, monitoring vital signs closely, limiting the scope time in the airway, and understanding patient’s physiology may help decrease risk of complications. In this review, we discuss indications, techniques, complications, and yield associated with bronchoscopy in critically ill hypoxic patients.     

Emergency department management of patients with acute decompensated heart failure

The Acute Decompensated HEart Failure National REgistry (ADHERE(R)) confirms that the management of decompensated heart failure is an emergency department (ED) problem, as more than 75% of patients admitted to the hospital with heart failure arrive through the ED. This emphasizes the need for collaboration among emergency medicine, cardiology, nephrology, and hospitalists in the management of acute decompensated heart failure. Such collaboration is important for several reasons, including the enhancement of patient care. It is also known that most hospitals lose money on heart failure admissions. Strategies that can be employed to limit hospital losses on heart failure include reducing admissions from the ED; decreasing the length of hospital stay; increasing the use of the observation unit; reducing re-admissions, particularly through the first 30 days; and reducing the use of high-resource areas such as the intensive care unit (ICU). This article will focus on initiatives that can be implemented in the ED to help with these strategies. In particular, we will discuss early initiation of therapy and its ability to improve length of stay, reduce re-admissions, and reduce ICU admissions. Use of the observation unit for the management of heart failure will also be discussed as a way of decreasing admissions from the ED.     

Intensive care for the elderly: outcome of elective and nonelective admissions

Survival, quality of life, and need for continuing medical care were evaluated for 134 elderly patients admitted to the intensive care units (ICU) at Stanford University Hospital and for a control group. Of the patient group, 57.5% were admitted to the ICU following elective surgery; 42.5% were emergency surgical and medical patients. Hospital mortality was 3.9% for elective and 22.8% for nonelective patients; 18-month mortality was 13.0% and 47.4%, respectively. Fifty-nine patients (60.8% of survivors) completed follow-up questionnaires. Subjective and objective quality of life was good. Quality of life was slightly worse for ICU survivors than for controls; elective and nonelective patients did not differ significantly. Although the cost of ICU hospitalization was high, additional medical care was not excessive. Nonelective patients required more continuing care than elective patients, and both groups required more than controls.     

Emergency Department Management of Patients with Acute Decompensated Heart Failure

The Acute Decompensated HEart Failure National REgistry (ADHERE®) confirms that the management of decompensated heart failure is an emergency department (ED) problem, as more than 75% of patients admitted to the hospital with heart failure arrive through the ED. This emphasizes the need for collaboration among emergency medicine, cardiology, nephrology, and hospitalists in the management of acute decompensated heart failure. Such collaboration is important for several reasons, including the enhancement of patient care. It is also known that most hospitals lose money on heart failure admissions. Strategies that can be employed to limit hospital losses on heart failure include reducing admissions from the ED; decreasing the length of hospital stay; increasing the use of the observation unit; reducing re-admissions, particularly through the first 30 days; and reducing the use of high-resource areas such as the intensive care unit (ICU). This article will focus on initiatives that can be implemented in the ED to help with these strategies. In particular, we will discuss early initiation of therapy and its ability to improve length of stay, reduce re-admissions, and reduce ICU admissions. Use of the observation unit for the management of heart failure will also be discussed as a way of decreasing admissions from the ED.Supported by an unrestricted educational grant from Scios Inc.     

Beyond diabetes: saving lives with insulin in the ICU

The risk of mortality or significant moridity is high among long-stay intensive care unit (ICU) patients. Sepsis, polyneuropathy and multiple organ failure are prominent causes of mortality and morbidity in the ICU. Many ICU patients are hyperglycaemic, presumably reflecting an adaptive development of insulin resistance. We hypothesized that this hyperglycaemia predisposes patients to many of the typical ICU complications, prolonged intensive care dependence and excess mortality. Insulin therapy directed at establishing normoglycaemia was investigated in a series of 1548 ICU patients. An intensive treatment group received insulin infusion tailored to control blood glucose levels in the range 4.4-6.1 mmol/l (80-110 mg/dl), whereas the conventional treatment group only received insulin when glucose levels exceeded 11.1 mmol/l (200 mg/dl) and in that event were maintained in a target range of 10.0-11.1 mmol/l (180-200 mg/dl). Intensive management of blood glucose levels was reflected in a 43% reduction in intensive care mortality risk (P=0.036 after correction for interim analyses) and a 34% reduction in hospital mortality (P=0.01). A reduced risk of infection was reflected in a 46% reduction in the risk of septicaemia (P=0.003) and a 35% reduction in the need for prolonged (>10 d) antibiotic therapy (P<0.001). Regression analysis suggests that control of glucose levels, rather than insulin administration itself, was responsible for the clinical benefits observed. Use of insulin infusion to control glucose levels in ICU patients, at least in populations similar to those in our study, can be expected to achieve clinically welcome improvements in outcome. An algorithm is proposed for implementing this. Further data are needed to establish the applicability of this strategy to other patient groups in the ICU and in general hospital care.