The surprise question - "Would I be surprised if this patient died in the next 12 months?" - has been used to identify patients at high risk of death who might benefit from palliative care services. ...Our objective was to systematically review the performance characteristics of the surprise question in predicting death.
We searched multiple electronic databases from inception to 2016 to identify studies that prospectively screened patients with the surprise question and reported on death at 6 to 18 months. We constructed models of hierarchical summary receiver operating characteristics (sROCs) to determine prognostic performance.
Sixteen studies (17 cohorts, 11 621 patients) met the selection criteria. For the outcome of death at 6 to 18 months, the pooled prognostic characteristics were sensitivity 67.0% (95% confidence interval CI 55.7%-76.7%), specificity 80.2% (73.3%-85.6%), positive likelihood ratio 3.4 (95% CI 2.8-4.1), negative likelihood ratio 0.41 (95% CI 0.32-0.54), positive predictive value 37.1% (95% CI 30.2%-44.6%) and negative predictive value 93.1% (95% CI 91.0%-94.8%). The surprise question had worse discrimination in patients with noncancer illness (area under sROC curve 0.77 95% CI 0.73-0.81) than in patients with cancer (area under sROC curve 0.83 95% CI 0.79-0.87;
= 0.02 for difference). Most studies had a moderate to high risk of bias, often because they had a low or unknown participation rate or had missing data.
The surprise question performs poorly to modestly as a predictive tool for death, with worse performance in noncancer illness. Further studies are needed to develop accurate tools to identify patients with palliative care needs and to assess the surprise question for this purpose.
Purpose
Oral chlorhexidine is used widely for mechanically ventilated patients to prevent pneumonia, but recent studies show an association with excess mortality. We examined whether de-adoption of ...chlorhexidine and parallel implementation of a standardized oral care bundle reduces intensive care unit (ICU) mortality in mechanically ventilated patients.
Methods
A stepped wedge cluster-randomized controlled trial with concurrent process evaluation in 6 ICUs in Toronto, Canada. Clusters were randomized to de-adopt chlorhexidine and implement a standardized oral care bundle at 2-month intervals. The primary outcome was ICU mortality. Secondary outcomes were time to infection-related ventilator-associated complications (IVACs), oral procedural pain and oral health dysfunction. An exploratory post hoc analysis examined time to extubation in survivors.
Results
A total of 3260 patients were enrolled; 1560 control, 1700 intervention. ICU mortality for the intervention and control periods were 399 (23.5%) and 330 (21.2%), respectively (adjusted odds ratio aOR, 1.13; 95% confidence interval CI 0.82 to 1.54;
P
= 0.46). Time to IVACs (adjusted hazard ratio aHR, 1.06; 95% CI 0.44 to 2.57;
P
= 0.90), time to extubation (aHR 1.03; 95% CI 0.85 to 1.23;
P
= 0.79) (survivors) and oral procedural pain (aOR, 0.62; 95% CI 0.34 to 1.10;
P
= 0.10) were similar between control and intervention periods. However, oral health dysfunction scores (− 0.96; 95% CI − 1.75 to − 0.17;
P
= 0.02) improved in the intervention period.
Conclusion
Among mechanically ventilated ICU patients, no benefit was observed for de-adoption of chlorhexidine and implementation of an oral care bundle on ICU mortality, IVACs, oral procedural pain, or time to extubation. The intervention may improve oral health.
•Candida colonization is associated with an increased chance of invasive Candida infection as a cause of sepsis in critically ill patients.•A lack of history of Candida colonization is helpful to ...rule out Candida as a cause of sepsis.•A history of Candida colonization has a low positive predictive value for ruling in Candida as a cause of sepsis.
Candida colonization is a risk factor for the development of invasive candidiasis. This study sought to estimate the magnitude of this association, and determine if this information can be used to guide empirical antifungal therapy initiation in critically ill septic patients.
PubMed/MEDLINE and Embase were systematically reviewed for all published studies evaluating predictors of invasive candidiasis in ICU patients with sepsis. Meta-analysis was used to determine the pooled odds ratio for invasive candidiasis among colonized versus non-colonized patients. Sensitivity (SN), specificity (SP), positive and negative predictive values (PPV, NPV), and positive and negative likelihood ratios (+LR, ―LR) were then calculated by considering the presence/absence of Candida colonization as the diagnostic test, and the presence/absence of invasive candidiasis as the disease of interest.
Out of 9825 patients in the 10 eligible studies, 3886 (40%) were colonized with Candida and 462 patients (4.7%) developed invasive candidiasis. Meta-analysis indicated that critically ill patients with sepsis who are colonized with candida are more likely to develop invasive candidiasis (odds ratio 3.32; 95% CI 1.68–6.58) compared with non-colonized patients. The pooled SN was 75.2% (95% CI 59.6–86.2%), while the pooled SP was 49.2% (95% CI 33.2–65.3%).The NPV of Candida colonization was high (96.9%; 95% CI 92.0–98.9%), but the PPV was low (9.1%; 95% CI 5.5–14.6%).
Candida colonization is strongly associated with the likelihood of invasive candidiasis among ICU patients with sepsis. Available data argue against initiating empirical antifungal treatment in non-neutropenic septic patients without prior documented Candida colonization.
In this trial of intravenous vitamin C in adult patients with sepsis, those who received a vitamin C infusion had a higher risk of death or persistent organ dysfunction at 28 days than those who ...received placebo.
Ebola virus disease emerged in West Africa in March of 2014. In this report, the clinical presentation of 37 patients with confirmed EVD in Guinea is described during the early stages of the ...outbreak.
Ebola virus is one of three members of the Filoviridae family and comprises five distinct species. Infection with
Zaire ebolavirus
(EBOV) has historically resulted in the highest case fatality rate — up to 90%.
1
Outbreaks typically originate with introduction of the virus into humans from a wild animal reservoir, with subsequent human-to-human transmission, often fueled by nosocomial amplification in resource-poor settings. Aside from a single infection with
Tai Forest ebolavirus,
West Africa has never had an outbreak of Ebola virus disease (EVD).
2
,
3
The Republic of Guinea, on the west coast of Africa, has a population of approximately 11 million . . .
Limited data are available to characterize the long-term outcomes and associated costs for patients who require prolonged mechanical ventilation (PMV; defined here as mechanical ventilation for ...longer than 21 d).
To examine the association between PMV and mortality, health care utilization, and costs after critical illness.
Population-based cohort study of adults who received mechanical ventilation in an intensive care unit (ICU) in Ontario, Canada between 2002 and 2013.
We used linked administrative databases to determine discharge disposition, and ascertain 1-year mortality (primary outcome), readmissions to hospital and ICU, and health care costs for hospital survivors. Overall, 11,594 (5.4%) patients underwent PMV, with 42.4% of patients dying in the hospital (vs. 27.6% of patients who did not undergo prolonged ventilation; P < 0.0001). Patients on prolonged ventilation were more frequently discharged to other facilities or home with health care support (84.8 vs. 43.5%, P < 0.0001). Among hospital survivors, estimated mortality was higher for patients who underwent PMV: 16.6 versus 11% at 1 year and 42.0 versus 30.4% at 5 years. At 1 year after hospital discharge, patients on prolonged ventilation had higher rates of hospital readmission (47.2 vs. 37.7%; adjusted odds ratio = 1.20; 95% confidence interval = 1.14-1.26), ICU readmission (19.0 vs. 11.6%; adjusted odds ratio = 1.49; 95% confidence interval: 1.39, 1.60), and total health care costs: median (interquartile range) Can $32,526 ($20,821-$56,102) versus Can $13,657 ($5,946-$38,022). Increasing duration of mechanical ventilation was associated with higher mortality and health care utilization.
Critically ill patients who undergo mechanical ventilation in an ICU for longer than 21 days have high in-hospital mortality and greater postdischarge mortality, health care utilization, and health care costs compared with patients who undergo mechanical ventilation for a shorter period of time.
Hyperglycemia during the acute phase after burn is associated with increased morbidity and mortality. There is little knowledge regarding the effect of pre-existing hyperglycemia in the form of ...diabetes on the outcomes after severe burns. The objective is to determine the impact of diabetes on clinical outcomes after burns.
Single-center cohort study where adult diabetic (n = 76) and non-diabetic (n = 1186) burn patients admitted between 2006 and 2016 were included. Diabetic patients were stratified into those with well-controlled diabetes (n = 24) and poorly controlled diabetes (n = 33) using a HbA1c of 7% as a cutoff; additionally, diabetics were divided into well-controlled glycemia (n = 47) and poorly controlled glycemia (n = 22) based on daily blood glucose measurements during hospitalization.
On univariate analysis, diabetics had a significantly increased median length of stay per percent total body surface area burn (2.1 vs. 1.6 days; p = 0.0026) and a greater number of overall morbidity (1.39 ± 1.63 vs. 0.8 ± 1.24; p = 0.001). After adjustment for patient characteristics, diabetics were associated with significantly increased total morbidity (RR 1.5; 95% CI 1.1-1.9). At discharge, almost two thirds of diabetics needed an escalation of anti-diabetic medication and a quarter had newly developed insulin dependency. There were no differences in morbidity or mortality in the diabetic subgroups.
Diabetics had a longer hospitalization and increased morbidity, regardless of the quality of their anti-diabetic therapy prior to injury. Additionally, diabetes in burn patients is associated with an increased risk of total morbidity.
To determine how patient, healthcare system and study-specific factors influence reported mortality associated with critical illness during the 2009-2010 Influenza A (H1N1) pandemic.
Systematic ...review with meta-regression of studies reporting on mortality associated with critical illness during the 2009-2010 Influenza A (H1N1) pandemic.
Medline, Embase, LiLACs and African Index Medicus to June 2009-March 2016.
226 studies from 50 countries met our inclusion criteria. Mortality associated with H1N1-related critical illness was 31% (95% CI 28-34). Reported mortality was highest in South Asia (61% 95% CI 50-71) and Sub-Saharan Africa (53% 95% CI 29-75), in comparison to Western Europe (25% 95% CI 22-30), North America (25% 95% CI 22-27) and Australia (15% 95% CI 13-18) (P<0.0001). High income economies had significantly lower reported mortality compared to upper middle income economies and lower middle income economies respectively (P<0.0001). Mortality for the first wave was non-significantly higher than wave two (P = 0.66). There was substantial variability in reported mortality among the specific subgroups of patients: unselected critically ill adults (27% 95% CI 24-30), acute respiratory distress syndrome (37% 95% CI 32-44), acute kidney injury (44% 95% CI 26-64), and critically ill pregnant patients (10% 95% CI 5-19).
Reported mortality for outbreaks and pandemics may vary substantially depending upon selected patient characteristics, the number of patients described, and the region and economic status of the outbreak location. Outcomes from a relatively small number of patients from specific regions may lead to biased estimates of outcomes on a global scale.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Previous trials of higher positive end-expiratory pressure (PEEP) for acute respiratory distress syndrome (ARDS) failed to demonstrate mortality benefit, possibly because of differences in lung ...recruitability among patients with ARDS.
To determine whether the physiological response to increased PEEP is associated with mortality.
In a secondary analysis of the Lung Open Ventilation Study (LOVS, n = 983), we examined the relationship between the initial response to changes in PEEP after randomization and mortality. We sought to corroborate our findings using data from a different trial of higher PEEP (ExPress, n = 749).
The oxygenation response (change in ratio of arterial partial pressure of oxygen to fraction of inspired oxygen: P/F) after the initial change in PEEP after randomization varied widely (median, 9.5 mm Hg; interquartile range, -16 to 47) and was only weakly related to baseline P/F or the magnitude of PEEP change. Among patients in whom PEEP was increased after randomization, an increase in P/F was associated with reduced mortality (multivariable logistic regression; adjusted odds ratio, 0.80 95% confidence interval, 0.72-0.89 per 25-mm Hg increase in P/F), particularly in patients with severe disease (baseline P/F less-than-or-equal-to 150 mm Hg). Changes in compliance and dead space were not associated with mortality. These findings were confirmed by a similar analysis of data from the ExPress trial.
Patients with ARDS who respond to increased PEEP by improved oxygenation have a lower risk of death. The oxygenation response to PEEP might be used to predict whether patients will benefit from higher versus lower PEEP.
We aimed to rigorously evaluate the impact of prospective audit and feedback on broad-spectrum antimicrobial use among critical care patients.
Prospective, controlled interrupted time series.
Single ...tertiary care center with 3 intensive care units.
A formal review of all critical care patients on their third or tenth day of broad-spectrum antibiotic therapy was conducted, and suggestions for antimicrobial optimization were communicated to the critical care team.
The primary outcome was broad-spectrum antibiotic use (days of therapy per 1000 patient-days; secondary outcomes included overall antibiotic use, gram-negative bacterial susceptibility, nosocomial Clostridium difficile infections, length of stay, and mortality.
The mean monthly broad-spectrum antibiotic use decreased from 644 days of therapy per 1,000 patient-days in the preintervention period to 503 days of therapy per 1,000 patient-days in the postintervention period (P < .0001); time series modeling confirmed an immediate decrease (± standard error) of 119 ± 37.9 days of therapy per 1,000 patient-days (P = .0054). In contrast, no changes were identified in the use of broad-spectrum antibiotics in the control group (nonintervention medical and surgical wards) or in the use of control medications in critical care (stress ulcer prophylaxis). The incidence of nosocomial C. difficile infections decreased from 11 to 6 cases in the study intensive care units, whereas the incidence increased from 87 to 116 cases in the control wards (P = .04). Overall gram-negative susceptibility to meropenem increased in the critical care units. Intensive care unit length of stay and mortality did not change.
Institution of a formal prospective audit and feedback program appears to be a safe and effective means to improve broad-spectrum antimicrobial use in critical care.
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