Objectives
Diagnosing persistent acute kidney injury (AKI) as opposed to transient AKI in critically ill patients may help physicians in making treatment decisions. This diagnosis relies chiefly on ...urinary indices, which may be of limited value or difficult to obtain. We assessed the performance of the Doppler renal resistive index (RI) in diagnosing persistent AKI.
Design
Prospective observational study.
Setting
Twenty-four-bed medical intensive care unit in a university hospital.
Patients
Consecutive patients requiring mechanical ventilation, without severe chronic renal dysfunction or receiving diuretic therapy.
Definitions
Persistent AKI was defined as AKI lasting longer than 3 days. AKI resolving within 3 days in a patient with a cause of renal hypoperfusion was considered to be transient AKI. Results are reported as median values with interquartile range (IQR).
Measurements and main results
Of the 51 patients enrolled in the study, 16 had no AKI, 13 had transient AKI, and 22 had persistent AKI. The RI was 0.71 (0.66–0.77) in the no-AKI group, 0.71 (0.62–0.77) in the transient AKI group, and 0.82 (0.80–0.89) in the persistent AKI group (
P
< 0.0001). The RI was better than urinary indices for diagnosing persistent AKI. The area under the RI ROC curve was 0.91 95% confidence interval (95% CI) 0.83–0.99;
P
< 0.0001. An RI > 0.795 had a 92% sensitivity and 85% specificity for persistent AKI. Logistic regression analysis revealed that an RI > 0.795 odds ratio (OR) 28.2; 95% CI 4.0–198 and a higher logistic organ dysfunction score (OR 1.85/point; 95% CI 1.20–2.85) predicted persistent AKI.
Conclusion
These preliminary results suggest that Doppler renal RI may be a promising tool for predicting the reversibility of AKI in critically ill patients.
Burnout Syndrome in Critical Care Nursing Staff Poncet, Marie Cecile; Toullic, Philippe; Papazian, Laurent ...
American journal of respiratory and critical care medicine,
04/2007, Letnik:
175, Številka:
7
Journal Article
Recenzirano
Burnout syndrome (BOS) associated with stress has been documented in health care professionals in many specialties. The intensive care unit (ICU) is a highly stressful environment. Little is known ...about BOS in critical care nursing staff.
To identify determinants of BOS in critical care nurses.
We conducted a questionnaire survey in France. Among 278 ICUs contacted for the study, 165 (59.4%) included 2,525 nursing staff members, of whom 2,392 returned questionnaires with complete Maslach Burnout Inventory data.
Of the 2,392 respondents (82% female), 80% were nurses, 15% nursing assistants, and 5% head nurses. Severe BOS-related symptoms were identified in 790 (33%) respondents. By multivariate analysis, four domains were associated with severe BOS: (1) personal characteristics, such as age (odds ratio OR, 0.97/yr; confidence interval CI, 0.96-0.99; p=0.0008); (2) organizational factors, such as ability to choose days off (OR, 0.69; CI, 0.52-0.91; p=0.009) or participation in an ICU research group (OR, 0.74; CI, 0.56-0.97; p=0.03); (3) quality of working relations (1-10 scale), such as conflicts with patients (OR, 1.96; CI, 1.16-1.30; p=0.01), relationship with head nurse (OR, 0.92/point; CI, 0.86-0.98; p=0.02) or physicians (OR, 0.81; CI, 0.74-0.87; p=0.0001); and (4) end-of-life related factors, such as caring for a dying patient (OR, 1.39; CI, 1.04-1.85; p=0.02), and number of decisions to forego life-sustaining treatments in the last week (OR, 1.14; CI, 1.01-1.29; p=0.04).
One-third of ICU nursing staff had severe BOS. Areas for improvement identified in our study include conflict prevention, participation in ICU research groups, and better management of end-of-life care. Interventional studies are needed to investigate these potentially preventive strategies.
Patients with chronic known or unknown interstitial lung disease (ILD) may present with severe respiratory flares that require intensive management. Outcome data in these patients are scarce.
...Clinical and radiological features were collected in 83 patients with ILD-associated acute respiratory failure (ARF). Determinants of hospital mortality and response to corticosteroid therapy were identified by logistic regression.
Hospital and 1-year mortality rates were 41% and 54% respectively. Pulmonary hypertension, computed tomography (CT) fibrosis and acute kidney injury were independently associated with mortality (odds ratio (OR) 4.55; 95% confidence interval (95%CI) (1.20-17.33); OR, 7.68; (1.78-33.22) and OR 10.60; (2.25-49.97) respectively). Response to steroids was higher in patients with shorter time from hospital admission to corticosteroid therapy. Patients with fibrosis on CT had lower response to steroids (OR, 0.03; (0.005-0.21)). In mechanically ventilated patients, overdistension induced by high PEEP settings was associated with CT fibrosis and hospital mortality.
Mortality is high in ILD-associated ARF. CT and echocardiography are valuable prognostic tools. Prompt corticosteroid therapy may improve survival.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
To determine whether the survival gains achieved in critically ill cancer patients in recent years exist in the subset with neutropenia and severe sepsis or septic shock.
Retrospective 11-yr study ...(1998-2008).
Medical intensive care unit in a teaching hospital.
Four hundred twenty-eight intensive care unit patients with cancer, neutropenia, and severe sepsis or septic shock. The primary outcome was hospital mortality.
The main underlying diseases were acute leukemia (35.7%), lymphoma (31.7%), and solid tumors (16.5%). Two hundred thirty-seven (55.5%) patients had microbiologically documented infections, 141 (32.9%) clinically documented infections, and 50 (11.9%) fever of unknown origin. Acute noninfectious conditions were diagnosed in 175 of 428 (41%) patients, including 26 of 50 (52%) patients with fever of unknown origin, 66 of 141 (47%) patients with clinically documented infections, and 83 of 237 (35%) patients with microbiologically documented infections. Early indwelling catheter removal was performed routinely in the 107 (25%) patients without clinical evidence of a septic focus at intensive care unit admission. Early beta-lactam plus aminoglycoside therapy was used in 391 (91.3%) patients. Hospital mortality was 49.8%. Hospital mortality decreased from 58.7% (108 of 184) in 1998-2003 to 43% in 2004-2008 (105 of 244, p = .006). Multivariate analysis identified nine independent predictors of hospital mortality, of which six were associated with higher mortality (older age; need for vasopressors; neurologic, respiratory, or hepatic dysfunction; and acute noninfectious condition) and three with lower mortality (intensive care unit admission after 2003, combination antibiotic therapy including an aminoglycoside, and early indwelling catheter removal).
In neutropenic patients with severe sepsis or septic shock, survival improved over time. Aminoglycoside use and early catheter removal in patients with undocumented sepsis may improve survival. Acute noninfectious conditions are associated with increased mortality, underlining the need for thorough and repeated clinical assessments.
Respiratory events are common in hematology and oncology patients and manifest as hypoxemic acute respiratory failure (ARF) in up to half the cases. Identifying the cause of ARF is crucial. ...Fiberoptic bronchoscopy with bronchoalveolar lavage (FO-BAL) is an invasive test that may cause respiratory deterioration. Recent noninvasive diagnostic tests may have modified the risk/benefit ratio of FO-BAL.
To determine whether FO-BAL in cancer patients with ARF increased the need for intubation and whether noninvasive testing alone was not inferior to noninvasive testing plus FO-BAL.
We performed a multicenter randomized controlled trial with sample size calculations for both end points. Patients with cancer and ARF of unknown cause who were not receiving ventilatory support at intensive care unit admission were randomized to early FO-BAL plus noninvasive tests (n = 113) or noninvasive tests only (n = 106). The primary end point was the number of patients needing intubation and mechanical ventilation. The major secondary end point was the number of patients with no identified cause of ARF.
The need for mechanical ventilation was not significantly greater in the FO-BAL group than in the noninvasive group (35.4 vs. 38.7%; P = 0.62). The proportion of patients with no diagnosis was not smaller in the noninvasive group (21.7 vs. 20.4%; difference, -1.3% -10.4 to 7.7).
FO-BAL performed in the intensive care unit did not significantly increase intubation requirements in critically ill cancer patients with ARF. Noninvasive testing alone was not inferior to noninvasive testing plus FO-BAL for identifying the cause of ARF. Clinical trial registered with www.clinicaltrials.gov (NCT00248443).
Many sources of conflict exist in intensive care units (ICUs). Few studies recorded the prevalence, characteristics, and risk factors for conflicts in ICUs.
To record the prevalence, characteristics, ...and risk factors for conflicts in ICUs.
One-day cross-sectional survey of ICU clinicians. Data on perceived conflicts in the week before the survey day were obtained from 7,498 ICU staff members (323 ICUs in 24 countries).
Conflicts were perceived by 5,268 (71.6%) respondents. Nurse-physician conflicts were the most common (32.6%), followed by conflicts among nurses (27.3%) and staff-relative conflicts (26.6%). The most common conflict-causing behaviors were personal animosity, mistrust, and communication gaps. During end-of-life care, the main sources of perceived conflict were lack of psychological support, absence of staff meetings, and problems with the decision-making process. Conflicts perceived as severe were reported by 3,974 (53%) respondents. Job strain was significantly associated with perceiving conflicts and with greater severity of perceived conflicts. Multivariate analysis identified 15 factors associated with perceived conflicts, of which 6 were potential targets for future intervention: staff working more than 40 h/wk, more than 15 ICU beds, caring for dying patients or providing pre- and postmortem care within the last week, symptom control not ensured jointly by physicians and nurses, and no routine unit-level meetings.
Over 70% of ICU workers reported perceived conflicts, which were often considered severe and were significantly associated with job strain. Workload, inadequate communication, and end-of-life care emerged as important potential targets for improvement.
Pneumocystis pneumonia (PCP) is common in patients with HIV infection but may also occur in patients with other causes of immunodeficiency, including hematologic and solid malignancies.
To better ...describe the clinical picture of PCP as to maintain a high level of suspicion in adequate cases, we studied 56 cancer patients with PCP and compared them to 56 cancer patients with bacterial pneumonia.
Among 56 PCP patients, 44 patients (78.6%) had hematologic malignancies (18 recipients of bone marrow transplantation) and 12 patients had solid tumors. The time since diagnosis was 24 months (range, 4 to 49 months). All patients with solid tumors and 20 patients (45.4%) with hematologic malignancies were receiving steroids. Only six patients were receiving PCP prophylaxis. The main symptoms were fever (85.7%), dyspnea (78.6%), and cough (57.1%). Time from symptom onset was 7 days (range, 3 to 14 days). PCP presented as severe pneumonia (Pao2, 58 mm Hg range, 50 to 70 mm Hg) with bilateral interstitial infiltrates (80.4%) and bilateral ground-glass attenuation (89.3%) by CT. Of the 24 ICU patients (42.9%), 16 patients (19.6%) required mechanical ventilation. Eleven patients (19.6%) died. Compared to 56 patients with bacterial pneumonia, PCP patients were more likely to have non-Hodgkin lymphoma and be receiving long-term steroids; they had longer times since diagnosis, longer symptom duration, higher frequencies of fever and of diffuse lung disease (diffuse crackles, bilateral infiltrates, and hypoxemia), higher frequency of ground-glass opacities, and lower frequency of pleural involvement.
PCP presents as subacute, febrile, hypoxemic, and diffuse pulmonary involvement in patients with solid tumors or hematologic malignancies receiving long-term steroids.
To evaluate the outcome of cancer patients considered for admission to the intensive care unit (ICU).
Prospective, one-year hospital-wide study of all cancer and hematology patients, including bone ...marrow transplantation patients, for whom admission to the ICU was requested.
Of the 206 patients considered for ICU admission, 105 patients (51%) were admitted. Of the 101 patients who were not admitted, 54 patients (26.2%) were considered too sick to benefit, and 47 patients (22.8%) were considered to be too well to benefit from the ICU. Of these 47 patients, 13 patients were admitted later. Survival rates after 30 and 180 days were significantly associated with admission status (P < .0001). Remission of the malignancy (odds ratio OR, 3.37; 95% CI, 1.25 to 9.07) was independently associated with ICU admission, whereas poor chronic health status (OR, 0.38; 95% CI, 0.16 to 0.74) and solid tumor (OR, 0.43; 95% CI, 0.24 to 0.78) were associated with ICU refusal. In admitted patients, 30-day and 6-month survival rates were 54.3% and 32.4%, respectively. Of the patients considered too sick to benefit from ICU admission, 26% were alive on day 30 and 16.7% on day 180. Among patients considered too well to benefit, the 30-day survival rate was a worrisome 78.7%. Calibration of the Mortality Probability Model (the only score available at triage) was of limited value for predicting 30-day survival (area under the curve, 0.62).
Both the excess mortality in too-well patients later admitted to the ICU and the relatively good survival in too-sick patients suggest the need for a broader admission policy.
Objective
To report incidence and characteristics of decisions to forgo life-sustaining therapies (DFLSTs) in the 282 ICUs who contributed to the SAPS3 database.
Methods
We reviewed data on DFLSTs in ...14,488 patients. Independent predictors of DFLSTs have been identified by stepwise logistic regression.
Results
DFLSTs occurred in 1,239 (8.6%) patients 677 (54.6%) withholding and 562 (45.4%) withdrawal decisions. Hospital mortality was 21% (3,050/14,488); 36.2% (1,105) deaths occurred after DFLSTs. Across the participating ICUs, hospital mortality in patients with DFLSTs ranged from 80.3 to 95.4% and time from admission to decisions ranged from 2 to 4 days. Independent predictors of decisions to forgo LSTs included 13 variables associated with increased incidence of DFLSTs and 7 variables associated with decrease incidence of DFLST. Among hospital and ICU-related variables, a higher number of nurses per bed was associated with increased incidence of DFLST, while availability of an emergency department in the same hospital, presence of a full time ICU-specialist and doctors presence during nights and week-ends were associated with a decreased incidence of DFLST.
Conclusion
This large study identifies structural variables that are associated with substantial variations in the incidence and the characteristics of decisions to forgo life-sustaining therapies.
Rationale: Pneumocystis jiroveci polymerase chain reaction (PCR) has higher sensitivity than conventional stains but cannot distinguish colonization from
infection.
Methods: We compared P jiroveci ...PCR and conventional stains in HIV-uninfected immunocompromised patients.
Results: Among the 448 patients, 296 (66%) patients had hematologic malignancies; 72 (16.1%), bone marrow transplants; 44 (9.8%),
solid tumors; 21 (4.7%), renal transplants; and 15 (3.4%) were taking immunosuppressants for systemic diseases. Diagnostic
strategy consisted of BAL in 351 patients and induced sputum (IS) in 97 patients. Conventional pneumocystic pneumonia (PCP)
stain was positive in 39 (8.7%) patients, including 34 with positive PCR. In addition, PCR was positive in 32 patients, including
21 with complete follow-up, of whom 14 were diagnosed with probable or definitive PCP (a 36% increase). PCR was 87.2% sensitive
and 92.2% specific; positive and negative predictive values were 51.5% and 98.7%, respectively. Sensitivity and negative predictive
value were 100% on IS.
Conclusions: In HIV-uninfected immunocompromised patients with acute pulmonary infiltrates, P jiroveci PCR correlates with clinical evidence of PCP. A negative PCR allows withdrawing anti-PCP therapy.
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