Centers for Disease Control and Prevention built up new surveillance paradigms for the patients on mechanical ventilation and the ventilator-associated events, comprising ventilator-associated ...conditions and infection-related ventilator-associated complications. We assess 1) the current epidemiology of ventilator-associated event, 2) the relationship between ventilator-associated event and ventilator-associated pneumonia, and 3) the impact of ventilator-associated event on antimicrobials consumption and mechanical ventilation duration.
Inception cohort study from the longitudinal prospective French multicenter OUTCOMEREA database (1996-2012).
Patients on mechanical ventilation for greater than or equal to 5 consecutive days were classified as to the presence of a ventilator-associated event episode, using slightly modified Centers for Disease Control and Prevention definitions.
None.
Among the 3,028 patients, 2,331 patients (77%) had at least one ventilator-associated condition, and 869 patients (29%) had one infection-related ventilator-associated complication episode. Multiple causes, or the lack of identified cause, were frequent. The leading causes associated with ventilator-associated condition and infection-related ventilator-associated complication were nosocomial infections (27.3% and 43.8%), including ventilator-associated pneumonia (14.5% and 27.6%). Sensitivity and specificity of diagnosing ventilator-associated pneumonia were 0.92 and 0.28 for ventilator-associated condition and 0.67 and 0.75 for infection-related ventilator-associated complication, respectively. A good correlation was observed between ventilator-associated condition and infection-related ventilator-associated complication episodes, and ventilator-associated pneumonia occurrence: R = 0.69 and 0.82 (p < 0.0001). The median number of days alive without antibiotics and mechanical ventilation at day 28 was significantly higher in patients without any ventilator-associated event (p < 0.05). Ventilator-associated condition and infection-related ventilator-associated complication rates were closely correlated with antibiotic use within each ICU: R = 0.987 and 0.99, respectively (p < 0.0001).
Ventilator-associated event is very common in a population at risk and more importantly highly related to antimicrobial consumption and may serve as surrogate quality indicator for improvement programs.
Although increasing numbers of very elderly patients are requiring intensive care, few large sample studies have investigated ICU admission of very elderly patients. Data on pre triage by physicians ...from other specialities is limited. This observational cohort study aims at examining inter-hospital variability of ICU admission rates and its association with patients' outcomes. All patients over 80 years possibly qualifying for ICU admission who presented to the emergency departments (ED) of 15 hospitals in the Paris (France) area during a one-year period were prospectively included in the study. Main outcome measures were ICU eligibility, as assessed by the ED and ICU physicians; in-hospital mortality; and vital and functional status 6 months after the ED visit. 2646 patients (median age 86; interquartile range 83-91) were included in the study. 94% of participants completed follow-up (n = 2495). 12.4% (n = 329) of participants were deemed eligible for ICU admission by ED physicians and intensivists. The overall in-hospital and 6-month mortality rates were respectively 27.2% (n = 717) and 50.7% (n = 1264). At six months, 57.5% (n = 1433) of patients had died or had a functional deterioration. Rates of patients deemed eligible for ICU admission ranged from 5.6% to 38.8% across the participating centers, and this variability persisted after adjustment for patients' characteristics. Despite this variability, we found no association between level of ICU eligibility and either in-hospital death or six-month death or functional deterioration. In France, the likelihood that a very elderly person will be admitted to an ICU varies widely from one hospital to another. Influence of intensive care admission on patients' outcome remains unclear.
ClinicalTrials.gov NCT00912600.
To investigate the respective impact of ventilator-associated pneumonia and ICU-hospital-acquired pneumonia on the 30-day mortality of ICU patients.
Longitudinal prospective studies.
French ICUs.
...Patients at risk of ventilator-associated pneumonia and ICU-hospital-acquired pneumonia.
The first three episodes of ventilator-associated pneumonia or ICU-hospital-acquired pneumonia were handled as time-dependent covariates in Cox models. We adjusted using the case-mix, illness severity, Simplified Acute Physiology Score II score at admission, and procedures and therapeutics used during the first 48 hours before the risk period. Baseline characteristics of patients with regard to the adequacy of antibiotic treatment were analyzed, as well as the Sequential Organ Failure Assessment score variation in the 2 days before the occurrence of ventilator-associated pneumonia or ICU-hospital-acquired pneumonia. Mortality was also analyzed for Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species(ESKAPE) and P. aeruginosa pathogens.
Of 14,212 patients who were admitted to the ICUs and who stayed for more than 48 hours, 7,735 were at risk of ventilator-associated pneumonia and 9,747 were at risk of ICU-hospital-acquired pneumonia. Ventilator-associated pneumonia and ICU-hospital-acquired pneumonia occurred in 1,161 at-risk patients (15%) and 176 at-risk patients (2%), respectively. When adjusted on prognostic variables, ventilator-associated pneumonia (hazard ratio, 1.38 (1.24-1.52); p < 0.0001) and even more ICU-hospital-acquired pneumonia (hazard ratio, 1.82 1.35-2.45; p < 0.0001) were associated with increased 30-day mortality. The early antibiotic therapy adequacy was not associated with an improved prognosis, particularly for ICU-hospital-acquired pneumonia. The impact was similar for ventilator-associated pneumonia and ICU-hospital-acquired pneumonia mortality due to P. aeruginosa and the ESKAPE group.
In a large cohort of patients, we found that both ICU-hospital-acquired pneumonia and ventilator-associated pneumonia were associated with an 82% and a 38% increase in the risk of 30-day mortality, respectively. This study emphasized the importance of preventing ICU-hospital-acquired pneumonia in nonventilated patients.
Thrombocytopenia is common in ICU patients. The objective of this study was to evaluate possible links between declining platelet counts early in the ICU stay and survival.
All patients who were ...admitted to the ICU for at least 5 days and had no thrombocytopenia at the time of admission were included in the study. A multivariable logistic regression model, with hospital mortality as the outcome variable, was built.
We included 1,077 patients in the study. At ICU admission, the median platelet count was not significantly different in survivors (256 x 10(9) cells/L; interquartile range IQR, 206 to 330 x 10(9) cells/L) and nonsurvivors (262 x 10(9) cells/L; 211 to 351 x 10(9) cells/L). Median simplified acute physiology scores II (SAPS II) at ICU admission was worse in nonsurvivors than in survivors (50 IQR, 37 to 63 vs 37 IQR, 27 to 48, respectively; p < 0.0001), as was the mean (+/- SD) sequential organ failure assessment (SOFA) score on day 3 (6.3 +/- 3.24 vs 4 +/- 2.8, respectively; p < 0.0001). Absolute platelet counts were lowest on day 4, but differed significantly between survivors and nonsurvivors only on day 7. Conversely, any percentage decline in platelet counts from 10 to 60% on day 4 was significantly associated with mortality. By multivariable analysis, a 30% decline in platelet count independently predicted death (odds ratio, 1.54; 95% confidence interval, 1.12 to 2.14; p = 0.008), in addition to increasing or stable SOFA scores from ICU admission to day 4, older age, male gender, ICU admission for coma, worse SAPS II score at ICU admission, transfer from another ward, and comorbidity.
In patients who spend > 5 days in the ICU and have normal platelet counts at ICU admission, a decline in platelet counts provides prognostic information. This parameter deserves to be included in new scoring systems.
Purpose
Noninvasive ventilation (NIV) had proven benefits in clinical trials that included selected patients admitted to highly skilled centers. Whether these benefits apply to every patient and in ...everyday practice deserves appraisal. The aim of the study was to assess the use and outcomes of NIV over the last 15 years.
Methods
Multicenter database study of critically ill patients who required ventilatory support for acute respiratory failure between 1997 and 2011. The impact of first-line NIV on 60-day mortality was evaluated using a marginal structural model. Follow-up was censored on day 60.
Results
Of 3,163 patients, 1,232 (39 %) received NIV. Over the study period, first-line NIV increased from 29 to 42 %, and NIV success rates increased from 69 to 84 %. NIV decreased 60-day mortality adjusted hazard ratio (aHR), 0.75; 95 % confidence interval (95 % CI), 0.68–0.83;
P
< 0.0001. This protective effect was observed in patients with acute-on-chronic respiratory failure (aHR, 0.71; 95 % CI, 0.57–0.90;
P
= 0.004), but not in patients with cardiogenic pulmonary edema (aHR, 0.85; 95 % CI, 0.70–1.03;
P
= 0.10) or in patients with hypoxemic ARF, either immunocompetent (aHR, 1.18; 95 % CI, 0.87–1.59;
P
= 0.30) or immunocompromised (aHR, 0.89; 95 % CI, 0.70–1.13;
P
= 0.35). NIV failure was an independent time-dependent risk factor for mortality (aHR, 4.2; 95 % CI, 2.8–6.2;
P
< 0.0001).
Conclusions
The use of NIV increased steadily over the study period. First-line NIV was associated with better 60-day survival and fewer ICU-acquired infections compared to first-line intubation. Survival benefits from NIV occurred only in patients with acute-on-chronic respiratory failure and immunocompromised patients.
Abstract Purpose The aims of the study were to assess opinions of caregivers, families, and patients about involvement of families in the care of intensive care unit (ICU) patients; to evaluate the ...prevalence of symptoms of anxiety and depression in family members; and to measure family satisfaction with care. Materials and Methods Between days 3 and 5, perceptions by families and ICU staff of family involvement in care were collected prospectively at a single center. Family members completed the Hospital Anxiety and Depression Scale (HADS) and a satisfaction scale (Critical Care Family Needs Inventory). Nurses recorded care provided spontaneously by families. Characteristics of patient-relative pairs (n = 101) and ICU staff (n = 45) were collected. Patients described their perceptions of family participation in care during a telephone interview, 206 ± 147 days after hospital discharge. Results The numbers of patient-relative pairs for whom ICU staff reported favorable perceptions were 101 (100%) of 101 for physicians, 91 (90%) for nurses, and 95 (94%) for nursing assistants. Only 4 (3.9%) of 101 families refused participation in care. Only 14 (13.8%) of 101 families provided care spontaneously. The HADS score showed symptoms of anxiety in 58 (58.5%) of 99 and of depression in 26 (26.2%) of 99 family members. The satisfaction score was high (11.0 ± 1.25). Among patients, 34 (77.2%) of 44 had a favorable perception of family participation in care. Conclusions Families and ICU staff were very supportive of family participation in care. Most patients were also favorable to care by family members.
Purpose
To develop an instrument designed specifically to assess the experience of relatives of patients who die in the intensive care unit (ICU).
Methods
The instrument was developed using a mixed ...methodology and validated in a prospective multicentre study. Relatives of patients who died in 41 ICUs completed the questionnaire by telephone 21 days after the death, then completed the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised and Inventory of Complicated Grief after 3, 6, and 12 months.
Results
A total of 600 relatives were included, 475 in the main cohort and 125 in the reliability cohort. The 15-item questionnaire, named CAESAR, covered the patient’s preferences and values, interactions with/around the patient and family satisfaction. We defined three groups based on CAESAR score tertiles: lowest (≤59,
n
= 107, 25.9 %), middle (
n
= 185, 44.8 %) and highest (≥69,
n
= 121, 29.3 %). Factorial analysis showed a single dimension. Cronbach’s alpha in the main and reliability cohorts was 0.88 (0.85–0.90) and 0.85 (0.79–0.89), respectively. Compared to a high CAESAR score, a low CAESAR score was associated with greater risks of anxiety and depression at 3 months 1.29 (1.13–1.46),
p
= 0.001, post-traumatic stress-related symptoms at 3 1.34 (1.17–1.53),
p
< 0.001, 6 OR = 1.24 (1.06–1.44),
p
= 0.008 and 12 OR = 1.26 (1.06–1.50),
p
= 0.01 months and complicated grief at 6 OR = 1.40 (1.20–1.63),
p
< 0.001 and 12 months OR = 1.27 (1.06–1.52),
p
= 0.01.
Conclusions
The CAESAR score 21 days after death in the ICU is strongly associated with post-ICU burden in the bereaved relatives. The CAESAR score should prove a useful primary endpoint in trials of interventions to improve relatives’ well-being.
In the No NV-ICU-AP population, the number of patients with No decrease in consciousness Day 1–Day 2 (Glasgow Coma Scale = 15) is 312 (38.9%) In the NV-ICU-AP population, the number of patients with ...No decrease in consciousness Day 1–Day 2 (Glasgow Coma Scale = 15) is 28 (66.7%) The correct Table 1 values are: In the No NV-ICU-AP population, the number of patients with No decrease in consciousness Day 1–Day 2 (Glasgow Coma Scale = 15) is 490 (61.1%) In the NV-ICU-AP population, the number of patients with No decrease in consciousness Day 1–Day 2 (Glasgow Coma Scale = 15) is 14 (33.1%) Table 1 has been updated in this correction article and the original article 1 has been corrected. Table 1 Baseline characteristics and mortality rate for patients with non-ventilator-associated ICU-acquired pneumonia admitted to an ICU for severe acute exacerbation of chronic obstructive pulmonary disease Full size table The incorrect Table 1 values are: In the No NV-ICU-AP population, the number of patients with No decrease in consciousness Day 1–Day 2 (Glasgow Coma Scale = 15) is 312 (38.9%) In the NV-ICU-AP population, the number of patients with No decrease in consciousness Day 1–Day 2 (Glasgow Coma Scale = 15) is 28 (66.7%) The correct Table 1 values are: In the No NV-ICU-AP population, the number of patients with No decrease in consciousness Day 1–Day 2 (Glasgow Coma Scale = 15) is 490 (61.1%) In the NV-ICU-AP population, the number of patients with No decrease in consciousness Day 1–Day 2 (Glasgow Coma Scale = 15) is 14 (33.1%) Table 1 has been updated in this correction article and the original article 1 has been corrected.
To describe intensive care unit referral decisions by emergency room physicians in patients aged > or =80 yrs.
Prospective, observational cohort study of patients aged > or =80 yrs who were triaged ...in the emergency room, using a list of intensive care unit admission criteria selected by emergency physicians among 76 preliminary criteria adapted from the 1999 Society of Critical Care Medicine guidelines. The Delphi method was used to select the criteria.
Fifteen French hospitals.
A total of 2646 patients aged > or =80 yrs with at least one criterion.
None.
In the Delphi process, level of agreement was assessed as follows: when all answers fell within a single interval (7-9 = definite admission criteria; 4-6 = equivocal admission criteria or 1-3 = inappropriate admission), agreement was strong; when answers spanned two intervals, agreement was fair; and when answers spanned all three intervals, agreement was poor. Of the 76 preliminary criteria, two were removed; 44 were selected as definite intensive care unit admission criteria; and 30 were selected as equivocal intensive care unit admission criteria. Of the 1426 patients meeting definite admission criteria, 441 (30.9%) were referred for intensive care unit admission and 231 of 441 (52.4%) were admitted to the intensive care unit. Of the 1041 patients with equivocal admission criteria, 181 (17.3%) were referred for intensive care unit admission; and, of these, 79 (43.6%) were admitted to the intensive care unit. Factors associated independently with no intensive care unit referral were age odds ratio OR, 1.04; 95% confidence interval CI, 1.04-1.07), active cancer (OR, 1.61; 95% CI, 1.09-1.38), unknown hospitalization status (OR, 1.53; 95% CI, 1.11-2.11), unknown living arrangements (OR, 1.69; 95% CI, 1.19-2.42), regular psychotropic medications (OR, 1.42; 95% CI, 1.10-1.81), low severity at referral (OR, 0.60; 95% CI, 0.53-0.68), low activity in daily living score (OR, 0.93; 95% CI, 0.88-0.99).
Emergency and intensive care unit physicians were extremely reluctant to consider intensive care unit admission of patients aged > or =80 yrs, despite the presence of criteria indicating that intensive care unit admission was certainly or possibly appropriate.
Purpose
The recent increase in drug-resistant micro-organisms complicates the management of hospital-acquired bloodstream infections (HA-BSIs). We investigated the epidemiology of HA-BSI and ...evaluated the impact of drug resistance on outcomes of critically ill patients, controlling for patient characteristics and infection management.
Methods
A prospective, multicentre non-representative cohort study was conducted in 162 intensive care units (ICUs) in 24 countries.
Results
We included 1,156 patients mean ± standard deviation (SD) age, 59.5 ± 17.7 years; 65 % males; mean ± SD Simplified Acute Physiology Score (SAPS) II score, 50 ± 17 with HA-BSIs, of which 76 % were ICU-acquired. Median time to diagnosis was 14 interquartile range (IQR), 7–26 days after hospital admission. Polymicrobial infections accounted for 12 % of cases. Among monomicrobial infections, 58.3 % were gram-negative, 32.8 % gram-positive, 7.8 % fungal and 1.2 % due to strict anaerobes. Overall, 629 (47.8 %) isolates were multidrug-resistant (MDR), including 270 (20.5 %) extensively resistant (XDR), and 5 (0.4 %) pan-drug-resistant (PDR). Micro-organism distribution and MDR occurrence varied significantly (
p
< 0.001) by country. The 28-day all-cause fatality rate was 36 %. In the multivariable model including micro-organism, patient and centre variables, independent predictors of 28-day mortality included MDR isolate odds ratio (OR), 1.49; 95 % confidence interval (95 %CI), 1.07–2.06, uncontrolled infection source (OR, 5.86; 95 %CI, 2.5–13.9) and timing to adequate treatment (before day 6 since blood culture collection versus never, OR, 0.38; 95 %CI, 0.23–0.63; since day 6 versus never, OR, 0.20; 95 %CI, 0.08–0.47).
Conclusions
MDR and XDR bacteria (especially gram-negative) are common in HA-BSIs in critically ill patients and are associated with increased 28-day mortality. Intensified efforts to prevent HA-BSIs and to optimize their management through adequate source control and antibiotic therapy are needed to improve outcomes.
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