Faculty Bibliography

BACKGROUND: Ventilator-associated pneumonia (VAP) occurs in more than half of mechanically ventilated patients with Guillain-Barre syndrome (GBS) and is associated with prolonged mechanical ventilation (MV). We investigated the impact of selective decontamination of the digestive tract (SDD), an intervention that reduces hospital acquired infections in ICU patients, on duration of MV in GBS and neurological outcome at 6 months. METHODS: We performed a retrospective study in mechanically ventilated GBS patients in the Netherlands. We compared patients treated with and without SDD. Main outcomes were duration of MV and the ability to walk independently at 6 months. Statistical comparison was done with logistic and ordinal regression analyses. RESULTS: We included 124 GBS patients on MV at 2 weeks after first symptoms (SDD, n = 54 and non-SDD, n = 70). The median duration of MV without SDD was 42 days (interquartile range, IQR 25-77 days) versus 29 days with SDD (IQR 17-45 days). Median duration of MV for all included patients was 35 days. The adjusted odds ratio (OR) for duration of MV > 35 days in the SDD versus the non-SDD cohort was 0.37 (95% CI 0.17-0.77). SDD did not affect neurological recovery after 6 months from first symptoms. VAP occurred in 12% (95% CI 2-22%) in the SDD cohort and in 47% (95% CI 35-59%) in the non-SDD cohort. CONCLUSIONS: SDD in mechanically ventilated GBS patients reduced the time on the ventilator, probably by preventing VAP, but did not affect neurological recovery after 6 months.

INTRODUCTION: Intensive care is generally regarded as expensive, and as a result beds are limited. This has raised serious questions about rationing when there are insufficient beds for all those referred. However, the evidence for the cost effectiveness of intensive care is weak and the work that does exist usually assumes that those who are not admitted do not survive, which is not always the case. Randomised studies of the effectiveness of intensive care are difficult to justify on ethical grounds; therefore, this observational study examined the cost effectiveness of ICU admission by comparing patients who were accepted into ICU after ICU triage to those who were not accepted, while attempting to adjust such comparison for confounding factors. METHODS: This multi-centre observational cohort study involved 11 hospitals in 7 EU countries and was designed to assess the cost effectiveness of admission to intensive care after ICU triage. A total of 7,659 consecutive patients referred to the intensive care unit (ICU) were divided into those accepted for admission and those not accepted. The two groups were compared in terms of cost and mortality using multilevel regression models to account for differences across centres, and after adjusting for age, Karnofsky score and indication for ICU admission. The analyses were also stratified by categories of Simplified Acute Physiology Score (SAPS) II predicted mortality (< 5%, 5% to 40% and >40%). Cost effectiveness was evaluated as cost per life saved and cost per life-year saved. RESULTS: Admission to ICU produced a relative reduction in mortality risk, expressed as odds ratio, of 0.70 (0.52 to 0.94) at 28 days. When stratified by predicted mortality, the odds ratio was 1.49 (0.79 to 2.81), 0.7 (0.51 to 0.97) and 0.55 (0.37 to 0.83) for <5%, 5% to 40% and >40% predicted mortality, respectively. Average cost per life saved for all patients was $103,771 (euro82,358) and cost per life-year saved was $7,065 (euro5,607). These figures decreased substantially for patients with predicted mortality higher than 40%, $60,046 (euro47,656) and $4,088 (euro3,244), respectively. Results were very similar when considering three-month mortality. Sensitivity analyses performed to assess the robustness of the results provided findings similar to the main analyses. CONCLUSIONS: Not only does ICU appear to produce an improvement in survival, but the cost per life saved falls for patients with greater severity of illness. This suggests that intensive care is similarly cost effective to other therapies that are generally regarded as essential.

BACKGROUND: We studied the frequency of withdrawal of mechanical ventilation (MV) and/or vasoactive agents (VAs), the time until death, and dosages of opioids and sedatives in a Dutch academic intensive care unit (ICU), and compared these practices with international observations in this field. METHODS: Retrospective data were collected from the electronic and paper files of all patients who died after withdrawal of treatment in a Dutch ICU between October 2006 and February 2007. RESULTS: In this period, 471 patients were admitted to the ICU, of whom 88 died (18%). In 60 of these patients (68%), MV and/or VAs were withdrawn. This group represented 13% of the total ICU population. Of the 60 patients for whom MV and/or VAs were withdrawn, 54 (90%) died after withdrawal of MV (with or without VAs). Six (10%) died after withdrawal of VAs only, 33 (55%) after withdrawal of MV in combination with VAs, and 21 (35%) after withdrawal of MV only. Death occurred after withdrawal of MV in combination with VAs after a median of 30 minutes (interquartile range [IQR], 10-195 minutes). When only MV was discontinued, the median time until death was 50 minutes (IQR, 15-530 minutes). When only VAs were withdrawn, patients died after a median of 45 minutes (IQR, 20-715 minutes). Ten patients (17%) did not receive opioids or sedatives in their last hours. Fifty patients received opioids in their last hours. Fentanyl, with a median dosage at time of death of 100 mug/h, was the most frequently used opioid. Forty (80%) of the 50 patients mentioned above received some kind of sedative until death. In the MV withdrawal group, 34 of the 54 patients (63%) received sedatives in the last hours of their lives: 16 (27%) received midazolam (median, 10 mg/h), 12 (22%) propofol (median, 160 mg/h), and 6 (11%) lorazepam (2.0 mg/h). Sedatives were administered to all patients in whom only VAs were withdrawn. CONCLUSIONS: Dutch patients who die in the ICU, or die after discharge from the ICU, die after MV and/or VAs are withdrawn. When treatments are withdrawn, death follows within 1 hour in most patients, which is a reflection of the severity of illnesses. At least 80% of patients receive opioids, and 67% receive sedatives until death. Fentanyl is the most used opioid, whereas midazolam is the most used sedative. Dosages of opioids and sedatives did not significantly exceed the ranges described as usual in the international literature.

PURPOSE: It is desirable to identify a potential organ donor (POD) as early as possible to achieve a donor conversion rate (DCR) as high as possible which is defined as the actual number of organ donors divided by the number of patients who are regarded as a potential organ donor. The DCR is calculated with different assessment tools to identify a POD. Obviously, with different assessment tools, one may calculate different DCRs, which make comparison difficult. Our aim was to determine which assessment tool can be used for a realistic estimation of a POD pool and how they compare to each other with regard to DCR. METHODS: Retrospective chart review of patients diagnosed with a subarachnoid haemorrhage, traumatic brain injury or intracerebral haemorrhage. We applied three different assessment tools on this cohort of patients. RESULTS: We identified a cohort of 564 patients diagnosed with a subarachnoid haemorrhage, traumatic brain injury or intracerebral haemorrhage of whom 179/564 (31.7%) died. After applying the three different assessment tools the number of patients, before exclusion of medical reasons or age, was 76 for the IBD-FOUR definition, 104 patients for the IBD-GCS definition and 107 patients based on the OPTN definition of imminent neurological death. We noted the highest DCR (36.5%) in the IBD-FOUR definition. CONCLUSION: The definition of imminent brain death based on the FOUR-score is the most practical tool to identify patients with a realistic chance to become brain dead and therefore to identify the patients most likely to become POD.

BACKGROUND: First we aimed to evaluate the ability of neutrophil gelatinase-associated lipocalin (NGAL) and cystatin-C (CyC) in plasma and urine to discriminate between sustained, transient and absent acute kidney injury (AKI), and second to evaluate their predictive performance for sustained AKI in adult intensive care unit (ICU) patients. METHODS: A prospective cohort study of 700 patients was studied. Sample collection was performed over 8 time points starting on admission. RESULTS: After exclusion 510 patients remained for the analysis. All biomarkers showed significant differentiation between sustained and no AKI at all time points (p