Faculty Bibliography

The process of death in patients in whom cardiorespiratory support is withdrawn is related to the occurrence of tissue hypoxia that results from an imbalance between the demand for oxygen and the delivery of oxygen to the organs. Limiting the demand for oxygen may thus delay the occurrence of tissue hypoxia. Because the demand for oxygen increases significantly after ventilator withdrawal and because sedatives and opioids are known to decrease the demand for oxygen in patients with cardiorespiratory distress, these agents might thus actually prolong life rather than hasten death.

BACKGROUND: The time course of changes in health-related quality of life (HRQOL) following discharge from the ICU and during a general ward stay has not been studied. We therefore studied the immediate impact of critical illness on HRQOL and its recovery over time. METHODS: In a prospective study, all patients admitted to the ICU for > 48 h who ultimately survived to follow-up at 6 months were included. The Medical Outcomes Study 36-item short form was used to measure HRQOL before ICU admission, at discharge from the ICU and hospital, and at 3 and 6 months following discharge from the ICU and hospital. An age-matched healthy Dutch population was used as a reference. RESULTS: Of the 451 included patients, 252 could be evaluated at 6 months (40 were lost to follow-up, and 159 died). Pre-ICU admission HRQOL in survivors was significantly worse compared to the healthy population. Patients who died between ICU admission and long-term follow-up had significantly worse HRQOL in all dimensions already at ICU admission when compared to the long-term survivors. HRQOL decreased in all dimensions (p < 0.001) during ICU stay followed by a rapid improvement during hospital stay, gradually improving to near pre-ICU admission HRQOL at 6 months following ICU discharge. Physical functioning (PF), general health (GH), and social functioning (SF) remained significantly lower than pre-ICU admission values. Compared to the healthy Dutch population, ICU survivors had significantly lower HRQOL 6 months following ICU discharge (except for the bodily pain score). CONCLUSIONS: A sharp multidimensional decline in HRQOL occurs during ICU admission where recovery already starts following ICU discharge to the general ward. Recovery is incomplete for PF, GH, and SF when compared to baseline values and the healthy population.

BACKGROUND AND OBJECTIVES: Cryptogenic fibrosing pleuritis is an extremely rare disease, which can affect both lungs from a very young age. The most common finding is severe lung restriction resulting in both hypoxemic and ventilatory failure. CASE REPORT: Male patient, 26 year old with acute deterioration of chronic respiratory failure. Following admission prolonged mechanical ventilation was necessary. An atypical clinical presentation made the diagnosis difficult, but eventually cryptogenic fibrosing pleuritis and lung fibrosis were established. CONCLUSIONS: The prognostic outcome of patients with the final diagnosis of cryptogenic fibrosing pleuritis is extremely poor, especially in an advanced phase of this disease. We recommend early treatment with corticosteroids or surgical pleural decortication.

OBJECTIVE: To describe a case of deliberate termination of life (euthanasia) in intensive care. DESIGN: Case report and review of the literature. PATIENT: A 56-yr-old man experienced a bilateral hemorrhage in the pontine structures and the medulla oblongata, resulting in a locked-in syndrome. The patient was taught to communicate by eye opening. On day 10 after the hemorrhage, he was informed about his diagnosis and prognosis. He was asked if he wished prolonged care, but this was refused. He was offered withdrawal of fluids and ventilation under sedation or deliberate termination of life (euthanasia). He chose euthanasia. INTERVENTIONS: The patient was admitted to the intensive care unit and was mechanically ventilated. The patient was euthanized 33 days after the diagnosis by the injection of 30 mg of midazolam, discontinuation of ventilation, and injection of 1.4 g of thiopentone. MAIN RESULTS: The tetraplegic aphonic patient was declared competent. His refusal of prolonged care was taken seriously. The requirements of due care according to the Dutch euthanasia act were met in this case. CONCLUSIONS: Euthanasia is an option in terminal illness in the Netherlands, but it is very rarely performed in intensive care. This case demonstrates that euthanasia is possible in a conscious patient who is unable to speak or write and who is mechanically ventilated.

INTRODUCTION: Predicting whether a critically ill patient will survive intensive care treatment remains difficult. The advantages of a validated strategy to identify those patients who will not benefit from intensive care unit (ICU) treatment are evident. Providing critical care treatment to patients who will ultimately die in the ICU is accompanied by an enormous emotional and physical burden for both patients and their relatives. The purpose of the present study was to examine whether health-related quality of life (HRQOL) before admission to the ICU can be used as a predictor of mortality. METHODS: We conducted a prospective cohort study in a university-affiliated teaching hospital. Patients admitted to the ICU for longer than 48 hours were included. Close relatives completed the Short-form 36 (SF-36) within the first 48 hours of admission to assess pre-admission HRQOL of the patient. Mortality was evaluated from ICU admittance until 6 months after ICU discharge. Logistic regression and receiver operating characteristic analyses were used to assess the predictive value for mortality using five models: the first question of the SF-36 on general health (model A); HRQOL measured using the physical component score (PCS) and mental component score (MCS) of the SF-36 (model B); the Acute Physiology and Chronic Health Evaluation (APACHE) II score (an accepted mortality prediction model in ICU patients; model C); general health and APACHE II score (model D); and PCS, MCS and APACHE II score (model E). Classification tables were used to assess the sensitivity, specificity, positive and negative predictive values, and likelihood ratios. RESULTS: A total of 451 patients were included within 48 hours of admission to the ICU. At 6 months of follow up, 159 patients had died and 40 patients were lost to follow up. When the general health item was used as an estimate of HRQOL, area under the curve for model A (0.719) was comparable to that of model C (0.721) and slightly better than that of model D (0.760). When PCS and MCS were used, the area under the curve for model B (0.736) was comparable to that of model C (0.721) and slightly better than that of model E (0.768). When using the general health item, the sensitivity and specificity in model D (sensitivity 0.52 and specificity 0.81) were similar to those in model A (0.45 and 0.80). Similar results were found when using the MCS and PCS. CONCLUSION: This study shows that the pre-admission HRQOL measured with either the one-item general health question or the complete SF-36 is as good at predicting survival/mortality in ICU patients as the APACHE II score. The value of these measures in clinical practice is limited, although it seems sensible to incorporate assessment of HRQOL into the many variables considered when deciding whether a patient should be admitted to the ICU.

In this study a specific taste modulating flavor ingredient, N-lactoylguanosine 5'-monophosphate (N-lactoyl GMP), was determined in bonito (Japanese, Katsuobushi, dried fermented skipjack) and in powdered bonito using liquid chromatography-electrospray ionization (+) mass spectrometry-mass spectrometry (LC-ESI(+)-MS/MS) with a methanol/ammonium acetate or formate gradient. Furthermore, the influence of ion suppression due to sample matrix effect was investigated and was found to substantially influence the total MS response of N-lactoyl GMP; by adjusting the LC conditions the response could be approximately 5-fold-enhanced. The N-lactoyl GMP concentrations in different types of bonito products were between 0.2 and 2.4 microg/g.

INTRODUCTION: Effective planning of elective surgical procedures requiring postoperative intensive care is important in preventing cancellations and empty intensive care unit (ICU) beds. To improve planning, we constructed, validated and tested three models designed to predict length of stay (LOS) in the ICU in individual patients. METHODS: Retrospective data were collected from 518 consecutive patients who underwent oesophagectomy with reconstruction for carcinoma between January 1997 and April 2005. Three multivariable linear regression models for LOS, namely preoperative, postoperative and intra-ICU, were constructed using these data. Internal validation was assessed using bootstrap sampling in order to obtain validated estimates of the explained variance (r2). To determine the potential gain of the best performing model in day-to-day clinical practice, prospective data from a second cohort of 65 consecutive patients undergoing oesophagectomy between May 2005 and April 2006 were used in the model, and the predictive performance of the model was compared with prediction based on mean LOS. RESULTS: The intra-ICU model had an r2 of 45% after internal validation. Important prognostic variables for LOS included greater patient age, comorbidity, type of surgical approach, intraoperative respiratory minute volume and complications occurring within 72 hours in the ICU. The potential gain of the best model in day-to-day clinical practice was determined relative to mean LOS. Use of the model reduced the deficit number (underestimation) of ICU days by 65 and increased the excess number (overestimation) of ICU days by 23 for the cohort of 65 patients. A conservative analysis conducted in the second, prospective cohort of patients revealed that 7% more oesophagectomies could have been accommodated, and 15% of cancelled procedures could have been prevented. CONCLUSION: Patient characteristics can be used to create models that will help in predicting LOS in the ICU. This will result in more efficient use of ICU beds and fewer cancellations.