RESUMEN
BACKGROUND: In this time of outcome measurements predictive models are needed for correction of comorbidity, in order to perform audits on the outcome of patients. The aim of this study was to evaluate the use of risk-predicting scoring methods in the treatment of RAAA with emergency endovascular aneurysm repair (eEVAR) and open repair in order to analyze outcomes. METHODS: Two hundred and six consecutive patients underwent open repair or eEVAR for RAAA. Patients data were compared with preoperative risk assessments according to the V-POSSUM and the Glasgow Aneurysm Score (GAS). RESULTS: The 30-day mortality rate was 45/206 (22%) in the whole cohort, 41/179 (23%) (95% Confidence Interval [CI] 17-30) after open repair and 4/27 (15%, 95% CI 6-32) after eEVAR. The patient population did not significantly change over time, according to age, gender, V-POSSUM and GAS, neither did the 30-day mortality. The GAS appeared to be a reasonable predictor of postoperative outcome for both open and endovascular RAAA repair, with an area under the curve (AUC) of 0.73 (SD 0.04; 95% CI 0.65-0.80; P<0.001). The V-POSSUM predicted mortality was somewhat less accurate: AUC 0.69 (SD 0.05; 95% CI 0.60-0.77; P<0.001). The only pre-operative variables independently predicting 30-day mortality were age (P=0.006) and lowest pre-operative systolic blood pressure (P=0.032). CONCLUSIONS: Preoperative risk assessment with either V-POSSUM or GAS does not identify patients with fatal outcome at the individual level. However, these risk models may be useful as a relative estimate, in surgical audit or for inter- and intra-hospital comparisons.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/cirugía , Técnicas de Apoyo para la Decisión , Procedimientos Endovasculares , Procedimientos Quirúrgicos Vasculares , Factores de Edad , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/fisiopatología , Rotura de la Aorta/diagnóstico , Rotura de la Aorta/mortalidad , Rotura de la Aorta/fisiopatología , Aortografía/métodos , Área Bajo la Curva , Presión Sanguínea , Angiografía por Tomografía Computarizada , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Masculino , Selección de Paciente , Valor Predictivo de las Pruebas , Curva ROC , Reproducibilidad de los Resultados , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Sístole , Factores de Tiempo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
INTRODUCTION: Tele-intensive care (teleIC) can be used to increase the level of care in the intensive care unit (ICU) with the tele-intensivist being at a remote site. In this study we describe the implementation and outcomes, including patient and family satisfaction, of the first Dutch teleIC. METHODS: In a retrospective analysis the patient characteristics are described with a focus on patient outcomes and patient and family satisfaction. The teleIC started on 6 December 2010 in an ICU with three beds. Data for all admitted patients were collected from 1 January 2011 through 31 December 2013 from available systems. Severity of disease (APACHE IV) and standardized mortality ratios (SMR) were available over the complete calendar years 2012 and 2013. A prospective self-made survey of patient and family satisfaction was performed over a 14-month period after the implementation of teleIC. RESULTS: In 2012 and 2013, 556 patients were admitted. The number of operating room recovery patients in the ICU declined over time. One hundred and seven patients were transferred to a higher-level ICU (19%). The SMR for non-transferred patients was 0.73 (95% CI (confidence interval) 0.54-0.98) and 0.66 (95% CI (confidence interval) 0.40-1.02) for transferred patients. These numbers are in line with national data. Thirty-six percent of family and 38% of the patients responded to the survey and showed a positive response concerning communication within the tele IC setting. CONCLUSION: Implementation of teleIC in a Dutch situation was successful and showed favourable results in patient outcomes and the satisfaction of patients and family members.
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Cuidados Críticos/métodos , Calidad de la Atención de Salud/normas , Telemedicina , Adulto , Anciano , Anciano de 80 o más Años , Cuidados Críticos/normas , Familia/psicología , Femenino , Mortalidad Hospitalaria , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Países Bajos , Satisfacción del Paciente , Estudios Retrospectivos , Telemedicina/instrumentación , Telemedicina/métodos , Telemedicina/normasRESUMEN
BACKGROUND: The purpose of this study was to determine the one-year mortality rate and its predictors regarding long-term intensive care-treated patients together with their health-related quality of life (HRQL), place of living, healthcare use and long-term complication characteristics after intensive care unit (ICU) discharge. METHODS: A retrospective cohort study was performed in a 20-bed mixed ICU. The patients that were treated for more than 72 h between 2007 and 2012 were included in this study. The one-year mortality rate was calculated, and the characteristics of the ICU survivors that died within one year after ICU discharge were further analysed. For all patients, the Dutch version of the SF-36 questionnaire was used to assess their current HRQL. The results were compared with a normal population. Additionally, patients were questioned about their place of living, and their general practitioners (GPs) were questioned about the patients' possible long-term complications. RESULTS: Seven hundred and forty patients were included in this study, and their one-year mortality rate was 28 %, of which half died within the first week after ICU discharge. The one-year mortality rate predictors included age at the time of ICU admission, APACHE IV-predicted mortality score, number of comorbidities and ICU re-admissions. The ICU survivor HRQL was significantly lower compared with the normal population. Half of the patients did not return to their pre-hospital place of living, and numerous possible long-term complications were reported, particularly decreased tolerance, chronic fatigue and processing problems of relatives. CONCLUSIONS: One-year mortality rate of long-term ICU-treated patient was 28 %, and this was predicted by age, disease severity, comorbidities and ICU re-admissions. The ICU survivors reported a lower HRQL, and a minority of these patients returned home directly after hospital discharge; however, GPs reported numerous possible long-term complications.
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Cuidados Críticos/tendencias , Médicos Generales/tendencias , Mortalidad Hospitalaria/tendencias , Unidades de Cuidados Intensivos/tendencias , Aceptación de la Atención de Salud , Calidad de Vida , Anciano , Estudios de Cohortes , Cuidados Críticos/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Organ failure in severe sepsis and septic shock may be caused by microcirculatory failure. OBJECTIVE: The objective of this study is to test a conceptual model of microcirculatory failure by using a resuscitation strategy targeting early opening of the constricted microcirculation with active vasodilatation. DESIGN: A randomised controlled pilot study. SETTING: Single-centre mixed medical and surgical tertiary ICU. PATIENTS: Ninety severe sepsis and septic shock patients randomised to early opening microcirculation resuscitation group or standard resuscitation group. INTERVENTIONS: Standard resuscitation group: fluids, noradrenaline, dobutamine and hydrocortisone were given to achieve a mean arterial pressure (MAP) of more than 60âmmHg, cardiac index more than 2.5âlâminâm and ScvO2 more than 70%. Microcirculation resuscitation group: nitroglycerin, enoximone, dopamine and dexamethasone targeting a microvascular flow index (MFI), measured by sublingual side-stream dark field imaging, more than 2.5. MAIN OUTCOME MEASURE: A decrease in organ failure score (SOFA) on day four of ICU treatment. RESULTS: Data from 37 microcirculation resuscitation and 28 standard resuscitation patients were analysed. In the microcirculation resuscitation group, MFI of more than 2.5 was achieved after a meanâ±âSD of 7.0â±â4.6âh. The microcirculation resuscitation group received more fluids, and noradrenaline was equally prescribed in both groups. Per protocol, the decrease in SOFA score at day 4 was not different between groups (Pâ=â0.64). There was a significant reduction in SOFA score in both groups compared with admission (1.2 and 1.6 in microcirculation resuscitation and standard resuscitation groups, respectively; Pâ=â0.028 and Pâ=â0.045). CONCLUSION: Early opening of the microcirculation in patients with severe sepsis and septic shock using nitroglycerin, enoximone, dopamine and corticosteroids did not result in a faster reduction in organ failure than standard resuscitation. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT00484133.
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Microcirculación/efectos de los fármacos , Insuficiencia Multiorgánica/prevención & control , Resucitación/métodos , Sepsis/terapia , Choque Séptico/terapia , Vasodilatación/efectos de los fármacos , Vasodilatadores/uso terapéutico , Anciano , Femenino , Humanos , Unidades de Cuidados Intensivos , Análisis de Intención de Tratar , Tiempo de Internación , Masculino , Persona de Mediana Edad , Insuficiencia Multiorgánica/diagnóstico , Insuficiencia Multiorgánica/mortalidad , Insuficiencia Multiorgánica/fisiopatología , Países Bajos , Puntuaciones en la Disfunción de Órganos , Proyectos Piloto , Resucitación/efectos adversos , Resucitación/mortalidad , Factores de Riesgo , Sepsis/diagnóstico , Sepsis/mortalidad , Sepsis/fisiopatología , Índice de Severidad de la Enfermedad , Choque Séptico/diagnóstico , Choque Séptico/mortalidad , Choque Séptico/fisiopatología , Centros de Atención Terciaria , Factores de Tiempo , Resultado del Tratamiento , Vasodilatadores/efectos adversosRESUMEN
INTRODUCTION: Glucose measurement in intensive care medicine is performed intermittently with the risk of undetected hypoglycemia. The workload for the ICU nursing staff is substantial. Subcutaneous continuous glucose monitoring (CGM) systems are available and may be able to solve some of these issues in critically ill patients. METHODS: In a randomized controlled design in a mixed ICU in a teaching hospital we compared the use of subcutaneous CGM with frequent point of care (POC) to guide insulin treatment. Adult critically ill patients with an expected stay of more than 24 hours and in need of insulin therapy were included. All patients received subcutaneous CGM. CGM data were blinded in the control group, whereas in the intervention group these data were used to feed a computerized glucose regulation algorithm. The same algorithm was used in the control group fed by intermittent POC glucose measurements. Safety was assessed with the incidence of severe hypoglycemia (<2.2 mmol/L), efficacy with the percentage time in target range (5.0 to 9.0 mmol/L). In addition, we assessed nursing workload and costs. RESULTS: In this study, 87 patients were randomized to the intervention and 90 to the control group. CGM device failure resulted in 78 and 78 patients for analysis. The incidence of severe glycemia and percentage of time within target range was similar in both groups. A significant reduction in daily nursing workload for glucose control was found in the intervention group (17 versus 36 minutes; P <0.001). Mean daily costs per patient were significantly reduced with EUR 12 (95% CI -32 to -18, P = 0.02) in the intervention group. CONCLUSIONS: Subcutaneous CGM to guide insulin treatment in critically ill patients is as safe and effective as intermittent point-of-care measurements and reduces nursing workload and daily costs. A new algorithm designed for frequent measurements may lead to improved performance and should precede clinical implementation. TRIAL REGISTRATION: Clinicaltrials.gov, NCT01526044. Registered 1 February 2012.
Asunto(s)
Glucemia/análisis , Enfermedad Crítica/terapia , Hipoglucemia/diagnóstico , Insulina/administración & dosificación , Monitoreo Fisiológico/enfermería , Glucemia/efectos de los fármacos , Costos y Análisis de Costo , Economía de la Enfermería , Femenino , Hospitales de Enseñanza , Humanos , Hipoglucemia/inducido químicamente , Hipoglucemia/prevención & control , Hipoglucemiantes/administración & dosificación , Hipoglucemiantes/efectos adversos , Hipoglucemiantes/uso terapéutico , Insulina/efectos adversos , Insulina/uso terapéutico , Unidades de Cuidados Intensivos/economía , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico/economía , Monitoreo Fisiológico/métodos , Países Bajos , Atención de Enfermería/estadística & datos numéricos , Sistemas de Atención de Punto/economía , Carga de TrabajoRESUMEN
BACKGROUND: The prognostic value of biochemical tests in critically ill patients with multiple organ failure and suspected bowel ischemia is unknown. METHODS: In a prospective observational cohort study intensive care patients were included when the attending intensivist considered intestinal ischemia in the diagnostic workup at any time during intensive care stay. Patients were only included once. When enrolment was ended each patient was classified as 'proven intestinal ischemia', 'ischemia likely', 'ischemia unlikely' or 'no intestinal ischemia'. Proven intestinal ischemia was defined as the gross disturbance of blood flow in the bowel, regardless of extent and grade. Classification was based on reports from the operating surgeon, pathology department, endoscopy reports and CT-scan. Lactate dehydrogenase (LDH), creatine kinase (CK), alanine aminotransferase (ALAT), L-lactate were available for the attending physician. D-lactate and intestinal fatty acid binding protein (I-FABP) were analysed later in a batch. I-FABP was only measured in patients with proven ischemia or no ischemia. RESULTS: For 44 of the 120 included patients definite diagnostic studies were available. 23/44 patients (52%) had proven intestinal ischemia as confirmed by surgery, colonoscopy, autopsy and/or histopathological findings. LDH in these patients was 285 U/l (217-785) vs 287 U/l (189-836) in no-ischemia; p = 0.72. CK was 226 U/l in patients with proven ischemia (126-2145) vs 347 U/l (50-1427), p = 0.88. ALAT was 53 U/l (18-300) vs 34 U/l (14-34), p-0,56. D-lactate 0.41 mmol/l (0.11-0.75) vs 0.56 mmol/l (0.27-0.77), p = 0.46. L-lactate 3.5 mmol/l (2.2-8.4) vs 2.6 mmol/l (1.7-3.9), p = 0.09. I-FABP 2872 pg/ml (229-4340) vs 1020 pg/ml (239-5324), p = 0.98. Patient groups proven and likely ischemia together compared to unlikely and no-ischemia together showed significant higher L-lactate (p = 0.001) and higher D-lactate (p = 0.003). CONCLUSIONS: Measurement of LDH, CK, and ALAT did not discriminate critically ill patients with proven intestinal ischemia from those with definite diagnosis no-ischemia. However, L-lactate and D-lactate levels were higher in patients with proven or likely ischemia and need further study just as I-FABP.
Asunto(s)
Creatina Quinasa/sangre , Enfermedad Crítica , Proteínas de Unión a Ácidos Grasos/sangre , Intestinos/irrigación sanguínea , Isquemia/sangre , Isquemia/diagnóstico , Ácido Láctico/sangre , Anciano , Biomarcadores/sangre , Estudios de Cohortes , Enfermedad Crítica/terapia , Femenino , Humanos , Mucosa Intestinal/metabolismo , Intestinos/patología , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
INTRODUCTION: More than half of in-hospital adverse events can be attributed to a surgical discipline. Checklists can effectively decrease errors and adverse events. However, the mechanisms by which checklists lead to increased safety are unclear. This study aimed to assess the number, nature and timing of incidents intercepted by use of the Surgical Patient Safety System (SURPASS) checklist, a patient-specific multidisciplinary checklist that covers the entire surgical patient pathway. METHODS: The checklist was implemented in two academic hospitals and four teaching hospitals in the Netherlands. Users of the checklist had three options for each item that was checked: 'not applicable', 'yes' and 'intercepted by checklist'. In each hospital, the first 1000 completed checklists were entered into an online central database. RESULTS: In six participating hospitals, 6313 checklists were collected. One or more incidents were intercepted in 2562 checklists (40.6%). In total, 6312 incidents were intercepted. After correction for the number of items and the extent of adherence in each part of the checklist, the number of intercepted incidents was highest in the preoperative and postoperative stages. CONCLUSIONS: The checklist intercepts many potentially harmful incidents across all stages of the surgical patient pathway. The majority of incidents were intercepted in the preoperative and postoperative stages of the pathway. The degree to which these incidents would have been intercepted by a single checklist in the operating room only, compared with a checklist for the entire surgical pathway, remains a subject for future study.