摘要:

Objective:To characterize hospital costs of pediatric intensive care and to determine which demographic and disease characteristics are associated with cost.Design:Prospective cohort study.Setting:A 20-bed pediatric intensive care unit (PICU) in an urban university-affiliated teaching children's hospital.Patients:All children (n = 1,376) admitted to the multidisciplinary PICU during the fiscal year 1994.Interventions:None.Measurements and Main Results:Demographics, diagnoses, organ failure, Pediatric Risk of Mortality score, length of stay (LOS), and outcome were recorded. All hospital charges were obtained. The actual hospital costs were calculated by two separate methods. First, we converted the itemized patient charges into costs, using corresponding cost-to-charge ratios for each charge. In addition, we examined all direct and indirect expenses for the PICU. Univariate and multivariate regression analyses were used to determine the correlates to cost. The study population was similar to that of other studies of pediatric intensive care. The PICU was 86% efficient. The total cost for PICU care was $16,983,323. Average cost per admission was $12,342 ± $22,313, and average cost per patient day was $2,264 ± $868. The cost because of the PICU location (room cost) was 52.1% of all costs, and cost of laboratory studies was 18.3%. Respiratory therapy, pharmacy services, and radiology each accounted for between 6% and 8%. Total cost was most closely related to LOS, but severity of illness (Pediatric Risk of Mortality), diagnosis, and organ failure were also significant. Severity of illness was the most important factor in determining the variation in daily costs. Increased severity of illness was associated with higher laboratory and diagnostic study costs. We found little difference in the PICU room cost when calculated by adding direct and indirect expenses, compared with that obtained by using the cost-to-charge ratio.Conclusions:The maintenance of the specialty location and its personnel is the most costly component of pediatric intensive care. The strongest correlate with total cost for pediatric intensive care is LOS, but if costs are normalized for LOS, severity of illness best explains cost variation among patients. These data may serve as the basis for additional studies of resource allocation and consumption in the future.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:The purpose of this study was to compare the effects of two acute-care management strategies on the frequency of jugular venous desaturation and refractory intracranial hypertension and on long-term neurologic outcome in patients with severe head injury.Design:Randomized clinical trial.Setting:Level I trauma hospital.Patients:One hundred eighty-nine adults admitted in coma because of severe head injury.Interventions:Patients were assigned to either cerebral blood flow (CBF)-targeted or intracranial pressure (ICP)-targeted management protocols during randomly assigned time blocks. In the CBF-targeted protocol, cerebral perfusion pressure was kept at > 70 mm Hg and PaCO2was kept at approximately 35 torr (4.67 kPa). In the ICP-targeted protocol, cerebral perfusion pressure was kept at >50 mm Hg and hyperventilation to a PaCO2of 25-30 torr (3.33-4.00 kPa) was used to treat intracranial hypertension.Measurements and Main Results:The CBF-targeted protocol reduced the frequency of jugular desaturation from 50.6% to 30% (p= .006). Even when the frequency of jugular desaturation was adjusted for all confounding factors that were significant, the risk of cerebral ischemia was 2.4-fold greater with the ICP-targeted protocol. Despite the reduction in secondary ischemic insults, there was no difference in neurologic outcome. Failure to alter long-term neurologic outcome was probably attributable to two major factors. A low jugular venous oxygen saturation was treated in both groups, minimizing the injury that occurred in the ICP-targeted group. The beneficial effects of the CBF-targeted protocol may have been offset by a five-fold increase in the frequency of adult respiratory distress syndrome.Conclusions:Secondary ischemic insults caused by systemic factors after severe head injury can be prevented with a targeted management protocol. However, potential adverse effects of this management strategy may offset these beneficial effects.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:To assess the effect of plasmafiltration (PF) on biochemical markers of inflammation, cytokines, organ dysfunction, and 14-day mortality in human sepsis.Design:Multicenter, prospective, randomized, controlled clinical trial.Setting:Seven university-affiliated intensive care units.Patients:Thirty patients (22 adults, eight children) with new (<24 hrs) clinical evidence of infection and sepsis syndrome were enrolled. Fourteen of 30 (nine adults, five children) were randomized to PF.Interventions:All patients received protocol-driven supportive intensive care, and those randomized to PF received continuous plasma exchange for 34 hrs using a hollow-fiber plasma filter.Measurements and Main Results:Illness severity and risk of death were calculated with the Pediatric Risk of Mortality (children) and the Acute Physiology and Chronic Health Evaluation II (adults) scales. Plasma samples (0, 6, 24, and 48 hrs) were assayed for acute-phase proteins (albumin, globulin, C-reactive protein, α1-antitrypsin, haptoglobin), inflammatory mediators (complement fragment C3, thromboxane B2), and cytokines (interleukin-6, granulocyte colony-stimulating factor, leukemia inhibitory factor). Sieving coefficients were estimated from filtrate concentrations at 3 hrs. The two groups were matched for incidence of septic shock (13 of 14 vs. 11 of 16), refractory shock (three of 14 vs. six of 16), bacteremia (six of 14 vs. five of 16), severity of illness, and calculated risk of death (0.68 vs. 0.64). There was no difference in mortality. Eight of 14 PF patients (57%) and eight of 16 controls (50%) survived for 14 days (p= .73, Fisher's exact test). Multiple logistic regression revealed age (odds ratio, 16.4:1; 95% confidence interval, 2.12-∞) and shock (10.6:1; 1.32-∞) as significant predictors of death; plasmafiltration was associated with a nonsignificant reduction in the risk of death (odds ratio, 1.78:1; 95% confidence interval, 0.20-18.1). The mean (SD) number of organs failing in the first 7 days in the PF group was 2.57 (0.94) vs. 2.94 (0.85) in controls (p= .37, Mann-Whitney U test). Both groups had similarly elevated plasma concentrations of all inflammatory mediators except complement fragment C3at study entry. Leukemia inhibitory factor was detectable in four patients only. PF did not influence mean concentrations of interleukin-6, granulocyte colony-stimulating factor, thromboxane B2, total white cell count, neutrophil count, or platelet count, but it was associated with significant reductions of α1-antitrypsin, haptoglobin, C-reactive protein, and complement fragment C3in the first 6 hrs (p< .05). The sieving coefficients for all inflammatory mediators approached unity.Conclusions:PF caused a significant attenuation of the acute-phase response in sepsis. There was no significant difference in mortality, but there was a trend toward fewer organs failing in the PF group that suggests that this procedure might be beneficial.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:To determine if there is a correlation between an increase in glomerular permeability, the magnitude of trauma, and the severity of illness.Design:Prospective study.Setting:Two university hospital intensive care units.Patients:Forty consecutive critically ill trauma patients admitted directly to the intensive care unit within 120 mins of their injuries.Interventions:None.Measurements and Main Results:For each patient, urine was collected from the time of admission until 7 am the next day. Within 48 hrs, only one sample of all urine collected (5 mL) was examined for microalbuminuria and urinary creatinine. Results were expressed as the microalbuminuria/urinary creatinine ratio (MACR). The mortality rate in the intensive care unit, Injury Severity Score at the moment of admission, Acute Physiology and Chronic Health Evaluation III score, and Simplified Acute Physiology Score in the first 24 hrs were calculated for each patient. The data were analyzed using the Pearson test for linear regression and Student'st-test. During the first 24 hrs after trauma, there was an increase of MACR (6.9 ± 0.6 mg/mmol) above normal (reference range, <3 mg/mmol) that was positively correlated with Injury Severity Score (31.4 ± 1.9; r2= .73,p< .05). However, there was no correlation between MACR, Acute Physiology and Chronic Health Evaluation III score, Simplified Acute Physiology Score, and mortality rate.Conclusions:Patients with trauma show an increase in glomerular permeability during the first 24 hrs after injury. The magnitude of this increase is correlated with the extent of trauma but does not seem significant enough to be predictive of severity of illness and/or outcome.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:To determine the frequency and effects of weaning-related myocardial ischemia on weaning outcomes in patients with coronary artery disease.Design:Prospective cohort study.Setting:Medical and cardiac intensive care units of a 300-bed teaching community hospital.Measurements and Main Results:Three-lead ST segments, heart rate-systolic blood pressure products, and respiratory rate/tidal volume ratios were obtained for patients with coronary artery disease just before and during their initial trials of weaning from mechanical ventilation. ST segments were interpreted by a blinded cardiologist. Eighty-three patients with a mean age of 72.4 ± 1.1 years (mean ± SEM), a mean Acute Physiology and Chronic Health Evaluation II score of 16.4 ± 0.8, and a mean duration of mechanical ventilation of 4.6 ± 0.9 days were studied. Eight patients showed electrocardiographic evidence of ischemia during weaning, and seven of these patients failed to be liberated on their first day of weaning. The presence of ischemia significantly increased the risk of weaning failure (risk ratio, 2.1; 95% confidence interval, 1.4-3.1). The rate-pressure product for the group as a whole increased significantly during weaning, from 11.9 ± 0.4 to 13.5 ± 0.5 mm Hg × beats/min × 103(p< .01). The increase in rate-pressure product tended to be greater in patients who became ischemic (12.8 ± 0.9 to 17.3 ± 2.0 mm Hg × beats/min × 103) than in patients who were not ischemic during weaning (11.8 ± 0.4 to 13.0 ± 0.5 mm Hg × beats/min × 103;p= .05). The rate/volume ratio did not change significantly during weaning, but the rate/volume ratios after both 1 min (65.6 ± 4.6 vs. 98.0 ± 9.4 breaths/min/L;p< .05) and 30 mins (68.6 ± 4.3 vs. 91.1 ± 8.9 breaths/min/L;p< .05) of unassisted breathing were lower in successful than in unsuccessful patients.Conclusion:Electrocardiographic evidence of myocardial ischemia occurs frequently and is associated with significantly increased risk of first-day weaning failure in patients with coronary artery disease.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objectives:To report a series of patients with clinically diagnosed venous air embolism (VAE) and major sequelae as a complication of the use of central venous catheters (CVCs), to survey health care professionals' practices regarding CVCs, and to implement an educational intervention for optimizing approaches to CVC insertion and removal.Setting:Tertiary care, university-based 806-bed medical center.Interventions:We surveyed 140 physicians and 53 critical care nurses to appraise their awareness of the proper management and complications of CVCs. We then designed, delivered, and measured the effects of a multidisciplinary educational intervention given to 106 incoming house officers.Measurements and Main Results:Although most physicians (127, 91%) chose the Trendelenburg position for CVC insertion, only 42 physicians (30%) reported concern for VAE. On CVC removal, only 36 physicians (26%) cited concern for VAE. Some physicians (13, 9%) reported elevating the head of the bed during CVC removal, possibly increasing the risk of VAE. Awareness of VAE or its prevention did not correlate with the level of physician training, experience, or specialty. After the educational intervention, concern for and awareness of proper methods of prevention of VAE improved (p< .001). At 6-month follow-up, reported use of the Trendelenburg position continued, but concern cited for VAE had returned to baseline.Conclusions:There is inadequate awareness of VAE as a complication of CVC use. Focused instruction can improve appreciation of this potentially fatal complication and knowledge of its prevention, but the effect declines rapidly. To achieve a more sustained improvement, a more intensive, hands-on, periodic educational program will likely be necessary, as well as reinforcement through enhanced supervision of CVC insertion and removal practices.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:In this study, clinical practice guidelines were developed by a multidisciplinary team for patients with infections admitted to a surgical intensive care unit (ICU).Design:A 51-day baseline audit period (Phase I) in a 20-bed (private rooms) surgical ICU was compared with a 34-day period in the same unit after implementation of the guidelines (Phase II).Patients:Phase I included 182 patients (670 patient days), and Phase II included 139 patients (427 patient days).Results:There was no significant difference between patients in the Phase I and Phase II groups regarding age (65.4/19-95 vs. 64.8/18-90 yrs), gender (56% male vs. 55% male), severity of illness (mean Acute Physiology and Chronic Health Evaluation III, 38 vs. 39.1), total infections (respiratory, 8% vs. 4%; urinary tract, 15% vs. 4%; wound, 4% vs. 3%; skin/soft tissue, 3% vs. 7%; sepsis, 5% vs. 3%; intra-abdominal, 9% vs. 17%), and no infection (64% vs. 67%). Clinical outcomes of patients with infections in the Phase I group compared with those in the Phase II group were as follows: clinical improvement or cure, 64% vs. 76%; persistent infection, 17% vs. 11%; clinical failure, 0 vs. 2%; and death, 18% vs. 7% (p= NS). When patients with infections were compared, death rates were 20% in the Phase I group and 5.6% in the Phase II group (p= .02). After implementation of the clinical pathways, antibiotic costs were reduced from $676.54 per patient to $157.88 per patient (p= .001). Length of stay in the ICU was 3.7 days in the Phase I trial and a mean of 3 days in the Phase II trial (p= NS). Specimens ofEscherichia colidemonstrated a trend toward a decreased resistance to all antibiotics andPseudomonas aeruginosato ciprofloxacin and aminoglycosides (p= NS).Conclusions:In this study, the use of clinical practice guidelines for patients who were admitted to the surgical ICU was shown to reduce costs, without adversely affecting patients' outcomes. This study has important implications for the use of clinical practice guidelines for the management of patients with infections who are admitted to surgical ICUs.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:To assess the influence of patient access to a private attending physician on the withdrawal of life-sustaining therapies in a medical intensive care unit (ICU).Design:Prospective cohort study.Setting:A university-affiliated teaching hospital.Patients:A total of 501 consecutive patients admitted to the medical ICU during a 5-month period.Interventions:NoneMeasurements and Main Results:Among patients dying in the medical ICU, those without a private attending physician (n = 26) were statistically more likely to undergo the active withdrawal of life-sustaining therapies than patients with a private attending physician (n = 87) (80.8% vs. 29.9%; relative risk = 2.70; 95% confidence interval = 1.86−3.92;p< .001). Despite having similar predicted mortality rates by Acute Physiology and Chronic Health Evaluation II score (60.5% ± 27.0% vs. 66.1% ± 21.3%;p= .280), patients dying in the medical ICU without a private attending physician had statistically shorter hospital and ICU lengths of stay, a shorter duration of mechanical ventilation, and fewer total hospital costs and charges compared with patients with access to a private attending physician. Multiple logistic regression analysis, controlling for severity of illness, demographic characteristics, and patient diagnoses, demonstrated that lack of access to a private attending physician (adjusted odds ratio = 23.10; 95% confidence interval = 9.10−58.57;p< .001) and the presence of a do-not-resuscitate order while in the ICU (adjusted odds ratio = 7.33; 95% confidence interval = 3.69−14.54;p= .004) were the only variables independently associated with the withdrawal of life-sustaining therapies before death.Conclusions:Patients dying in a medical ICU setting without access to a private attending physician are more likely to undergo the active withdrawal of life-sustaining therapies before death than patients with a private attending physician. Health care providers should be aware of possible variations in the practice of withdrawal of life-sustaining therapies in their ICUs based on this patient characteristic.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:To determine whether oxygen consumption (&OV0312;O2), CO2production, and resting energy expenditure (REE) in critically ill patients differ in varying grades of systemic inflammatory response syndrome (SIRS).Design:Prospective, clinical study.Setting:Intensive care unit at a university hospital.Patients:Twenty-six critically ill patients requiring mechanical ventilation.Interventions:None.Measurements and Main Results:A total of 100 metabolic measurements were performed. The grade of SIRS and the Acute Physiology and Chronic Health Evaluation II score were evaluated at the time of the metabolic cart study. &OV0312;O2and REE differed among the groups inadequate for SIRS (non-SIRS), with SIRS without infection (nonseptic SIRS), and with SIRS with infection (septic SIRS) (125 ± 37 mL/min/m2and 855 ± 204 kcal/day/m2, 135 ± 33 mL/min/m2and 948 ± 214 kcal/day/m2, and 166 ± 55 mL/min/m2and 1149 ± 339 kcal/day/m2, respectively;p< .005). Patients with septic SIRS had higher &OV0312;O2and REE than patients with non-SIRS and nonseptic SIRS.Conclusion:&OV0312;O2and REE differ among groups of patients with non-SIRS, nonseptic SIRS, and septic SIRS. Patients with septic SIRS have higher &OV0312;O2and REE than patients with non-SIRS or nonseptic SIRS. The present study shows that classifying patients into three grades (non-SIRS, nonseptic SIRS, and septic SIRS) is a valid predictor of metabolic stress in critically ill patients.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:Assess the frequency and outcome of inhospital resuscitation and determine the relationship between patient age and survival and whether it is affected by initial rhythm.Design:Retrospective, single-institution, registry study of inhospital resuscitation.Setting:A 550-bed, tertiary-care, teaching hospital in Macon, GA.Patients:All admissions for which a resuscitation was attempted in the Medical Center of Central Georgia during the period of January 1, 1987 through December 31, 1993. The registry sample included 2,394 admissions, for which 2,813 resuscitation attempts were made; only the first resuscitation attempt during an admission was analyzed.Interventions:None.Measurements and Main Results:Rates of survival to discharge steadily increased from 24.4% in 1987 to 38.6% in 1993; the overall survival rate was 26.8%. Age, used as a continuous variable, was strongly related to survival (odds ratio = 0.984;p< .0001). Categorically, overall survival rates for pediatric, adult, and geriatric patients were 56.4%, 29.0%, and 24.0%, respectively. Survival rates also varied significantly (odds ratio = 0.469;p< .0001) among initial rhythms, i.e., supraventricular tachycardia (60.7%), ventricular tachycardia (57.6%), perfusing rhythms (49.84%), ventricular fibrillation (32.0%), pulseless electrical activity (14.6%), and asystole (9.1%). The relationship between age and survival did not change across the years included in the study, but did vary as a function of initial rhythm (p< .0001). Age was positively related to survival when initial rhythm was supraventricular tachycardia (p= .04), negatively related to survival when the initial rhythm was perfusing (p< .0001) or pulseless electrical activity (p= .0002), and not related to survival when the initial rhythm was ventricular tachycardia (p= .98), ventricular fibrillation (p= .14), or asystole (p= .21).Conclusions:The relationship between patient age and a successful resuscitation attempt is not as simple as reported earlier. Whether age is related to increased or decreased survival, or is unrelated to survival, depends on the rhythm extant when resuscitation attempts begin. Survival rates were higher than most reported elsewhere and improved significantly over time. Multicentered studies are needed to determine whether these results are unique to the institution studied.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID