Citations

BACKGROUND: Many patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) have had recent healthcare interventions prior to developing ALI/ARDS. OBJECTIVE: To determine the timing of ALI/ARDS onset in relation to hospital admission and other healthcare interventions. METHODS: We conducted a population-based observational cohort study with a validated electronic surveillance tool, and identified patients with possible ALI/ARDS among critically ill adults at Mayo Clinic hospitals that provide critical care services for Olmsted County, Minnesota, in 2006. Trained investigators independently reviewed electronic medical records and confirmed the presence and timing of ALI/ARDS based on the American-European consensus definition. RESULTS: Of 124 episodes of ALI in 118 patients, only 5 did not fulfill the ARDS criteria. The syndrome developed a median 30 hours (IQR 10–82 h) after hospital admission in 79 patients (67%). ARDS was present on admission in 39 patients (33%), of whom 14 had recent hospitalization, 6 were transferred from nursing homes, and 3 had recent out-patient contact (1 antibiotic prescription, 1 surgical intervention, and 1 chemotherapy). Only 16 ARDS patients (14%) did not have known recent contact with a healthcare system. Compared to ARDS on admission, hospital-acquired ARDS was more likely to occur in surgery patients (54% vs 15%, P < .001), and had longer adjusted hospital stay (mean difference 8.9 d, 95% CI 0.3–17.4, P = .04). CONCLUSIONS: ARDS in the community most often develops either during hospitalization or in patients who recently had contact with a healthcare system. These findings have important implications for potential preventive strategies.

Context: The delivery of end-of-life care (EOLC) in the intensive care unit (ICU) varies widely among medical care providers. The differing opinions of nurses and physicians regarding EOLC may help identify areas of improvement. Objective: To explore the differences of physicians and nurses on EOLC in the ICU and how these differences vary according to self-reported proficiency level and primary work unit. Design: Cross-sectional survey of 69 ICU physicians and 629 ICU nurses. Setting: Single tertiary care academic medical institution. Results: A total of 50 physicians (72%) and 331 nurses (53%) participated in the survey. Significant differences between physicians and nurses were noted in the following areas: ability to safely raise concerns, do not resuscitate (DNR) decision making, discussion of health care directives, timely hospice referral, spiritual assessment documentation, utilization of social services, and the availability of EOLC education. In every domain of EOLC, physicians reported a more positive perception than nurses. Additional differences were noted among physicians based on experience, as well as among nurses based on their primary work unit and self-reported proficiency level. Conclusions: Even with an increased focus on improving EOLC, significant differences continue to exist between the perspectives of nurses and physicians, as well as physicians among themselves and nurses among themselves. These differences may represent significant barriers toward providing comprehensive, consistent, and coordinated EOLC in the ICU.

Abstract Rationale Accurate, early identification of patients at risk for developing acute lung injury (ALI) provides the opportunity to test and implement secondary prevention strategies. Objectives To determine the frequency and outcome of ALI development in patients at risk and validate a lung injury prediction score (LIPS). Methods In this prospective multicenter observational cohort study, predisposing conditions and risk modifiers predictive of ALI development were identified from routine clinical data available during initial evaluation. The discrimination of the model was assessed with area under receiver operating curve (AUC). The risk of death from ALI was determined after adjustment for severity of illness and predisposing conditions. Measurements and Main Results Twenty-two hospitals enrolled 5,584 patients at risk. ALI developed a median of 2 (interquartile range 1–4) days after initial evaluation in 377 (6.8%; 148 ALI-only, 229 adult respiratory distress syndrome) patients. The frequency of ALI varied according to predisposing conditions (from 3% in pancreatitis to 26% after smoke inhalation). LIPS discriminated patients who developed ALI from those who did not with an AUC of 0.80 (95% confidence interval, 0.78–0.82). When adjusted for severity of illness and predisposing conditions, development of ALI increased the risk of in-hospital death (odds ratio, 4.1; 95% confidence interval, 2.9–5.7). Conclusions ALI occurrence varies according to predisposing conditions and carries an independently poor prognosis. Using routinely available clinical data, LIPS identifies patients at high risk for ALI early in the course of their illness. This model will alert clinicians about the risk of ALI and facilitate testing and implementation of ALI prevention strategies. Clinical trial registered with www.clinicaltrials.gov (NCT00889772).

Abstract Rationale Significant progress has been made in understanding the pathogenesis of acute respiratory distress syndrome (ARDS). Recent advances in hospital practice may have reduced the incidence of this lethal syndrome. Objectives To observe incidence trends and associated outcomes of ARDS. Methods This population-based cohort study was conducted in Olmsted County, Minnesota. Using a validated screening protocol, investigators identified intensive care patients with acute hypoxemia and bilateral pulmonary infiltrates. The presence of ARDS was independently confirmed according to American-European Consensus Conference criteria. The incidence of ARDS and associated outcomes were compared over the 8-year study period (2001–2008). Measurements and Main Results Over the 8-year period, critically ill Olmsted County residents presented with increasing severity of acute illness, a greater number of comorbidities, and a higher prevalence of major predisposing conditions for ARDS. The ARDS incidence decreased significantly from 82.4 to 38.9 per 100,000 person-years during the study period (P &lt; 0.001). A decline in hospital-acquired ARDS (P &lt; 0.001) was responsible for the fall in the incidence density with no change on admission (P = 0.877). Overall, mortality and hospital and intensive care unit lengths of stay decreased over time (P &lt; 0.001), whereas the ARDS case-fatality did not change significantly. Conclusions Despite an increase in patients' severity of illness, number of comorbidities, and prevalence of major ARDS risk factors, the incidence of ARDS in this suburban community decreased by more than half. Correlation of the observed findings with changes in health care delivery may have important implications for the planning of acute care services in other regions.

Abstract Mortality in National Heart, Lung and Blood Institute–sponsored clinical trials of treatments for acute lung injury (ALI) has decreased dramatically during the past two decades. As a consequence, design of such trials based on a mortality outcome requires ever-increasing numbers of patients. Recognizing that advances in clinical trial design might be applicable to these trials and might allow trials with fewer patients, the National Heart, Lung and Blood Institute convened a workshop of extramural experts from several disciplines. The workshop assessed the current state of clinical research addressing ALI, identified research needs, and recommended: (1) continued performance of trials evaluating treatments of patients with ALI; (2) development of strategies to perform ALI prevention trials; (3) observational studies of patients without ALI undergoing prolonged mechanical ventilation; and (4) development of a standardized format for reporting methods, endpoints, and results of ALI trials.

This retrospective population-based study evaluated the effects of alcohol consumption on the development of acute respiratory distress syndrome (ARDS). Alcohol consumption was quantified based on patient and/or family provided information at the time of hospital admission. ARDS was defined according to American-European consensus conference (AECC). From 1,422 critically ill Olmsted county residents, 1,357 had information about alcohol use in their medical records, 77 (6%) of whom developed ARDS. A history of significant alcohol consumption (more than two drinks per day) was reported in 97 (7%) of patients. When adjusted for underlying ARDS risk factors (aspiration, chemotherapy, high-risk surgery, pancreatitis, sepsis, shock), smoking, cirrhosis and gender, history of significant alcohol consumption was associated with increased risk of ARDS development (odds ratio 2.9, 95% CI 1.3–6.2). This population-based study confirmed that excessive alcohol consumption is associated with higher risk of ARDS.

Background: Studies have failed to show a survival difference between intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT). Comparative cost analyses are limited and fail to control for differences in patient disease severity and comorbid conditions. The authors retrospectively estimated clinical and economic outcomes associated with CRRT and IHD among critically ill patients experiencing acute renal failure (ARF) in 2 tertiary care hospitals in Rochester, Minnesota, between January 1, 2000, and December 12, 2001. Methods: 161 critically ill patients requiring dialysis for ARF were analyzed. Patient demo-graphics, comorbid conditions, ARF etiology, mode of renal replacement therapy (RRT), renal recovery, and survival were abstracted from medical chart. APACHE II scores at dialysis initiation were calculated. Administrative data tracked length of stay (LOS) and direct medical costs from initiation of RRT to death or intensive care unit (ICU) and hospital discharge. Multivariate modeling was used to adjust outcomes for baseline differences. Results: 84 (52%) of the patients received CRRT and 77 (48%) received IHD. CRRT-treated patients were younger (58 vs 65 years), less likely male (58% vs 77%), had higher APACHE II scores (32 vs 27) with a higher incidence of sepsis (46% vs 30%) and respiratory disease (56% vs 39%), and were less likely to have chronic renal insufficiency (32% vs 49%). With adjustment for differences in baseline patient characteristics, the RRT method did not affect the likelihood of renal recovery, in-hospital survival, or survival during follow-up. Mean adjusted ICU LOS was 9.5 days shorter for IHD-treated than CRRT-treated patients ( P < .001), and the adjusted mean difference in hospital and total costs associated with ICU stay was $56 564 and $60 827, in favor of IHD ( P < .001). Mean adjusted total costs through hospital discharge were $93 611 and $140 733 among IHD-treated and CRRT-treated patients, respectively ( P < .001). Conclusions: This observational study suggests that costs may significantly differ by mode of RRT despite similar severity-adjusted patient outcomes. Future prospective comparisons of renal replacement modalities will need to include both clinical and economic outcomes.

The objective of this retrospective cohort study was to describe the incidence of paroxysmal atrial fibrillation and to determine its risk factors and effect on outcome in critically ill patients with sepsis. The study included 81 patients with sepsis admitted to an intensive care unit. In all, 25 patients (31%) developed paroxysmal atrial fibrillation. Advanced age, history of paroxysmal atrial fibrillation, higher severity of illness at intensive care unit admission, and lower left ventricular ejection fraction were risk factors for paroxysmal atrial fibrillation. Multiple logistic regression analysis showed that paroxysmal atrial fibrillation was independently associated with 28-day mortality (odds ratio = 3.284; 95% confidence interval, 1.126-9.574). The incidence of paroxysmal atrial fibrillation is high in critically ill patients with sepsis. It occurs more frequently in patients with advanced age, history of paroxysmal atrial fibrillation, high severity of illness, and lower left ventricular ejection fraction and is associated with increased mortality.