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Charles L Sprung

Publications and source records attributed to Charles L Sprung.

At least 37 records · Page 2Linked to original sources
PubMed2005

Conventional terrorist bomb incidents and the intensive care unit.

PURPOSE OF REVIEW: A terror bombing creates a momentary stress on acute care services, including the emergency medical system, emergency departments, and intensive care units. A knowledge of the progression of events, the anticipated volume of injured survivors, and the pattern of injuries will enable the physician in the intensive care unit to prepare the unit quickly and efficiently for the expected rush of injured survivors. RECENT FINDINGS: In the past 2 years it has become apparent in the medical literature that terror bombing causes more complicated injuries than other types of trauma. The injuries are a combination of blast, penetrating, and blunt trauma, as well as burns. As a result, a significant number of patients will need care in the intensive care unit for a long time. Treating these injuries mandates an understanding of the combination of injury mechanisms because the ideal treatment for one mechanism might cause harm if another coexists. In addition, recent literature delineates the volume of admissions an intensive care unit should anticipate. This information should allow the preparation of sufficient vacant intensive care unit beds and facilitate the efficient use of equipment and personnel. SUMMARY: This review, based on recently published data, aims to provide the intensive care unit physician with crucial information about the anticipated progression of events, the possible numbers of patients, and the nature of their injuries after a terrorist bombing. This information should aid in rational crisis planning.

Adolescent↗
PubMed2005

An internet web site as a data collection platform for multicenter research.

The Internet can be an effective alternative for data collection for multicenter studies. It has major advantages over the "classical" method of using paper and traditional ("snail") mail. We developed an Internet site and implemented collection of data for a multicenter study of ethical decision-making. The Web site was built with Microsoft FrontPage as the authoring tool. Database management was performed with Microsoft Access. Security issues were the major concerns for the web design. Thirty-seven European centers enrolled 4248 patients during 1.5 yr using the Internet site. The use of this Internet site for data acquisition was highly effective, and the investigators were able to use the system without training. Overall satisfaction of the investigators was high. After security issues, interactivity and user-friendly design are the main cornerstones for the success of such a system.

Computer Security↗
PubMed2005

Use of the pulmonary artery catheter is not associated with worse outcome in the ICU.

STUDY OBJECTIVES: In critically ill patients, the impact of pulmonary artery catheter (PAC) use on outcome is debatable. We investigated the epidemiology of PAC use in European ICUs and its relation to outcome. DESIGN: International cohort, observational study. SETTING: One hundred ninety-eight European ICUs participating in the Sepsis Occurrence in Acutely Ill Patients Study. PATIENTS: All 3,147 adult patients admitted to one of the participating ICUs between May 1, 2002, and May 15, 2002. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Patients were classified according to whether or not they had a PAC at any time during their ICU stay, and were followed up until death, hospital discharge, or for 60 days. Propensity score case matching was performed, and matched pairs were examined for baseline characteristics and outcome. Of 3,147 patients, 481 patients (15.3%) had a PAC. Patients with a PAC were older, had a higher incidence of heart failure, a lower incidence of cancer, and were more commonly surgical admissions. Fluid balance was comparable between the two groups. ICU and hospital mortality rates were higher in patients with a PAC (28.1% vs 16.8% and 32.5% vs 22.5%, respectively; p < 0.001). However, PAC use was not an independent risk factor for 60-day mortality in multivariate analysis, and in 453 propensity-matched pairs ICU and hospital mortality rates were comparable between groups (26.7% vs 26.3% and 31.4% vs 32.8%, p = not significant). Survival to 60 days was similar between the two matched groups (log rank = 0.02; p = 0.894). CONCLUSIONS: This observational study suggests that PAC use is not associated with increased mortality in this heterogeneous population.

Catheterization↗
PubMed2005

High tidal volume and positive fluid balance are associated with worse outcome in acute lung injury.

STUDY OBJECTIVES: Recent data have suggested that ventilatory strategy could influence outcomes from acute lung injury (ALI) and ARDS. We tested the hypothesis that infection/sepsis and use of higher tidal volumes than those applied in the ARDS Network (ARDSnet) study (> 7.4 mL/kg of predicted body weight) would worsen outcome in patients with ALI/ARDS. DESIGN: International cohort, observational study. SETTING: One hundred ninety-eight European ICUs participating in the Sepsis Occurrence in Acutely Ill Patients study. PATIENTS OR PARTICIPANTS: All 3,147 adult patients admitted to one of the participating ICUs between May 1, 2002, and May 15, 2002. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Patients were followed up until death, hospital discharge, or for 60 days. Of the 3,147 patients, 393 patients (12.5%) had ALI/ARDS. ICU and hospital mortality was higher in patients with ALI/ARDS than those without ALI/ARDS (38.9% vs 15.6% and 45.5% vs 21.0%, respectively; p < 0.001). A multivariable logistic regression analysis with ICU outcome as the dependent factor showed that the independent risks for mortality were as follows: presence of cancer, use of tidal volumes higher than those used by the ARDSnet study, degree of multiorgan dysfunction, and higher mean fluid balance. Sepsis, septic shock, and oxygenation at the onset of ALI/ARDS were not independently associated with higher mortality rates. CONCLUSIONS: In addition to comorbidities and organ dysfunction, high tidal volumes and positive fluid balance are associated with a worse outcome from ALI/ARDS.

Aged↗
PubMed2004

Peter Sjokvist.

Explore the source record for details and available documents.

Critical Care↗
PubMed2004

Intensive care physicians' attitudes concerning distribution of intensive care resources. A comparison of Israeli, North American and European cohorts.

OBJECTIVE: To evaluate the attitudes of Israeli intensive care physicians regarding intensive care unit (ICU) triage issues. DESIGN: An opinion survey using questionnaires similar to those used in a previous study in the United States. SETTING AND PARTICIPANTS: Forty-three physicians, members of the Israel Society of Critical Care Medicine (45%). RESULTS: Important factors for admission to the last ICU bed were: small likelihood of surviving hospitalization, irreversibility of acute disorder, nature of chronic disorders and the physician's personal attitude. Most respondents would admit a patient with a predicted survival of a few weeks (70%) or a patient whose quality of life would be poor according to the physician's (98%) or patient's (77%) definition, to the last ICU bed. The personal attitude of the respondents and their own view of the patient's quality of life were considered as important as the quality of life as viewed by the patient. Israeli physicians tended to refuse patient admission into the ICU more than their US counterparts. Most Israeli physicians refused to discharge an ICU patient in order to admit another, despite bed shortage. CONCLUSIONS: The attitudes of Israeli intensive care physicians towards distribution of ICU resources differ from those of their United States counterparts; they are more paternalistic and comply less with requests for admission. Such attitudes are comparable to those expressed by some European intensive care physicians, highlighting the existence of diversity in the factors important to physicians' decision-making.

Attitude of Health Personnel↗
PubMed2004

Corticosteroid therapy in patients with severe sepsis and septic shock.

Corticosteroids have been considered for decades for the treatment of severe sepsis and septic shock, based on their pivotal role in the stress response and their hemodynamic and antiinflammatory effects. Whereas short-term therapy with high doses of corticosteroids (up to 42 g hydrocortisone equivalent for 1-2 days) has been ineffective or potentially harmful, prolonged therapy with lower doses (200-300 mg hydrocortisone for 5-7 days or longer) in septic shock has recently revealed beneficial effects in several randomized, controlled trials. Assuming relative adrenal insufficiency (RAI) and peripheral cortisol resistance, treatment with low-dose hydrocortisone improved shock reversal, reduced inflammation, and improved outcome. Shock reversal and reduction of mortality were more effective in patients with RAI, and most significant in patients with severe shock. Diagnosis of RAI with corticotropin tests in septic shock, however, is highly dependent on cut-off values and definition of RAI. Thus, it is not clear yet which patients benefit most from low-dose hydrocortisone and if treatment should be restricted to patients with RAI. In addition the role of fludrocortisone is uncertain. Nevertheless, based on current data, low-dose hydrocortisone therapy should definitely be considered in vasopressor-dependent septic shock. This review will address some critical points.

Journal Article↗
PubMed2004

Survival of critically ill patients hospitalized in and out of intensive care units under paucity of intensive care unit beds.

OBJECTIVE: The demand for intensive care beds far exceeds their availability in many European countries. Consequently, many critically ill patients occupy hospital beds outside intensive care units, throughout the hospital. The outcome of patients who fit intensive care unit admission criteria but are hospitalized in regular wards needs to be assessed for policy implications. The object was to screen entire hospital patient populations for critically ill patients and compare their 30-day survival in and out of the intensive care unit. DESIGN: Screening teams visited every hospital ward on four selected days in five acute care Israeli hospitals. The teams listed all patients fitting a priori developed study criteria. One-month data for each patient were abstracted from the medical records. SETTING: Five acute care Israeli hospitals. PATIENTS: All patients fitting a priori developed study criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Survival in and out of the intensive care unit was compared for screened patients from the day a patient first met study criteria. Cox multivariate models were constructed to adjust survival comparisons for various confounding factors. The effect of intensive care unit vs. other departments was estimated separately for the first 3 days after deterioration and for the remaining follow-up time. Results showed that 5.5% of adult hospitalized patients were critically ill (736 of 13,415). Of these, 27% were admitted to intensive care units, 24% to specialized care units, and 49% to regular departments. Admission to an intensive care unit was associated with better survival during the first 3 days of deterioration, after we adjusted for age and severity of illness (p =.018). There was no additional survival advantage for intensive care unit patients (p =.9) during the remaining follow-up time. CONCLUSIONS: The early survival advantage in the intensive care unit suggests a window of critical opportunity for these patients. Under economic constraints and dearth of intensive care unit beds, increasing the turnover of patients in the intensive care unit, thus exposing more needy patients to the early benefit of treatment in the intensive care unit, may be advantageous.

Adult↗
PubMed2004

Use of corticosteroid therapy in patients with sepsis and septic shock: an evidence-based review.

OBJECTIVE: In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for the use of corticosteroid therapy in patients with sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis. DESIGN: The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. METHODS: The modified Delphi methodology used for grading recommendations built upon a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591. CONCLUSIONS: Low doses of corticosteroids are recommended in patients with septic shock. In the absence of vasopressor requirement, corticosteroids should not be used to treat sepsis. High-dose corticosteroids are not recommended in severe sepsis. The use of adrenal function tests to guide decisions on corticosteroid therapy, the weaning of steroids at the end of the treatment period, the decision to discontinue steroids earlier with resolution of shock, and the addition of oral fludrocortisone are considered optional approaches.

Adrenal Cortex Hormones↗
PubMed2004

Family-physician interactions in the intensive care unit.

Surrogate designation has the potential to represent the patient's wishes and promote successful family involvement in decision making when options exist as to the patient's medical management. In recent years, intensive care unit physicians and nurses have promoted family-centered care on the basis that adequate and effective communication with family members is the key to substitute decision making, thereby protecting patient autonomy. The two-step model for the family-physician relationship in the intensive care unit including early and effective provision of information to the family followed by family input into decision making is described as well as specific needs of the family members of dying patients. A research agenda is outlined for further investigating the family-physician relationship in the intensive care unit. This agenda includes a) improvement of communication skills for health care workers; b) research in the area of information and communication; c) interventions in non-intensive care unit areas to promote programs for teaching communication skills to all members of the medical profession; d) research on potential conflict between medical best interest and the ethics of autonomy; and e) publicity to enhance society's interest in advance care planning and surrogate designation amplified by debate in the media and other sounding boards. These studies should focus both on families and on intensive care unit workers. Assessments of postintervention outcomes in family members would provide insights into how well family-centered care matches family expectations and protects families from distress, not only during the intensive care unit stay but also during the ensuing weeks and months.

Advance Care Planning↗
PubMed2004

Multiple casualty terror events: the anesthesiologist's perspective.

UNLABELLED: In a 28-mo period 14 multiple-casualty terror events occurred in Jerusalem, challenging the Department of Anesthesiology and Critical Care Medicine of the city's sole Level 1 trauma center. We performed a retrospective review of the response of the department to evaluate staff activities, resource use (emergency department, operating rooms, and intensive care unit [ICU]), and patient flow. A total of 1062 people were injured in the 14 multi-casualty terror incidents. The emergency department treated 355 victims; 108 of them were hospitalized, and 58 underwent surgery during the first 8 h. Only two surgeries were performed during the first hour, and the average time to the first surgery was 124 min. Fifty-one patients were admitted to the ICU an average of 5.5 h after the terror event. After a terrorist act, multiple, simultaneous efforts were required of the anesthesiology department, including taking part in the initial resuscitation in the emergency department, anesthetizing victims for surgery and angiographies, and caring for them in the recovery room and ICU. Therefore, anesthesiology departments are greatly impacted by such events and must plan for them to maximize the use of available personnel and to have the appropriate equipment and supplies available. IMPLICATIONS: Anesthesiologists provide essential care to patients injured in terror events, from the initial resuscitation through therapeutic/diagnostic procedures and surgeries. Operational issues faced by a department of anesthesiology during the initial 8 h after terrorist actions were examined. Multiple, and often parallel, efforts were required of the department.

Anesthesiology↗
PubMed2004

Evaluation of changes in forgoing life-sustaining treatment in Israeli ICU patients.

INTRODUCTION: Over the last several years, there have been legal decisions and changes in medical directives concerning end-of-life decisions in Israel. METHODS: The data were compared to evaluate the changes in the frequency and types of forgoing of life-sustaining treatment (FLST) in patients who were admitted to the ICU during period I (November 1994 to July 1995) and period II (January 1998 to January 1999). RESULTS: During period I, there were 385 ICU admissions, and during period II there were 627 ICU admissions. In period I, FLST or death occurred in 13.5% of patients, and in 12% in period II. There was no significant difference in cardiopulmonary resuscitation (9% vs 13%, respectively), withholding therapy (90% vs 91%, respectively), or withdrawing therapy (0% vs 0%, respectively) between the two study periods. CONCLUSIONS: There was no significant change in the frequency or types of FLST in an Israeli ICU between 1994 and 1998, despite passage of a new Patients' Rights Law and the issuing of a Ministry of Health directive on the treatment of the terminally ill, both of which occurred in 1996, and recent district court decisions favoring the termination of life-sustaining therapies.

Cardiopulmonary Resuscitation↗
PubMed2003

End-of-life practices in European intensive care units: the Ethicus Study.

CONTEXT: While the adoption of practice guidelines is standardizing many aspects of patient care, ethical dilemmas are occurring because of forgoing life-sustaining therapies in intensive care and are dealt with in diverse ways between different countries and cultures. OBJECTIVES: To determine the frequency and types of actual end-of-life practices in European intensive care units (ICUs) and to analyze the similarities and differences. DESIGN AND SETTING: A prospective, observational study of European ICUs. PARTICIPANTS: Consecutive patients who died or had any limitation of therapy. INTERVENTION: Prospectively defined end-of-life practices in 37 ICUs in 17 European countries were studied from January 1, 1999, to June 30, 2000. MAIN OUTCOME MEASURES: Comparison and analysis of the frequencies and patterns of end-of-life care by geographic regions and different patients and professionals. RESULTS: Of 31 417 patients admitted to ICUs, 4248 patients (13.5%) died or had a limitation of life-sustaining therapy. Of these, 3086 patients (72.6%) had limitations of treatments (10% of admissions). Substantial intercountry variability was found in the limitations and the manner of dying: unsuccessful cardiopulmonary resuscitation in 20% (range, 5%-48%), brain death in 8% (range, 0%-15%), withholding therapy in 38% (range, 16%-70%), withdrawing therapy in 33% (range, 5%-69%), and active shortening of the dying process in 2% (range, 0%-19%). Shortening of the dying process was reported in 7 countries. Doses of opioids and benzodiazepines reported for shortening of the dying process were in the same range as those used for symptom relief in previous studies. Limitation of therapy vs continuation of life-sustaining therapy was associated with patient age, acute and chronic diagnoses, number of days in ICU, region, and religion (P<.001). CONCLUSION: The limiting of life-sustaining treatment in European ICUs is common and variable. Limitations were associated with patient age, diagnoses, ICU stay, and geographic and religious factors. Although shortening of the dying process is rare, clarity between withdrawing therapies and shortening of the dying process and between therapies intended to relieve pain and suffering and those intended to shorten the dying process may be lacking.

Adolescent↗
PubMed2003

Efficacy and safety of tifacogin (recombinant tissue factor pathway inhibitor) in severe sepsis: a randomized controlled trial.

CONTEXT: The expression and release of tissue factor is a major trigger for the activation of coagulation in patients with sepsis. Tissue factor pathway inhibitor (TFPI) forms a complex with tissue factor and blood protease factors leading to inhibition of thrombin generation and fibrin formation. OBJECTIVES: To determine if administration of tifacogin (recombinant TFPI) provides mortality benefit in patients with severe sepsis and elevated international normalized ratio (INR) and to assess tifacogin safety in severe sepsis, including patients with low INR. DESIGN AND SETTING: A randomized, double-blind, placebo-controlled, multicenter, phase 3 clinical trial conducted from March 21, 2000, through September 27, 2001, in 245 hospitals in 17 countries in North America, Europe, and Israel. PATIENTS: The primary efficacy population consisted of 1754 patients (> or =18 years) with severe sepsis and a high INR (> or =1.2) randomly assigned to intravenous infusion of either tifacogin (0.025 mg/kg per hour for 96 hours, n = 880) or placebo (arginine citrate buffer, n = 874), and 201 patients with a low INR (<1.2) randomly assigned to receive the same dose of either tifacogin or placebo. MAIN OUTCOME MEASURE: All-cause 28-day mortality. RESULTS: Overall mortality at 28 days in the tifacogin-treated group (n = 880) vs the placebo group (n = 874) for high INR was 34.2% vs 33.9%, respectively (P =.88, Pearson chi2 test; P =.75, logistic regression model). None of the protocol-specified secondary end points differed between the tifacogin vs placebo groups. An analysis on the first 722 patients demonstrated a mortality rate of 38.9% for placebo vs 29.1% for tifacogin (P =.006, Pearson chi2 test). Tifacogin significantly attenuated prothrombin fragment 1.2 and thrombin:antithrombin complex levels (P<.001, 2-sample t test) in patients with high and low INR. Overall mortality was lower in the tifacogin response in patients with low INR (12%; n = 83) vs placebo (22.9%; n = 118) (P =.051, Pearson chi2 test; P =.03, logistic regression model). There was an increase in serious adverse events with bleeding in the tifacogin group in both cohorts (6.5% tifacogin and 4.8% placebo for high INR; 6.0% tifacogin and 3.3% placebo for low INR). CONCLUSIONS: Treatment with tifacogin had no effect on all-cause mortality in patients with severe sepsis and high INR. Tifacogin administration was associated with an increase in risk of bleeding, irrespective of baseline INR.

Anticoagulants↗
PubMed2003

Intensive care outflow limitation--frequency, etiology, and impact.

OBJECTIVE: To assess the frequency, causes, and effect of unsuccessful discharge decisions from the ICU. SETTING: An 11-bed general intensive care unit of a 750-bed urban university hospital, tertiary referral center and level one trauma center. DESIGN: A prospective, observational study. PATIENTS: All ICU patients judged appropriate for discharge by the ICU attending physician. MEASUREMENTS AND RESULTS: A total of 856 attempted discharges in 706 patients were analyzed over 16 months. Of these, 703 (82%) were successful within 24 hours. Of the remaining 153 unsuccessful discharges, 51 (33%) were deferred because of medical deterioration, 32 (21%) at the request of the ward physicians or nurses and 70 (46%) because of administrative difficulties (lack of ward bed space or disagreement over admitting service). When compared to patients successfully discharged on the first attempt, those whose discharge was deferred had a significantly longer ICU admission prior to the first discharge attempt (median 4d v 3d, P =.009), and a higher proportion required intermediate care (48% v 26%, P <.001). Both these factors were independently associated with unsuccessful discharge in a logistic regression analysis (OR 1.04, 95%CI 1.02, 1.06, P =.0001, OR 2.05 95%CI 1.30, 3.26, P =.002, respectively). Deferred discharges accounted for 153 days of ICU care (2.6% of the total) and were associated with ICU overflow on 118 days (2% of all ICU days). CONCLUSION: ICU outflow limitation occurs in up to 1 in 6 discharges. It can be due to medical deterioration, level of care issues or administrative problems, and may lead to inefficient use of ICU resources.

Bed Occupancy↗
PubMed2003

Optimizing admissions to an intensive care unit.

This paper presents a model for optimizing admissions to an intensive care unit (ICU) where the objective is to maximize the expected incremental number of lives saved from operating the ICU. The probability distribution of the number of occupied ICU beds is modeled using queueing theory. Three different admissions policies are considered: first come first served (FCFS), first come firstserved for all referrals whose expected incremental survival benefits gained from ICU admission exceed some hurdle (FCFS-H), and first come first served for all referrals whose expected incremental survival benefits exceed a bed specific hurdle (BSH) that depends upon the number of occupied beds (FCFS-BSH). The model is applied to data describing patients referred to the ICU at Jerusalem's Hebrew University-Hadassah Hospital. After statistically estimating the distribution of expected incremental survival benefits among those referred to the ICU, we show that if only those referrals where ICU admission would improve the probability of survival by at least 19.4 percentage points were admitted, an additional 18 statistical lives would be saved annually compared to the FCFS policy, a relative life saving improvement of 17.9%. Implementing the more complex optimal bed specific hurdle policy would save an additional 1.4 statistical lives annually beyond what can be achieved with FCFS-H, a marginal improvement of only 1.2%.

Decision Support Techniques↗
PubMed2003

End-of-life intensive care unit decisions, communication, and documentation: an evaluation of physician training.

PURPOSE: The majority of patients dying in intensive care units (ICUs) do so after the forgoing of life-sustaining therapies (FLST). Communication between physicians, patients, and their families regarding the decision to FLST has not been evaluated in Israel. MATERIALS AND METHODS: All patients who had FLST in a general ICU were enrolled in the study. We evaluated whether physicians communicated and documented the FLST decisions with patients or the patients' families. We also assessed the effect of the physician's geographic place of training on communication behavior. RESULTS: Over a period of 8.5 months, 385 patients were admitted to a general ICU in Israel. Fifty-seven patients died or had FLST. Twelve of these 57 were excluded from the study. Thus, 45 (79%) patients had FLST and were enrolled in the study. All patients were deemed medically incompetent to make FLST decisions. In 24 (53%) patients, FLST was discussed with the family before the decision to forgo therapy. Discussion occurred later with 6 other families, who were unavailable at the time the FLST decision was made. In 15 patients, there were no discussions with families. American-trained physicians discussed FLST with 22 of 29 families initially and 5 other families later (93%), whereas the Eastern European-trained physicians discussed FLST with only 3 of 16 (19%) families (P <.001). Documentation of FLST was present in 26 (90%) patients of American-trained physicians and 8 (50%) patients of Eastern European-trained physicians (P <.001). CONCLUSIONS: FLST is common in an Israeli ICU. Patients are not medically competent to make FLST decisions. American-trained physicians discuss and document FLST more often than Eastern European-trained physicians.

Aged↗