Caring for the critically ill in developing countries--our collective challenge.
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Critical Care↗
Biomedical subjects
Yaw Amoateng-Adjepong
Publications and source records attributed to Yaw Amoateng-Adjepong.
Fluid balance and weaning outcomes.
OBJECTIVE: To examine the relationship of fluid balance and weaning outcomes. METHODS: We prospectively collected demographic, physiological, daily fluid balance (measured inputs minus outputs), and weaning data from 87 mechanically ventilated patients. PATIENTS: We examined 87 patients, a median age of 66 years, APACHE II of 22, and performed 205 breathing trials (BT); 38 patients (44%) were successfully extubated after their first BT with minimal or no pressure support. RESULTS: Positive fluid balance (inputs>outputs) in the 24, 48, and 72 h and cumulatively (from hospital admission) prior to weaning were significantly greater in weaning failures than successes. Both univariate and multivariate analyses, adjusted for duration of mechanical ventilation and presence of chronic obstructive pulmonary disease, showed negative cumulative fluid balance 24 h prior to BTs (OR=2.9) and cumulative fluid balance (OR=3.4) to be independently associated with first-day weaning success. Similar relationships were demonstrated when all weaning attempts were analyzed. Negative fluid balance was as predictive of weaning outcomes as f/V(t) (likelihood of success was 1.7 for patients with negative fluid balance 24 h prior to weaning and 1.2 for those with f/Vt<100 min-1 l-1). Although administration of diuretics was associated with more negative fluid balance, it was not independently associated with weaning outcomes. CONCLUSIONS: These data suggest that fluid balance, a potentially modifiable factor, is associated with weaning outcomes. A randomized study is required to determine whether diuresis to treat positive fluid balance expedites liberation from mechanical ventilation.
Adult↗
Outcomes of critically ill patients.
OBJECTIVE: We hypothesized that critically ill patients who remain in the ED for more than 24 hours experience worse outcomes and longer lengths of stay than those transferred to the medical intensive care unit (MICU) within 24 hours. METHODS: Medical records were examined of all patients admitted to the MICU directly from the ED of a 325-bed community teaching hospital between 2001 and 2002. RESULTS: Of 443 patients, 104 remained in the ED for 24 hours or longer (ED>or=24) before being transferred to the MICU. There were no significant differences in demographic characteristics of the 339 who were in the ED for less than 24 hours (ED <24 ) as compared with ED>or=24. APACHE II scores were 18.9+/-1.0 for a random sample of ED<24 and 20.5+/-0.9 for ED>or=24 (P=.2). Lengths of hospital stay were 10.9+/-0.8 days for ED<24 and 9.8+/-0.9 days for ED>or=24 (P=.7). Mortality rates were 26.8% for ED<24 and 26.9% for ED>or=24 (P=.5). CONCLUSIONS: These data suggest that outcomes of critically ill patients transferred from the ED to our MICU within 24 hours were not better than those who remained in the ED for longer durations. Larger studies are required to examine this hypothesis.
APACHE↗
Patients' understanding of advance directives and cardiopulmonary resuscitation.
OBJECTIVE: To describe understanding of end-of-life issues and compare characteristics of patients with and without advance directives. SETTING: A 325-bed community teaching hospital. MEASUREMENTS: Questionnaires were administered to all patients admitted to the medical-surgical wards. RESULTS: Of 755 patients admitted during the study period, 264 patients participated in the study, and 82 (31%) had living wills. Patients with living wills were more likely to be white, Protestant, and highly educated. Most (76%) created them with a lawyer or family member, whereas only 7% involved physicians. Although these patients were able to identify some components of cardiopulmonary resuscitation (CPR), few (19%) understood the prognosis after CPR. After explaining CPR, 37% of those with living wills did not want it, which was not stated in their directive or hospital record. If life-sustaining therapies were already started, 39% of these patients stated that they would not want CPR or mechanical ventilation if the likelihood of recovery was < or =10%. Patients without living wills either had not heard (18%) or did not know enough (51%) about them. After education, 5% did not want CPR, and 32% would terminate life-sustaining therapies if the likelihood of recovery was < or =10%. Seventy percent of these patients expressed interest in creating a living will. CONCLUSIONS: Patients with living wills understand poorly "life-sustaining therapies" and the implications of their advance directives. Most fail to involve physicians in creating directives. A significant number of those without living wills have end-of-life wishes that could be addressed by and appear open to the idea of creating advance directives.
Adult↗
Weaning by protocol.
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Clinical Protocols↗
Neurologic status, cough, secretions and extubation outcomes.
OBJECTIVE: To determine the degree to which neurologic function, cough peak flows and quantity of endotracheal secretions affected the extubation outcomes of patients who had passed a trial of spontaneous breathing (SBT). DESIGN: Prospective observational study. SETTING: The medical intensive care unit of a 325-bed teaching hospital. MEASUREMENTS AND MAIN RESULTS: Cough peak flow (CPF), endotracheal secretions and ability to complete four simple tasks were measured just before extubation in patients who had passed a SBT. Eighty-eight patients were studied; 14 failed their first trials of extubation. The CPF of patients who failed was lower than that of those who had a successful extubation (58.1+/-4.6 l/min vs 79.7+/-4.1 l/min, p=0.03) and those with CPF 60 l/min or less were nearly five times as likely to fail extubation compared to those with CPF higher than 60 l/min (risk ratio [RR]=4.8; 95% CI=1.4-16.2). Patients with secretions of more than 2.5 ml/h were three times as likely to fail (RR=3.0; 95% CI=1.0-8.8) as those with fewer secretions. Patients who were unable to complete four simple tasks (i.e. open eyes, follow with eyes, grasp hand, stick out tongue) were more than four times as likely to fail as those who completed the four commands (RR=4.3; 95% CI=1.8-10.4). There was synergistic interaction between these risk factors. The failure rate was 100% for patients with all three risk factors compared to 3% for those with no risk factors (RR=23.2; 95% CI=3.2-167.2). The presence of any two of the above risk factors had a sensitivity of 71 and specificity of 81% in predicting extubation failure. Patients who failed a trial of extubation were 3.8 times as likely to have any two risk factors compared to those who were successful. CONCLUSIONS: These simple, reproducible methods may provide a clinically useful approach to guiding the extubation of patients who have passed a SBT.
APACHE↗
Aspergillus rib and vertebral osteomyelitis in a former intravenous drug user.
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Aspergillosis↗
Predictors and consequences of pneumonia in critically ill patients with stroke.
OBJECTIVE: Ascertain the incidence, predictors and consequences of early (within 48 hours of admission) and nosocomial pneumonia among critically ill patients with stroke. METHODS: Medical records of critically ill patients with acute stroke were reviewed. Predictors and consequences of pneumonia were determined with analysis of variance. RESULTS: 55 patients, aged 33 to 91 (median 74) years, were admitted. The stroke was located at the brainstem in 14 (26.4%) patients. Nine patients (16.4%) had early pneumonia and additional 17 patients (30.9%) developed nosocomial pneumonia. Patients with brain-stem stroke were more likely to develop early pneumonia (p =.04). Nosocomial pneumonia incidence was higher in patients who failed swallowing evaluation (RR = 6.3, 95% CI: 0.9-43.0) and in those who were intubated (58.6% v 0%, p =.00008). Also, nosocomial pneumonia was associated with longer duration of mechanical ventilation and prolonged hospital stay. Nineteen patients (34.5%) died at the hospital. They were more likely to be older (median 77 versus 69 years, p =.03) with higher admission acuity of illness. CONCLUSION: Pneumonia complicated stroke in 47% of critically ill patients and adversely impacted the duration of mechanical ventilation and overall length of hospital stay. Aggressive preventive measures are needed to reduce pneumonia occurrence in stroke patients.
Aged↗
Anticoagulation in hospitalized patients with renal insufficiency: a comparison of bleeding rates with unfractionated heparin vs enoxaparin.
OBJECTIVES: To compare the rates of bleeding complications in patients with renal insufficiency who receive anticoagulation therapy with the full therapeutic dose, unfractionated heparin (UFH), or with twice-daily enoxaparin. SETTING: A 325-bed community teaching hospital. STUDY TYPE: Retrospective cohort study. METHODS: The medical records of all patients with renal insufficiency who received anticoagulation therapy with UFH or enoxaparin during a 13-month period were reviewed for the occurrence of major and minor bleeding. Incidence rates were computed per 1,000-person days of anticoagulation therapy. Comparisons were made across categories of renal insufficiency and other potential confounders. RESULTS: A total of 620 patients with estimated glomerular filtration rates of < 60 mL/min were studied. Of these, 331 received anticoagulation therapy with UFH, 250 with enoxaparin, and 39 with both (not simultaneously). The major bleeding rates were 26.3 per 1,000 person-days for UFH and 20.7 per 1,000 person-days for enoxaparin. Major bleeding complications were similarly increased for both UFH and enoxaparin therapy across categories of worsening renal insufficiency. Patients with severe renal insufficiency while receiving enoxaparin had a 154% excess incidence of minor bleeding compared to those receiving UFH (incidence ratio, 2.54; 95% confidence interval, 1.01 to 6.36). Worsening renal insufficiency, female gender, and prolonged duration of anticoagulation therapy emerged as the main determinants for bleeding complications. CONCLUSION: Both the twice-daily enoxaparin and UFH regimens are associated with comparable increases in major bleeding complications in patients with renal dysfunction receiving full-dose anticoagulation therapy. Both agents should be used with caution in anticoagulation therapy for patients with renal insufficiency.
Aged↗
Informed consent for invasive medical procedures from the patient's perspective.
BACKGROUND: Written informed consent is not obtained uniformly for invasive medical procedures in critically ill patients across America. The general consent-to-treat is used by some institutions in lieu of separate, procedure-by-procedure consent. OBJECTIVES: To determine whether hospitalized patients recall the general consent-to-treat and to ascertain their preferences regarding informed consent for invasive medical procedures. METHODS: A questionnaire was administered to patients admitted to a 325-bed community teaching hospital. RESULTS: Of 265 patients who participated in the study, only 8% correctly recalled all of the elements of the general consent-to-treat. One hundred twelve respondents (42.3%) trusted their doctors to perform necessary medical procedures, "as long as they were told what was going to happen and why the medical procedure was needed." These patients were older (67 vs 62 years, P = 0.02) and were less likely to hold college or advanced degrees (33% vs 44%, P = 0.04). One hundred fifty-three patients wanted to know the important benefits, risks and alternatives, and to give written permission for performance of medical procedures. On further questioning, 29 (19%) of 153 patients responded that no medical procedure should be done without getting consent first. Forty-three (28%) thought procedures with complications in < 1% of cases should not require consent, while nine (6%) thought consent should be required at a threshold of 10% complications. One hundred patients (65%) responded that procedures with small and nonserious risks (i.e., IV's, bladder catheters) should not require separate written consent. CONCLUSIONS: The general consent-to-treat is not recalled well by hospitalized patients and is unlikely to suffice as informed consent for invasive medical procedures. A majority of patients do not want to have invasive procedures without first giving their informed consent.
Adult↗
Informed consent for invasive procedures in a community hospital medical intensive care unit.
OBJECTIVE: To describe the informed consent practices in the medical intensive care unit (MICU) of a university-affiliated, community teaching hospital. DESIGN: Prospective, observational study. SUBJECTS: 177 critically ill patients. MEASUREMENTS: Study personnel identified all critically ill patients who had an invasive medical procedure during the study period (120 days). It was first determined whether written informed consent was obtained for the procedure. If it was, standardized questionnaires were used to determine whether consent-givers recalled the indications, complications, and alternatives of invasive medical procedures. Documentation of consent and of the performance of invasive procedures in the medical records was also examined. An educational in-service was created to help improve the informed consent process. After a 45-day lead-in (control) period, the in-service was administered and IC was again studied for 75 days. RESULTS: A total of 181 procedures were performed on 112 patients over 120 days in the MICU. The rates of written consent for invasive procedures averaged 89%; rates of consent were not affected by the educational in-service. Following administration of the in-service, consent-givers recalled a greater number of complications (2.5 to 4.1, P=0.01) and documentation of consent improved. CONCLUSIONS: These results suggest that informed consent can be obtained procedure-by-procedure, as needed, at a high frequency, and with reasonable consenter comprehension.
Adult↗
Gender and status asthmaticus.
BACKGROUND: Adult women may be more susceptible to asthma than men. HYPOTHESIS: Women are more likely to develop status asthmaticus (SA) requiring critical care. METHODS: The medical records of patients admitted to our medical intensive care unit (ICU) for SA between 1994 and 2000 were examined. A number of demographic and physiologic variables were extracted from the medical records. RESULTS: Of 103 total admissions, 53 (of 37 patients) were age < 50 years and had clinical evidence suggesting SA. Among these 37 patients, the average (+/-SE) age was 30.8 +/- 1.0 y with average acute physiology and chronic health evaluation (APACHE) II of 9.5 +/- 0.8. Seventeen patients were Hispanic, 13 were black, and 7 were white. Twenty-four patients (accounting for 37 admissions) were female and 13 patients (16 admissions) were male. Although women accounted for a greater absolute number of endotracheal intubations (ETI; 17 vs. 12) and were more likely to be admitted to ICU more than once (7 vs. 3), men had a higher incidence of ETI (RR=1.6; 95%CI=1.04-2.6). The need for using therapeutic permissive hypercapnia and lengths of stay (ventilator, ICU, and hospital) were similar between men and women. Two patients, both women, died of causes not related to treatment of SA. CONCLUSIONS: These data suggest that although women accounted for more ICU admissions for SA, men were more likely to require ETI.
Adult↗
Microalbuminuria in critically ill medical patients: prevalence, predictors, and prognostic significance.
OBJECTIVE: To ascertain the prevalence, predictors, and prognostic significance of microalbuminuria in critically ill patients. DESIGN: Prospective cohort study. SETTING: Medical intensive care unit of a community teaching hospital. PATIENTS: Admitted critically ill patients. MEASUREMENTS AND MAIN RESULTS: We measured serial spot urine albumin-creatinine ratios in 104 critically ill patients, with a median age of 64.5 yrs and median Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores of 20.5 and 5.0, respectively. Sixty-nine percent of the patients had microalbuminuria or clinical proteinuria and 43.3% had an albumin-creatinine ratio >/=100 mg/g at admission. The acuity of illness, being non-White, and having diabetes mellitus were independent predictors of albumin-creatinine ratio >/=100 mg/g. The overall mortality rate was 26.9% (28/104). Patients with an albumin-creatinine ratio >/=100 mg/g were 2.7 times as likely to die compared with those with an albumin-creatinine ratio <100 mg/g, even after simultaneous adjustments for age, and APACHE II and SOFA scores (odds ratio, 2.7; 95% confidence interval, 1.1-7.2, p =.04). The association of albumin-creatinine ratio >/=100 mg/g with death was consistent across age, ethnicity, renal function, acuity of illness, and comorbid conditions. Among survivors, patients with an albumin-creatinine ratio >/=100 mg/g stayed approximately 5 days longer in the hospital (p =.0007). Overall, the albumin-creatinine ratio shared similar predictive characteristics with APACHE II and SOFA scores. CONCLUSIONS: This study confirms a high prevalence of microalbuminuria in critically ill patients and suggests that an albumin-creatinine ratio >/=100 mg/g is an independent predictor of mortality and hospital stay.
APACHE↗
Sepsis workup in febrile infants 0-90 days of age with respiratory syncytial virus infection.
OBJECTIVES: To ascertain the incidence, determinants, and outcome of sepsis workup in febrile infants aged 0-90 days with respiratory syncytial virus (RSV) infection. DESIGN: Retrospective chart review. RESULTS: 191 infants with RSV, 21.5% younger than 28 days, were identified; 101 (52.9%) were febrile and 90 were afebrile. Among the febrile infants, 84.2% had blood cultures, 68.3% had urine cultures, and 58.4% had lumbar punctures. Complete sepsis workup was done in 52.5% of the febrile cohort, including 77.3% of those aged less than 28 days. There were 5 cases of urinary tract infection (UTI) [7.2%, 95% confidence interval (CI) = 2.4-16.1] and 1 case of bacteremia (1.2%, 95% CI = 0.0-6.4) among the tested febrile patients. There was no case (0%, 95% CI = 0.0-6.1) of meningitis. Age, maximum temperature, irritability, apnea, decreased intake, chest x-ray findings, and white blood cell count were not predictive of a positive culture. Only 7.8% of the afebrile patients had complete sepsis workup. Fever [risk ratio (RR) = 5.8, 95% CI = 2.8-12], absence of wheezing (RR = 2.1, 95% CI = 1.3-3.6), and age less than 28 days (RR = 1.6, 95% CI = 1.2-2.2) were independent predictors of complete sepsis workup. Overall, complete sepsis workup was associated with a higher rate of antibiotic use (RR = 10.7, 95% CI = 4.9-23.4), increased hospitalization (RR = 2.1, 95% CI = 1.0-4.7), and prolonged hospital stay (median of 2 days vs. 1 day, P = 0.003) compared with those without complete workup. CONCLUSION: Considerable variability exists in the sepsis workup of febrile infants with suspected RSV infection at our site. Concomitant UTIs are common in febrile, RSV-infected infants.
Bacteremia↗
Recurrent bilateral spontaneous pneumothorax complicating chemotherapy for metastatic sarcoma.
We present the case of a 63-year-old woman with metastatic, high-grade pleomorphic sarcoma who had recurrent, bilateral pneumothorax while on a regimen of doxorubicin and dacarbazine. We postulate that her doxorubicin-based chemotherapy induced rapid cell lysis and necrosis of peripherally located, metastatic pulmonary nodules, leading to the pneumothoraces. Other potential mechanisms include bronchopleural fistula, rupture of dilated alveoli distal to a stenosis, chemotherapy-induced impairment of repair processes, and persistent local infection. Pneumothoraces related to pulmonary metastases tend to be refractory to conventional therapy and necessitate surgical intervention to prevent recurrences.
Acute Disease↗
Cough peak flows and extubation outcomes.
BACKGROUND: Semiobjective methods of quantifying cough strength and endotracheal secretions have been demonstrated to predict extubation outcomes of patients who have passed a spontaneous breathing trial (SBT). HYPOTHESIS: Cough strength, measured by voluntary cough peak expiratory flow (PEF), and endotracheal secretions, measured volumetrically, predict extubation outcomes of patients who have passed an SBT. PATIENT POPULATION: Critically ill patients admitted to the medical ICU of a 300-bed community teaching hospital. METHODS: All patients who passed an SBT and were about to be extubated were studied. The best of three cough attempts, measured with an in-line spirometer, and the average hourly rate of suctioned secretions prior to extubation were recorded with other weaning parameters and demographic data. RESULTS: Ninety-five patients were studied before and after 115 extubations. There were 13 unsuccessful extubations. There were no differences in age, gender, duration of intubation, or APACHE (acute physiology and chronic health evaluation) II scores between successful and unsuccessful extubations. The magnitude of endotracheal secretions was not associated with outcomes. The PEF of patients with unsuccessful extubations was significantly lower than that of those with successful extubations (64.2 +/- 6.8 L/min vs 81.9 +/- 2.7 L/min, p = 0.03). Patients with unsuccessful extubations stayed longer in the ICU than those with successful extubations (11.7 +/- 2.1 days vs 5.3 +/- 0.4 days, p = 0.009). Those with PEF <or= 60 L/min were five times as likely to have unsuccessful extubations and were 19 times as likely to die on that hospital stay. PEF and the rapid shallow breathing index were independently associated with extubation outcomes, while only the PEF (<or= 60 L/min) was independently associated with in-hospital mortality. CONCLUSION: These data suggest that cough strength, measured objectively, is a predictor of extubation outcome, morbidity, and mortality.
APACHE↗
Informed consent for medical procedures: local and national practices.
BACKGROUND: No studies have assessed whether clinicians obtain informed consent for invasive medical procedures, and there are no explicit national standards to guide the process. HYPOTHESIS: Informed consent practices are inconsistent for commonly performed invasive medical procedures. METHODS: A simple questionnaire was electronically mailed and/or faxed to training program directors of critical care medicine and internal medicine departments, and to ICU directors in the state of Connecticut. The questionnaire listed common invasive medical procedures and asked the respondents to check those for which practitioners routinely obtain informed consent in their hospital. RESULTS: The three samples, national intensivists (88 respondents), Connecticut intensivists (29 respondents), and national internists (56 respondents) demonstrated heterogeneity of consenting practices. The rate of obtaining consent for common vascular access procedures ranged from 20 to 90%. The rates of obtaining consent for Foley catheterization and nasogastric intubation were uniformly < 10%, and those for endoscopic procedures were > 90%. Separate consent (beyond the general consent to treat) was not uniformly obtained for the transfusion of blood products (range, 74 to 93%) and common diagnostic medical procedures (eg, thoracentesis, paracentesis, or lumbar puncture; range, 77 to 96%). Surgical intensivists reported that the obtaining of consent for invasive procedures was less routine compared to medical intensivists. Lower rates of consent were noted by those respondents who used a "blanket" consent form, which was signed at the time of hospital admission, to cover subsequent procedures. CONCLUSIONS: In this relatively small sample, there was no uniform practice of informed consent for commonly performed invasive medical procedures. Consent was routinely obtained for GI endoscopy, bronchoscopy, and medical research, and was not obtained for Foley catheterization and nasogastric intubation. The obtaining of consent for vascular cannulation and diagnostic procedures was not routine in the ICUs of a substantial number of respondents. Explicit standards that delineate specifically which procedures require consent may be required to assure more uniform practices.
Connecticut↗
The effect of arterial blood gas values on extubation decisions.
BACKGROUND: No studies have examined the clinical utility of arterial blood gas (ABG) values during spontaneous breathing trials (SBTs) for making extubation decisions. Nonetheless many intensive care units measure ABGs during an SBT to determine, in conjunction with other data, whether the SBT was successful. OBJECTIVE: Determine how often ABG values change extubation decisions. METHODS: Each patient was assessed at the bedside by one of 3 critical care attending physicians. Each assessment was made at the end of the SBT in which ABGs were obtained with the expectation of extubation. When a nurse, respiratory therapist, or resident was available, he or she also simultaneously and independently evaluated the patient and then reassessed with the ABG values. Physiologic data were recorded before and during the SBT, as the attending physician performed the bedside assessment. RESULTS: Eighty-three patients were studied during 100 SBTs. Heart rate, respiratory rate, and mean blood pressure increased. Blood oxygen saturation (measured via pulse oximetry [F(IO)(2)]) and the P(aO)(2)/F(IO)(2) ratio decreased significantly during SBTs. Concordant clinical and ABG assessment (to attempt a trial of extubation) led to extubation in 86 patients, 76 of whom remained extubated after 72 hours. Following 14 of the SBTs, the patients were not extubated. Seven of these were judged by the attending physicians to fail both clinically and following review of ABG values. Seven were judged successful clinically, but the patients were not extubated because the attending physician thought the ABG values were unfavorable. Bedside nurses, who assessed 72 SBTs, had 1 case in which the ABG values changed their extubation opinion. Resident-trainees assessed 76 cases and had 5 changes of opinion based on ABG values. Respiratory therapists assessed 77 patients and had 4 such cases. The average changes in heart rate and blood pressure of patients not extubated were double those of extubated patients, but there were no significant differences in respiratory rate or P(aO)(2)/F(IO)(2) ratio between those groups. Ten patients (11.6%) were extubated based on the attending physician's decision but required re-intubation within 72 hours. CONCLUSION: These data suggest that ABG values did not change extubation decisions in 93% of cases. However, in 7 cases the ABG values changed the extubation decision. If even a few of those cases would have failed extubation without knowledge of the ABG values, the increased patient risk and cost associated with failed extubation would more than offset the relatively small cost of collecting ABG values from all patients who undergo SBT.
Adult↗