Search

Objectives To conduct a cost analysis of adjunctive hydrocortisone therapy for severe septic shock from the perspective of a third-party payer in the United States. Design Estimates of outcomes were aggregate data from the Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock and Activated Protein C and Corticosteroids for Human Septic Shock trials. In these trials, the outcomes of interests were ICU length of stay, vasopressor-free days, ventilation-free days, and the proportion of patients receiving blood transfusion. Each outcome was monetized into a set of mutually exclusive components and was aggregated to estimate the cost-per-patient based on each trial. Cost inputs for each outcome were obtained from literature and adjusted based on the medical care consumer price index. To estimate the budget impact using adjunctive hydrocortisone therapy, per-patient avoided cost was multiplied by expected septic shock annual incidence. Deterministic one-way sensitivity analysis evaluated the robustness of the findings, and Monte Carlo simulation estimated 95% CI of the findings. Setting A total of 103 medical-surgical ICU (69 for Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock and 34 for Activated Protein C and Corticosteroids for Human Septic Shock). Patients Adults greater than or equal to 18 years old with septic shock. Interventions Adjunctive hydrocortisone therapy (hydrocortisone at a dose of 200 mg/d for 7 d for Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock and hydrocortisone at a 50 mg IV bolus every 6 hr and fludrocortisone as a 50 μg tablet once daily). Measurements and main results Per Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock, adjunctive hydrocortisone therapy showed a 90-day monetized benefit of $8,111 (95% CI, $3,914-$12,307) per patient, driven by improvements in ICU-free days, vasopressor-free days, ventilation-free days, and blood transfusion proportion. The total estimated annual impact of adjunctive hydrocortisone therapy, in 2019 dollars, was $750 million. Per Activated Protein C and Corticosteroids for Human Septic Shock, adjunctive hydrocortisone therapy showed a 90-day monetized benefit of $25,539 per patient (95% CI, $22,853-$28,224), driven by improvements in ICU free-days, vasopressor-free days, and ventilation-free days. The total estimated annual impact of adjunctive hydrocortisone therapy, in 2019 dollars, was $2.3 billion. The deterministic one-way sensitivity analysis showed the cost of ICU stays to be the most influential factor in both analyses. The sensitivity analysis using the reported median showed a greater monetized benefit of $10,658 (Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock) and $30,911 (Activated Protein C and Corticosteroids for Human Septic Shock) per patient. Conclusions Using adjunctive hydrocortisone therapy yields a significant monetized benefit based on inputs from the Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock and Activated Protein C and Corticosteroids for Human Septic Shock trials.

OBJECTIVES: To assess the risk of coronavirus transmission to healthcare workers performing aerosol-generating procedures and the potential benefits of personal protective equipment during these procedures. DATA SOURCES: MEDLINE, EMBASE, and Cochrane CENTRAL were searched using a combination of related MeSH terms and keywords. STUDY SELECTION: Cohort studies and case controls investigating common anesthetic and critical care aerosol-generating procedures and transmission of severe acute respiratory syndrome coronavirus 1, Middle East respiratory syndrome coronavirus, and severe acute respiratory syndrome coronavirus 2 to healthcare workers were included for quantitative analysis. DATA EXTRACTION: Qualitative and quantitative data on the transmission of severe acute respiratory syndrome coronavirus 1, severe acute respiratory syndrome coronavirus 2, and Middle East respiratory syndrome coronavirus to healthcare workers via aerosol-generating procedures in anesthesia and critical care were collected independently. The Risk Of Bias In Non-randomized Studies - of Interventions tool was used to assess the risk of bias of included studies. DATA SYNTHESIS: Seventeen studies out of 2,676 yielded records were included for meta-analyses. Endotracheal intubation (odds ratio, 6.69, 95% CI, 3.81-11.72; p < 0.001), noninvasive ventilation (odds ratio, 3.65; 95% CI, 1.86-7.19; p < 0.001), and administration of nebulized medications (odds ratio, 10.03; 95% CI, 1.98-50.69; p = 0.005) were found to increase the odds of healthcare workers contracting severe acute respiratory syndrome coronavirus 1 or severe acute respiratory syndrome coronavirus 2. The use of N95 masks (odds ratio, 0.11; 95% CI, 0.03-0.39; p < 0.001), gowns (odds ratio, 0.59; 95% CI, 0.48-0.73; p < 0.001), and gloves (odds ratio, 0.39; 95% CI, 0.29-0.53; p < 0.001) were found to be significantly protective of healthcare workers from contracting severe acute respiratory syndrome coronavirus 1 or severe acute respiratory syndrome coronavirus 2. CONCLUSIONS: Specific aerosol-generating procedures are high risk for the transmission of severe acute respiratory syndrome coronavirus 1 and severe acute respiratory syndrome coronavirus 2 from patients to healthcare workers. Personal protective equipment reduce the odds of contracting severe acute respiratory syndrome coronavirus 1 and severe acute respiratory syndrome coronavirus 2.

OBJECTIVES Antimicrobial stewardship is advocated to reduce antimicrobial resistance in ICUs by reducing unnecessary antimicrobial consumption. Evidence has been limited to short, single-center studies. We evaluated whether antimicrobial stewardship in ICUs could reduce antimicrobial consumption and costs. DESIGN We conducted a phased, multisite cohort study of a quality improvement initiative. SETTING Antimicrobial stewardship was implemented in four academic ICUs in Toronto, Canada beginning in February 2009 and ending in July 2012. PATIENTS All patients admitted to each ICU from January 1, 2007, to December 31, 2015, were included. INTERVENTIONS Antimicrobial stewardship was delivered using in-person coaching by pharmacists and physicians three to five times weekly, and supplemented with unit-based performance reports. Total monthly antimicrobial consumption (measured by defined daily doses/100 patient-days) and costs (Canadian dollars/100 patient-days) before and after antimicrobial stewardship implementation were measured. MEASUREMENTS AND MAIN RESULTS A total of 239,123 patient-days (57,195 patients) were analyzed, with 148,832 patient-days following introduction of antimicrobial stewardship. Antibacterial use decreased from 120.90 to 110.50 defined daily dose/100 patient-days following introduction of antimicrobial stewardship (adjusted intervention effect -12.12 defined daily dose/100 patient-days; 95% CI, -16.75 to -7.49; p < 0.001) and total antifungal use decreased from 30.53 to 27.37 defined daily doses/100 patient-days (adjusted intervention effect -3.16 defined daily dose/100 patient-days; 95% CI, -8.33 to 0.04; p = 0.05). Monthly antimicrobial costs decreased from $3195.56 to $1998.59 (adjusted intervention effect -$642.35; 95% CI, -$905.85 to -$378.84; p < 0.001) and total antifungal costs were unchanged from $1771.86 to $2027.54 (adjusted intervention effect -$355.27; 95% CI, -$837.88 to $127.33; p = 0.15). Mortality remained unchanged, with no consistent effects on antimicrobial resistance and candidemia. CONCLUSIONS Antimicrobial stewardship in ICUs with coaching plus audit and feedback is associated with sustained improvements in antimicrobial consumption and cost. ICUs with high antimicrobial consumption or expenditure should consider implementing antimicrobial stewardship programs.

Many comatose patients following cardiac arrest have ischemic brain injury. Diffusion-weighted imaging is a sensitive tool to identify hypoxic-ischemic brain injury. The accurate prediction of the prognosis for comatose cardiac arrest survivors has been challenging, and thus, a multimodal approach, combining diffusion-weighted image findings, could be feasible. The aim of this study was to assess regional brain injury on diffusion-weighted imaging and to test the potential association with its neurologic outcome in patients treated with target temperature management after out-of-hospital cardiac arrest.A multicenter, registry-based, retrospective cohort study was conducted using cases from 24 hospitals across South Korea. Of the 930 adult (≥18 yr) nontraumatic out-of-hospital cardiac arrest patients treated with target temperature management between January 2007 and December 2012 at these hospitals, we included the patients who underwent brain diffusion-weighted imaging in the first week after cardiac arrest. The brain regions examined included the four cerebral lobes, basal ganglia-thalamus, brain stem, and cerebellum. Imaging results were compared between a good neurologic outcome, defined as a cerebral performance category score of 1 or 2, and a poor neurologic outcome (cerebral performance category score≥3).Poor neurologic outcome occurred in 118 of the 172 patients analyzed (68.6%). Positive diffusion-weighted image findings, defined as any regional brain injury lesion in diffusion-weighted imaging, were present in 106 patients. Positive diffusion-weighted image findings had 93% sensitivity, 86% specificity, 76% positive predictive value, and 96% negative predictive value for a poor neurologic outcome. The poor outcome group had higher numbers of affected brain lesions than the good outcome group (3.8±1.9 vs 0.1±0.6; p0.01). By multivariate analysis, positive diffusion-weighted image findings (odds ratio, 58.2; 95% CI, 13.29-254.91) and lack of a shockable rhythm (odds ratio, 0.13; 95% CI, 0.03-0.57) were associated with a poor neurologic outcome.Diffusion-weighted imaging allows reliable prediction of poor neurologic outcome in comatose patients treated with target temperature management after out-of-hospital cardiac arrest. Further prospective validation study will be required to generalize this result.

This study aimed to compare the prognostic value of lactate level and lactate clearance at 6 hours after septic shock recognition. And, we performed it to determine lactate kinetics in the Sepsis-3 defined septic shock.This retrospective study was performed from a prospective septic shock registry.This study was performed at single urban tertiary center. And, all patients were treated with protocol-driven resuscitation bundle therapy between 2010 and 2016.We included septic shock patients who met the Sepsis-3 definition, which involves lactate levels greater than or equal to 2 mmol/L and vasopressor use.Serum lactate levels were measured at initial and 6 hours from septic shock recognition.Lactate clearance was calculated as ([initial lactate - 6-hr lactate]/initial lactate) × 100. The prognostic value of measured lactate levels and lactate clearance for 28-day mortality was analyzed and compared with that of subsequent lactate levels greater than or equal to 2 mmol/L, greater than or equal to 3 mmol/L, and greater than or equal to 4 mmol/L and less than 10%, less than 20%, and less than 30% lactate clearance. A total of 1,060 septic shock patients by Sepsis-3, 265 patients died (28-d mortality: 25%). In survivor, groups had lower median 6-hour lactate level and higher lactate clearance than nonsurvivors (2.5 vs 4.6 mmol/L and 35.4% vs 14.8%; p0.01). Both lactate and lactate clearance were associated with mortality after adjusting for confounders (odd ratio, 1.27 [95% CI, 1.21-1.34] and 0.992 [95% CI, 0.989-0.995]), but lactate had a significantly higher prognostic value than lactate clearance (area under the curve, 0.70 vs 0.65; p0.01). The prognostic value of subsequent lactate levels (≥ 2, ≥ 3, and ≥ 4 mmol/L) and lactate clearances (10%,20%, and30%) was not significantly differed. However, lactate levels of greater than or equal to 2 mmol/L had the greatest sensitivity (85.3%).Our findings indicate lactate and lactate clearance are both useful targets in patients with septic shock defined by Sepsis-3. Serum lactate level at 6-hour can be an easier and more effective tool for prognosis of septic shock patients who were treated with protocol-driven resuscitation bundle therapy.

OBJECTIVES\ud \ud Interventions to reduce hospital-acquired bloodstream infection have succeeded in reducing rates in U.S. PICUs, but there is a lack of evidence for the impact of similar interventions in the United Kingdom. We assessed variation in bloodstream infection rates within and between PICUs over a 10-year period, during which time infection control strategies (care bundles) were implemented.\ud \ud DESIGN\ud \ud Observational study linking laboratory data to national audit data of pediatric intensive care admissions (Paediatric Intensive Care Audit Network).\ud \ud SETTING\ud \ud Twenty PICUs in England and Wales, 2003-2012.\ud \ud PATIENTS\ud \ud One hundred and two thousand nine hundred ninety-nine children less than 16 years.\ud \ud INTERVENTIONS\ud \ud Implementation of infection control strategies in PICU captured through a survey of clinicians.\ud \ud MEASUREMENTS AND MAIN RESULTS\ud \ud Rates of bloodstream infection per 1,000 bed-days were estimated from samples taken between 2 days after admission and up to 2 days following discharge from PICU. Two percent of children experienced at least one bloodstream infection, corresponding to 5.11 (95% CI, 4.90-5.31) per 1,000 bed-days. There was a significant difference in trends preimplementation of infection control strategies (annual decrease of 8.0%; 95% CI, 6.3-9.7%) versus postimplementation (annual decrease of 13.4%; 95% CI, 10.3-16.4%). By 24 months postimplementation, the rate of bloodstream infection had fallen 25.5% and was 15.1% lower than would have been expected if preimplementation trends had continued.\ud \ud CONCLUSIONS\ud \ud Our population-based study of PICUs in England and Wales demonstrates a steady decline in bloodstream infection rates over time. In addition, there was a significant and incremental further decrease in rates associated with timing of implementation of infection control strategies. Assessment of bloodstream infection trends before as well as after implementation of infection control strategies can be facilitated using data linkage and is important to avoid overestimating the impact of unit-level interventions to improve infection control. Advances in collection and linkage of real-time data could further support quality improvement efforts.

Objective: Comparison of investigations of the airway in ventilator-dependent infants. Design: Consecutive infants with suspected upper airway abnormalities were investigated using rigid bronchoscopy and tracheobronchography. Setting: Tertiary pediatric and neonatal intensive care units. Patients: Eight Infants with suspected airway abnormalities. Interventions: Rigid bronchoscopy and tracheobronchography. Measurements and Main Results: Structural abnormalities, segmental narrowing of the airways and the effect of various levels of positive-end expiratory pressures on the narrowings were documented. In six of the eight cases, additional airway abnormalities were diagnosed with tracheobronchography compared with rigid bronchoscopy. Conclusions: In cases of suspected abnormalities of the upper airway in small infants unable to be weaned from ventilatory support, tracheobronchography may be a more reliable investigation method than rigid bronchoscopy. The ability to assess the structural and dynamic components of the airway accurately and safely allows a correct and long-term treatment plan to be established in this group of patients.

Introduction: Acute respiratory distress syndrome (ARDS) represents the most severe form of acute lung injury. The epidemiology of ARDS in children in Singapore has not been previously described. Our overall objective was to describe the epidemiology and resource utilization in children with ARDS; and to identify risk factors for poor outcomes in these critically ill children. Methods: We reviewed the medical records of patients who were admitted to our hospital with the discharge diagnosis of ARDS between January 2009 and December 2012. We utilized the American-European Consensus Conference's definition for ARDS. Demographic, clinical and radiographic data were extracted through chart review. Pertinent ventilator data and arterial blood gas results were collected on diagnosis, day one, three and seven of ARDS. We considered the requirement of invasive ventilation support as ventilator-free days with the maximum cut-off duration of 28 days. Primary outcome of interest was survival to pediatric intensive care unit (PICU) discharge. We summarized continuous and categorical variables as median with ranges and absolute numbers with percentages respectively. Wilcoxon rank-sum test and Fisher exact test were used for analysis. Results: Twenty children were identified to have the diagnosis of ARDS. Median age of these children was 8.3 years (4.0 days – 16.0 years). Of these children, 12 (60%) had significant comorbidities (three cardiovascular, five hematologic, one metabolic and three genetic syndromes). Median admission PRISM II score was 4.1 (0.7 – 86.3). On diagnosis of ARDS, the median arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2:FiO2) ratio and oxygenation index (OI) were 93.6 (36.2 - 186.7) and 27.4 (9.4 – 101.1) respectively. The most common modes of ventilator strategy on day of diagnosis of ARDS were high frequency ventilation (HFV) [n=7(35%)] and airway pressure release ventilation (APRV) [n =4 (20%)]. The following adjunct therapies were used for ARDS: inhaled nitric oxide [2(10%)], prone position [8(40%)] and steroids [9(45%)]. 17 (85%) patients required inotrope support during their PICU stay. 15 (75%) patients had sepsis/pneumonia as risk factor for ARDS. Eight (40%) patients had evidence of air leaks. Median 28-day ventilation-free duration was 0 (0 – 23) days. PICU mortality from ARDS was 12/20 (60%). There was no difference between the median OI at diagnosis of ARDS between survivors and non-survivors [25.3 (13.9 – 46.4) vs. 34.1 (9.4 – 101.1), p=0.56]. However, there was a statistical difference in OI at 24 hours [21.2 (5.8 – 44.0) vs. 65.0 (5.0 – 131.0), p=0.032], day three [13.6 (5.8 – 34) vs. 61.6 (4.0 – 117.4), p=0.038] and day seven [8.4 (5.4 – 31.8) vs. 49.1 (31.8-57.4), p=0.017] between survivors and non survivors respectively. We did not find any association between lactate levels, need for continuous renal replacement therapy and transfusion requirements with mortality. Conclusions: In our center, we supported more than half of our children with ARDS with open lung ventilation strategies (HFV and APRV). There was no association between OI at diagnosis and mortality from ARDS. However, we did find an association with subsequent OIs and mortality.

Objective: To review the outcome of bone marrow transplant (BMT) recipients admitted to a pediatric intensive care unit (ICU) and attempt to identify admission characteristics that might accurately predict a poor outcome.Design: Retrospective case-note review.Setting: Pediatric ICU of a tertiary teaching hospital.Patients: A total of 40 BMT recipients, accounting for 57 admissions to the ICU, in the 5 yrs between 1994 and 1998 were identified.Measurements and Main Results: Median time to ICU admission after BMT was 42 days. Of the 40 patients admitted to ICU, 11 (22.5%) are still alive, with a median time of follow-up since their most recent ICU admission of 587 days (absolute range, 308-1803 days). A total of 32 of 57 admissions (56.1%) resulted in the patient's discharge from the ICU, and 21 admissions (36.8%) resulted in survival to at least 30 days after discharge. There was no difference between the survivors and nonsurvivors in terms of underlying diagnoses, age at BMT, or time to ICU admission after BMT. Type of BMT, conditioning regimen, and presence of significant graft vs. host disease was not found to influence outcome. Although patients who died in the ICU had a significantly longer length of stay compared with the survivors (median, 7.9 days, vs. 2.1 days, p = .02), 11 of 21 admissions (52.4%) associated with survival to 30 days post-ICU discharge were of greater than or equal to2 days of duration, the longest being 22.8 days. Thirty-one of 40 patients (77.5%) required intubation and mechanical ventilation during 36 of the 57 admissions, and 15 of these episodes (41.6%) ended with the patient's discharge from the ICU. Of ten patients with respiratory failure associated with pulmonary infection, there were no survivors among those who remained ventilated at 48 hrs (n = 8). Four patients who required mechanical ventilation (12.9%) were alive at the 6-month follow-up. The majority of patients who died in the ICU did so after either withdrawal (65%) or limitation (22%) of treatment.Conclusions: Despite the generally poor prognosis for pediatric patients admitted to the ICU after BMT, intensive care continues to play an important role in the care of these patients. Although it is clear that patients who require mechanical ventilation have a worse prognosis, we were unable to identify factors that accurately predict with 100% sensitivity which patients will not survive. Those patients requiring mechanical ventilation due to pneumonitis have a particularly poor outcome, and our findings support the limitation of intensive care in certain circumstances. Decisions regarding treatment options and limitation of care in this group of patients should be based on ongoing outcome research in this field. (Crit Care Med 2003; 31:1299-1305).

To assess the accuracy of the expired tidal volumes (VT(E)) displayed by one of the most frequently used ventilators that measures exhaled volume at the expiratory valve.Prospective study.The intensive care units of a pediatric tertiary referral center in London, UK.A total of 56 intubated children aged between 3 wks and 16.6 yrs who were clinically stable and ventilated with a Servo 300 ventilator.The CO2SMO Plus respiratory monitor, which measures flow at the airway opening, was validated using calibrated syringes and appropriate tracheal tubes and connections. Simultaneous in vivo recordings of VT(E) from the Servo 300 and CO2SMO Plus were compared before (displayed Servo VT(E)) and after (effective Servo VT(E)) compensating for ventilator circuit compliance.The in vitro accuracy of the CO2SMO Plus was within +/-5% over a wide range of volumes and measurement conditions. The displayed Servo 300 VT(E) overestimated the true VT(E) by between 2% and 91%. The magnitude of error varied within and between children, according to pressure change (peak inspiratory pressure minus positive end-expiratory pressure), VT(E), and circuit size. Mean (sd) error was 32% (20%) in 40 children with displayed Servo VT(E) of160 mL and 18% (6%) in 16 subjects with displayed Servo VT(E) of/=160 mL. After correcting for gas compression, effective VT(E) from the Servo 300 underestimated the true VT(E) by up to 64% in the smallest infants but continued to overestimate by as much as 29% in older children.The accuracy of tidal volume values is crucially dependent on the site of measurement. Unless measured at the airway opening, displayed values are an inconsistent and misleading indicator of the true volumes delivered.