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Purpose Intensive care patients have increased risk of death and their care is expensive. We investigated whether risk-adjusted mortality and resources used to achieve survivors change over time and if their variation is associated with variables related to intensive care unit (ICU) organization and structure. Methods Data of 207,131 patients treated in 2008-2017 in 21 ICUs in Finland, Estonia and Switzerland were extracted from a benchmarking database. Resource use was measured using ICU length of stay, daily Therapeutic Intervention Scoring System Scores (TISS) and purchasing power parity-adjusted direct costs (2015-2017; 17 ICUs). The ratio of observed to severity-adjusted expected resource use (standardized resource use ratio; SRUR) was calculated. The number of expected survivors and the ratio of observed to expected mortality (standardized mortality ratio; SMR) was based on a mortality prediction model covering 2015-2017. Fourteen a priori variables reflecting structure and organization were used as explanatory variables for SRURs in multivariable models. Results SMR decreased over time, whereas SRUR remained unchanged, except for decreased TISS-based SRUR. Direct costs of one ICU day, TISS score and ICU admission varied between ICUs 2.5-5-fold. Differences between individual ICUs in both SRUR and SMR were up to > 3-fold, and their evolution was highly variable, without clear association between SRUR and SMR. High patient turnover was consistently associated with low SRUR but not with SMR. Conclusion The wide and independent variation in both SMR and SRUR suggests that they should be used together to compare the performance of different ICUs or an individual ICU over time., Author(s): Jukka Takala [sup.1], André Moser [sup.2], Rahul Raj [sup.3], Ville Pettilä [sup.4], Irina Irincheeva [sup.2] [sup.8], Tuomas Selander [sup.5], Olli Kiiski [sup.6], Tero Varpula [sup.4], Matti Reinikainen [sup.7], Stephan [...]

Purpose The interpretation of septic shock trial data is profoundly affected by patients, control intervention, co-interventions and selected outcome measures. We evaluated the reporting of control groups in recent septic shock trials. Methods We searched for original articles presenting randomized clinical trials (RCTs) in adult septic shock patients from 2006 to 2016. We included RCTs focusing on septic shock patients with at least two parallel groups and at least 50 patients in the control group. We selected and evaluated data items regarding patients, control group characteristics, and mortality outcomes, and calculated a data completeness score to provide an overall view of quality of reporting. Results A total of 24 RCTs were included (mean n = 287 patients and 71 % of eligible patients were randomized). Of the 24 studies, 14 (58 %) presented baseline data on vasopressors and 58 % the proportion of patients with elevated lactate values. Five studies (21 %) provided data to estimate the proportion of septic shock patients fulfilling the Sepsis-3 definition. The mean data completeness score was 19 out of 36 (range 8-32). Of 18 predefined control group characteristics, a mean of 8 (range 2-17) were reported. Only 2 (8 %) trials provided adequate data to confirm that their control group treatment represented usual care. Conclusions Recent trials in septic shock provide inadequate data on the control group treatment and hemodynamic values. We propose a standardized trial dataset to be created and validated, comprising characteristics of patient population, interventions administered, hemodynamic values achieved, surrogate organ dysfunction, and mortality outcomes, to allow better analysis and interpretation of future trial results., Author(s): Ville Pettilä [sup.1] [sup.2], Peter Buhl Hjortrup [sup.3], Stephan M. Jakob [sup.1], Erika Wilkman [sup.2], Anders Perner [sup.3] [sup.4], Jukka Takala [sup.1] Author Affiliations: (1) Department of Intensive Care [...]

Purpose Rapid assessment and intervention is important for the prognosis of acutely ill patients admitted to the emergency department (ED). The aim of this study was to prospectively develop and validate a model predicting the risk of in-hospital death based on all available information available at the time of ED admission and to compare its discriminative performance with a non-systematic risk estimate by the triaging first health-care provider. Methods Prospective cohort analysis based on a multivariable logistic regression for the probability of death. Results A total of 8,607 consecutive admissions of 7,680 patients admitted to the ED of a tertiary care hospital were analysed. Most frequent APACHE II diagnostic categories at the time of admission were neurological (2,052, 24 %), trauma (1,522, 18 %), infection categories [1,328, 15 %; including sepsis (357, 4.1 %), severe sepsis (249, 2.9 %), septic shock (27, 0.3 %)], cardiovascular (1,022, 12 %), gastrointestinal (848, 10 %) and respiratory (449, 5 %). The predictors of the final model were age, prolonged capillary refill time, blood pressure, mechanical ventilation, oxygen saturation index, Glasgow coma score and APACHE II diagnostic category. The model showed good discriminative ability, with an area under the receiver operating characteristic curve of 0.92 and good internal validity. The model performed significantly better than non-systematic triaging of the patient. Conclusions The use of the prediction model can facilitate the identification of ED patients with higher mortality risk. The model performs better than a non-systematic assessment and may facilitate more rapid identification and commencement of treatment of patients at risk of an unfavourable outcome., Author(s): Michael Coslovsky [sup.1], Jukka Takala [sup.2], Aristomenis K. Exadaktylos [sup.3], Luca Martinolli [sup.3], Tobias M. Merz [sup.2] Author Affiliations: (1) grid.5734.5, 0000000107265157, Clinical Trials Unit, Institute of Social and [...]

Purpose We hypothesized that reduced arousability (Richmond Agitation Sedation Scale, RASS, scores -2 to -3) for any reason during delirium assessment increases the apparent prevalence of delirium in intensive care patients. To test this hypothesis, we assessed delirium using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC) in intensive care patients during sedation stops, and related the findings to the level of sedation, as assessed with RASS score. Methods We assessed delirium in 80 patients with ICU stay longer than 48 h using CAM-ICU and ICDSC during daily sedation stops. Sedation was assessed using RASS. The effect of including patients with a RASS of -2 and -3 during sedation stop ('light to moderate sedation', eye contact less than 10 s or not at all, respectively) on prevalence of delirium was analyzed. Results A total of 467 patient days were assessed. The proportion of CAM-ICU-positive evaluations decreased from 53 to 31 % (p < 0.001) if assessments from patients at RASS -2/-3 (22 % of all assessments) were excluded. Similarly, the number of positive ICDSC results decreased from 51 to 29 % (p < 0.001). Conclusions Sedation per se can result in positive items of both CAM-ICU and ICDSC, and therefore in a diagnosis of delirium. Consequently, apparent prevalence of delirium is dependent on how a depressed level of consciousness after sedation stop is interpreted (delirium vs persisting sedation). We suggest that any reports on delirium using these assessment tools should be stratified for a sedation score during the assessment., Author(s): Matthias Haenggi [sup.1], Sina Blum [sup.1], Ruth Brechbuehl [sup.1], Anna Brunello [sup.1], Stephan M. Jakob [sup.1], Jukka Takala [sup.1] Author Affiliations: (1) grid.5734.5, 0000000107265157, Department of Intensive Care Medicine, [...]

Byline: Esko Ruokonen (1), Ilkka Parviainen (1), Stephan M. Jakob (2), Silvia Nunes (3), Maija Kaukonen (4), Stephen T. Shepherd (5), Toni Sarapohja (5), J. Raymond Bratty (5), Jukka Takala (2) Keywords: Dexmedetomidine; Sedatives; Deep sedation; Conscious sedation; Intensive care; Critical care; Mechanical ventilation Abstract: Purpose To compare dexmedetomidine (DEX) with standard care (SC, either propofol or midazolam) for long-term sedation in terms of maintaining target sedation and length of intensive care unit (ICU) stay. Methods A pilot, phase III, double-blind multicenter study in randomized medical and surgical patients (n = 85) within the first 72 h of ICU stay with an expected ICU stay of aY=48 h and sedation need for aY=24 h after randomization. Patients were assigned to either DEX (a$?1.4 ug kg.sup.-1 h.sup.-1 n = 41) or SC (n = 44), with daily sedation stops. Results Non-inferiority of DEX versus SC was not confirmed. Target Richmond agitation--sedation score (RASS) was reached a median of 64% (DEX) and 63% (SC) of the sedation time (ns). The length of ICU stay was similar in DEX and SC. Patients with RASS target 0--3 (DEX 78%, SC 80%) were at target sedation 74% (DEX) and 64% (SC) of the time (ns), whereas those with RASS target -4 or less reached the target 42% (DEX) and 62% (SC) of the time (P = .006). Post hoc analyses suggested shorter duration of mechanical ventilation for DEX (P = 0.025). Conclusions This pilot study suggests that in long-term sedation, DEX is comparable to SC in maintaining sedation targets of RASS 0 to -3 but not suitable for deep sedation (RASS -4 or less). DEX had no effect on length of ICU stay. Its effects on other relevant clinical outcomes, such as duration of mechanical ventilation, should be tested further. Author Affiliation: (1) Department of Anesthesiology and Intensive Care Medicine, Kuopio University Hospital, P.O. Box 1777, 70211, Kuopio, Finland (2) Department of Intensive Care Medicine, Bern University Hospital and University of Bern, 3010, Bern, Switzerland (3) Department of Intensive Care, Tampere University Hospital, P.O. Box 2000, 33521, Tampere, Finland (4) Units of Intensive Care Medicine, Division of Anesthesiology and Intensive Care Medicine, Department of Surgery, Helsinki University Central Hospital, P.O. Box 340, 00029, HUS, Helsinki, Finland (5) Orion Pharma, P.O. Box 65, 02101, Espoo, Finland Article History: Registration Date: 03/09/2008 Received Date: 13/05/2008 Accepted Date: 14/08/2008 Online Date: 16/09/2008 Article note: Registered at ClinicalTrials.gov, number NCT00226785. A complete list of investigators and study centers appears in the Appendix. This study was sponsored by Orion Pharma, Helsinki, Finland, through research contracts negotiated directly with the participating hospitals. Electronic supplementary material The online version of this article (doi: 10.1007/s00134-008-1296-0) contains supplementary material, which is available to authorized users.