To evaluate the incidence, treatment and mortality of acute respiratory failure (ARF) in Finnish intensive care units (ICUs).
Prospective multicentre cohort study.
All adult patients in 25 ICUs were screened for use of invasive or non-invasive ventilatory support during an 8-week period. Patients needing ventilatory support for more than 6 h were included and defined as ARF patients. Risk factors for ARF and details of prior chronic health status were assessed. Ventilatory and concomitant treatments were evaluated and recorded daily throughout the ICU stay. ICU and 90-day mortalities were assessed.
A total of 958 (39%) from the 2,473 admitted patients were treated with ventilatory support for more than 6 h. Incidence of ARF, acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) was 149.5, 10.6 and 5.0/100,000 per year, respectively. Ventilatory support was started with non-invasive interfaces in 183 of 958 (19%) patients. Ventilatory modes allowing triggering of spontaneous breaths were preferred (81%). Median tidal volume/predicted body weight was 8.7 (7.6-9.9) ml/kg and plateau pressure 19 (16-23) cmH2O. The 90-day mortality of ARF was 31%.
While the incidence of ARF requiring ventilatory support is higher, the incidence of ALI and ARDS seems to be lower in Finland than previously reported in other countries. Tidal volumes are higher than recommended in the concept of lung protective strategy. However, restriction of peak airway pressure was used in the majority of ARF patients.
Comment In: Intensive Care Med. 2009 Aug;35(8):1328-3019526219
BACKGROUND AND PURPOSE: The elderly constitute a significant and increasing proportion of the population. The aim of this investigation was to study time trends in clinical management and outcome in elderly patients with subarachnoid hemorrhage. METHODS: Two hundred eighty-one patients >/=65 years of age with aneurysmal subarachnoid hemorrhage who were accepted for treatment at the Uppsala University Hospital neurosurgery clinic during 1981 to 1998 were included. Hunt and Hess grades on admission, specific management components, and clinical outcomes were recorded. Three periods were compared: A, 1981 to 1986 (before neurointensive care); B, 1987 to 1992; and C, 1993 to 1998. RESULTS: The volume of elderly patients (>/=65 years of age) increased with time, especially patients >/=70 years of age. Furthermore the proportion of patients with more severe clinical conditions increased. A greater proportion of patients had a favorable outcome (A, 45%; B, 61%; C, 58%) despite older ages and more severe neurological and clinical conditions. In period C, Hunt and Hess I to II patients had a favorable outcome in 85% of cases compared with 64% in period A. This was achieved without any increase in the number of severely disabled patients. CONCLUSIONS: Elderly patients with subarachnoid hemorrhage can be treated successfully, and results are still improving. The introduction of neurointensive care may have contributed to the improved outcome without increasing the proportion of severely disabled patients. A defeatist attitude toward elderly patients with this otherwise devastating disease is not justified.
Several North American studies have observed survival benefit in patients exposed to ß-blockers following traumatic brain injury (TBI). The purpose of this study was to evaluate the effect of ß-blockade on mortality in a Swedish cohort of isolated severe TBI patients.
The trauma registry of an urban academic trauma center was queried to identify patients with an isolated severe TBI between 1/2007 and 12/2011. Isolated severe TBI was defined as an intracranial injury with an Abbreviated Injury Scale (AIS)=3 excluding extra-cranial injuries AIS=3. Multivariable logistic regression analysis was used to determine the effect of ß-blocker exposure on mortality. Also, a subgroup analysis was performed to investigate the risk of mortality in patients on pre-admission ß-blocker versus not and the effect of specific type of ß-blocker on the overall outcome.
Overall, 874 patients met the study criteria. Of these, 33% (n=287) were exposed to ß-blockers during their hospital admission. The exposed patients were older (62±16 years vs. 49±21 years, p
We examined local differences in prescription pattern of home mechanical ventilation (HMV) within the homogenous health care system in Sweden. We used 6 years prospective data from the national HMV Register covering the entire Swedish HMV patient population (more than 1000 patients). The treatment prevalence of HMV in Sweden, January 1, 1996 was 6.2/100,000 and January 1, 2002 10.5/100,000 with a steady increase each year in all counties. The differences between leading and non-leading counties showed a tendency to diminish due to an increasing prescription rate in the non-leading counties. During the 6 years, the proportion of Pickwickian patients increased significantly in the country as a whole, but remained considerably and significantly higher in the leading counties, in spite of similar and temporally stable prescription criteria. Even if the evident dissimilarities in treatment prevalence may be levelling out, it will most probably do so at a level as high as or higher than today's top level of more than 20/100,000 since we found that HMV therapy was well founded also in the counties with the highest prescription rates and that the prescription rate of the non-leading counties was approaching the level of the leading counties.
As widely reported, the progress in burn care during recent decades has reduced the hospital mortality. The effect of the burns on long-term outcome has not received so much attention, and more study is indicated. The aim of this retrospective study was to investigate the long-time survival among patients who had been treated for burns.
We studied 1487 patients who were discharged alive from the Linköping University Hospital Burn Centre during the period 1993 until the end of December 2012. We used Cox's regression analysis to study the effect of burns on long-term survival after adjustment for different factors.
Age and a full-thickness burn were significantly associated with mortality after discharge (p
Although long-term ventilation (LTV) has been shown to extend the lives of individuals with Duchenne muscular dystrophy (DMD), initiating LTV is still considered controversial. The purpose of the study was to describe the LTV-related attitudes and practices of Canadian physicians who follow up patients with DMD.
The study consisted of a mail questionnaire supplemented by face-to-face interviews.
Forty-five physicians who follow up patients with DMD through Canadian neuromuscular clinics.
A mail questionnaire of 66 closed-ended questions related to practice and attitudes was completed by all respondents. Qualitative semistructured interviews were conducted with six volunteer physicians, and were audiotaped and transcribed.
The results indicated that 25.0% of physicians do not discuss LTV with all of their DMD patients. The most frequently cited reason for advising against LTV was poor patient quality of life (52.6%). Three themes emerged from the qualitative data: mentioning and discussing LTV are discrete events with different purposes, nighttime and full-time LTV decisions are approached differently, and physicians modify their discussions to influence outcome.
The study demonstrated considerable agreement among the physicians regarding disclosure practices. Concerns are raised by the number of physicians who do not disclose to all patients and families and the role of quality-of-life judgments in decision making. It is suggested that because of their subjective nature, quality-of-life judgments should not be made without the participation of the patient and family, and that an initial disclosure is the minimum requirement of informed consent/decision making.
To estimate the rate of admissions to NICUs, as well as infants' morbidity and neonatal interventions, after exposure to antidepressant drugs in utero.
Data on pregnancies, deliveries, prescription drug use, and health status of the newborn infants were obtained from the Swedish Medical Birth Register, the Prescribed Drug Register, and the Swedish Neonatal Quality Register. We included 741?040 singletons, born between July 1, 2006, and December 31, 2012. Of the infants, 17?736 (2.4%) had mothers who used selective serotonin reuptake inhibitors (SSRIs) during pregnancy. Infants exposed to an SSRI were compared with nonexposed infants, and infants exposed during late pregnancy were compared with those exposed during early pregnancy only. The results were analyzed with logistic regression analysis.
After maternal use of an SSRI, 13.7% of the infants were admitted to the NICU compared with 8.2% in the population (adjusted odds ratio: 1.5 [95% confidence interval: 1.4-1.5]). The admission rate to the NICU after treatment during late pregnancy was 16.5% compared with 10.8% after treatment during early pregnancy only (adjusted odds ratio: 1.6 [95% confidence interval: 1.5-1.8]). Respiratory and central nervous system disorders and hypoglycemia were more common after maternal use of an SSRI. Infants exposed to SSRIs in late pregnancy compared with early pregnancy had a higher risk of persistent pulmonary hypertension (number needed to harm: 285).
Maternal use of antidepressants during pregnancy was associated with increased neonatal morbidity and a higher rate of admissions to the NICU. The absolute risk for severe disease was low, however.
Patent Ductus Arteriosus (PDA) ligation in premature infants is an urgent procedure performed by some but not all pediatric surgeons. Proficiency in PDA ligation is not a requirement of Canadian pediatric surgery training. Our purpose was to determine the outcomes of neonatal PDA ligation done by pediatric surgeons.
We performed a retrospective review of premature infants who underwent PDA ligation by pediatric surgeons in 3 Canadian centers from 2005 to 2009. Outcomes were compared to published controls.
The review identified 98 patients with a mean corrected GA and weight at repair of 29 weeks and 1122 g, respectively. There were no intraoperative deaths. The 30-day and inhospital mortality rates were 1% and 5%. Mortality and morbidity were comparable to the published outcomes.
This study documents that a significant number of preterm infant PDA ligations are safely done by pediatric surgeons. To meet the Canadian needs for this service by pediatric surgeons, proficiency in PDA ligation should be considered important in pediatric surgery training programs.
A prenatal diagnosis of congenital diaphragmatic hernia (CDH) enables therapeutic decision making during the intrapartum period. This study seeks to identify the gestational age and delivery mode associated with optimal outcomes.
A national data set was used to study CDH babies born between 2005 and 2009. The primary outcome was survival to discharge. Primary and secondary outcomes were analyzed by categorical gestational age (preterm, 39 weeks) by intended and actual route of delivery and by birth plan conformity, regardless of route.
Of 214 live born babies (gestational age, 37.6 ± 4.0 weeks; birth weight, 3064 ± 696 g), 143 (66.8%) had a prenatal diagnosis and 174 (81.3%) survived to discharge. Among 143 prenatally diagnosed pregnancies, 122 (85.3%) underwent abdominal delivery (AD) and 21 (14.6%) underwent cesarean delivery (CS). Conformity between intended and actual delivery occurred in 119 (83.2%). Neither categorical gestational age nor delivery route influenced outcome. Although babies delivered by planned CS had a lower mortality than those delivered by planned AD (2/21 and 36/122, respectively; P = .04), this difference was not significant by multivariate analysis. Conformity to any birth plan was associated with a trend toward improved survival.
Our data do not support advocacy of any specific delivery plan or route nor optimal gestational age for prenatally diagnosed CDH.