Interpretation of Transbronchial Lung Biopsies from Lung Transplant Recipients:Inter- and Intraobserver Agreement

BACKGROUND: Transbronchial lung biopsy results are crucial for the management of lung transplant recipients. Little information is available regarding the reliability and reproducibility of the interpretation of transbronchial lung biopsies

Association of hemoglobin concentration and mortality in critically ill patients with severe traumatic brain injury

Introduction: The critical care management of traumatic brain injury focuses on preventing secondary ischemic injury. Cerebral oxygen delivery is dependent upon the cerebral perfusion pressure and the oxygen content of blood, which is principally determined by hemoglobin. Despite its importance to the cerebral oxygen delivery, the precise hemoglobin concentration to provide adequate oxygen delivery to injured neuronal tissue in TBI patients is controversial with limited evidence to provide transfusion thresholds. Methods: We conducted a retrospective cohort study of severe TBI patients, investigating the association between mean 7-day hemoglobin concentration and hospital mortality. Demographic, physiologic, intensive care interventions, clinical outcomes and daily hemoglobin concentrations were recorded for all patients. Patients were all cared for at a tertiary, level 1 trauma center in a mixed medical and surgical intensive unit. Patients were divided into quartiles based on their mean 7-day hemoglobin concentration: 110 g/L. Multivariable log-binomial regression was used to model the association between mean daily hemoglobin concentration and hospital mortality. Results: Two hundred seventy-three patients with traumatic brain injury were identified and 169 were included in the analysis based on inclusion/exclusion criteria. Of these, 77% of the patients were male, with a mean age of 38 (SD 17) years and a median best GCS of 6 (IQR 5 - 7). One hundred fifteen patients (68%) received a red blood cell (RBC) transfusion. In RBCs administered in the ICU, the median pre-transfusion hemoglobin was 79 g/L (IQR 73 - 85). Thirty-seven patients (22%) died in hospital. Multivariable analysis revealed that mean 7-day hemoglobin concentration < 90 g/L was independently associated with an increased risk of hospital mortality (RR 3.1, 95% CI 1.5 - 6.3, p = 0.03). Other variables associated with increased mortality on multivariable regression were insertion of external ventricular drain, age and decreased GCS. Red blood cell transfusion was not associated with mortality following multivariable adjustment. Conclusions A mean 7-day hemoglobin concentration of < 90g/L is associated with increased hospital mortality in patients with severe traumatic brain injury.Anesthesiology, Pharmacology and Therapeutics, Department ofCritical Care Medicine, Division ofMedicine, Department ofMedicine, Faculty ofOther UBCNon UBCReviewedFacult

Identifying Missed Opportunities to Curtail Antimicrobial Therapy for Presumed Ventilator-Associated Pneumonia Using the Clinical Pulmonary Infection Score

ABSTRACT Background: Early discontinuation of antimicrobial therapy for ventilator-associated pneumonia can reduce the emergence of antimicrobial resistance, the occurrence of adverse drug events, and the cost of therapy. Evidence suggests that discontinuation of therapy by day 3 may be appropriate for patients with a clinical pulmonary infection score of 6 or less at baseline and on day 3.Objectives: To determine the proportion of patients eligible for antimicrobial discontinuation on day 3 and day 7 of therapy and to determine the proportion of eligible patients for whom antimicrobials were discontinued within these timeframes.Methods: A 6-month observational study was conducted from October 3, 2005, to March 31, 2006, in a 27-bed medical–surgical tertiary care intensive care unit. Clinical pharmacists attended daily rounds and prospectively identified patients for inclusion in the study. A study pharmacist retrospectively calculated clinical pulmonary infection scores. Other data were obtained from the quality-improvement database and patient health records for the intensive care unit.Results: Ninety-two patients were treated for ventilator-associated pneumonia during the study period, of whom 49 were included in the analysis. At day 3, 17 (35%) of the 49 patients were eligible for early discontinuation of antimicrobial therapy, but therapy was discontinued for only 2 (12%) of these 17 patients. At day 7, 10 (32%) of 31 patients were eligible for antimicrobial discontinuation, but therapy was discontinued for only 1 (10%) of these 10 patients.Conclusions: A significant opportunity exists at the authors’ institution to develop and implement an antimicrobial discontinuation policy that uses the clinical pulmonary infection score to guide antimicrobial use for patients with ventilator-associated pneumonia.RÉSUMÉ Contexte : L’arrêt précoce de l’antibiothérapie dans les cas de pneumonie sous ventilation assistée pourrait réduire l’apparition de résistance antimocrobienne, la survenue d’événements indésirables liés aux médicaments et le coût du traitement. Des données suggèrent que l’arrêt du traitement au jour 3 pourrait être approprié chez les patients présentant un score d’infection pulmonaire clinique de 6 ou moins au début et au 3e jour du traitement.Objectifs : Déterminer la proportion de patients admissibles à l’arrêt de l’antibiothérapie, aux jours 3 et 7 du traitement, et la proportion de ces patients dont l’antibiothérapie a été effectivement interrompue à ces dates.Méthodes : Une étude d’observation de six mois a été menée du 3 octobre 2005 au 31 mars 2006, dans une unité de soins intensifs médico-chirurgicale de 27 lits d’un hôpital de soins tertiaires. Des pharmaciens cliniciens participaient aux tournées quotidiennes et ont répertorié de façon prospective les patients admissibles à l’étude. Un pharmacien investigateur a calculé de façon rétrospective les scores d’infection pulmonaire clinique. D’autres données ont aussi été collectées de la base de données sur l’amélioration de la qualité et des dossiers médicaux des patients de l’unité de soins intensifs.Résultats : En tout, 92 patients ont reçu une antibiothérapie pour une pneumonie sous ventilation assistée au cours de la période de l’étude, et 49 d’entre eux ont été retenus aux fins d’analyse. Au jour 3, 17 (35 %) des 49 patients étaient admissibles à un arrêt précoce de l’antibiothérapie, mais on a procédé à l’arrêt de l’antibiothérapie chez seulement 2 (12 %) de ces 17 patients. Au jour 7, 10 patients (32 %) sur 31 étaient admissibles à l’arrêt de l’antibiothérapie, mais on a interrompu l’antibiothérapie chez seulement 1 (10 %) de ces 10 patients.Conclusions : L’établissement des auteurs se prêterait particulièrement bien à l’élaboration et la mise en place d’une politique d’arrêt de l’antibiothérapie, qui se fonderait sur les scores d’infection pulmonaire clinique dans les cas de pneumonie sous ventilation assistée

Hypoglycemia and risk of death in critically ill patients

BACKGROUND: Whether hypoglycemia leads to death in critically ill patients is unclear. METHODS: We examined the associations between moderate and severe hypoglycemia (blood glucose, 41 to 70 mg per deciliter [2.3 to 3.9 mmol per liter] and ≥40 mg per d

Intensive versus conventional glucose control in critically ill patients with traumatic brain injury: long-term follow-up of a subgroup of patients from the NICE-SUGAR study

Purpose: To compare the effect of intensive versus conventional blood glucose control in patients with traumatic brain injury. Methods: In a large international randomized trial patients were randomly assigned to a target blood glucose (BG) range of either 4.5–6.0\ua0mmol/L (intensive control) o

Intensive versus Conventional Glucose Control in Critically Ill Patients

Background The optimal target range for blood glucose in critically ill patients remains unclear. Methods Within 24 hours after admission to an intensive care unit(ICU), adults who were expected to require treatment in the ICU on 3 or more consecutive days were randomly assigned to undergo either intensive glucose control, with a target blood glucose range of 81 to 108 mg per deciliter(4.5 to 6.0 mmol per liter), or conventional glucose control, with a target of 180 mg or less per deciliter(10.0 mmol or less per liter). We defined the primary end point as death from any cause within 90 days after randomization. Results Of the 6104 patients who underwent randomization, 3054 were assigned to undergo intensive control and 3050 to undergo conventional control; data with regard to the primary outcome at day 90 were available for 3010 and 3012 patients, respectively. The two groups had similar characteristics at baseline. A total of 829 patients(27.5%) in the intensive-control group and 751(24.9%) in the conventional-control group died(odds ratio for intensive control, 1.14; 95% confidence interval, 1.02 to 1.28; P=0.02). The treatment effect did not differ significantly between operative(surgical) patients and nonoperative(medical) patients(odds ratio for death in the intensive-control group, 1.31 and 1.07, respectively; P = 0.10). Severe hypoglycemia(blood glucose level, <40 mg per deciliter [2.2 mmol per liter]) was reported in 206 of 3016 patients(6.8%) in the intensive-control group and 15 of 3014(0.5%) in the conventional-control group(P<0.001). There was no significant difference between the two treatment groups in the median number of days in the ICU(P = 0.84) or hospital(P = 0.86) or the median number of days of mechanical ventilation(P = 0.56) or renal-replacement therapy(P=0.39). Conclusions In this large, international, randomized trial, we found that intensive glucose control increased mortality among adults in the ICU: a blood glucose target of 180 mg or less per deciliter resulted in lower mortality than did a target of 81 to 108 mg per deciliter.(ClinicalTrials.gov number, NCT00220987.

Risk factors for and prediction of mortality in critically ill medical–surgical patients receiving heparin thromboprophylaxis

Abstract Background Previous studies have suggested that prediction models for mortality should be adjusted for additional risk factors beyond the Acute Physiology and Chronic Health Evaluation (APACHE) score. Our objective was to identify risk factors independent of APACHE II score and construct a prediction model to improve the predictive accuracy for hospital and intensive care unit (ICU) mortality. Methods We used data from a multicenter randomized controlled trial (PROTECT, Prophylaxis for Thromboembolism in Critical Care Trial) to build a new prediction model for hospital and ICU mortality. Our primary outcome was all-cause 60-day hospital mortality, and the secondary outcome was all-cause 60-day ICU mortality. Results We included 3746 critically ill non-trauma medical–surgical patients receiving heparin thromboprophylaxis (43.3 % females) in this study. The new model predicting 60-day hospital mortality incorporated APACHE II score (main effect: hazard ratio (HR) = 0.97 for per-point increase), body mass index (BMI) (main effect: HR = 0.92 for per-point increase), medical admission versus surgical (HR = 1.67), use of inotropes or vasopressors (HR = 1.34), acetylsalicylic acid or clopidogrel (HR = 1.27) and the interaction term between APACHE II score and BMI (HR = 1.002 for per-point increase). This model had a good fit to the data and was well calibrated and internally validated. However, the discriminative ability of the prediction model was unsatisfactory (C index < 0.65). Sensitivity analyses supported the robustness of these findings. Similar results were observed in the new prediction model for 60-day ICU mortality which included APACHE II score, BMI, medical admission and invasive mechanical ventilation. Conclusion Compared with the APACHE II score alone, the new prediction model increases data collection, is more complex but does not substantially improve discriminative ability. Trial registration: ClinicalTrials.gov Identifier: NCT0018214