Long-term medical utilization following ventilator-associated pneumonia in acute stroke and traumatic brain injury patients: a case-control study

<p>Abstract</p> <p>Background</p> <p>The economic burden of ventilator-associated pneumonia (VAP) during the index hospitalization has been confirmed in previous studies. However, the long-term economic impact is still unclear. The aim of this study is to examine the effect of VAP on medical utilization in the long term.</p> <p>Methods</p> <p>This is a retrospective case-control study. Study subjects were patients experiencing their first traumatic brain injury, acute hemorrhagic stroke, or acute ischemic stroke during 2004. All subjects underwent endotracheal intubation in the emergency room (ER) on the day of admission or the day before admission, were transferred to the intensive care unit (ICU) and were mechanically ventilated for 48 hours or more. A total of 943 patients who developed VAP were included as the case group, and each was matched with two control patients without VAP by age ( ± 2 years), gender, diagnosis, date of admission ( ± 1 month) and hospital size, resulting in a total of 2,802 patients in the study. Using robust regression and Poisson regression models we examined the effect of VAP on medical utilization including hospitalization expenses, outpatient expenses, total medical expenses, number of ER visits, number of readmissions, number of hospitalization days and number of ICU days, during the index hospitalization and during the following 2-year period.</p> <p>Results</p> <p>Patients in the VAP group had higher hospitalization expenses, longer length of stay in hospital and in ICU, and a greater number of readmissions than the control group patients.</p> <p>Conclusions</p> <p>VAP has a significant impact on medical expenses and utilization, both during the index hospitalization during which VAP developed and in the longer term.</p

Predictors of hospital mortality among septic ICU patients with Acinetobacter spp. bacteremia: A cohort study

BACKGROUND: We hypothesized that among septic ICU patients with Acinetobacter spp. bacteremia (Ac-BSI), carbapenem-resistant Acinetobacter spp. (CRAc) increase risk for inappropriate initial antibiotic therapy (non-IAAT), and non-IAAT is a predictor of hospital death. METHODS: We conducted a retrospective cohort study of adult septic ICU patients with Ac-BSI. Non-IAAT was defined as exposure to initially prescribed antibiotics not active against the pathogen based on in vitro susceptibility testing, and having no exposure to appropriate antimicrobial treatment within 24 hours of drawing positive culture. We compared patients who died to those who survived, and derived regression models to identify predictors of hospital mortality and of non-IAAT. RESULTS: Out of 131 patients with Ac-BSI, 65 (49.6%) died (non-survivors, NS). NS were older (63 [51, 76] vs. 56 [45, 66] years, p = 0.014), and sicker than survivors (S): APACHE II (24 [19, 31] vs. 18 [13, 22], p < 0.001) and Charlson (5 [2, 8] vs. 3 [1, 6], p = 0.009) scores. NS were also more likely than S to require pressors (75.4% vs. 42.4%, p < 0.001) and mechanical ventilation (75.4% vs. 53.0%, p = 0.008). Both CRAc (69.2% vs. 47.0%, p = 0.010) and non-IAAT (83.1% vs. 59.1%, p = 0.002) were more frequent among NS than S. In multivariate analyses, non-IAAT emerged as an independent predictor of hospital death (risk ratio [RR] 1.42, 95% confidence interval [CI] 1.10-1.58), while CRAc was the single strongest predictor of non-IAAT (RR 2.66, 95% CI 2.43-2.72). CONCLUSIONS: Among septic ICU patients with Ac-BSI, non-IAAT predicts mortality. Carbapenem resistance appears to mediate the relationship between non-IAAT and mortality

Multidrug resistance, inappropriate empiric treatment and hospital mortality in Acinetobacter baumannii pneumonia and sepsis

Background: The relationship between multidrug resistance (MDR), inappropriate empiric therapy (IET), and mortality among patients with Acinetobacter baumannii (AB) remains unclear. We examined it using a large U.S. database. Methods: We conducted a retrospective cohort study using the Premier Research database (2009–2013) of 175 U.S. hospitals. We included all adult patients admitted with pneumonia or sepsis as their principal diagnosis, or as a secondary diagnosis in the setting of respiratory failure, along with antibiotic administration within 2 days of admission. Only culture-confirmed infections were included. Resistance to at least three classes of antibiotics defined multidrug-resistant AB (MDR-AB). We used logistic regression to compute the adjusted relative risk ratio (RRR) of patients with MDR-AB receiving IET and IET’s impact on mortality. Results: Among 1423 patients with AB infection, 1171 (82.3 %) had MDR-AB. Those with MDR-AB were older (63.7 ± 15.4 vs. 61.0 ± 16.9 years, p = 0.014). Although chronic disease burden did not differ between groups, the MDR-AB group had higher illness severity than those in the non-MDR-AB group (intensive care unit 68.0 % vs. 59. 5 %, p < 0.001; mechanical ventilation 56.2 % vs. 42.1 %, p < 0.001). Patients with MDR-AB were more likely to receive IET than those in the non-MDR-AB group (76.2 % MDR-AB vs. 13.8 % non-MDR-AB, p < 0.001). In a regression model, MDR-AB strongly predicted receipt of IET (adjusted RRR 5.5, 95 % CI 4.0–7.7, p < 0.001). IET exposure was associated with higher hospital mortality (adjusted RRR 1.8, 95 % CI 1.4–2.3, p < 0.001). Conclusions: In this large U.S. database, the prevalence of MDR-AB among patients with AB infection was > 80 %. Harboring MDR-AB increased the risk of receiving IET more than fivefold, and IET nearly doubled hospital mortality

randomized controlled trial

Background. The aim of this study was to compare spinal anesthesia effects of low-dose hyperbaric levobupivacaine and low-dose hyperbaric bupivacaine for transurethral procedures.Methods. In this double-blind, randomized, controlled study, a total of 60 patients who were ASA I-III were randomized into two groups. Group B received 7.5 mg hyperbaric bupivacaine plus 25 mu g fentanyl, and Group L received 7.5 mg hyperbaric levobupivacaine plus 25 mu g fentanyl intrathecally. The onset time to T10 dermatome, times to maximum sensory and motor block levels, time to two-segment regression of sensory block, time to Bromage score zero, time to full recovery of sensory block, and hemodynamic values, as well as adverse effects, were recorded. The primary outcome was the time to complete regression of motor block.Results. The onset time of block to T10, time to maximum sensory block, and time to two-segment regression were similar in both groups. The time to maximum motor block was shorter in Group B (7 +/- 3 min) than in Group L (12 +/- 5 min), (P<0.001). The time to a Bromage score of zero (recovery of motor block) was shorter in Group L (105 +/- 19 min) than in Group B (113 +/- 7 min), (P=0.04). The time to full recovery of sensory block was shorter in Group B (127 14 min) than in Group L (157 34 min), (P<0.001). The requirement for analgesia was earlier in Group B (305 +/- 50 min) than in Group L (389 +/- 146 min), (P=0.004).Conclusion. Although both techniques provide adequate spinal block and have few similar side effects for transurethral surgery, the use of low-dose hyperbaric levobupivacaine plus fenranyl may be preferable to low-dose hyperbaric bupivacaine plus fentanyl because of the reduced motor block, shorter duration of motor block, longer duration of sensory block and longer time to the first requirement for analgesia. (Minerva Anestesiol 2010;76:992-1001

Comparison of spinal, low-dose spinal and epidural anesthesia with ropivacaine plus fentanyl for transurethral surgical procedures.

The aim of This study was to compare spinal, low-dose spinal, and epidural anesthesia using ropivacaine and fentanyl combinations for transurethral surgical procedures. Sixty patients with American Society of Anesthesiologists scores of I-III were allocated into three groups. After pre- loading with 5 mL/kg normal saline, patients in the spinal anesthesia group (Group S) received 15 mg of hyperbaric ropivacaine plus 25 microg of fentanyl intrathecally; patients in the epidural anesthesia group (Group E) received 112.5 mg of ropivacaine plus 25 microg of fentanyl epidurally via an epidural catheter; and patients in the low-dose spinal anesthesia group (Group L) received 10 mg of hyperbaric ropivacaine plus 25 microg of fentanyl intrathecally. Blood pressure, heart rate, peripheral oxygen saturation, time to onset of thoracic (T)-10 dermatome, two-segment sensorial block regression time, full recovery of sensorial block, maximum motor blockade levels, motor blockade regression time, additional analgesic administration, patient comfort, and complications were recorded. The time to the onset of T10 dermatome level was shortest in Group S and longest in Group E (p < 0.001). The sensorial blockade time and motor blockade regression time were shorted in Group L (p < 0.001). The two-segment sensorial block regression time in Group E exceeded that in the other groups. Additional analgesic administration was not needed in any group. No complications or adverse effects were observed in any patient. We conclude that all three anesthetic techniques may be used safely and are appropriate for transurethral surgical procedures. However, low-dose spinal anesthesia with ropivacaine plus fentanyl may be preferable in transurethral surgery because we reach an adequate sensorial level with less motor blockade

Intensive Care Unit

Objective: To determine the characteristics and outcomes of patients with prolonged stay in a tertiary-care ICU. Method: Electronic database records of patients 18 years or older and hospitalized in the ICU from March 2010 to March 2013 were enrolled. Age, gender, main reason for ICU admission, length of mechanical ventilation and ICU stay, in-hospital and one year mortality were noted. Results: The records of 1,908 patients from their initial ICU stays were analyzed. The mean Length Of Stay (LOS) for patients with a LOS >= 28 days (n: 215) was 85.6+/-81.9 days. The main disease category necessitating prolonged stays was neurologic disorders according to the diagnosis by the admission to ICU, while the main disease category necessitating a LOS< 28 days stays was elective surgery. Among the prolonged stay patients, 37 (17.2%) were alive one year post-discharge and only 13 (6%) were living independently. Conclusion: Patients with a prolonged ICU stay constituted a small percentage of all ICU admissions but they proportionally used many more ICU bed days than short-stay patients. The mortality of prolonged ICU stay patients was very high. Very few survivors were living independently at one year. Thus, development of intermediate care units, palliative care and home care services are emerging necessities, to decrease the LOS in ICUs

Factors Affecting Anxiety and Depression Symptoms in Relatives of Intensive Care Unit Patients.

AIM: To determine the incidences of anxiety and depression in relatives of patients admitted to an intensive care unit (ICU) and to investigate the relationships between psychological symptoms and demographic features of the patients and their relatives. METHODOLOGY: Relatives of 78 ICU patients were enrolled in the study. Sociodemographic features of patients and their relatives were recorded. The Turkish version of the Hospital Anxiety and Depression Scale was used to assess anxiety and depression. RESULTS: Twenty-eight (35.9%) cases with anxiety and 56 (71.8%) cases with depression were identified. The mean anxiety and depression scores were 9.49 ± 4.183 and 9.40 ± 4.286, respectively. Anxiety (P = .028) and concomitant anxiety with depression (P = .035) were more frequent among family members of young patients. The relationship to the patient, especially being a spouse, was significantly associated with symptoms (anxiety, P = .009; depression, P = .019; and both, P = .005). CONCLUSION: Spouses and family members of relatively young patients had higher rates of anxiety and depression. In contrast to the literature, depression was more common than anxiety among the relatives of ICU patients. Further research is needed on the impact of cultural and regional differences on anxiety and depression rates in family members of ICU patients