Cerebral perfusion in sepsis

This article is one of ten reviews selected from the Yearbook of Intensive Care and Emergency Medicine 2010 (Springer Verlag) and co-published as a series in Critical Care. Other articles in the series can be found online at http://ccforum.com/series/yearbook. Further information about the Yearbook of Intensive Care and Emergency Medicine is available from http://www.springer.com/series/2855

Intensive care triage in the elderly

We read the editorial by Dr. Levy (1) regarding our manuscript (2) with interest but disagree with several of his points. We used the Acute Physiology Score II, part of the Simplified Acute Physiology Score (SAPS II), without age points to adjust for severity within age groups. Dr. Levy believes that we should have added the age points in calculating the score as was performed in the original SAPS II study. A serious drawback in the interpretation of multivariate analyses occurs when collinear variables are entered. In order to examine, the effect of age per se and to avoid collinearity, age points were excluded from the SAPS II scores. We believe that SAPS without age is still a measure of the risk for 28-day mortality. When the study population is stratified by age and the comparisons are between accepted and rejected patients, the impact of age on the SAPS score is minor as the age points within each stratum are similar for the groups being compared. In addition, other studies have adjusted for severity between groups by using acute physiological scores without age points (3), including one that evaluated illness severity in the elderly (4). One cannot really compare different age group severities if one adds additional points just for the patient’s age. Our previously reported propensity score (5) demonstrated that although patients refused intensive care unit admission were older and had higher SAPS II scores than those accepted, they had lower Acute Physiology Score II scores, suggesting that the observed association of admission refusal with higher severity of illness could be due to a confounding effect of old age in increasing SAPS II scores. The rationale for ascribing a “mortality benefit” to elderly patients was based on a bivariate analysis comparing refused and admitted patients within age groups =65, demonstrating a greater reduction in the survival among the refused elderly compared to younger patients. The odds of survival, refused relative to accepted patients controlling for SAPS II, were 0.74 for the younger group and 0.65 in the elder one. Dr. Levy states that the manuscript appears to be written with a bias toward the belief that elderly patients are being denied access to intensive care unit care. The Eldicus study was performed without any bias toward the belief that the elderly are or are not being denied intensive care unit access. Prior to the results of the study we did not think that the elderly would have greater mortality differences between accepted and rejected patients, but these were the findings of the study. We believe the fact that the triage literature is replete with studies showing that physicians reject the elderly more than younger patients together with our new findings compels physicians to relook at their triage policies for the elderly. This is not bias, but rather an evaluation of the facts and recommendations based on them

Intensive care triage in the elderly

We read the editorial by Dr. Levy (1) regarding our manuscript (2) with interest but disagree with several of his points. We used the Acute Physiology Score II, part of the Simplified Acute Physiology Score (SAPS II), without age points to adjust for severity within age groups. Dr. Levy believes that we should have added the age points in calculating the score as was performed in the original SAPS II study. A serious drawback in the interpretation of multivariate analyses occurs when collinear variables are entered. In order to examine, the effect of age per se and to avoid collinearity, age points were excluded from the SAPS II scores. We believe that SAPS without age is still a measure of the risk for 28-day mortality. When the study population is stratified by age and the comparisons are between accepted and rejected patients, the impact of age on the SAPS score is minor as the age points within each stratum are similar for the groups being compared. In addition, other studies have adjusted for severity between groups by using acute physiological scores without age points (3), including one that evaluated illness severity in the elderly (4). One cannot really compare different age group severities if one adds additional points just for the patient\u2019s age. Our previously reported propensity score (5) demonstrated that although patients refused intensive care unit admission were older and had higher SAPS II scores than those accepted, they had lower Acute Physiology Score II scores, suggesting that the observed association of admission refusal with higher severity of illness could be due to a confounding effect of old age in increasing SAPS II scores. The rationale for ascribing a \u201cmortality benefit\u201d to elderly patients was based on a bivariate analysis comparing refused and admitted patients within age groups =65, demonstrating a greater reduction in the survival among the refused elderly compared to younger patients. The odds of survival, refused relative to accepted patients controlling for SAPS II, were 0.74 for the younger group and 0.65 in the elder one. Dr. Levy states that the manuscript appears to be written with a bias toward the belief that elderly patients are being denied access to intensive care unit care. The Eldicus study was performed without any bias toward the belief that the elderly are or are not being denied intensive care unit access. Prior to the results of the study we did not think that the elderly would have greater mortality differences between accepted and rejected patients, but these were the findings of the study. We believe the fact that the triage literature is replete with studies showing that physicians reject the elderly more than younger patients together with our new findings compels physicians to relook at their triage policies for the elderly. This is not bias, but rather an evaluation of the facts and recommendations based on them

Reasons for refusal of admission to intensive care and impact on mortality

Purpose: To identify factors influencing triage decisions and investigate whether admission to the intensive care unit (ICU) could reduce mortality compared with treatment on the ward. Methods: A multicentre cohort study in 11 university hospitals from seven countries, evaluating triage decisions and outcomes of patients referred for admission to ICU who were either accepted, or refused and treated on the ward. Confounding in the estimation of the effect of ICU admission on mortality was controlled by use of a propensity score approach, which adjusted for the probability of being admitted. Variability across centres was accounted for in both analyses of factors influencing ICU admission and effect of ICU admission on mortality. Results: Eligible were 8,616 triages in 7,877 patients referred for ICU admission. Variables positively associated with probability of being admitted to ICU included: ventilators in ward; bed availability; Karnofsky score; absence of comorbidity; presence of haematological malignancy; emergency surgery and elective surgery (versus medical treatment); trauma, vascular involvement, liver involvement; acute physiologic score II; ICU treatment (versus ICU observation). Multiple triages during patient's hospital stay and age were negatively associated with ICU admission. The area under the receiver operating characteristic (ROC) curve of the model was 0.83 [95% confidence interval (CI): 0.81-0.84], with Hosmer-Lemeshow test P = 0.300. ICU admission was associated with a statistically significant reduction of both 28-day mortality [odds ratio (OR): 0.73; 95% CI: 0.62-0.87] and 90-day mortality (0.79; 0.66-0.93). The benefit of ICU admission increased substantially in patients with greater severity of illness. Conclusions: We suggest that intensivists take great care to avoid ICU admission of patients judged not severe enough for ICU or with low performance status, and they tend to admit surgical patients more readily than medical patients. Interestingly, they do not judge age per se as a reason for refusal of ICU admission. Admission to ICU was associated with a reduction of both 28- and 90-day mortality, particularly in patients with greater severity of illness at time of triage

Consensus statement of the ESICM task force on colloid volume therapy in critically ill patients

Colloids are administered to more patients than crystalloids, although recent evidence suggests that colloids may possibly be harmful in some patients. The European Society of Intensive Care Medicine therefore assembled a task force to compile consensus recommendations based on the current best evidence for the safety and efficacy of the currently most frequently used colloids-hydroxyethyl starches (HES), gelatins and human albumin. Meta-analyses, systematic reviews and clinical studies of colloid use were evaluated for the treatment of volume depletion in mixed intensive care unit (ICU), cardiac surgery, head injury, sepsis and organ donor patients. Clinical endpoints included mortality, kidney function and bleeding. The relevance of concentration and dosage was also assessed. Publications from 1960 until May 2011 were included. The quality of available evidence and strength of recommendations were based on the Grading of We recommend not to use HES with molecular weight a parts per thousand yen200 kDa and/or degree of substitution > 0.4 in patients with severe sepsis or risk of acute kidney injury and suggest not to use 6% HES 130/0.4 or gelatin in these populations. We recommend not to use colloids in patients with head injury and not to administer gelatins and HES in organ donors. We suggest not to use hyperoncotic solutions for fluid resuscitation. We conclude and recommend that any new colloid should be int

A step towards medical ethics modeling

Modeling of ethical reasoning has been a matter of discussion and research among distinct scientific fields, however no definite model has demonstrated undeniable global superiority over the others. However, the context of application of moral reasoning can require one methodology over the other. In areas such as medicine where quality of life and the life itself of a patient may be at stake, the ability to make the reasoning process understandable to staff and to change is of a paramount importance. In this paper we present some of the modeling lines of ethical reasoning applied to medicine, and defend that continuous logic programming presents potential for the development of trustworthy morally aware decision support systems. It is also presented a model of moral decision in two situations that emerge recurrently at the Intensive Care Units, a service where the moral complexity of regular decisions is a motivation for the analyze and development of moral decision support methodologies