The authors reply

No abstract available

http://ift.tt/2sbL7Ac

Sepsis-Associated 30-Day Risk-Standardized Readmissions: Analysis of a Nationwide Medicare Sample*

Objectives: To determine national readmission rates among sepsis survivors, variations in rates between hospitals, and determine whether measures of quality correlate with performance on sepsis readmissions. Design: Cross-sectional study of sepsis readmissions between 2008 and 2011 in the Medicare fee-for-service database. Setting: Acute care, Medicare participating hospitals from 2008 to 2011. Patients: Septic patients as identified by International Classification of Diseases, Ninth Revision codes using the Angus method. Interventions: None. Measurements and Main Results: We generated hospital-level, risk-standardized, 30-day readmission rates among survivors of sepsis and compared rates across region, ownership, teaching status, sepsis volume, hospital size, and proportion of underserved patients. We examined the relationship between risk-standardized readmission rates and hospital-level composite measures of quality and mortality. From 633,407 hospitalizations among 3,315 hospitals from 2008 to 2011, median risk-standardized readmission rates was 28.7% (interquartile range, 26.1–31.9). There were differences in risk-standardized readmission rates by region (Northeast, 30.4%; South, 29.6%; Midwest, 28.8%; and West, 27.7%; p

http://ift.tt/2tcPObb

Pheochromocytoma Crisis in the ICU: A French Multicenter Cohort Study With Emphasis on Rescue Extracorporeal Membrane Oxygenation

Objectives: To describe the characteristics, management, and outcome of patients admitted to ICUs for pheochromocytoma crisis. Design: A 16-year multicenter retrospective study. Setting: Fifteen university and nonuniversity ICUs in France. Patients: Patients admitted in ICU for pheochromocytoma crisis. Interventions: None. Measurement and Main Results: We included 34 patients with a median age of 46 years (40–54 yr); 65% were males. At admission, the median Sequential Organ Failure Assessment score was 8 (4–12) and median Simplified Acute Physiology Score II 49.5 (27–70). The left ventricular ejection fraction was consistently decreased with a median value of 30% (15–40%). Mechanical ventilation was required in 23 patients, mainly because of congestive heart failure. Vasoactive drugs were used in 23 patients (68%) and renal replacement therapy in eight patients (24%). Extracorporeal membrane oxygenation was used as a rescue therapy in 14 patients (41%). Pheochromocytoma was diagnosed by CT in 33 of 34 patients. When assayed, urinary metanephrine and catecholamine levels were consistently elevated. Five patients underwent urgent surgery, including two during extracorporeal membrane oxygenation. Overall ICU mortality was 24% (8/34), and overall 90-day mortality was 27% (9/34). Crude 90-day mortality was not significantly different between patients managed with versus without extracorporeal membrane oxygenation (22% vs 30%) (p = 0.7) despite higher severity scores at admission in the extracorporeal membrane oxygenation group. Conclusions: Mortality is high in pheochromocytoma crisis. Routinely considering this diagnosis and performing abdominal CT in patients with unexplained cardiogenic shock may allow an earlier diagnosis. Extracorporeal membrane oxygenation and adrenalectomy should be considered as a therapeutic in most severe cases.

http://ift.tt/2sbvb0G

Simulation of a Novel Schedule for Intensivist Staffing to Improve Continuity of Patient Care and Reduce Physician Burnout

Objective: Despite widespread adoption of in-house call for ICU attendings, there is a paucity of research on optimal scheduling of intensivists to provide continuous on-site coverage. Overnight call duties have traditionally been added onto 7 days of continuous daytime clinical service. We designed an alternative ICU staffing model to increase continuity of attending physician care for patients while also decreasing interruptions to attendings' nonclinical weeks. Design: Computer-based simulation of a 1-year schedule. Setting: A simulated ICU divided into two daytime teams each covered by a different attending and both covered by one overnight on-call attending. Subjects: Simulated patients were randomly admitted on different service days to assess continuity of care. Interventions: A "shared service schedule" was compared to a standard "7 days on schedule." For the 7 days on schedule, an attending covered a team for 7 consecutive days and off-service attendings cross-covered each night. For the shared schedule, four attendings shared the majority of daytime and nighttime service for two teams over 2 weeks, with recovery periods built into the scheduled service time. Measurements and Main Results: Continuity of care as measured by the Continuity of Attending Physician Index increased by 9% with the shared schedule. Annually, the shared service schedule was predicted to increase free weekends by 3.4 full weekends and 1.3 weekends with either Saturday or Sunday off. Full weeks without clinical obligations increased by 4 weeks. Mean time between clinical obligations increased by 5.8 days. Conclusions: A shared service schedule is predicted to improve continuity of care while increasing free weekends and continuity of uninterrupted nonclinical weeks for attendings. Computer-based simulation allows assessment of benefits and tradeoffs of the alternative schedule without disturbing existing clinical systems.

http://ift.tt/2tcPOId

Accuracy of Zero-Heat-Flux Cutaneous Temperature in Intensive Care Adults

Objectives: To compare accuracy of a continuous noninvasive cutaneous temperature using zero-heat-flux method to esophageal temperature and arterial temperature. Design: Prospective study. Setting: ICU and NeuroICU, University Hospital. Patients: Fifty-two ICU patients over a 4-month period who required continuous temperature monitoring were included in the study, after informed consent. Interventions: All patients had esophageal temperature probe and a noninvasive cutaneous device to monitor their core temperature continuously. In seven patients who required cardiac output monitoring, continuous iliac arterial temperature was collected. Simultaneous core temperatures were recorded from 1 to 5 days. Comparison to the esophageal temperature, considered as the reference in this study, used the Bland and Altman method with adjustment for multiple measurements per patient. Measurements and Main Results: The esophageal temperature ranged from 33°C to 39.7°C, 61,298 pairs of temperature using zero-heat-flux and esophageal temperature were collected and 1,850 triple of temperature using zero-heat-flux, esophageal temperature, and arterial temperature. Bias and limits of agreement for temperature using zero-heat-flux were 0.19°C ± 0.53°C compared with esophageal temperature with an absolute difference of temperature pairs equal to or lower than 0.5°C of 92.6% (95% CI, 91.9–93.4%) of cases and equal to or lower than 1°C for 99.9% (95% CI, 99.7–100.0%) of cases. Compared with arterial temperature, bias and limits of agreement were –0.00°C ± 0.36°C with an absolute difference of temperature pairs equal to or lower than 0.5°C of 99.8% (95% CI, 95.3–100%) of cases. All absolute difference of temperature pairs between temperature using zero-heat-flux and arterial temperature and between arterial temperature and esophageal temperature were equal to or lower than 1°C. No local or systemic serious complication was observed. Conclusions: These results suggest a comparable reliability of the cutaneous sensor using the zero-heat-flux method compared with esophageal or iliac arterial temperatures measurements.

http://ift.tt/2sbL7jG

Neuron-Specific Enolase Predicts Poor Outcome After Cardiac Arrest and Targeted Temperature Management: A Multicenter Study on 1,053 Patients

Objective: Outcome prediction after cardiac arrest is important to decide on continuation or withdrawal of intensive care. Neuron-specific enolase is an easily available, observer-independent prognostic biomarker. Recent studies have yielded conflicting results on its prognostic value after targeted temperature management. Design, Setting, and Patients: We analyzed neuron-specific enolase serum concentrations 3 days after nontraumatic in-hospital cardiac arrest and out-of-hospital cardiac arrest and outcome of patients from five hospitals in Germany, Austria, and Italy. Patients were treated at 33°C for 24 hours. Cerebral Performance Category was evaluated upon ICU discharge. We performed case reviews of good outcome patients with neuron-specific enolase greater than 90 μg/L and poor outcome patients with neuron-specific enolase less than or equal to 17 μg/L (upper limit of normal). Measurements and Main Results: A neuron-specific enolase serum concentration greater than 90 μg/L predicted Cerebral Performance Category 4–5 with a positive predictive value of 99%, false positive rate of 0.5%, and a sensitivity of 48%. All three patients with neuron-specific enolase greater than 90 μg/L and Cerebral Performance Category 1–2 had confounders for neuron-specific enolase elevation. An neuron-specific enolase serum concentration less than or equal to 17 μg/L excluded Cerebral Performance Category 4–5 with a negative predictive value of 92%. The majority of 14 patients with neuron-specific enolase less than or equal to 17 μg/L who died had a cause of death other than hypoxic-ischemic encephalopathy. Specificity and sensitivity for prediction of poor outcome were independent of age, sex, and initial rhythm but higher for out-of-hospital cardiac arrest than for in-hospital cardiac arrest patients. Conclusion: High neuron-specific enolase serum concentrations reliably predicted poor outcome at ICU discharge. Prediction accuracy differed and was better for out-of-hospital cardiac arrest than for in-hospital cardiac arrest patients. Our "in-the-field" data indicate 90 μg/L as a threshold associated with almost no false positives at acceptable sensitivity. Confounders of neuron-specific enolase elevation should be actively considered: neuron-specific enolase–producing tumors, acute brain diseases, and hemolysis. We strongly recommend routine hemolysis quantification. Neuron-specific enolase serum concentrations less than or equal to 17 μg/L argue against hypoxic-ischemic encephalopathy incompatible with reawakening.

http://ift.tt/2tcFosf

The authors reply

No abstract available

http://ift.tt/2rGhJOE