Histological damage of colonic epithelium is associated with clinical severity and outcome in colectomized critically Ill patients.

BACKGROUND: Severe intestinal mucosal damage and organ failure has been associated in experimental models. Our purpose was to determine whether there is any association between histopathological findings and postoperative mortality among ICU patients undergoing emergency colectomies for various illnesses. METHODS: In a retrospective case control study, total colectomy specimens from 50 patients in a mixed ICU were analysed: 18 had sepsis, 11 vascular operations, and 21 Clostridium difficile colitis. Overall thickness, the width of epithelial defects, and presence of cryptal damage were assessed. Extent of necrosis and amount of neutrophils were separately evaluated in the layers of the colonic wall. Clinical features, including sequential organ failure assessment (SOFA) scores and survival, were registered. RESULTS: The histopathological findings for the three clinical entities were similar, except for the abundance of characteristic pseudomembranes in the Clostridium group. Mucosal height (maximum) showed a negative correlation with SOFA score on admission (ρ = -0.296, P = 0.037), and with preoperative blood lactate level (ρ = -0.316; P = 0.027). The nonsurvivors had wider enterocyte defects (60 vs. 40.8, P = 0.002) and more severe crypt damage (61 vs. 27 %; P = 0.024) than the survivors. CONCLUSIONS: The histopathological damage involves all layers of the colon wall among ICU patients being largely similar in sepsis, C. difficile infection, and ischemia after vascular operations. Mucosal epithelial damage is associated with clinical severity of the illness and mortality.

Hospital and long-term outcomes of ICU-treated severe community- and hospital-acquired, and ventilator-associated pneumonia patients.

BACKGROUND: Our purpose was to analyse the association of pneumonia types with hospital and long-term outcomes of intensive care unit (ICU)-treated pneumonia patients. METHODS: The occurrence of pneumonia was retrospectively evaluated among prospectively registered patients admitted into a mixed university-level ICU during a 14-month period. Their age, severity of underlying disease, malignancy, immunosuppressive therapy and organ dysfunctions were recorded, as well as the length of hospital stay and short- and long-term mortalities. RESULTS: There were 117 severe community-acquired pneumonia (SCAP), 66 hospital-acquired pneumonia (HAP) and 25 ventilator-associated pneumonia (VAP) cases among the 817 patients admitted. ICU and hospital mortality did not differ between pneumonia groups. VAP and HAP patients had more malignant underlying diseases than SCAP patients (P < 0.001). HAP patients were older than SCAP and VAP patients (P = 0.023). The admission Acute Physiology and Chronic Health Evaluation II scores did not differ between the groups (P > 0.90). The patients with VAP had higher Sequential Organ Failure Assessment maximum scores compared with patients with SCAP and HAP (P < 0.001). In an adjusted multivariate logistic regression model, there were no significant differences in odds ratios for hospital mortality between the three pneumonia types. Mortality among the hospital survivors during the 12-month follow-up period was 18% (16/89) in the SCAP group, 35% (18/51) in the HAP group and 41% (7/17) in the VAP group (P = 0.023). CONCLUSION: The type of pneumonia (i.e. SCAP, HAP or VAP) had no significant association with hospital mortality, whereas the SCAP patients had the lowest 1-year mortality.

Improved outcome after trauma care in university-level intensive care units.

BACKGROUND: Centralized trauma care has been shown to be associated with improved patient outcome. We compared the outcomes of trauma patients in relation to the size of the intensive care unit (ICU) using a large Finnish database. METHODS: A national prospectively collected ICU data registry was used for analysis. All adult trauma admissions excluding isolated head trauma and burns registered from July 1999 to December 2006 were analyzed. Data from 22 ICUs were available. The non-university-affiliated units were categorized according to the number of beds and referral population as small, mid size and large. Acute physiology and chronic health evaluation (APACHE II)- and sequential organ failure assessment (SOFA)-adjusted mortalities were compared between the units. RESULTS: There were 2067 trauma admissions that fulfilled the inclusion criteria; 38% were treated in the university hospitals, 26% in large non-teaching ICUs, 20% in mid size ICUs and 15% in small ICUs. The crude hospital mortality was 5.6%, being 4.7% in university ICU and 6.6% in mid size ICU. In two subgroup analyses of severely ill trauma patients with APACHE II points >25 or SOFA score >8 points, respectively, hospital mortality was significantly lower in university ICUs. CONCLUSIONS: University-level hospitals were associated with better outcomes with critically ill trauma patients. These results can be used in planning future organization of trauma patient care in Finland.

Multi-detector computed tomography in critically ill patients.

BACKGROUND: There is a lack of studies showing the overall impact of multi-detector computed tomography (MDCT) on the treatment of critically ill patients in a general intensive care unit (ICU) setting. METHODS: A prospective observational study on the effects of MDCT on the treatment of patients in a 12-bed medical-surgical ICU in a university hospital providing tertiary care. RESULTS: During the 9-month study period, there were 343 admissions with ICU length of stay longer than 48 h. Of these patients, 64 (19%) had had inconclusive findings with other modalities of radiological imaging, and they underwent altogether 82 MDCT examinations. Fifty examinations (61%) resulted in a change of treatment. The changes included 22 surgical interventions, 16 percutaneous or paranasal interventions, 15 changes of antimicrobial therapy, three withdrawals of active treatment, and four other changes of treatment. Eight patients underwent two and one patient underwent three changes of treatment. Twenty examinations (24%) were regarded as otherwise necessary for clinical decision-making, although no change in the treatment was indicated. Twelve examinations (15%) failed to provide any additional information relevant to the patient's treatment. CONCLUSION: Sixty-one percent of the MDCT examinations led to a change of treatment, and 24% of them otherwise contributed to or supported clinical decision-making, suggesting that MDCT examination is helpful in the case of general ICU patients, with inconclusive findings with other imaging modalities.

Incidence of infections in patients with status epilepticus requiring intensive care and effect on resource utilization.

Data from a six-year period were retrospectively retrieved from medical records and an intensive care unit data management system to study the impact of infections on patients with status epilepticus. Out of 161 admitted patients, 33 had a community-acquired infection and 35 acquired an infection during their hospital stay, 10 while in a ward before admission to the intensive care unit and 25 while in an intensive care unit, giving an infection rate of 42% of all admissions (68 patients). The patients with intensive care unit-acquired infection had three times longer stays in the intensive care unit than those without any infection (P<0.001), and they utilized almost four times more nursing resources than those without infections (P<0.001). Furthermore, they were more often sedated with thiopentone infusion, either alone or in combination with other drugs, than the non-infectious patients (80% vs 20%, P <0.001). Both community- and hospital-acquired infections were related to longer intensive care unit stays (P<0.001). The hospital stay of patients with hospital-acquired infection was threefold compared to that of patients without infection (P<0.001), and these patients utilized almost three times more nursing resources than those without any infection (P<0.001). Patients with infections consumed 65.5% of the intensive care unit nursing resources of status epilepticus patients. In conclusion, the infection rate of status epilepticus patients was high and nosocomial infections were associated with more severe illness, treatment escalation, prolonged hospital stay and enhanced resource utilization.

Histopathology of acute acalculous cholecystitis in critically ill patients.

AIMS: To illustrate the histopathological features of acute acalculous cholecystitis (AAC) of critically ill patients and to compare them with those of acute calculous cholecystitis (ACC) and normal gallbladders. METHODS AND RESULTS: We studied 34 gallbladders with AAC and compared them with 28 cases of ACC and 14 normal gallbladders. Histological features were systematically evaluated. Typical features in AAC were bile infiltration, leucocyte margination of blood vessels and lymphatic dilation. Bile infiltration in the gallbladder wall was more common and extended wider and deeper into the muscle layer in AAC compared with ACC. Epithelial degeneration and defects and widespread occurrence of inflammatory cells were typical features in ACC. Necrosis in the muscle layer was also more common and extended wider and deeper in ACC. There were no differences in the occurrence of capillary thromboses, lymphatic follicles or Rokitansky-Aschoff sinuses between the AAC and ACC samples. CONCLUSIONS: There are characteristic differences in histopathology between AAC and ACC, although due to overlap, none appeared to be specific as such for either condition. These results suggest that AAC is largely a manifestation of systemic critical illness, whereas ACC is a local disease of the gallbladder.

Cardiac tamponade and septic shock caused by viral infection in a previously healthy woman.

A previously healthy woman was admitted to hospital after 'flu-like' symptoms for 5 days followed by acute intense abdominal and lower back pain. On admission she was found to be in severe shock and was transferred to the ICU. Echocardiography revealed cardiac tamponade, and pericardiocentesis was performed immediately. Thereafter her cardiovascular state improved, but she developed hypotension with low systemic vascular resistance and required vasoactive treatment for 4 days. Nine days after admission the patient was transferred to the ward, after which she recovered rapidly and completely. The cause of her illness was extensively screened. No underlying disease was found, and all bacterial cultures remained negative. Acute virus infection was confirmed by diagnostic elevations of antibody titers to Influenza A and adenovirus. Adenovirus was also isolated from her bronchoalveolar lavage fluid.

Nursing staff resources in direct patient care: comparison of TISS and ICNSS.

BACKGROUND: The aim was to study the variation in the nursing workload and nursing staff resources in direct patient care. METHODS: Nursing staff resources and the patient-nurse ratio (P/N) were compared between postoperative and mixed-type intensive care units (ICUs) using the Therapeutic Intervention Scoring System (TISS) and the Intensive Care Nursing Scoring System (ICNSS) during a 4-month period. RESULTS: A total of 832 patients were treated. In the postoperative ICU, the mean daily TISS score per nurse was 41.1, corresponding to a P/N of 1:1, and the mean ICNSS score was 33.8, corresponding to a P/N of 1:1.5. In the mixed-type ICU, the mean TISS score per nurse was 34.7, corresponding to a P/N of 2:1, and the mean ICNSS score was 27.7, corresponding to a P/N of 1:1. In the postoperative unit, 50.4% of the patients would have required a 1:1 P/N ratio based on their TISS scores and 47.5% would have required 1.5 or two nurses as estimated by the ICNSS score. In the mixed ICU 57.1% of the patients would have required a P/N ratio of 1:1 based on TISS scores and 61.3% a ratio of 1:1.5 or 1:2 according to the ICNSS score. CONCLUSION: Intensive Care Nursing Scoring System gives additional information about the nursing staff resources and yields a higher number of nurses needed in direct patient care even when TISS scores show the number of nurses to be adequate.

Ropivacaine 1 mg x ml(-1) does not decrease the need for epidural fentanyl after hip replacement surgery.

BACKGROUND: Ropivacaine is a new long-acting local anesthetic. Laboratory trials have demonstrated a synergistic analgesic effect between intrathecal opioids and local anesthetics. We tested the hypothesis that addition of ropivacaine 1 mg x ml(-1) to epidural fentanyl (10 microg x ml(-1)) postoperatively decreases the need for fentanyl, improves the quality of analgesia and decreases the side-effects of fentanyl. METHODS: Forty patients were enrolled in this double-blind, randomized study to receive either fentanyl 10 microg x ml(-1) (group F) alone or fentanyl combined with ropivacaine 1 mg x ml(-1) (group R) for 20 h as an epidural infusion at TH12-L1 or L1-L2 for analgesia after hip replacement surgery. The patients were free to use a patient-controlled epidural analgesia device, which was programmed to infuse 3 ml of the study medication hourly and to allow a 3-ml bolus when needed (maximal hourly dose of fentanyl was 150 microg). The consumption of medication, visual pain scores at rest and on movement, hemodynamic and respiratory parameters, motor and sensory block, nausea, pruritus and sedation were recorded. RESULTS: There were no significant differences between the groups in the total mean fentanyl consumption (1.10+/-0.18 mg in group F, 1.08+/-0.31 mg in group R, 95% CI: -0.14 to 0.19, P = 0.774). The pain scores were similar at rest (median scores < or = 1) and on movement (median scores < or = 3). The adverse effects were similar and of a minor nature, consisting mostly of pruritus and nausea. CONCLUSION: Addition of ropivacaine 1 mg x ml(-1) to epidural fentanyl 10 microg x ml(-1) did not significantly decrease the requirement for fentanyl administered for pain relief after hip replacement surgery.

Use of recombinant human granulocyte-colony stimulating factor in colorectal surgery.

The purpose of the current study was to assess the effects and safety of administering perioperative recombinant human granulocyte colony-stimulating factor (r-metHuG-CSF, Filgrastim; Roche, Switzerland) to patients undergoing elective colorectal surgery. Thirty consecutive patients were prospectively randomized to receive either r-metHuG-CSF or placebo. Treatment with r-metHuG-CSF induced transient leukocytosis with shift to the left. The phagocytic or killing capacities of neutrophils were not altered in the patients treated with r-metHuG-CSF, but there was a decline in neutrophil chemotaxis. There were no serious adverse events associated with r-metHuG-CSF treatment. Thus, perioperative r-metHuG-CSF is safe for patients undergoing colorectal surgery. The presence of an increased number of functioning neutrophils may offer advantages in combating imminent infection.