Long-term outcome and health-related quality of life in difficult-to-wean patients with and without ventilator dependency at ICU discharge: a retrospective cohort study.

BACKGROUND: Long-term outcome and quality of life (QOL) in patients requiring prolonged mechanical ventilation after failure to wean in the ICU is scarcely documented. We aimed to evaluate long-term survival and QOL in patients discharged from the ICU with a tracheostomy for difficult weaning, and with or without ventilator dependency at ICU discharge. METHODS: We retrospectively investigated post-ICU trajectories and survival in patients requiring tracheostomy for difficult weaning admitted to the medical ICU of a tertiary center between 1999 and 2013, discriminating between patients who were ventilator dependent or were weaned at ICU discharge. In 2014, a QOL assessment was done in survivors with the use of the Short Form Health Survey (SF-36) and the Severe Respiratory Insufficiency questionnaire. RESULTS: A total of 114 patients was included, of whom 59 were ventilator dependent and 55 were weaned at ICU discharge. One-year survival rates were 73 % and 69 %, respectively. Overall QOL scores for physical functioning were low, and not significantly different between patients ventilated and those weaned at ICU discharge; scores for social functioning and mental health were less below norm and similar between both groups. CONCLUSIONS: Long-term survival in patients discharged from the ICU with tracheostomy and ventilator dependency after failure to wean was not significantly different from that of patients with tracheostomy and weaned at ICU discharge. Despite the physical QOL scores being low in both groups, mental QOL was acceptable. Given the intrinsic limitations of this retrospective study, prospective and preferentially multicenter studies are required to confirm these preliminary results.

Long-term outcomes and quality of life in critically ill patients with hematological or solid malignancies: a single center study.

PURPOSE: Data concerning long-term outcomes and quality of life (QOL) in critically ill cancer patients are scarce. The aims of this study were to assess long-term outcomes and QOL in critically ill patients with hematological (HM) or solid malignancies (SM) 3 months and 1 year after intensive care unit (ICU) discharge, to compare these with QOL before ICU admission, and to identify prognostic indicators of long-term QOL. METHODS: During a 1 year prospective observational cohort analysis, consecutive patients with HM or SM admitted to the medical or surgical ICU of a university hospital were screened for inclusion. Cancer data, demographics, co-morbidity, severity of illness, organ failures, and outcomes were collected. The QOL before ICU admission, 3 months, and 1 year after ICU discharge was assessed using standardized questionnaires (EuroQoL-5D, Medical Outcomes Study 36-item Short Form Health Survey). Statistical significance was attained at P < 0.05. RESULTS: There were 483 patients (85 HM, 398 SM) (64% men) with a median age of 62 years included. Mortality rates of HM compared to SM were, respectively: hospital (34 vs. 13%), 3 months (42 vs. 17%), and 1 year (66 vs. 36%) (P < 0.001). QOL declined at 3 months, but improved at 1 year although it remained under baseline QOL, particularly in HM. Older age (P = 0.007), severe comorbidity (P = 0.035), and HM (P = 0.041) were independently associated with poorer QOL at 1 year. CONCLUSIONS: Long-term outcomes and QOL were poor, particularly in HM. Long-term expectations should play a larger role during multidisciplinary triage decisions upon referral to the ICU.

A 50-year-old man with severe hypercalcemia: a case report.

OBJECTIVE: We present this case to emphasize the importance of early diagnosis and treatment of an acute severe hypercalcemic syndrome due to primary hyperparathyroidism as a consequence of an undiagnosed adenoma of the parathyroid gland. CASE REPORT: A 50-year-old man presented at another hospital with non-specific symptoms such as anorexia, nausea, vomiting, polyuria, dehydration, abdominal pain, weight loss, fatigue, muscular weakness, irritability and lethargy. Serum levels of calcium and parathyroid hormone (PTH) were markedly increased to 23.6 mg/dL (reference values 8.6-10.2 mg/dL) and > 1900 ng/L (reference values 14-72 ng/L) respectively. After initial treatment, the patient was transferred to the intensive care unit (ICU) of a tertiary care university hospital for further stabilization and treatment because the typical signs of hypercalcemia were not resolving. A parathyroid adenoma was diagnosed and a few days later a parathyroidectomy was performed. The postoperative course was uneventful and the patient could be discharged from the hospital in a good general condition. CONCLUSION: Acute primary hyperparathyroidism, also known as parathyroid storm or parathyroid crisis, is a rare but potentially fatal endocrine emergency if unrecognized and untreated. Appropriate diagnosis and immediate adequate management of hypercalcemia are important in reducing mortality. Nevertheless, mortality remains high, even with surgical treatment which is the cornerstone of the definitive therapy.

Hyperglycaemia upon onset of ICU-acquired bloodstream infection is associated with adverse outcome in a mixed ICU population.

This study aimed to assess whether a relationship exists between hyperglycaemia and outcome in a mixed cohort of critically ill patients with nosocomial bloodstream infection (BSI), and to evaluate patterns of blood glucose levels between survivors and non-survivors. A historical observational cohort study was conducted in the intensive care unit (ICU) of a tertiary care referral centre. One-hundred-and-thirty patients with a microbiologically documented ICU-acquired BSI (period 2003 to 2004) were included. For the study, morning blood glucose levels were evaluated from one day prior until five days after onset of BSI. The contribution of hyperglycaemia, divided in three subgroups (> or = 150 mg/dl, > or = 175 mg/dl and > or = 200 mg/dl), to in-hospital mortality was estimated by logistic regression. In-hospital mortality was 36.2%. Over the seven study days, no differences were found in daily morning blood glucose levels between survivors (n = 83) and non-survivors (n = 47). Nevertheless, the trend of blood glucose levels upon onset of BSI showed a remarkable increase in the non-survivors, whereas it decreased in the survivors. Hyperglycaemia (> or = 175 mg/dl and > or = 200 mg/dl) was observed more often among the non-survivors. Multivariate logistic regression showed that APACHE II (P = 0.002), antibiotic resistance (P = 0.004) and hyperglycaemia (> or = 175 mg/dl) upon onset of BSI (P = 0.017) were independently associated with in-hospital mortality, whereas a history of diabetes (P = 0.041) was associated with better outcome. Hyperglycaemia (> or = 175 mg/dl) upon onset of ICU-acquired BSI is associated with worse outcome in a heterogeneous ICU population. Patterns of morning blood glucose levels have only limited value in the prediction of the individual course.

Long-term outcome after acute kidney injury in critically-ill patients.

Assessment of short-term outcome in critically-ill patients who develop acute kidney injury (AKI) may underestimate the true burden of disease. It is important to focus on long-term survival, renal recovery and quality of life beyond hospital discharge. Although the majority of critically-ill patients with AKI die during hospital stay, there is only a minor increase in mortality after hospital discharge among AKI patients treated in the intensive care unit (ICU). Estimates of mortality rates at 1 year following hospital discharge range from 57% to 78% with an absolute difference between hospital mortality and 1-year mortality ranging from 4% to 18%. Renal recovery is another important measure of outcome since chronic renal replacement therapy (RRT) does not only significantly affect health-related quality of life (HRQoL), it is also costly. Fortunately, renal recovery occurs in most AKI survivors leading to independence of RRT at 1 year following hospital discharge. Potential factors associated with reduced recovery of renal function are female sex, high comorbidity, older age, a parenchymal aetiology of AKI, late initiation of RRT, and use of intermittent haemodialysis (IHD). HRQoL in survivors of critical illness and severe AKI is perceived as acceptable and good, despite the fact that HRQoL scores are lower than these of the general population.

Acute kidney injury, length of stay, and costs in patients hospitalized in the intensive care unit.

Acute kidney injury (AKI) in patients hospitalized in the intensive care unit (ICU) results in increased morbidity, mortality, and as a consequence, higher health-care costs. The bad prognosis associated with this condition and limited health-care budgets both have raised the issue of how much therapy should be dedicated to ICU patients with AKI. As no universally-agreed standardized definition for AKI is available, wide ranges of incidence are reported and precise estimates of its associated excess of costs are, therefore, difficult to explore. Nonetheless, significantly prolonged hospital length of stay (LOS) and higher costs in ICU patients whose course was complicated with AKI are reported. Moreover, among survivors, even greater requirements of in-hospital and post-hospitalization care was noted. Notwithstanding the high health-economic burden, full supportive intensive care treatment is justified in this particular cohort of patients. Major efforts are highly required in terms of public health prevention initiatives and the early recognition and timely management of AKI, in ICU hospitalized patients in particular.