Health-related quality of life of long-term survivors of intensive care: changes after intensive care treatment. Experience of an Austrian intensive care unit.

OBJECTIVE: The aim of the study was to determine if health-related quality of life of long-term survivors changes 24 months after intensive care treatment compared to the quality of life before admission. METHODS: From 281 patients treated at the ICU in 2001, 132 survivors were contacted by phone on average 24 months after discharge. Fernandez questionnaire was used to assess preadmission quality of life prospectively and postdischarge quality of life, retrospectively. In addition, age, sex, admission diagnosis, ICU length of stay, presence of organ failure, and necessity of mechanical ventilation were determined. RESULTS: In the 101 ICU survivors who responded to the questionnaire, the total score of quality of life did not change significantly over time (5.48 ± 5.3 before admission vs. 5.6 ± 5.8 at follow-up; p = 0.9). Similarly, the performance of normal daily activities did not alter (3.0 ± 3.5 vs. 3.39 ± 3.6; p = 0,3). In contrast, the ability to perform basic physiological activities worsened significantly (0.39 ± 0.76 vs. 0.76 ± 1.52; p = 0.037), whereas the emotional state improved significantly after intensive care treatment (2.08 ± 1.78 vs. 1.46 ± 1.56, p = 0.003). In a stepwise multiple regression analysis the total score of quality of life before admission was the only variable which influenced the quality of life 2 years after ICU-stay. CONCLUSIONS: In the interviewed population the total score of health-related quality of life did not change after intensive care treatment. Surprisingly, emotional state improved significantly although physical performance decreased. Quality of life after ICU discharge was predominantly influenced by preadmission quality of life. However, these results are not reflective of all ICU survivors.

Severity of insulin resistance in critically ill medical patients.

Critical illness is characterized by a hypermetabolic state associated with increased mortality, which is partly ascribed to the occurrence of hyperglycemia caused by enhanced endogenous glucose production and insulin resistance (IR). Insulin resistance is well described in patients after surgery and trauma. However, it is less clearly quantified in critically ill medical patients. In this clinical cohort study, IR (M value) was quantified in 40 critically ill medical patients and 25 matched, healthy controls by isoglycemic hyperinsulinemic clamps after an overnight fast on the day after admission to a medical intensive care unit. Energy and substrate metabolism were measured by using indirect calorimetry in the patients before and during the clamp. The severity of illness was assessed by the acute physiology and chronic health evaluation (APACHE) III score. M values of critically ill medical patients were significantly lower compared with healthy controls (2.29 +/- 1.0 and 7.6 +/- 2.9 mg/kg per minute, respectively; P < .001) and were closely related to APACHE III scores (r = -0.43, P < .01), body mass index (r = -0.41, P < .01), and resting energy expenditure (r = 0.40, P < .05). The M value was not associated with age, basal glucose concentrations, and respiratory quotient, and it did not differ among patients with various admission diagnoses. In conclusion, insulin sensitivity was found to be reduced by 70% in critically ill medical patients. The severity of IR was associated with the severity of illness, body mass index, and resting energy expenditure, but not with substrate oxidation rates. In addition, the severity of IR did not vary among patients with different admission diagnoses.

Metabolic inefficacy of a short-term low-dose insulin regimen in critically ill patients: a randomized, placebo-controlled trial.

OBJECTIVE: Hyperglycemia and protein catabolism frequently occur in critically ill patients and both are associated with increased complication rates. These metabolic alterations can be improved by insulin administered exogenously. Since a wide range of insulin dosages have been used, this randomized, placebo-controlled, investigator-blinded, clinical study tests the hypothesis that a low-dose insulin regimen improves hyperglycemia and protein catabolism in critically ill medical patients. PATIENTS AND METHODS: The day after their admission to a medical intensive care unit, forty consecutive, critically ill medical patients were randomized for receiving either a low-dose insulin regimen (i.e. 1 IU/h) (treatment group, n = 20) or placebo (control group, n = 20) continuously over 24 hours. The primary endpoint was the efficacy of the low-dose insulin regimen to decrease serum glucose concentrations; the secondary endpoint was its influence on protein catabolism. Serum glucose concentrations and protein catabolism, which was assessed by the urea nitrogen appearance rate, were determined at baseline and at 8 and 24 hours thereafter. Serum insulin concentrations were measured at baseline and after 24 hours. RESULTS: After 24 hours the low-dose insulin regimen increased serum insulin concentrations compared with baseline (16.8+/-13.3 microU/ml and 11.5+/-16.9 microU/ml, respectively; p<0.05). Hyperglycemia and the urea nitrogen appearance rate did not change within the two groups of patients and there was no difference between the groups at the different time points. CONCLUSIONS: Administration of the low-dose insulin regimen was safe. However, the short-term low-dose insulin regimen was inefficient in influencing mild hyperglycemia and protein catabolism in critically ill medical patients.

Single-dose pharmacokinetics of ofloxacin during continuous venovenous hemofiltration in critical care patients.

BACKGROUND: Ofloxacin is a quinolone administered to patients with severe infections. Pharmacokinetic data on ofloxacin in critically ill patients on renal replacement therapy are sparse and conflicting. METHODS: Eight patients with anuric acute renal failure were administered 400 mg of ofloxacin intravenously. The pharmacokinetics of ofloxacin was analyzed during continuous venovenous hemofiltration (CVVH) with a high-flux polysulfone membrane. Serum and ultrafiltrate levels of ofloxacin were measured by means of high-performance liquid chromatography. RESULTS: Mean serum ofloxacin concentration peak was 5.5 +/- 0.7 mg/L. Elimination half-life, hemofiltration clearance, and total removal were 2.8 +/- 0.5 hours, 89.9 +/- 4.5 mL/min, and 76.9% +/- 7.1%, respectively. CONCLUSION: Ofloxacin is significantly and rapidly eliminated by CVVH with a high-flux polysulfone membrane.

Impaired subcortical and cortical sensory evoked potential pathways in septic patients.

OBJECTIVE: Sensory evoked potential (SEP) peak latencies were recorded in order to evaluate the incidence and severity of septic encephalopathy, testing the hypothesis that the occurrence of septic encephalopathy is more frequent than generally assumed. DESIGN: Prospective cohort study. SETTING: Medical intensive care unit of a university hospital. PATIENTS: Sixty-eight critically ill patients were studied within 48 hrs after the development of severe sepsis (n = 41) or septic shock (n = 27). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Septic encephalopathy was defined as prolongation of SEP peak latencies beyond the upper limit of the reference range of subcortical (N13-N20 interpeak latency) and cortical SEP pathways (N20-N70 interpeak latency), as well as asymmetry of peak latencies marked by the presence of subclinical cerebral focal signs. Subcortical SEP pathways were impaired in 34% and cortical SEP pathways in 84% of all patients. The prolongation of the cortical SEP pathway correlated with the Acute Physiology and Chronic Health Evaluation III score (r = 0.23; p <.0001). SEP peak latencies did not differ in patients with severe sepsis compared with those with septic shock. Subclinical cerebral focal signs were present in 24% of the subcortical SEP pathways and in 6% of the cortical SEP pathways. CONCLUSIONS: Septic encephalopathy occurs more frequently than generally assumed, and its severity is associated with the severity of illness. The impairment of subcortical and cortical SEP pathways was not different between patients with severe sepsis and those with septic shock.

Clearance of ceftazidime during continuous venovenous haemofiltration in critically ill patients.

Published recommendations for the optimal dosing regimen of ceftazidime in critically ill patients with continuous venovenous haemofiltration (CVVH) differ. The aim of this prospective study was to analyse the pharmacokinetic and pharmacodynamic parameters of ceftazidime during CVVH with a high-flux polysulphone membrane, and derive a dosage recommendation. Twelve critically ill patients (five female, seven male) with acute renal failure undergoing CVVH using a 0.7 m(2) polysulphone high-flux membrane were investigated. All patients received ceftazidime 2 g i.v. q8h. Peak ceftazidime concentrations were 58.2 +/- 11.6 mg/L, with trough concentrations 14.0 +/- 3.2 mg/L at the arterial port. The elimination half-life, haemofiltration clearance, volume of distribution and total removal were 4.3 +/- 0.6 h, 32.1 +/- 7.9 mL/min, 36.4 +/- 6.4 L and 74.5 +/- 6.5%, respectively. Based on these pharmacokinetic parameters and that maximal killing is at 4 x MIC we recommend at least ceftazidime 2 g i.v. q8h.