Witnessed out-of-hospital cardiac arrest- effects of emergency dispatch recognition.

BACKGROUND: Survival from an out-of-hospital cardiac arrest (OHCA) depends on the sequence of interventions in "the chain of survival". If OHCA is recognized in the emergency medical communication centre (EMCC), the proper emergency medical service (EMS) should be dispatched and cardiopulmonary resuscitation (CPR) instructions should be given to a bystander. The study aimed to examine the impact of OHCA recognition in the EMCC on survival rates and the main elements of the chain of survival. METHODS: Data from the Helsinki University Hospital's registry of OHCA patients between 1997 and 2013 were studied. Altogether, 2054 EMCC-handled and bystander-witnessed OHCA proven events of cardiac origin were analysed. RESULTS: In 80.5% of the victims, two EMS units were correctly dispatched and the OHCA was classified as recognized. Achieved return of spontaneous circulation (ROSC) and survival to hospital discharge were 49% and 23%, respectively, if cardiac arrest was recognized by the EMCC and 40% and 16% when it was not (P = 0.003 and 0.002). Dispatchers gave CPR instructions in 60% of the recognized OHCA cases. Bystander-performed CPR increased over time and was given in 58% of the recognized OHCAs and also in 17% of the unrecognized events. EMS delays were shorter if OHCA was recognized as opposed to unrecognized (8 min with an IQR 6.5-10 min vs. 9 min with an IQR 6.5-11 min; P = 0.001). CONCLUSIONS: Recognition of OHCA by the EMCC was significantly associated with an increased rate of bystander-performed CPR, reduced EMS response time, and increased OHCA patient ROSC and survival rates.

Assessment of plasma endostatin to predict acute kidney injury in critically ill patients.

BACKGROUND: We evaluated whether plasma endostatin predicts acute kidney injury (AKI), need for renal replacement therapy (RRT), or death. METHODS: Prospective, observational, multicenter study from 1 September 2011 to 1 February 2012 with data from 17 intensive care units (ICUs) in Finland. RESULTS: A total of 1112 patients were analyzed. We measured plasma endostatin within 2 h of ICU admission. Early AKI (KDIGO stage within 12 h of ICU admission) was found in 20% of the cohort, and 18% developed late AKI (KDIGO criteria > 12 h from ICU admission). Median (IQR) admission endostatin was higher in the early AKI group, 29 (19.1, 41.9) ng/ml as compared to 22.4 (16.1, 30.1) ng/ml for the late AKI group, and 18 (14.0, 23.6) ng/ml for non-AKI patients (P < 0.001). Endostatin level increased with increasing KDIGO stage. Significantly higher endostatin levels were found in patients with sepsis as compared to those without. Predictive properties for AKI, RRT, and mortality were low with corresponding areas under the receiver operating characteristic curve (AUC) of 0.62, 0.67, and 0.59. Sensitivity analyses among patients with chronic kidney disease or sepsis did not improve the predictive ability of endostatin. Adding endostatin to a clinical AKI prediction model (illness severity score, urine output, and age) insignificantly changed the AUC from 0.67 to 0.70 (P = 0.14). CONCLUSIONS: Endostatin increases with AKI severity but has limited value as a predictor of AKI, RRT and 90-day mortality in patients admitted to ICU. Moreover, endostatin does not improve AKI risk prediction when added to a clinical risk model.

Association of automated data collection and data completeness with outcomes of intensive care. A new customised model for outcome prediction.

BACKGROUND: The Finnish Intensive Care Consortium coordinates a national intensive care benchmarking programme. Clinical information systems (CISs) that collect data automatically are widely used. The aim of this study was to explore whether the severity of illness-adjusted hospital mortality of Finnish intensive care unit (ICU) patients has changed in recent years and whether the changes reflect genuine improvements in the quality of care or are explained by changes in measuring severity of illness. METHODS: We retrospectively analysed data collected prospectively to the database of the Consortium. During the years 2001-2008, there were 116,065 admissions to the participating ICUs. We excluded readmissions, cardiac surgery patients, patients under 18 years of age and those discharged from an ICU to another hospital's ICU. The study population comprised 85,547 patients. The Simplified Acute Physiology Score II (SAPS II) was used to measure severity of illness and to calculate standardised mortality ratios (SMRs, the number of observed deaths divided by the number of expected deaths). RESULTS: The overall hospital mortality rate was 18.4%. The SAPS II-based SMRs were 0.74 in 2001-2004 and 0.64 in 2005-2008. The severity of illness-adjusted odds of death were 24% lower in 2005-2008 than in 2001-2004. One fifth of this computational difference could be explained by differences in data completeness and the automation of data collection with a CIS. CONCLUSION: The use of a CIS and improving data completeness do decrease severity-adjusted mortality rates. However, this explains only one fifth of the improvement in measured outcomes of intensive care in Finland.

Nationwide survey of resuscitation education in Finland.

AIMS: Good-quality cardiopulmonary resuscitation (CPR) is highlighted in the International Resuscitation Guidelines, but clinically the quality of CPR is often poor. Education of CPR has a major role in the primary skills imparted to students. Different methods can be used to teach CPR quality. We evaluated the current status of their usage in Finland institutes teaching students of emergency medicine at different levels. METHODS: The following institutes were included in an anonymous survey: medical schools (teaching future physicians), universities of applied sciences (paramedics), colleges (emergency medical technicians) and emergency services college (fire-fighters). Hours of teaching theory lessons of CPR and hours of small group training were evaluated. In particular, we focussed on the teaching methods for adequate chest compression rate and depth. RESULTS: Twenty-one of 30 institutes responded to the questionnaire. The median for hours of theory lessons of CPR was 8h (range: 2-28 h). The median for hours of small group training was 10 (range: 3-40 h). The methods of teaching adequate chest compression rate were instructors' visual estimation in 28.5% of the institutions, watch in 33.3%, metronome in 9.5% and manikins' graphic in 28.5% of institutions. The methods of teaching adequate chest compression depth were instructors' visual estimation in 33.3%, in manikins light indicators in 23.8% and manikins' graphics in 52.3% of institutions. CONCLUSION: The hours of theoretic lessons and small group training vary widely among different institutes. In one-third of institutions, the instructor's visual estimation was a sole method used to teach adequate chest compression rate and depth. Different technical methods were surprisingly seldom used.

Quality of cardiopulmonary resuscitation on manikins: on the floor and in the bed.

BACKGROUND: In general, in-hospital resuscitation is performed in a bed and out-of-hospital resuscitation on the floor. The surface under the patient may affect the cardiopulmonary resuscitation (CPR) quality; therefore, we evaluated CPR quality (the percentage of chest compressions of correct depth) and rescuer's fatigue (the mean compression depth minute by minute) when CPR is performed on a manikin on the floor or in the bed. METHODS: Forty-four simulated cardiac arrest scenarios of 10 min were treated by intensive care unit (ICU) nurses in pairs using a 30 : 2 chest compression-to-ventilation ratio. The rescuer who performed the compressions was changed every 2 min. CPR was randomly performed either on the floor or in the bed without a backboard; in both settings, participants kneeled beside the manikin. RESULTS: A total number of 1060 chest compressions, 44% with correct depth, were performed on the floor; 1068 chest compressions were performed in the bed, and 58% of these were the correct depth. These differences were not significant between groups. The mean compression depth during the scenario was 44.9+/-6.2 mm (mean+/-SD) on the floor and 43.0+/-5.9 mm in the bed (P=0.3). The mean chest compression depth decreased over time on both surfaces (P<0.001), indicating rescuer fatigue, but this change was not different between the groups (P=0.305). CONCLUSIONS: ICU nurses perform chest compression as effectively on the floor as in the bed. The mean chest compression depth decreases over time, but the surface had no significant effect.

Influence of chest compression rate guidance on the quality of cardiopulmonary resuscitation performed on manikins.

AIMS: The adequate chest compression rate during CPR is associated with improved haemodynamics and primary survival. To explore whether the use of a metronome would affect also chest compression depth beside the rate, we evaluated CPR quality using a metronome in a simulated CPR scenario. METHODS: Forty-four experienced intensive care unit nurses participated in two-rescuer basic life support given to manikins in 10min scenarios. The target chest compression to ventilation ratio was 30:2 performed with bag and mask ventilation. The rescuer performing the compressions was changed every 2min. CPR was performed first without and then with a metronome that beeped 100 times per minute. The quality of CPR was analysed with manikin software. The effect of rescuer fatigue on CPR quality was analysed separately. RESULTS: The mean compression rate between ventilation pauses was 137+/-18compressions per minute (cpm) without and 98+/-2cpm with metronome guidance (p<0.001). The mean number of chest compressions actually performed was 104+/-12cpm without and 79+/-3cpm with the metronome (p<0.001). The mean compression depth during the scenario was 46.9+/-7.7mm without and 43.2+/-6.3mm with metronome guidance (p=0.09). The total number of chest compressions performed was 1022 without metronome guidance, 42% at the correct depth; and 780 with metronome guidance, 61% at the correct depth (p=0.09 for difference for percentage of compression with correct depth). CONCLUSIONS: Metronome guidance corrected chest compression rates for each compression cycle to within guideline recommendations, but did not affect chest compression quality or rescuer fatigue.

The effects of changes to the ERC resuscitation guidelines on no flow time and cardiopulmonary resuscitation quality: a randomised controlled study on manikins.

AIM OF THE STUDY: The European Resuscitation Council (ERC) guidelines changed in 2005. We investigated the impact of these changes on no flow time and on the quality of cardiopulmonary resuscitation (CPR). MATERIALS AND METHODS: Simulated cardiac arrest (CA) scenarios were managed randomly in manikins using ERC 2000 or 2005 guidelines. Pairs of paramedics/paramedic students treated 34 scenarios with 10min of continuous ventricular fibrillation. The rhythm was analysed and defibrillation shocks were delivered with a semi-automatic defibrillator, and breathing was assisted with a bag-valve-mask; no intravenous medication was given. Time factors related to human intervention and time factors related to device, rhythm analysis, charging and defibrillation were analysed for their contribution to no flow time (time without chest compression). Chest compression quality was also analysed. RESULTS: No flow time (mean+/-S.D.) was 66+/-3% of CA time with ERC 2000 and 32+/-4% with ERC 2005 guidelines (P<0.001). Human factor interventions occupied 114+/-4s (ERC 2000) versus 107+/-4s (ERC 2005) during 600-s scenarios (P=0.237). Device factor interventions took longer using ERC 2000 guidelines: 290+/-19s versus 92+/-15s (P<0.001). The total number of chest compressions was higher with ERC 2005 guidelines (808+/-92s versus 458+/-90s, P<0.001), but the quality of CPR did not differ between the groups. CONCLUSIONS: The use of a single shock sequence with guidelines 2005 has decreased the no flow time during CPR when compared with guidelines 2000 with multiple shocks.

Intensive care of the elderly in Finland.

BACKGROUND: The ageing of the population will increase the demand for health care resources. The aim of this study was to determine how age affects resource consumption and outcome of intensive care in Finland. METHODS: Data on 79,361 admissions to 26 Finnish intensive care units (ICUs) during the years 1998-2004 were analysed. The severity of illness was measured using Simplified Acute Physiology II scores and the intensity of care using Therapeutic Intervention Scoring System scores. RESULTS: The median age was 62 years; 8.9% of patients were aged 80 years or over. The hospital mortality rate was 16.2% in the overall patient population, but 28.4% in patients aged 80 years or over. Old age was an independent risk factor for hospital mortality. The mean intensity of care was at its highest in the age groups 60-69, 70-74 and 75-79 years. It was notably lower for patients aged 80 years or over. If the need for intensive care remains unchanged in each age group, the change in the age distribution of the Finnish population will increase the demand for ICU beds by 19% by the year 2020 and by 25% by the year 2030. CONCLUSION: The hospital mortality rate increases with increasing age. The mean intensity of care is lower for the oldest patients than for patients aged less than 80 years. The ageing of the population will probably cause a remarkable increase in the need for intensive care in the near future.

Propofol causes more hypotension than etomidate in patients with severe aortic stenosis: a double-blind, randomized study comparing propofol and etomidate.

BACKGROUND: Vasodilatation and hypotension are thought to be harmful in patients with severe aortic stenosis. Etomidate is preferred to propofol for anaesthesia induction in haemodynamically unstable patients, but may disturb cortisol synthesis. We assessed the haemodynamic effects of etomidate vs. propofol as anaesthesia induction agents, and the effects of these drugs on cortisol concentrations, in patients with severe aortic stenosis. The main end-point of the study was the incidence of hypotension. METHODS: Sixty-six patients with severe aortic stenosis scheduled for elective aortic valve replacement were enrolled in the study. The patients were randomized to receive either propofol or etomidate for induction of anaesthesia. Haemodynamic parameters, i.e. mean arterial pressure (MAP), pulmonary capillary wedge pressure (PCWP) and cardiac index (CI), were measured. If MAP decreased below 70 mmHg for more than 30 s, phenylephedrine was administered. Serum cortisol concentrations were also measured. RESULTS: MAP decreased in all patients (P < 0.001). MAP decreased to a greater extent in patients receiving propofol than in those receiving etomidate (P = 0.006). Patients receiving propofol needed phenylephedrine more often than those receiving etomidate (20/30 vs. 8/30, P = 0.002). CI and PCWP decreased in both groups (P < 0.001), with no difference between the groups. Patients receiving etomidate had a lower serum cortisol concentration immediately after the operation than those receiving propofol (P < 0.001), but no differences between the groups were observed on the first post-operative morning. CONCLUSION: Propofol is twice as likely as etomidate to evoke hypotension in anaesthesia induction of patients with severe aortic stenosis; however, etomidate transiently decreases post-operative serum cortisol concentrations.

Excess mortality in winter in Finnish intensive care.

BACKGROUND: In the general population, mortality from acute myocardial infarctions, strokes and respiratory causes is increased in winter. The winter climate in Finland is harsh. The aim of this study was to find out whether there are seasonal variations in mortality rates in Finnish intensive care units (ICUs). METHODS: We analysed data on 31,040 patients treated in 18 Finnish ICUs. We measured severity of illness with acute physiology and chronic health evaluation II (APACHE II) scores and intensity of care with therapeutic intervention scoring system (TISS) scores. We assessed mortality rates in different months and seasons and used logistic regression analysis to test the independent effect of various seasons on hospital mortality. We defined 'winter' as the period from December to February, inclusive. RESULTS: The crude hospital mortality rate was 17.9% in winter and 16.4% in non-winter, P = 0.003. Even after adjustment for case mix, winter season was an independent risk factor for increased hospital mortality (adjusted odds ratio 1.13, 95% confidence interval 1.04-1.22, P = 0.005). In particular, the risk of respiratory failure was increased in winter. Crude hospital mortality was increased during the main holiday season in July. However, the severity of illness-adjusted risk of death was not higher in July than in other months. An increase in the mean daily TISS score was an independent predictor of increased hospital mortality. CONCLUSION: Severity of illness-adjusted hospital mortality for Finnish ICU patients is higher in winter than in other seasons.

Red blood cell and tissue water content in experimental thermal injury.

UNLABELLED: Oedema formation and changes in local blood flow are known phenomena in burns. The relationship between these two is not clearly described. The aim of this study was firstly to examine both the contents of red blood cells and tissue water in skin and subcutaneous fat after experimental burns of different depths in pigs, and secondly, to confirm our recent findings of the increased dielectric constant of skin and subcutaneous fat reflecting considerable oedema formation, especially in fat after thermal injury. METHODS: Superficial, partial and full thickness contact burns were created to pigs and followed for 24h. Radioactive Cr-51 labelling of red cells was used to estimate the number of red cells in tissue, and the absolute amount of water was determined by lyophilization. RESULTS: A decreased number of labelled red cells in skin and an increase in tissue water in subcutaneous fat were found regardless of burn depth. The highest water amount in fat was found in the partial thickness burns. CONCLUSION: All burn depths resulted in a diminished number of labelled red blood cells in skin and a significant increase in the absolute water amount in subcutaneous fat at 24h post injury. The findings in fat support our recent findings of highly elevated dielectric constants measured by the new in vivo method of dielectric measurements.

The proportion of intensive care unit admissions related to alcohol use: a prospective cohort study.

BACKGROUND: Alcohol abuse is a risk factor for serious illnesses, and a history of chronic alcohol abuse adversely affects the outcome of critically ill patients. It is not known what proportion of intensive care unit (ICU) admissions is related to alcohol use. Therefore, we investigated the proportion of emergency admissions related to alcohol. METHODS: A prospective cohort study was conducted in a university hospital ICU. All adult patients (n = 893) who underwent emergency admission to our ICU during a period of 1 year were studied. RESULTS: The admitting physician determined whether there was a relationship between alcohol use and admission. ICU and hospital mortality and ICU length of stay (LOS) were recorded. The Therapeutic Intervention Scoring System (TISS) was used for ICU resource use estimation. There was a relationship between alcohol use and admission in 24% (215/893) of admissions and, in 156/893 admissions (17.5%), this seemed to be definite. ICU LOS was 1.2 days (0.7; 2.3) (median; interquartile range) for alcohol-related and 1.8 days (0.9; 3.6) for other admissions (P < 0.001). Patients with alcohol-related admissions consumed 17.8% of ICU patient-days and 18.7% of all accumulated TISS scores. ICU (8.8 vs. 10.5%, P = 0.603) and hospital (19.1 vs. 20.2%, P = 0.769) mortalities were no different between alcohol-related and other admissions. CONCLUSION: ICU admission is very often related to long-term chronic and/or occasional alcohol use.

Impact of gender on treatment and outcome of ICU patients.

BACKGROUND: Gender modifies immunologic responses caused by severe trauma or critical illness. The aim of this study was to investigate the impact of gender on hospital mortality, length of intensive care unit (ICU) stay, and intensity of care of patients treated in ICUs. METHODS: Data on 24,341 ICU patients were collected from a national database. We measured severity of illness with Acute Physiology and Chronic Health Evaluation II (APACHE II) scores and intensity of care with Therapeutic Intervention Scoring System (TISS) scores. We used logistic regression analysis to test the independent effect of gender on hospital mortality. We compared the lengths of ICU stay and the intensity of care of men and women. RESULTS: Male gender was associated with increased hospital mortality among postoperative ICU patients [adjusted odds ratio 1.33 (95% confidence interval 1.12-1.58, P = 0.001)] but not among medical patients [adjusted odds ratio 1.02 (95% confidence interval 0.92-1.13, P = 0.74)]. Male gender was associated with an increased risk of death particularly in the oldest age group (75 years or older) and among the patients with relatively low APACHE II scores (<16). Mean length of ICU stay was 3.2 days for men and 2.6 days for women (P < 0.001). Male patients comprised 61.7% of the study population but consumed 66.0% of days in intensive care. CONCLUSION: Male gender contributes to poor outcome in postoperative ICU patients. Approximately two-thirds of ICU resources are consumed by male patients.

Microdialysis for detection of dynamic changes in tissue histamine levels in experimental thermal injury.

Histamine is an important mediator contributing to oedema formation after thermal injury. Tissue histamine concentrations have been previously determined by analyzing tissue biopsies. The microdialysis method enables continuous collection of samples from the extracellular tissue fluid. In this experimental burn study on pigs samples from the extracellular fluid for histamine analysis were collected from superficial, partial thickness and full thickness burn sites during a 24-h period. There was a burn depth-related increase in histamine concentrations during the first 2 h post injury. Deep burns induced a more profound initial increase in tissue histamine concentration than the partial thickness and superficial burns. Histamine concentrations at all burn sites declined until 12 h post injury. There was a second rise in tissue histamine concentrations between 12 and 24 h post injury without a rise in plasma histamine concentrations. Histamine concentrations at all burn sites were higher than at the non-burned control sites. The microdialysis technique is an easily applicable method of collecting on-line samples from burned tissue. This method provides a useful tool in investigating the effects of different treatment modalities on the secretion of substances into interstitial fluid within burned tissue.

Lack of effect of ranitidine on gastric luminal pH and mucosal PCO2 during the first day in the ICU.

BACKGROUND: Histamine(2) (H(2))-blocking agents can attenuate intragastric CO(2)-production by reducing gastric acid secretion and preventing the interaction between H(+) and bicarbonate. However, gastric acid production may be impaired in acute circulatory failure due to poor mucosal perfusion, and H(2)-blockade could further impair mucosal perfusion. METHODS: Forty patients with acute circulatory and/or respiratory failure, age 61 +/- 16 years (mean +/- SD), APACHE II score 21 +/- 7, and SOFA score 8 +/- 3, received randomly either ranitidine, 50 mg (R) or placebo (P) every 8 h. Gastric intraluminal pH (gpH; antimony probe with external reference electrode) and mucosal pCO(2) (prCO(2), semicontinuous air-tonometry) were measured during 24 h, and blood gases were taken at 6-h intervals. RESULTS: Gastric intraluminal pH was 4.3 +/- 2.4 in P and 5.1 +/- 1.6 in R (NS). Mean prCO(2) was 6.8 +/- 2.7 kPa in P and 7.4 +/- 2.1 kPa in R, and mucosal-arterial pCO(2) gradient (Delta pCO(2)) was 2.2 +/- 2.9 kPa and 2.4 +/- 2.4 kPa, respectively (NS). Within-patient variabilities of gpH and prCO(2) were not influenced by ranitidine. A posthoc analysis revealed that non-survival in R was associated with a low mucosal pHi after 24 h (P = 0.002). This was explained by a low arterial pH but not by differences in gpH or prCO(2). CONCLUSION: In acute respiratory and circulatory failure, H(2) blockade has an inconsistent impact on gpH and does not reduce variabilities of gpH or prCO(2).

The progression of burn depth in experimental burns: a histological and methodological study.

UNLABELLED: This study was designed to create a reproducible model for experimental burn wound research in pigs. Previously, the thicker paraspinal skin has been used. We used the more human-like ventral skin to create burns of different depths. Contact burns were created to 11 pigs using a brass plate heated to 100 degrees C in boiling water. Different contact times were used to create burns of different depths. In pigs 1-6, the follow-up time was 72 h and in pigs 7-11 24 h. Burn depth was determined by histology. Histologically, samples were classified into five anatomical layers: epidermis, upper one-third of the dermis, middle third of the dermis, deepest third of the dermis and subcutaneous fat. The location of both thromboses and burn marks were evaluated, respectively. The 1 s contact time lead to a superficial thermal injury, 3 s to a partial thickness and 9 s to a full thickness injury. A progression of burn depth was found until 48 h post-injury. The intra-observer correlation after repeated histological analyses of burn depths by the same histopathologist and the repeatability of burn depth creation yielded kappa coefficients 0.83 and 0.92, respectively. CONCLUSION: a reproducible burn model for further research purposes was obtained.

Dobutamine compensates deleterious hemodynamic and metabolic effects of vasopressin in the splanchnic region in endotoxin shock.

BACKGROUND: Vasopressin is a potent vasopressor in septic shock, but it may impair splanchnic perfusion. We compared the effects of vasopressin alone and in combination with dobutamine on systemic and splanchnic circulation and metabolism in porcine endotoxin shock. METHODS: Twelve pigs were randomized to receive either vasopressin (VASO, n = 6) or vasopressin in combination with dobutamine (DOBU, n = 6) during endotoxin shock (E. coli endotoxin infusion). Endotoxin infusion rate was increased to induce hypotension after which vasoactive drugs were started. We aimed to keep systemic mean arterial pressure (MAP) >70 mmHg by vasopressin; the goal of dobutamine infusion was to prevent decrease in cardiac output often associated with vasopressin infusion. Regional blood flows, oxygen delivery and consumption, arterial and regional lactate concentrations were measured. RESULTS: Mean arterial pressure >70 mmHg was achieved in both the VASO and DOBU groups. After the primary decrease of cardiac output by vasopressin, systemic blood flow remained stable in vasopressin-treated animals. However, vasopressin as a monotherapy decreased portal venous blood flow. This was prevented by dobutamine. Vasopressin also induced splanchnic lactate release and arterial hyperlactatemia, which were not observed when dobutamine was combined with vasopressin. CONCLUSION: Dobutamine prevents adverse hemodynamic and metabolic effects of vasopressin in septic shock.

Pressure-volume relationships in acute lung injury: methodological and clinical implications.

BACKGROUND: Pressure-volume relationships (PV curves) are the only available method for bedside monitoring of respiratory mechanics. Alveolar recruitment modifies the results obtained from the PV curves. We hypothesized that method-related differences may influence PV-curve guided ventilatory management. METHODS: Twelve acute lung injury (ALI) patients [PaO2/FiO2 13.0 +/- 1.5 kPa (97.6 +/- 11.3 mmHg), bilateral pulmonary infiltrates] were studied. Two PV curves [one at variable, and another at constant level of positive end-expiratory pressure (PEEP)] were obtained from each patient using constant inspiratory flow and end-inspiratory and -expiratory occlusions. Upper and lower inflection points (UIP, LIP) were estimated. Recruitment due to PEEP and during inflation was assessed by respiratory inductive plethysmography (RIP). RESULTS: (1) Pressure-volume curves at constant PEEP tended to provide higher LIP values compared with curves at variable PEEP (mean difference +/- SEM 5.1 +/- 1.9 cmH2O); and (2) recruitment occurred throughout the PV curve with no relationship with LIP or UIP. CONCLUSION: Pressure-volume curves obtained using variable PEEP translate a different physiological reality and seem to be clinically more relevant than curves constructed at constant PEEP. If curves constructed at constant PEEP are used to set the ventilator, unnecessarily high PEEP levels may be used. Respiratory inductive plethysmography technology may be used for monitoring of recruitment at the bedside.

Results and costs of intensive care in a tertiary university hospital from 1996-2000.

BACKGROUND: Costs of intensive care may be 20% of all hospital costs. Population aging likely increases the demand for intensive care services, while health care has financial limitations. Therefore data about outcome and costs of intensive care are needed. We studied changes in patient characteristics, outcome, intensity of care and costs of intensive care in a tertiary university hospital in Finland. METHODS: We analyzed retrospectively data of patients admitted to the ICU between 1 January 1996 and 31 December 2000 using the patient data management system. Postoperative and ICU patients were analyzed separately. Data included age, Apache II score, cause of intensive care admission, length and intensity of ICU care. ICU, hospital and 6-month mortality were analyzed. Intensity of care was assessed by TISS points and the annual costs of intensive care were evaluated. RESULTS: The number of ICU admissions from 1996-2000 was 11,323. The proportions of ICU and postoperative patients were 39% and 61%, respectively. The mean age of the patients did not change. The mean Apache II score increased over time both in the ICU and postoperative patients. There was no change in crude hospital mortality. Total ICU costs decreased from 8,660,000 euros (in 1997) to 7,480,000 euros (in 2000). In the ICU patients, the costs of hospital survival decreased towards the end of the study period. CONCLUSIONS: We treated more severely ill patients with unchanged outcome but at lower costs towards the end of the study period. Costs of intensive care are not necessarily increasing.

Myocardial function and haemodynamics in extensive burn trauma: evaluation by clinical signs, invasive monitoring, echocardiography and cytokine concentrations. A prospective clinical study.

BACKGROUND: The objectives of this study were to (1). describe the haemodynamic profile of patients with extensive burns during the early fluid resuscitation phase, (2). evaluate myocardial performance by invasive monitoring and echocardiography and (3). analyze the relations between serum cytokine (IL-6, IL-8, TNF) and natriuretic peptide (ANP, BNP) concentrations and myocardial function in these patients. METHODS: Prospective, clinical study in a tertiary care burn centre. Invasive haemodynamic measurements including a pulmonary artery catheter, echocardiography, blood samples for cytokine and atriopeptide analyses. The follow-up time was up to 72 h postinjury. RESULTS: According to echocardiography, patients were hypovolaemic despite aggressive (median 7,9 ml kg(-1) h(-1), range 3.3-11.7) fluid resuscitation and adequate urine output (median 0.9 ml kg(-1) h(-1), range 0.46-1.35) during the first day postinjury. There were no consistent findings of hyperlactatemia, metabolic acidosis or low mixed venous oxygen saturations. Daily highest and lowest values of cardiac index and stroke volume index increased and the lowest and highest values of systemic vascular resistance decreased. Cardiac performance (stroke volume index) improved during the study period even though there were no initial signs of myocardial depression in echocardiography. Three patients received a dobutamine infusion based on clinical judgement. There was no consistent association between haemodynamic changes and plasma cytokine concentrations. CONCLUSION: Persisting hypovolaemia is evident in the resuscitation phase of extensive burns despite aggressive fluid therapy and the lack of classic signs of hypoperfusion. Cardiac performance improves during the first days after extensive burn injury without association with plasma cytokine profile.