Physicians' and nurses' opinions on selective decontamination of the digestive tract and selective oropharyngeal decontamination: a survey.

INTRODUCTION: Use of selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) in intensive care patients has been controversial for years. Through regular questionnaires we determined expectations concerning SDD (effectiveness) and experience with SDD and SOD (workload and patient friendliness), as perceived by nurses and physicians. METHODS: A survey was embedded in a group-randomized, controlled, cross-over multicenter study in the Netherlands in which, during three 6-month periods, SDD, SOD or standard care was used in random order. At the end of each study period, all nurses and physicians from participating intensive care units received study questionnaires. RESULTS: In all, 1024 (71%) of 1450 questionnaires were returned by nurses and 253 (82%) of 307 by physicians. Expectations that SDD improved patient outcome increased from 71% and 77% of respondents after the first two study periods to 82% at the end of the study (P = 0.004), with comparable trends among nurses and physicians. Nurses considered SDD to impose a higher workload (median 5.0, on a scale from 1 (low) to 10 (high)) than SOD (median 4.0) and standard care (median 2.0). Both SDD and SOD were considered less patient friendly than standard care (medians 4.0, 4.0 and 6.0, respectively). According to physicians, SDD had a higher workload (median 5.5) than SOD (median 5.0), which in turn was higher than standard care (median 2.5). Furthermore, physicians graded patient friendliness of standard care (median 8.0) higher than that of SDD and SOD (both median 6.0). CONCLUSIONS: Although perceived effectiveness of SDD increased as the trial proceeded, both among physicians and nurses, SOD and SDD were, as compared to standard care, considered to increase workload and to reduce patient friendliness. Therefore, education about the importance of oral care and on the effects of SDD and SOD on patient outcomes will be important when implementing these strategies. TRIAL REGISTRATION: ISRCTN35176830.

Predictive models for thoracic aorta surgery. Is the Euroscore the optimal risk model in the Netherlands?

Prediction models do not optimally perform in the case of aorta surgery. We tried to define models that predict intensive care death for patients who underwent thoracic aorta surgery in the Netherlands. Therefore, we used data of 1290 patients who underwent interventions on the thoracic aorta from 1997 to 2002 which were prospectively collected in seven centers. One outcome was examined: intensive care death. Predicting models were made by multiple logistic regression analysis. The area under the receiver operating characteristics curve was used to study the discriminatory abilities of these models. We compared the models with the Euroscore. Eleven percent of the patients died during operation or on intensive care. Age, creatinine level >/=150 mumol/l, poor left ventricular ejection fraction and urgent indication were most related with intensive care-death. Prolonged extracorporal circulation and deep hypothermia were also of importance in the peri-operative model. The models performed better than the Euroscore. We conclude that the developed models perform relatively well in discriminating patients with respect to intensive care-death and even better than the Euroscore.

Effects of transfusion with red cells filtered to remove leucocytes: randomised controlled trial in patients undergoing major surgery.

OBJECTIVE: To compare postoperative complications in patients undergoing major surgery who received non-filtered or filtered red blood cell transfusions. DESIGN: Prospective, randomised, double blinded trial. SETTING: 19 hospitals throughout the Netherlands (three university; 10 clinical; six general). PARTICIPANTS: 1051 evaluable patients: 79 patients with ruptured aneurysm, 412 patients undergoing elective surgery for aneurysm, and 560 undergoing gastrointestinal surgery. INTERVENTIONS: The non-filtered products had the buffy coat removed and were plasma reduced. The filtered products had the buffy coat removed, were plasma reduced, and filtered before storage to remove leucocytes. MAIN OUTCOME MEASURES: Mortality and duration of stay in intensive care. Secondary end points were occurrence of multi-organ failure, infections, and length of hospital stay. RESULTS: No significant differences were found in mortality (odds ratio for filtered v non-filtered 0.80, 95% confidence interval 0.53 to 1.21) and in mean stay in intensive care (- 0.4 day, - 1.6 to 0.6 day). In the filtered group the mean length of hospital stay was 2.4 days shorter (- 4.8 to 0.0 day; P = 0.050) and the incidence of multi-organ failure was 30% lower (odds ratio 0.70, 0.49 to 1.00; P = 0.050). There were no differences in rates of infection (0.98, 0.73 to 1.32). CONCLUSION: The use of filtered transfusions in some types of major surgery may reduce the length of hospital stay and the incidence of postoperative multi-organ failure.

Deep hypothermic circulatory arrest and antegrade selective cerebral perfusion during ascending aorta-hemiarch replacement: a retrospective comparative study.

OBJECTIVE: We sought to compare the results of ascending aorta-hemiarch replacement by using 2 different methods of cerebral protection in terms of hospital mortality, neurologic outcome, and systemic morbidity and to determine predictive risk factors associated with hospital mortality and neurologic outcome after ascending aorta-hemiarch replacement. METHODS: Between January 1995 and September 2001, 289 patients (mean age, 62.2 +/- 13.2 years; urgent status, 122/289 [42.2%]) underwent ascending aorta-hemiarch replacement with the aid of antegrade selective cerebral perfusion (161 patients) or deep hypothermic circulatory arrest (128 patients). RESULTS: Overall hospital mortality was 11.4% (deep hypothermic circulatory arrest group, 13.3%; antegrade selective cerebral perfusion group, 9.9%; P =.375). A logistic regression analysis revealed acute type A dissection (P =.001; odds ratio, 4.3) and age of greater than 70 years (P =.019; odds ratio, 2.5) to be independent predictors of hospital mortality. The permanent neurologic dysfunction rate was 9.3% (deep hypothermic circulatory arrest group, 12.5%; antegrade selective cerebral perfusion group, 7.6%; P =.075). Logistic regression analysis revealed acute type A dissection (P =.001; odds ratio, 6.7) and history of cerebral infarction-transient ischemic attack (P =.038; odds ratio, 3.4) to be independent predictors of permanent neurologic dysfunction. The transient neurologic dysfunction rate was 8.0% (deep hypothermic circulatory arrest group, 7.1%; antegrade selective cerebral perfusion group, 8.7%; P =.530). Acute type A dissection (P =.001; odds ratio, 5.1) was indicated as an independent predictor of transient neurologic dysfunction by means of logistic regression. Renal dysfunction (postoperative creatinine level of >250 micromol/L; deep hypothermic circulatory arrest, 10 [7.8%]; antegrade selective cerebral perfusion, 6 [3.7%]; P =.030), as well as prolonged intubation time (deep hypothermic circulatory arrest, 3.8 +/- 6.3 days; antegrade selective cerebral perfusion, 2.2 +/- 2.5 days; P =.005) were more common in the deep hypothermic circulatory arrest group. CONCLUSION: The use of antegrade selective cerebral perfusion and deep hypothermic circulatory arrest during ascending aorta-hemiarch replacement resulted in acceptable hospital mortality and neurologic outcome. Reduced postoperative intubation time and better renal function preservation were observed in the antegrade selective cerebral perfusion group.