ABSTRACT
BACKGROUND: Repeated pupillary examination is a key element of neurologic surveillance in intensive care units (ICU). However, in non-selected critically ill patients, the clinical interest of monitoring pupillary diameter and light reflex is poorly documented. We aimed to determine the prevalence and the etiologies of pupillary abnormalities (PAs) in this ICU patient population. METHODS: We performed a prospective, observational study in a medical university affiliated ICU over a 6-month period. All patients with at least one pupillary examination were included. PA was defined as areflexia and/or anisocoria present at the time of ICU admission or occurring during the ICU stay. RESULTS: During the study period, we included 297 patients who had 6±9 pupillary examinations per day (totaling 11,360 pupillary assessments). The majority of patients (n=161, 54%) were admitted to the ICU for acute respiratory or cardiovascular failure. A total of 128 PAs were recorded in 109 patients: 78 areflexia alone (61%), 33 anisocoria alone (26%) and 17 (13%) with associated anisocoria and areflexia. The main causes of PAs were related to acute brain ischemia (n=41, 32%) and sedation/analgesia (n=50, 39%). Among the PAs, 59 (46%) were present upon ICU admission. The etiologies of the PAs at admission did not differ from those occurring during ICU stay (P=NS). Interestingly, 9 (7%) PAs were attributed to ipratropium nebulization in patients with chronic obstructive pulmonary disease exacerbation. CONCLUSIONS: The high prevalence of PAs, frequently associated with both brain organic lesions and drug side effects, highlights the clinical interest of pupillary surveillance in non-selected critically ill patients.
ABSTRACT
PURPOSE: Physicians play an important role in strategies to control health care spending. Being aware of the cost of prescriptions is surely the first step to incorporating cost-consciousness into medical practice. The aim of this study was to evaluate current intensivists' knowledge of the costs of common prescriptions and to identify factors influencing the accuracy of cost estimations. METHODS: Junior and senior physicians in 99 French intensive care units were asked, by questionnaire, to estimate the true hospital costs of 46 selected prescriptions commonly used in critical care practice. RESULTS: With an 83% response rate, 1092 questionnaires were examined, completed by 575 (53%) and 517 (47%) junior and senior intensivists, respectively. Only 315 (29%) of the overall estimates were within 50% of the true cost. Response errors included a 14,756 ± 301 underestimation, i.e., -58 ± 1% of the total sum (25,595 ). High-cost drugs (>1000 ) were significantly (p < 0.001) the most underestimated prescriptions (-67 ± 1%). Junior grade physicians underestimated more costs than senior physicians (p < 0.001). Using multivariate analysis, junior physicians [odds ratio (OR), 2.1; 95% confidence interval (95% CI), 1.43-3.08; p = 0.0002] and female gender (OR, 1.4; 95% CI, 1.04-1.89; p = 0.02) were both independently associated with incorrect cost estimations. CONCLUSIONS: ICU physicians have a poor awareness of prescriptions costs, especially with regards to high-cost drugs. Considerable emphasis and effort are still required to integrate the cost-containment problem into the daily prescriptions in ICUs.
