Night-shift discharge from intensive care unit increases the mortality-risk of ICU survivors.

UNLABELLED: Intensive Care (ICU) survivors discharged from ICU to the general ward at night have a higher mortality. We sought to clarify which factors, including night-shift discharge, influence outcome following ICU discharge in a metropolitan hospital, using a cohort study of critically-ill patients between 1/1/1999-30/4/2003. Patients were excluded from analysis if they (a) died in ICU, (b) were transferred to another hospital, (c) had an ICU length of stay <8 hours, or (d) age <16 years. Logistic regression was used to derive a predictive model based on the following variables: patient demographics, severity of illness following ICU admission (APACHE II mortality-risk, p(m)), final diagnosis, discharge timing including premature or delayed (>4 hours) ICU discharge, and "limitation of medical treatment" orders. The outcome measures were patient status at hospital discharge and ICU readmission rate. Of the 1870 ICU survivors, 92 (4.9%) died after discharge from ICU. Patients discharged to the ward during the night-shift (2200-0730 hours) had a higher APACHE II score and crude mortality. The difference in APACHE II p(m) did not reach statistical significance. No significant calendar or seasonal pattern was identified. Logistic regression identified night-shift discharge (RR=1.7; 95% CI 1.03-2.9; P=0.03), limited medical treatment order (RR=5.1; 95% CI 2.2-12) and admission APACHE II p(m) (RR=3.3; 95% CI 1.3-7.6) as independent predictors of patient outcome following ICU transfer to the ward. CONCLUSION: At the time of ICU discharge to the ward three factors are predictive of hospital outcome: timing of ICU discharge, limited medical treatment orders and initial illness severity.

Renal support in critically ill patients: low-dose dopamine or low-dose dobutamine?

OBJECTIVE: Low-dose dopamine has been used in critically ill patients to minimize renal dysfunction without sufficient data to support its use. The aim of this study was to determine whether low-dose dopamine improves renal function, and whether dobutamine, a nondopaminergic inotrope, improves renal function. DESIGN: Prospective, randomized, double-blind trial. PATIENTS: Twenty-three patients at risk for renal dysfunction were entered into the study. Five patients were later withdrawn. Study data for the remaining 18 patients were: mean age 55 yrs; mean Acute Physiology and Chronic Health Evaluation (APACHE) II score of 18; mean weight 71 kg). The following conditions were present: mechanical ventilation (n = 17 [inverse-ratio ventilation, n = 6]); inotrope administration (n = 11); sepsis (n = 13); and adult respiratory distress syndrome or multiple organ failure syndrome (n = 9). INTERVENTIONS: The study patients were administered dopamine (200 micrograms/min), dobutamine (175 micrograms/min), and placebo (5% dextrose) over 5 hrs each in a randomized order. Ventilator settings, fluid management, and preexisting inotropic support were not altered during the study. MEASUREMENTS AND MAIN RESULTS: Systemic hemodynamic values and indices of renal function (4-hr urine volume, fractional excretion of sodium, and creatinine clearance) were measured during the last 4 hrs of each infusion. Dopamine produced a diuresis (145 +/- 148 mL/hr) compared with placebo (90 +/- 44 mL/hr; p < .01) without a change in creatinine clearance. Conversely, dobutamine caused a significant increase in creatinine clearance (97 +/- 54 mL/min) compared with placebo (79 +/- 38 mL/min; p < .01), without an increase in urine output. CONCLUSIONS: In stable critically ill patients, dopamine acted primarily as a diuretic and did not improve creatinine clearance. Dobutamine improved creatinine clearance without a significant change in urine output.