Outcome of patients requiring medical ICU admission following bone marrow transplantation.

Despite encouraging results seen following bone marrow transplantation (BMT), it has been observed that once these patients become critically ill and require medical intensive care unit (MICU) admission, the chances of survival are poor. We hypothesized that while mechanical ventilation would be an important predictor for death in the MICU, those patients not requiring mechanical ventilation could be successfully discharged from the MICU. The records of 36 patients with 43 admissions to the MICU following BMT were analyzed. Of these admissions, 33 (76.7 percent) patients had allogeneic and 10 (23.3 percent) had autologous transplants, respectively. Overall, 14 (32.6 percent) of the admissions resulted in a satisfactory discharge from the MICU. There was no significant difference in the survival rates between those patients undergoing allogeneic or autologous transplantations, 11 (33.3 percent) vs 3 (30.0 percent), respectively. Twenty-seven (62.8 percent) of the admissions resulted in mechanical ventilation and were performed in 20 (66.7 percent) patients with allogeneic BMTs and 7 (70.0 percent) patients with autologous BMTs, which was not significantly different. The survival rate for those requiring mechanical ventilation was significantly less than for those not mechanically ventilated during their MICU stay, 1 (3.7 percent) vs 13 (81.3 percent), respectively (p < 0.001). Those patients who did not survive their MICU stay had a significantly higher mean APACHE II score of 21.2 +/- 4.7 than the survivors' score of 15.8 +/- 3.8 (p < 0.001). The average length of stay for the survivors was 4.4 + 3.0 days, which was significantly less than the 17.8 +/- 24.0 days for those patients not surviving (p < 0.001). These data indicate that admission to the MICU may result in a beneficial outcome for critically ill patients with BMTs, but for those requiring mechanical ventilation due to respiratory failure, the chances of survival are poor. This information may be useful for providing patients with BMTs and their families with realistic estimates of prognosis prior to transfer to the MICU and mechanical ventilation.

Motility agents for the placement of weighted and unweighted feeding tubes in critically ill patients.

OBJECTIVE: To determine if successful attempts at feeding tube placement into the small bowel could be increased with the use of a weighted end or by pre-treatment with a drug to increase gastric motility. DESIGN: A prospective randomized control study, double blinded for a drug study drug, in a population of critically ill patients. SETTING: A 635-bed acute care hospital in Philadelphia, Pennsylvania. PATIENTS: Eighty-three patients in the critical care setting randomized into four groups receiving either parenteral normal saline (NS) 100 cc, erythromycin (EMY) 200 mg, or metoclopramide (MET), 10 mg, 30 min prior to attempted tube placement with either a weighted (WEI) (57 patients) or unweighted tube (UNW) (26 patients). RESULTS: When analyzed for number of attempts prior to successful tube placement into the stomach there was a significant difference between the unweighted and weighted groups: 2.08 +/- 1.03 attempts vs 1.51 +/- 0.94, P < or = 0.015. Duodenal migration at 24 h was demonstrated in three patients in the NS/UNW group and in two patients in the NS/WEI group as compared to no patients in either the EMY/WEI or the MET/WEI groups (p < or = 0.025, Fisher's exact test). CONCLUSIONS: These data demonstrate that the use of weighted feeding tubes decreases the number of attempts required to achieve gastric intubation, but that motility agents given prior to tube insertion do not augment advancement of the feeding tube beyond the stomach and may in fact hinder placement into the duodenum.

Effect of clinical outcomes data on intensive care unit utilization by bone marrow transplant patients.

OBJECTIVE: To determine if a program to educate referring physicians as to the poor outcome of mechanically ventilated bone marrow transplant patients would result in a change in intensive care unit (ICU) utilization. DESIGN: Retrospective chart review. SETTING: Medical ICU at an urban university hospital. PATIENTS: Patients undergoing bone marrow transplantation in the interval before (n = 236) vs. the interval after (n = 144) a physician education program. INTERVENTIONS: Two separate educational programs were conducted for oncologists and intensivists to review the findings of an earlier study demonstrating the outcome of bone marrow transplant patients in the ICU. MEASUREMENTS AND MAIN RESULTS: The results demonstrated that this physician education intervention did not result in a change in the utilization of medical ICU resources by these patients. Comparing the time periods before and after the intervention, there were no statistically significant differences in the proportion of patients who were admitted to the medical ICU, the proportion who received mechanical ventilation, or the medical ICU lengths of stay. Similarly, the two groups did not differ regarding the 100-day survival rate of all bone marrow transplant patients studied, all bone marrow transplant patients admitted to the medical ICU, or all bone marrow transplant patients intubated. CONCLUSION: Simple educational interventions are not a powerful mechanism by which to alter the practice of physicians regarding the utilization of scarce and expensive resources, even when the physicians generally agree that the use of those resources results in dismal patient outcomes.