The societal costs of intracerebral hemorrhage in Spain.

This study estimates the lifetime societal costs associated with incident intracerebral hemorrhage (ICH) in Spain. An epidemiological model of ICH incidence, survival and morbidity was developed using retrospective data from 28 hospitals in Andalusia and published data identified in a systematic literature review. Data on resource utilization and costs were obtained from five hospitals in the Canary Islands, whereas cost of outpatient care, informal care and lost productivity were obtained from standardized questionnaires completed by survivors of ICH. The lifetime societal costs of incident ICH in Spain is estimated at 46,193 euros per patient. Direct medical costs accounted for 32.7% of lifetime costs, whilst 67.3% were related to indirect costs. One-third of direct medical costs over the first year were attributable to follow-up care, including rehabilitation. Indirect costs were dominated by costs of informal care (71.2%). The aggregated lifetime societal costs for the estimated 12,534 Spanish patients with a first-ever ICH in 2004 was 579 million euros. ICH implies substantial costs to society primarily due to formal and informal follow-up care and support needed after hospital discharge. Interventions that offer survival benefits without improving patients' functional status are likely to further increase the societal costs of ICH.

[Thrombolysis in stroke: inappropriate consideration of the 'window period' as the time available]. / Trombólisis en el ictus: consideración inapropiada del 'período de ventana' como tiempo disponible.

AIMS: The earlier r-TPA is administered in ischaemic strokes, the more effective it is. The aim of this study is to analyse the delay times in health care afforded in a consecutive series of cases that had received treatment, with a view to shortening them. PATIENTS AND METHODS: We analysed the medical records of the first patients to be treated in our centre. The paper describes several variables involving demographic and clinical factors, as well as the delay in entering the Emergency department, performing a CAT scan and especially the time elapsed between the CAT scan and starting treatment. We have examined the existence of an inappropriate correlation between delays that should be independent of one another. RESULTS: The mean age of the 17 patients treated was 68 years and they had a stroke severity score of 17 points on the NIHSS. The mean time of delay until arrival, arrival-CAT, and CAT-treatment were slightly under 1 hour each, and onset-treatment delay was 165 minutes, which is very close to the limit of the therapeutic window period. We found a strong inverse linear association between the time elapsed between onset and the CAT scan, and from the latter to the beginning of treatment (Spearman's r: -0.664, p = 0.004). CONCLUSIONS: Findings indicate that in our hospital, as in other centres in the initial phases of implementation, the therapeutic time window for intravenous thrombolysis in ischaemic stroke tends to run out. It must be highlighted that the resolve of the physician who indicates the treatment exerts a decisive effect on the delay.

Computed tomography vs clinical and multidisciplinary procedures for early evaluation of severe abdomen and chest trauma--a cost analysis approach.

OBJECTIVE: To compare contrast computed tomography (CT) for evaluating abdominal and vascular chest injuries after emergency room resuscitation with multidisciplinary management based on bedside procedure (BP), e.g., peritoneal lavage, abdomen ultrasonography urography and, if indicated, CT and/or aortography or transesophageal echocardiography. DESIGN: Randomized study. SETTING: Emergency, critical care and radiology departments in a trauma center. PATIENTS: The study was performed in 103 severe blunt trauma patients with a revised trauma index < 8, admitted over a 16 month period and divided into group (G1, n = 52, CT management) and group 2 (G2, n = 51, BP management). INTERVENTIONS: A relative direct cost scale used in our trauma center was applied, and cost units (U) were assigned to each diagnostic test for cost-minimization analysis (abdomen ultrasonograph = 7.5 U, peritoneal lavage = 8 U, urography = 9 U, computed tomography = 9 U, transesophageal echocardiography = 13.5 U, and aortography = 15 U). One unit is approximately equivalent to $43.7. RESULTS: Injury severity score (ISS) was 31.7 +/- 15.4 in G1 and 33.8 +/- 18.3 in G2. Sensitivity for CT was 90.4% (G1) vs 72.5% for BP (G2) in abdomen (P < 0.01) and 60% in chest for evaluating mediastinal hematoma etiology (G1). As Table 2 shows, G1 needed 59 tests for evaluating injuries (1.1 +/- 0.3 tests patient) while G2 required 81 tests (1.68 +/- 0.8 tests/patient) (P < 0.01). The total relative cost was 538 U for G1, 7.04 +/- 2.2 U cost/injury and 10.3 +/- 3.3 U/evaluation of trauma vs 698 U for G2, 9.84 +/- 5.03 U cost/injury and 13.68 +/- 8.5 U/evaluation (P < 0.05). CONCLUSIONS: This cost-minimization study suggests that CT is a more cost-effective method for the post-emergency room resuscitation evaluation of severe abdominal blunt trauma than the multidisciplinary BP. Chest CT is a screening method for mediastinal hematoma but not for etiology.

Acute respiratory distress syndrome in trauma patients: ICU mortality and prediction factors.

OBJECTIVES: To study the factors that influence the intensive care unit (ICU) mortality of trauma patients who develop acute respiratory distress syndrome (ARDS) and to evaluate determinants of length of ICU stay among these patients. DESIGN: Study on a prospective cohort of 59 trauma patients that developed ARDS. SETTING: ICU of a referral trauma center. Fifty-nine patients were included during the study period from 1994 to 1997. METHODS: The dependent variables studied were the mortality and length of ICU stay. The main independent variables studied included the general severity score APACHE III, the revised trauma and injury severity scores (RTS, ISS), emergency treatment measures, the gas exchange index (PaO2/FIO2) recorded after the onset of ARDS and the development of multiple system organ failure (MSOF). Univariate and multivariate analyses were performed. RESULTS: The mean age of patients was 42.1 +/- 16.7 years, 49 patients (83 %) were male, the mean APACHE III score was 52.7 +/- 33.7 points, the ISS 28.5 +/- 11.4 points and the RTS 8.9 +/- 2.5 points. ICU length of stay was 28.5 +/- 24.5 days and the mortality rate 31.7 % (19 deaths). Mortality was associated with the following: PaO2/FIO2 ratio on the 3rd, 5th and 7th days post-ARDS; high volume of crystalloid/colloid infusion during resuscitation; the APACHE III score; and the development of MSOF According to the multivariate analysis, the mortality of these patients was correlated with the PaO2/FIO2 ratio on the 3rd day of ARDS, the APACHE III score and the development of MSOF. This analysis also showed days on mechanical ventilation to be the only variable that predicted ICU length of stay. CONCLUSIONS: The ICU mortality of trauma patients with ARDS is related to the APACHE III score, the gas exchange evolution as measured by the PaO2/FIO2 on the 3rd day and the progressive complications indicated by the onset of MSOF. The length of ICU stay of these patients is related to the number of days on mechanical ventilation.

Acute respiratory distress syndrome among trauma patients: trends in ICU mortality, risk factors, complications and resource utilization.

OBJECTIVE: To evaluate trends in mortality and related factors among trauma patients who developed acute respiratory distress syndrome (ARDS). STUDY: Observational study based on data prospectively gathered in computerized trauma registry. SETTING: Trauma intensive care unit (ICU) of 48 beds in level I trauma center. PATIENTS: All trauma patients with ARDS admitted during 1985-87 (486, group 1 [G1]) and 1993-95 (552, group 2[G2]). METHODS: ARDS was defined by American-European Consensus Conference criteria and the need for 48 h or more on mechanical ventilation with FIO2 greater than 0.50 and PEEP of more than 5 cmH2O. Demographics, severity score, injury-admission delay time, first 24-h transfusion and septic and organ system failure complications were independent variables. ICU mortality was the dependent variable. ICU length of stay (LOS) and life support techniques were considered. Respiratory and renal support strategies were different in the two time periods. RESULTS: Mortality decreased over the period (G1: 29.2% vs G2: 21.4%, p < 0.04), in patients aged both over and under 65 years. Multivariate analysis showed mortality was related to age, severity and time period (G1 1.68-fold that in G2) and that the greater G1 mortality was related to more renal failure and hematologic failure/dysfunction. ICU LOS decreased from 31.7+/-26.7 days (G1) to 27.3+/-22 days (G2) (p < 0.003). CONCLUSIONS: Mortality among trauma patients with ARDS declined over the 8 years studied and was associated with less organ failure. This reduction was probably the result of new approaches to mechanical ventilation, renal failure replacement and vasoactive drug therapy.

Increase in lung volume originated by extrinsic PEEP in patients with auto-PEEP. The role of static lung compliance.

The use of extrinsic positive end expiratory pressure (PEEPe) in patients with auto-PEEP (AP) can reduce the respiratory work during weaning from mechanical ventilation. However, the application of PEEPe can produce a certain level of hyperinflation, an undesirable effect which can limit the efficacy of the reduction of respiratory work. The objective of the present study has been to determine if the increase in end expiratory lung volume (EELV) originated by the PEEPe is related to static lung compliance (SLC). We have studied 14 patients on mechanical ventilation in whom an AP of between 4 and 12 cmH2O was detected. On applying PEEPe equal to half the AP, the EELV increased slightly (77 +/- 64 ml) and was not related to pulmonary compliance. When PEEPe equal to the AP was applied, the EELV increased by 178 +/- 110 ml (range 45-375 ml, p less than 0.05), and there was a significant correlation with SLC (r = 0.659, p less than 0.05). In conclusion, the application of PEEPe equal to the AP causes a moderate increase in EELV. However, in patients with high pulmonary compliance this increase can be more important and must be taken into account when considering the use of PEEPe during weaning.

Adult respiratory distress syndrome among blunt and penetrating trauma patients: demographics, mortality, and resource utilization over 8 years.

PURPOSE: The purpose of this study was to compare demographics, resources used, and mortality rates among a subset of trauma patients (blunt versus penetrating) who developed adult respiratory distress syndrome (ARDS) and over two time periods, 8 years apart. PATIENTS AND METHODS: This retrospective observational study was based on an analysis of the computerized Trauma Registry of the Shock Trauma Center of the University of Maryland Medical Systems. All trauma patients with ARDS admitted to a 48-bed trauma intensive care unit (ICU) at a Level I Trauma Center during two time periods of 3 consecutive years each were considered: from January 1, 1985, to December 31, 1987 (G1), and January 1, 1993, to December 31, 1995 (G2). Data were collected in the two time periods on demographics, severity (Revised Trauma Score), injury-admission delay time, first 24-hour transfusion fluids and blood, septic and organ system failure complications, life-support techniques, ICU mortality, and length of stay (LOS). The independent variables were the age, type of trauma, severity scores, transport time, fluid therapy, infectious and organ system failure complications, and life-support techniques. The dependent variable was ICU mortality. RESULTS: A total of 1,108 patients satisfied the entry criteria, 486 in period G1 and 552 in period G2; 929 (89.5%) suffered blunt trauma and 109 (10.5%) penetrating trauma. Mean age was lower for the penetrating trauma populations. There were no significant differences in ICU mortality between the blunt and penetrating trauma patients with ARDS. A significant decrease in ICU mortality was observed between the time periods studied among both blunt (29.5% vs. 21.7%, P <.001) and penetrating trauma patients (25.7% vs. 18.9%, P <.001). A similar rate of renal, hematologic, and cardiovascular organ system failure was observed for both blunt and penetrating trauma patients. Resource utilization measured by ICU LOS and time on mechanical ventilation was also similar in the two groups. The multivariate analysis showed that ICU mortality was related to age, RTS-measured severity, and time period (G1 mortality 1.68-fold that in G2). Renal and hematologic failures entered a second analysis, replacing the time period variable (G2). CONCLUSIONS: ARDS in patients with blunt and penetrating trauma showed similar trends in ICU mortality, complications, and resource utilization. The ARDS mortality rate decreased over the time period studied in both blunt and penetrating trauma.

Acute respiratory distress syndrome: resource use and outcomes in 1985 and 1995, trends in mortality and comorbidities.

PURPOSE: The purpose of this study was to compare resource consumption and mortality between (ARDS) patients with adult respiratory distress syndrome treated at our center in 1985 (45 patients) and those treated in 1995. MATERIALS AND METHODS: This was a retrospective observational study, considering trauma and nontrauma ARDS separately. We recorded severity index scores (APACHE III), infectious complications and multiorgan failure, intensive care unit (ICU) resource consumption (TISS 28), length of stay, time on mechanical ventilation, and ICU mortality. RESULTS: We found no variation in overall ARDS mortality and no reduction in mortality in the ARDS trauma group (43.5% in 1985 vs. 38.5% in 1995, not significant) but a significant increase in mortality among nontrauma septic ARDS patients (68.2% vs. 82.9%, P < .001), largely attributable to the new comorbidities of human immunodeficiency virus (HIV) infection and hematologic malignancy. TISS-28 showed an overall reduction over this time period (49.7 +/- 6.6 vs. 38.3 +/- 9.7, P < .001), due to fewer monitoring measures, particularly a lower use of pulmonary artery catheter. There were no overall changes in length of stay or days on mechanical ventilation between 1985 and 1995, but these variables did increase among the trauma subgroup. CONCLUSION: In our setting, mortality remained constant from 1985 to 1995 among ARDS trauma patients but not among nontrauma ARDS patients because of the new case-mix of the latter population, which now includes HIV and other immunodepressed patients.

[The EHSA project: the study of spontaneous subarachnoid haemorrhages in Andalusia. Incidence and results]. / Proyecto EHSA: estudio de hemorragias subaracnoideas espontáneas en Andalucia. Incidencia y resultados.

AIM: To evaluate the incidence and results of spontaneous subarachnoid haemorrhages (SAH) in Andalusia. PATIENTS AND METHODS: We conducted a longitudinal prospective study of the cases of SAH attended in 28 hospitals in Andalusia over a three month period in 2000. SAH was defined as cases of acute haemorrhagic strokes diagnosed by tomography. The gross incidence rate (GR) was determined from census information from the Instituto Andaluz de Estad stica. Standard rates (SR) were estimated with relation to the European population. Results were evaluated on hospital discharge according to the Glasgow Outcome Score (GOS) and at 12 months, according the Barthel index (BI). RESULTS: The GR per 100,000 inhabitants/year was found to be 5.7 cases and the SR was 5.8. A comparison of incidences by province or sex showed no statistically significant differences. The period of maximum risk was the age bracket between 55 74 years (GR: 14.1). The acute fatality GR and SR rose to 1.9 per 100,000 inhabitants and year. Mortality was concentrated in a statistically significant way (p< 0.01) among those over the age of 65; sex did not exert any influence, but clinical gravity (p< 0.001) and the amount of bleeding did (p< 0.005). CONCLUSIONS: The incidence of spontaneous SAH in Andalusia was found to be within the average rates. Unfavourable results were high, although similar to those in other series. Fatality is significantly associated with factors that cannot be modified medically (age, clinical gravity and volume of bleeding)

[Improving the outcomes in spontaneous subarachnoid haemorrhage: the EHSA project]. / Mejora de los resultados en la hemorragia subaracnoidea espontánea: proyecto EHSA.

AIM: To investigate our clinical practices with the aim of identifying opportunities to improve the medico-surgical management of spontaneous subarachnoid haemorrhages (SAH). PATIENTS AND METHODS A prospective, longitudinal cohort study was conducted of the cases of SAH attended consecutively in the critical care and emergency services in 29 public hospitals in Andalusia over a period of 20 months, between the years 2000 and 2002. SAH were considered to be acute haemorrhagic cerebrovascular accidents diagnosed as such by imaging. Results at 12 months and care management (medical and surgical therapy, diagnostic techniques, care times and specific neurological complications) were analysed and the latter was then compared with the clinical practices that scientific evidence has proved to be the most useful. Deaths due to rebleeding in patients with no arteriographic study or without exclusion of the aneurysm were catalogued as potentially avoidable deaths. RESULTS: A total of 506 SAH were included. During the follow-up 5% of the sample were lost. In all 155 patients died. The non-modifiable independent risk variables for mortality were: age, being male, history of arterial hypertension, coma on arrival at the hospital and hydrocephalus. The independent risk variables for death that can be influenced were: absence of urgent analgesic, no arteriographic diagnosis, appearance of ischaemic neurological impairment and rebleeding. Twenty per cent of the overall mortality could be considered potentially avoidable. CONCLUSIONS: Although fatality is mostly dependent on variables that cannot be influenced (sex, age, history, clinical severity and hydrocephalus), 20% of deaths are associated to modifiable factors.

Mediastinal, left, and right atrial pressure variations with different modes of mechanical and spontaneous ventilation.

Variations in mediastinal, left, and right atrial pressures (MedP, LAP, RAP, respectively) were measured by means of catheters and tubes positioned in ten patients with nonvalvular cardiac surgery. For each pressure, a maximum, minimum, and mean value was determined in relation to its oscillations during the respiratory cycle. Thus, we compared the variations in MedP, LAP, and RAP in controlled mechanical ventilation (CMV), CMV with 5 cm H2O PEEP, synchronous intermittent mandatory ventilation (SIMV), SIMV with 5 cm H2O PEEP, continuous positive airway pressure (CPAP), and spontaneous respiration (SR). We built an experimental model to compare the measurements obtained by air-filled tubes inserted at surgery with those obtained by esophageal balloons filled with water. The maximum MedP did not vary significantly in these patients except when SIMV and SR were compared; however, the minimum MedP diminished significantly (p less than .001) in SIMV, SIMV-PEEP, CPAP, and SR, with negative inspiratory values reaching significant proportions. The mean values of MedP, LAP, and RAP showed a similar tendency although to a lesser degree. The experimental model revealed a strong linear relation between the values obtained with air-filled tubes and those obtained with water-filled esophageal balloons (r = .99, p less than .001). These results suggest that the mean values of MedP, LAP, and RAP do not reflect the dynamic variations in ventricular filling pressure accurately, nor the important negative inspiratory peaks that appear in different types of ventilation using spontaneous cycles with and without PEEP. These inspiratory peaks can overload the left ventricle by hydrostatic gradients, and lead to pulmonary edema in susceptible patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of quality of life in polytraumatized patients two years after discharge from an intensive care unit.

OBJECTIVE: Analysis of quality of life of polytraumatized critical care patients. DESIGN: Prospective study. MATERIAL AND METHODS: Patients admitted in a 2-year period in a traumatologic intensive care unit (ICU) were evaluated. A quality of life questionnaire was completed on admission (N = 351), 1 year and 2 years after discharge from the ICU. The three questionnaires evaluated patients' ability to function and communicate over the previous 2 months. A quality of life score of 0 corresponded to no limitations. Quality of life was also evaluated by the Glasgow Outcome Scale. Information was collected on the severity of illness and the diagnosis prompting ICU admission. RESULTS: The mean quality of life score of survivors worsened from 0.46 +/- 0.11 points on ICU admission to 6.68 +/- 0.41 1 year after discharge, and then improved to 4.86 +/- 0.38 2 years after discharge, although the quality of life score continued to be worse than on admission (p < 0.001). On admission, 93.2% of patients had normal quality of life (0 points), after 1 year 36.5% were normal, and after 2 years 51.6% were normal. Three patients (0.9%) remained in vegetative state. On admission, 96.6% were working, while after 2 years, only 57.5% had returned to employment, although the high levels of unemployment in our country during this study may have been a particular factor in this result. All age groups except pediatric patients showed a worsened quality of life after 2 years, and patients over 60 years had worst scores on admission and after 1 and 2 years. Patients with least severity by Acute Physiology and Chronic Health Evaluation (APACHE) II score (< 10 points) had a better quality of life score after 1 and 2 years. Severity by Injury Severity Score showed patients with > 25 points having the greatest deterioration in quality of life. A multivariate study showed that quality of life after 2 years is influenced by age, severity of injury, and previous quality of life. CONCLUSIONS: Polytraumatized patients admitted into ICU showed a worsening of their quality of life 1 and 2 years after ICU discharge, with an improvement between 1 and 2 years. Quality of life after 2 years is influenced by age, severity of illness, and previous quality of life.