Assessment of Tissue Perfusion Using the Peripheral Perfusion Index and Lactate Clearance in Shock in Pediatric Patients.

BACKGROUND: Pediatric shock has a high mortality rate because many of the early clinical signs are subtle and have poor sensitivity and specificity. Pediatric shock was categorized either: compensated with normal blood pressure, poor skin perfusion (CRT >2 s, mottled, cool peripheries, peripheral cyanosis), weak peripheral pulse, age specific tachycardia, tachypnoea, and oliguria or decompensated with hypotension (SBP < 70 + (2× age in years) mm Hg and decreased mental status. The perfusion index is a non-invasive method for assessing peripheral perfusion and may be a useful marker for identifying shock early in pediatric patients. OBJECTIVE: This prospective cohort study (November 2019 to August 2020) evaluated whether the perfusion index, lactate, and/or lactate clearance could predict mortality among pediatric shock patients. METHODS: Fifty children (68% male) with shock underwent assessments at presentation to the emergency room to evaluate their heart rate, blood pressure, capillary refill time, central venous pressure, perfusion index, cardiac index, systemic vascular resistance, central venous oxygen saturation, and lactate clearance. RESULTS: The perfusion index range was 0.03 to 2.2 and ≤0.18 as the cut-off for mortality prediction providing 74% sensitivity and 78% specificity. The serum lactate concentration range was 0 to 16 mmol/L and >5.7 mmol/L as the cut-off for mortality prediction provided 70% sensitivity and 96% specificity at presentation to the emergency room. The lactate clearance range was 3% to 75% and >10% as the cut-off for survival prediction after resuscitation and at 6 h later. CONCLUSION: Perfusion index (PI), lactate, and lactate clearance provided comparable sensitivity and specificity for predicting outcomes among pediatric patients with shock Therefore, we suggest that the PI is an inexpensive, rapid, and non-invasive tool that can be used to predict illness severity and mortality in busy pediatric intensive care units and emergency departments. This tool may guide better patient triage and an earlier diagnosis of shock in this setting.

Variation in Fluid and Vasopressor Use in Shock With and Without Physiologic Assessment: A Multicenter Observational Study.

OBJECTIVES: To characterize the association between the use of physiologic assessment (central venous pressure, pulmonary artery occlusion pressure, stroke volume variation, pulse pressure variation, passive leg raise test, and critical care ultrasound) with fluid and vasopressor administration 24 hours after shock onset and with in-hospital mortality. DESIGN: Multicenter prospective cohort study between September 2017 and February 2018. SETTINGS: Thirty-four hospitals in the United States and Jordan. PATIENTS: Consecutive adult patients requiring admission to the ICU with systolic blood pressure less than or equal to 90 mm Hg, mean arterial blood pressure less than or equal to 65 mm Hg, or need for vasopressor. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Of 1,639 patients enrolled, 39% had physiologic assessments. Use of physiologic assessment was not associated with cumulative fluid administered within 24 hours of shock onset, after accounting for baseline characteristics, etiology and location of shock, ICU types, Acute Physiology and Chronic Health Evaluation III, and hospital (beta coefficient, 0.04; 95% CI, -0.07 to 0.15). In multivariate analysis, the use of physiologic assessment was associated with a higher likelihood of vasopressor use (adjusted odds ratio, 1.98; 95% CI, 1.45-2.71) and higher 24-hour cumulative vasopressor dosing as norepinephrine equivalent (beta coefficient, 0.37; 95% CI, 0.19-0.55). The use of vasopressor was associated with increased odds of in-hospital mortality (adjusted odds ratio, 1.88; 95% CI, 1.27-2.78). In-hospital mortality was not associated with the use of physiologic assessment (adjusted odds ratio, 0.86; 95% CI, 0.63-1.18). CONCLUSIONS: The use of physiologic assessment in the 24 hours after shock onset is associated with increased use of vasopressor but not with fluid administration.

Optimal treatment strategies for hepatic portal venous gas: A retrospective assessment.

BACKGROUND: Hepatic portal venous gas (HPVG) generally indicates poor prognoses in patients with serious intestinal damage. Although surgical removal of the damaged portion is effective, some patients can recover with conservative treatments. AIM: To establish an optimal treatment strategy for HPVG, we attempted to generate computed tomography (CT)-based criteria for determining surgical indication, and explored reliable prognostic factors in non-surgical cases. METHODS: Thirty-four cases of HPVG (patients aged 34-99 years) were included. Necessity for surgery had been determined mainly by CT findings (i.e. free-air, embolism, lack of contrast enhancement of the intestinal wall, and intestinal pneumatosis). The clinical data, including treatment outcomes, were analyzed separately for the surgical cases and non-surgical cases. RESULTS: Laparotomy was performed in eight cases (surgical cases). Seven patients (87.5%) survived but one (12.5%) died. In each case, severe intestinal damage was confirmed during surgery, and the necrotic portion, if present, was removed. Non-occlusive mesenteric ischemia was the most common cause (n = 4). Twenty-six cases were treated conservatively (non-surgical cases). Surgical treatments had been required for twelve but were abandoned because of the patients' poor general conditions. Surprisingly, however, three (25%) of the twelve inoperable patients survived. The remaining 14 of the 26 cases were diagnosed originally as being sufficiently cured by conservative treatments, and only one patient (7%) died. Comparative analyses of the fatal (n = 10) and recovery (n = 16) cases revealed that ascites, peritoneal irritation signs, and shock were significantly more frequent in the fatal cases. The mortality was 90% if two or all of these three clinical findings were detected. CONCLUSION: HPVG related to intestinal necrosis requires surgery, and our CT-based criteria are probably useful to determine the surgical indication. In non-surgical cases, ascites, peritoneal irritation signs and shock were closely associated with poor prognoses, and are applicable as predictors of patients' prognoses.

Angiotensin II for the treatment of distributive shock in the intensive care unit: A US cost-effectiveness analysis.

BACKGROUND: Patients with distributive shock who are unresponsive to traditional vasopressors are commonly considered to have severe distributive shock and are at high mortality risk. Here, we assess the cost-effectiveness of adding angiotensin II to the standard of care (SOC) for severe distributive shock in the US critical care setting from a US payer perspective. METHODS: Short-term mortality outcomes were based on 28-day survival rates from the ATHOS-3 study. Long-term outcomes were extrapolated to lifetime survival using individually estimated life expectancies for survivors. Resource use and adverse event costs were drawn from the published literature. Health outcomes evaluated were lives saved, life-years gained, and quality-adjusted life-years (QALYs) gained using utility estimates for the US adult population weighted for sepsis mortality. Deterministic and probabilistic sensitivity analyses assessed uncertainty around results. We analyzed patients with severe distributive shock from the ATHOS-3 clinical trial. RESULTS: The addition of angiotensin II to the SOC saved .08 lives at Day 28 compared to SOC alone. The cost per life saved was estimated to be $108,884. The addition of angiotensin II to the SOC was projected to result in a gain of .96 life-years and .66 QALYs. This resulted in an incremental cost-effectiveness ratio of $12,843 per QALY. The probability of angiotensin II being cost-effective at a threshold of $50,000 per QALY was 86 percent. CONCLUSIONS: For treatment of severe distributive shock, angiotensin II is cost-effective at acceptable thresholds.

The Value of Claims-Based Nontraditional Risk Factors in Predicting Long-term Mortality After MitraClip Procedure.

BACKGROUND: We sought to identify nontraditional risk factors coded in administrative claims data and evaluate their ability to improve prediction of long-term mortality in patients undergoing percutaneous mitral valve repair. METHODS: Patients undergoing transcatheter mitral valve repair using MitraClip implantation between September 28, 2010, and September 30, 2015 were identified among Medicare fee-for-service beneficiaries. We used nested Cox regression models to identify claims codes predictive of long-term mortality. Four groups of variables were introduced sequentially: cardiac and noncardiac risk factors, presentation characteristics, and nontraditional risk factors. RESULTS: A total of 3782 patients from 280 clinical sites received treatment with MitraClip over the study period. During the follow-up period, 1114 (29.5%) patients died with a median follow-up time period of 13.6 (9.6 to 17.3) months. The discrimination of a model to predict long-term mortality including only cardiac risk factors was 0.58 (0.55 to 0.60). Model discrimination improved with the addition of noncardiac risk factors (c = 0.63, 0.61 to 0.65; integrated discrimination improvement [IDI] = 0.038, P < 0.001), and with the subsequent addition of presentation characteristics (c = 0.67, 0.65 to 0.69; IDI = 0.033, P < 0.001 compared with the second model). Finally, the addition of nontraditional risk factors significantly improved model discrimination (c = 0.70, 0.68 to 0.72; IDI = 0.019, P < 0.001, compared with the third model). CONCLUSIONS: Risk-prediction models, which include nontraditional risk factors as identified in claims data, can be used to predict long-term mortality risk more accurately in patients who have undergone MitraClip procedures.

Acute circulatory failure-chronic liver failure-sequential organ failure assessment score: a novel scoring model for mortality risk prediction in critically ill cirrhotic patients with acute circulatory failure.

BACKGROUND AND AIM: Acute circulatory failure (ACF) is associated with high mortality rates in critically ill cirrhotic patients. Only a few accurate scoring models exist specific to critically ill cirrhotic patients with acute circulatory failure (CICCF) for mortality risk assessment. The aim was to develop and evaluate a novel model specific to CICCF. PATIENTS AND METHODS: This study collected and analyzed the data on CICCF from the Multiparameter Intelligent Monitoring in Intensive Care-III database. The acute circulatory failure-chronic liver failure-sequential organ failure assessment (ACF-CLIF-SOFA) score was derived by Cox's proportional hazards regression. Performance analysis of ACF-CLIF-SOFA against CLIF-SOFA and model for end-stage liver disease systems was completed using area under the receiver operating characteristic curve. RESULTS: ACF-CLIF-SOFA identified six independent factors: mean arterial pressure [hazard ratio (HR)=0.984, 95% confidence interval (CI): 0.978-0.990, P<0.001], vasopressin (HR=1.548, 95% CI: 1.273-1.883, P<0.001), temperature (HR=0.764, 95% CI: 0.694-0.840, P<0.001), bilirubin (HR=1.031, 95% CI: 1.022-1.041, P<0.001), lactate (HR=1.113, 95% CI: 1.084-1.142, P<0.001), and urine output (HR=0.854, 95% CI: 0.767-0.951, P=0.004). ACF-CLIF-SOFA showed a better predictive performance than CLIF-SOFA and model for end-stage liver disease in terms of predicting mortality (0.769 vs. 0.729 vs. 0.713 at 30 days, 0.757 vs. 0.707 vs. 0.698 at 90 days, 0.733 vs. 0.685 vs. 0.691 at 1 year, respectively, all P<0.05). CONCLUSION: ACF-CLIF-SOFA, as the first model specific to CICCF, enables a more accurate prediction at 30-day, 90-day, and 1-year follow-up periods than other existing scoring systems.

Health insurance status and outcomes of critically ill obstetric patients: a prospective cohort study in Argentina.

PURPOSE: In Argentina, uninsured patients receive public health care, and the insured receive private health care. Our aim was to compare different outcomes between critically ill obstetric patients from both sectors. METHODS: This is a prospective cohort, including pregnant/postpartum patients requiring admission to 1 intensive care unit in the public sector (uninsured) and 1 in the private (insured) from January 1, 2008, to September 30, 2011. RESULTS: A total of 151 patients were included in the study. In uninsured (n = 63) vs insured (n = 88) patients, Acute Physiology and Chronic Evaluation II (APACHE II) and Sequential Organ Failure Assessment scores were 11 ± 6.5 vs 8 ± 4 and 3 (2-7) vs 1 (0-2), respectively, and 84% vs 100% received prenatal care (P = .001 for all). Multiple organ dysfunction syndrome (MODS) was present in 32 (54%) uninsured vs 9 (10%) insured patients (P = .001), and acute respiratory distress syndrome developed in 18 (30.5%) of 59 vs 2(2%) of 88 (P = .001). Neonatal survival was 80% vs 96% (P = .003). Variables independently associated with the development of MODS were APACHE II (odds ratio, 1.30 [1.13-1.49]), referral from another hospital (odds ratio, 11.43 [1.86-70.20]), lack of health insurance (odds ratio 6.75 [2.17-20.09]), and shock (odds ratio 4.82 [1.54-15.06]). Three patients died, all uninsured. CONCLUSIONS: Uninsured critically ill obstetric patients (public sector) were more severely ill on admission and experienced worse outcomes than insured patients (private sector). Variables independently associated with MODS were APACHE II, shock, referral from another hospital, and lack of insurance.

Nurses in low resource settings save mothers' lives with non-pneumatic anti-shock garment.

PURPOSE: To discuss the role of nurses and nurse-midwives in preventing and treating postpartum hemorrhage (PPH) from uterine atony in developing countries and examine the role of a new device, the non-pneumatic anti-shock garment (NASG), in improving the outcomes for these patients. STUDY DESIGN AND METHODS: In this subanalysis of a larger preintervention phase/intervention phase study of 1,442 women with obstetric hemorrhage, postpartum women with hypovolemic shock (N = 578) from uterine atony (≥750 mL blood loss; systolic blood pressure <100 mmHg and/or pulse >100 beats per minute) were enrolled in two referral facilities in Egypt and four referral facilities in Nigeria. The study had two temporal phases: a preintervention phase and an NASG-intervention phase. Women with hemorrhage and shock in both phases were treated with the same evidence-based protocols for management of hypovolemic shock and hemorrhage, but women in the NASG-intervention phase also received the NASG. Relative risks (RRs) with 95% confidence intervals (CIs) were estimated for primary outcomes-measured blood loss, incidence of emergency hysterectomy, and mortality. RESULTS: Women in the NASG-intervention phase had significantly better outcomes, 50% lower blood loss, reduced rates of hysterectomy (8.9% vs. 4%), and mortality decreased from 8.5% to 2.3% (RR = 0.27, 95% CI: 0.12-0.60). CLINICAL IMPLICATIONS: In low-resource settings nurses have few resources with which to stabilize women with severe PPH. With training nurses and nurse-midwives can stabilize hemorrhaging women with the NASG, a low-technology first-aid device that shows promise for reducing blood loss, rates of hysterectomy, and mortality.

Prediction of 30-day mortality after endovascular repair or open surgery in patients with ruptured abdominal aortic aneurysms.

OBJECTIVE: To validate the Glasgow Aneurysm Score (GAS) in patients with ruptured abdominal aortic aneurysms (AAAs) treated with endovascular repair or open surgery and to update the GAS so that it predicts 30-day mortality for patients with ruptured AAA treated with endovascular repair or open surgery. METHODS: In a multicenter prospective observational study, 233 consecutive patients with ruptured AAAs were evaluated; 32 patients did not survive to repair and statistical analysis was performed using collected data on 201 patients. All patients who were treated with endovascular repair (n = 58) or open surgery (n = 143) were included. The GAS was calculated for each patient. The area under the receiver operating characteristics curve (AUC) was used to indicate discriminative ability. We tested for interactions between risk factors and the procedure performed. The GAS was updated to predict 30-day mortality after endovascular repair or open surgery in patients with ruptured AAAs using logistic regression analysis. RESULTS: Thirty-day mortality was 15/58 (26%) for patients treated with endovascular repair and 57/143 (40%) for patients treated with open surgery (P = .06). The AUC for GAS was 0.69. No relevant interactions were found. The updated prediction rule (AUC = 0.70) can be calculated with the following formula: + 7 for open surgery + age in years + 17 for shock + 7 for myocardial disease + 10 for cerebrovascular disease + 14 for renal insufficiency. CONCLUSION: We showed limited discriminative ability of the GAS and therefore updated the GAS by adding the type of procedure performed. This updated prediction rule predicts 30-day mortality for patients with ruptured AAAs treated with endovascular repair or open surgery.

Medical emergency team implementation: experiences of a mentor hospital.

Rapid response teams (RRTs) provide assessment and early intervention for patients not in critical care. The implementation of RRT using an evidence-based practice framework, which led to decreased resuscitations, critical care transfers, overall mortality, and cost, is described.

The association between nursing factors and patient mortality in the Veterans Health Administration: the view from the nursing unit level.

CONTEXT: Nurse staffing is not the same across an entire hospital. Nursing care is delivered in geographically-based units, with wide variation in staffing levels. In particular, staffing in intensive care is much richer than in nonintensive care acute units. OBJECTIVE: To evaluate the association of in-hospital patient mortality with registered nurse staffing and skill mix comparing hospital and unit level analysis using data from the Veterans Health Administration (VHA). DESIGN, SETTINGS, AND PATIENTS: A retrospective observational study using administrative data from 129,579 patients from 453 nursing units (171 ICU and 282 non-ICU) in 123 VHA hospitals. METHODS: We used hierarchical multilevel regression models to adjust for patient, unit, and hospital characteristics, stratifying by whether or not patients had an ICU stay during admission. MAIN OUTCOME MEASURE: In-hospital mortality. RESULTS: : Of the 129,579 patients, mortality was 2.9% overall: 6.7% for patients with an ICU stay compared with 1.6% for those without. Whether the analysis was done at the hospital or unit level affected findings. RN staffing was not significantly associated with in-hospital mortality for patients with an ICU stay (OR, 1.02; 95% CI, 0.99-1.03). For non-ICU patients, increased RN staffing was significantly associated with decreased mortality risk (OR, 0.91; 95% CI, 0.86-0.96). RN education was not significantly associated with mortality. CONCLUSIONS: Our findings suggest that the association between RN staffing and skill mix and in-hospital patient mortality depends on whether the analysis is conducted at the hospital or unit level. Variable staffing on non-ICU units may significantly contribute to in-hospital mortality risk.

Mortality from burns in Zaria: an experience in a developing economy.

OBJECTIVE: To determine the cause of morbidity and mortality in burns patients managed over a period of eight years in our hospital. DESIGN: A retrospective study. SETTING: Ahmadu Bello University Teaching Hospital. SUBJECTS: Two hundred and seven patients admitted and treated for burn care between January 1980 and August 1987. RESULTS: There were 114 males and 93 females with male/female ratio 1.2:1. Fifty four percent of the admissions occurred during the harmattan period, which is cold and dry season of November to February, 52% of admissions were children below the age of five years. The severest injury was caused by petrol burn with a mean % BSA of 53 and range 23-100. Scalds accounted for 39% while flame accounted for 57% of the injuries. Clothing injury was a cause of extensive burns accounting for 12% of burn injury with % BSA of 36. Complications leading to morbidity and mortality include, wound infection leading to septicaemia and septic shock, hypovoleamia with hypovolaemic shock, which gave a mortality of 100% of those who developed shock state. Seventy three patients died giving a crude mortality rate of 35%. CONCLUSIONS: There is a need for health education to reduce incidence of burn injury. Since burn injuries are largely preventable, it is important to define clearly, the social, cultural and economic factors, which contribute to burn causation in order to combat them effectively.

Comparación entre el monitoreo invasivo y no invasivo para el diagnóstico precoz de hipoperfusión tisular, mortalidad y costo/beneficio / Comparison between invasive and not invasive monitoring for the precocious diagnostic of tisular hypoperfution, mortality and cost/benefit

Se analizaron once pacientes ingresados a una terapia polivalente que requirieron la colocación de un catéter en arteria pulmonar. Se sometieron los pacientes a monitoreo invasivo hemodinámico, con mediciones de DO2, VO2, resistencias vasculares pulmonares y sistémicas presiones pulmonares, gasto cardíaco, presión de wedge, monitoreo de laboratorio: lactato, gases en sangre arterial y pHi gástrico con la finalidad de detectar cuál variable era la más sensible para detectar estados de hipoperfusión tisulaar, evaluar un índice pronóstico de mortalidad al ingreso y estimar los costos beneficios del uso del tonómetro gástrico en pacientes que requirieron catéter en arteria pulmonar. Las mediciones se hicieron al ingreso y luego cada 12 horas hasta que el paciente salía de protocolo por normalización de los valores o fallecimiento. Se analizaron los pacientes en dos grupos: sobrevivientes y no sobrevivientes, comparando las variables hemodinámicas entre ambos grupos, solamente resultaron estadísticamente significativas la frecuencia cardíaca (p < 0,05) y el pHi (p < 0,05). Hubo una relación lineal entre DO2 y VO2. El coeficiente de correlación entre DO2 y pHi fue cero. La diferencia de pHi entre el grupo de sobrevivientes y no sobrevivientes fue estadísticamente significativa. El lactato no fue un predictor precoz de hipoxia tisular en ningún grupo. La variable que mejor predijo mortalidad en este grupo fue pHi gástrico (p 0,05). En nuestra terapia intensiva el costo del tonómetro fue elevado y la única utilidad que tuvo fue pronosticar mortalidad ya que la conducta terapéutica fue tomada en función de los resultados obtenidos de las mediciones hemodinámicas invasivas

MAST 96.

The Military Anti-Shock Trouser, or MAST suit, is a controversial device that has been used to support blood pressure in hypotensive trauma patients. Most studies on humans have shown that the device has limited clinical utility. In this study, a telephone survey of all 50 State Emergency Medical Services was conducted to determine the nature and extent of MAST suit usage in the United States. The trend in MAST suit usage in San Diego County over the last 7 years was also analyzed. Thirty (60%) states still require MAST suits to be carried on ambulances. In San Diego County, MAST suit inflations for adult, hypotensive (systolic blood pressure < 90 mmHg,) blunt trauma patients has declined from 37% in 1987, to 2% in 1993. Despite a lack of data supporting efficacy in areas of severe hypotensive shock, blunt trauma, long transport times, and pelvic fractures, states continue to expend resources on the MAST suit. It is for this reason that we believe that the clinical use of the MAST suit should be based upon medical control philosophy rather than legislation.

[Effectiveness of preclinical emergency management. Fiction or fact?]. / Effektivität präklinischer Notfallversorgung. Fiktion oder Fakt?

The current increase in the cost of health care must be considered as a severe threat to the prehospital emergency services system. Two examples have been selected--the patient with polytrauma and the patient in cardiac arrest--to demonstrate the dilemma between a need for objective data and the requirements of emergency patients. Study results obtained in trauma patients indicating that total prehospital time, including scene time, is correlated to patient outcome have led to the conclusion that at the scene treatment by emergency physicians may be dispensable. It has, however also been demonstrated that the time required for medical treatment at the scene is equivalent to 20% of the total scene time, thus representing only a fraction of the total prehospital time. Correlating the total prehospital time or scene time to outcome therefore appears absurd. The treatment principle of aggressive shock treatment in polytrauma needs critical reevaluation on the basis of results obtained by recent preclinical studies in patients with penetrating torso injuries. Small volume resuscitation could not be demonstrated to improve outcome in polytrauma patients, although a slight improvement in patients with brain injury may be assumed. Endotracheal intubation and early artificial ventilation are proven therapeutic principles in polytraumatized patients. Unfortunately, for ethical reasons randomised carefully controlled comparative studies can not be performed in polytrauma patients unless the patient is fully conscious. The importance of endotracheal intubation and artificial ventilation in unconscious trauma patients becomes apparent under conditions of anaesthesia where the application of the endotracheal tube averts regurgitation, aspiration and concomitant morbidity and mortality. The common causes of cardiovascular collapse and their pathomechanisms, as well as the mechanisms of cardiopulmonary resuscitation, have been widely investigated. Nevertheless, various aspects of their application are still controversial. The most recent study results have recommended initial ventilation prior to thoracic compression. New methods of assisting mechanical cardiopulmonary resuscitation, such as ACD CPR or vest CPR, have shown promising results in animal experiments. However, the importance of results obtained by preclinical randomised controlled investigations in humans need to be confirmed by further studies as to outcome. The efficacy of defibrillation in cases of ventricular fibrillation has been clearly demonstrated, particularly with a view to the interval between ventricular fibrillation and defibrillation. It has further been demonstrated that basic cardiopulmonary resuscitation preserves ventricular fibrillation and thus improves the chance of survival. The present generation of defibrillators has been further improved, particularly by the introduction of biphasic defibrillator wave forms, which may reduce the required energy, as well as possible complications, while offering an increase in the efficacy of defibrillation and a reduction in defibrillator size. Scientific emergency medicine is responsible not only for the development and validation of new methods and concepts, but in particular for their application under quality control conditions. Politicians require an improvement in the quality of the validation of emergency measures, although the instruments available for the investigation of these measures are known to be obsolete (experimental models, experimental design). Additionally, the financial support of research in emergency medicine suffers from being accourded low priority by public research funds such as the German Research Fund. However, in view of the rapid application of experimental results to daily practice it should be emphasized that patients also support research in emergency medicine via their direct financial contributions to the health insurance companies.

Variation in outcome after acute upper gastrointestinal haemorrhage. The National Audit of Acute Upper Gastrointestinal Haemorrhage.

Hospital mortality after acute upper gastrointestinal haemorrhage varies widely. In a population-based, multi-centre, prospective survey of the management and outcome of unselected cases of acute upper gastrointestinal haemorrhage, we have assessed the effect of risk standardisation on this variation. We collected data from 74 acute hospitals in four health regions in the UK on patients aged 16 years and over who presented with acute upper gastrointestinal haemorrhage during 4 months in 1993 (3981 cases) and 3 months in 1994 (1584 cases). The overall mortality was 14.3% (798/5565). Crude mortality in individual hospitals ranged from 0% to 29%, and differed significantly from the overall rate in eight. Risk-standardised mortality ratios were calculated with a risk score derived from well-established risk factors. Only two hospitals had standardised mortality ratios significantly different from the reference value. When hospitals were ranked in order of increasing mortality, risk standardisation for age, shock, and comorbidity resulted in 21 of the 74 hospitals changing ranks by ten or more places. After further standardisation for diagnosis, endoscopic stigmata of recent haemorrhage, and rebleeding, 32 hospitals moved ten or more places from their original rank; one hospital moved 45 places. Risk standardisation to correct for variation in case mix results in apparently significant differences in mortality rates becoming non-significant. The current state of routine data collection does not allow for anything but the most basic case-mix adjustment to be made. Simple league tables of crude mortality are misleading in this disorder and cannot be regarded as a reflection of the quality of health care.

Effect of maximizing oxygen delivery on morbidity and mortality rates in critically ill patients: a prospective, randomized, controlled study.

OBJECTIVE: To determine the effects of optimizing oxygen delivery (DO2) to "supranormal" levels on morbidity and mortality in patients with sepsis, septic shock, and adult respiratory distress syndrome. DESIGN: A prospective, randomized, controlled trial. SETTING: A 16-bed surgical intensive care unit (ICU) and 14-bed mixed medical/surgical ICU in two separate hospitals in the University of Hawaii Surgical and Internal Medicine Residency programs. PATIENTS: During a 1-yr period, 67 patients who had pulmonary artery catheters and who met the criteria for sepsis or septic shock, adult respiratory distress syndrome, or hypovolemic shock were enrolled in the study. Patients admitted to the ICU who were < 18 yrs old, or with a do-not-resuscitate order, or those patients who faced imminent death (< 24 hrs), such as those patients with uncontrollable hemorrhage or brain death, were excluded from the study. INTERVENTIONS: Patients were randomized into treatment and control groups. The treatment group was assigned a therapeutic DO2 indexed (DO2I) goal of > 600 mL/min/m2. Interventions to attain this goal included fluid boluses, administration of blood products, and the use of inotropes. The control group was not assigned to a specific therapeutic goal other than "normal" values of DO2I of 450 to 550 mL/min/m2. Every attempt was made to reach the therapeutic goals within the first 24 hrs after entry into the study. Hemodynamic measurements were obtained on study patients every 4 hrs until the end of the study. The severity of illness was evaluated using the Therapeutic Intervention Scoring System, and the Acute Physiology and Chronic Health Evaluation II scoring system. MEASUREMENTS AND MAIN RESULTS: There were 32 patients in the control group and 35 patients in the treatment group. The groups were similar in age, sex, number of organ dysfunctions, Acute Physiology and Chronic Health Evaluation II and Therapeutic Intervention scores. There were no statistical differences between the two groups in mortality, development of organ failure, ICU days, and hospital days. Upon analysis, it became apparent that the patients comprised clinically distinct subgroups, including: a) a treatment group who achieved supranormal DO2I; b) a control group with normal DO2I; c) a treatment group who failed to reach target DO2I; d) a control group who self-generated to high DO2I values; and e) a small number of patients who could not even reach a normal DO2I of 450 mL/min/m2. These subgroups were found to be similar and matched. The mortality rate was significantly lower for patients in groups who reached supranormal values of DO2I whether treated or self-generated as compared with patients who reached normal DO2I values (14% vs. 56%, p = .01). CONCLUSIONS: Although there was no statistically significant difference in the control vs. treatment groups, subgroup analysis demonstrated a strong, significant difference between patients with supranormal values of oxygen transport vs. patients with normal levels of DO2. Supranormal values of DO2I, whether self-generated or as a result of treatment, resulted in a statistically significant decrease in mortality rate. This study adds to the weight of evidence that current standard of care of treating critically ill patients to normal DO2I should be reconsidered, and that maximizing to high DO2I might be a more appropriate therapeutic end-point.

[Cardiopulmonary resuscitation performed by laymen--the Nord-Gudbrandsdal Project--circulatory arrest in sparsely populated regions]. / Hjerte-lunge-redning foretatt av lekfolk--Prosjekt Nord-Gudbrandsdal--sirkulasjonsstans i grisgrendte strøk.

Previous investigations from densely populated areas have shown that more patients with prehospital circulatory arrest caused by ischemic heart disease can be successfully treated by strengthening a chain of survival. This chain consists of immediate alarm followed by prompt cardiopulmonary resuscitation, early defibrillation and advanced medical support before transportation to hospital. This paper describes the methods used in the training of lay people in cardiopulmonary resuscitation, as well as how ambulance personnel were trained to use a semiautomatic defibrillator. During the period 1987-89 11.7% of the inhabitants in Nord-Gudbrandsdal attended a course in heart lung resuscitation and all the ambulance personnel were trained and certified to use Heartstart 2000 semiautomatic defibrillators.

A comparison of mortality and charges in two differently staffed intensive care units.

All patients entering the two differently staffed adult intensive care units (ICUs) of Baystate Medical Center were studied for a three-month period. In one unit, patients were cared for by medical and surgical resident teams specifically assigned to the ICU, who were supervised by private and teaching ICU attending physicians; patients admitted to the other ICU were cared for entirely by private physicians. Significantly lower hospital mortality rates were observed in the resident-staffed ICU for three categories of patients. Median charges for the two groups of ICU patients were either the same or higher for the resident-staffed ICU when controlling for levels of condition and treatment variables.