[Critical care of Onco-hematology patients: new therapeutic targets, new complications and new admission policies]. / Réanimation des patients d'onco-hématologie: nouvelles thérapeutiques, nouvelles complications, nouveaux contrats d'admission.

Overall prognosis of cancer or haematological has dramatically decreased over the last decades. Thus advances regarding cancer or haematological treatment, improved knowledge of usual complications and of their pathophysiology and changes in ICU admission policy and management are among factors which participated to the overall prognostic changes. Tyrosine-Kinase inhibitors in patients with chronic myeloid leukemia and anti-CD20 antibodies in patients with non-hodgkin's lymphoma were among the first success of targeted therapies. These success stories have been followed by others and no less than 13 targeted therapies were available for cancer patients in December 2013. Additionally, pathophysiology of complication is better understood and prognostic impact of organ failure better apprehended. Standardized diagnostic criteria of tumor lysis syndrome along with improved understanding of short-term and long term influence of acute kidney injury (AK) in this setting have led to specific management strategiesfocusing on prevention. In non-malignant haematological diseases, pathophysiological processes leading to thrombotic thrombocytopenic purpura or atypical haemolytic and uremic syndrome are now better understood leading to additional therapeutic options. Last, diversification of ICU admission policies may help in taking into account uncertainties, therapeutic advances and patients' autonomy. This review will give an overview of these recent advances.

[Burn out syndrome among critical care workers]. / Epuisement professionnel en réanimation.

Burnout syndrome (BOS) is a psychological state resulting from prolonged exposure to job stressors. Because intensive care units (ICUs) are characterized by a high level of work-related stress, we reviewed the available literature on BOS among ICU-healthcare workers. Recent studies suggest that severe BOS (measured with the Maslach Burnout Inventory) is present in about half of all critical care physicians and one-third of critical care nurses. Interestingly, the determinants of BOS difer between the two groups of caregivers. Intensivists with severe BOS tend to be those with a large number of working hours (number of night shifts, and time since last vacation), whereas severe BOS among ICU nurses is mainly related to ICU organization and end-of-life care policy. ICU conflicts were independent predictors of severe BOS in both groups. Recent studies also identify potential preventive measures, such as ICU working groups, better communication during end-of-life care, and prevention and management of ICU conflicts.

Outcome prediction in critical care: the Simplified Acute Physiology Score models.

PURPOSE OF REVIEW: Outcome prediction models measuring severity of illness of patients admitted to the intensive care unit should predict hospital mortality. This review describes the state-of-the-art of Simplified Acute Physiology Score models from the clinical and managerial perspectives. Methodological issues concerning the effects of differences between new samples and original databases in which the models were developed are considered. RECENT FINDINGS: The progressive lack of fit of the Simplified Acute Physiology Score II in independent intensive care unit populations induced investigators to propose customizations and expansions as potential evolutions for Simplified Acute Physiology Score II. We do not know whether those solutions did solve the issue because there are no demonstrations of consistent good fit in new databases. The recently developed Simplified Acute Physiology Score 3 Admission Score with customization for geographical areas is discussed. The points shared by the Simplified Acute Physiology Score models and the pros and cons for each of them are introduced. SUMMARY: Comparisons of intensive care unit performance should take into account not only the patient severity of illness, but also the effect of the 'intensive care unit variable', that is, differences in human resources, structure, equipment, management and organization of the intensive care unit. In the future, moving from patient and geographical area adjustment to resource use could allow the user to adjust for differences in healthcare provision.

[Performance of adult intensive care units. Thirty years' experience]. / Comment évaluer la performance d'un service de réanimation d'adultes? Une expérience de 30 ans.

ICU performance can be evaluated by using the standard mortality ratio (SMR), but the points of view of the patients, families, and medical and non medical staff must also be taken in account. The SMR is the ratio between the observed (O) and predicted hospital mortality rates (P), based on a statistical model. If for 100 consecutive unselected patients the O/P ratio is less than 1, then the performance is considered good, and otherwise as bad. Most studies show good post-ICU quality of life. Management of dying patients in the ICU is an important issue. Families are stressed, both during and after the ICU stay, and they often have signs of anxiety and depression. It is illogical to involve them in hard decisions such as halting active therapy. Medical and non medical staff are also under pressure and may suffer from the burn-out syndrome. Causes include conflicts among doctors, or between doctors and nurses. There is a close relationship between ICU organisation and performance: good management makes for high performance.

Outcome of cancer patients considered for intensive care unit admission: a hospital-wide prospective study.

PURPOSE: To evaluate the outcome of cancer patients considered for admission to the intensive care unit (ICU). PATIENTS AND METHODS: Prospective, one-year hospital-wide study of all cancer and hematology patients, including bone marrow transplantation patients, for whom admission to the ICU was requested. RESULTS: Of the 206 patients considered for ICU admission, 105 patients (51%) were admitted. Of the 101 patients who were not admitted, 54 patients (26.2%) were considered too sick to benefit, and 47 patients (22.8%) were considered to be too well to benefit from the ICU. Of these 47 patients, 13 patients were admitted later. Survival rates after 30 and 180 days were significantly associated with admission status (P < .0001). Remission of the malignancy (odds ratio [OR], 3.37; 95% CI, 1.25 to 9.07) was independently associated with ICU admission, whereas poor chronic health status (OR, 0.38; 95% CI, 0.16 to 0.74) and solid tumor (OR, 0.43; 95% CI, 0.24 to 0.78) were associated with ICU refusal. In admitted patients, 30-day and 6-month survival rates were 54.3% and 32.4%, respectively. Of the patients considered too sick to benefit from ICU admission, 26% were alive on day 30 and 16.7% on day 180. Among patients considered too well to benefit, the 30-day survival rate was a worrisome 78.7%. Calibration of the Mortality Probability Model (the only score available at triage) was of limited value for predicting 30-day survival (area under the curve, 0.62). CONCLUSION: Both the excess mortality in too-well patients later admitted to the ICU and the relatively good survival in too-sick patients suggest the need for a broader admission policy.

An evaluation of systemic inflammatory response syndrome signs in the Sepsis Occurrence In Acutely Ill Patients (SOAP) study.

OBJECTIVE: To define the frequency and prognostic implications of SIRS criteria in critically ill patients hospitalized in European ICUs. DESIGN AND SETTING: Cohort, multicentre, observational study of 198 ICUs in 24 European countries. PATIENTS AND INTERVENTIONS: All 3,147 new adult admissions to participating ICUs between 1 and 15 May 2002 were included. Data were collected prospectively, with common SIRS criteria. RESULTS: During the ICU stay 93% of patients had at least two SIRS criteria [respiratory rate (82%), heart rate (80%)]. The frequency of having three or four SIRS criteria vs. two was higher in infected than non-infected patients (p < 0.01). In non-infected patients having more than two SIRS criteria was associated with a higher risk of subsequent development of severe sepsis (odds ratio 2.6, p < 0.01) and septic shock (odds ratio 3.7, p < 0.01). Organ system failure and mortality increased as the number of SIRS criteria increased. CONCLUSIONS: Although common in the ICU, SIRS has prognostic importance in predicting infections, severity of disease, organ failure and outcome.

Post-ICU mortality in critically ill infected patients: an international study.

OBJECTIVE: To determine the incidence and risk factors for post-ICU mortality in patients with infection. DESIGN AND SETTING: International observational cohort study including 28 ICUs in eight countries. PATIENTS: All 1,872 patients discharged alive from the ICU over a 1-year period were screened for infection at ICU admission and daily throughout the ICU stay. Outcomes at ICU and hospital discharge were recorded. MEASUREMENTS AND RESULTS: Post-ICU death occurred in 195 (10.4%) patients and was associated in the multivariable analysis with age, chronic respiratory failure, immunosuppression, cirrhosis, Simplified Acute Physiology Score II on the first day with infection, and LOD score at ICU discharge. Post-ICU death was more common among medical patients and patients with hospital-acquired infection or microbiologically documented infection and was less common in patients with pneumonia. CONCLUSIONS: Post-ICU death in patients with infection was within previously reported ranges in overall ICU populations. The main risk factors were patient and infection characteristics, severity at ICU admission, and persistent organ dysfunction at ICU discharge. Further interventions such as further ICU management, discharge to a step-down unit, or follow-up by intensivists on the ward should be evaluated in patients with a high risk of post-ICU mortality.

SAPS 3--From evaluation of the patient to evaluation of the intensive care unit. Part 2: Development of a prognostic model for hospital mortality at ICU admission.

OBJECTIVE: To develop a model to assess severity of illness and predict vital status at hospital discharge based on ICU admission data. DESIGN: Prospective multicentre, multinational cohort study. PATIENTS AND SETTING: A total of 16,784 patients consecutively admitted to 303 intensive care units from 14 October to 15 December 2002. MEASUREMENTS AND RESULTS: ICU admission data (recorded within +/-1 h) were used, describing: prior chronic conditions and diseases; circumstances related to and physiologic derangement at ICU admission. Selection of variables for inclusion into the model used different complementary strategies. For cross-validation, the model-building procedure was run five times, using randomly selected four fifths of the sample as a development- and the remaining fifth as validation-set. Logistic regression methods were then used to reduce complexity of the model. Final estimates of regression coefficients were determined by use of multilevel logistic regression. Variables selection and weighting were further checked by bootstraping (at patient level and at ICU level). Twenty variables were selected for the final model, which exhibited good discrimination (aROC curve 0.848), without major differences across patient typologies. Calibration was also satisfactory (Hosmer-Lemeshow goodness-of-fit test H=10.56, p=0.39, C=14.29, p=0.16). Customized equations for major areas of the world were computed and demonstrate a good overall goodness-of-fit. CONCLUSIONS: The SAPS 3 admission score is able to predict vital status at hospital discharge with use of data recorded at ICU admission. Furthermore, SAPS 3 conceptually dissociates evaluation of the individual patient from evaluation of the ICU and thus allows them to be assessed at their respective reference levels.

SAPS 3--From evaluation of the patient to evaluation of the intensive care unit. Part 1: Objectives, methods and cohort description.

OBJECTIVE: Risk adjustment systems now in use were developed more than a decade ago and lack prognostic performance. Objective of the SAPS 3 study was to collect data about risk factors and outcomes in a heterogeneous cohort of intensive care unit (ICU) patients, in order to develop a new, improved model for risk adjustment. DESIGN: Prospective multicentre, multinational cohort study. PATIENTS AND SETTING: A total of 19,577 patients consecutively admitted to 307 ICUs from 14 October to 15 December 2002. MEASUREMENTS AND RESULTS: Data were collected at ICU admission, on days 1, 2 and 3, and the last day of the ICU stay. Data included sociodemographics, chronic conditions, diagnostic information, physiological derangement at ICU admission, number and severity of organ dysfunctions, length of ICU and hospital stay, and vital status at ICU and hospital discharge. Data reliability was tested with use of kappa statistics and intraclass-correlation coefficients, which were >0.85 for the majority of variables. Completeness of the data was also satisfactory, with 1 [0-3] SAPS II parameter missing per patient. Prognostic performance of the SAPS II was poor, with significant differences between observed and expected mortality rates for the overall cohort and four (of seven) defined regions, and poor calibration for most tested subgroups. CONCLUSIONS: The SAPS 3 study was able to provide a high-quality multinational database, reflecting heterogeneity of current ICU case-mix and typology. The poor performance of SAPS II in this cohort underscores the need for development of a new risk adjustment system for critically ill patients.

Mortality prediction using SAPS II: an update for French intensive care units.

INTRODUCTION: The standardized mortality ratio (SMR) is commonly used for benchmarking intensive care units (ICUs). Available mortality prediction models are outdated and must be adapted to current populations of interest. The objective of this study was to improve the Simplified Acute Physiology Score (SAPS) II for mortality prediction in ICUs, thereby improving SMR estimates. METHOD: A retrospective data base study was conducted in patients hospitalized in 106 French ICUs between 1 January 1998 and 31 December 1999. A total of 77,490 evaluable admissions were split into a training set and a validation set. Calibration and discrimination were determined for the original SAPS II, a customized SAPS II and an expanded SAPS II developed in the training set by adding six admission variables: age, sex, length of pre-ICU hospital stay, patient location before ICU, clinical category and whether drug overdose was present. The training set was used for internal validation and the validation set for external validation. RESULTS: With the original SAPS II calibration was poor, with marked underestimation of observed mortality, whereas discrimination was good (area under the receiver operating characteristic curve 0.858). Customization improved calibration but had poor uniformity of fit; discrimination was unchanged. The expanded SAPS II exhibited good calibration, good uniformity of fit and better discrimination (area under the receiver operating characteristic curve 0.879). The SMR in the validation set was 1.007 (confidence interval 0.985-1.028). Some ICUs had better and others worse performance with the expanded SAPS II than with the customized SAPS II. CONCLUSION: The original SAPS II model did not perform sufficiently well to be useful for benchmarking in France. Customization improved the statistical qualities of the model but gave poor uniformity of fit. Adding simple variables to create an expanded SAPS II model led to better calibration, discrimination and uniformity of fit, producing a tool suitable for benchmarking.

The prognosis of acute respiratory failure in critically ill cancer patients.

Acute respiratory failure (ARF) in patients with cancer is frequently a fatal event. To identify factors associated with survival of cancer patients admitted to an intensive care unit (ICU) for ARF, we conducted a prospective 5-year observational study in a medical ICU in a teaching hospital in Paris, France. The patients were 203 cancer patients with ARF mainly due to infectious pneumonia (58%), but also noninfectious pneumonia (9%), congestive heart failure (12%), and no identifiable cause (21%). We measured clinical characteristics and ICU and hospital mortality rates.ICU mortality was 44.8% and hospital mortality was 47.8%. Noninvasive mechanical ventilation was used in 79 (39%) patients and conventional mechanical ventilation in 114 (56%), the mortality rates being 48.1% and 75.4%, respectively. Among the 14 patients with late noninvasive mechanical ventilation failure (>48 hours), only 1 survived. The mortality rate was 100% in the 19 noncardiac patients in whom conventional mechanical ventilation was started after 72 hours. By multivariable analysis, factors associated with increased mortality were documented invasive aspergillosis (odds ratio [OR], 2.13; 95% confidence intervals [CI], 1.05-14.74), no definite diagnosis (OR, 3.85; 95% CI, 1.26-11.70), vasopressors (OR, 3.19; 95% CI, 1.28-7.95), first-line conventional mechanical ventilation (OR, 8.75; 95% CI, 2.35-35.24), conventional mechanical ventilation after noninvasive mechanical ventilation failure (OR, 17.46; 95% CI, 5.04-60.52), and late noninvasive mechanical ventilation failure (OR, 10.64; 95% CI, 1.05-107.83). Hospital mortality was lower in patients with cardiac pulmonary edema (OR, 0.16; 95% CI, 0.03-0.72). Survival gains achieved in critically ill cancer patients in recent years extend to patients requiring ventilatory assistance. The impact of conventional mechanical ventilation on survival depends on the time from ICU admission to conventional mechanical ventilation and on the patient's response to noninvasive mechanical ventilation.

High-dose plasma infusion versus plasma exchange as early treatment of thrombotic thrombocytopenic purpura/hemolytic-uremic syndrome.

Thrombotic thrombocytopenic purpura and adult hemolytic-uremic syndrome (TTP/HUS) have a substantial mortality rate even with currently available treatments. Although therapeutic plasma exchange is the recommended treatment of TTP/HUS, this cumbersome procedure may not be available for all patients in an emergency. In this context, plasma infusion may represent an alternative first-line therapy. We compared the effectiveness of high-dose plasma infusion (25-30 mL/kg per day) and therapeutic plasma exchange as first-line treatment of adult TTP/HUS at a single center. Two groups of patients with TTP/HUS were identified according to their initial therapy, that is, high-dose plasma infusion (19 patients) and therapeutic plasma exchange (18 patients). Clinical charts and outcomes were retrospectively analyzed. Endpoints for comparison were the duration of platelet counts below 150 x 10 /L and LDH levels above normal values; the volumes of plasma administered and the duration of treatment; complete remission, relapse, and mortality rates; and treatment-related complications. Patients of the 2 groups had comparable clinical and laboratory features on admission. Sixteen patients achieved complete remission in each group. Median times to recovery of platelet counts and LDH levels were comparable between the 2 groups. Eight patients in the high-dose plasma infusion (HD-PI) group were switched to therapeutic plasma exchange because of fluid overload (6 patients), persistent biologic disturbances (1 patient), or unresponsiveness to high-dose plasma infusion treatment (1 patient). This latter patient had severe TTP/HUS that remained refractory to therapeutic plasma exchange and vincristine, and rapidly died. All 7 remaining patients achieved complete remission with therapeutic plasma exchange. Four patients in the HD-PI group and 3 patients in the therapeutic plasma exchange (TPE) group died. In the HD-PI group, 5 patients experienced a transient nephrotic-range proteinuria during treatment. Main complications in the TPE group were collapse (1 patient) and central venous catheter infection (2 patients) or thrombosis (1 patient). Three patients in each group relapsed. High-dose plasma infusion may be an efficient treatment of TTP/HUS in patients who cannot have early plasma exchange. However, the large volumes of plasma required to reach complete remission may result in fluid overload, which may necessitate subsequent therapeutic plasma exchange.

Clinically documented pleural effusions in medical ICU patients: how useful is routine thoracentesis?

STUDY OBJECTIVES: To assess the impact of routine thoracentesis on diagnostic assessment and therapeutic measures in patients with clinically documented pleural effusions. DESIGN AND SETTING: Prospective, 1-year, three-center study in medical ICU (MICU) patients with physical and radiographic evidence of pleural effusion. PATIENTS: Of 1,351 patients admitted to three MICUs during the study period, 113 patients had physical and radiographic evidence of pleural effusion, yielding an annual incidence of 8.4%. INTERVENTION: Routine thoracentesis in 82 patients without contraindications to thoracentesis. MEASUREMENTS AND RESULTS: Twenty patients (24.4%) had a transudate, 35 patients (42.7%) had an infectious exudate (parapneumonic, n = 21; empyema, n = 14), and 27 patients (32.9%) had a noninfectious exudate. Laboratory parameters including the leukocyte count, the neutrophil percentage in pleural fluid, and the fluid/serum protein and lactate dehydrogenase ratios differed significantly among the three groups. Thoracentesis yielded improvements in the diagnosis and/or treatment in 46 patients (56%): the presumptive (prethoracentesis) diagnosis was changed in 37 patients (32 patients with certain benefit and 5 patients with probable benefit from thoracentesis), of whom 27 patients received a change in treatment based on the new diagnosis; 9 other patients received a change in treatment although the diagnosis remained the same. The only complications were pneumothorax in six patients (7%), all with a favorable outcome after drainage. CONCLUSION: Infection was the main cause of pleural effusions detected based on physical and radiographic findings in our MICU population. Routine thoracentesis proved a simple and safe means of improving the diagnosis and treatment.

Critically ill patients readmitted to intensive care units--lessons to learn?

OBJECTIVE: To evaluate risk factors in critically ill patients who were readmitted to an intensive care unit (ICU) during their hospital stay. DESIGN: Prospective multicenter cohort study. PATIENTS AND SETTING: A total of 15180 patients discharged from 30 medical, surgical and mixed ICUs in Austria over a 2-year period. MEASUREMENTS AND RESULTS: The data analyzed included data on patients' clinical characteristics, Simplified Acute Physiology Score II (SAPS II), Logistic Organ Dysfunction system (LOD), Simplified Therapeutic Intervention Scoring System (TISS-28), length of ICU stay, ICU mortality and hospital mortality. Of the 15180 patients who survived the first ICU stay, 780 patients (5.1%) were readmitted. These patients had more than a fourfold risk of dying during their hospital stay (21.7 vs 5.2%, p<0.001). For mechanically ventilated patients, the time between extubation and discharge during the first ICU stay was significantly shorter for readmitted than for non-readmitted patients (median 1 vs 2 days, p<0.001). On the day of their first ICU discharge, readmitted patients were in greater need of organ support, with more patients still requiring ventilatory, cardiovascular and renal support than non-readmitted patients. CONCLUSIONS: The results of this study provide evidence that there exists a group of patients at higher risk of readmission to the ICU. At the time of their first ICU discharge, these patients presented with residual organ dysfunctions, which were associated with an increased risk of being readmitted. Optimizing organ functions in these patients before discharge from the ICU could result in reduced readmission rates.

Impact of neutropenia duration on short-term mortality in neutropenic critically ill cancer patients.

OBJECTIVE: To identify predictors of 30-day mortality and to assess the impact of neutropenia recovery (NR) on 30-day mortality in critically ill cancer patients (CICPs). DESIGN AND SETTING: Retrospective review of the medical records of the 102 neutropenic CICPs admitted to a medical intensive care unit (ICU) over a 10-year period. INTERVENTION: None. MEASUREMENTS AND RESULTS: Malignancies consisted of acute leukemia (n=42), lymphoma (n=23), myeloma (n=28), and solid tumors (n=9). Reasons for ICU admission were acute respiratory failure (n=81), shock (n=58), acute renal failure (n=33), and coma (n=13). Seventy patients needed conventional mechanical ventilation (MV) and 21 noninvasive MV, 67 vasopressor agents, and 28 dialysis. Sixty-two patients experienced NR during their ICU stay. In a multivariate logistic regression model, 30-day mortality was higher in patients with acute respiratory or renal failure and lower in patients with NR (OR, 0.09 [0.01-0.86]). This model assumed that patients who experienced NR in the ICU were merely these who did not die early in the ICU. To take into account the effect of time to occurrence of NR on time to death we secondarily used a Cox model including neutropenia duration and NR as time-dependent variables. In this second model, the only significant predictors of 30-day mortality were age, respiratory failure, renal failure, and coma. CONCLUSION: Organ failure but not disease progression or neutropenia duration affect 30-day mortality in neutropenic CICPs. ICU-acquired events might be modeled as time-dependent variables in a Cox model, rather than standard covariates in logistic regression models.

Infectious diseases as a trigger in thrombotic microangiopathies in intensive care unit (ICU) patients?

OBJECTIVE: Thrombotic microangiopathy (TMA) has been associated with a large number of underlying diseases. We conducted a descriptive, retrospective study including all TMA adult patients admitted to our ICU, with a particular interest in infectious episodes as a trigger of TMA. PATIENTS: All adult patients (30) with a diagnosis of TMA admitted to the medical ICU at Saint-Louis Hospital (Paris, France) between 1992 and 1998 were retrospectively included. METHODS: All patients with clinical and microbiological evidence of bacterial infection were treated with intravenous antibiotics. The specific treatment of TMA consisted in solvent/detergent-treated plasma administration by plasma exchange or high volume plasma infusion (30 ml/kg per day) in fractionated doses. RESULTS: Among the 30 adult patients studied, TMA in 16 (53%) was associated with microbiologically documented infection. An acute infection was found in 8/9 patients with an HIV-related TMA, in 2/6 patients with a systemic lupus erythematosus (SLE)-related TMA and in 3/6 patients with TMA associated with other disorders. In three patients, an acute infectious disease was the only cause associated with the TMA. Four other patients had clinical manifestations suggesting an infection process but without bacteriological documentation. Escherichia coli was isolated in 7/16 cases and verotoxin was found in the stools of two other patients. All patients were treated with plasma administration and those with evidence of infection were systematically and intensively treated with antibiotics. Eventually 8 patients died (27%), 20 (67%) reached complete remission and 2 partial remission. CONCLUSION: Bacterial infections are commonly observed amongst TMA patients hospitalized in ICUs and may act as a trigger of this disease. Screening for infection is a requirement in patients with TMA, either idiopathic or associated with other conditions.

Improved survival of critically ill cancer patients with septic shock.

OBJECTIVE: To identify predictors of 30-day mortality in critically ill cancer patients with septic shock. DESIGN: Retrospective study over a 6-year period. SETTING: Twelve-bed medical intensive care unit (ICU). PATIENTS: Eighty-eight patients (55 men, 33 women) aged 55 (43.5-63) years admitted to the ICU for septic shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eighty (90.9%) patients had hematological malignancies and eight (9.1%) had solid tumors; 47 patients (53.4%) were neutropenic, 19 (21.6%) were hematopoietic stem cell transplantation (HSCT) recipients, and 27 (30.7%) were in remission. Microbiologically documented infections were found in 60 (68.2%) patients. The Simplified Acute Physiologic Score II (SAPS II) and Logistic Organ Dysfunction (LOD) scores at ICU admission were 66 (47-89) and 7 (5-10), respectively, and the LOD score on day 3 was 8 (4-10). Sixty-eight (78.1%) patients received invasive mechanical ventilation (MV), 12 (13.6%) noninvasive MV, 22 (25%) dialysis. Thirty-day mortality was 65.5% (57/88). By multivariable analysis, mortality was higher when time to antibiotic treatment was >2 h [odds ratio (OR), 7.05; 95% confidence interval (95% CI), 1.17-42.21] and when DLOD (day 3-day 1 LOD score/day 3 LOD score) was high (OR, 3.47; 95% CI, 1.44-8.39); mortality was lower when admission occurred between 1998 and 2000 (OR, 0.23; 95% CI, 0.05-0.98) and when initial antibiotics were adapted (OR, 0.24; 95% CI, 0.06-0.09). CONCLUSIONS: Earlier ICU admission and antibiotic treatment of critically ill cancer patients with septic shock is associated with higher 30-day survival. The LOD score change on day 3 as compared to admission is useful for predicting survival.

Family participation in care to the critically ill: opinions of families and staff.

BACKGROUND: Allowing family members to participate in the care of patients in intensive care units (ICUs) may improve the quality of their experience. No previous study has investigated opinions about family participation in ICUs. METHODS: Prospective multicenter survey in 78 ICUs (1,184 beds) in France involving 2,754 ICU caregivers and 544 family members of 357 consecutive patients. We determined opinions and experience about family participation in care; comprehension (of diagnosis, prognosis, and treatment) and satisfaction (Critical Care Family Needs Inventory) scores to assess the effectiveness of information to families and the Hospital Anxiety and Depression score for family members. RESULTS: Among caregivers 88.2% felt that participation in care should be offered to families. Only 33.4% of family members wanted to participate in care. Independent predictors of this desire fell into three groups: patient-related (SAPS II at ICU admission, OR 0.984); ICU stay length, OR 1.021), family-related (family member age, OR 0.97/year); family not of European descent, OR 0.294); previous ICU experience in the family, OR 1.59), and those related to emotional burden and effectiveness of information provided to family members (symptoms of depression in family members, OR 1.58); more time wanted for information, OR 1.06). CONCLUSIONS: Most ICU caregivers are willing to invite family members to participate in patient care, but most family members would decline.

Measuring performance in health care: case-mix adjustment by boosted decision trees.

OBJECTIVE: The purpose of this paper is to investigate the suitability of boosted decision trees for the case-mix adjustment involved in comparing the performance of various health care entities. METHODS: First, we present logistic regression, decision trees, and boosted decision trees in a unified framework. Second, we study in detail their application for two common performance indicators, the mortality rate in intensive care and the rate of potentially avoidable hospital readmissions. RESULTS: For both examples the technique of boosting decision trees outperformed standard prognostic models, in particular linear logistic regression models, with regard to predictive power. On the other hand, boosting decision trees was computationally demanding and the resulting models were rather complex and needed additional tools for interpretation. CONCLUSION: Boosting decision trees represents a powerful tool for case-mix adjustment in health care performance measurement. Depending on the specific priorities set in each context, the gain in predictive power might compensate for the inconvenience in the use of boosted decision trees.

[Epidemiology of infection and sepsis in intensive care unit patients]. / Epidémiologie de l'infection et des états septiques en réanimation. Résultats d'une étude de cohorte internationale.

Since 1992, epidemiological and clinical studies have classified severe infections into three categories: sepsis, severe sepsis and septic shock. Microbiological documentation is not always provided. We used a different approach, focusing on the infection itself, whether or not it is microbiologically documented or associated with sepsis. In an international prospective cohort study, all patients admitted to the participating units from May 1997 to May 1998 were followed until hospital discharge. Twenty-eight intensive care units (ICU) in eight countries enrolled 14,364 patients. Of these, 6011 stayed in the ICU for less than 24 hours and 8353 for more than 24 hours. Overall, 3034 infectious episodes were recorded at ICU admission (crude incidence rate 21.1%). Among patients hospitalized for more than 24 hours, 1581 infectious episodes occurred in the ICU (crude incidence rate 18.9%), including 713 cases (45%) in patients who were already infected at ICU admission. These rates varied among the ICUs. Respiratory, gastrointestinal, urinary tract and primary bloodstream infections represented about 80% of all infections. Hospital-acquired and Intensive Care Unit-acquired infections were more frequently microbiologically documented than community-acquired infections (71% and 86%, respectively, vs 55%). About 28% of all infections were associated with sepsis, 24% with severe sepsis and 30% with septic shock (18% were not classified). Crude in-hospital mortality rates ranged from 16.9% in uninfected patients to 53.6% in patients who were both infected at the time of ICU admission and subsequently acquired an infection during the ICU stay. The in-hospital mortality rate increased with severity, from 20% for sepsis to 40% for severe sepsis and 60% for septic shock, but also depended on the origin of infection (community vs hospital/ICU). Crude incidence rates of ICU infection were high, varying among ICUs and patient subsets. Thus, vital outcome depends not only on the severity of sepsis but also on the characteristics of the infection.