Fluid balance and weaning outcomes.

OBJECTIVE: To examine the relationship of fluid balance and weaning outcomes. METHODS: We prospectively collected demographic, physiological, daily fluid balance (measured inputs minus outputs), and weaning data from 87 mechanically ventilated patients. PATIENTS: We examined 87 patients, a median age of 66 years, APACHE II of 22, and performed 205 breathing trials (BT); 38 patients (44%) were successfully extubated after their first BT with minimal or no pressure support. RESULTS: Positive fluid balance (inputs>outputs) in the 24, 48, and 72 h and cumulatively (from hospital admission) prior to weaning were significantly greater in weaning failures than successes. Both univariate and multivariate analyses, adjusted for duration of mechanical ventilation and presence of chronic obstructive pulmonary disease, showed negative cumulative fluid balance 24 h prior to BTs (OR=2.9) and cumulative fluid balance (OR=3.4) to be independently associated with first-day weaning success. Similar relationships were demonstrated when all weaning attempts were analyzed. Negative fluid balance was as predictive of weaning outcomes as f/V(t) (likelihood of success was 1.7 for patients with negative fluid balance 24 h prior to weaning and 1.2 for those with f/Vt<100 min-1 l-1). Although administration of diuretics was associated with more negative fluid balance, it was not independently associated with weaning outcomes. CONCLUSIONS: These data suggest that fluid balance, a potentially modifiable factor, is associated with weaning outcomes. A randomized study is required to determine whether diuresis to treat positive fluid balance expedites liberation from mechanical ventilation.

Patients' understanding of advance directives and cardiopulmonary resuscitation.

OBJECTIVE: To describe understanding of end-of-life issues and compare characteristics of patients with and without advance directives. SETTING: A 325-bed community teaching hospital. MEASUREMENTS: Questionnaires were administered to all patients admitted to the medical-surgical wards. RESULTS: Of 755 patients admitted during the study period, 264 patients participated in the study, and 82 (31%) had living wills. Patients with living wills were more likely to be white, Protestant, and highly educated. Most (76%) created them with a lawyer or family member, whereas only 7% involved physicians. Although these patients were able to identify some components of cardiopulmonary resuscitation (CPR), few (19%) understood the prognosis after CPR. After explaining CPR, 37% of those with living wills did not want it, which was not stated in their directive or hospital record. If life-sustaining therapies were already started, 39% of these patients stated that they would not want CPR or mechanical ventilation if the likelihood of recovery was < or =10%. Patients without living wills either had not heard (18%) or did not know enough (51%) about them. After education, 5% did not want CPR, and 32% would terminate life-sustaining therapies if the likelihood of recovery was < or =10%. Seventy percent of these patients expressed interest in creating a living will. CONCLUSIONS: Patients with living wills understand poorly "life-sustaining therapies" and the implications of their advance directives. Most fail to involve physicians in creating directives. A significant number of those without living wills have end-of-life wishes that could be addressed by and appear open to the idea of creating advance directives.

Neurologic status, cough, secretions and extubation outcomes.

OBJECTIVE: To determine the degree to which neurologic function, cough peak flows and quantity of endotracheal secretions affected the extubation outcomes of patients who had passed a trial of spontaneous breathing (SBT). DESIGN: Prospective observational study. SETTING: The medical intensive care unit of a 325-bed teaching hospital. MEASUREMENTS AND MAIN RESULTS: Cough peak flow (CPF), endotracheal secretions and ability to complete four simple tasks were measured just before extubation in patients who had passed a SBT. Eighty-eight patients were studied; 14 failed their first trials of extubation. The CPF of patients who failed was lower than that of those who had a successful extubation (58.1+/-4.6 l/min vs 79.7+/-4.1 l/min, p=0.03) and those with CPF 60 l/min or less were nearly five times as likely to fail extubation compared to those with CPF higher than 60 l/min (risk ratio [RR]=4.8; 95% CI=1.4-16.2). Patients with secretions of more than 2.5 ml/h were three times as likely to fail (RR=3.0; 95% CI=1.0-8.8) as those with fewer secretions. Patients who were unable to complete four simple tasks (i.e. open eyes, follow with eyes, grasp hand, stick out tongue) were more than four times as likely to fail as those who completed the four commands (RR=4.3; 95% CI=1.8-10.4). There was synergistic interaction between these risk factors. The failure rate was 100% for patients with all three risk factors compared to 3% for those with no risk factors (RR=23.2; 95% CI=3.2-167.2). The presence of any two of the above risk factors had a sensitivity of 71 and specificity of 81% in predicting extubation failure. Patients who failed a trial of extubation were 3.8 times as likely to have any two risk factors compared to those who were successful. CONCLUSIONS: These simple, reproducible methods may provide a clinically useful approach to guiding the extubation of patients who have passed a SBT.

The effect of arterial blood gas values on extubation decisions.

BACKGROUND: No studies have examined the clinical utility of arterial blood gas (ABG) values during spontaneous breathing trials (SBTs) for making extubation decisions. Nonetheless many intensive care units measure ABGs during an SBT to determine, in conjunction with other data, whether the SBT was successful. OBJECTIVE: Determine how often ABG values change extubation decisions. METHODS: Each patient was assessed at the bedside by one of 3 critical care attending physicians. Each assessment was made at the end of the SBT in which ABGs were obtained with the expectation of extubation. When a nurse, respiratory therapist, or resident was available, he or she also simultaneously and independently evaluated the patient and then reassessed with the ABG values. Physiologic data were recorded before and during the SBT, as the attending physician performed the bedside assessment. RESULTS: Eighty-three patients were studied during 100 SBTs. Heart rate, respiratory rate, and mean blood pressure increased. Blood oxygen saturation (measured via pulse oximetry [F(IO)(2)]) and the P(aO)(2)/F(IO)(2) ratio decreased significantly during SBTs. Concordant clinical and ABG assessment (to attempt a trial of extubation) led to extubation in 86 patients, 76 of whom remained extubated after 72 hours. Following 14 of the SBTs, the patients were not extubated. Seven of these were judged by the attending physicians to fail both clinically and following review of ABG values. Seven were judged successful clinically, but the patients were not extubated because the attending physician thought the ABG values were unfavorable. Bedside nurses, who assessed 72 SBTs, had 1 case in which the ABG values changed their extubation opinion. Resident-trainees assessed 76 cases and had 5 changes of opinion based on ABG values. Respiratory therapists assessed 77 patients and had 4 such cases. The average changes in heart rate and blood pressure of patients not extubated were double those of extubated patients, but there were no significant differences in respiratory rate or P(aO)(2)/F(IO)(2) ratio between those groups. Ten patients (11.6%) were extubated based on the attending physician's decision but required re-intubation within 72 hours. CONCLUSION: These data suggest that ABG values did not change extubation decisions in 93% of cases. However, in 7 cases the ABG values changed the extubation decision. If even a few of those cases would have failed extubation without knowledge of the ABG values, the increased patient risk and cost associated with failed extubation would more than offset the relatively small cost of collecting ABG values from all patients who undergo SBT.

Informed consent for invasive medical procedures from the patient's perspective.

BACKGROUND: Written informed consent is not obtained uniformly for invasive medical procedures in critically ill patients across America. The general consent-to-treat is used by some institutions in lieu of separate, procedure-by-procedure consent. OBJECTIVES: To determine whether hospitalized patients recall the general consent-to-treat and to ascertain their preferences regarding informed consent for invasive medical procedures. METHODS: A questionnaire was administered to patients admitted to a 325-bed community teaching hospital. RESULTS: Of 265 patients who participated in the study, only 8% correctly recalled all of the elements of the general consent-to-treat. One hundred twelve respondents (42.3%) trusted their doctors to perform necessary medical procedures, "as long as they were told what was going to happen and why the medical procedure was needed." These patients were older (67 vs 62 years, P = 0.02) and were less likely to hold college or advanced degrees (33% vs 44%, P = 0.04). One hundred fifty-three patients wanted to know the important benefits, risks and alternatives, and to give written permission for performance of medical procedures. On further questioning, 29 (19%) of 153 patients responded that no medical procedure should be done without getting consent first. Forty-three (28%) thought procedures with complications in < 1% of cases should not require consent, while nine (6%) thought consent should be required at a threshold of 10% complications. One hundred patients (65%) responded that procedures with small and nonserious risks (i.e., IV's, bladder catheters) should not require separate written consent. CONCLUSIONS: The general consent-to-treat is not recalled well by hospitalized patients and is unlikely to suffice as informed consent for invasive medical procedures. A majority of patients do not want to have invasive procedures without first giving their informed consent.

Tuberculosis-induced tracheobronchial stenosis during pregnancy.

Central airway stenosis is extremely rare in pregnancy and could lead to respiratory and cardiovascular embarrassment, especially at the time of delivery. Initially, patients may not show obvious signs of respiratory difficulty. Early recognition of the disease and anticipatory management of a complicated delivery are very important. We present a pregnant patient with tuberculosis-induced severe tracheobronchial stenosis and discuss the management challenges of her delivery.

Thalidomide-Related Eosinophilic Pneumonia: A case report and brief literature review.

Thalidomide has regained value in the multimodality treatment of leprosy, multiple myeloma, prostate, ovarian and renal cancer. Complications related to arterial and venous complications are well described. However, pulmonary complications remain relatively uncommon. The most common pulmonary side-effect reported is non-specific dyspnea. We report a patient with multiple myeloma, who developed an eosinophilic pneumonia, shortly after starting thalidomide. She had complete resolution of her symptoms and pulmonary infiltrates on discontinuation of the drug and treatment with corticosteroids. Physicians should be cognizant of this potential complication in patients receiving thalidomide who present with dyspnea and pulmonary infiltrates.

Outcomes of critically ill patients.

OBJECTIVE: We hypothesized that critically ill patients who remain in the ED for more than 24 hours experience worse outcomes and longer lengths of stay than those transferred to the medical intensive care unit (MICU) within 24 hours. METHODS: Medical records were examined of all patients admitted to the MICU directly from the ED of a 325-bed community teaching hospital between 2001 and 2002. RESULTS: Of 443 patients, 104 remained in the ED for 24 hours or longer (ED>or=24) before being transferred to the MICU. There were no significant differences in demographic characteristics of the 339 who were in the ED for less than 24 hours (ED <24 ) as compared with ED>or=24. APACHE II scores were 18.9+/-1.0 for a random sample of ED<24 and 20.5+/-0.9 for ED>or=24 (P=.2). Lengths of hospital stay were 10.9+/-0.8 days for ED<24 and 9.8+/-0.9 days for ED>or=24 (P=.7). Mortality rates were 26.8% for ED<24 and 26.9% for ED>or=24 (P=.5). CONCLUSIONS: These data suggest that outcomes of critically ill patients transferred from the ED to our MICU within 24 hours were not better than those who remained in the ED for longer durations. Larger studies are required to examine this hypothesis.