Challenges during long-term follow-up of ICU patients with and without chronic disease.

INTRODUCTION: Reflecting on researchers' experiences during follow-up of patients enrolled in research may lead to improved understanding of the challenges faced in maintaining contact when patients leave hospital. AIMS: (1) Describe the challenges researchers face when following-up patients who survive ICU. (2) Identify issues that influenced our ability to follow-up patients. METHODS: This sub-study was part of a larger "case-control" study investigating the quality of life of ICU survivors with and without pre-existing chronic disease. Patients completed self-assessment QLQ and symptom assessment before hospital discharge and at six months, plus they were asked to keep a paper diary of healthcare services used. Patient contact was maintained by monthly telephone calls. Each telephone call was logged and summaries of conversations documented. Our experience of conducting the study was reviewed by the identification of common issues which arose from the follow-up of patients. RESULTS: Thirty patients with a history of chronic disease and 30 patients without underlying chronic disease were followed-up. A total of 582 telephone calls were made for 60 patients discharged from hospital of which 261 (45%) calls led to a telephone interview. Only 19 (30%) of diaries were completed and returned. We identified six challenges associated with issues that arose from the follow-up of patients. CONCLUSION: We underestimated the number of telephone calls required for follow-up after discharge. Diaries were unreliable sources of data suggesting strategies are needed to improve compliance. How patients respond to follow-up is not always predictable. Processes are needed to deal with unexpected information provided during telephone follow-up.

A systematic review and meta-analysis of clinical trials of thyroid hormone administration to brain dead potential organ donors.

OBJECTIVES: To review all published clinical studies of thyroid hormone administration to brain-dead potential organ donors. METHODS: A search of PubMed using multiple search terms retrieved 401 publications including 35 original reports describing administration of thyroid hormone to brain-dead potential organ donors. Detailed review of the 35 original reports led to identification of two additional publications not retrieved in the original search. The 37 original publications reported findings from 16 separate case series or retrospective audits and seven randomized controlled trials, four of which were placebo-controlled. Meta-analysis was restricted to the four placebo-controlled randomized controlled trials. RESULTS: Whereas all case series and retrospective audits reported a beneficial effect of thyroid hormone administration, all seven randomized controlled trials reported no benefit of thyroid hormone administration either alone or in combination with other hormonal therapies. In four placebo-controlled trials including 209 donors, administration of thyroid hormone (n=108) compared with placebo (n=101) had no significant effect on donor cardiac index (pooled mean difference, 0.15 L/min/m²; 95% confidence interval -0.18 to 0.48). The major limitation of the case series and retrospective audits was the lack of consideration of uncontrolled variables that confound interpretation of the results. A limitation of the randomized controlled trials was that the proportion of donors who were hemodynamically unstable or marginal in other ways was too small to exclude a benefit of thyroid hormone in this subgroup. CONCLUSIONS: The findings of this systematic review do not support a role for routine administration of thyroid hormone in the brain-dead potential organ donor. Existing recommendations regarding the use of thyroid hormone in marginal donors are based on low-level evidence.

Neurological outcome in adult out-of-hospital cardiac arrest - Not all doom and gloom!

AIMS: To describe neurological and functional outcomes among out-of-hospital cardiac arrest (OHCA) patients who survived to hospital discharge; to determine the association between neurological outcome at hospital discharge and 12-month survival. METHODS: Our cohort comprised adult OHCA patients (≥18 years) attended by St John WA (SJWA) paramedics in Perth, Western Australia (WA), who survived to hospital discharge, between 1st January 2004 and 31st December 2019. Neurological and functional status at hospital discharge (and before the arrest) was determined by medical record review using the five-point 'Cerebral Performance Category (CPC)' and 'Overall Performance Category (OPC)' scores. Adjusted multivariable logistic regression analysis was used to estimate the association of CPC score at hospital discharge with 12-month survival, adjusted for prognostic variables. RESULTS: Over the study period, SJWA attended 23,712 OHCAs. Resuscitation was attempted in 43.4% of cases (n = 10,299) with 2171 subsequent admissions, 99.4% (n = 2158) of these were admitted to a study hospital. Of the 1062 hospital survivors, 71.3% (n = 757) were CPC1 (highest category of neurological performance), 21.4% (n = 227) CPC2, 6.3% (n = 67) CPC3 and 1.0% (n = 11) CPC4. OPC scores followed a similar distribution. Of the 1,011 WA residents who survived to hospital discharge, 92.3% (n = 933) survived to 12-months. A CPC1-2 at hospital discharge was significantly associated with 12-month survival (adjusted odds ratio 3.28, 95% confidence interval 1.69-6.39). CONCLUSION: Whilst overall survival is low, most survivors of OHCA have a good neurological outcome at hospital discharge and are alive at 12-months.

Arterial carbon dioxide tension has a non-linear association with survival after out-of-hospital cardiac arrest: A multicentre observational study.

PURPOSE: International guidelines recommend targeting normocapnia in mechanically ventilated out-of-hospital cardiac arrest (OHCA) survivors, but the optimal arterial carbon dioxide (PaCO2) target remains controversial. We hypothesised that the relationship between PaCO2 and survival is non-linear, and targeting an intermediate level of PaCO2 compared to a low or high PaCO2 in the first 24-h of ICU admission is associated with an improved survival to hospital discharge (STHD) and at 12-months. METHODS: We conducted a retrospective multi-centre cohort study of adults with non-traumatic OHCA requiring admission to one of four tertiary hospital intensive care units for mechanical ventilation. A four-knot restricted cubic spline function was used to allow non-linearity between the mean PaCO2 within the first 24 h of ICU admission after OHCA and survival, and optimal PaCO2 cut-points were identified from the spline curve to generate corresponding odds ratios. RESULTS: We analysed 3769 PaCO2 results within the first 24-h of ICU admission, from 493 patients. PaCO2 and survival had an inverted U-shape association; normocapnia was associated with significantly improved STHD compared to either hypocapnia (<35 mmHg) (adjusted odds ratio [aOR] 0.45, 95% confidence interval [CI] 0.24-0.83) or hypercapnia (>45 mmHg) (aOR 0.45, 95% CI 0.24-0.84). Of the twelve predictors assessed, PaCO2 was the third most important predictor, and explained >11% of the variability in survival. The survival benefits of normocapnia extended to 12-months. CONCLUSIONS: Normocapnia within the first 24-h of intensive care admission after OHCA was associated with an improved survival compared to patients with hypocapnia or hypercapnia.

Non-linear association between arterial oxygen tension and survival after out-of-hospital cardiac arrest: A multicentre observational study.

BACKGROUND: Studies to identify safe oxygenation targets after out-of-hospital cardiac arrest (OHCA) have often assumed a linear relationship between arterial oxygen tension (PaO2) and survival, or have dichotomised PaO2 at a supra-physiological level. We hypothesised that abnormalities in mean PaO2 (both high and low) would be associated with decreased survival after OHCA. METHODS: We conducted a retrospective multicentre cohort study of adult OHCA patients who received mechanical ventilation on admission to the intensive care unit (ICU). The potential non-linear relationship between the mean PaO2 within the first 24 -hs of ICU admission and survival to hospital discharge (STHD) was assessed by a four-knot restricted cubic spline function with adjustment for potential confounders. RESULTS: 3764 arterial blood gas results were available for 491 patients in the first 24-hs of ICU admission. The relationship between mean PaO2 over the first 24-hs and STHD was an inverted U-shape, with highest survival for those with a mean PaO2 between 100 and 180 mmHg (reference category) compared to a mean PaO2 of <100 mmHg (adjusted odds ratio [aOR] 0.50 95% confidence interval [CI] 0.30, 0.84), or >180 mmHg (aOR 0.41, 95% CI 0.18, 0.92). Mean PaO2 within 24 -hs was the third most important predictor and explained 9.1% of the variability in STHD. CONCLUSION: The mean PaO2 within the first 24-hs after admission for OHCA has a non-linear association with the highest STHD seen between 100 and 180 mmHg. Randomised controlled trials are now needed to validate the optimal oxygenation targets in mechanically ventilated OHCA patients.

Global utilization of low-dose corticosteroids in severe sepsis and septic shock: a report from the PROGRESS registry.

INTRODUCTION: The benefits and use of low-dose corticosteroids (LDCs) in severe sepsis and septic shock remain controversial. Surviving sepsis campaign guidelines suggest LDC use for septic shock patients poorly responsive to fluid resuscitation and vasopressor therapy. Their use is suspected to be wide-spread, but paucity of data regarding global practice exists. The purpose of this study was to compare baseline characteristics and clinical outcomes of patients treated or not treated with LDC from the international PROGRESS (PROmoting Global Research Excellence in Severe Sepsis) cohort study of severe sepsis. METHODS: Patients enrolled in the PROGRESS registry were evaluated for use of vasopressor and LDC (equivalent or lesser potency to hydrocortisone 50 mg six-hourly plus 50 microg 9-alpha-fludrocortisone) for treatment of severe sepsis at any time in intensive care units (ICUs). Baseline characteristics and hospital mortality were analyzed, and logistic regression techniques used to develop propensity score and outcome models adjusted for baseline imbalances between groups. RESULTS: A total of 8,968 patients with severe sepsis and sufficient data for analysis were studied. A total of 79.8% (7,160/8,968) of patients received vasopressors, and 34.0% (3,051/8,968) of patients received LDC. Regional use of LDC was highest in Europe (51.1%) and lowest in Asia (21.6%). Country use was highest in Brazil (62.9%) and lowest in Malaysia (9.0%). A total of 14.2% of patients on LDC were not receiving any vasopressor therapy. LDC patients were older, had more co-morbidities and higher disease severity scores. Patients receiving LDC spent longer in ICU than patients who did not (median of 12 versus 8 days; P <0.001). Overall hospital mortality rates were greater in the LDC than in the non-LDC group (58.0% versus 43.0%; P <0.001). After adjusting for baseline imbalances, in all mortality models (with vasopressor use), a consistent association remained between LDC and hospital mortality (odds ratios varying from 1.30 to 1.47). CONCLUSIONS: Widespread use of LDC for the treatment of severe sepsis with significant regional and country variation exists. In this study, 14.2% of patients received LDC despite the absence of evidence of shock. Hospital mortality was higher in the LDC group and remained higher after adjustment for key determinates of mortality.

Determinants of long-term survival after intensive care.

OBJECTIVE: To identify prognostic determinants of long-term survival for patients treated in intensive care units (ICUs) who survived to hospital discharge. DESIGN: An ICU clinical cohort linked to state-wide hospital records and death registers. SETTING AND PATIENTS: Adult patients admitted to a 22-bed ICU at a major teaching hospital in Perth, Western Australia, between 1987 and 2002 who survived to hospital discharge (n = 19,921) were followed-up until December 31, 2003. MEASUREMENTS: The main outcome measures are crude and adjusted survival. MAIN RESULTS: The risk of death in the first year after hospital discharge was high for patients who survived the ICU compared with the general population (standardized mortality rate [SMR] at 1 yr = 2.90, 95% confidence interval [CI] 2.73-3.08) and remained higher than the general population for every year during 15 yrs of follow up (SMR at 15 yrs = 2.01, 95% CI 1.64-2.46). Factors that were independently associated with survival during the first year were older age (hazard ratio [HR] = 4.09; 95% CI 3.20-5.23), severe comorbidity (HR = 5.23; 95% CI 4.25-6.43), ICU diagnostic group (HR range 2.20 to 8.95), new malignancy (HR = 4.60; 95% CI 3.68-5.76), high acute physiology score on admission (HR = 1.55; 95% CI 1.23-1.96), and peak number of organ failures (HR = 1.51; 95% CI 1.11-2.04). All of these factors were independently associated with subsequent survival for those patients who were alive 1 yr after discharge from the hospital with the addition of male gender (HR = 1.17; 95% CI 1.10-1.25) and prolonged length of stay in ICU (HR = 1.42; 95% CI 1.29-1.55). CONCLUSIONS: Patients who survived an admission to the ICU have worse survival than the general population for at least 15 yrs. The factors that determine long-term survival include age, comorbidity, and primary diagnosis. Severity of illness was also associated with long-term survival and this suggests that an episode of critical illness, or its treatment, may shorten life-expectancy.

C-reactive protein concentration as a predictor of in-hospital mortality after ICU discharge: a prospective cohort study.

OBJECTIVE: The objective was to assess the ability of potential clinical predictors and inflammatory markers within 24 h of intensive care unit (ICU) discharge to predict subsequent in-hospital mortality. DESIGN AND SETTING: A prospective cohort study of 603 consecutive patients who survived their first ICU admission, between 1 June and 31 December 2005, in a 22-bed multidisciplinary ICU of a university hospital. MEASUREMENTS AND RESULTS: A total of 26 in-hospital deaths after ICU discharge (4.3%) were identified. C-reactive protein (CRP) concentrations at ICU discharge were associated with subsequent in-hospital mortality in the univariate analysis (mean CRP concentrations of non-survivors=174 vs. survivors=85.6 mg/l, p=0.001). CRP concentrations remained significantly associated with post-ICU mortality (a 10-mg/l increment in CRP concentrations increased the odds ratio [OR] of death: 1.09, 95% confidence interval [CI]: 1.03-1.16); after adjusting for age, the Acute Physiology and Chronic Health Evaluation (APACHE) II predicted mortality, and the Delta Sequential Organ Failure Assessment (Delta SOFA) score. The area under the receiver operating characteristic curve of this multivariate model to discriminate between survivors and non-survivors after ICU discharge was 0.85 (95% CI: 0.73-0.96). The destination and timing of ICU discharge, and the Discharge SOFA score, white cell counts and fibrinogen concentrations at ICU discharge were not significantly associated with in-hospital mortality after ICU discharge. CONCLUSIONS: A high CRP concentration at ICU discharge was an independent predictor of in-hospital mortality after ICU discharge in our ICU.

Duration of mechanical ventilation in an adult intensive care unit after introduction of sedation and pain scales.

BACKGROUND: Sedation and analgesia scales promote a less-distressing experience in the intensive care unit and minimize complications for patients receiving mechanical ventilation. OBJECTIVES: To evaluate outcomes before and after introduction of scales for sedation and analgesia in a general intensive care unit. METHOD: A before-and-after design was used to evaluate introduction of the Richmond Agitation-Sedation Scale and the Behavioral Pain Scale for patients receiving mechanical ventilation. Data were collected for 6 months before and 6 months after training in and introduction of the scales. RESULTS: A total of 769 patients received mechanical ventilation for at least 6 hours (369 patients before and 400 patients after implementation). Age, scores on the Acute Physiology and Chronic Health Evaluation (APACHE) II, and diagnostic groups were similar in the 2 groups, but the after group had more men than did the before group. Duration of mechanical ventilation did not change significantly after the scales were introduced (median, 24 vs 28 hours). For patients who received mechanical ventilation for 96 hours or longer (24%), mechanical ventilation lasted longer after implementation of the scales (P=.03). Length of stay in the intensive care unit was similar in the 2 groups (P= .18), but patients received sedatives for longer after implementation (P=.01). By logistic regression analysis, APACHE II score (P<.001) and diagnostic group (P<.001) were independent predictors of mechanical ventilation lasting 96 hours or longer. CONCLUSION: Sedation and analgesia scales did not reduce duration of ventilation in an Australian intensive care unit.

A comparison of early gastric and post-pyloric feeding in critically ill patients: a meta-analysis.

OBJECTIVE: To investigate the potential beneficial and adverse effects of early post-pyloric feeding compared with gastric feeding in critically ill adult patients with no evidence of impaired gastric emptying. DESIGN: Randomised controlled studies comparing gastric and post-pyloric feeding in critically ill adult patients from Cochrane Controlled Trial Register (2005 issue 3), EMBASE and MEDLINE databases (1966 to 1 October 2005) without any language restriction were included. Two reviewers reviewed the quality of the studies and performed data extraction independently. MEASUREMENTS AND RESULTS: Eleven randomised controlled studies with a total of 637 critically ill adult patients were considered. The mortality (relative risk [RR] 1.01, 95% CI 0.76-1.36, p=0.93; I2=0%) and risk of aspiration or pneumonia (RR 1.28, 95% CI 0.91-1.80, p=0.15; I2=0%) were not significantly different between patients treated with gastric or post-pyloric feeding. The effect of post-pyloric feeding on the risk of pneumonia or aspiration was similar when studies were stratified into those with and those without the use of concurrent gastric decompression (RR ratio 0.95, 95% CI 0.48-1.91, p=0.89). The risk of diarrhoea and the length of intensive care unit stay (weighted mean difference in days -1.46, 95% CI -3.74 to 0.82, p=0.21; I2=24.6%) were not statistically different. The gastric feeding group had a much lower risk of experiencing feeding tube placement difficulties or blockage (0 vs 9.6%, RR 0.13, 95% CI 0.04-0.44, p=0.001; I2=0%). CONCLUSIONS: Early use of post-pyloric feeding instead of gastric feeding in critically ill adult patients with no evidence of impaired gastric emptying was not associated with significant clinical benefits.

A comparison of admission and worst 24-hour Acute Physiology and Chronic Health Evaluation II scores in predicting hospital mortality: a retrospective cohort study.

INTRODUCTION: The Acute Physiology and Chronic Health Evaluation (APACHE) II score is widely used in the intensive care unit (ICU) as a scoring system for research and clinical audit purposes. Physiological data for calculation of the APACHE II score are derived from the worst values in the first 24 hours after admission to the ICU. The collection of physiological data on admission only is probably logistically easier, and this approach is used by some ICUs. This study compares the performance of APACHE II scores calculated using admission data with those obtained from the worst values in the first 24 hours. MATERIALS AND METHODS: This was a retrospective cohort study using prospectively collected data from a tertiary ICU. There were no missing physiological data and follow-up for mortality was available for all patients in the database. The admission and the worst 24-hour physiological variables were used to generate the admission APACHE II score and the worst 24-hour APACHE II score, and the corresponding predicted mortality, respectively. RESULTS: There were 11,107 noncardiac surgery ICU admissions during 11 years from 1 January 1993 to 31 December 2003. The mean admission and the worst 24-hour APACHE II score were 12.7 and 15.4, and the derived predicted mortality estimates were 15.5% and 19.3%, respectively. The actual hospital mortality was 16.3%. The overall discrimination ability, as measured by the area under the receiver operating characteristic curve, of the admission APACHE II model (83.8%, 95% confidence interval = 82.9-84.7) and the worst 24-hour APACHE II model (84.6%, 95% confidence interval = 83.7-85.5) was not significantly different (P = 1.00). CONCLUSION: Substitution of the worst 24-hour physiological variables with the admission physiological variables to calculate the admission APACHE II score maintains the overall discrimination ability of the traditional APACHE II model. The admission APACHE II model represents a potential alternative model to the worst 24-hour APACHE II model in critically ill nontrauma patients.

C-reactive protein concentration as a predictor of intensive care unit readmission: a nested case-control study.

PURPOSE: The purpose of this study is to assess the ability of potential clinical predictors and inflammatory markers to predict intensive care unit (ICU) readmission during the same hospitalization. MATERIALS AND METHODS: A nested case-control study utilized prospectively collected de-identified data of a 22-bed multidisciplinary ICU in a university hospital. RESULTS: There were 1,405 consecutive ICU admissions in 2004, and of these, 18 were regarded as ICU readmissions (1.3%). The destination and timing of ICU discharge, the Sequential Organ Failure Assessment scores, white cell counts, and fibrinogen concentrations at discharge were not associated with ICU readmission. C-reactive protein (CRP) concentration within 24 hours before ICU discharge was associated with ICU readmission (mean CRP concentrations of cases vs controls, 177.8 vs 56.5 mg/L, respectively; P < .0001). The results remained unchanged after adjustment with the propensity scores. The area under the receiver operating characteristic curve for the CRP concentrations to predict ICU readmission was 0.884 (95% confidence interval, 0.765-0.999; P < .0001). Patients readmitted to the ICU had a higher predicted mortality in their second ICU admission (34.9% vs 26.1%; P < .01) and a longer total hospital stay (33.3 vs 20.3 days; P < .003) than patients without ICU readmission. CONCLUSIONS: A high CRP concentration within 24 hours before ICU discharge is associated with a higher risk of readmission to the ICU.

A comparison of prognostic significance of strong ion gap (SIG) with other acid-base markers in the critically ill: a cohort study.

BACKGROUND: This cohort study compared the prognostic significance of strong ion gap (SIG) with other acid-base markers in the critically ill. METHODS: The relationships between SIG, lactate, anion gap (AG), anion gap albumin-corrected (AG-corrected), base excess or strong ion difference-effective (SIDe), all obtained within the first hour of intensive care unit (ICU) admission, and the hospital mortality of 6878 patients were analysed. The prognostic significance of each acid-base marker, both alone and in combination with the Admission Mortality Prediction Model (MPM0 III) predicted mortality, were assessed by the area under the receiver operating characteristic curve (AUROC). RESULTS: Of the 6878 patients included in the study, 924 patients (13.4 %) died after ICU admission. Except for plasma chloride concentrations, all acid-base markers were significantly different between the survivors and non-survivors. SIG (with lactate: AUROC 0.631, confidence interval [CI] 0.611-0.652; without lactate: AUROC 0.521, 95 % CI 0.500-0.542) only had a modest ability to predict hospital mortality, and this was no better than using lactate concentration alone (AUROC 0.701, 95 % 0.682-0.721). Adding AG-corrected or SIG to a combination of lactate and MPM0 III predicted risks also did not substantially improve the latter's ability to differentiate between survivors and non-survivors. Arterial lactate concentrations explained about 11 % of the variability in the observed mortality, and it was more important than SIG (0.6 %) and SIDe (0.9 %) in predicting hospital mortality after adjusting for MPM0 III predicted risks. Lactate remained as the strongest predictor for mortality in a sensitivity multivariate analysis, allowing for non-linearity of all acid-base markers. CONCLUSIONS: The prognostic significance of SIG was modest and inferior to arterial lactate concentration for the critically ill. Lactate concentration should always be considered regardless whether physiological, base excess or physical-chemical approach is used to interpret acid-base disturbances in critically ill patients.

Long-term survival from intensive care: a review.

OBJECTIVE: To determine whether the long-term benefit of an ICU requires prolonged patient follow-up we reviewed long-term survival of patients from general ICUs. METHOD: We carried out a computerised search of online databases Medline (1966-2004), Embase (1966-2004) and Cochrane Library (1966-2004) for studies reporting patients' long-term survival for greater than 12 months from general ICUs. SELECTED STUDIES: We identified 19 studies that met the selection criteria. The casemix and severity of illness varied. Differences included the services provided, investigator inclusion/exclusion criteria and proportion of medical patients (range 13-79%). RESULTS: Mean reported ICU length of stay was 5.3 days. The study initiation time for follow-up varied (mostly from time of ICU admission), as did the duration of follow-up (16 months-13 years). ICU and hospital mortality rates ranged from 8% to 33% and 11% to 64%, respectively. The reported 5-year mortality ranged from 40% to 58%. CONCLUSIONS: Well designed studies on long-term outcomes are needed to demonstrate the value of intensive care. Deficiencies in design, methodology, and reporting make interpretation and comparison difficult. Recommendations are made for the reporting of outcome from the ICU. Optimum duration of follow-up has not been determined.

The use of prophylactic fluconazole in immunocompetent high-risk surgical patients: a meta-analysis.

INTRODUCTION: High-risk surgical patients are at increased risk of fungal infections and candidaemia. Evidence from observational and small randomised controlled studies suggests that prophylactic fluconazole may be effective in reducing fungal infection and mortality. We evaluated the effects of prophylactic fluconazole on the incidence of candidaemia and hospital mortality in immunocompetent high-risk surgical patients. METHODS: Randomised controlled studies involving the use of fluconazole in immunocompetent high-risk surgical patients from the Cochrane Controlled Trial Register (2005, issue 1) and from the EMBASE and MEDLINE databases (1966-30 April 2005), without any language restriction, were included. Two reviewers reviewed the quality of the studies and performed data extraction independently. RESULTS: Seven randomised controlled studies with a total of 814 immunocompetent high-risk surgical patients were considered. The use of prophylactic fluconazole was associated with a reduction in the proportion of patients with candidaemia (relative risk [RR] = 0.21, 95% confidence interval [CI] = 0.06-0.72, P = 0.01; I2 = 0%) and fungal infections other than lower urinary tract infection (RR = 0.39, 95% CI = 0.24-0.65, P = 0.0003; I2 = 0%), but was associated with only a trend towards a reduction in hospital mortality (RR = 0.82, 95% CI = 0.62-1.08, P = 0.15; I2 = 7%). The proportion of patients requiring systemic amphotericin B as a rescue therapy for systemic fungal infection was lower after prophylactic use of fluconazole (RR = 0.35, 95% CI = 0.17-0.72, P = 0.004; I2 = 0%). The proportion of patients colonised with or infected with fluconazole-resistant fungi was not significantly different between the fluconazole group and the placebo group (RR = 0.66, 95% CI = 0.22-1.96, P = 0.46; I2 = 0%). CONCLUSION: The use of prophylactic fluconazole in immunocompetent high-risk surgical patients is associated with a reduced incidence of candidaemia but with only a trend towards a reduction in hospital mortality.

Adult-population incidence of severe sepsis in Australian and New Zealand intensive care units.

OBJECTIVE: To determine the population incidence and outcome of severe sepsis occurring in adult patients treated in Australian and New Zealand intensive care units (ICUs), and compare with recent retrospective estimates from the USA and UK. DESIGN: Inception cohort study. SETTING: Twenty-three closed multi-disciplinary ICUs of 21 hospitals (16 tertiary and 5 university affiliated) in Australia and New Zealand. PATIENTS: A total of 5878 consecutive ICU admission episodes. MEASUREMENTS AND RESULTS: Main outcome measures were population-based incidence of severe sepsis, mortality at ICU discharge, mortality at 28 days after onset of severe sepsis, and mortality at hospital discharge. A total of 691 patients, 11.8 (95% confidence intervals 10.9-12.6) per 100 ICU admissions, were diagnosed with 752 episodes of severe sepsis. Site of infection was pulmonary in 50.3% of episodes and abdominal in 19.3% of episodes. The calculated incidence of severe sepsis in adults treated in Australian and New Zealand ICUs is 0.77 (0.76-0.79) per 1000 of population. 26.5% of patients with severe sepsis died in ICU, 32.4% died within 28 days of the diagnosis of severe sepsis and 37.5% died in hospital. CONCLUSION: In this prospective study, 11.8 patients per 100 ICU admissions were diagnosed with severe sepsis and the calculated annual incidence of severe sepsis in adult patients treated in Australian and New Zealand ICUs is 0.77 per 1000 of population. This figure for the population incidence falls in the lower range of recent estimates from retrospective studies in the U.S. and the U.K.

A prospective randomized trial of enteral glutamine in critical illness.

OBJECTIVE: To assess the influence of enteral glutamine on the incidence of severe sepsis and death in critically ill patients. DESIGN: This two-armed clinical trial was triple blind (patients, attending staff, research nurse). SETTING: The 10 bed general ICU at Royal Perth Hospital, Western Australia. PATIENTS: This trial evaluated 363 patients requiring mechanical ventilation (median APACHE II score=14); of these, 85 had trauma. INTERVENTION: The intervention solution contained 20 g/l glutamine and the control solution was isojoulic and isonitrogenous. MEASUREMENTS AND RESULTS: The groups had similar characteristics at baseline, and they also received equivalent amounts of protein and energy. Patients in the glutamine group received a median of 19 g/glutamine per day and 91% (332 of 363) of the patients were fed via a nasogastric tube (median duration=10 days). The outcomes were similar in the two groups: (a) death within 6 months: glutamine group 15% (27 of 179) vs control group 16% (30 of 184); p=0.75; relative risk, 0.95 (95% confidence interval, 0.71-1.28); and (b) severe sepsis: glutamine group 21% (38 of 179) vs control group 23% (43 of 184); p=0.62; relative risk, 0.94 (95% confidence interval, 0.72-1.22). There was also no discernable difference in the secondary outcomes relating to infections, febrile period, antimicrobial therapy, and consumption of inotropes. CONCLUSION: This clinical trial did not support the use of enteral glutamine supplements in similar cohorts of critically ill patients.