Comparing mortality among adult, general intensive care units in England with varying intensivist cover patterns: a retrospective cohort study.

INTRODUCTION: Research has demonstrated that intensivist-led care of the critically ill is associated with reduced intensive care unit (ICU) and hospital mortality. The objective of this study was to evaluate whether a relation exists between intensivist cover pattern (for example, number of days of continuous cover) and patient outcomes among adult general ICUs in England. METHODS: We conducted a retrospective cohort study by using data from a pooled case mix and outcome database of adult general critical care units participating in the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme. Consecutive admissions to participating units for the years 2010 to 2011 were linked to a survey of intensivist cover practices. Our primary outcome of interest was mortality at ultimate discharge from acute-care hospital. RESULTS: The analysis included 80,122 patients admitted to 130 ICUs in 128 hospitals. Multivariable logistic regression analysis was used to assess the relation between intensivist cover patterns (days of continuous cover, grade of physician staffing at nighttime, and frequency of daily handovers) and acute hospital mortality, adjusting for patient case mix. No relation was seen between days of continuous cover by a single intensivist or grade of physician staffing at nighttime and acute hospital mortality. Acute hospital mortality and ICU length of stay were not associated with intensivist characteristics, intensivist full-time equivalents per bed, or years of clinical experience. Intensivist participation in handover was associated with increased mortality (odds ratio, 1.27; 95% confidence interval, 1.04 to 1.55); however, only nine units reported no intensivist participation. CONCLUSIONS: We found no relation between days of continuous cover by a single intensivist or grade of physician staffing at nighttime and patient outcomes in adult, general ICUs in England. Intensivist participation in handover was associated with increased mortality; further research to confirm or refute this finding is required.

Hemodynamic advantages of right heart decompression during off-pump surgery.

Cardiac maneuvering during off-pump coronary artery bypass surgery can compress the right ventricle, causing temporary dysfunction and hemodynamic instability. The hemodynamic impact of a decompression technique comprising right pleurotomy and pericardial release was investigated during cardiac elevation. Intraoperative continuous real-time monitoring of cardiac index and stroke volume index was carried out using the PulseCO system in 12 consecutive patients with normal ventricular function who underwent off-pump coronary artery bypass by a single surgeon. A pulmonary artery catheter was used to monitor pulmonary artery pressure and systemic venous O(2) saturation. Hemodynamic changes during vertical displacement of the heart were measured before and after performing a right pleurotomy and pericardial release. Following right heart decompression, stroke volume index, cardiac index, mean arterial pressure, and systemic venous O(2) saturation were significantly better preserved during cardiac elevation. This demonstrates that right heart decompression via pleurotomy and pericardial release significantly improves hemodynamic stability during cardiac manipulation. We recommend the use of this procedure in off-pump coronary artery bypass when cardiac tilting is required.

Lithium dilution measurement of cardiac output and arterial pulse waveform analysis: an indicator dilution calibrated beat-by-beat system for continuous estimation of cardiac output.

Lithium dilution cardiac output (LiDCO trade mark; LiDCO, London, UK) is a minimally invasive indicator dilution technique for the measurement of cardiac output. It was primarily developed as a simple calibration for the PulseCO trade mark (LiDCO, London, UK) continuous arterial waveform analysis monitor. The technique is quick and simple, requiring only an arterial line and central or peripheral venous access. These lines would probably already have been inserted in critical care patients. A small dose of lithium chloride is injected as an intravenous bolus, and cardiac output is derived from the dilution curve generated by a lithium-sensitive electrode attached to the arterial line. Studies in humans and animals have shown good agreement compared with results obtained with other techniques, and the efficacy of LiDCO trade mark in pediatric patients has also been proven. Compared with thermodilution, lithium dilution showed closer agreement in clinical studies with electromagnetic flow measurement.PulseCO trade mark is a beat-to-beat cardiac output monitor that calculates stroke volume from the arterial pressure waveform using an autocorrelation algorithm. The algorithm is not dependent on waveform morphology, but, rather, it calculates nominal stroke volume from a pressure-volume transform of the entire waveform. The nominal stroke volume is converted to actual stroke volume by calibration of the algorithm with LiDCO trade mark. Initial studies indicate good fidelity, and the results from centers in the United States and the United Kingdom are extremely encouraging. The PulseCO trade mark monitor incorporates software for interpretation of the hemodynamic data generated and provides a real-time analysis of arterial pressure variations (ie, stroke volume variation, pulse pressure variation, and systolic pressure variation) as theoretical guides to intravascular and cardiac filling.