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Journal of critical care 06/2013; · 2.13 Impact Factor
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ABSTRACT: PURPOSE: Budget restrictions have led to shortage of intensive care unit (ICU) beds in several countries. Consequently, ventilated patients are often kept on the wards. This study examined survival likelihood among patients ventilated on the wards and the predictive value of commonly used severity-of-illness scores. METHODS: This study is a prospective observation and characterization of consecutive, mechanically ventilated patients in 3 internal medicine wards of a single hospital who were denied ICU admission. Outcome measures are as follows: 28-day mortality, survival to hospital discharge, and 3 months postdischarge. RESULTS: Eighty-six patients were examined. The patients were 78.9 ± 8.9 years old; 53% were independent preadmission. Respiratory insufficiency due to infection was the main reason for mechanical ventilation (58%). Charlson and acute physiology scores (APS) averaged 4 ± 2.2 and 91.8 ± 26.7, respectively. Twenty-eight-day mortality was 71%, whereas in-hospital mortality was 74% and 3 months postdischarge mortality was 79%. Survivors were significantly younger than nonsurvivors (74.4 ± 8.5 years vs 80.4 ± 8.6 years, P < .01), were more likely to be ventilated for cardiac causes (41% vs 11%, P = .04), and had significantly higher initial mean blood pressure (79.4 mm Hg vs 58.2 mm Hg, P = .02) and blood albumin levels (29.8 g/L vs 25.7 g/L, P = .05). Death rate was 10 times more likely, with an APS greater than 90 on the day of intubation as compared with an APS less than 90. CONCLUSION: Mortality in patients ventilated on the ward was high, especially in the subgroup of patients with an APS score greater than 90. The early calculation of APS may assist in focusing therapeutic efforts on patients with better survival chances.
Journal of critical care 10/2012; · 2.13 Impact Factor
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Annals of surgery 09/2012; 256(5):e28-e29. · 7.90 Impact Factor
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ABSTRACT: Objective: To determine the reliability of blood cultures obtained through indwelling arterial lines as compared to that of blood cultures
obtained by venipuncture.
Design: A prospective observational study.
Setting: Six-bed mixed medical surgical intensive care unit (ICU) of a 550-bed university-affiliated medical center.
Measurements: During a 3-month period blood culture sets, when clinically indicated, were drawn in parallel from indwelling arterial catheters
and one-time venipuncture and the results compared. Each blood sample consisted of 15 ml and was distributed equally between
three blood culture bottles: aerobic, anaerobic and one aerobic resin-containing bottle. Blood culture results from the two
sources were compared according to preset definitions.
Main results: During the study period 90 parallel blood culture sets (540 bottles) were obtained from 36 patients. Forty-three (16%) venipuncture
bottles were positive versus 88 (32%) arterial line culture bottles (p<0.001). Of the parallel sets, 83% yielded equivalent results – either both sterile or both growing the same organism. Amongst
the discordant sets, the arterial line cultures grew 37 gram-positive and 18 gram-negative isolates not found in venipuncture
sets (i.e. 50% of 109 arterial line isolates), while only two gram-positive isolates were solely grown in venipuncture cultures
(4% of all 55 venipuncture isolates, p<0.001). On clinical correlation, all the gram-positive organisms in the discordant cultures were found not to reflect bacteremia, while five of the 18 gram-negative isolates (28%) grown only in arterial line cultures probably did
reflect ongoing bacteremia.
Conclusion: The results of blood cultures taken from the arterial line are frequently equivalent to those taken from venipuncture. When
discordant, the growth of gram-positive bacteria almost certainly reflects contamination or arterial line colonization, whereas
the growth of gram-negative bacteria may have to be considered as reflecting bacteremia.
Blood cultures–Line sepsis–Contamination–Colonization–Arterial catheter–Central venous catheter–Venipuncture–Intensive care unit–Critical illness–Septicemia–Bacteremia–Bacteriological methods–Microbiological techniques
Intensive Care Medicine 04/2012; 26(9):1350-1354. · 5.40 Impact Factor
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Jacob Dreiher,
Yaniv Almog,
Charles L Sprung,
Shlomi Codish,
Moti Klein,
Sharon Einav,
Yaron Bar-Lavie,
Pierre P Singer,
Adi Nimrod,
Jeffrey Sachs,
Daniel Talmor,
Michael Friger,
Dan Greenberg,
David Olsfanger, Moshe Hersch,
Victor Novack
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ABSTRACT: To estimate in-hospital, 1-yr, and long-term mortality and to assess time trends in incidence and outcomes of sepsis admissions in the intensive care unit.
A population-based, multicenter, retrospective cohort study.
Patients hospitalized with sepsis in the intensive care unit in seven general hospitals in Israel during 2002-2008.
None.
Survival data were collected and analyzed according to demographic and background clinical characteristics, as well as features of the sepsis episode, using Kaplan-Meier approach for long-term survival.
A total of 5,155 patients were included in the cohort (median age: 70, 56.3% males; median Charlson comorbidity index: 4). The mean number of intensive care unit admissions per month increased over time, while no change in in-hospital mortality was observed. The proportion of patients surviving to hospital discharge was 43.9%. The 1-, 2-, 5-, and 8-yr survival rates were 33.0%, 29.8%, 23.3%, and 19.8%, respectively. Mortality was higher in older patients, patients with a higher Charlson comorbidity index, and those with multiorgan failure, and similar in males and females. One-year age-standardized mortality ratio was 21-fold higher than expected, based on the general population rates.
Mortality following intensive care unit sepsis admission remains high and is correlated with underlying patients' characteristics, including age, comorbidities, and the number of failing organ systems.
Critical care medicine 03/2012; 40(3):855-60. · 6.37 Impact Factor
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ABSTRACT: Sepsis results in significant morbidity and mortality, with current treatment options limited with respect to efficacy as well as safety. The complex homeopathic remedy Traumeel S has been shown to have both anti-inflammatory and immunostimulatory effects in the in vitro setting.
The objective was to explore the effects of Traumeel S in an in vivo setting, using a cecal ligation and puncture (CLP) sepsis model in rats, evaluating the effects of the medication on cytokine activity.
Sepsis was induced in 30 rats using accepted CLP methodology. Following the procedure, rats were randomly allocated to receive an intraperitoneal injection of either Traumeel S (n=15) or normal saline (n=15). At 6 hours post-CLP, serum cytokines (interleukin [IL]-1β, tumor necrosis factor-α, IL-6, and IL-10) were evaluated.
IL-1β levels were significantly higher in the treatment group (p=0.03) with no significant differences found between the groups with respect to the other cytokines tested.
In contrast to in vitro studies, Traumeel significantly increased IL-1β levels in an in vivo model, without influencing other cytokines. IL-1β is a proinflammatory cytokine that has been shown to have a protective effect in the CLP rat model. Further research is warranted to examine this finding, as well as its clinical implications.
Journal of alternative and complementary medicine (New York, N.Y.) 10/2011; 17(10):909-13. · 1.69 Impact Factor
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ABSTRACT: To determine whether variables in physicians' backgrounds influenced their decision to forego resuscitating a patient they did not previously know.
Questionnaire survey of a convenience sample of 204 physicians working in the departments of internal medicine, anaesthesiology and cardiology in 11 hospitals in Israel.
Twenty per cent of the participants had elected to forego resuscitating a patient they did not previously know without additional consultation. Physicians who had more frequently elected to forego resuscitation had practised medicine for more than 5 years (p=0.013), estimated the number of resuscitations they had performed as being higher (p=0.009), and perceived their experience in resuscitation as sufficient (p=0.001). The variable that predicted the outcome of always performing resuscitation in the logistic regression model was less than 5 years of experience in medicine (OR 0.227, 95% CI 0.065 to 0.793; p=0.02).
Physicians' level of experience may affect the probability of a patient's receiving resuscitation, whereas the physicians' personal beliefs and values did not seem to affect this outcome.
Emergency Medicine Journal 09/2011; 29(9):709-14. · 1.44 Impact Factor
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ABSTRACT: To investigate the workup/treatment provided to pregnant motor vehicle accident (MVA) casualties in a mature trauma system. Adherence to recommendations was used to measure quality of care.
MVAs affect approximately 3% of pregnant women. Trauma casualty outcome improves after implementation of guidelines.
A 5-year audit of clinical practice in 2 university hospitals with a trauma call system where the general surgeon is the primary care physician. Trauma guidelines (general/specific to treatment of pregnant MVA casualties) were used to examine adherence. Pregnant casualties aged >18 years, injured in a private vehicle were identified via computerized hospital databases. Data relevant to the study were extracted from ED/admission files.
Among the 236 casualties included there were no maternal deaths. Six casualties (2.5%) had significant injuries and 3 (1.2%) required surgery (all within 24-hours of admission). Contrary to established procedure, maternal vital signs were often not documented. In contrast, fetal viability was usually documented; most casualties underwent ultrasound fetal evaluation (233 of 236, 98.7%) and those with viable pregnancies underwent fetal heart rate monitoring (162 of 169, 96%). A sixth of the MVA casualties (16%) were examined only by an obstetrician. All casualties were admitted but only 15 (6.4%) were admitted in accordance with guidelines. Readmission rates (1.3%) were similar to those observed in nonpregnant casualties.
Pregnant MVA casualties are underexamined and overadmitted. Concerns regarding potential obstetrical complications distract medical attention away from basic trauma guidelines. Education programs should emphasize prioritizing the mother and adhering to the basic rules of trauma care despite the presence of the fetus.
Annals of surgery 08/2011; 254(2):346-52. · 7.90 Impact Factor
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ABSTRACT: We present two cases of rare human poisoning in one family following ingestion of cooked leaves from the tobacco tree plant, Nicotiana glauca. The toxic principle of N. glauca, anabasine (C10H14N2), is a small pyridine alkaloid, similar in both structure and effects to nicotine, but appears to be more potent in humans. A 73-year-old female tourist from France, without remarkable medical history, collapsed at home following a few hours long prodrome of dizziness, nausea, vomiting, and malaise. The symptoms developed shortly after eating N. glauca cooked leaves that were collected around her daughter's house in Jerusalem and mistaken for wild spinach. She was found unconscious, with dilated pupils and extreme bradycardia. Following resuscitation and respiratory support, circulation was restored. However, she did not regain consciousness and died 20 days after admission because of multi-organ failure. Anabasine was identified by gas chromatography/mass spectrometry method in N. glauca leaves and in the patient's urine. Simultaneously, her 18-year-old grandson developed weakness and myalgia after ingesting a smaller amount of the same meal. He presented to the same emergency room in a stable condition. His exam was remarkable only for sinus bradycardia. He was discharged without any specific treatment. He recovered in 24 h without any residual sequelae. These cases raise an awareness of the potential toxicity caused by ingestion of tobacco tree leaves and highlight the dangers of ingesting botanicals by lay public. Moreover, they add to the clinical spectrum of N. glauca intoxication.
Journal of medical toxicology: official journal of the American College of Medical Toxicology 03/2011; 7(1):47-51.
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The American journal of medicine 03/2011; 124(3):215-7. · 4.47 Impact Factor
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Critical care medicine 12/2010; 38(12):2427-8; author reply 2428. · 6.37 Impact Factor
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Jonathan Cohen,
Ilya Kagan,
Remos Hershcovici,
Sylvianne Bursztein-De Myttenaere,
Nicola Makhoul,
Alexander Samkohvalov, Moshe Hersch,
Sharon Einav,
Vadim Berezovsky,
Daniel Jorge Jakobson,
Pierre Singer
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ABSTRACT: The aim of the study was to document transfusion practices in a cross section of general intensive care units (ICUs) in Israel and to determine whether current guidelines are being applied.
This prospective study was performed in 5 general ICUs in Israel over a 3-month period. Red cell transfusion data collected on consecutive patients included the trigger, units transfused per transfusion event, and indications, categorized either to treat a specified condition for which transfusions may be beneficial (acute hemorrhage, acute myocardial ischemia, or severe sepsis) or to treat a low hemoglobin concentration.
Of the 238 patients studied, 50% received at least one red blood cell transfusion. The main indication for transfusion (43.7%, or 162/368 U transfused) was to treat a low hemoglobin concentration, in the absence of one of the specified conditions. Total red cell use was 3.0 ± 2.9 U per admission, and patients received a mean of 1.2 ± 0.4 U per transfusion event. The transfusion trigger for the whole group was 7.9 ± 1.1 g/dL. This did not differ significantly between the indications apart from a significantly higher trigger for patients with acute myocardial ischemia (8.8 ± 0.9 g/dL). In addition, patients with a history of heart disease had a higher trigger irrespective of the primary indication for transfusion and received significantly more units per transfusion event. Patients receiving a transfusion had significantly longer ICU stay and hospital mortality.
Our study showed that evidence-practice gaps continue to exist, and it appears that physician behavior is mainly driven by the absolute level of hemoglobin. Educational interventions focused on these factors are required to limit the widespread and often unnecessary use of this scarce and potentially harmful resource.
Journal of critical care 04/2010; 26(1):106.e1-6. · 2.13 Impact Factor
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ABSTRACT: To examine whether case managers affect patient evaluation/treatment/outcome and staffing requirements during Multiple Casualty Incidents (MCIs).
Multiple patient relocations during MCIs may contribute to chaos. One hospital changed its MCI patient relocation policy during a wave of MCIs; rather than transfer patients from one medical team to another in each location, patients were assigned case-managers +/- teams who accompanied them throughout the diagnostic/treatment cascade until definitive placement.
MCI data (n = 17, 2001-2006) were taken from the hospital database which is updated by registrars in real-time. ISSs were calculated retrospectively. Matched events before (n = 5)/after (n = 3) the change yielded data on staff utilization. Semi-structured interviews were conducted with 26 experienced staff members regarding the effect of the change on patient care.
Twelve events occurred before (n = 379 casualties) and 5 occurred after (n = 152 casualties) the change. Event extent/severity, manpower demands and patient mortality remained similar before/after the change. Reductions were observed in: the number of x-rays/patient/1st 24-hour (P < 0.001), time to performance of first chest x-ray (P = 0.015), time from first chest x-ray to arrival at the next diagnostic/treatment location (P = 0.016), time from ED arrival to surgery (P = 0.022) and hospital lengths of stay for critically injured casualties (37.1 +/- 24.7 versus 12 +/- 4.4 days, P = 0.016 for ISS > or = 25). Most interviewees (62%, n = 16) noted improved patient care, communication and documentation.
During an MCI, case managers increase surge capacity by improving efficacy (workup/treatment times and use of resources) and may improve patient care via increased personal accountability, continuity of care, and involvement in treatment decisions.
Annals of surgery 04/2009; 249(3):496-501. · 7.90 Impact Factor
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ABSTRACT: Urine output (UO) is a critical parameter in the intensive care unit not yet electronically monitored. This study tested the accuracy and ease of use of a new electronic continuous UO monitoring device (Urinfo 2000; Medynamix, Jerusalem, Israel).
This article is a prospective study in a 6-bed intensive care unit. In consecutive patients with indwelling urinary catheter and expected stay of 24 hours or more, hourly UO was measured by either Urinfo or manual urinometer, validated by cylinder measurements. Overall accuracy was assessed comparing each method with the cylinder, using regression analysis, Bland-Altman plots, and, for UO of 40 mL/h or less, standard evaluation of diagnostics. Staff satisfaction was assessed by a short questionnaire.
In 20 patients, 453 measurements were obtained, 167 by urinometer and cylinder and 286 by Urinfo and cylinder. The mean relative percentage deviation from the cylinder measurement was 8% and 26% for the Urinfo and urinometer, respectively (P < .05). Bland-Altman plots of each method vs the cylinder showed a better agreement with the Urinfo. Positive predictive value for UO of 40 mL/h or less (cylinder as criterion standard) was 91% and 77% for the Urinfo and urinometer, respectively. The questionnaire revealed an 87% satisfaction with the Urinfo.
Urinfo is significantly more accurate and "user friendly" than the urinometer. It promises future incorporation of these data into patient data management systems for the benefit of patients' management.
Journal of critical care 03/2009; 24(4):629.e13-7. · 2.13 Impact Factor
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ABSTRACT: To investigate the effect of intravenous propacetamol, a parenteral bioprecursor of acetaminophen, on systemic blood pressure in critically ill patients with fever, and to establish the prevalence and clinical significance of this effect.
Prospective, observational study.
A six-bed medical-surgical intensive care unit (ICU) of a university-affiliated tertiary care hospital in Israel.
Fourteen critically ill patients (aged 17-83 yrs) with sepsis and fever (body temperature > or = 38 degrees C) who received an intravenous infusion of propacetamol 2 g over 15-20 minutes every 6 hours as needed to reduce fever.
Demographic data, including degree of sepsis, were collected at baseline (before propacetamol infusion). Blood pressure, heart rate, body temperature, and need for fluid or vasopressor therapy were recorded at baseline, at end of infusion, and at 15, 30, 45, 60, 90, and 120 minutes after propacetamol administration. The drug was administered on 72 occasions in the 14 patients. Mean +/- SE systolic, diastolic, and mean arterial pressures recorded 15 minutes after propacetamol administration were significantly lower than baseline measurements: 123 +/- 29 versus 148 +/- 33, 62 +/- 12 versus 70 +/- 15, and 83 +/- 16 versus 97 +/- 19 mm Hg, respectively (p<0.05). In 24 (33%) of the 72 infusions, systolic blood pressure decreased to below 90 mm Hg and required intervention with fluid bolus administration on six occasions; a fluid bolus was accompanied by a dosage increase or initiation of a norepinephrine infusion on 18 occasions. No correlation, however, was noted between the degree of decrease in mean arterial pressure and decrease in temperature (r(2)=0.01), or the degree of decrease in mean arterial pressure and decrease in heart rate (r2=0.23), at each data collection time point, as measured by linear regression.
Intravenous propacetamol, given in antipyretic doses, caused a significant decrease in blood pressure 15 minutes after administration in febrile critically ill patients. This drug-induced hypotension was clinically relevant in that interventions to control blood pressure were required. Thus, clinicians should be aware of this potential deleterious effect, particularly in specific populations such as critically ill patients.
Pharmacotherapy 11/2008; 28(10):1205-10. · 2.90 Impact Factor
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ABSTRACT: To characterize the injuries incurred by involvement in terror-related multiple casualty incidents (TR-MCIs) during pregnancy and describe the maternal and fetal outcomes.
Retrospective (January 1, 2001-December 31, 2003), descriptive, multicenter study of all pregnant women injured in TR-MCIs.
Twelve pregnant women (singletons, gestational age 20.6 +/- 10.5 weeks) who were injured during the study period. One victim was intubated on location of the event, another was hemodynamically compromised upon arrival. All women survived. Seven women required surgical intervention with general anesthesia. Four of the five women with viable pregnancies required cesarean delivery within minutes to hours of arrival. Three of these fetuses were delivered in extremis and one died.
Women with a viable pregnancy who have been injured in TR-MCIs have a high incidence of surgical procedures and a high likelihood of undergoing cesarean delivery within minutes to hours of injury. Fetal outcome may be poor under these circumstances.
The Journal of trauma 04/2008; 64(3):727-32. · 2.48 Impact Factor
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ABSTRACT: We studied the response of the Shaare Zedek Medical Center (SZMC) in Jerusalem, Israel, to terrorist multiple- or mass-casualty events (TMCEs) that occurred between 1983 and 2004, to document the role of the intensive care unit (ICU) in this response.
The SZMC Disaster Plan was reviewed in detail. Hospital and ICU records were retrospectively reviewed for all patients presenting to SZMC between 1983 and 2004 after a TMCE. Data were coded for age, sex, injuries, length of stay, and mortality.
Eight hundred seventy-five patients presented to SZMC after 31 TMCEs. The number of patients presenting ranged from 1 to 84 with an average of 28 patients per TMCE. Forty-one (4.7%) of the patients were admitted to the ICU. The age of the ICU patients ranged from 4 to 80 with an average of 30.9 years. Twenty-nine (70%) of the patients had blast lung injury, 3 (7%) had intestinal blast injury, and 30 (73%) had ruptured tympanic membranes. Forty-two surgical procedures were performed in 23 patients. Thirty (73%) patients required mechanical ventilation. One patient (2.4%) died of multiple organ failure caused by a delay in diagnosis of intestinal blast injury.
Of the patients presenting to SZMC after TMCE, 4.7% required ICU care. Seventy-three percent of the ICU patients required mechanical ventilation. The ICU plays a critical role in the SZMC response to TMCEs.
The Journal of trauma 06/2007; 62(5):1234-9. · 2.48 Impact Factor
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Critical Care Medicine 05/2007; 35(4):1193-4. · 6.33 Impact Factor
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ABSTRACT: In some hospitals, patients are mechanically ventilated on the wards in addition to the intensive care unit (ICU) because of the shortage of ICU beds.
The aim of the study was to compare the outcome and ventilatory management of medical patients mechanically ventilated on the medical wards and in the ICU.
This was a prospective, observational, noninterventional study over a 6-month period.
The study was conducted in internal medicine wards and the ICU of a 500-bed community university-affiliated hospital.
Ninety-nine mechanically ventilated medical patients in the ICU or on the medical wards because of shortage of ICU beds were included in the study.
Baseline characteristics of the patients ventilated in the ICU (group 1) and in the medical wards (group 2) were collected. Thirty-four patients were ventilated in the ICU and 65 in the wards during the study period. In-hospital survival rate in group 1 was 38% vs 20% in group 2 (P < .05). The Acute Physiologic and Chronic Health Evaluation (APACHE) II score in group 1 was 24 +/- 7 vs 27 +/- 7 in group 2 (P < .05). Other prognostic factors were similar. The age of the survivors in the 2 groups was similar: 57 +/- 25 years in group 1 vs 69 +/- 13 years in group 2 (P = NS). Mean number of ventilatory changes in group 1 was 7.5 +/- 1.4 per day per patient, whereas it was 1.3 +/- 1.0 in group 2 (P < .001). The number of arterial blood gas analyses in group 1 was 7.7 +/- 1.2 per day per patient compared with 2.3 +/- 1.3 in group 2 (P < .001). Twenty percent (20%) of the patients in group 1 had endotracheal tube-related inadvertent events compared with 62% of the patients in group 2 (P < .05).
We conclude that in medical patients requiring mechanical ventilation, there is a higher in-hospital survival rate in ICU-ventilated patients as compared with ventilated patients managed on the medical wards. In addition, ICU provides a better monitoring associated with less endotracheal tube-related complications and more active ventilatory management.
Journal of Critical Care 04/2007; 22(1):13-7. · 2.13 Impact Factor
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ABSTRACT: Whether outcome from in-hospital cardiopulmonary resuscitation (CPR) is poorer when it occurs during the night remains controversial. This study examined the relationship between CPR during the various hospital shifts and survival to discharge.
CPR attempts occurring in a tertiary hospital with a dedicated, certified resuscitation team were recorded prospectively (Utstein template guidelines) over 24 months. Medical records and patient characteristics were retrieved from patient admission files.
Included were 174 in-hospital cardiac arrests; 43%, 32% and 25% in morning evening and night shifts, respectively. Shift populations were comparable in demographic and treatment related variables. Asystole (p < 0.01) and unwitnessed arrests (p = 0.05) were more common during the night. Survival to discharge was poorer following night shift CPR than following morning and evening shift CPR (p = 0.04). When asystole (being synonymous with death) was excluded from the analysis, the odds of survival to discharge was not higher for witnessed compared to unwitnessed arrest but was 4.9 times higher if the cardiac arrest did not occur during the night shift (p = 0.05, logistic regression). The relative risk of eventual in-hospital death for patients with return of spontaneous circulation (ROSC) following night shift resuscitation was 1.9 that of those with ROSC following morning or evening resuscitation (Cox regression).
Although unwitnessed arrest is more prevalent during night shift, resuscitation during this shift is associated with poorer outcomes independently of witnessed status. Further research is required into the causes for the increased mortality observed after night shift resuscitation.
Resuscitation 10/2006; 71(1):56-64. · 3.60 Impact Factor
