Critical care : the official journal of the Critical Care Forum
-
Multicenter Study Comparative Study
Implications of ICU triage decisions on patient mortality: a cost-effectiveness analysis.
Intensive care is generally regarded as expensive, and as a result beds are limited. This has raised serious questions about rationing when there are insufficient beds for all those referred. However, the evidence for the cost effectiveness of intensive care is weak and the work that does exist usually assumes that those who are not admitted do not survive, which is not always the case. Randomised studies of the effectiveness of intensive care are difficult to justify on ethical grounds; therefore, this observational study examined the cost effectiveness of ICU admission by comparing patients who were accepted into ICU after ICU triage to those who were not accepted, while attempting to adjust such comparison for confounding factors. ⋯ Not only does ICU appear to produce an improvement in survival, but the cost per life saved falls for patients with greater severity of illness. This suggests that intensive care is similarly cost effective to other therapies that are generally regarded as essential.
-
Septic syndromes represent a major healthcare problem worldwide. Clinical and experimental evidence indicates that septic patients rapidly present with numerous compromised immune functions. Although flow cytometry remains a relatively confidential diagnostic tool, it could be useful at every step of ICU patient management. ⋯ The potential of flow cytometry is further illustrated by use of the biomarkers listed above as stratification tools in preliminary clinical studies. Importantly, many other markers of immune dysfunctions are currently under development that could further enable the administration of targeted individualized therapy in ICU patients. The next critical step would be to use these standardized flow cytometry protocols in large multicentric clinical trials testing individualized immunotherapy.
-
Multicenter Study
'Score to Door Time', a benchmarking tool for rapid response systems: a pilot multi-centre service evaluation.
Rapid Response Systems were created to minimise delays in recognition and treatment of deteriorating patients on general wards. Physiological 'track and trigger' systems are used to alert a team with critical care skills to stabilise patients and expedite admission to intensive care units. No benchmarking tool exists to facilitate comparison for quality assurance. This study was designed to create and test a tool to analyse the efficiency of intensive care admission processes. ⋯ Score to Door Time seemed to be largely independent of illness severity and, when combined with qualitative feedback from centres, suggests that admission delays could be due to organisational issues, rather than patient factors. Score to Door Time could act as a suitable benchmarking tool for Rapid Response Systems and helps to delineate avoidable organisational delays in the care of patients at risk of catastrophic deterioration.
-
Studies on the role of programmed death-1(PD-1) and its main ligand (PD-L1) during experimental models of sepsis have shown that the PD-1/PD-L1 pathway plays a pathologic role in altering microbial clearance, the innate inflammatory response and accelerated apoptosis in sepsis. However, the expression of PD-1 and PD-L1 and their role during the development of immune suppression in septic patients have not been elucidated. The present study was designed to determine whether the expression of PD-1 and PD-L1 is upregulated in septic shock patients and to explore the role of this pathway in sepsis-induced immunosuppression. ⋯ The expression of PD-1 on T cells and PD-L1 on monocytes was upregulated in septic shock patients. The PD-1/PD-L1 pathway might play an essential role in sepsis-induced immunosuppression.
-
Despite recent advances in the management of septic shock, mortality rates are still unacceptably high. Early identification of the high-mortality risk group for early intervention remains an issue under exploration. Vascular endothelial growth factor (VEGF), soluble vascular endothelial growth factor receptor-1 (sVEGFR1) and urokinase plasminogen activator (uPA) have diverse effects in the pathogenesis of sepsis, which involve pro-inflammation, anti-inflammation, endothelial cell repair, and vascular permeability change. Their roles in predicting mortality and organ dysfunction remain to be clarified. ⋯ High plasma sVEGFR1 level in the early stage of pneumonia-related septic shock independently predicted 28-day mortality and multi-organ dysfunction.