2011 April 09

A national study of plasma use in critical care: clinical indications, dose, and effect on prothrombin time.

Apr 092011

A national study of plasma use in critical care: clinical indications, dose, and effect on prothrombin time.

Crit Care. 2011 Apr 5;15(2):R108

Authors: Stanworth SJ, Walsh TS, Prescott RJ, Lee RJ, Watson DM, Wyncoll D, Intensive Care Study Of Coagulopathy Isoc Investigators T

ABSTRACT: INTRODUCTION: Fresh frozen plasma (FFP) is widely used, but few studies have described patterns of plasma use in critical care. We carried out a multicentre study of coagulopathy in intensive care units (ICUs) and described overall FFP utilisation in adult critical care, the indications for transfusions, factors indicating the doses used, and the effects of plasma on coagulation. METHODS: A prospective multicentre observational study of all sequentially admitted patients to 29 adult UK general ICUs over 8 weeks. Daily data throughout ICU admission were collected concerning coagulation, relevant clinical outcomes (including bleeding), coagulopathy (defined as International Normalised Ratio, INR >1.5, or equivalent prothrombin time, PT), FFP and cryoprecipitate use, and indications for transfusion. RESULTS: Of 1923 admissions, 12.7% received FFP in the ICU during 404 FFP treatment episodes (1212 FFP units). Overall, 0.63 FFP units per ICU admission were transfused (0.11 units per ICU day). Reasons for FFP transfusion were: bleeding (48%), pre-procedural prophylaxis (15%), and prophylaxis without planned procedure (36%). Overall, median FFP dose was 10.8 ml.kg-1, but varied widely (1st, 3rd quartile 7.2, 14.4 ml.kg-1). 31% of FFP treatments were to patients without PT prolongation, and 41% were to patients without recorded bleeding and only mildly deranged INR (<2.5). Higher volumes of FFP were administered when the indication was bleeding (median dose: bleeding 11.1 mL.kg-1, pre-procedural prophylaxis 9.8 mL.kg-1, prophylaxis without procedure 8.9 mL.kg-1; P=0.009 across groups) and when the pre-transfusion INR was higher (ranging from median dose 8.9 mL.kg-1 when INR [less than or equal to]1.5, to 15.7 mL.kg-1 at INR >3; P<0.001 across ranges). Regression analyses suggested bleeding was the strongest predictor of higher FFP dose. Pre-transfusion INR was more frequently normal when the transfusion indication was bleeding. Overall, post transfusion corrections of INR were consistently small unless the pre-transfusion INR was >2.5, but administration during bleeding was associated with greater INR corrections. CONCLUSIONS: There is wide variation in FFP use by ICU clinicians and a high proportion of current FFP transfusions are of unproven clinical benefit. Better evidence from clinical trials could significantly alter patterns of use and modify current treatment costs.

PMID: 21466676 [PubMed - as supplied by publisher]

Link to Article at PubMed

Characteristics and Outcomes of Very Elderly Patients Following First Hospitalization for Heart Failure.

Circ Heart Fail Start a Discussion »

Apr 092011

Characteristics and Outcomes of Very Elderly Patients Following First Hospitalization for Heart Failure.

Circ Heart Fail. 2011 Apr 5;

Authors: Shah RU, Tsai V, Klein L, Heidenreich PA

BACKGROUND: -The very elderly (age 80 and older) with heart failure (HF) is a growing population that is rarely included in clinical trials. The aim of this investigation was to describe the characteristics and outcomes of very elderly patients after a first HF hospitalization. METHODS AND RESULTS: -We identified very elderly patients (age 80 and older) discharged with HF from the Veteran's Administration (VA) National Patient Care Database from 1999 to 2008. Outcomes of interest were death during index admission, 30-day and one-year mortality, 30-day all cause and HF readmissions. We used generalized estimating equations to evaluate outcome differences between age groups within the very elderly cohort (ages 80-84, 85-89, 90 and older), adjusting for comorbidities, demographics, and clustering by treatment facility. We identified 21,397 very elderly veterans with a first HF hospitalization during the study period. Thirty-day mortality decreased from 14% to 7% (both p<.001) and one-year mortality decreased from 49% to 27% (p<0.001). While these improvements were most notable for patients age 90 and older (one-year mortality improved by 25.9%), the adjusted odds of death within one year were highest for the oldest veterans (OR 1.85, 95% CI 1.64-2.09, using 80-85 age group as reference). For all patients, 30-day all-cause readmissions remained largely unchanged and did not differ between age groups. CONCLUSIONS: -Mortality for very elderly HF patients has improved over time, but 30-day readmissions remain frequent. Future studies should identify interventions to reduce cardiac and non-cardiac re-hospitalization of very elderly HF patients.

PMID: 21467294 [PubMed - as supplied by publisher]

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An Official ATS/ERS/JRS/ALAT Statement: Idiopathic Pulmonary Fibrosis: Evidence-based Guidelines for Diagnosis and Management.

Am J Respir Crit Care Med Start a Discussion »

Apr 092011

An Official ATS/ERS/JRS/ALAT Statement: Idiopathic Pulmonary Fibrosis: Evidence-based Guidelines for Diagnosis and Management.

Am J Respir Crit Care Med. 2011 Mar 15;183(6):788-824

Authors: Raghu G, Collard HR, Egan JJ, Martinez FJ, Behr J, Brown KK, Colby TV, Cordier JF, Flaherty KR, Lasky JA, Lynch DA, Ryu JH, Swigris JJ, Wells AU, Ancochea J, Bouros D, Carvalho C, Costabel U, Ebina M, Hansell DM, Johkoh T, Kim DS, King TE, Kondoh Y, Myers J, Müller NL, Nicholson AG, Richeldi L, Selman M, Dudden RF, Griss BS, Protzko SL, Schünemann HJ,

This document is an international evidence-based guideline on the diagnosis and management of idiopathic pulmonary fibrosis, and is a collaborative effort of the American Thoracic Society, the European Respiratory Society, the Japanese Respiratory Society, and the Latin American Thoracic Association. It represents the current state of knowledge regarding idiopathic pulmonary fibrosis (IPF), and contains sections on definition and epidemiology, risk factors, diagnosis, natural history, staging and prognosis, treatment, and monitoring disease course. For the diagnosis and treatment sections, pragmatic GRADE evidence-based methodology was applied in a question-based format. For each diagnosis and treatment question, the committee graded the quality of the evidence available (high, moderate, low, or very low), and made a recommendation (yes or no, strong or weak). Recommendations were based on majority vote. It is emphasized that clinicians must spend adequate time with patients to discuss patients' values and preferences and decide on the appropriate course of action.

PMID: 21471066 [PubMed - as supplied by publisher]

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Early Corticosteroids in Severe Influenza A/H1N1 Pneumonia and Acute Respiratory Distress Syndrome.

Am J Respir Crit Care Med Start a Discussion »

Apr 092011

Early Corticosteroids in Severe Influenza A/H1N1 Pneumonia and Acute Respiratory Distress Syndrome.

Am J Respir Crit Care Med. 2011 Mar 4;

Authors: Brun-Buisson C, Richard JC, Mercat A, Thiébaut AC, Brochard L,

Rationale - Despite their controversial role, corticosteroids are often administered to patients with the Adult Respiratory Distress Syndrome (ARDS) secondary to viral pneumonia. We analyzed the outcome of ARDS patients receiving steroids during the recent Influenza A(H1N1) pandemic. Methods - Patients from the French registry of critically ill patients with Influenza A/H1N1v 2009 infection were selected if fulfilling criteria for ARDS, excluding patients having other indication for corticosteroids, or decompensated underlying disease as the primary cause for intensive care unit admission. Survival to hospital discharge was analyzed using Cox regression, accounting for the time to administration of steroids, and after adjustment on the propensity for receiving steroid therapy. Main results - Of 208 patients with ARDS, 83 (39.9 %) received corticosteroids (median initial dose of 270 mg equivalent hydrocortisone per day for a median of 11 days). Steroid therapy was associated with death, both in crude analysis (33.7% vs. 16.8%; hazard ratio [HR] 2.4; 95% CI, 1.3-4.3, P = .004) and after propensity score -adjusted analysis (aHR 2.82; 95% CI, 1.5 - 5.4; P= .002), controlling for an admission severity score SAPS 3 > 50, initial administration of vasopressors, and immunodepression. Early therapy (?3 days of mechanical ventilation) appeared more strongly associated with mortality than late administration. Patients receiving steroids had more acquired pneumonia, and a trend to a longer duration of ventilation. Conclusion - Our study provides no evidence of a beneficial effect of corticosteroids in patients with ARDS secondary to influenza pneumonia, but suggests that very early corticosteroid therapy may be harmful.

PMID: 21471082 [PubMed - as supplied by publisher]

Link to Article at PubMed

Lung Transplantation.

Am J Respir Crit Care Med Start a Discussion »

Apr 092011

Lung Transplantation.

Am J Respir Crit Care Med. 2011 Mar 31;

Authors: Kotloff RM, Thabut G

First performed in 1963, lung transplantation is approaching the half-century mark. With over 32,000 procedures having been carried out worldwide, lung transplantation has become the standard of care for select patients with advanced lung diseases of various non-malignant etiologies. Indications for transplantation have broadened over the years and selection criteria have become less restrictive. A relatively scarce donor pool limits wider application of this therapy but this is being addressed in part through relaxation of donor selection criteria, donor management protocols that preserve and optimize lung function, and development of ex vivo perfusion techniques to "recondition" suboptimal organs. Bilateral lung transplantation has become the procedure of choice for most indications, though its preferential use in patients with idiopathic pulmonary fibrosis remains controversial. Post-transplantation survival has steadily improved, but significant constraints on long-term survival persist as evidenced by a median survival rate that currently stands at 5.7 years. This has brought into focus the question of whether and for whom transplantation actually confers a survival advantage, a question that in the absence of randomized trials can only be answered with statistical modeling. Primary graft dysfunction, infection, and bronchiolitis obliterans syndrome are common complications encountered by the lung transplant recipient and major impediments to long-term survival. This review provides an overview of the current status of lung transplantation, highlighting both the many advances that have taken place as well as the challenges that remain.

PMID: 21471083 [PubMed - as supplied by publisher]

Link to Article at PubMed

Corticosteroid Treatment in Critically Ill Patients with Pandemic Influenza A/H1N1 2009 Infection: Analytic Strategy using Propensity Scores.

Am J Respir Crit Care Med Start a Discussion »

Apr 092011

Corticosteroid Treatment in Critically Ill Patients with Pandemic Influenza A/H1N1 2009 Infection: Analytic Strategy using Propensity Scores.

Am J Respir Crit Care Med. 2011 Mar 4;

Authors: Kim SH, Hong SB, Yun SC, Choi WI, Ahn JJ, Lee YJ, Lee HB, Lim CM, Koh Y,

RATIONALE: Administration of adjuvant corticosteroids to patients with pandemic influenza A/H1N1 2009 (pH1N1) may reduce inflammation and improve outcomes. OBJECTIVES: To access the effect of adjuvant corticosteroid treatment on the outcome of critically ill patients with pH1N1 infection. METHODS: All adult patients with confirmed pH1N1 admitted to ICU of 28 hospitals in Korea from September 2009 to February 2010 were enrolled. Patients with and without adjuvant corticosteroid treatment were retrospectively compared by two risk stratification models: (i) a retrospective cohort study that used propensity score to adjust for confounding by treatment assignment and (ii) a propensity-matched case-control study. MEASUREMENTS AND MAIN RESULTS: A total of 245 patients were enrolled in the cohort study, 107 of whom (44%) received adjuvant steroid treatment. In the cohort study, the 90-day mortality rate of patients given steroids (58%, 62/107) was significantly higher than that of those not given steroids (27%, 37/138) (P < 0.001). The steroid group was more likely to have superinfection such as secondary bacterial pneumonia or invasive fungal infection, and had more prolonged ICU stays than the no-steroid group. Multivariate analysis indicated that steroid treatment was associated with increased 90-day mortality when independent predictors for 90-day mortality and propensity score were considered (adjusted OR 2.20; 95% CI 1.03-4.71). In the case-control study, 90-day mortality rate in the steroid group was 54% (35/65) and 31% (20/65) in the no-steroid group (McNemar test's test, P=0.004). CONCLUSIONS: Adjuvant corticosteroids were significantly associated with higher mortality in critically ill with pH1N1.

PMID: 21471084 [PubMed - as supplied by publisher]

Link to Article at PubMed

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