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One of the characteristics of acute lung injury is noncardiogenic pulmonary edema. Arguments have been made for the management of acute lung injury with either a liberal or conservative approach to fluid administration. In this trial, neither approach offered a mortality benefit; there were clinical and physiological benefits to conservative fluid management. Arguments have been made for the management of acute lung injury with either a liberal or conservative approach to fluid administration. In this trial, neither approach offered a mortality benefit; there were clinical and physiological benefits to conservative fluid management. Pulmonary edema resulting from increased capillary permeability, a hallmark of acute lung injury, worsens as intravascular hydrostatic pressure rises and oncotic pressure falls. 1 , 2 Although lung failure alone can be lethal, death in patients with acute lung injury is usually due to the failure of nonpulmonary organs. 1 , 3 The optimal fluid management of acute lung injury is not settled. 4 – 7 The usual practice is wide-ranging, and many practitioners weigh the risks and benefits of strategies of conservative as compared with liberal fluid management. In the conservative approach, fluid intake is restricted and urinary output is increased in an attempt to . . .

Variation in practice and outcomes, not explained by patient or illness characteristics, is common in health care, including in intensive care units (ICUs). To quantify within-ICU, between-physician variation in resource use in a single medical ICU. This was a prospective, noninterventional study in a medical ICU where nine intensivists provide care in 14-d rotations. Consecutive sample consisted of 1,184 initial patient admissions whose care was provided by a single intensivist. Multivariate models were constructed for average daily discretionary costs, ICU length of stay, and hospital mortality, adjusting for patient and illness characteristics, and workload. The identity of the intensivist was a significant predictor for average daily discretionary costs (p < 0.0001), but not ICU length of stay (p = 0.33) or hospital mortality (p = 0.83). The intensivists had more influence on costs than all other variables except the severity and type of acute illness. Average daily discretionary costs varied by 43% across the different intensivists, equating to a mean difference of 1,003 dollars per admission between the highest and lowest terciles of intensivists. There are large differences among intensivists in the amount of resources they use to manage critically ill patients. Higher resource use was not associated with lower length of stay or mortality.

Hemodynamic monitoring is a common physiological intervention in patients with acute lung injury. In this randomized, controlled trial in which patient care was dictated by a specific hemodynamic protocol, there was no significant difference in 60-day mortality whether monitoring was performed with a pulmonary-artery catheter or a central venous catheter. Hemodynamic monitoring is a common physiological intervention in patients with acute lung injury. In this trial there was no significant difference in 60-day mortality whether monitoring was performed with a pulmonary-artery catheter or a central venous catheter. The pulmonary-artery catheter (PAC) provides unique hemodynamic data, including the cardiac index and pulmonary-artery–occlusion pressure. People who advocate the use of the PAC note that the clinician's ability to predict intravascular pressure with the use of this catheter is poor 1 – 3 ; central venous pressure, as obtained by means of the PAC, correlates imperfectly with pulmonary-artery–occlusion pressure 4 – 6 ; and the insertion of a PAC often changes therapy. 6 – 8 Although many critically ill patients receive PACs, 9 no clear clinical benefit has been associated with their use. 10 – 12 Practitioners often misinterpret the information obtained by means of a PAC or act . . .

BackgroundThe decision to undertake a surgical intervention for an emergency general surgery (EGS) condition (appendicitis, diverticulitis, cholecystitis, hernia, peptic ulcer, bowel obstruction, ischemic bowel) involves a complex consideration of factors, particularly in older adults. We hypothesized that identifying variability in the application of operative management could highlight a potential pathway to improve patient survival and outcomes.MethodsWe included adults aged 65+ years with an EGS condition from the 2016–2017 National Inpatient Sample. Operative management was determined from procedure codes. Each patient was assigned a propensity score (PS) for the likelihood of undergoing an operation, modeled from patient and hospital factors: EGS diagnosis, age, gender, race, presence of shock, comorbidities, and hospital EGS volumes. Low and high probability for surgery was defined using a PS cut-off of 0.5. We identified two model-concordant groups (no surgery-low probability, surgery-high probability) and two model-discordant groups (no surgery-high probability, surgery-low probability). Logistic regression estimated the adjusted OR (AOR) of in-hospital mortality for each group.ResultsOf 375 546 admissions, 21.2% underwent surgery. Model-discordant care occurred in 14.6%; 5.9% had no surgery despite a high PS and 8.7% received surgery with low PS. In the adjusted regression, model-discordant care was associated with significantly increased mortality: no surgery-high probability AOR 2.06 (1.86 to 2.27), surgery-low probability AOR 1.57 (1.49 to 1.65). Model-concordant care showed a protective effect against mortality (AOR 0.83, 0.74 to 0.92).ConclusionsNearly one in seven EGS patients received model-discordant care, which was associated with higher mortality. Our study suggests that streamlined treatment protocols can be applied in EGS patients as a means to save lives.Level of evidenceIII.

The pulmonary artery catheter (PAC) remains widely used in acute lung injury (ALI) despite known complications and little evidence of improved short-term mortality. Concurrent with NHLBI ARDS Clinical Trials Network Fluid and Catheters Treatment Trial (FACTT), we conducted a prospectively-defined comparison of healthcare costs and long-term outcomes for care with a PAC vs. central venous catheter (CVC). We explored if use of the PAC in ALI is justified by a beneficial cost-effectiveness profile. We obtained detailed bills for the initial hospitalization. We interviewed survivors using the Health Utilities Index Mark 2 questionnaire at 2, 6, 9 and 12 m to determine quality of life (QOL) and post-discharge resource use. Outcomes beyond 12 m were estimated from federal databases. Incremental costs and outcomes were generated using MonteCarlo simulation. Of 1001 subjects enrolled in FACTT, 774 (86%) were eligible for long-term follow-up and 655 (85%) consented. Hospital costs were similar for the PAC and CVC groups ($96.8k vs. $89.2k, p = 0.38). Post-discharge to 12 m costs were higher for PAC subjects ($61.1k vs. 45.4k, p = 0.03). One-year mortality and QOL among survivors were similar in PAC and CVC groups (mortality: 35.6% vs. 31.9%, p = 0.33; QOL [scale: 0-1]: 0.61 vs. 0.66, p = 0.49). MonteCarlo simulation showed PAC use had a 75.2% probability of being more expensive and less effective (mean cost increase of $14.4k and mean loss of 0.3 quality-adjusted life years (QALYs)) and a 94.2% probability of being higher than the $100k/QALY willingness-to-pay threshold. PAC use increased costs with no patient benefit and thus appears unjustified for routine use in ALI. www.clinicaltrials.gov NCT00234767.

To use an existing database from a large cohort study with follow-up as long as 5.5 years to assess the extended prognosis of patients who survived their hospitalizations for severe acute respiratory failure (ARF). Secondary analysis of an inception cohort of 1,722 patients with ARF requiring mechanical ventilation from five major medical centers who were entered into the prospective Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. The 1,075 patients (62.4%) who survived hospitalization had systematic follow-up of vital status for a median time of 662 days (interquartile range, 327 to 1,049 days; range, 2 to 2,014 days). Interviews performed a median of 5 months after hospital discharge assessed functional capacity and quality of life (QOL). The main outcome measure was survival after hospital discharge. Secondary measures were functional status and QOL. Cox proportional hazard regression identified factors influencing posthospital survival. The median survival time after hospital discharge for ARF was > 5.3 years. The posthospital survival time was shorter for those with older age, male gender, several preexisting comorbid conditions, worse prehospital functional status, greater acute physiologic derangement, and a do-not-resuscitate order while in the hospital, and for those discharged to a location other than home. Five months after hospital discharge, 48% of survivors needed help with at least one activity of daily living, and 27% rated their QOL as poor or fair. However, most of these impairments were present before respiratory failure occurred. Extended survival is common among patients with ARF who require mechanical ventilation and who survive hospitalization. Among these patients, only a small fraction of the impairment in activity and QOL can be considered to be a sequela of the respiratory failure or its therapy. These findings are relevant to the care decisions for such critically ill patients.

ICU-acquired paresis (ICUAP) is common in survivors of critical illness. There is significant associated morbidity, including prolonged time on the ventilator and longer hospital stay. However, it is unclear whether ICUAP is independently associated with mortality, as sicker patients are more prone and existing studies have not adjusted for this. To test the hypothesis that ICUAP is independently associated with increased mortality. Secondarily, to determine if handgrip dynamometry is a concise measure of global strength and is independently associated with mortality. A prospective multicenter cohort study was conducted in intensive care units (ICU) of five academic medical centers. Adults requiring at least 5 days of mechanical ventilation without evidence of preexisting neuromuscular disease were followed until awakening and were then examined for strength. We measured global strength and handgrip dynamometry. The primary outcome was in-hospital mortality and secondary outcomes were hospital and ICU-free days, ICU readmission, and recurrent respiratory failure. Subjects with ICUAP (average MRC score of < 4) had longer hospital stays and required mechanical ventilation longer. Handgrip strength was lower in subjects with ICUAP and had good test performance for diagnosing ICUAP. After adjustment for severity of illness, ICUAP was independently associated with hospital mortality (odds ratio [OR], 7.8; 95% confidence interval [CI], 2.4-25.3; P = 0.001). Separately, handgrip strength was independently associated with hospital mortality (OR, 4.5; 95% CI, 1.5-13.6; P = 0.007). ICUAP is independently associated with increased hospital mortality. Handgrip strength is also independently associated with poor hospital outcome and may serve as a simple test to identify ICUAP. Clinical trial registered with www.clinicaltrials.gov (NCT00106665).