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Purpose To quantify the numbers of critical care beds in Europe and to understand the differences in these numbers between countries when corrected for population size and gross domestic product. Methods Prospective data collection of critical care bed numbers for each country in Europe from July 2010 to July 2011. Sources were identified in each country that could provide data on numbers of critical care beds (intensive care and intermediate care). These data were then cross-referenced with data from international databases describing population size and age, gross domestic product (GDP), expenditure on healthcare and numbers of acute care beds. Results We identified 2,068,892 acute care beds and 73,585 (2.8 %) critical care beds. Due to the heterogeneous descriptions of these beds in the individual countries it was not possible to discriminate between intensive care and intermediate care in most cases. On average there were 11.5 critical care beds per 100,000 head of population, with marked differences between countries (Germany 29.2, Portugal 4.2). The numbers of critical care beds per country corrected for population size were positively correlated with GDP ( r 2  = 0.16, p  = 0.05), numbers of acute care beds corrected for population ( r 2  = 0.12, p  = 0.05) and the percentage of acute care beds designated as critical care ( r 2  = 0.59, p  < 0.0001). They were not correlated with the proportion of GDP expended on healthcare. Conclusions Critical care bed numbers vary considerably between countries in Europe. Better understanding of these numbers should facilitate improved planning for critical care capacity and utilization in the future.

The “very old intensive care patients” (abbreviated to VOPs; greater than 80 years old) are probably the fastest expanding subgroup of all intensive care unit (ICU) patients. Up until recently most ICU physicians have been reluctant to admit these VOPs. The general consensus was that there was little survival to gain and the incremental life expectancy of ICU admission was considered too small. Several publications have questioned this belief, but others have confirmed the poor long-term mortality rates in VOPs. More appropriate triage (resource limitation enforced decisions), admission decisions based on shared decision-making and improved prediction models are also needed for this particular patient group. Here, an expert panel proposes a research agenda for VOPs for the coming years.

Background During septic shock management, the evaluation of microvascular perfusion by skin analysis is of interest. We aimed to study the skin capillary refill time (CRT) in a selected septic shock population. Methods We conducted a prospective observational study in a tertiary teaching hospital. After a preliminary study to calculate CRT reproducibility, all consecutive patients with septic shock during a 10-month period were included. After initial resuscitation at 6 h (H6), we recorded hemodynamic parameters and analyzed their predictive value on 14-day mortality. CRT was measured on the index finger tip and on the knee area. Results CRT was highly reproducible with an excellent inter-rater concordance calculated at 80 % [73–86] for index CRT and 95 % [93–98] for knee CRT. A total of 59 patients were included, SOFA score was 10 [7–14], SAPS II was 61 [50–78] and 14-day mortality rate was 36 %. CRT measured at both sites was significantly higher in non-survivors compared to survivors (respectively 5.6 ± 3.5 vs 2.3 ± 1.8 s, P  < 0.0001 for index CRT and 7.6 ± 4.6 vs 2.9 ± 1.7 s, P  < 0.0001 for knee CRT). The CRT at H6 was strongly predictive of 14-day mortality as the area under the curve was 84 % [75–94] for the index measurement and was 90 % [83–98] for the knee area. A threshold of index CRT at 2.4 s predicted 14-day outcome with a sensitivity of 82 % (95 % CI [60–95]) and a specificity of 73 % (95 % CI [56–86]). A threshold of knee CRT at 4.9 s predicted 14-day outcome with a sensitivity of 82 % (95 % CI [60–95]) and a specificity of 84 % (95 % CI [68–94]). CRT was significantly related to tissue perfusion parameters such as arterial lactate level and SOFA score. Finally, CRT changes during shock resuscitation were significantly associated with prognosis. Conclusion CRT is a clinical reproducible parameter when measured on the index finger tip or the knee area. After initial resuscitation of septic shock, CRT is a strong predictive factor of 14-day mortality.

The endothelium is a highly dynamic cell layer that is involved in a multitude of physiological functions, including the control of vascular tone, the movement of cells and nutrients, the maintenance of blood fluidity and the growth of new vessels. During severe sepsis, the endothelium becomes proadhesive, procoagulant, antifibrinolytic and is characterized by alterations of vasomotor regulation. Most of these functions have been discovered using in vitro and animal models, but in vivo exploration of endothelium in patients remains difficult. New tools to analyze endothelial dysfunction at bedside have to be developed.

Objective To assess on a multinational level the frequency, characteristics, contributing factors, and preventive measures of administration errors in parenteral medication in intensive care units.Design Observational, prospective, 24 hour cross sectional study with self reporting by staff.Setting 113 intensive care units in 27 countries.Participants 1328 adults in intensive care.Main outcome measures Number of errors; impact of errors; distribution of error characteristics; distribution of contributing and preventive factors. Results 861 errors affecting 441 patients were reported: 74.5 (95% confidence interval 69.5 to 79.4) events per 100 patient days. Three quarters of the errors were classified as errors of omission. Twelve patients (0.9% of the study population) experienced permanent harm or died because of medication errors at the administration stage. In a multiple logistic regression with patients as the unit of analysis, odds ratios for the occurrence of at least one parenteral medication error were raised for number of organ failures (odds ratio per increase of one organ failure: 1.19, 95% confidence interval 1.05 to 1.34); use of any intravenous medication (yes v no: 2.73, 1.39 to 5.36); number of parenteral administrations (per increase of one parenteral administration: 1.06, 1.04 to 1.08); typical interventions in patients in intensive care (yes v no: 1.50, 1.14 to 1.96); larger intensive care unit (per increase of one bed: 1.01, 1.00 to 1.02); number of patients per nurse (per increase of one patient: 1.30, 1.03 to 1.64); and occupancy rate (per 10% increase: 1.03, 1.00 to 1.05). Odds ratios for the occurrence of parenteral medication errors were decreased for presence of basic monitoring (yes v no: 0.19, 0.07 to 0.49); an existing critical incident reporting system (yes v no: 0.69, 0.53 to 0.90); an established routine of checks at nurses’ shift change (yes v no: 0.68, 0.52 to 0.90); and an increased ratio of patient turnover to the size of the unit (per increase of one patient: 0.73, 0.57 to 0.93).Conclusions Parenteral medication errors at the administration stage are common and a serious safety problem in intensive care units. With the increasing complexity of care in critically ill patients, organisational factors such as error reporting systems and routine checks can reduce the risk for such errors.

Objectives To define a set of indicators that could be used to improve quality in intensive care medicine. Methodology An European Society of Intensive Care Medicine Task Force on Quality and Safety identified all commonly used key quality indicators. This international Task Force consisted of 18 experts, all with a self-proclaimed interest in the area. Through a modified Delphi process seeking greater than 90% consensual agreement from this nominal group, the indicators were then refined through a series of iterative processes. Results A total of 111 indicators of quality were initially found, and these were consolidated into 102 separate items. After five discrete rounds of debate, these indicators were reduced to a subset of nine that all had greater than 90% agreement from the nominal group. These indicators can be used to describe the structures (3), processes (2) and outcomes (4) of intensive care. Across this international group, it was much more difficult to obtain consensual agreement on the indicators describing processes of care than on the structures and outcomes. Conclusion This document contains nine indicators, all of which have a high level of consensual agreement from an international Task Force, which could be used to improve quality in routine intensive care practice.

PurposeWhether epinephrine or norepinephrine is preferable as the continuous intravenous vasopressor used to treat post-resuscitation shock is unclear. We assessed outcomes of patients with post-resuscitation shock after out-of-hospital cardiac arrest according to whether the continuous intravenous vasopressor used was epinephrine or norepinephrine.MethodsWe conducted an observational multicenter study of consecutive patients managed in 2011–2018 for post-resuscitation shock. The primary outcome was all-cause hospital mortality, and secondary outcomes were cardiovascular hospital mortality and unfavorable neurological outcome (Cerebral Performance Category 3–5). A multivariate regression analysis and a propensity score analysis were performed, as well as several sensitivity analyses.ResultsOf the 766 patients included in five hospitals, 285 (37%) received epinephrine and 481 (63%) norepinephrine. All-cause hospital mortality was significantly higher in the epinephrine group (OR 2.6; 95%CI 1.4–4.7; P = 0.002). Cardiovascular hospital mortality was also higher with epinephrine (aOR 5.5; 95%CI 3.0–10.3; P < 0.001), as was the proportion of patients with CPC of 3–5 at hospital discharge. Sensitivity analyses produced consistent results. The analysis involving adjustment on a propensity score to control for confounders showed similar findings (aOR 2.1; 95%CI 1.1–4.0; P = 0.02).ConclusionAmong patients with post-resuscitation shock after out-of-hospital cardiac arrest, use of epinephrine was associated with higher all-cause and cardiovascular-specific mortality, compared with norepinephrine infusion. Until additional data become available, intensivists may want to choose norepinephrine rather than epinephrine for the treatment of post-resuscitation shock after OHCA.

Background Experimental and clinical studies have identified a crucial role of microcirculation impairment in severe infections. We hypothesized that mottling, a sign of microcirculation alterations, was correlated to survival during septic shock. Methods We conducted a prospective observational study in a tertiary teaching hospital. All consecutive patients with septic shock were included during a 7-month period. After initial resuscitation, we recorded hemodynamic parameters and analyzed their predictive value on mortality. The mottling score (from 0 to 5), based on mottling area extension from the knees to the periphery, was very reproducible, with an excellent agreement between independent observers [kappa = 0.87, 95% CI (0.72–0.97)]. Results Sixty patients were included. The SOFA score was 11.5 (8.5–14.5), SAPS II was 59 (45–71) and the 14-day mortality rate 45% [95% CI (33–58)]. Six hours after inclusion, oliguria [OR 10.8 95% CI (2.9, 52.8), p  = 0.001], arterial lactate level [<1.5 OR 1; between 1.5 and 3 OR 3.8 (0.7–29.5); >3 OR 9.6 (2.1–70.6), p  = 0.01] and mottling score [score 0–1 OR 1; score 2–3 OR 16, 95% CI (4–81); score 4–5 OR 74, 95% CI (11–1,568), p  < 0.0001] were strongly associated with 14-day mortality, whereas the mean arterial pressure, central venous pressure and cardiac index were not. The higher the mottling score was, the earlier death occurred ( p  < 0.0001). Patients whose mottling score decreased during the resuscitation period had a better prognosis (14-day mortality 77 vs. 12%, p  = 0.0005). Conclusion The mottling score is reproducible and easy to evaluate at the bedside. The mottling score as well as its variation during resuscitation is a strong predictor of 14-day survival in patients with septic shock.