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ACP HospitalistWeekly

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In the News for the Week of August 8, 2012

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Highlights

U.S. in-hospital death rates after cardiac arrest declined from 2001 to 2009

In-hospital mortality from cardiac arrest declined in the U.S. from 2001 to 2009, according to a new study. More...

Organ failure in ICU predicts five-year survival

Organ failure during critical illness strongly predicts five-year survival, including in patients who survive up to a year after ICU admission, a study found. More...

Critical care

Greater sedative use associated with delirium, longer time on mechanical ventilation

Reducing exposure to sedatives among mechanically ventilated patients, both at night and during the day, may improve their outcomes, a new study found. More...

Stroke

Higher HDL, triglycerides associated with 30-day survival

Patients with lower HDL cholesterol and triglycerides had a higher risk of dying after an ischemic stroke and treatment with intravenous thrombolysis. More...

Cartoon caption contest

Put words in our mouth

ACP HospitalistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...

Physician editor: A. Scott Keller, MD, FACP

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Highlights

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U.S. in-hospital death rates after cardiac arrest declined from 2001 to 2009

In-hospital mortality from cardiac arrest declined in the U.S. from 2001 to 2009, according to a new study.

Researchers used data from the U.S. National Inpatient Sample to determine whether in-hospital mortality rates after cardiac arrest have improved in the past decade, which was marked by noteworthy advances in post-resuscitation care, including therapeutic hypothermia. The ICD-9 code 427.5 was used to determine which patients were hospitalized with cardiac arrest in the U.S. from 2001 to 2009. Patients were stratified by age, sex and race, and comorbid conditions were also assessed. In-hospital mortality was the study's main outcome measure. The results were published in the July 31 Circulation.

Overall, 1,190,860 patients had a hospitalization for cardiac arrest over the study period. The in-hospital mortality rate decreased each year, from 69.6% in 2001 to 57.8% in 2009. The researchers performed a multivariable analysis controlling for age, sex, race and comorbid conditions and found a strong independent correlation between hospitalization in an earlier year and in-hospital death. In addition, all subgroups of age, sex, race and comorbidity saw a decrease in the in-hospital mortality rate over time.

The authors noted that their study was limited by lack of data on the location of the cardiac arrests, the initial cardiac rhythm, and cardiopulmonary resuscitation, among other factors. They also stressed that their findings apply only to patients who survived cardiac arrest long enough to be hospitalized. However, they concluded that the data indicate a substantial, consistent decline in mortality among patients hospitalized for cardiac arrest over the study period. "Although we cannot definitively conclude which specific factor is responsible for the decline in mortality, our results suggest that advances in post-resuscitation care have positively impacted survival rates of patients hospitalized with cardiac arrest in the United States from 2001 to 2009," the authors wrote.

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Organ failure in ICU predicts five-year survival

Organ failure during critical illness strongly predicts five-year survival, including in patients who survive up to a year after ICU admission, a study found.

Researchers undertook a secondary analysis of data from a study involving sequential admissions to ten Scottish ICUs during a 100-day period in 2001. For each of the 872 patients, researchers evaluated the five organ systems (cardiovascular, respiratory, renal, coagulation and liver) daily and determined the Sequential Organ Failure Assessment (SOFA) score ranging from 0 (no dysfunction) to 4 (severe dysfunction). Results were grouped such that a score of 3-4 described organ failure and a score of 0-2 described no organ failure. Total organ failure burden was derived by adding the worst individual organ failure scores at any time point during the ICU stay, with groups defined as mild (0-5), moderate (6-10) and severe (≥11). Researchers used logistic regression analysis to determine independent associations between mortality and organ failures over five years, with adjustment for possible confounders. Results were published online July 26 in the American Journal of Respiratory and Critical Care Medicine.

Higher total burden of organ failure was strongly associated with mortality; patients in the severe category had an 80.7% five-year mortality rate compared to 35% mortality for mild patients (odds ratio [OR], 6.3; P<0.001). Moderate patients had 57.4% mortality at five years. Patients who lived more than 12 months after their ICU stay were still more likely to die if they had had a higher organ failure burden in the ICU (OR, 2.4; P=0.02 for severe vs. mild groups). In the multivariable analysis adjusting for each organ failure and confounders, cardiovascular (OR, 2.5; P<0.001), liver (OR, 2.3; P=0.04) and respiratory failure (OR, 2.1; P=0.004) were associated with higher five-year mortality while coagulation and renal failure were not.

Using a cumulative score of organ failure to measure total organ failure burden yielded a stronger association with long-term mortality than have other existing measures of illness severity, like the Acute Physiology and Chronic Health Evaluation (APACHE) II, the Simplified Acute Physiology Score (SAPS) II, or the daily total SOFA or total SOFA at discharge, the authors noted. It may be that acute organ failure that necessitates ICU admission leads to residual organ damage which lowers survival; or, a high cumulative score may be a marker for those who are likely to develop chronic ICU-acquired morbidities, the authors wrote. Future studies should gather comprehensive information on comorbidities present before ICU admission as well as those that develop after critical illness, to better tease out any confounding due to pre-existing illness, they advised.

Critical care

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Greater sedative use associated with delirium, longer time on mechanical ventilation

Reducing exposure to sedatives among mechanically ventilated patients, both at night and during the day, may improve their outcomes, a new study found.

In a prospective cohort study, researchers examined 140 ICU patients at a hospital in Nashville, Tenn. who received mechanical ventilation (MV) for more than 12 hours. They recorded patients' doses of benzodiazepines and propofol every hour, in order to determine whether daytime and/or nighttime increases in dosage were independently associated with delirium, coma and more time on mechanical ventilation. For study purposes, daytime was considered 7 a.m. to 11 p.m. and nighttime was 11 p.m. to 7 a.m. Nighttime dose increases were quantified by subtracting the average hourly daytime dose on the previous day from the subsequent average hourly nighttime dose. Results were published online July 20 by Critical Care Medicine.

Among patients who received sedatives, benzodiazepine doses were increased at night (vs. day) on 40% of patient-days and propofol doses were increased at night on 41% of patient-days. Delirium was present on 33% of patient-days and coma was present on 42% of patient-days. Higher daytime benzodiazepine dosage was independently associated with failed spontaneous breathing trials and extubation, and subsequent delirium (P<0.02 for all), in adjusted models. Nighttime increase in benzodiazepine dose was associated with failed spontaneous breathing trials (P<0.01) and with delirium (P<0.05). Over the first five days of the study, patients spent 75% of their time in delirium or coma.

The study confirms previous findings that benzodiazepines are an independent risk factor for developing delirium during critical illness, but expands the findings by showing the drug increases the odds even when given more than eight hours before delirium assessment. The results argue for wider adoption of structured sedation protocols to reduce total exposure to sedatives, the authors wrote, with particular emphasis on nighttime care.

Stroke

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Higher HDL, triglycerides associated with 30-day survival

Patients with lower HDL cholesterol and triglycerides had a higher risk of dying after an ischemic stroke and treatment with intravenous thrombolysis.

In this retrospective study of over 1,800 ischemic stroke patients (all treated with intravenous thrombolysis), researchers identified factors associated with three-month mortality. Patients who died had a median HDL of 1.34 mmol/L (51.82 mg/dL) at presentation compared to 1.40 mmol/L (54.13 mg/dL) in survivors. When triglyceride levels were compared, lower levels were also associated with mortality: a median of 1.00 mmol/L (88.57 mg/dL) in patients who died compared to 1.15 mmol/L (101.86 mg/dL) in those who survived at least three months. Other predictors of mortality were higher NIH Stroke Scale score, age, C-reactive protein and serum creatinine.

Symptomatic intracerebral hemorrhage (ICH) was associated with higher mortality, but not with total cholesterol, LDL, HDL or triglycerides. Thus, the association between low HDL and triglycerides and mortality was not due to ICH, the researchers concluded. They also found that patients who had excellent outcomes at three months after stroke (a modified Rankin score of 0-1) had higher HDL levels at the time of their strokes. The results were published online by Neurology on July 25.

The study couldn't determine the mechanisms behind these associations, the authors acknowledged. One possible explanation for the association between triglycerides and mortality is that lower triglycerides indicate a poor nutritional state. Or, triglycerides may provide a neuroprotective effect against fatty acid neurotoxicity, the authors speculated.

The association between low HDL and mortality (even when controlling for statin use) is novel, but consistent with previous research finding higher mortality in obese patients. There are several mechanisms by which HDL could contribute neuroprotective or vasculoprotective effects, the authors said. HDL also could be a marker for some other factor, such as fitness, since exercise is known to increase HDL levels. More research is needed to understand the mechanism of the association between high HDL and triglycerides and survival after stroke, the authors concluded.

Cartoon caption contest

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Put words in our mouth

ACP HospitalistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

E‑mail all entries to acphospitalist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated