ICU (Intensive care unit)
From Standard of Care
Critical care resource accounts for almost 1% of US gross domestic product.
More than 50,000 patients are in ICUs each day in the US.
When ICUs are full, sick patients in the emergency room experience delays in admission, and delays are associated morbidity and mortality.
Full ICUs strain physicians and lead to burnout and to preventable medical errors.
ICU beds increase the fixed costs of hospital care.
In 1999 540,000 people died in an ICU, nearly one fourth of all US deaths (Angus DC et al).
In an analysis of 289,310 hospital admissions in VA hospitals most patients admitted to the ICU were of low acuity, with 53% of patients having a predicted hospital mortality of less than 2% (Chen LM et al).
The above study demonstrated widespread variability in admission rates to ICUs across hospitals in the United States, with similar predicted mortality rates ranging from only 2% of such patients in some hospitals to 30% of the time in other hospitals.
In the above study ICU care was significantly associated with a reduced ninety-day mortality for only a few patients with the greatest illness severity.
Secondary infections and multiple organ dysfunction are the leading causes of mortality in patients admitted to an ICU.
More than half of ICU bed-days in the U.S. involve patients over the age of 65 years.
Occurrence rate of ICU acquired nosocomial pneumonia about 20%.
The Extended Prevalence of Infection in Intensive Care (EPIC II) study of 14,414 patients in 1265 ICUs in 75 countries on a study day revealed that 51% patients were considered infected and 71% were receiving antibiotics, 70% had positive biological cultures, 62% of the organisms were gram-negative, 47% gram-positive and 19% were fungi,patients with low stays in the ICU at greater rates of infection, mortality rate infected patient was more than twice that of an uninfected patients( 25% vs. 11%), hospital mortality rate was 33% in infected patients and 15% in uninfected patients(Vincent JL).
A prospective study of 3877 patients in 454 ICUs in Germany prevalence of sepsis was 12.4% (Engel C).
Infections involve the lung, abdomen and blood stream.
77% of patients admitted to the ICU develop anemia.
Underfeeding critically ill patients is associated with weakness, infection, increased duration of mechanical ventilation and death.
Critically ill patients in an ICU receive a mean of 1 U.S. of packed red blood cells per patient day.
16% of patients in a medical ICU and 27% of patients in a surgical ICU receive blood transfusions on any given day.
Between 37% and 60% of all patients admitted to the ICU receive at least 1 transfusion.
Patients in ICU with arterial lines have a mean of 944 mL of blood withdrawn during their stay.
Use of transfusions in patients in the ICU associated with an increased risk of nosocomial infection and a longer ICU and hospital stay.
In a randomized study, the use of insulin to normalize blood glucose was associated with a survival benefit in a surgical ICU (Van Den Berghe G). but this has not been confirmed by other studies in the general ICU population or in patients with severe sepsis (Finfer S, Brunkhorst FM).
Stress hyperglycemia in critical illness related to release of stress hormones such as cortisol and epinephrine, the use of glucocorticoid and catecholamine medications, and the release of mediators with sepsis or surgery: these factors inhibit release of insulin and inhibit insulin action with enhanced gluconeogenesis, inhibition of glycogen synthesis and impair insulin mediated uptake of glucose by tissues.
In a randomized, multi-center trial comparing the early initiation of parenteral nutrition within 48 hours of an ICU admission versus late initiation of parenteral nutrition beginning day eight or later: late initiation of parenteral nutrition was associated with faster recovery and fewer complications as compared with early initiation (Casaer MP et al).
In the above study no significant difference in mortality occurred between late initiation and early initiation of PN among patients in the ICU at risk for malnutrition, despite the use of early enteral feedings plus micronutrients that prevented hyperglycemia.
Withholding parenteral nutrition, in the above study, was associated with fewer ICU infections, but a higher degree of acute inflammation.
Late initiation of parenteral nutrition, in the above study, was associated with shorter duration of mechanical ventilation and a shorter course of renal replacement therapy, shorter ICU stay, a slight increase in hypoglycemia episodes, a shorter hospital stay would allocate decreased in functional status and reduced hospital costs.
Hyperglycemia in the ICU setting increased by the use of intravenous solutions and parenteral nutrition.
Hyperglycemia in the ICU does not consistently portend a worse prognosis for individuals with known diabetes, but is associated with worse prognoses in patients admitted to the ICU without previously diagnosed diabetes, particularly for patients with acute coronary syndromes and stroke (Egi M et al).
Observational data suggests prolonged hyperglycemia inversely associated with survival in acutely ill patients (Eli M et al).
In elderly survivors of ICU stays have a high mortality over subsequent years in excess of that seen in comparable controls, and the risk is concentrated early after hospital discharge among those requiring mechanical ventilation (Wunsch H).
The risk in death for elderly survivors of an ICU stay remains elevated at 3 years, but almost two-thirds of ICU survivors are alive at 3 years (Wunsch H).
Venous thromboembolism is an important complication of critical illness in patients in the ICU with increased risk because of complex acute and chronic illnesses, need for life support measures, sedation, analgesia, central venous catheterization, and paralysis.
In a trial of dalteparin vs unfractionated heparin randomly assigned in 3764 patients, and given subcutaneoulsy 5000 u daily or 5000 u bi, respectively in ICU patients: among critically ill patients dalteparin was not superior to unfractionated heparin in decreasing the incidence of proximal deep vein thrombosis (PROTECT Investigators).
Mortality rates for cancer patients admitted to the ICU is high.
Up to 42% of cancer patients admitted to an ICU died during their hospitalization (Groeger JS et al).
Cancer patients that require mechanical ventilation have a mortality rate of up to 76% (Groeger JS et al).
Up to 70% of patients in ICU's have constipation.
Opioids contribute to perioperative and ICU bowel dysfunction.
Bowel dysfunction in critically ill patients associated with adverse outcomes such as delayed gastric emptying with gastroesophageal reflux, aspiration, decreased enteral feeding and delayed ICU discharge.