ICU (Intensive care unit)

Critical care resource accounts for almost 1% of US gross domestic product.

Infection is a major cause of admissions and prolonged stays in ICUs.

There is a high rate of antibiotic use relative to the prevalence of infections: antibiotic use for prophylaxis was 28%, empirical use 51%, and only in 35% were there positive micro biological cultures in the EPIC III study.

The United Kingdom spends only 0.1% of this gross domestic product on critical care services, with no evidence of worse patient outcomes and similar life expectancy is in the US.

Critical care accounts for 20% of all US health costs.

ICU outcomes have improved due to better management techniques, early identification of sicker patients, more lenient admission criteria and more than 35% relative decrease in the mortality patients admitted to the ICU, despite increase in age and severity of illness, and increase in discharges to care facilities.

Increased capacity due to societal expectations, financial incident. This, changing medical practice, desire to adopt technological innovations.

20% of deaths in the United States occur during or shortly after a stay in the ICU.

Almost 40% of deaths in the US occur in the hospital, and of those, more than half occur in the intensive care unit.

More than 50,000 patients are in ICUs each day in the US.

More than 5 million patients are admitted to ICU each year.

The US has 30 ICU beds per hundred thousand people, compared with 5 per hundred thousand in the United Kingdom.

When ICUs are full, sick patients in the emergency room experience delays in admission, and delays are associated morbidity and mortality.

In critically ill patients admitted to an ICU, hyperglycemia is common and is associated with a poor outcome.

When gram-negative bacteria are predominant  microorganisms isolated in patients with positive cultures the in-hospital mortality is 30%.

More patients in the US die in the ICU compared to United Kingdom, suggesting that increased bed availability appears to reduce the incentive to keep dying patients out of the ICU.

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).

Between 2000 and 2009 ICU utilization rates and number of transitions in the last three days of life increased.

Up to 15% of patients with admission to ICUs have diagnosis of cancer.

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.

Infection is common in patients in the ICU and a prerequisite for the development of sepsis.

Approximately 50% of patients who receive care in the ICU experience debilitating muscle wasting and its consequences, ICU-acquired weakness, which may prolong duration of mechanical ventilation and persist for up to five years after hospital discharge.

Acquired-weakness is caused by inflammation, metabolic disorders, forced muscular rest in bed ridden or sedated patients, particularly those with sepsis, multiple organ failure, or receiving prolonged mechanical ventilation.

Musculoskeletal mobilization prevents ICU-acquired weakness, shortens ICU and hospital stays, decreases the incidence of delirium, and reduces the time until return of autonomy.

Among adults undergoing mechanical ventilation in the ICU early mobilization did not result in a greater number of days patients were alive and out of the hospital than usual mobilization efforts.

Precautions to disinfect all ICU patients as if they had methicillin-resistant Staphylococcus aureus (MRSA) cut infections substantially more than other more targeted strategies: that is universal decolonization reduced the likelihood of MRSA infection in the ICU by 37% and brings down the risk of any bloodstream infection by 44% (Huang, SS et al).

In the above study the number of patients needed to treat to prevent one bloodstream infection was 54.

Screening and then isolating MRSA-colonized patients was found to be the least effective option among the three tested in the trial and had almost no impact on the prevalence of MRSA or blood stream infection.

Targeted decolonization with chlorhexidine baths and nasal mupirocin (Bactroban) has an intermediate impact on effectiveness.

Across-the-board decolonization benefit patients by cutting down on contact precautions.

Universal decolonization involves a 5-day regimen of twice-daily intranasal mupirocin and daily bathing with chlorhexidine cloths during the ICU stay.

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.

Delirium in the ICU increases the length of mechanical ventilation, hospital length of stay, rates of post discharge institutionalization and in-hospital mortality.

Delirium incidents in non-ventilated ICU patients is approximately 50%, and the incidence in ventilated patients is higher, at approximately 80%.

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.

A flexible family visiting program did not significantly reduce the incidence of delirium among patients in the ICU.

Survivors of an ICU can experience a variety of mental health disorders:

Anxiety, depression, posttraumatic stress disorder, and complicated grief for families.

For most patients and their families ICU admission is an unanticipated event that causes psychological distress.

Consequences of ICU stay include: delirium, anxiety, depression, and acute and post traumatic stress disorder.

In ICU delirium treated with haloperidol did not lead to a significantly greater number of days alive and out of the hospital at 90 days than placebo.

Psychological consequences of an ICU stay may be exacerbated by delusions experienced during delirium which is common in critically ill patients and has an adverse effect on physical and cognitive function and leads to increased healthcare use and costs.

Families of patients in the ICU experience anxiety and acute stress arising from uncertainty regarding the prognosis of their family member.

Long-term psychological effects in family members are similar to those experienced by patients themselves.

Pediatric post intensive care syndrome

Most children treated in the pediatric ICU survive to hospital discharge and there has been a shift from mortality to long-term morbidity.

There are physical, emotional, social, and cognitive sequelae of critical illness which can affect surviving children and their families long after hospitalization.

The presence of chronic comorbidities, acute critical illness, effects of PICU therapies in the child home environment may influence post PICU outcomes.

Of patients surviving critical illness there is a high level of fatigue, muscle weakness and other symptoms that contribute to delayed recovery.

ICU acquired weakness is prevalent among survivors of ICU hospitalizations and encompasses a critical illness myopathy with myosin-depletion, polyneuropathy, or a combination of these disorders.

ICU acquired weakness, accounts for increased number of days on mechanical ventilation, prolonged ICU stays, complex post ICU transition, care, and increased number of emergency department visits or hospital and ICU readmissions, and increased long-term disposition and healthcare costs: the condition may be permanent.

Cognitive impairment, posttraumatic disstress, anxiety, and depression are common in patients who survived critical illness.

ICU outcomes are related to coexistent conditions, including frailty, oral and dental complications, swallowing difficulties, taste changes, vision, or hearing loss, a new need for renal replacement therapy, procedure related trauma: such as incontinence, rectal or urethral trauma, vocal cord dysfunction, or tracheal stenosis, entrapment neuropathies, endocrinopathies, frozen joints and contractures, rotator cuff injuries, cosmetic changes of alopecia, nail changes, scarring, and disfigurement from tracheostomy, placement of arterial essential lines, or extracorporeal membrane, oxygenation sites, and complicated pressure injuries.

When frailty occurs or worsens after ICU admission it is associated with increased in-hospital and long-term mortality, increased functional dependency, reduced health related quality of life, a lower likelihood of return to community-based living, and a greater likelihood of hospital readmission.

The one year cognitive outcome among ICU survivors is independent of age, similar to severity to mild Alzheimer’s type dementia, or moderate traumatic brain injury and related to cortical loss, white matter injury, or both diring critical illness.

The duration of ICU delirium is the most potent risk factor for a one year, global cognitive dysfunction and impaired executive function.

Following critical illness rehabilitation programs including physical and nutritional therapy does not improve physical recovery or health-related quality-of-life (Walsh TS et al).

Generally healthy children with a single episode of acute respiratory failure have favorable neurocognitive outcomes, but with a slightly lowered IQ than unexposed siblings.


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