A restrictive strategy of red-cell transfusion is at least as effective as and possibly superior to a liberal transfusion strategy in critically ill patients, with the possible exception of patients with acute myocardial infarction and unstable angina.

No abstract

Among critically ill patients requiring mechanical ventilation, those receiving ranitidine had a significantly lower rate of clinically important gastrointestinal bleeding than those treated with sucralfate. There were no significant differences in the rates of ventilator-associated pneumonia, the duration of the stay in the ICU, or mortality.

A restrictive red blood cell transfusion strategy generally appears to be safe in most critically ill patients with cardiovascular disease, with the possible exception of patients with acute myocardial infarcts and unstable angina.

Purpose: To determine, retrospectively, the age of packed red blood cell (PRBC) units transfused to patients admitted to the ICU with the diagnosis of severe sepsis and to correlate this variable with outcome. Methods: All patients admitted to the ICU during 1992 with a diagnosis of severe sepsis were selected retrospectively. The criteria for the diagnosis of severe sepsis and septic shock were based on established guidelines. For each patient the total number of PRBC units transfused, the number of units transfused before, during and after the septic episode, and the age of each PRBC unit transfused were recorded.Results: Of the 31 patients admitted to the ICU with severe sepsis, 19 died and 12 survived. No statistical differences between survivors and nonsurvivors were found with respect to age, sex, number of days in ICU, duration of sepsis, incidence of septic shock, admission Apache II score or total number of PRBC units transfused. During sepsis the median age of PRBC units transfused to survivors was 17 days (range 5-35) vs 25 days (range 9-36) for nonsurvivors (P < 0.000 I). A negative correlation (r = -0.73) was found between the proportion of PRBC units of a given age transfused to survivors and increasing age of PRBC.Conclusion: This is the first study to report a correlation of mortality with the age of PRBC transfused. The cause of this association is unclear. If this association is confirmed by a prospective randomised trial it would have major implications for the use of PRBC in severe sepsis.Objectif : DEterminer rEtrospectivement I'~ge des concentrEs Erythrocytaires (CE) transfuses ~ des patients admis ~ I'unitE des soins intensifs (USI) avec un diagnostic de sepsis grave et vEriJier si cette variable a une correlation avec le devenir des patients.M&hodes : Tousles patients admis ~ I'USI en 1992 avec un diagnostic de sepsis grave ont fait I'objet de cette recherche retrospective. Les signes et sympt6mes usuels ont servi ~ Etablir les critEres de sepsis grave et de choc septique. Pour chacun des patients la quantitE totale des CE transfuses, le nombre de CE transfuses avant, pendant et aprEs I'Episode septique et I'~ge de chaque CE transfuse ont EtE enregistrEs. R~ultats : Parmi les 31 patients admis ~ I'USI pour sepsis grave, 19 sont dEcEdEs et 12 ont surv&u. II n'y avait pas de difference statistique entre survivants et non survivants en rapport ~ I'~ge, le sexe, la durEe du sEjour I'USI, la durEe du sepsis, I'incidence du choc septique, le score APACHE II ~ I'admission et le nombre de CE transfuses. Au cours du sepsis, I'~ge median des CE transfuses Etait de 17 jours (Ecart 5--35) vs 25 jours (&art 9-39) pour les non survivants (P < 0,0001). On a trouvE une correlation negative (r = -0,73) entre la proportion de CE d'un ~ge dEterminE transfuse aux survivants et I'accroissement de I'~ge des CE. Conclusion : II s'agit ici de la premiere Etude concluant ,~ une correlation avec I'~-ge des CE transfuses. La raison de cette association n'est pas claire. Si une Etude alEatoire prospective parvient ~...

In 4,470 critically ill patients, we examined the impact of transfusion practice on mortality rates. As compared with survivors, patients who died in intensive care units (ICU) had lower hemoglobin values (95 +/- 26 versus 104 +/- 23 g/L, p < 0.0001) and were transfused red cells more frequently (42.6% versus 28.0%, p < 0.0001). In patients with cardiac disease, there was a trend toward an increased mortality when hemoglobin values were < 95 g/L (55% versus 42%, p = 0.09) as compared with anemic patients with other diagnoses. Patients with anemia, a high APACHE II score (> 20), and a cardiac diagnosis had a significantly lower mortality rate when given 1 to 3 or 4 to 6 units of allogeneic red cells (55% [no transfusions] versus 35% [1 to 3 units] or 32% [4 to 6 units], respectively, p = 0.01). Adjusted odds ratio (OR) predicting survival were 0.61 (95% CI; 0.37 to 1.00, p = 0.026) after 1 to 3 units and 0.49 (95% CI; 0.23 to 1.03, p = 0.03) after 4 to 6 units compared with nontransfused anemic patients. In the subgroup with cardiac disease, increasing hemoglobin values in anemic patients was associated with improved survival (OR = 0.80 for each 10 g/L increase, p = 0.012). We conclude that anemia increases the risk of death in critically ill patients with cardiac disease. Blood transfusions appear to decrease this risk.

Summary:The role of ICU support in BMT patients is controversial. In an era of constrained resources, the use of prognostic factors predicting outcome may be helpful in identifying patients who are most likely (or unlikely) to benefit from this intervention. We attempted to define the survival of patients admitted to ICU following autologous or allogeneic BMT and to identify those factors important in determining patient outcome. A retrospective study of all adult BMT recipients admitted to intensive care over a 6 year study period was performed to determine overall and prognostic indicators of poor outcome. Pre-treatment, pre-ICU admission and ICU admission data were analyzed to identify factors predicting long-term survival. 116 patients were admitted to ICU on 135 separate occasions with the primary reasons for admission being respiratory failure (66%), sepsis associated with hypotension (10%), and cardiorespiratory failure (8%). No pre-ICU characteristics were predictive of survival. Univariate analysis identified the number of support measures required, the need for ventilation or hemodynamic support, the APACHE II score, the year of ICU admission and the serum bilirubin as significant predictors of post-discharge survival. On multivariate analysis the year of ICU admission, the need for hemodynamic support and the serum bilirubin remained significant. The APACHE II score significantly underestimated survival in the 46% of patients with scores less than 35, and could only be used to predict 100% mortality when it exceeded 45. Twenty-three percent of all BMT patients admitted to the ICU and 17% of ventilated patients survived to hospital discharge. Of the 27 patients surviving to leave hospital, 16 remain alive with a median follow-up of 4. was identified which could be used to predict futility but patients requiring both hemodynamic support and mechanical ventilation, and those with an APACHE II score greater than 45 have a very poor prognosis and are unlikely to benefit from lengthy ICU support.

This trial compared the cost of an integrated home-based care model with traditional inpatient care for acute chronic obstructive pulmonary disease (COPD). 25 patients with acute COPD were randomised to either home or hospital management following request for hospital admission. The acute care at home group costs per separation ($745, n=13) were significantly lower (p<0.01) than the hospital group ($2543($ , CI95% $1766