The primary objective of the present study was to evaluate the effect on hospital mortality of a delay in intensive care unit (ICU) admission for severe community-acquired pneumonia (CAP). The secondary objectives were to assess if such delays were associated with treatment variations by the emergency department (ED) and deterioration in the general wards, and to evaluate the prognostic ability of the Infectious Disease Society of America (IDSA)/American Thoracic Society (ATS) minor criteria.We retrospectively compared patients who were admitted straight from the ED to the ICU (direct group, n = 54) and those who were first admitted from the ED to the general wards before ICU transfer (delayed group, n = 49), over 2.5 yrs.Even after excluding patients who required mechanical ventilation and/or vasopressors at the ED, delayed ICU admission was an independent predictor of hospital mortality (OR 9.61). The delayed group received fewer fluid boluses in the ED and rapidly deteriorated in the general wards. The presence of ≥3 IDSA/ATS minor criteria was associated with increased mortality in the delayed group.In conclusion, prompt recognition of severe CAP using the IDSA/ATS minor criteria, followed by aggressive management at the ED and direct ICU admission, are all crucial toward improving outcomes.

Mortality rates for severe community-acquired pneumonia (CAP) range from 17 to 48 % in published studies. In this review, we searched PubMed for relevant papers published between 1981 and June 2016 and relevant files. We explored how early and aggressive management measures, implemented within 24 hours of recognition of severe CAP and carried out both in the emergency department and in the ICU, decrease mortality in severe CAP. These measures begin with the use of severity assessment tools and the application of care bundles via clinical decision support tools. The bundles include early guideline-concordant antibiotics including macrolides, early haemodynamic support (lactate measurement, intravenous fluids, and vasopressors), and early respiratory support (high-flow nasal cannulae, lung-protective ventilation, prone positioning, and neuromuscular blockade for acute respiratory distress syndrome). While the proposed interventions appear straightforward, multiple barriers to their implementation exist. To successfully decrease mortality for severe CAP, early and close collaboration between emergency medicine and respiratory and critical care medicine teams is required. We propose a workflow incorporating these interventions.

Introduction: Anaemia and the associated need for packed red blood cell (PRBC) transfusions are common in patients admitted to the intensive care unit (ICU). Among many causes, blood losses from repeated diagnostic tests are contributory. Methods: This is a before and after study in a medical ICU of a university hospital. We used a closed blood conservation device (Venous Arterial blood Management Protection, VAMP, Edwards Lifesciences, Irvine, CA, USA) to decrease PRBC transfusion requirements. We included all adult (≥18 years) patients admitted to the ICU with indwelling arterial catheters, who were expected to stay more than 24 hours and were not admitted for active gastrointestinal or any other bleeding. We collected data for six months without VAMP (control group) immediately followed by nine months (active group) with VAMP. A restrictive transfusion strategy in which clinicians were strongly discouraged from any routine transfusions when haemoglobin (Hb) levels were above 7.5 g/dL was adopted during both periods. Results: Eighty (mean age 61.6 years, 49 male) and 170 patients (mean age 60.5 years, 101 male) were included in the control and active groups respectively. The groups were comparable for age, gender, Acute Physiology and Chronic Health Evaluation (APACHE) II score, need for renal replacement therapy, length of stay, and Hb levels on discharge and at transfusion. The control group had higher Hb levels on admission (12.4 ± 2.5 vs. 11.58 ± 2.8 gm/dL, P = 0.02). Use of a blood conservation device was significantly associated with decreased requirements for PRBC transfusion (control group 0.131 unit vs. active group 0.068 unit PRBC/patient/day, P = 0.02) on multiple linear regression analysis. The control group also had a greater decline in Hb levels (2.13 ± 2.32 vs. 1.44 ± 2.08 gm/dL, P = 0.02) at discharge. Conclusions: The use of a blood conservation device is associated with 1) reduced PRBC transfusion requirements and 2) a smaller decrease in Hb levels in the ICU.

To describe the outcomes of patients with bronchiectasis and acute respiratory failure (ARF) treated with noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV) after a failure of conservative measures, and to identify the predictors of hospital mortality and NIV failure. Retrospective review of bronchiectatic patients on NIV (n = 31) or IMV (n = 26) for ARF over 8 years in a medical intensive care unit (ICU) experienced in NIV. At baseline, the NIV group had more patients with acute exacerbations without identified precipitating factors (87.1 vs. 34.6%, p < 0.001), higher pH (mean 7.25 vs. 7.18, p = 0.008) and PaO₂/FiO₂ ratio (mean 249.4 vs. 173.2, p = 0.02), and a trend towards a lower APACHE II score (mean 25.3 vs. 28.4, p = 0.07) than the IMV group. There was no difference in hospital mortality between the two groups (25.8 vs. 26.9%, p > 0.05). The NIV failure rate (need for intubation or death in the ICU) was 32.3%. Using logistic regression, the APACHE II score was the only predictor of hospital mortality (OR 1.19 per point), and the PaO₂/FiO₂ ratio was the only predictor of NIV failure (OR 1.02 per mmHg decrease). The hospital mortality of patients with bronchiectasis and ARF approximates 25% and is predicted by the APACHE II score. When selectively applied, NIV fails in one-third of the patients, and this is predicted by hypoxemia. Our findings call for randomised controlled trials to compare NIV versus IMV in such patients.