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m o r PREDICTING MORTALITY IN CRITICALLY ILL OBSTETRIC
f d PATIENTS REQUIRING INTENSIVE CARE
a ns UNIT ADMISSION IN INDIA
o l tio n w lica o d ub Starting with the intensive coronary care units Several disease-severity-scoring systems e . P for predicting (ICCUs) in the early 1970s and the have mortality in ICU ) re evolved f respiratory care units in the mid 1970s, patients. Acute physiology and chronic health w om r o critical care medicine has come a long wayfo evaluation simplified acute n .c(APACHE), k in India, to emerge as a specialty in its own physiology score (SAPS) and mortality e w d l o rights. Presently, several centers provide models (MPMs) are some of the b e probability n systems lametrosM scoring critical care facilities not only in large that are commonly used for k i d a small y but also in smaller cities andveven objectively assessing the clinical status and e b a towns; these are run by the corporatedsector, m severity of disease of critically ill patients. is steand thew. Given this scenario, the study authored by charitable institutions/societies F oonly a feww of Tempe et al. is unique in that it attempts to government sector. However, D w h to pregnant these centers are accessible provide a retrospective review of the utility of ( P e women. Even then, t and postpartum SAPS II for predicting maternal mortality in isto 7%pregnant siadmissions women form up of in Indian obstetric patients admitted to a h T unitsa (ICUs), especially intensive care in multidisciplinary ICU at a tertiary care center [1]
[4]
[5]
public hospitals. [2,3] Even though obstetric patients constitute a considerable proportion of patients admitted to intensive ICUs, sparse data are available from developing countries regarding the critical care perspective of pregnant women. Critical care in obstetrics still remains a neglected area, especially in developing countries like India.
in a teaching hospital in New Delhi, India. They have observed that maternal mortality in obstetric ICU admissions was 1.15/1,000 deliveries, and the mean SAPS II was significantly higher (40.04 ± 12.97 vs. 22.6 ± 7.31; P < 0.001) in those patients who died compared to survivors. The authors suggest that computation of SAPS II score as a
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routine in obstetric patients admitted to the ICU may help in identifying those at high risk of mortality so that an attempt may be made to reduce this risk.
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These scoring systems were tested, refined and validated in the developed world, mainly in the American and European ICUs, in non-pregnant patients to predict adverse outcomes based on data available in the first 24 h of admission. ICUs from the Indian subcontinent seldom ever participated in these studies. Critical-illness-scoring systems require modification for obstetric patients to adjust for the normal physiologic responses to pregnancy. Evidence is also available suggesting that the critical care issues in obstetric patients in India are different from those observed in patients in western countries. For example, studies from India [3,6,7] and Sri Lanka [8] have shown that rheumatic valvular heart disease, malaria and viral hepatitis are important reasons for ICU admission during pregnancy and are also significant causes of maternal mortality. Therefore, several factors such as differences in the case mix, variations in the extent of prenatal care, delays in reaching the tertiary care hospital, differences in the severity of illness and limited availability of ICU beds should be kept in mind while interpreting studies of this nature.
studies with a larger sample size are required from India to validate the observations documented in the study reported by Tempe et al. [5] Given the large number of teaching hospitals attached to medical colleges in India that are equipped with ICUs, the issue of evolving and validating a new scoring system or a modified version of existing systems such as SAPS II appears to be a feasible prospect.
m rf o d s REFERENCES a o tion l n a w c do ubli e P ). e fr w m r fo kno .co le ed ow b la M dkn i a by e v a is sted w.m F o w D P te h (w is si h T a
1. Prayag S. ICUs worldwide: Critical care in India. Crit Care 2002;6:479-80.
2. Parikh CR, Karnad DR. Quality, cost and outcome
of intensive care in a public hospital in Mumbai,
India. Crit Care Med 1999;27:1754-9.
3. Karnad DR, Lapsia V, Krishnan A, Salvi VS.
Prognostic factors in obstetric patients admitted to
an Indian intensive care unit. Crit Care Med 2004;32:1294-9.
4. Aggarwal AN, Sarkar P, Gupta D, Jindal SK. Performance of standard severity scoring systems for outcome prediction in patients admitted to a respiratory intensive care unit in North India. Respirology 2006;11:196-204.
5. Tempe A, Wadhwa L, Gupta S, Bansal S, Satyanarayana L. Prediction of mortality and morbidity by simplified acute physiology score (SAPS II) in obstetric ICU admissions. Indian J Med Sci 2007;61:179-85. 6. Tripathi R, Rathore AM, Saran S. Intensive care for critically ill obstetric patients. Int J Gynaecol
The paper by Tempe et al.[5] suggests that SAPS II scoring system appears to be one such model which has the potential to either be customized or used as a prototype to develop locally appropriate severity-scoring systems for predicting mortality in critically ill obstetric patients in India. Multicentric
Obstet 2000;68:257-8. 7. Munnur U, Karnad DR, Bandi VD, Lapsia V, Suresh MS, Ramshesh P, et al. Critically ill obstetric patients in an American and an Indian public hospital: Comparison of case-mix organ dysfunction, intensive care requirements and outcomes. Intensive Care Med 2005;31:1087-94.
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8. Wagaarachchi PT, Fernando L. The impact of an intensive care unit on maternal mortality. Int J Gynaecol Obstet 2001;74:199-201.
ALLADI MOHAN, SRINIVAS BOLLINENI*
The Division of Pulmonary and Critical Care
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Medicine, Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India, *Department of Internal Medicine, St. Luke’s Hospital,
Chesterfield, MO, USA.
E-mail:
[email protected]
m rf o d s a In recent years, there has been a global trend stay. These results arenimportant for the o l io in intensive care units (ICUs) to change from implementation of evidence-based clinical t n a the established system of open endotracheal practice butware notcyet conclusive, considering o bli themselves may have suctioning (OES) to the newer (and more that thedmeta-analyses u .to detect a true difference costly) closed-suctioning systems. The been eunderpowered P e )systems. r wsuctioning reasons for this change were initially the between f m reported benefits in terms of preventing OES- r o o o induced alveolar derecruitment and hypoxia,f Thendisadvantages .c of CES include the risk of k e w l edproducing particularly in the context of severe lung high negative pressures if the o b disease with high PEEP requirements. It amount of air suctioned exceeds the gas flow n a M k l i has been suggested that closed endotracheal d to the patient by the ventilator; athe riskbyof edelivered v suctioning (CES) should reduce reduced efficiency in clearing thick secretions a (VAP) d by .m from the airways; and the high financial cost ventilator-associated pneumonia s e i t wof of the system, which has to be replaced daily eliminating environmental contamination s F wthe in order to avoid microbial lower respiratory o into the catheter beforeDintroduction w h ( of tract colonization. Practically, there is also endotracheal tube P (ETT). Another benefit e t CES, often overlooked, is si is the limitation of a risk of not withdrawing the catheter h aerosolization of infectious after the suctioning event, thus T a mucus particles. completely Thus, CES potentially has a role in partially occluding the ETT and increasing CLOSED-SYSTEM SUCTIONING: WHY IS THE DEBATE STILL OPEN?
[3]
[1]
[6]
[7]
[8]
[2]
[9]
preventing the spread of infection between patients and from patients to clinical staff.[2]
airway resistance. These disadvantages may actually favor the use of OES.
However, these potential advantages have not been shown to translate into clinically meaningful improvements, with several recent meta-analyses [3-5] having reproducibly demonstrated no benefit of CES over OES for a number of outcome measures, including incidence of VAP, mortality and length of ICU
The majority of clinical trials included in the meta-analysis by Peter et al. [3] were conducted in first-world environments and it may, therefore, not be appropriate to directly apply these results to other ICU populations. In first-world ICUs, with adequate staffing and sufficient resources, the choice of suctioning Indian J Med Sci, Vol. 61, No. 4, April 2007
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systems could be made according to staff preference; although considering the lack of evidence supporting CES, a recommendation to change from OES at this stage cannot be considered prudent. Instead, it should be recommended that ICU staff continue with the suctioning method to which they are accustomed and at which they are proficient. However, the debate is clearly still open when addressing the specific challenges faced in ICUs in developing countries- issues which may predispose to a particularly high incidence of nosocomial infection. These include inadequate staffing, patient overcrowding, an increased burden of infectious diseases, and resource limitations. With the high incidence of infectious diseases such as pulmonary tuberculosis, the focus should perhaps be broadened from the individual patient to the wider ICU population (including staff and other patients). If CES were to reduce the risk of infection to nursing staff and patients, it may be worth the extra cost of using the system. However, until objective clinical benefit has been demonstrated, the use of CES cannot be justified in developing nations.
3.
contamination during tracheal suction: A comparison of disposable conventional catheters with a multiple-use closed system device. Anesthesia 1991;46:957-61. Peter JV, Chacko B, Moran JL. Comparison of closed endotracheal suction versus open endotracheal suction in the development of ventilator associated pneumonia in intensive care patients: An evaluation using meta-analytic techniques. Indian J Med Sci 2007;61:(in this issue). Jongerden IP, Rovers MM, Grypdonck MH, Bonten MJ. Open and closed endotracheal suction systems in mechanically ventilated intensive care patients: A meta-analysis. Crit Care Med 2007;35:260-70. Vonberg RP, Eckmanns T, Welte T, Gastmeier P. Impact of the suctioning system (open vs. closed) on the incidence of ventilation-associated pneumonia: Meta-analysis of randomized controlled trials. Intensive Care Med 2006;32:1329-35. Stenqvist O, Lindgren S, Karason S, Söndergaard S, Lundin S. Warning! Suctioning. A lung model evaluation of closed suctioning systems. Acta Anaesthesiol Scand 2001;45:167-72. Lindgren S, Almgren B, Hogman M, Lethvall S, Houltz E, Lundin S, et al. Effectiveness and side effects of closed and open suctioning: An experimental evaluation. Intensive Care Med 2004;30:1630-7. Lorente L, Lecuona M, Martin MM, Garcia C, Mora ML, Sierra A. Ventilator-associated pneumonia using a closed versus an open tracheal suction system. Crit Care Med 2005;33:115-9. Freytag CC, Thies FL, König W, Welte T. Prolonged application of closed in-line suction catheters increases microbial colonization of the lower respiratory tract and bacterial growth on catheter surface. Infection 2003;31:31-7.
m rf o d s a o tion l n a w c do ubli e P ). e fr w m r fo kno .co le ed ow b la M dkn i a by e v a is sted w.m F o w D P te h (w s developing ithe Therefore, it is si world which h T focus aof well-designed clinical should be the 4.
5.
6.
7.
8.
trials so that the suction debate can finally be closed - one way or the other.
REFERENCES 1. Cereda M, Villa F, Colombo E, Greco G, Nacoti M, Pesenti A. Closed system endotracheal suctioning maintains lung volume during volume-controlled mechanical ventilation. Intensive Care Med 2001;27:648-54. 2. Cobley M, Atkins M, Jones FL. Environmental
9.
BRENDA M. MORROW
Division of Paediatric Critical Care and Children’s Heart Disease, School of Child and Adolescent Health, University of Cape Town, South Africa. E-mail:
[email protected]
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