Acquired immunodeficiency syndrome and critical care

What determines do-not-resuscitate status in critically ill HIV-infected patients admitted to ICU?

PURPOSE

To identify factors associated with do-not-resuscitate (DNR) status in critically ill patients infected with human immunodeficiency virus (HIV) admitted to the Intensive Care Unit (ICU) in the era of combination antiretroviral therapy (cART).

MATERIALS AND METHODS

Retrospective cohort study of first-time admissions of HIV-infected patients to ICUs in Edmonton, Alberta, from 2002 to 2014. Multivariable logistic regression analysis was performed to identify factors associated with DNR status.

RESULTS

There were 282 HIV-infected patients with first-time ICU admissions, with an incidence rate of 6.6 per 1000 ICU admissions. Sixty-seven (24%) patients had a DNR designation and support was withdrawn in 37 (13%). In multivariable analysis, APACHE II score (OR 1.13; 95% CI, 1.08-1.19, p < 0.001), coronary artery disease (OR 5.70; 95% CI, 1.18-27.76, p = 0.031), prior opportunistic infection (OR 2.59; 95% CI, 1.20-5.57, p = 0.015) and duration of HIV infection (OR 1.07 per year; 95% CI, 1.01-1.14, p = 0.025) were independently associated with DNR status. Ethnicity, HIV risk factors, CD4 count and viral load were not associated with DNR status.

CONCLUSIONS

One in four patients had a DNR designation. Illness acuity, selected comorbidity, previous opportunistic infection and HIV duration were associated with DNR designation.

Critical care of HIV-infected patients: still a dilemma for Italian intensivists--results of a multicentre survey

BACKGROUND AND OBJECTIVE

To survey the Italian intensivist policy towards critically ill patients with HIV or AIDS in the era of highly active antiretroviral therapy (HAART).

METHODS

This was a multicentre questionnaire survey involving all of the 239 ICUs of the GiViTI (Italian Group for Evaluation of Interventions in ICU) network. In January 2006, a detailed questionnaire (see Appendix) was e-mailed to the GiViTI referring ICU physician in each of the 239 ICUs on the GiViTI list. There were no interventions.

RESULTS

A total of 126 ICU physicians (52.7%) responded. The number of referred yearly admissions was low: 85.7% of ICUs usually admit five or fewer patients infected with HIV or AIDS per year; only 10.2 and 4.2% of them admitted at least 15 HIV-infected and at least 15 AIDS patients, respectively; the admission of patients with HIV or AIDS is perceived as always appropriate in only 30.4 and 14.3% of ICUs, respectively. A bivariate correlation was found between the presence of an infectious disease ward and the number of referred yearly admissions of both HIV-infected (Spearman rho=0.295, P<0.05) and AIDS patients (Spearman rho=0.304, P<0.05) and the decision to admit or not patients with HIV or AIDS patients to ICU. If an infectious disease ward was available, the intensivist was more likely to take the decision to admit a patient with HIV (Spearman rho=0.637, P<0.05) or AIDS in consultation with an infectious disease specialist (Spearman rho=0.578, P=0.01).

CONCLUSION

The recorded wide variation in intensivists' approach towards patients with HIV or AIDS requires the production of high-quality evidence to identify an optimal shared policy for such patients.

Bed rationing and allocation in the intensive care unit

That the resources available for intensive care cannot be infinite is self-evident. Parallel increases in medical capability, cost, and community expectations have forced intensivists to confront the reality of resource limitation. Traditional bioethical structures cope poorly with this focus beyond the traditional patient-doctor relationship. Allocation of funds for intensive care may be case-based, historically based, per diem, or capitation-based but is always heavily influenced by political and economic considerations. Attempts have been made to relate costs to severity or intervention scores, but all these techniques are limited by the high fixed costs of intensive care. Methods available to help the physician faced with patient-selection dilemmas include cost-effectiveness and cost-utility analysis. These techniques involve assessment of the quality of life with the help of several well-validated quantitative approaches. Choosing between competing patients for intensive care beds is often more a theoretical issue than a practical one, because alternative arrangements can almost always be made. Physicians have an ethical and social responsibility to further develop the tools to inform community debate on these issues.

CPAP, effective respiratory support in patients with AIDS-related Pneumocystis carinii pneumonia

Human Immunodeficiency Virus (HIV) related Pneumocystis carinii pneumonia (PCP) associated with severe respiratory failure is an increasingly common problem in major centres and is associated with a high mortality in previous and recent studies. Early in the epidemic, alternatives to invasive intensive care treatment were utilized in our institution and found to be successful. When respiratory failure developed, mask CPAP was used instead of intubation and ventilation. A retrospective review of 175 cases of HIV infected patients with confirmed first presentation PCP was undertaken. Treatment with our protocol resulted in an overall hospital mortality of 9%. Those patients who did not require supplemental oxygen or respiratory support had no in-hospital mortality. The group who required supplemental oxygen had a mortality of 10%. If respiratory failure supervened (severe respiratory distress, PaO2 less than 50 mmHg, SaO2 less than 90% on mask oxygen), CPAP was introduced. The mortality in this group was 22%. Only two patients were admitted to the intensive care unit for respiratory support after failure of CPAP. Both patients were intubated and received intermittent positive pressure ventilation (IPPV). Both patients died.