For longevity, is it better to be short or tall?

Being short is associated with worse outcomes for critically ill adults.

A large retrospective study of 233,000 men and 184,000 women consecutively admitted to 210 ICUs in the UK over a six-year period found hospital and ICU mortality decreased with increasing height after adjusting for available potential confounders. The difference was statistically significant.

The definition of short or tall was based on the median height of the subjects—175 cm (5’9”) for men and 162 cm (5’2”) for women. These figures are nearly the same as the averages for non-hospitalized adults.

The study had several limitations. Height was measured in just 44.5% of the group while the rest were based on estimates. However, the authors noted the median estimated height was exactly the same as the measured height for men and only 1 cm different for women, and measuring height in critically ill patients is difficult.

Surgery at the End of Life: Reality Check

The medical segment of Twitter is abuzz today over a paper by Atul Gawande and colleagues pointing out that almost a third of elderly Medicare recipients undergo an inpatient surgical procedure in the last year of their lives. Just over 18% have such surgery in the last month and 8% in the last week of their lives. The paper was published online in the journal The Lancet.

There is a lot to think about in this paper including the fact that there are marked geographic regional variations in the amount of surgery performed.

I’d like to focus on an issue that is not discussed enough, which is futility. In response to the flurry of tweets linking to the abstract of the paper, I replied that I felt that families (and sometimes patients) refuse to accept reality.

Here’s a common scenario. An elderly patient is transferred to the emergency department of an acute care hospital in the middle of the night with what proves to be ischemic bowel on CT scan. Even if the surgeon says she has no chance of leaving the hospital alive, the family wants “everything done” for their 85 year old grandmother who has been demented and bed-ridden in a nursing home for five years. There is often an inverse relationship between the current level of involvement of the family in the patient’s life and their enthusiasm for wanting everything done. The relative who lives the farthest away is usually the most passionate advocate for intervention and “full code” status.

Unfortunately, the patient usually does not have a personal primary care physician. The nursing home doctor probably didn’t see her before she was sent to the hospital. There is no advance directive. The family never discussed the patient’s wishes when she was lucid enough to express them.

Now picture yourself as the surgeon who had the bad luck to have been on call for emergencies that night. Despite knowing that surgery would be futile, the surgeon is in a difficult spot. Some family member always says, “If there is one chance in a thousand that she can be saved, I want you to operate.” I know people think we surgeons believe we are God, but how can anyone say that some miracle will not occur and she will live? What would you do?

I have had many conversations with families in similar situations. Trust me; there is intense pressure to “do something.” I would estimate that in fewer than 10% of cases, the family eventually sees the light and lets Grandma die in peace. If the patient survives the operation, she likely will be in an intensive care unit on a ventilator for days to weeks, develop pneumonia and sepsis and die. Meanwhile, the tab is running and the eventual hospital bill will be well into six figures.

Don’t forget, even the one survivor in a thousand returns to the nursing home and is still demented and bed-ridden.

There are other types of futile procedures such as placement of feeding tubes which have never been shown to prolong life or improve quality of life in elderly demented patients. Surgical or endoscopic feeding tube placement is associated with numerous complications, both procedure-related and caused by the presence of the tube itself. The tubes fall out or become occluded leading to ambulance trips to the emergency department for replacement.

I do not have the answer. Maybe an all out effort to educate the public about this problem would work, but I doubt it.

Less is more. Conventional wisdom challenged in two NEJM articles

Classical views on fluid resuscitation and nutrition in critically ill patients were questioned in two papers published today in the New England Journal of Medicine.

A large study involving febrile, under-perfused children in Africa reveals that those aggressively resuscitated with fluid boluses of either saline or albumin had higher mortality rates than a control group who were not given boluses of fluid. The study was stopped earlier than planned when the research group’s data and safety monitoring committee performed an interim analysis. This paper adds to a growing body of research that shows that large-volume fluid resuscitation may be harmful in many situations.

A second article demonstrated that in some 4600 critically ill patients given enteral nutrition, late (day 8 of ICU admission) initiation of parenteral nutrition to supplement the enteral nutrition and achieve caloric goals leads to fewer complications and faster discharge from the ICU than patients whose parenteral nutrition was started within 48 hours of their ICU stay.

The papers are accompanied by editorials (here and here) that provide perspective and as usual caution against overly interpreting the results.

Although the messages seem quite clear (especially regarding large-volume fluid resuscitation), clinicians should read both papers and decide for themselves.

Alarms! Sounding the Alarm on Alarms, Finally

“Patient alarms often unheard, unheeded” states a recent headline in the Boston Globe. Now the Joint Commission and the FDA are going to target “alarm fatigue” as a patient safety priority. Apparently it is not a very high priority as the article describing the effort states that the two organizations will be meeting “over the next few months” to “pinpoint a strategy.”

My question is, where has everyone been? This issue has been apparent for years to anyone who has ever worked in an intensive care unit. Walk into any ICU and within 30 seconds, you will hear an alarm sound its annoying bleat and see the staff going about their business without a second thought.

As far back as the early 1990s, studies documented the issues. There are too many alarms. In 1994, researchers from Ohio published a study in which they played some 33 different common alarm tones for 100 ICU staff members. Only 50% of them were able to identify the source of each alarm. The authors concluded that there were too many alarms for even experienced staff to identify and proposed that alarms should be used for only critical problems.

Another 1994 study from a pediatric ICU observed alarm activity over a week’s time. They noted that of 2,176 alarm soundings, 68% were false, 26.5% were induced by staff dealing with patients and only 5.5% were actually significant.

An interesting study performed on college students in 1995 showed that people respond to alarms on the basis of their expectations. In other words, if an alarm is known to usually be false, the individual is less likely to respond to it. Obviously, if 95% of alarms in an ICU are false, the staff will be conditioned to ignore them.

There have been many other papers on the subject documenting the above as well as the stress on the staff that the constant level of noise produces.

In 2011, the problem is even worse as more and more devices have related alarms. For example, the push to prevent patient falls has prompted the invention of the bed alarm. Some of these alarms are so sensitive that the mere touching of the bed by staff triggers the alarm.

The solution to the problem of alarm fatigue is not simple. Every new device seems to come with its own random noise and sound level. A concerted effort by device manufacturers, regulatory agencies and hospitals is needed. My suggestion is to 1) scrap all current alarms and develop standardized tones for a select few important events and 2) improve the sensitivity of triggers to reduce the false alarm rate. Good luck.