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Critical Care Medicine
Journal Prestige (SJR): 3.116
Citation Impact (citeScore): 3
Number of Followers: 328  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0090-3493 - ISSN (Online) 1530-0293
Published by LWW Wolters Kluwer Homepage  [302 journals]
  • Toward Increased Understanding of the Steroid Controversy in Septic Shock
    • Authors: Russell; James A.; Sevransky, Jonathan
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Which Multicenter Randomized Controlled Trials in Critical Care Medicine
           Have Shown Reduced Mortality' A Systematic Review
    • Authors: Santacruz; Carlos A.; Pereira, Adriano J.; Celis, Edgar; Vincent, Jean-Louis
      Abstract: imageObjectives: To determine which multicenter randomized controlled trials in critically ill patients have shown that the study intervention was associated with a statistically significant reduction in mortality. Our analysis provides an update to a report published 10 years ago.Data Sources: MEDLINE database and PubMed interface from inception until April 30, 2019.Study Selection: All adult multicenter randomized controlled trials that evaluated the effects of any intervention or monitoring system in critically ill patients and reported mortality as a primary or secondary outcome were included.Data Extraction: Numbers of centers and patients, type of intervention, reported mortality outcome, and rate and level of significance were extracted into predefined tables. Included randomized controlled trials were classified as reporting reduced, increased, or no effect of the intervention on mortality. Methodologic quality of trials was evaluated using the updated Consolidated Standards of Reporting Trials statement.Data Synthesis: A total of 212 trials met the inclusion criteria: 27 (13%) reported a significant reduction in mortality, 16 (7%) an increase in mortality, and 170 (80%) no difference in mortality (one study was reported in 2 groups). Of the 27 trials reporting reduced mortality, six had assessed interventions likely to decrease ventilator-induced lung injury, including low tidal volume, prone position, and neuromuscular blockers, demonstrating the negative effects of mechanical ventilation strategies or improved process of care rather than positive effects of new therapies. Seven of the 27 trials reported beneficial effects of noninvasive ventilation. Results from some positive randomized controlled trials, for example, studies of recombinant activated protein C, talactoferrin, interleukin-1 receptor antagonist in sepsis, and muscle relaxants in severe acute respiratory distress syndrome were not replicated in subsequent randomized controlled trials. Other interventions, for example, gastric tonometry, have been abandoned.Conclusions: A systematic literature search provided no conclusive evidence of any pharmacologic intervention that has consistently reduced mortality in critically ill patients. Strategies associated with improved or noninvasive mechanical ventilation were associated with reduced mortality.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Promoting Family Engagement in the ICU: Experience From a National
           Collaborative of 63 ICUs*
    • Authors: Kleinpell; Ruth; Zimmerman, Jerry; Vermoch, Kathleen L.; Harmon, Lori A.; Vondracek, Hugh; Hamilton, Rebekah; Hanson, Bruce; Hwang, David Y.
      Abstract: imageObjectives: As part of an improvement program targeting ICU, a national collaborative was launched to help hospitals implement patient- and family-centered care engagement initiatives.Design: Ten-month quality improvement collaborative.Setting: Guided by a national patient and family advisory group, participating teams implemented an individual project including open visitation; integrating families on rounds; establishing a patient and family advisory committee; using patient and family diaries, among others.Subjects: Sixty-three adult and PICU teams from both academic and community hospitals in 34 states participated.Interventions: Monthly team calls, quarterly webinars, newsletters, an online eCommunity, and team reporting assignments were used to facilitate project implementation.Measurements and Main Results: The Family Satisfaction with Care in the ICU 24 was used to assess family satisfaction. Clinician perceptions were assessed with the Institute for Patient- and Family-Centered Care Self-Assessment Inventory. Thematic analysis was used to explore narrative data captured from team reports of project barriers, facilitators, and the experience of participating in the collaborative. A total of 2,530 family member and 3,999 clinician surveys were completed. Postimplementation, family members reported statistically significant increases in overall family satisfaction, satisfaction with decision-making, and satisfaction with quality of care (Family Satisfaction with Care in the ICU mean score change range 0.83–1.24; p ≤ 0.027). Clinicians reported that opportunities for families to participate as members of the care team increased. Major barriers included lack of buy-in and ability to promote change in the clinical setting, managing the workload of implementation, and funding to support initiatives.Conclusions: A national collaborative format was useful to assist ICU teams to implement patient- and family-engagement initiatives. Enlisting stakeholder support, engaging unit-based champions, and highlighting benefits of family engagement can help ICU teams to promote family member involvement and engagement.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Incidence and Outcomes of Acute Laryngeal Injury After Prolonged
           Mechanical Ventilation*
    • Authors: Shinn; Justin R.; Kimura, Kyle S.; Campbell, Benjamin R.; Sun Lowery, Anne; Wootten, Christopher T.; Garrett, C. Gaelyn; Francis, David O.; Hillel, Alexander T.; Du, Liping; Casey, Jonathan D.; Ely, E. Wesley; Gelbard, Alexander
      Abstract: imageObjectives: Upper airway injury is a recognized complication of prolonged endotracheal intubation, yet little attention has been paid to the consequences of laryngeal injury and functional impact. The purpose of our study was to prospectively define the incidence of acute laryngeal injury and investigate the impact of injury on breathing and voice outcomes.Design: Prospective cohort study.Setting: Tertiary referral critical care center.Patients: Consecutive adult patients intubated greater than 12 hours in the medical ICU from August 2017 to May 2018 who underwent laryngoscopy within 36 hours of extubation.Interventions: Laryngoscopy following endotracheal intubation.Measurements and Main Results: One hundred consecutive patients (62% male; median age, 58.5 yr) underwent endoscopic examination after extubation. Acute laryngeal injury (i.e., mucosal ulceration or granulation tissue in the larynx) was present in 57 patients (57%). Patients with laryngeal injury had significantly worse patient-reported breathing (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 1.05; interquartile range, 0.48–2.10) and vocal symptoms (Voice Handicap Index-10: median, 2; interquartile range, 0–6) compared with patients without injury (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 0.20; interquartile range, 0–0.80; p < 0.001; and Voice Handicap Index-10: median, 0; interquartile range, 0–1; p = 0.005). Multivariable logistic regression independently associated diabetes, body habitus, and endotracheal tube size greater than 7.0 with the development of laryngeal injury.Conclusions: Acute laryngeal injury occurs in more than half of patients who receive mechanical ventilation and is associated with significantly worse breathing and voicing 10 weeks after extubation. An endotracheal tube greater than size 7.0, diabetes, and larger body habitus may predispose to injury. Our results suggest that acute laryngeal injury impacts functional recovery from critical illness.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Early Palliative Care Consultation in the Medical ICU: A Cluster
           Randomized Crossover Trial
    • Authors: Ma; Jessica; Chi, Stephen; Buettner, Benjamin; Pollard, Katherine; Muir, Monica; Kolekar, Charu; Al-Hammadi, Noor; Chen, Ling; Kollef, Marin; Dans, Maria
      Abstract: imageObjectives: To assess the impact of early triggered palliative care consultation on the outcomes of high-risk ICU patients.Design: Single-center cluster randomized crossover trial.Setting: Two medical ICUs at Barnes Jewish Hospital.Patients: Patients (n = 199) admitted to the medical ICUs from August 2017 to May 2018 with a positive palliative care screen indicating high risk for morbidity or mortality.Interventions: The medical ICUs were randomized to intervention or usual care followed by washout and crossover, with independent assignment of patients to each ICU at admission. Intervention arm patients received a palliative care consultation from an interprofessional team led by board-certified palliative care providers within 48 hours of ICU admission.Measurements and Main Results: Ninety-seven patients (48.7%) were assigned to the intervention and 102 (51.3%) to usual care. Transition to do-not-resuscitate/do-not-intubate occurred earlier and significantly more often in the intervention group than the control group (50.5% vs 23.4%; p < 0.0001). The intervention group had significantly more transfers to hospice care (18.6% vs 4.9%; p < 0.01) with fewer ventilator days (median 4 vs 6 d; p < 0.05), tracheostomies performed (1% vs 7.8%; p < 0.05), and postdischarge emergency department visits and/or readmissions (17.3% vs 38.9%; p < 0.01). Although total operating cost was not significantly different, medical ICU (p < 0.01) and pharmacy (p < 0.05) operating costs were significantly lower in the intervention group. There was no significant difference in ICU length of stay (median 5 vs 5.5 d), hospital length of stay (median 10 vs 11 d), in-hospital mortality (22.6% vs 29.4%), or 30-day mortality between groups (35.1% vs 36.3%) (p> 0.05).Conclusions: Early triggered palliative care consultation was associated with greater transition to do-not-resuscitate/do-not-intubate and to hospice care, as well as decreased ICU and post-ICU healthcare resource utilization. Our study suggests that routine palliative care consultation may positively impact the care of high risk, critically ill patients.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Perceptions of Ethical Decision-Making Climate Among Clinicians Working in
           European and U.S. ICUs: Differences Between Nurses and Physicians*
    • Authors: Jensen; Hanne Irene; Hebsgaard, Stine; Hansen, Tina Charlotte Bitsch; Johnsen, Rikke Frank Aagaard; Hartog, Christiane S.; Soultati, Ioanna; Szucs, Orsolya; Wilson, Michael E.; van den Bulcke, Bo; Benoit, Dominique D.; Piers, Ruth
      Abstract: imageObjectives: To examine perceptions of nurses and physicians in regard to ethical decision-making climate in the ICU and to test the hypothesis that the worse the ethical decision-making climate, the greater the discordance between nurses’ and physicians’ rating of ethical decision-making climate with physicians hypothesized to rate the climate better than the nurses.Design: Prospective observational study.Setting: A total of 68 adult ICUs in 13 European countries and the United States.Subjects: ICU physicians and nurses.Interventions: None.Measurements and Main Results: Perceptions of ethical decision-making climate among clinicians were measured in April-May 2014, using a 35-items self-assessment questionnaire that evaluated seven factors (empowering leadership by physicians, interdisciplinary reflection, not avoiding end-of-life decisions, mutual respect within the interdisciplinary team, involvement of nurses in end-of-life care and decision-making, active decision-making by physicians, and ethical awareness). A total of 2,275 nurses and 717 physicians participated (response rate of 63%). Using cluster analysis, ICUs were categorized according to four ethical decision-making climates: good, average with nurses’ involvement at end-of-life, average without nurses’ involvement at end-of-life, and poor. Overall, physicians rated ethical decision-making climate more positively than nurses (p < 0.001 for all seven factors). Physicians had more positive perceptions of ethical decision-making climate than nurses in all 13 participating countries and in each individual participating ICU. Compared to ICUs with good or average ethical decision-making climates, ICUs with poor ethical decision-making climates had the greatest discordance between physicians and nurses. Although nurse/physician differences were found in all seven factors of ethical decision-making climate measurement, the factors with greatest discordance were regarding physician leadership, interdisciplinary reflection, and not avoiding end-of-life decisions.Conclusions: Physicians consistently perceived ICU ethical decision-making climate more positively than nurses. ICUs with poor ethical decision-making climates had the largest discrepancies.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Host-Response Subphenotypes Offer Prognostic Enrichment in Patients With
           or at Risk for Acute Respiratory Distress Syndrome*
    • Authors: Kitsios; Georgios D.; Yang, Libing; Manatakis, Dimitris V.; Nouraie, Mehdi; Evankovich, John; Bain, William; Dunlap, Daniel G.; Shah, Faraaz; Barbash, Ian J.; Rapport, Sarah F.; Zhang, Yingze; DeSensi, Rebecca S.; Weathington, Nathaniel M.; Chen, Bill B.; Ray, Prabir; Mallampalli, Rama K.; Benos, Panayiotis V.; Lee, Janet S.; Morris, Alison; McVerry, Bryan J.
      Abstract: imageObjectives: Classification of patients with acute respiratory distress syndrome into hyper- and hypoinflammatory subphenotypes using plasma biomarkers may facilitate more effective targeted therapy. We examined whether established subphenotypes are present not only in patients with acute respiratory distress syndrome but also in patients at risk for acute respiratory distress syndrome (ARFA) and then assessed the prognostic information of baseline subphenotyping on the evolution of host-response biomarkers and clinical outcomes.Design: Prospective, observational cohort study.Setting: Medical ICU at a tertiary academic medical center.Patients: Mechanically ventilated patients with acute respiratory distress syndrome or ARFA.Interventions: None.Measurements and Main Results: We performed longitudinal measurements of 10 plasma biomarkers of host injury and inflammation. We applied unsupervised latent class analysis methods utilizing baseline clinical and biomarker variables and demonstrated that two-class models (hyper- vs hypoinflammatory subphenotypes) offered improved fit compared with one-class models in both patients with acute respiratory distress syndrome and ARFA. Baseline assignment to the hyperinflammatory subphenotype (39/104 [38%] acute respiratory distress syndrome and 30/108 [28%] ARFA patients) was associated with higher severity of illness by Sequential Organ Failure Assessment scores and incidence of acute kidney injury in patients with acute respiratory distress syndrome, as well as higher 30-day mortality and longer duration of mechanical ventilation in ARFA patients (p < 0.0001). Hyperinflammatory patients exhibited persistent elevation of biomarkers of innate immunity for up to 2 weeks postintubation.Conclusions: Our results suggest that two distinct subphenotypes are present not only in patients with established acute respiratory distress syndrome but also in patients at risk for its development. Hyperinflammatory classification at baseline is associated with higher severity of illness, worse clinical outcomes, and trajectories of persistently elevated biomarkers of host injury and inflammation during acute critical illness compared with hypoinflammatory patients. Our findings provide strong rationale for examining treatment effect modifications by subphenotypes in randomized clinical trials to inform precision therapeutic approaches in critical care.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Allergic Immune Diseases and the Risk of Mortality Among Patients
           Hospitalized for Acute Infection*
    • Authors: Verhoef; Philip A.; Bhavani, Sivasubramanium V.; Carey, Kyle A.; Churpek, Matthew M.
      Abstract: imageObjectives: The immune response during sepsis remains poorly understood and is likely influenced by the host’s preexisting immunologic comorbidities. Although more than 20% of the U.S. population has an allergic-atopic disease, the type 2 immune response that is overactive in these diseases can also mediate beneficial pro-resolving, tissue-repair functions. Thus, the presence of allergic immunologic comorbidities may be advantageous for patients suffering from sepsis. The objective of this study was to test the hypothesis that comorbid type 2 immune diseases confer protection against morbidity and mortality due to acute infection.Design: Retrospective cohort study of patients hospitalized with an acute infection between November 2008 and January 2016 using electronic health record data.Setting: Single tertiary-care academic medical center.Patients: Admissions to the hospital through the emergency department with likely infection at the time of admission who may or may not have had a type 2 immune-mediated disease, defined as asthma, allergic rhinitis, atopic dermatitis, or food allergy, as determined by International Classification of Diseases, 9th Revision, Clinical Modification codes.Interventions: None.Measurements and Main Results: Of 10,789 admissions for infection, 2,578 (24%) had a type 2 disease; these patients were more likely to be female, black, and younger than patients without type 2 diseases. In unadjusted analyses, type 2 patients had decreased odds of dying during the hospitalization (0.47; 95% CI, 0.38–0.59, p < 0.001), while having more than one type 2 disease conferred a dose-dependent reduction in the risk of mortality (p < 0.001). When adjusting for demographics, medications, types of infection, and illness severity, the presence of a type 2 disease remained protective (odds ratio, 0.55; 95% CI, 0.43–0.70; p < 0.001). Similar results were found using a propensity score analysis (odds ratio, 0.57; 95% CI, 0.45–0.71; p < 0.001).Conclusions: Patients with type 2 diseases admitted with acute infections have reduced mortality, implying that the type 2 immune response is protective in sepsis.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Vasopressin Versus Norepinephrine for the Management of Septic Shock in
           Cancer Patients: The VANCS II Randomized Clinical Trial*
    • Authors: Hajjar; Ludhmila Abrahão; Zambolim, Cristiane; Belletti, Alessandro; de Almeida, Juliano Pinheiro; Gordon, Anthony C.; Oliveira, Gisele; Park, Clarice Hyesuk Lee; Fukushima, Julia Tizue; Rizk, Stephanie Itala; Szeles, Tais Felix; dos Santos Neto, Nestor Cordeiro; Filho, Roberto Kalil; Galas, Filomena Regina Barbosa Gomes; Landoni, Giovanni
      Abstract: imageObjectives: Previous trials suggest that vasopressin may improve outcomes in patients with vasodilatory shock. The aim of this study was to evaluate whether vasopressin could be superior to norepinephrine to improve outcomes in cancer patients with septic shock.Design: Single-center, randomized, double-blind clinical trial, and meta-analysis of randomized trials.Setting: ICU of a tertiary care hospital.Patients: Two-hundred fifty patients 18 years old or older with cancer and septic shock.Interventions: Patients were assigned to either vasopressin or norepinephrine as first-line vasopressor therapy. An updated meta-analysis was also conducted including randomized trials published until October 2018.Measurements and Main Results: The primary outcome was all-cause mortality at 28 days after randomization. Prespecified secondary outcomes included 90-days all-cause mortality rate; number of days alive and free of advanced organ support at day 28; and Sequential Organ Failure Assessment score 24 hours and 96 hours after randomization. We also measure the prevalence of adverse effects in 28 days. A total of 250 patients were randomized. The primary outcome was observed in 71 patients (56.8%) in the vasopressin group and 66 patients (52.8%) in the norepinephrine group (p = 0.52). There were no significant differences in 90-day mortality (90 patients [72.0%] and 94 patients [75.2%], respectively; p = 0.56), number of days alive and free of advanced organ support, adverse events, or Sequential Organ Failure Assessment score.Conclusions: In cancer patients with septic shock, vasopressin as first-line vasopressor therapy was not superior to norepinephrine in reducing 28-day mortality rate.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Ramelteon for Prevention of Postoperative Delirium: A Randomized
           Controlled Trial in Patients Undergoing Elective Pulmonary
           Thromboendarterectomy*
    • Authors: Jaiswal; Stuti J.; Vyas, Anuja D.; Heisel, Andrew J.; Ackula, Haritha; Aggarwal, Ashna; Kim, Nick H.; Kerr, Kim M.; Madani, Michael; Pretorius, Victor; Auger, William R.; Fernandes, Timothy M.; Malhotra, Atul; Owens, Robert L.
      Abstract: imageObjectives: To assess the efficacy of ramelteon in preventing delirium, an acute neuropsychiatric condition associated with increased morbidity and mortality, in the perioperative, ICU setting.Design: Parallel-arm, randomized, double-blinded, placebo-controlled trial.Setting: Academic medical center in La Jolla, California.Patients: Patients greater than or equal to 18 years undergoing elective pulmonary thromboendarterectomy.Interventions: Ramelteon 8 mg or matching placebo starting the night prior to surgery and for a maximum of six nights while in the ICU.Measurements and Main Results: Incident delirium was measured twice daily using the Confusion Assessment Method-ICU. The safety outcome was coma-free days assessed by the Richmond Agitation-Sedation Scale. One-hundred twenty participants were enrolled and analysis completed in 117. Delirium occurred in 22 of 58 patients allocated to placebo versus 19 of 59 allocated to ramelteon (relative risk, 0.8; 95% CI, 0.5–1.4; p = 0.516). Delirium duration, as assessed by the number of delirium-free days was also similar in both groups (placebo median 2 d [interquartile range, 2–3 d] vs ramelteon 3 d [2–5 d]; p = 0.181). Coma-free days was also similar between groups (placebo median 2 d [interquartile range, 1–3 d] vs ramelteon 3 d [2–4 d]; p = 0.210). We found no difference in ICU length of stay (median 4 d [interquartile range, 3–5 d] vs 4 d [3–6 d]; p = 0.349), or in-hospital mortality (four vs three deaths; relative risk ratio, 0.7; 95% CI, 0.2–3.2; p = 0.717), all placebo versus ramelteon, respectively.Conclusions: Ramelteon 8 mg did not prevent postoperative delirium in patients admitted for elective cardiac surgery.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Retrospective Assessment of Desmopressin Effectiveness and Safety in
           Patients With Antiplatelet-Associated Intracranial Hemorrhage*
    • Authors: Feldman; Elizabeth A.; Meola, Gregory; Zyck, Stephanie; Miller, Christopher D.; Krishnamurthy, Satish; Cwikla, Gregory M.; Darko, William; Jennings, Shane; Sullivan, Ross; Seabury, Robert
      Abstract: imageObjective: Current international guidelines offer a conditional recommendation to consider a single dose of IV desmopressin (DDAVP) for antiplatelet-associated intracranial hemorrhage based on low-quality evidence. We provide the first comparative assessment analyzing DDAVP effectiveness and safety in antiplatelet-associated intracranial hemorrhage.Design: Retrospective chart review.Setting: Single tertiary care academic medical center.Patients: Adult patients taking at least one antiplatelet agent based on presenting history and documented evidence of intracranial hemorrhage on cerebral CT scan were included. Patients were excluded for the following reasons: repeat cerebral CT scan not performed within the first 24 hours, noncomparative repeat cerebral CT scan, chronic anticoagulation, administration of fibrinolytic medications, concurrent ischemic stroke, and neurosurgical intervention. In total, 124 patients were included, 55 received DDAVP and 69 did not.Interventions: DDAVP treatment at recognition of antiplatelet-associated intracranial hemorrhage versus nontreatment.Measurements and Main Results: Primary effectiveness outcome was intracranial hemorrhage expansion greater than or equal to 3 mL during the first 24 hospital hours. Primary safety outcomes were the largest absolute decrease from baseline serum sodium during the first 3 treatment days and new-onset thrombotic events during the first 7 days. DDAVP was associated with 88% decreased likelihood of intracranial hemorrhage expansion during the first 24 hours ([+] DDAVP, 10.9% vs [–] DDAVP, 36.2%; p = 0.002; odds ratio [95% CI], 0.22 [0.08–0.57]). Largest median absolute decrease from baseline serum sodium ([+] DDAVP, 0 mEq/L [0–5 mEq/L] vs [–] DDAVP, 0 mEq/L [0–2 mEq/L]; p = 0.089) and thrombotic events ([+] DDAVP, 7.3% vs [–] DDAVP, 1.4%; p = 0.170; odds ratio [95% CI], 5.33 [0.58–49.16]) were similar between groups.Conclusions: DDAVP was associated with a decreased likelihood of intracranial hemorrhage expansion during the first 24 hours. DDAVP administration did not significantly affect serum sodium and thrombotic events during the study period.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Bleeding Assessment Scale in Critically Ill Children (BASIC):
           Physician-Driven Diagnostic Criteria for Bleeding Severity
    • Authors: Nellis; Marianne E.; Tucci, Marisa; Lacroix, Jacques; Spinella, Philip C.; Haque, Kelly D.; Stock, Arabela; Steiner, Marie E.; Faustino, E. Vincent S.; Zantek, Nicole D.; Davis, Peter J.; Stanworth, Simon J.; Cholette, Jill M.; Parker, Robert I.; Demaret, Pierre; Kneyber, Martin C. J.; Russell, Robert T.; Stricker, Paul A.; Vogel, Adam M.; Willems, Ariane; Josephson, Cassandra D.; Luban, Naomi L. C.; Loftis, Laura L.; Leteurtre, Stéphane; Stocker, Christian F.; Goobie, Susan M.; Karam, Oliver; on behalf of the Pediatric Acute Lung Injury the Pediatric Critical Care Blood Research Network (BloodN
      Abstract: imageObjective: Although bleeding frequently occurs in critical illness, no published definition to date describes the severity of bleeding accurately in critically ill children. We sought to develop diagnostic criteria for bleeding severity in critically ill children.Design: Delphi consensus process of multidisciplinary experts in bleeding/hemostasis in critically ill children, followed by prospective cohort study to test internal validity.Setting: PICU.Patients: Children at risk of bleeding in PICUs.Interventions: None.Measurements and Main Results: Twenty-four physicians worldwide (10 on a steering committee and 14 on an expert committee) from disciplines related to bleeding participated in development of a definition for clinically relevant bleeding. A provisional definition was created from 35 descriptors of bleeding. Using a modified online Delphi process and conference calls, the final definition resulted after seven rounds of voting. The Bleeding Assessment Scale in Critically Ill Children definition categorizes bleeding into severe, moderate, and minimal, using organ dysfunction, proportional changes in vital signs, anemia, and quantifiable bleeding. The criteria do not include treatments such as red cell transfusion or surgical interventions performed in response to the bleed. The definition was prospectively applied to 40 critically ill children with 46 distinct bleeding episodes. The kappa statistic between the two observers was 0.74 (95% CI, 0.57–0.91) representing substantial inter-rater reliability.Conclusions: The Bleeding Assessment Scale in Critically Ill Children definition of clinically relevant bleeding severity is the first physician-driven definition applicable for bleeding in critically ill children derived via international expert consensus. The Bleeding Assessment Scale in Critically Ill Children definition includes clear criteria for bleeding severity in critically ill children. We anticipate that it will facilitate clinical communication among pediatric intensivists pertaining to bleeding and serve in the design of future epidemiologic studies if it is validated with patient outcomes.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Neurocritical Care for Extracorporeal Membrane Oxygenation Patients
    • Authors: Cho; Sung-Min; Farrokh, Salia; Whitman, Glenn; Bleck, Thomas P.; Geocadin, Romergryko G.
      Abstract: Objectives: To review the neurocritical care aspects of patients supported by extracorporeal membrane oxygenation, including cerebral physiology, neurologic monitoring, use of sedatives and anti-seizure medications, and prevalence and management of extracorporeal membrane oxygenation associated brain injury.Data Sources: PubMed database search using relevant search terms related to neurologic complications, neurocritical care management, and brain injury management in patients with extracorporeal membrane oxygenation.Study Selection: Articles included original investigations, review articles, consensus statements and guidelines.Data Extraction: A detailed review of publications performed and relevant publications were summarized.Data Synthesis: We found no practice guidelines or management strategies for the neurocritical care of extracorporeal membrane oxygenation patients. Such patients are at high risk for hypoxic-ischemic brain injury, intracranial hemorrhage, cerebral edema, and brain death. Improving clinical outcomes will depend on better defining the neurologic complications and underlying pathophysiology that are specific to extracorporeal membrane oxygenation. Currently, insufficient understanding of the pathophysiology of neurologic complications prevents us from addressing their etiologies with specific, targeted monitoring techniques and interventions.Conclusions: A large knowledge gap exists in our understanding and treatment of extracorporeal membrane oxygenation-related neurologic complications. A systematic and multidisciplinary approach is needed to reduce the prevalence of these complications and to better manage the neurologic sequelae of extracorporeal membrane oxygenation in a way that will improve patient outcomes.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Why Understanding Sepsis Endotypes Is Important for Steroid Trials in
           Septic Shock
    • Authors: Antcliffe; David B.; Gordon, Anthony C.
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Why the Adjunctive Corticosteroid Treatment in Critically Ill Patients
           With Septic Shock (ADRENAL) Trial Did Not Show a Difference in Mortality
    • Authors: Venkatesh; Balasubramanian; Cohen, Jeremy
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Why My Steroid Trials in Septic Shock Were “Positive”
    • Authors: Annane; Djillali
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Airway Pressure Release Ventilation in Adult Patients With Acute Hypoxemic
           Respiratory Failure: A Systematic Review and Meta-Analysis*
    • Authors: Lim; Jolene; Litton, Edward
      Abstract: imageObjectives: To evaluate the efficacy and safety of airway pressure release ventilation in critically ill adults with acute hypoxemic respiratory failure.Data Sources: A systematic literature search of MEDLINE via PUBMED, EMBASE, the Cochrane Library, published conference proceedings and abstracts, reference lists of eligible studies and review articles, and hand searches of relevant journals and trial registers.Study Selection: Eligible studies included randomized controlled trials published between years 2000 and 2018, comparing airway pressure release ventilation to any ventilation mode, in critically ill adults with acute hypoxemic respiratory failure and reporting at least one mortality outcome.Data Extraction: Screened citations were reviewed and extracted independently by two investigators onto a prespecified proforma.Data Synthesis: There were 412 patients from seven randomized controlled trials included in the qualitative and quantitative data synthesis. Airway pressure release ventilation was associated with a significant mortality benefit (relative risk, 0.67; 95% CI, 0.48–0.94; I2 < 0.1%; p = 0.97) and improvement in day 3 Pao2/Fio2 ratio (weighted mean difference, 60.4; 95% CI, 10.3–110.5). There was no significant difference in requirement to initiate rescue treatments including inhaled pulmonary vasodilators, prone positioning, or extracorporeal membrane oxygenation (relative risk, 0.51; 95% CI, 0.22–1.21; I2 = 64.7%; p = 0.04). The risk of barotrauma was only reported in three studies and did not differ between groups (relative risk, 0.39; 95% CI, 0.12–1.19; I2 < 0.1%; p = 0.99).Conclusions: In adult patients requiring mechanical ventilation for acute hypoxic respiratory failure, airway pressure release ventilation is associated with a mortality benefit and improved oxygenation when compared with conventional ventilation strategies. Given the limited number of patients enrolled in the available studies, larger multicenter studies are required to validate these findings.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Family-Centered Care in the ICU: Strength in Numbers*
    • Authors: Mount; Cristin A.; Colombo, Christopher J.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Acute Laryngeal Injury Following Mechanical Ventilation: Revisiting the
           Known Unknowns*
    • Authors: Gowardman; John Robert
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Focusing on the Big Picture to Improve Ethical Decision-Making in ICUs*
    • Authors: Dickert; Neal W.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • The Challenge and the Promise of Identifying More Homogeneous Subgroups in
           Acute Respiratory Distress Syndrome*
    • Authors: Leligdowicz; Aleksandra
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Allergic Diseases: Can They Be Good for You'*
    • Authors: Busch; Lindsay M.; Torabi-Parizi, Parizad
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Just a Little Off the Top, Please*
    • Authors: Busse; Laurence W.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Ramelteon for ICU Delirium Prevention: Is It Time to Melt Away'*
    • Authors: Hamblin; Susan E.; Burka, Abigail T.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • From One-Size-Fits-All to Mechanism-Guided Treatment for Intracranial
           Hemorrhage*
    • Authors: Naidech; Andrew M.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Airway Pressure Release Ventilation in Acute Hypoxemic Respiratory
           Failure: Curb Your Enthusiasm*
    • Authors: Hager; David N.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Insights Into a “Negative” ICU Trial Derived From Gene
           Expression Profiling
    • Authors: Hoekstra; Mary; Maslove, David M.; Veldhoen, Richard A.; Marshall, John C.; Muscedere, John
      Abstract: imageObjectives: Randomized controlled trials in the ICU often fail to show differences in endpoints between groups. We sought to explore reasons for this at a molecular level by analyzing transcriptomic data from a recent negative trial. Our objectives were to determine if randomization successfully balanced transcriptomic features between groups, to assess transcriptomic heterogeneity among the study subjects included, and to determine if the study drug had any effect at the gene expression level.Design: Bioinformatics analysis of transcriptomic and clinical data collected in the course of a randomized controlled trial.Setting: Tertiary academic mixed medical-surgical ICU.Patients: Adult, critically ill patients expected to require invasive mechanical ventilation more than 48 hours.Interventions: Lactoferrin or placebo delivered enterally and via an oral swab for up to 28 days.Measurements and Main Results: We found no major imbalances in transcriptomic features between groups. Unsupervised analysis did not reveal distinct clusters among patients at the time of enrollment. There were marked differences in gene expression between early and later time points. Patients in the lactoferrin group showed changes in the expression of genes associated with immune pathways known to be associated with lactoferrin.Conclusions: In this clinical trial, transcriptomic data provided a useful complement to clinical data, suggesting that the reasons for the negative result were less likely related to the biological efficacy of the study drug, and may instead have been related to poor sensitivity of the clinical outcomes. In larger studies, transcriptomics may also prove useful in predicting response to treatment.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • A Prospective Analysis of Motor and Cognitive Skill Retention in Novice
           Learners of Point of Care Ultrasound
    • Authors: Rappaport; Charles A.; McConomy, Bryan C.; Arnold, Nicholas R.; Vose, Aaron T.; Schmidt, Gregory A.; Nassar, Boulos
      Abstract: imageObjectives: To identify the time at which point of care ultrasound static image recognition and image acquisition skills decay in novice learners.Setting: The University of Iowa Hospitals and Clinics.Subjects: Twenty-four subjects (23 first-year medical students and one first-year physician assistant student).Design: The subjects completed an initial didactic and hands-on session with immediate testing of learned image acquisition and static image identification skills.Interventions: Retesting occurred at 1, 4, and 8 weeks after the initial training session with no retraining in between. Image acquisition skills were obtained on the same healthy male volunteers, and the students were given no immediate feedback on their performance. The image identification skills were assessed with a 10 question test at each follow-up session.Measurements and Main Results: For pleural ultrasound by 4 weeks, there was a significant decline of the ability to identify A-lines (p = 0.0065). For pleural image acquisition, there was no significant decline in the ability to demonstrate lung sliding. Conversely, cardiac image recognition did not significantly decline throughout the study, while the ability to demonstrate cardiac images at 4 weeks (parasternal short axis view) did (p = 0.0008).Conclusions: Motor and cognitive skills decay at different times for pleural and cardiac images. Future ultrasound curricula should retrain skills at a maximum of 8 weeks from initial training. They should focus more on didactic sessions related to image identification for pleural images, and more hands-on image acquisition training for cardiac images, which represents a novel finding.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • One-Year Prognosis of Kidney Injury at Discharge From the ICU: A
           Multicenter Observational Study
    • Authors: Legrand; Matthieu; Hollinger, Alexa; Vieillard-Baron, Antoine; Dépret, François; Cariou, Alain; Deye, Nicolas; Fournier, Marie-Céline; Jaber, Samir; Damoisel, Charles; Lu, Qin; Monnet, Xavier; Rennuit, Isabelle; Darmon, Michael; Zafrani, Lara; Leone, Marc; Guidet, Bertrand; Friedman, Diane; Sonneville, Romain; Montravers, Philippe; Pili-Floury, Sébastien; Lefrant, Jean-Yves; Duranteau, Jacques; Laterre, Pierre-François; Brechot, Nicolas; Oueslati, Haikel; Cholley, Bernard; Launay, Jean-Marie; Ishihara, Shiro; Sato, Naoki; Mebazaa, Alexandre; Gayat, Etienne; on behalf of the French euRopean Outcome reGistry in ICUs (FROG-ICU Investigators
      Abstract: imageObjectives: The association between outcome and kidney injury detected at discharge from the ICU using different biomarkers remains unknown. The objective was to evaluate the association between 1-year survival and kidney injury at ICU discharge.Design: Ancillary investigation of a prospective observational study.Setting: Twenty-one ICUs with 1-year follow-up.Patients: Critically ill patients receiving mechanical ventilation and/or hemodynamic support for at least 24 hours were included.Interventions: Serum creatinine, plasma Cystatin C, plasma neutrophil gelatinase-associated lipocalin, urinary neutrophil gelatinase-associated lipocalin, plasma Proenkephalin A 119-159, and estimated glomerular filtration rate (on serum creatinine and plasma Cystatin C) were measured at ICU discharge among ICU survivors.Measurements and Main Results: The association between kidney biomarkers at discharge and mortality was estimated using logistic model with and without adjustment for prognostic factors previously identified in this cohort. Subgroup analyses were performed in patients with discharge serum creatinine less than 1.5-fold baseline at ICU discharge. Among 1,207 ICU survivors included, 231 died during the year following ICU discharge (19.2%). Estimated glomerular filtration rate was significantly lower and kidney injury biomarkers higher at discharge in nonsurvivors. The association between biomarker levels or estimated glomerular filtration rate and mortality remained after adjustment to potential cofounding factors influencing outcome. In patients with low serum creatinine at ICU discharge, 25–47% of patients were classified as subclinical kidney injury depending on the biomarker. The association between kidney biomarkers and mortality remained and mortality was higher than patients without subclinical kidney injury. The majority of patients who developed acute kidney injury during ICU stay had elevated biomarkers of kidney injury at discharge even with apparent recovery based on serum creatinine (i.e., subclinical acute kidney disease).Conclusions: Elevated kidney biomarkers measured at ICU discharge are associated with poor 1-year outcome, including in patients with low serum creatinine at ICU discharge.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Validation of Early Warning Scores at Two Long-Term Acute Care Hospitals
    • Authors: Churpek; Matthew M.; Carey, Kyle A.; Dela Merced, Nino; Prister, James; Brofman, John; Edelson, Dana P.
      Abstract: imageObjectives: Early warning scores were developed to identify high-risk patients on the hospital wards. Research on early warning scores has focused on patients in short-term acute care hospitals, but there are other settings, such as long-term acute care hospitals, where these tools could be useful. However, the accuracy of early warning scores in long-term acute care hospitals is unknown.Design: Observational cohort study.Setting: Two long-term acute care hospitals in Illinois from January 2002 to September 2017.Patients: Admitted adult long-term acute care hospital patients.Interventions: None.Measurements and Main Results: Demographic characteristics, vital signs, laboratory values, nursing flowsheet data, and outcomes data were collected from the electronic health record. The accuracy of individual variables, the Modified Early Warning Score, the National Early Warning Score version 2, and our previously developed electronic Cardiac Arrest Risk Triage score were compared for predicting the need for acute hospital transfer or death using the area under the receiver operating characteristic curve. A total of 12,497 patient admissions were included, with 3,550 experiencing the composite outcome. The median age was 65 (interquartile range, 54–74), 46% were female, and the median length of stay in the long-term acute care hospital was 27 days (interquartile range, 17–40 d), with an 8% in-hospital mortality. Laboratory values were the best predictors, with blood urea nitrogen being the most accurate (area under the receiver operating characteristic curve, 0.63) followed by albumin, bilirubin, and WBC count (area under the receiver operating characteristic curve, 0.61). Systolic blood pressure was the most accurate vital sign (area under the receiver operating characteristic curve, 0.60). Electronic Cardiac Arrest Risk Triage (area under the receiver operating characteristic curve, 0.72) was significantly more accurate than National Early Warning Score version 2 (area under the receiver operating characteristic curve, 0.66) and Modified Early Warning Score (area under the receiver operating characteristic curve, 0.65; p < 0.01 for all pairwise comparisons).Conclusions: In this retrospective cohort study, we found that the electronic Cardiac Arrest Risk Triage score was significantly more accurate than Modified Early Warning Score and National Early Warning Score version 2 for predicting acute hospital transfer and mortality. Because laboratory values were more predictive than vital signs and the average length of stay in an long-term acute care hospital is much longer than short-term acute hospitals, developing a score specific to the long-term acute care hospital population would likely further improve accuracy, thus allowing earlier identification of high-risk patients for potentially life-saving interventions.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Preoperative Diaphragm Function Is Associated With Postoperative Pulmonary
           Complications After Cardiac Surgery
    • Authors: Cavayas; Yiorgos Alexandros; Eljaiek, Roberto; Rodrigue, Élise; Lamarche, Yoan; Girard, Martin; Wang, Han Ting; Levesque, Sylvie; Denault, André Y.
      Abstract: imageObjectives: Postoperative pulmonary complications increase mortality, length, and cost of hospitalization. A better diaphragmatic strength may help face an increased work of breathing postoperatively. We, therefore, sought to determine if a low preoperative diaphragm thickening fraction (TFdi) determined by ultrasonography helped predict the occurrence of postoperative pulmonary complications after cardiac surgery independently of indicators of frailty, sarcopenia, and pulmonary function.Design: Prospective observational cohort study.Setting: Montreal Heart Institute, an academic cardiac surgery center in Canada.Patients: Adults undergoing nonemergency cardiac surgery.Interventions: We measured the preoperative thickness of the right and left hemidiaphragms at their zone of apposition at end-expiration (Tdi,ee) and peak-inspiration (Tdi,ei) with ultrasonography. Maximal thickening fraction of the diaphragm during inspiration (TFdi,max) was calculated using the following formula: TFdi,max = (Tdi,ei–Tdi,ee)/Tdi,ee. We also evaluated other potential risk factors including demographic parameters, comorbidities, Clinical Frailty Scale, grip strength, 5-meter walk test, and pulmonary function tests. We repeated TFdi,max measurements within 24 hours of extubation. The primary composite outcome of this study was the occurrence of postoperative pulmonary complications, defined as pneumonia, clinically significant atelectasis, or prolonged mechanical ventilation (> 24 hr).Measurement and Main Results: Of the 115 patients included, 34 (29.6%) developed postoperative pulmonary complications, including two with pneumonia, four with prolonged mechanical ventilation, and 32 with clinically significant atelectasis. Those with postoperative pulmonary complications had prolonged ICU and hospital length of stays. They had a lower TFdi,max (37% [interquartile range, 31–45%] vs 44% [interquartile range, 33–58%]; p = 0.03). In multiple logistic regression, a TFdi,max less than 38.1% was associated with postoperative pulmonary complications (odds ratio, 4.9; 95% CI, 1.81–13.50; p = 0.002). All patients who developed pneumonia or prolonged mechanical ventilation had a TFdi,max less than 38.1%. Respiratory rate and diabetes were also independently associated with postoperative pulmonary complications, while pulmonary function tests and the assessed indicators of frailty and sarcopenia were not.Conclusions: A low preoperative TFdi,max can help to identify patients at increased risk of postoperative pulmonary complications after cardiac surgery.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Enteral Acetaminophen Bioavailability in Pediatric Intensive Care Patients
           Determined With an Oral Microtracer and Pharmacokinetic Modeling to
           Optimize Dosing
    • Authors: Kleiber; Niina; Calvier, Elisa; Mooij, Miriam G.; Krekels, Elke H. J.; Vaes, Wouter H. J.; Tibboel, Dick; Knibbe, Catherijne A. J.; de Wildt, Saskia N.
      Abstract: imageObjectives: Decreasing morbidity and mortality by rationalizing drug treatment in the critically ill is of paramount importance but challenging as the underlying clinical condition may lead to large variation in drug disposition and response. New microtracer methodology is now available to gain knowledge on drug disposition in the intensive care. On the basis of studies in healthy adults, physicians tend to assume that oral doses of acetaminophen will be completely absorbed and therefore prescribe the same dose per kilogram for oral and IV administration. As the oral bioavailability of acetaminophen in critically ill children is unknown, we designed a microtracer study to shed a light on this issue.Design: An innovative microtracer study design with population pharmacokinetics.Setting: A tertiary referral PICU.Patients: Stable critically ill children, 0–6 years old, and already receiving IV acetaminophen.Interventions: Concomitant administration of an oral 14C radiolabeled acetaminophen microtracer (3 ng/kg) with IV acetaminophen treatment (15 mg/kg every 6 hr).Measurements: Blood was drawn from an indwelling arterial or central venous catheter up to 24 hours after 14C acetaminophen microtracer administration. Acetaminophen concentrations were measured by liquid chromatography-mass spectrometry and 14C concentrations by accelerated mass spectrometry.Main Results: In 47 patients (median age of 6.1 mo; Q1–Q3, 1.8–20 mo) the mean enteral bioavailability was 72% (range, 11–91%). With a standard dose (15 mg/kg 4 times daily), therapeutic steady-state concentrations were 2.5 times more likely to be reached with IV than with oral administration.Conclusions: Microtracer studies present a new opportunity to gain knowledge on drug disposition in the intensive care. Using this modality in children in the pediatric intensive care, we showed that enteral administration of acetaminophen results in less predictable exposure and higher likelihood of subtherapeutic blood concentration than does IV administration. IV dosing may be preferable to ensure adequate pain relief.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Bioelectrical Impedance Measurements for Assessment of Kidney Function in
           Critically Ill Patients
    • Authors: de Jong; Lutea A. A.; Otten – Helmers, Annemiek G.; Spronk, Peter E.; van Kan, Hendrikus J. M.
      Abstract: imageObjectives: To evaluate the use of multifrequency bioelectrical impedance analysis to predict creatinine/urea clearance based on 24 hours urine collection. A practical formula was developed, and its performance was compared with that of established formulas such as Cockcroft-Gault, Modification of Diet in Renal Disease, and Jelliffe’s.Design: An open-label prospective observational cohort study.Setting: A 12-bed ICU at a nonuniversity major teaching hospital (Gelre ziekenhuizen Apeldoorn/Zutphen, The Netherlands).Patients: Adult critical care patients with an expected ICU length of stay at admission of at least 48 hours.Interventions: Each patient’s body composition was assessed using a validated Quadscan 4000 analyzer (Bodystat, Isle of Man, British Isles). Twenty-four hours urine was collected, and laboratory variables in serum including creatinine, urea, and albumin were obtained at the beginning and end of the collection period.Measurements and Main Results: A total of 151 patients, stratified to an acute and nonacute ICU-group, were enrolled in the study over a 2-year period. A formula to predict creatinine/urea clearance based on 24 hours urine collection was developed using stepwise linear regression using a training data set of 75 patients. This formula was subsequently tested and compared with other relevant predictive equations using a validation data set of 76 patients. Serum creatinine values ranged from 40 to 446 µmol/L. With the predictive model based on estimated body cell mass and a “prediction marker” more than 71% of the observed variance in creatinine/urea clearance based on 24 hours urine collection could be explained. Predictive performance was superior to the other eight evaluated models (R2 = 0.39–0.55) and demonstrated to be constant over the whole range of creatinine/urea clearance based on 24 hours urine collection values.Conclusions: Multifrequency bioelectrical impedance analysis measurements can be used to predict creatinine/urea clearance based on 24 hours urine collection with superior performance than currently established prediction models. This rapid, noninvasive method enables correction for influences of a patient’s actual body composition and may prove valuable in daily clinical practice.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Incidence and Outcomes of Sepsis in Korea: A Nationwide Cohort Study From
           2007 to 2016
    • Authors: Oh; Seung-Young; Cho, Songhee; Kim, Ga Hee; Jang, Eun Jin; Choi, Seongmi; Lee, Hannah; Ryu, Ho Geol
      Abstract: imageObjectives: This study aimed to estimate the incidence and clinical outcomes of sepsis in Korea from 2007 to 2016.Design: Retrospective observational study.Setting: Nationwide study with population-based healthcare reimbursement claims database.Patients: Using data from the National Health Insurance Service of Korea, patients who were hospitalized with a diagnosis of sepsis from 2007 to 2016 were analyzed. The incidence of sepsis was calculated using mid-year census population and analyzed according to year, age, and sex. The Elixhauser Comorbidity Index score was calculated to adjust for the impact of comorbidities on clinical outcome. In-hospital mortality, hospital length of stay, ICU admission rates, and risk factors for in-hospital mortality were also analyzed.Interventions: None.Measurements and Main Results: The incidence of sepsis increased from 173.8 per 100,000 population in 2007 to 233.6 per 100,000 population in 2016. In-hospital mortality decreased from 30.9% in 2007 to 22.6% in 2016 (p < 0.0001). From 2007 to 2016, hospital length of stay and ICU admission rates associated with sepsis decreased from 26.0 ± 33.5 days to 21.3 ± 24.4 days (p < 0.0001) and from 16.2% to 12.7% (p < 0.0001), respectively. Male sex, age greater than 50 years, Elixhauser Comorbidity Index greater than 10, and mechanical ventilation were identified as risk factors for in-hospital mortality after adjusting for baseline characteristics.Conclusions: The incidence of sepsis in Korea increased from 2007 to 2016, while the associated in-hospital mortality, hospital length of stay, and ICU admission rates decreased.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Cell Cycle Biomarkers and Soluble Urokinase-Type Plasminogen Activator
           Receptor for the Prediction of Sepsis-Induced Acute Kidney Injury
           Requiring Renal Replacement Therapy: A Prospective, Exploratory Study
    • Authors: Nusshag; Christian; Rupp, Christoph; Schmitt, Felix; Krautkrämer, Ellen; Speer, Claudius; Kälble, Florian; Tamulyte, Sandra; Bruckner, Thomas; Zeier, Martin; Reiser, Jochen; Weigand, Markus A.; Uhle, Florian; Merle, Uta; Morath, Christian; Brenner, Thorsten
      Abstract: imageObjectives: Sepsis-induced acute kidney injury is the dominant acute kidney injury etiology in critically ill patients and is often associated with a need for renal replacement therapy. The indication and timing of renal replacement therapy are controversially discussed. We hypothesized that the product of the G1-cell cycle arrest biomarkers tissue inhibitor of metalloproteinase-2 and insulin-like growth factor-binding protein 7 ([TIMP-2] × [IGFBP7]), and the soluble urokinase-type plasminogen activator receptor are of diagnostic value for the prediction of septic acute kidney injury courses requiring renal replacement therapy.Design: In this prospective study, critically ill patients were enrolled immediately after the fulfillment of Sepsis-3 criteria. Urinary [TIMP-2] × [IGFBP7] levels over time and serum soluble urokinase-type plasminogen activator receptor levels once at inclusion were measured. The primary endpoint was the development of septic acute kidney injury with the need for renal replacement therapy. Area under the receiver operating characteristic curves, de Long’s tests, and logistic regression models were calculated.Setting: Two ICUs at Heidelberg University Hospital between May 2017 and July 2018.Patients: One-hundred critically ill patients with positive Sepsis-3 criteria.Interventions: None.Measurement and Main Results: Nineteen patients required renal replacement therapy. Diagnostic performance of urinary [TIMP-2] × [IGFBP7] improved over time with the highest area under the receiver operating characteristic curve of 0.89 (95% CI, 0.80–0.98) 24 hours after study inclusion. Soluble urokinase-type plasminogen activator receptor levels at inclusion showed an area under the receiver operating characteristic curve of 0.83 (0.75–0.92). The best discrimination ability for the primary outcome measure was achieved for [TIMP-2] × [IGFBP7] at 24 hours after inclusion by applying a cutoff value of greater than or equal to 0.6 (ng/mL)2/1,000 (sensitivity 90.9, specificity 67.1). Soluble urokinase-type plasminogen activator receptor performed best by using a cutoff value of greater than or equal to 8.53 ng/mL (sensitivity 84.2, specificity 82.7). A combination of newly tested biomarkers with cystatin C resulted in a significantly improved diagnostic accuracy. Cystatin C in combination with [TIMP-2] × [IGFBP7] 24 hours outperformed all standard renal parameters (area under the receiver operating characteristic curve 0.93 [0.86–1.00]).Conclusions: [TIMP-2] × [IGFBP7] and soluble urokinase-type plasminogen activator receptor are promising biomarker candidates for the risk stratification of septic acute kidney injury patients with the need for renal replacement therapy.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Diabetes Insipidus After Discontinuation of Vasopressin Infusion for
           Treatment of Shock
    • Authors: Ferenchick; Hannah; Cemalovic, Nail; Ferguson, Nadia; Dicpinigaitis, Peter V.
      Abstract: imageObjectives: Vasopressin has achieved common usage for the treatment of catecholamine-requiring and catecholamine-resistant shock. Diabetes insipidus is a syndrome characterized by excretion of abnormally large volumes of dilute urine. To date, very few reports of diabetes insipidus after discontinuation of vasopressin infusion have been published; the majority of previous reports describe neurosurgical patients. The purpose of the present study was to investigate the occurrence rate of diabetes insipidus after discontinuation of vasopressin infusion among patients treated with vasopressin infusion for shock.Design: Retrospective analysis of electronic health records of patients receiving continuous vasopressin infusion for the treatment of shock within a 5-year period (2012–2016).Setting: Medical, surgical, and cardiothoracic ICUs within one academic medical center.Patients: One-thousand eight-hundred ninety-six patients received vasopressin infusion for the treatment of shock.Interventions: None.Measurements and Main Results: The occurrence rate of diabetes insipidus after discontinuation of vasopressin infusion was 1.53% among all patients. Sixteen of 29 patients with diabetes insipidus after discontinuation of vasopressin infusion had undergone cardiothoracic intervention, such as coronary artery bypass graft and valve replacement surgery, extracorporeal membrane oxygenation, and placement of ventricular assist devices. No neurosurgical patients were identified in our cohort. In a control group of patients receiving norepinephrine but not vasopressin infusion for treatment of shock, criteria for diabetes insipidus were observed in two of 1,320 subjects (0.15%).Conclusions: Despite a paucity of published reports, diabetes insipidus after discontinuation of vasopressin infusion appears not to be a rare phenomenon, and is likely to be encountered by intensivists who regularly employ vasopressin for the treatment of vasoplegic shock. Previous reports consisted predominantly of neurosurgical patients. Our findings demonstrate the occurrence of diabetes insipidus after discontinuation of vasopressin infusion among patients with septic shock as well as vasoplegic shock after cardiothoracic intervention. The mechanism of diabetes insipidus after discontinuation of vasopressin infusion remains to be elucidated but may involve transient downregulation of V2 receptors induced by exposure to supraphysiological doses of vasopressin.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Occupational Therapy in the ICU: A Scoping Review of 221 Documents
    • Authors: Costigan; F. Aileen; Duffett, Mark; Harris, Jocelyn E.; Baptiste, Susan; Kho, Michelle E.
      Abstract: imageObjectives: Occupational therapists have specialized expertise to enable people to perform meaningful “occupations” that support health, well-being, and participation in life roles. Given the physical, cognitive, and psychologic disability experienced by ICU survivors, occupational therapists could play an important role in their recovery. We conducted a scoping review to determine the state of knowledge of interventions delivered by occupational therapists in adult ICU patients.Data Sources: Eight electronic databases from inception to 05/2018.Study Selection: We included reports of adult patients receiving direct patient care from an occupational therapist in the ICU, all study designs, and quantitative and qualitative traditions.Data Extraction: Independently in duplicate, interprofessional team members screened titles, abstracts, and full texts and extracted report and intervention characteristics. From original research articles, we also extracted study design, number of patients, and primary outcomes. We resolved disagreements by consensus.Data Synthesis: Of 50,700 citations, 221 reports met inclusion criteria, 74 (79%) published after 2010, and 125 (56%) appeared in critical care journals. The three most commonly reported types of interventions were mobility (81%), physical rehabilitation (61%), and activities of daily living (31%). We identified 46 unique original research studies of occupational therapy interventions; the most common study research design was before-after studies (33%).Conclusions: The role of occupational therapists in ICU rehabilitation is not currently well established. Current interventions in the ICU are dominated by physical rehabilitation with a growing role in communication and delirium prevention and care. Given the diverse needs of ICU patients and the scope of occupational therapy, there could be an opportunities for occupational therapists to expand their role and spearhead original research investigating an enriched breadth of ICU interventions.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Hyperosmolar Therapy in Pediatric Severe Traumatic Brain Injury—A
           Systematic Review
    • Authors: Stopa; Brittany M.; Dolmans, Rianne G. F.; Broekman, Marike L. D.; Gormley, William B.; Mannix, Rebekah; Izzy, Saef
      Abstract: imageObjectives: Traumatic brain injury is a leading cause of hospital visits for children. Hyperosmolar therapy is often used to treat severe traumatic brain injury. Hypertonic saline is used predominantly, yet there remains disagreement about whether hypertonic saline or mannitol is more effective.Data Sources: Literature search was conducted using Pubmed, Cochrane, and Embase. Systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.Study Selection: Retrospective and prospective studies assessing use of hyperosmolar therapy in pediatric patients with severe traumatic brain injury were included.Data Extraction: Two independent authors performed article review. Two-thousand two-hundred thirty unique articles were initially evaluated, 11 were included in the final analysis, with a total of 358 patients. Study quality was assessed using Modified Newcastle-Ottawa Scale and Jadad score.Data Synthesis: Of the 11 studies, all evaluated hypertonic saline and four evaluated both hypertonic saline and mannitol. Nine reported that hypertonic saline lowered intracranial pressure and two reported that mannitol lowered intracranial pressure. The studies varied significantly in dose, concentration, and administrations schedule for both hypertonic saline and mannitol. Five studies were prospective, but only one directly compared mannitol to hypertonic saline. The prospective comparison study found no difference in physiologic outcomes. Clinical outcomes were reported using different measures across studies. For hypertonic saline-treated patients, mechanical ventilation was required for 6.9–9 days, decompressive craniectomy was required for 6.25–29.3% of patients, ICU length of stay was 8.0–10.6 days, in-hospital mortality was 10–48%, and 6-month mortality was 7–17%. In mannitol-treated patients, ICU length of stay was 9.5 days, in-hospital mortality was 56%, and 6-month mortality was 19%.Conclusions: Both hypertonic saline and mannitol appear to lower intracranial pressure and improve clinical outcomes in pediatric severe traumatic brain injury, but the evidence is extremely fractured both in the method of treatment and in the evaluation of outcomes. Given the paucity of high-quality data, it is difficult to definitively conclude which agent is better or what treatment protocol to follow.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • The Impact of Atrial Fibrillation on Short-Term Mortality and Resource
           Utilization in Sepsis
    • Authors: Oud; Lavi
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • The authors reply
    • Authors: Hanna; Bishoy; Desai, Rupak; Kumar, Gautam; Sachdeva, Rajesh
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Expanding Choices of ICU Prediction Strategies
    • Authors: Kaufman; David; Delahanty, Ryan; Jones, Spencer
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • The authors reply
    • Authors: Yang; Shiming; Stansbury, Lynn G.; Rock, Peter; Scalea, Thomas; Hu, Peter F.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Was Adjunctive Corticosteroid Treatment in Critically Ill Patients with
           Septic Shock (ADRENAL) Insufficient'
    • Authors: Lemieux; Steven M.; Levine, Alexander R.; Gritsenko, Diana
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • The authors reply
    • Authors: Venkatesh; Balasubramanian; Cohen, Jeremy
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Pharmacists Are Associated With Reduced Mortality in Critically Ill
           Patients: Now What'
    • Authors: Newsome; Andrea Sikora; Jones, Timothy W.; Smith, Susan E.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • The authors reply
    • Authors: Lee; Heeyoung; Suh, Gee Young; Kim, EunYoung
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Awake Extracorporeal Membrane Oxygenation for Acute Respiratory Distress
           Syndrome, Details to Be Defined: Who, When, and How'
    • Authors: Ding; Lin; He, Hangyong
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • The author replies
    • Authors: Bharat; Ankit
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Extracorporeal Membrane Oxygenation in Adult Patients With Purpura
           Fulminans
    • Authors: Contou; Damien; Mekontso Dessap, Armand; de Prost, Nicolas
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • The authors reply
    • Authors: Falk; Lars; Hultman, Jan; Broman, Lars Mikael
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Comparison of Propofol and Dexmedetomidine Sedation in Septic Shock
    • Authors: Zhang; Weimin; Xu, Yingting; Du, Kailei
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • The authors reply
    • Authors: Morelli; Andrea; Rehberg, Sebastian W.; Ertmer, Christian
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • Dosing Matters! Vitamin C in Critical Illness
    • Authors: Long; Micah T.; Hess, Aaron S.; Ries, Michael P.; Coursin, Douglas B.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
  • The authors reply
    • Authors: Putzu; Alessandro; Lopez Delgado, Juan Carlos; Landoni, Giovanni
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
       
 
 
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