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Critical Care Medicine
Journal Prestige (SJR): 3.116
Citation Impact (citeScore): 3
Number of Followers: 359  
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0090-3493 - ISSN (Online) 1530-0293
Published by LWW Wolters Kluwer Homepage  [299 journals]
  • Key Takeaways From the U.S. CDC’s 2019 Antibiotic Resistance Threats
           Report for Frontline Providers
    • Authors: Kadri; Sameer S.
      Abstract: imageNo abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Adverse Events After Transition From ICU to Hospital Ward: A Multicenter
           Cohort Study*
    • Authors: Sauro; Khara M.; Soo, Andrea; de Grood, Chloe; Yang, Michael M. H.; Wierstra, Benjamin; Benoit, Luc; Couillard, Philippe; Lamontagne, François; Turgeon, Alexis F.; Forster, Alan J.; Fowler, Robert A.; Dodek, Peter M.; Bagshaw, Sean M.; Stelfox, Henry T.
      Abstract: imageObjectives: To examine adverse events and associated factors and outcomes during transition from ICU to hospital ward (after ICU discharge).Design: Multicenter cohort study.Setting: Ten adult medical-surgical Canadian ICUs.Patients: Patients were those admitted to one of the 10 ICUs from July 2014 to January 2016.Interventions: None.Measurements and Main Results: Two ICU physicians independently reviewed progress and consultation notes documented in the medical record within 7 days of patient’s ICU discharge date to identify and classify adverse events. The adverse event data were linked to patient characteristics and ICU and ward physician surveys collected during the larger prospective cohort study. Analyses were conducted using multivariable logistic regression. Of the 451 patients included in the study, 84 (19%) experienced an adverse event, the majority (62%) within 3 days of transfer from ICU to hospital ward. Most adverse events resulted only in symptoms (77%) and 36% were judged to be preventable. Patients with adverse events were more likely to be readmitted to the ICU (odds ratio, 5.5; 95% CI, 2.4–13.0), have a longer hospital stay (mean difference, 16.1 d; 95% CI, 8.4–23.7) or die in hospital (odds ratio, 4.6; 95% CI, 1.8-11.8) than those without an adverse event. ICU and ward physician predictions at the time of ICU discharge had low sensitivity and specificity for predicting adverse events, ICU readmissions, and hospital death.Conclusions: Adverse events are common after ICU discharge to hospital ward and are associated with ICU readmission, increased hospital length of stay and death and are not predicted by ICU or ward physicians.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Partnering With Family Members to Detect Delirium in Critically Ill
    • Authors: Fiest; Kirsten M.; Krewulak, Karla D.; Ely, E. Wesley; Davidson, Judy E.; Ismail, Zahinoor; Sept, Bonnie G.; Stelfox, Henry T.
      Abstract: imageObjectives: To evaluate the diagnostic accuracy of family-administered tools to detect delirium in critically ill patients.Design: Diagnostic accuracy study.Setting: Large, tertiary care academic hospital in a single-payer health system.Patients: Consecutive, eligible patients with at least one family member present (dyads) and a Richmond Agitation-Sedation Scale greater than or equal to –3, no primary direct brain injury, the ability to provide informed consent (both patient and family member), the ability to communicate with research staff, and anticipated to remain admitted in the ICU for at least a further 24 hours to complete all assessments at least once.Interventions: None.Measurements and Main Results: Family-administered delirium assessments (Family Confusion Assessment Method and Sour Seven) were completed once daily. A board-certified neuropsychiatrist and team of ICU research nurses conducted the reference standard assessments of delirium (based on Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition, criteria) once daily for a maximum of 5 days. The mean age of the 147 included patients was 56.1 years (sd, 16.2 yr), 61% of whom were male. Family members (n = 147) were most commonly spouses (n = 71, 48.3%) of patients. The area under the receiver operating characteristic curve on the Family Confusion Assessment Method was 65.0% (95% CI, 60.0–70.0%), 71.0% (95% CI, 66.0–76.0%) for possible delirium (cutpoint of 4) on the Sour Seven and 67.0% (95% CI, 62.0–72.0%) for delirium (cutpoint of 9) on the Sour Seven. These area under the receiver operating characteristic curves were lower than the Intensive Care Delirium Screening Checklist (standard of care) and Confusion Assessment Method for ICU. Combining the Family Confusion Assessment Method or Sour Seven with the Intensive Care Delirium Screening Checklist or Confusion Assessment Method for ICU resulted in area under the receiver operating characteristic curves that were not significantly better, or worse for some combinations, than the Intensive Care Delirium Screening Checklist or Confusion Assessment Method for ICU alone. Adding the Family Confusion Assessment Method and Sour Seven to the Intensive Care Delirium Screening Checklist and Confusion Assessment Method for ICU improved sensitivity at the expense of specificity.Conclusions: Family-administered delirium detection is feasible and has fair, but lower diagnostic accuracy than clinical assessments using the Intensive Care Delirium Screening Checklist and Confusion Assessment Method for ICU. Family proxy assessments are essential for determining baseline cognitive function. Engaging and empowering families of critically ill patients warrant further study.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Treatment in Disproportionately Minority Hospitals Is Associated With
           Increased Risk of Mortality in Sepsis: A National Analysis*
    • Authors: Rush; Barret; Danziger, John; Walley, Keith R.; Kumar, Anand; Celi, Leo Anthony
      Abstract: imageObjectives: Treatment in a disproportionately minority-serving hospital has been associated with worse outcomes in a variety of illnesses. We examined the association of treatment in disproportionately minority hospitals on outcomes in patients with sepsis across the United States.Design: Retrospective cohort analysis. Disproportionately minority hospitals were defined as hospitals having twice the relative minority patient population than the surrounding geographical mean. Minority hospitals for Black and Hispanic patient populations were identified based on U.S. Census demographic information. A multivariate model employing a validated algorithm for mortality in sepsis using administrative data was used.Setting: The National Inpatient Sample from 2008 to 2014.Patients: Patients over 18 years of age with sepsis.Interventions: None.Measurements and Main Results: A total of 4,221,221 patients with sepsis were identified. Of these, 612,217 patients (14.5%) were treated at hospitals disproportionately serving the black community (Black hospitals), whereas 181,141 (4.3%) were treated at hospitals disproportionately serving the Hispanic community (Hispanic hospitals). After multivariate analysis, treatment in a Black hospital was associated with a 4% higher risk of mortality compared to treatment in a nonminority hospital (odds ratio, 1.04; 95% CI, 1.03–1.05; p < 0.01). Treatment in a Hispanic hospital was associated with a 9% higher risk of mortality (odds ratio, 1.09; 95% CI, 1.07–1.11; p < 0.01). Median hospital length of stay was almost 1 day longer at each of the disproportionately minority hospitals (nonminority hospitals: 5.9 d; interquartile range, 3.1–11.0 d vs Hispanic: 6.9 d; interquartile range, 3.6–12.9 d and Black: 6.7 d, interquartile range, 3.4–13.2 d; both p < 0.01).Conclusions: Patients with sepsis regardless of race who were treated in disproportionately high minority hospitals suffered significantly higher rates of in-hospital mortality.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Opportunities to Improve Antibiotic Appropriateness in U.S. ICUs: A
           Multicenter Evaluation
    • Authors: Trivedi; Kavita K.; Bartash, Rachel; Letourneau, Alyssa R.; Abbo, Lilian; Fleisher, Jorge; Gagliardo, Christina; Kelley, Shannon; Nori, Priya; Rieg, Gunter K.; Silver, Phyllis; Srinivasan, Arjun; Vargas, Jaclyn; Ostrowsky, Belinda; the Partnership for Quality Care (PQC Inpatient Antimicrobial Stewardship Working Group
      Abstract: imageObjectives: To use a standardized tool for a multicenter assessment of antibiotic appropriateness in ICUs and identify local antibiotic stewardship improvement opportunities.Design: Pilot point prevalence conducted on October 5, 2016; point prevalence survey conducted on March 1, 2017.Setting: ICUs in 12 U.S. acute care hospitals with median bed size 563.Patients: Receiving antibiotics on participating units on March 1, 2017.Interventions: The Centers for Disease Control and Prevention tool for the Assessment of Appropriateness of Inpatient Antibiotics was made actionable by an expert antibiotic stewardship panel and implemented across hospitals. Data were collected by antibiotic stewardship program personnel at each hospital, deidentified and submitted in aggregate for benchmarking. hospital personnel identified most salient reasons for inappropriate use by category and agent.Measurements and Main Results: Forty-seven ICUs participated. Most hospitals (83%) identified as teaching with median licensed ICU beds of 70. On March 1, 2017, 362 (54%) of 667 ICU patients were on antibiotics (range, 8–81 patients); of these, 112 (31%) were identified as inappropriate and administered greater than 72 hours among all 12 hospitals (range, 9–82%). Prophylactic antibiotic regimens and PICU patients demonstrated a statistically significant risk ratio of 1.76 and 1.90 for inappropriate treatment, respectively. Reasons for inappropriate use included unnecessarily broad spectrum (29%), no infection or nonbacterial syndrome (22%), and duration longer than necessary (21%). Of patients on inappropriate antibiotic therapy in surgical ICUs, a statistically significant risk ratio of 2.59 was calculated for noninfectious or nonbacterial reasons for inappropriate therapy.Conclusions: In this multicenter point prevalence study, 31% of ICU antibiotic regimens were inappropriate; prophylactic regimens were often inappropriate across different ICU types, particularly in surgical ICUs. Engaging intensivists in antibiotic stewardship program efforts is crucial to sustain the efficacy of antibiotics and quality of infectious diseases care in critical care settings. This study underscores the value of standardized assessment tools and benchmarking to be shared with local leaders for targeted antibiotic stewardship program interventions.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Association Between Arterial Carbon Dioxide Tension and Clinical Outcomes
           in Venoarterial Extracorporeal Membrane Oxygenation*
    • Authors: Diehl; Arne; Burrell, Aidan J. C.; Udy, Andrew A.; Alexander, Peta M. A.; Rycus, Peter T.; Barbaro, Ryan P.; Pellegrino, Vincent A.; Pilcher, David V.
      Abstract: imageObjectives: The manipulation of arterial carbon dioxide tension is associated with differential mortality and neurologic injury in intensive care and cardiac arrest patients; however, few studies have investigated this relationship in patients on venoarterial extracorporeal membrane oxygenation. We investigated the association between the initial arterial carbon dioxide tension and change over 24 hours on mortality and neurologic injury in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiac arrest and refractory cardiogenic shock.Design: Retrospective cohort analysis of adult patients recorded in the international Extracorporeal Life Support Organization Registry.Setting: Data reported to the Extracorporeal Life Support Organization from all international extracorporeal membrane oxygenation centers during 2003-2016.Patients: Adult patients (≥ 18 yr old) supported with venoarterial extracorporeal membrane oxygenation.Interventions: None.Measurements and Main Results: A total of 7,168 patients had sufficient data for analysis at the initiation of venoarterial extracorporeal membrane oxygenation, 4,918 of these patients had arterial carbon dioxide tension data available at 24 hours on support. The overall in-hospital mortality rate was 59.9%. A U-shaped relationship between arterial carbon dioxide tension tension at extracorporeal membrane oxygenation initiation and in-hospital mortality was observed. Increased mortality was observed with a arterial carbon dioxide tension less than 30 mm Hg (odds ratio, 1.26; 95% CI, 1.08–1.47; p = 0.003) and greater than 60 mm Hg (odds ratio, 1.28; 95% CI, 1.10–1.50; p = 0.002). Large reductions (> 20 mm Hg) in arterial carbon dioxide tension over 24 hours were associated with important neurologic complications: intracranial hemorrhage, ischemic stroke, and/or brain death, as a composite outcome (odds ratio, 1.63; 95% CI, 1.03–2.59; p = 0.04), independent of the initial arterial carbon dioxide tension.Conclusions: Initial arterial carbon dioxide tension tension was independently associated with mortality in this cohort of venoarterial extracorporeal membrane oxygenation patients. Reductions in arterial carbon dioxide tension (> 20 mm Hg) from the initiation of extracorporeal membrane oxygenation were associated with neurologic complications. Further prospective studies testing these associations are warranted.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Concomitant Aspirin and Anticoagulation Is Associated With Increased Risk
           for Major Bleeding in Surgical Patients Requiring Postoperative Intensive
    • Authors: Rayes; Hamza A.; Subat, Yosuf W.; Weister, Timothy; Johnson, Madeline Q.; Hanson, Andrew; Schulte, Phillip J.; Trivedi, Vrinda; Gajic, Ognjen; Warner, Matthew A.
      Abstract: imageObjectives: Critically ill surgical patients may receive concomitant aspirin and therapeutic anticoagulation postoperatively, yet the safety of this practice remains unknown. We evaluated the risk of major bleeding with concomitant therapy compared with anticoagulation alone.Design: Observational cohort study. Inverse probability of treatment weighting was used to assess the association between concomitant therapy and a primary outcome of major bleeding.Setting: Postoperative ICUs at an academic medical center.Patients: Adults (≥ 18 yr old) receiving anticoagulation during postoperative ICU admission between 2007 and 2016.Interventions: None.Measurements and Main Results: Nine thousand five hundred eighteen anticoagulated patients were included, including 3,237 (34%) receiving aspirin. A total of 1,874 unique patients (19.7%) experienced a major bleeding event. In inverse probability of treatment weighting analyses, concomitant therapy was associated with increased odds for major bleeding (odds ratio, 1.20; 95% CI, 1.05–1.36; p = 0.006) compared with anticoagulation alone. An interaction test suggested a differential relationship between aspirin use and major bleeding based on aspirin use in the 7 days prior to anticoagulation, such that a strong association between aspirin and major bleeding was observed for recent initiators of aspirin (1.40; 1.13–1.72;p = 0.002) but not for those continuing prior aspirin use. Aspirin use prior to anticoagulation did not modify the relationship between concomitant therapy and new myocardial infarction or stroke (i.e., rates were not increased with aspirin discontinuation prior to anticoagulation).Conclusions: Concomitant aspirin and anticoagulation in critically ill surgical patients was associated with an increased rate of major bleeding. Future investigations are warranted to further define optimal management of antiplatelet therapy during anticoagulation in surgical patients.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Mechanical Ventilation and Predictors of In-Hospital Mortality in Fibrotic
           Interstitial Lung Disease With Acute Respiratory Failure: A Cohort
           Analysis Through the Paradigm of Acute Respiratory Distress Syndrome
    • Authors: Martin; Max J.; Moua, Teng
      Abstract: imageObjectives: Prior studies report significant mortality in fibrotic interstitial lung disease patients undergoing mechanical ventilation. Little is known about baseline characteristics or ventilator strategies that might improve outcomes. We analyzed the ventilator characteristics of a large cohort of fibrotic interstitial lung disease patients from the perspective of an acute respiratory distress syndrome paradigm to see if any specific mechanical ventilation strategies might improve in-hospital mortality.Design: Retrospective cohort study.Setting: Single-center, multihospital medical ICUs.Patients: Consecutive fibrotic interstitial lung disease patients who experienced mechanical ventilation for acute respiratory failure.Interventions: Interstitial lung disease characteristics, demographics, and ventilator variables were analyzed for univariable and multivariable predictors of in-hospital mortality, adjusted for confounding with an a priori causation model.Measurements and Main Results: A total of 111 patients accounted for 114 admissions. Idiopathic pulmonary fibrosis comprised 34% with idiopathic acute exacerbation (65%) being the most common admission type. Ninety-five percent were initiated on mandatory volume-control ventilation with only 50% achieving a low tidal volume strategy (plateau pressure ≤ 30 cm H2O) within 3 hours of intubation. Unadjusted clinical predictors of in-hospital mortality included age (unit odds ratio, 1.05; 1.01–1.10; p = 0.015), time from admission to intubation (hr) (unit odds ratio, 1.01; 1.01–1.03; p = 0.017), and use of paralytics (relative risk, 1.54; 1.26–1.90, p < 0.001). Adjusted mechanical ventilation-related predictors of in-hospital mortality included achieving early targeted plateau pressures (odds ratio, 0.23; 0.07–0.76; p = 0.016), Pao2/Fio2 ratio at 3 (unit odds ratio, 0.98; 0.96–0.99, p = 0.002) and 48 hours (unit odds ratio, 0.98; 0.97–0.99, p = 0.018), initial mean airway pressure (unit odds ratio, 1.13; 1.02–1.28, p = 0.019), and total net fluid status (mL) (unit odds ratio, 1.01; 1.001–1.02, p = 0.0001).Conclusions: Several factors predict in-hospital mortality in fibrotic interstitial lung disease-associated mechanical ventilation when viewed through an acute respiratory distress syndrome model. Further research is needed to refine strategies that may perhaps improve survival if mechanical ventilation is pursued in this set of patients.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Utility of Driving Pressure and Mechanical Power to Guide Protective
           Ventilator Settings in Two Cohorts of Adult and Pediatric Patients With
           Acute Respiratory Distress Syndrome: A Computational Investigation
    • Authors: Saffaran; Sina; Das, Anup; Laffey, John G.; Hardman, Jonathan G.; Yehya, Nadir; Bates, Declan G.
      Abstract: imageObjectives: Mechanical power and driving pressure have been proposed as indicators, and possibly drivers, of ventilator-induced lung injury. We tested the utility of these different measures as targets to derive maximally protective ventilator settings.Design: A high-fidelity computational simulator was matched to individual patient data and used to identify strategies that minimize driving pressure, mechanical power, and a modified mechanical power that removes the direct linear, positive dependence between mechanical power and positive end-expiratory pressure.Setting: Interdisciplinary Collaboration in Systems Medicine Research Network.Subjects: Data were collected from a prospective observational cohort of pediatric acute respiratory distress syndrome from the Children’s Hospital of Philadelphia (n = 77) and from the low tidal volume arm of the Acute Respiratory Distress Syndrome Network tidal volume trial (n = 100).Interventions: Global optimization algorithms evaluated more than 26.7 million changes to ventilator settings (approximately 150,000 per patient) to identify strategies that minimize driving pressure, mechanical power, or modified mechanical power.Measurements and Main Results: Large average reductions in driving pressure (pediatric: 23%, adult: 23%), mechanical power (pediatric: 44%, adult: 66%), and modified mechanical power (pediatric: 61%, adult: 67%) were achievable in both cohorts when oxygenation and ventilation were allowed to vary within prespecified ranges. Reductions in driving pressure (pediatric: 12%, adult: 2%), mechanical power (pediatric: 24%, adult: 46%), and modified mechanical power (pediatric: 44%, adult: 46%) were achievable even when no deterioration in gas exchange was allowed. Minimization of mechanical power and modified mechanical power was achieved by increasing tidal volume and decreasing respiratory rate. In the pediatric cohort, minimum driving pressure was achieved by reducing tidal volume and increasing respiratory rate and positive end-expiratory pressure. The Acute Respiratory Distress Syndrome Network dataset had limited scope for further reducing tidal volume, but driving pressure was still significantly reduced by increasing positive end-expiratory pressure.Conclusions: Our analysis identified different strategies that minimized driving pressure or mechanical power consistently across pediatric and adult datasets. Minimizing standard and alternative formulations of mechanical power led to significant increases in tidal volume. Targeting driving pressure for minimization resulted in ventilator settings that also reduced mechanical power and modified mechanical power, but not vice versa.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Early Administration of Desmopressin and Platelet Transfusion for Reducing
           Hematoma Expansion in Patients With Acute Antiplatelet Therapy Associated
           Intracerebral Hemorrhage*
    • Authors: Mengel; Annerose; Stefanou, Maria-Ioanna; Hadaschik, Katharina Anna; Wolf, Martin; Stadler, Vera; Poli, Khouloud; Lindig, Tobias; Ernemann, Ulrike; Grimm, Florian; Tatagiba, Marcos; Ziemann, Ulf; Poli, Sven
      Abstract: imageObjectives: To investigate the hemostatic efficacy of combined desmopressin (1-deamino-8-D-arginine vasopressin) and platelet transfusion in reducing hematoma expansion in acute, spontaneous intracerebral hemorrhage under antiplatelet treatment.Design: Single-center, nonrandomized study, performed between 2006 and 2014.Setting: Tertiary University Hospital of Tuebingen, Germany.Patients: Adult patients with intracerebral hemorrhage under antiplatelet treatment and follow-up CT at 24 ± 12 hours were included. Exclusion criteria included other intracerebral hemorrhage causes, anticoagulation, coagulopathy, or immediate surgery after baseline-CT.Interventions: Treatment with IV 1-deamino-8-D-arginine vasopressin (0.4 µg/kg) + platelet transfusion (2 U) within 60 minutes of intracerebral hemorrhage under antiplatelet treatment diagnosis on brain imaging.Measurements and Main Results: Primary outcome was relative hematoma expansion from baseline to follow-up CT. Secondary outcomes included secondary intraventricular hemorrhage or hydrocephalus upon follow-up CT, thromboembolic events before discharge, and the 3-month functional outcome (assessed by modified Rankin Scale). One-hundred forty patients were included, 72 treated versus 68 controls. Times of symptom-onset-to-baseline-CT (hr) (median [interquartile range]: 3 [4] vs 5 [5]; p = 0.468) and follow-up CT (26 [18] vs 19 [12]; p = 0.352) were similar between groups. No between-group differences of total intracerebral hematoma expansion (%) (median [interquartile range]: 8.5 [12.4] vs 9.1 [16.5]; p = 0.825), intraparenchymal (10.7 [23.1] vs 9.2 [20.7]; p = 0.900), and intraventricular hematoma expansion (14.5 [63.2] vs 6.1 [40.4]; p = 0.304) were noted. Among patients with hematoma expansion greater than or equal to 33% compared with baseline, 16 (52%) received treatment versus 15 (48%) controls. The occurrence of hematoma expansion greater than or equal to 33% was similar between groups (p = 0.981). Rates of secondary intraventricular hemorrhage, hydrocephalus, and thromboembolic events were similar between groups. Treatment with 1-deamino-8-D-arginine vasopressin + platelet transfusion was not associated with the 3-month functional outcome (adjusted odds ratio, 1.570; 95% CI, 0.721–3.419; p = 0.309).Conclusions: In line with the randomized Platelet Transfusion Versus Standard Care After Acute Stroke Due to Spontaneous Cerebral Hemorrhage Associated With Antiplatelet Therapy trial, our results suggest no hemostatic efficacy of early platelet transfusion in intracerebral hemorrhage under antiplatelet treatment. Contrary to results of preclinical and clinical nonintracerebral hemorrhage studies, adjunct 1-deamino-8-D-arginine vasopressin showed no benefit in limiting hematoma expansion or improving functional outcome.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Lateral Brain Displacement and Cerebral Autoregulation in Acutely Comatose
    • Authors: Adatia; Krishma; Geocadin, Romergryko G.; Healy, Ryan; Ziai, Wendy; Ponce-Mejia, Luciano; Anderson-White, Mirinda; Shah, Dhaval; Radzik, Batya R.; Palmisano, Caitlin; Hogue, Charles W.; Brown, Charles; Suarez, Jose I.; Rivera-Lara, Lucia
      Abstract: imageObjectives: Lateral displacement and impaired cerebral autoregulation are associated with worse outcomes following acute brain injury, but their effect on long-term clinical outcomes remains unclear. We assessed the relationship between lateral displacement, disturbances to cerebral autoregulation, and clinical outcomes in acutely comatose patients.Design: Retrospective analysis of prospectively collected data.Setting: Neurocritical care unit of the Johns Hopkins Hospital.Patients: Acutely comatose patients (Glasgow Coma Score ≤ 8).Interventions: None.Measurements and Main Results: Cerebral oximetry index, derived from near-infrared spectroscopy multimodal monitoring, was used to evaluate cerebral autoregulation. Associations between lateral brain displacement, global cerebral autoregulation, and interhemispheric cerebral autoregulation asymmetry were assessed using mixed random effects models with random intercept. Patients were grouped by functional outcome, determined by the modified Rankin Scale. Associations between outcome group, lateral displacement, and cerebral oximetry index were assessed using multivariate linear regression. Increasing lateral brain displacement was associated with worsening global cerebral autoregulation (p = 0.01 septum; p = 0.05 pineal) and cerebral autoregulation asymmetry (both p < 0.001). Maximum lateral displacement during the first 3 days of coma was significantly different between functional outcome groups at hospital discharge (p = 0.019 pineal; p = 0.008 septum), 3 months (p = 0.026; p = 0.007), 6 months (p = 0.018; p = 0.010), and 12 months (p = 0.022; p = 0.012). Global cerebral oximetry index was associated with functional outcomes at 3 months (p = 0.019) and 6 months (p = 0.013).Conclusions: During the first 3 days of acute coma, increasing lateral brain displacement is associated with worsening global cerebral autoregulation and cerebral autoregulation asymmetry, and poor long-term clinical outcomes in acutely comatose patients. The impact of acute interventions on outcome needs to be explored.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Risk of Mortality in Immunocompromised Children With Severe Sepsis and
           Septic Shock
    • Authors: Lindell; Robert B.; Nishisaki, Akira; Weiss, Scott L.; Traynor, Danielle M.; Fitzgerald, Julie C.
      Abstract: imageObjectives: To assess the prevalence of immunocompromised diagnoses among children with severe sepsis and septic shock, and to determine the association between immunocompromised diagnoses and clinical outcomes after adjustment for demographics and illness severity.Design: Retrospective multicenter cohort study.Setting: Eighty-three centers in the Virtual Pediatric Systems database.Patients: Children with severe sepsis or septic shock admitted to a participating PICU between January 1, 2012, and December 31, 2016.Interventions: None.Measurements and Main Results: Across 83 centers, we identified 10,768 PICU admissions with an International Classification of Diseases, 9th Revision, Clinical Modification code for severe sepsis or septic shock; 3,021 of these patients (28%) had an immunocompromised diagnosis. To evaluate variation across centers and determine factors associated with PICU mortality, we used mixed-effect logistic regression models. Among patients without hematopoietic cell transplant, congenital immunodeficiency (adjusted odds ratio, 1.90; 95% CI, 1.24–2.92), multiple prior malignancies (adjusted odds ratio, 1.86; 95% CI, 1.15–2.99), and hemophagocytic lymphohistiocytosis (adjusted odds ratio, 3.09; 95% CI, 1.91–4.98) were associated with an increased odds of PICU mortality. Among patients with prior hematopoietic cell transplant, liquid malignancy (adjusted odds ratio, 3.15; 95% CI, 2.09–4.74), congenital immunodeficiency (adjusted odds ratio, 6.94; 95% CI, 3.84–12.53), multiple prior malignancies (adjusted odds ratio, 3.54; 95% CI, 1.80–6.95), and hemophagocytic lymphohistiocytosis (adjusted odds ratio, 2.79; 95% CI, 1.36–5.71) were associated with an increased odds of PICU mortality. PICU mortality varied significantly by center, and a higher mean number of sepsis patients per month in a center was associated with lower PICU mortality (adjusted odds ratio, 0.94; 95% CI, 0.90–0.98). PICU resource utilization varied by immunocompromised diagnosis and history of hematopoietic cell transplant, and among survivors immunocompromised patients have shorter median PICU length of stay compared with patients without immunocompromised diagnoses (p < 0.001).Conclusions: Immunocompromised diagnoses are present in 28% of children with severe sepsis or septic shock. Multiple prior malignancies, hemophagocytic lymphohistiocytosis, congenital immunodeficiency, and hematopoietic cell transplant are independently associated with an increased odds of PICU mortality in children with severe sepsis or septic shock. Significant variation exists in PICU mortality among centers despite adjustment for immunocompromised diagnoses, known risk factors for sepsis-related mortality, and center-level sepsis volume.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Fluid Accumulation in Critically Ill Children*
    • Authors: Alobaidi; Rashid; Basu, Rajit K.; DeCaen, Allan; Joffe, Ari R.; Lequier, Laurance; Pannu, Neesh; Bagshaw, Sean M.
      Abstract: imageObjectives: To describe the characteristics of fluid accumulation in critically ill children and evaluate the association between the degree, timing, duration, and rate of fluid accumulation and patient outcomes.Design: Retrospective cohort study.Setting: PICUs in Alberta, Canada.Patients: All children admitted to PICU in Alberta, Canada, between January 1, 2015, and December 31, 2015.Interventions: None.Measurements and Main Results: A total of 1,017 patients were included. Fluid overload % increased from median (interquartile range) 1.58% (0.23–3.56%; n = 1,017) on day 1 to 16.42% (7.53–27.34%; n = 111) on day 10 among those remaining in PICU. The proportion of patients (95% CI) with peak fluid overload % greater than 10% and greater than 20% was 32.7% (29.8–35.7%) and 9.1% (7.4–11.1%), respectively. Thirty-two children died (3.1%) in PICU. Peak fluid overload % was associated with greater PICU mortality (odds ratio, 1.05; 95% CI, 1.02–1.09; p = 0.001). Greater peak fluid overload % was associated with Major Adverse Kidney Events within 30 days (odds ratio, 1.05; 95% CI, 1.02–1.08; p = 0.001), length of mechanical ventilation (B coefficient, 0.66; 95% CI, 0.54–0.77; p < 0.001), and length of PICU stay (B coefficient, 0.52; 95% CI, 0.46–0.58; p < 0.001). The rate of fluid accumulation was associated with PICU mortality (odds ratio, 1.15; 95% CI, 1.01–1.31; p = 0.04), Major Adverse Kidney Events within 30 days (odds ratio, 1.16; 95% CI, 1.03–1.30; p = 0.02), length of mechanical ventilation (B coefficient, 0.80; 95% CI, 0.24–1.36; p = 0.005), and length of PICU stay (B coefficient, 0.38; 95% CI, 0.11–0.66; p = 0.007).Conclusions: Fluid accumulation occurs commonly during PICU course and is associated with considerable mortality and morbidity. These findings highlight the need for the development and evaluation of interventional strategies to mitigate the potential harm associated with fluid accumulation.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Nebulized Bacteriophages for Prophylaxis of Experimental
           Ventilator-Associated Pneumonia Due to Methicillin-Resistant
           Staphylococcus aureus
    • Authors: Prazak; Josef; Valente, Luca; Iten, Manuela; Grandgirard, Denis; Leib, Stephen L.; Jakob, Stephan M.; Haenggi, Matthias; Que, Yok-Ai; Cameron, David R.
      Abstract: imageObjectives: There is a need for alternative strategies to combat and prevent antibiotic-resistant bacterial infections. Here, we assessed the potential for bacteriophage prophylaxis in the context of experimental ventilator-associated pneumonia due to methicillin-resistant Staphylococcus aureus in rats.Design: Nebulized phages (aerophages) were delivered to the lungs of rats using a modified vibrating mesh aerosol drug delivery system. Animals were intubated and ventilated for 4 hours, at which point they were infected with methicillin-resistant S. aureus strain AW7 via the endotracheal tube, extubated, and then monitored for 96 hours.Setting: Ventilator-associated pneumonia.Subjects: Male Wistar rats.Interventions: A single application of aerophages prior to ventilation at one of two concentrations (~1010 plaque forming units/mL or ~1011 plaque forming units/mL).Measurements and Main Results: 1) Animal survival at 96 hours, 2) enumeration of bacteria and phages in the lungs and spleen, and 3) lung tissue histopathology. Animals that received aerophages prior to ventilation and methicillin-resistant S. aureus challenge showed a higher survival rate compared with untreated controls (60% for animals that received 3 × 1010 plaque forming units; 70% for animals that received 3 × 1011 plaque forming units; 0% for controls; p < 0.01 for each treatment versus untreated). Surviving animals that received aerophage prophylaxis had fewer methicillin-resistant S. aureus in the lungs compared with untreated control animals that succumbed to pneumonia (1.6 × 106 colony forming units/g vs 8.0 × 108; p < 0.01).Conclusions: Prophylactically administered nebulized bacteriophages reduced lung bacterial burdens and improved survival of methicillin-resistant S. aureus infected rats, underscoring its potential in the context of ventilator-associated pneumonia.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Therapeutic Hypothermia in Critically Ill Patients: A Systematic Review
           and Meta-Analysis of High Quality Randomized Trials*
    • Authors: Kim; Jun Hyun; Nagy, Ádám; Putzu, Alessandro; Belletti, Alessandro; Biondi-Zoccai, Giuseppe; Likhvantsev, Valery V.; Yavorovskiy, Andrey G.; Landoni, Giovanni
      Abstract: imageObjectives: To investigate the effect of the application of therapeutic hypothermia (32–35°C) on survival and major clinical endpoints in critically ill patients.Data Sources: We searched online database and clinical trial registries dated up to April 30, 2019, and references of relevant studies.Study Selection: Low risk of bias randomized trials which compared hypothermia applied for at least 24 hours and conventional therapy in critically ill patients were included. We excluded trials investigating therapeutic hypothermia in indications already supported by international guidelines (adult cardiac arrest and hypoxic-ischemic encephalopathy of newborns) or intraoperative hypothermia.Data Extraction: Titles and abstracts were reviewed independently by two authors. If the articles seemed eligible, full-text articles were reviewed, and data were abstracted using a structured template.Data Synthesis: Our search retained 14 low risk of bias randomized trials (2,670 patients) performed in three different settings: traumatic brain injury, serious infections, and stroke. Therapeutic hypothermia was associated with an increase in mortality at longest follow-up available (432/1,375 [31%] vs 330/1,295 [25%]; risk ratio, 1.24; 95% CI, 1.10–1.39; p = 0.0004; I2 = 0%). Pooled results showed no difference of good neurologic outcome among survivors between the two treatment arms (493/1,142 [43%] vs 486/1,067 [46%]; risk ratio, 1.04; 95% CI, 0.97–1.12; p = 0.27; I2 = 1%). Arrhythmias were significantly increased among patients undergoing therapeutic hypothermia. We found no difference between groups in pneumonia, serious infections, any infection, hemorrhage, renal failure, deep vein thrombosis, and uncontrollable intracranial hypertension.Conclusions: High-quality randomized evidence indicates that therapeutic hypothermia is associated with higher mortality and no difference in good neurologic outcome compared with normothermia in critically ill patients. Although there still might be a possibility that therapeutic hypothermia is beneficial in a specific setting, routine application of therapeutic hypothermia would better be avoided outside the settings indicated by international guidelines (adult cardiac arrest and hypoxic-ischemic encephalopathy of newborns).
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Effects of Rehabilitation Interventions on Clinical Outcomes in Critically
           Ill Patients: Systematic Review and Meta-Analysis of Randomized Controlled
    • Authors: Waldauf; Petr; Jiroutková, Katerina; Krajcová, Adéla; Puthucheary, Zudin; Duška, František
      Abstract: imageObjectives: To assess the impact of rehabilitation in ICU on clinical outcomes.Data Sources: Secondary data analysis of randomized controlled trials published between 1998 and October 2019 was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.Study Selection: We have selected trials investigating neuromuscular electrical stimulation or cycling exercises or protocolized physical rehabilitation as compared to standard of care in critically ill adults.Data Extraction: Mortality, length of stay in ICU and at hospital, days on mechanical ventilator, and adverse events.Data Synthesis: We found 43 randomized controlled trials (nine on cycling, 14 on neuromuscular electrical stimulation alone and 20 on protocolized physical rehabilitation) into which 3,548 patients were randomized and none of whom experienced an intervention-related serious adverse event. The exercise interventions had no influence on mortality (odds ratio 0.94 [0.79–1.12], n = 38 randomized controlled trials) but reduced duration of mechanical ventilation (mean difference, –1.7 d [–2.5 to –0.8 d], n = 32, length of stay in ICU (–1.2 d [–2.5 to 0.0 d], n = 32) but not at hospital (–1.6 [–4.3 to 1.2 d], n = 23). The effects on the length of mechanical ventilation and ICU stay were only significant for the protocolized physical rehabilitation subgroup and enhanced in patients with longer ICU stay and lower Acute Physiology and Chronic Health Evaluation II scores. There was no benefit of early start of the intervention. It is likely that the dose of rehabilitation delivered was much lower than dictated by the protocol in many randomized controlled trials and negative results may reflect the failure to implement the intervention.Conclusions: Rehabilitation interventions in critically ill patients do not influence mortality and are safe. Protocolized physical rehabilitation significantly shortens time spent on mechanical ventilation and in ICU, but this does not consistently translate into long-term functional benefit. Stable patients with lower Acute Physiology and Chronic Health Evaluation II at admission (
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • A Systematic Review of Risk Factors for Sleep Disruption in Critically Ill
    • Authors: Honarmand; Kimia; Rafay, Hammad; Le, Jamie; Mohan, Sindu; Rochwerg, Bram; Devlin, John W.; Skrobik, Yoanna; Weinhouse, Gerald L.; Drouot, Xavier; Watson, Paula L.; McKinley, Sharon; Bosma, Karen J.
      Abstract: imageObjectives: Numerous risk factors for sleep disruption in critically ill adults have been described. We performed a systematic review of all risk factors associated with sleep disruption in the ICU setting.Data Sources: PubMed, EMBASE, CINAHL, Web of Science, Cochrane Central Register for Controlled Trials, and Cochrane Database of Systematic Reviews.Study Selection: English-language studies of any design published between 1990 and April 2018 that evaluated sleep in greater than or equal to 10 critically ill adults (> 18 yr old) and investigated greater than or equal to 1 potential risk factor for sleep disruption during ICU stay. We assessed study quality using Newcastle-Ottawa Scale or Cochrane Risk of Bias tool.Data Extraction: We abstracted all data independently and in duplicate. Potential ICU sleep disruption risk factors were categorized into three categories based on how data were reported: 1) patient-reported reasons for sleep disruption, 2) patient-reported ratings of potential factors affecting sleep quality, and 3) studies reporting a statistical or temporal association between potential risk factors and disrupted sleep.Data Synthesis: Of 5,148 citations, we included 62 studies. Pain, discomfort, anxiety/fear, noise, light, and ICU care-related activities are the most common and widely studied patient-reported factors causing sleep disruption. Patients rated noise and light as the most sleep-disruptive factors. Higher number of comorbidities, poor home sleep quality, home sleep aid use, and delirium were factors associated with sleep disruption identified in available studies.Conclusions: This systematic review summarizes all premorbid, illness-related, and ICU-related factors associated with sleep disruption in the ICU. These findings will inform sleep promotion efforts in the ICU and guide further research in this field.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Lost in Transition: A Call to Arms for Better Transition From ICU to
           Hospital Ward*
    • Authors: Co; Ivan; Hyzy, Robert C.
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Negative Studies Should Inform Our Research and Care: Engaging Family
           Members in the Care of the Critically Ill*
    • Authors: Tonna; Joseph E.
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Disparities in Sepsis Outcomes: A Problem in Need of Solutions*
    • Authors: Barbash; Ian J.
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Does the “Goldilocks Effect” Exist for Carbon Dioxide in Venoarterial
           Extracorporeal Membrane Oxygenation'*
    • Authors: Fortenberry; James D.
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Dual to the Death' Combined Anticoagulant and Antiplatelet Therapy in
           the Postoperative ICU Setting*
    • Authors: Ley; Eric J.; Martin, Matthew J.
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • To Transfuse or Not to Transfuse: Which Patients Benefit From Transfusion
           in Antiplatelet Associated Intracerebral Hemorrhage'*
    • Authors: Birch; Torrey Boland
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Water in the ICU: The Elixir of Life or the Flood of Noah'*
    • Authors: Arikan; Ayse Akcan; Mariscalco, M. Michele
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Therapeutic Hypothermia in Critically Ill Patients: The Role of
           Hypothermia in the Critical Care Toolbox*
    • Authors: Sadan; Ofer
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Mobilizing to Restore the Lives of Critically Ill People*
    • Authors: Engel; Heidi J.
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Preventing Cardiac Arrest in a Pediatric Cardiac ICU—Situational
           Awareness and Early Intervention Work Together!*
    • Authors: Medar; Shivanand; Cassel-Choudhury, Gina; Weingarten-Arams, Jacqueline; Ushay, H. Michael
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Mesenchymal Stem Cell-Derived Extracellular Vesicles: Good Things Come in
           Small Packages*
    • Authors: Tieu; Alvin; Stewart, Duncan J.; Lalu, Manoj M.
      Abstract: imageNo abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Reducing Cardiac Arrests in the PICU: Initiative to Improve Time to
           Administration of Prearrest Bolus Epinephrine in Patients With Cardiac
    • Authors: Ferguson; Lee P.; Thiru, Yamuna; Staffa, Steven J.; Guillén Ortega, Margarita
      Abstract: imageObjectives: To evaluate the effectiveness of a quality-improvement initiative in reducing cardiac arrests in infants and children in the cardiac ICU.Design: Prospective observational before-after cohort study.Setting: Single pediatric cardiac ICU in the United Kingdom.Patients: All patients less than 18 years old admitted to the ICU.Intervention: Initial interdisciplinary training in cardiac arrest prevention followed by clinical practice change whereby patients with high-risk myocardium were identified on daily rounds. High-risk patients had bolus epinephrine preordered and prepared for immediate administration in the event of acute hypotension.Measurements and Main Results: Interrupted time series analysis was used to compare the cardiac arrest rate in the 18 months before and 4.5 years after implementation. Mean monthly cardiac arrest rate was 17.2 per 1,000 patient days before and 7.6 per 1,000 patient days after the initiative (56% decrease). Patient characteristics and ICU interventions were similar in the control and intervention periods. In the time series analysis, monthly cardiac arrest rate in the ICU decreased by 12.4 per 1,000 patient days (95% CI, –1.5 to –23.3; p = 0.03) immediately following the intervention, followed by a nonsignificant downward trend of 0.36 per 1,000 patient days per month (95% CI, –1.3 to 0.6; p = 0.44). Bolus epinephrine was administered during 110 hypotension events in 77 patients (eight administrations per 1,000 ICU days); responder rate was 77%. There were no significant changes in ICU and hospital mortality.Conclusions: Implementation of the initiative led to a significant, sustained reduction in ICU cardiac arrest rate.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Unplanned ICU Admission From Hospital Wards After Rapid Response Team
           Review in Australia and New Zealand
    • Authors: Orosz; Judit; Bailey, Michael; Udy, Andrew; Pilcher, David; Bellomo, Rinaldo; Jones, Daryl
      Abstract: imageObjectives: To evaluate what proportion of unplanned ICU admissions from hospital wards occurred after rapid response team review and compare baseline characteristics and outcomes of patients admitted after rapid response team review with non-rapid response team-related admissions.Design: Multicenter binational retrospective cohort study.Setting: One-hundred seventy-eight ICUs across Australia and New Zealand.Patients: All adults (≥ 17 yr) in the Australian and New Zealand Intensive Care Society Adult Patient Database between 2012 and 2017.Interventions: None.Measurements and Main Results: Among 97,181 unplanned ICU admissions from the ward, prior rapid response team review occurred in 55,084 cases (56.7%). Rapid response team patients were slightly older (65.4 [16.9] vs 63.3 [18]), had a higher Acute Physiology and Chronic Health Evaluation III score (64.6 [27.1] vs 54.7 [25.3]) and more frequently had limitations of medical treatment (13.1% vs 8.5%) compared with patients with no rapid response team review. The strongest independent associations with ICU admission following rapid response team review included age, ICU admission diagnosis (especially sepsis-, neurologic-, respiratory-, and cardiovascular-related), tertiary ICU status, and presence of limitations of medical treatment (p < 0.0001 all comparisons). Rapid response team-related ICU admissions had a longer median ICU (2.4 d [1.2–4.6 d] vs 2.1 d [1.0–4.2 d]) and hospital (12.8 d [7.0–23.6 d] vs 10.8 d [5.9–20.3 d]) length of stay, and were more likely to die in the ICU (12.3% vs 7.5%) and in-hospital (20.8% vs 13.5%) (p < 0.0001). After adjusting for illness severity and institution, patients admitted following rapid response team review stayed longer in hospital but were not at increased risk of dying in-hospital (adjusted odds ratio, 1.03; 0.98–1.07).Conclusions: In Australia and New Zealand, hospital ward patients admitted to ICU following rapid response team review represent the majority of ward-based ICU admissions, are more chronically and acutely ill, and more frequently have sepsis than those admitted from the ward without rapid response team review. Their unadjusted outcomes are worse, but after adjustment their mortality is similar.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Predicting and Surviving Prolonged Critical Illness After Congenital Heart
    • Authors: DeWitt; Aaron G.; Rossano, Joseph W.; Bailly, David K.; Bhat, Priya N.; Chanani, Nikhil K.; Kirkland, Brandon W.; Moga, Michael-Alice; Owens, Gabe E.; Retzloff, Lauren B.; Zhang, Wenying; Banerjee, Mousumi; Costarino, Andrew T.; Bird, Geoffrey L.; Gaies, Michael
      Abstract: imageObjectives: Prolonged critical illness after congenital heart surgery disproportionately harms patients and the healthcare system, yet much remains unknown. We aimed to define prolonged critical illness, delineate between nonmodifiable and potentially preventable predictors of prolonged critical illness and prolonged critical illness mortality, and understand the interhospital variation in prolonged critical illness.Design: Observational analysis.Setting: Pediatric Cardiac Critical Care Consortium clinical registry.Patients: All patients, stratified into neonates (≤28 d) and nonneonates (29 d to 18 yr), admitted to the pediatric cardiac ICU after congenital heart surgery at Pediatric Cardiac Critical Care Consortium hospitals.Interventions: None.Measurements and Main Results: There were 2,419 neonates and 10,687 nonneonates from 22 hospitals. The prolonged critical illness cutoff (90th percentile length of stay) was greater than or equal to 35 and greater than or equal to 10 days for neonates and nonneonates, respectively. Cardiac ICU prolonged critical illness mortality was 24% in neonates and 8% in nonneonates (vs 5% and 0.4%, respectively, in nonprolonged critical illness patients). Multivariable logistic regression identified 10 neonatal and 19 nonneonatal prolonged critical illness predictors within strata and eight predictors of mortality. Only mechanical ventilation days and acute renal failure requiring renal replacement therapy predicted prolonged critical illness and prolonged critical illness mortality in both strata. Approximately 40% of the prolonged critical illness predictors were nonmodifiable (preoperative/patient and operative factors), whereas only one of eight prolonged critical illness mortality predictors was nonmodifiable. The remainders were potentially preventable (postoperative critical care delivery variables and complications). Case-mix–adjusted prolonged critical illness rates were compared across hospitals; six hospitals each had lower- and higher-than-expected prolonged critical illness frequency.Conclusions: Although many prolonged critical illness predictors are nonmodifiable, we identified several predictors to target for improvement. Furthermore, we observed that complications and prolonged critical care therapy drive prolonged critical illness mortality. Wide variation of prolonged critical illness frequency suggests that identifying practices at hospitals with lower-than-expected prolonged critical illness could lead to broader quality improvement initiatives.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Economic Implications of Chinese Diagnosis-Related Group–Based Payment
           Systems for Critically Ill Patients in ICUs
    • Authors: Meng; Zhaolin; Ma, Yanan; Song, Suhang; Li, Ye; Wang, Dan; Si, Yafei; Sun, Ruochen; Zhang, Ruochen; Xue, Hao; Jing, Limei; Wu, Huazhang
      Abstract: imageObjectives: To evaluate the economic implications of payments based on Chinese diagnosis-related groups for critically ill patients in ICUs in terms of total hospital expenditure, out-of-pocket payments, and length of stay.Design: A pre-post comparison of patient cohorts admitted to ICUs 1 year before and 1 year after Chinese diagnosis-related group reform was undertaken. Demographic characteristics, clinical data, and medical expenditures were collated from a health insurance database.Setting: Twenty-two public hospitals in Sanming, Southern China.Patients: All patients admitted to ICUs from January 1, 2017, to December 31, 2018.Intervention: The implementation of Chinese diagnosis-related group–based payments on January 1, 2018.Measurements and Main Results: Economic variables (total expenditures, out-of-pocket payments, and length of stay) were calculated for each patient from the day of hospital admission to the day of hospital discharge. Adjusted mean out-of-pocket payment estimates were 29.46% (p < 0.001) lower following reform. Adjusted mean out-of-pocket payments fell by 41.32% for patients in neonatal ICU, whereas there were no significant decreases in out-of-pocket payments for patients in PICU and adult ICU. Furthermore, adjusted mean out-of-pocket payments decreased by 55.74% in secondary hospitals, but there was no significant change in tertiary hospitals after Chinese diagnosis-related group reform. No significant changes were found in total expenditures and length of stay.Conclusions: Chinese diagnosis-related group policy provided an opportunity for critically ill patients in ICUs to achieve at least short-term financial benefits in reducing out-of-pocket payments, without affecting the total expenditures and length of stay. Chinese diagnosis-related group–based payment significantly relieved financial burdens for patients with lower illness severities, such as patients in neonatal ICU. The results of this study can offer significant insights for policymakers in reducing the financial burden on critically ill patients, both in China and in other countries with similar systems.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Artificial Intelligence Algorithm Detecting Lung Infection in Supine Chest
           Radiographs of Critically Ill Patients With a Diagnostic Accuracy Similar
           to Board-Certified Radiologists
    • Authors: Rueckel; Johannes; Kunz, Wolfgang G.; Hoppe, Boj F.; Patzig, Maximilian; Notohamiprodjo, Mike; Meinel, Felix G.; Cyran, Clemens C.; Ingrisch, Michael; Ricke, Jens; Sabel, Bastian O.
      Abstract: imageObjectives: Interpretation of lung opacities in ICU supine chest radiographs remains challenging. We evaluated a prototype artificial intelligence algorithm to classify basal lung opacities according to underlying pathologies.Design: Retrospective study. The deep neural network was trained on two publicly available datasets including 297,541 images of 86,876 patients.Patients: One hundred sixty-six patients received both supine chest radiograph and CT scans (reference standard) within 90 minutes without any intervention in between.Measurements and Main Results: Algorithm accuracy was referenced to board-certified radiologists who evaluated supine chest radiographs according to side-separate reading scores for pneumonia and effusion (0 = absent, 1 = possible, and 2 = highly suspected). Radiologists were blinded to the supine chest radiograph findings during CT interpretation. Performances of radiologists and the artificial intelligence algorithm were quantified by receiver-operating characteristic curve analysis. Diagnostic metrics (sensitivity, specificity, positive predictive value, negative predictive value, and accuracy) were calculated based on different receiver-operating characteristic operating points. Regarding pneumonia detection, radiologists achieved a maximum diagnostic accuracy of up to 0.87 (95% CI, 0.78–0.93) when considering only the supine chest radiograph reading score 2 as positive for pneumonia. Radiologist’s maximum sensitivity up to 0.87 (95% CI, 0.76–0.94) was achieved by additionally rating the supine chest radiograph reading score 1 as positive for pneumonia and taking previous examinations into account. Radiologic assessment essentially achieved nonsignificantly higher results compared with the artificial intelligence algorithm: artificial intelligence-area under the receiver-operating characteristic curve of 0.737 (0.659–0.815) versus radiologist’s area under the receiver-operating characteristic curve of 0.779 (0.723–0.836), diagnostic metrics of receiver-operating characteristic operating points did not significantly differ. Regarding the detection of pleural effusions, there was no significant performance difference between radiologist’s and artificial intelligence algorithm: artificial intelligence-area under the receiver-operating characteristic curve of 0.740 (0.662–0.817) versus radiologist’s area under the receiver-operating characteristic curve of 0.698 (0.646–0.749) with similar diagnostic metrics for receiver-operating characteristic operating points.Conclusions: Considering the minor level of performance differences between the algorithm and radiologists, we regard artificial intelligence as a promising clinical decision support tool for supine chest radiograph examinations in the clinical routine with high potential to reduce the number of missed findings in an artificial intelligence–assisted reading setting.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Association of Insurance Status With Treatment and Outcomes in Pediatric
           Patients With Severe Traumatic Brain Injury
    • Authors: Porter; Austin; Brown, Clare C.; Tilford, J. Mick; Thomas, Kevin; Maxson, R. Todd; Sexton, Kevin; Karim, Saleema; Zohoori, Namvar; Rodriguez, Analiz
      Abstract: imageObjective: To determine whether a health insurance disparity exists among pediatric patients with severe traumatic brain injury using the National Trauma Data Bank.Design: Retrospective cohort study.Setting: National Trauma Data Bank, a dataset containing more than 800 trauma centers in the United States.Patients: Pediatric patients (< 18 yr old) with a severe isolated traumatic brain injury were identified in the National Trauma Database (years 2007–2016). Isolated traumatic brain injury was defined as patients with a head Abbreviated Injury Scale score of 3+ and excluded those with another regional Abbreviated Injury Scale of 3+.Interventions: None.Measurement and Main Results: Procedure codes were used to identify four primary treatment approaches combined into two classifications: craniotomy/craniectomy and external ventricular draining/intracranial pressure monitoring. Diagnostic criteria and procedure codes were used to identify condition at admission, including hypotension, Glasgow Coma Scale, mechanism and intent of injury, and Injury Severity Score. Children were propensity score matched using condition at admission and other characteristics to estimate multivariable logistic regression models to assess the associations among insurance status, treatment, and outcomes. Among the 12,449 identified patients, 91.0% (n = 11,326) had insurance and 9.0% (n = 1,123) were uninsured. Uninsured patients had worse condition at admission with higher rates of hypotension and higher Injury Severity Score, when compared with publicly and privately insured patients. After propensity score matching, having insurance was associated with a 32% (p = 0.001) and 54% (p < 0.001) increase in the odds of cranial procedures and monitor placement, respectively. Insurance coverage was associated with 25% lower odds of inpatient mortality (p < 0.001).Conclusions: Compared with insured pediatric patients with a traumatic brain injury, uninsured patients were in worse condition at admission and received fewer interventional procedures with a greater odds of inpatient mortality. Equalizing outcomes for uninsured children following traumatic brain injury requires a greater understanding of the factors that lead to worse condition at admission and policies to address treatment disparities if causality can be identified.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Respiratory Dialysis—A Novel Low Bicarbonate Dialysate to Provide
           Extracorporeal Co2 Removal
    • Authors: Cove; Matthew E.; Vu, Lien Hong; Ring, Troels; Federspiel, William J.; Kellum, John A.
      Abstract: imageObjectives: We designed a novel respiratory dialysis system to remove Co2 from blood in the form of bicarbonate. We aimed to determine if our respiratory dialysis system removes Co2 at rates comparable to low-flow extracorporeal Co2 removal devices (blood flow < 500 mL/min) in a large animal model.Design: Experimental study.Setting: Animal research laboratory.Subjects: Female Yorkshire pigs.Interventions: Five bicarbonate dialysis experiments were performed. Hypercapnia (Pco2 90–100 mm Hg) was established in mechanically ventilated swine by adjusting the tidal volume. Dialysis was then performed with a novel low bicarbonate dialysate.Measurements and Main Results: We measured electrolytes, blood gases, and plasma-free hemoglobin in arterial blood, as well as blood entering and exiting the dialyzer. We used a physical-chemical acid-base model to understand the factors influencing blood pH after bicarbonate removal. During dialysis, we removed 101 (±13) mL/min of Co2 (59 mL/min when normalized to venous Pco2 of 45 mm Hg), corresponding to a 29% reduction in Paco2 (104.0 ± 8.1 vs 74.2 ± 8.4 mm Hg; p < 0.001). Minute ventilation and body temperature were unchanged during dialysis (1.2 ± 0.4 vs 1.1 ± 0.4 L/min; p = 1.0 and 35.3°C ± 0.9 vs 35.2°C ± 0.6; p = 1.0). Arterial pH increased after bicarbonate removal (7.13 ± 0.04 vs 7.21 ± 0.05; p < 0.001) despite no attempt to realkalinize the blood. Our modeling showed that dialysate electrolyte composition, plasma albumin, and plasma total Co2 accurately predict the measured pH of blood exiting the dialyser. However, the final effluent dose exceeded conventional doses, depleting plasma glucose and electrolytes, such as potassium and phosphate.Conclusions: Bicarbonate dialysis results in Co2 removal at rates comparable with existing low-flow extracorporeal Co2 removal in a large animal model, but the final dialysis dose delivered needs to be reduced before the technique can be used for prolonged periods.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Mesenchymal Stem Cell–Derived Extracellular Vesicles Alleviate Acute
           Lung Injury Via Transfer of miR-27a-3p*
    • Authors: Wang; Jiangmei; Huang, Ruoqiong; Xu, Qi; Zheng, Guoping; Qiu, Guanguan; Ge, Menghua; Shu, Qiang; Xu, Jianguo
      Abstract: imageObjectives: The goal of this study was to determine the role of microRNA transfer in mediating the effects of mesenchymal stem cell–derived extracellular vesicles in acute lung injury.Design: Experimental cell and animal studies.Setting: University-based research laboratory.Subjects: THP-1 monocytes, bone marrow–derived macrophages, and C57BL/6 mice.Interventions: To determine the microRNA transfer in vitro, mesenchymal stem cells and mesenchymal stem cell–derived extracellular vesicles were cultured with THP-1 cells and bone marrow–derived macrophages and then assayed for microRNA expression in the target cells. To examine the role of microRNA transfer in vivo, mesenchymal stem cell–derived extracellular vesicles were administered to mice with lipopolysaccharide-induced lung injury.Measurements and Main Results: Mesenchymal stem cell–derived extracellular vesicles were efficiently taken up by macrophages in vitro and in vivo. miR-27a-3p was one of the most highly expressed microRNAs in THP-1 cells in microarray analysis and was transferred from mesenchymal stem cells and mesenchymal stem cell–derived extracellular vesicles to THP-1/bone marrow–derived macrophages. Mesenchymal stem cell–derived extracellular vesicles promoted M2 polarization in bone marrow–derived macrophages, which was inhibited by lentiviral anti-miR-27a-3p transduction. Mesenchymal stem cell–derived extracellular vesicles administered systemically and intratracheally were as effective as mesenchymal stem cells in alleviating acute lung injury, elevating miR-27a-3p levels in alveolar macrophages, and promoting M2 macrophage polarization. Treatment of mesenchymal stem cell–derived extracellular vesicles concurrently decreased alveolar macrophage expression of nuclear factor kappa B subunit 1, a target of miR-27a-3p. Lentiviral transduction of mesenchymal stem cells with anti-miR-27a-3p or knockdown of miR-27a-3p in vivo abolished the effects of mesenchymal stem cell–derived extracellular vesicles on acute lung injury and M2 macrophage polarization.Conclusions: Mesenchymal stem cell–derived extracellular vesicles mitigate acute lung injury at least partially via transferring miR-27a-3p to alveolar macrophages. miR-27a-3p acts to target NFKB1 and is a crucial regulator of M2 macrophage polarization.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Brain Injury and Neurologic Outcome in Patients Undergoing Extracorporeal
           Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis
    • Authors: Migdady; Ibrahim; Rice, Cory; Deshpande, Abhishek; Hernandez, Adrian V.; Price, Carrie; Whitman, Glenn J.; Geocadin, Romergryko G.; Cho, Sung-Min
      Abstract: imageObjectives: Extracorporeal cardiopulmonary resuscitation has shown survival benefit in select patients with refractory cardiac arrest but there is insufficient data on the frequency of different types of brain injury. We aimed to systematically review the prevalence, predictors of and survival from neurologic complications in patients who have undergone extracorporeal cardiopulmonary resuscitation.Data Sources: MEDLINE (PubMed) and six other databases (EMBASE, Cochrane Library, CINAHL Plus, Web of Science, and Scopus) from inception to August 2019.Study Selection: Randomized controlled trials and observational studies in patients greater than 18 years old.Data Extraction: Two independent reviewers extracted the data. Study quality was assessed by the Cochrane Risk of Bias tool for randomized controlled trials, the Newcastle-Ottawa Scale for cohort and case-control studies, and the Murad tool for case series. Random-effects meta-analyses were used to pool data.Data Synthesis: The 78 studies included in our analysis encompassed 50,049 patients, of which 6,261 (12.5%) received extracorporeal cardiopulmonary resuscitation. Among extracorporeal cardiopulmonary resuscitation patients, the median age was 56 years (interquartile range, 52–59 yr), 3,933 were male (63%), 3,019 had out-of-hospital cardiac arrest (48%), and 2,289 had initial shockable heart rhythm (37%). The most common etiology of cardiac arrest was acute coronary syndrome (n = 1,657, 50% of reported). The median extracorporeal cardiopulmonary resuscitation duration was 3.2 days (interquartile range, 2.1–4.9 d). Overall, 27% (95% CI, 0.17–0.39%) had at least one neurologic complication, 23% (95% CI, 0.14–0.32%) hypoxic-ischemic brain injury, 6% (95% CI, 0.02–0.11%) ischemic stroke, 6% (95% CI, 0.01–0.16%) seizures, and 4% (95% CI, 0.01–0.1%) intracerebral hemorrhage. Seventeen percent (95% CI, 0.12–0.23%) developed brain death. The overall survival rate after extracorporeal cardiopulmonary resuscitation was 29% (95% CI, 0.26–0.33%) and good neurologic outcome was achieved in 24% (95% CI, 0.21–0.28%).Conclusions: One in four patients developed acute brain injury after extracorporeal cardiopulmonary resuscitation and the most common type was hypoxic-ischemic brain injury. One in four extracorporeal cardiopulmonary resuscitation patients achieved good neurologic outcome. Further research on assessing predictors of extracorporeal cardiopulmonary resuscitation-associated brain injury is necessary.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Harm of IV High-Dose Vitamin C Therapy in Adult Patients: A Scoping Review
    • Authors: Yanase; Fumitaka; Fujii, Tomoko; Naorungroj, Thummaporn; Belletti, Alessandro; Luethi, Nora; Carr, Anitra C.; Young, Paul J.; Bellomo, Rinaldo
      Abstract: imageObjectives: The potential harm associated with the use of IV vitamin C has not been systematically assessed. We aimed to review the available evidence on harm related to such treatment.Data Sources: We searched MEDLINE, EMBASE, Cochrane Library, National Institute of Health Clinical Trials Register, and World Health Organization International Clinical Trials Registry Platform.Study Selection: We included studies in adult population that reported harm related to IV high-dose vitamin C which we defined as greater than or equal to 6 g/d, greater than or equal to 75 mg/kg/d, or greater than or equal to 3 g/m2/d.Data Extraction: Two independent investigators screened records and extracted data.Data Synthesis: We identified 8,149 reports, of which 650 full text were assessed for eligibility, leaving 74 eligible studies. In these studies, 2,801 participants received high-dose vitamin C at a median (interquartile range) dose of 22.5 g/d (8.25–63.75 g/d), 455 mg/kg/d (260–925 mg/kg/d), or 70 g/m2/d (50–90 g/m2/d); and 932 or more adverse events were reported. Among nine double-blind randomized controlled trials (2,310 patients), adverse events were reported in three studies with an event rate per patient for high-dose vitamin C identical to placebo group in one study (0.1 [1/10] vs 0.1 [1/10]), numerically lower in one study (0.80 [672/839] vs 0.82 [709/869]), and numerically higher in one study (0.33 [24/73] vs 0.23 [17/74]). Six double-blind randomized controlled trials reported no adverse event in either group. Five cases of oxalate nephropathy, five cases of hypernatremia, three cases of hemolysis in glucose-6-phosphate dehydrogenase deficiency patients, two cases of glucometer error, and one case of kidney stones were also reported overall.Conclusions: There is no consistent evidence that IV high-dose vitamin C therapy is more harmful than placebo in double-blind randomized controlled trials. However, reports of oxalate nephropathy, hypernatremia, glucometer error, and hemolysis in glucose-6-phosphate dehydrogenase deficiency patients warrant specific monitoring.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • C—The Missing Tenet Within the ABCDEF Bundle
    • Authors: Patak; Lance; Tate, Judith A.; Happ, Mary Beth
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • The authors reply
    • Authors: Stollings; Joanna L.; Devlin, John W.; Barr, Juliana
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Preoperative Extracorporeal Membrane Oxygenation Implantation in Heart
           Transplantation. A Cautious Interpretation
    • Authors: Ortiz-Bautista; Carlos; Castrodeza, Javier; Martínez-Sellés, Manuel; Sousa, Iago; Fernández-Avilés, Francisco
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • The authors reply
    • Authors: Coutance; Guillaume; Leprince, Pascal; Combes, Alain; Lebreton, Guillaume
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • A Different Perspective on the Use of Sepsis Alert
    • Authors: Schinkel; Michiel; Boerman, Anneroos W.; Nanayakkara, Prabath W. B.
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • The authors reply
    • Authors: Rosenqvist; Mari; Bengtsson-Toni, Maria; Tham, Johan; Lanbeck, Peter; Melander, Olle; Åkesson, Per
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Application Prospect of Mesenchymal Stem Cells in the Treatment of Sepsis
    • Authors: Zhou; Yunxiang; Xu, Weilin; Shao, Anwen
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • The authors reply
    • Authors: Barbosa-Silva; Maria C.; Rocco, Patricia R. M.; Maron-Gutierrez, Tatiana
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Diagnosing Delirium in Neurocritically Ill Patients Using New Data
    • Authors: Williams Roberson; Shawniqua; Patel, Mayur B.; Ely, E. Wesley
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • The authors reply
    • Authors: Reznik; Michael E.; Drake, Jonathan; Margolis, Seth A.; Mahta, Ali; Wendell, Linda C.; Thompson, Bradford B.; Rao, Shyam S.; Daiello, Lori A.; Furie, Karen L.; Jones, Richard N.
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Delirium and Clarity in Research Regarding Biomarkers for Delirium in ICU
           Patients: Search for the Starting Point
    • Authors: Nadeem; Rashid; Alsharayri, Hind Mazen Hasan
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
  • Problems With the Study on the Readiness-to-Wean Criteria in Peru:
           Inadequacy of Assessing Oxygenation Only
    • Authors: Matsuda; Wataru
      Abstract: No abstract available
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT-
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