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Critical Care Medicine
Journal Prestige (SJR): 3.116
Citation Impact (citeScore): 3
Number of Followers: 319  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0090-3493
Published by LWW Wolters Kluwer Homepage  [310 journals]
  • Characteristics of Rapid Response Calls in the United States: An Analysis
           of the First 402,023 Adult Cases From the Get With the Guidelines
           Resuscitation-Medical Emergency Team Registry
    • Authors: Lyons; Patrick G.; Edelson, Dana P.; Carey, Kyle A.; Twu, Nicole M.; Chan, Paul S.; Peberdy, Mary Ann; Praestgaard, Amy; Churpek, Matthew M.; for the American Heart Association’s Get With the Guidelines – Resuscitation Investigators
      Abstract: imageObjectives: To characterize the rapid response team activations, and the patients receiving them, in the American Heart Association-sponsored Get With The Guidelines Resuscitation-Medical Emergency Team cohort between 2005 and 2015.Design: Retrospective multicenter cohort study.Setting: Three hundred sixty U.S. hospitals.Patients: Consecutive adult patients experiencing rapid response team activation.Interventions: Rapid response team activation.Measurements and Main Results: The cohort included 402,023 rapid response team activations from 347,401 unique healthcare encounters. Respiratory triggers (38.0%) and cardiac triggers (37.4%) were most common. The most frequent interventions—pulse oximetry (66.5%), other monitoring (59.6%), and supplemental oxygen (62.0%)—were noninvasive. Fluids were the most common medication ordered (19.3%), but new antibiotic orders were rare (1.2%). More than 10% of rapid response teams resulted in code status changes. Hospital mortality was over 14% and increased with subsequent rapid response activations.Conclusions: Although patients requiring rapid response team activation have high inpatient mortality, most rapid response team activations involve relatively few interventions, which may limit these teams’ ability to improve patient outcomes.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Antibiotic- and Fluid-Focused Bundles Potentially Improve Sepsis
           Management, but High-Quality Evidence Is Lacking for the Specificity
           Required in the Centers for Medicare and Medicaid Service’s Sepsis
           Bundle (SEP-1)*
    • Authors: Pepper; Dominique J.; Sun, Junfeng; Cui, Xizhong; Welsh, Judith; Natanson, Charles; Eichacker, Peter Q.
      Abstract: imageObjective: To address three controversial components in the Centers for Medicare and Medicaid Service’s sepsis bundle for performance measure (SEP-1): antibiotics within 3 hours, a 30 mL/kg fluid infusion for all hypotensive patients, and repeat lactate measurements within 6 hours if initially elevated. We hypothesized that antibiotic- and fluid-focused bundles like SEP-1 would probably show benefit, but evidence supporting specific antibiotic timing, fluid dosing, or serial lactate requirements would not be concordant. Therefore, we performed a meta-analysis of studies of sepsis bundles like SEP-1.Data Sources: PubMed, Embase, ClinicalTrials.gov through March 15, 2018.Study Selection: Studies comparing survival in septic adults receiving versus not receiving antibiotic- and fluid-focused bundles.Data Extraction: Two investigators (D.J.P., P.Q.E.).Data Synthesis: Seventeen observational studies (11,303 controls and 4,977 bundle subjects) met inclusion criteria. Bundles were associated with increased odds ratios of survival (odds ratio [95% CI]) in 15 studies with substantial heterogeneity (I2 = 61%; p < 0.01). Survival benefits were consistent in the five largest (1,697–12,486 patients per study) (1.20 [1.11–1.30]; I2 = 0%) and six medium-sized studies (167–1,029) (2.03 [1.52–2.71]; I2 = 8%) but not the six smallest (64–137) (1.25 [0.42–3.66]; I2 = 57%). Bundles were associated with similarly increased survival benefits whether requiring antibiotics within 1 hour (n = 7 studies) versus 3 hours (n = 8) versus no specified time (n = 2); or 30 mL/kg fluid (n = 7) versus another volume (≥ 2 L, n = 1; ≥ 20 mL/kg, n = 2; 1.5–2 L or 500 mL, n = 1 each; none specified, n = 4) (p = 0.19 for each comparison). In the only study employing serial lactate measurements, survival was not increased versus others. No study had a low risk of bias or assessed potential adverse bundle effects.Conclusions: Available studies support the notion that antibiotic- and fluid-focused sepsis bundles like SEP-1 improve survival but do not demonstrate the superiority of any specific antibiotic time or fluid volume or of serial lactate measurements. Until strong reproducible evidence demonstrates the safety and benefit of any fixed requirement for these interventions, the present findings support the revision of SEP-1 to allow flexibility in treatment according to physician judgment.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Clinical Examination for the Prediction of Mortality in the Critically
           Ill: The Simple Intensive Care Studies-I
    • Authors: Hiemstra; Bart; Eck, Ruben J.; Wiersema, Renske; Kaufmann, Thomas; Koster, Geert; Scheeren, Thomas W.L.; Snieder, Harold; Perner, Anders; Pettilä, Ville; Wetterslev, Jørn; Keus, Frederik; van der Horst, Iwan C.C.; SICS Study Group1
      Abstract: imageObjectives: Caregivers use clinical examination to timely recognize deterioration of a patient, yet data on the prognostic value of clinical examination are inconsistent. In the Simple Intensive Care Studies-I, we evaluated the association of clinical examination findings with 90-day mortality in critically ill patients.Design: Prospective single-center cohort study.Setting: ICU of a single tertiary care level hospital between March 27, 2015, and July 22, 2017.Patients: All consecutive adults acutely admitted to the ICU and expected to stay for at least 24 hours.Interventions: A protocolized clinical examination of 19 clinical signs conducted within 24 hours of admission.Measurements Main Results: Independent predictors of 90-day mortality were identified using multivariable logistic regression analyses. Model performance was compared with established prognostic risk scores using area under the receiver operating characteristic curves. Robustness of our findings was tested by internal bootstrap validation and adjustment of the threshold for statistical significance. A total of 1,075 patients were included, of whom 298 patients (28%) had died at 90-day follow-up. Multivariable analyses adjusted for age and norepinephrine infusion rate demonstrated that the combination of higher respiratory rate, higher systolic blood pressure, lower central temperature, altered consciousness, and decreased urine output was independently associated with 90-day mortality (area under the receiver operating characteristic curves = 0.74; 95% CI, 0.71–0.78). Clinical examination had a similar discriminative value as compared with the Simplified Acute Physiology Score-II (area under the receiver operating characteristic curves = 0.76; 95% CI, 0.73–0.79; p = 0.29) and Acute Physiology and Chronic Health Evaluation-IV (using area under the receiver operating characteristic curves = 0.77; 95% CI, 0.74–0.80; p = 0.16) and was significantly better than the Sequential Organ Failure Assessment (using area under the receiver operating characteristic curves = 0.67; 95% CI, 0.64–0.71; p < 0.001).Conclusions: Clinical examination has reasonable discriminative value for assessing 90-day mortality in acutely admitted ICU patients. In our study population, a single, protocolized clinical examination had similar prognostic abilities compared with the Simplified Acute Physiology Score-II and Acute Physiology and Chronic Health Evaluation-IV and outperformed the Sequential Organ Failure Assessment score.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Epidemiology and Outcomes of Cancer-Related Versus
           Non–Cancer-Related Sepsis Hospitalizations*
    • Authors: Hensley; Matthew K.; Donnelly, John P.; Carlton, Erin F.; Prescott, Hallie C.
      Abstract: imageObjective: Cancer and its treatment are known to be important risk factors for sepsis, contributing to an estimated 12% of U.S. sepsis admissions in the 1990s. However, cancer treatment has evolved markedly over the past 2 decades. We sought to examine how cancer-related sepsis differs from non–cancer-related sepsis.Design: Observational cohort.Setting: National Readmissions Database (2013–2014), containing all-payer claims for 49% of U.S. population.Patients: A total of 1,104,363 sepsis hospitalizations.Interventions: We identified sepsis hospitalizations in the U.S. National Readmissions Database using explicit codes for severe sepsis, septic shock, or Dombrovskiy criteria (concomitant codes for infection and organ dysfunction). We classified hospitalizations as cancer-related versus non–cancer-related sepsis based on the presence of secondary diagnosis codes for malignancy. We compared characteristics (site of infection and organ dysfunction) and outcomes (in-hospital mortality and 30-d readmissions) of cancer-related versus non–cancer-related sepsis hospitalizations. We also completed subgroup analyses by age, cancer types, and specific cancer diagnoses.Measurements and Main Results: There were 27,481,517 hospitalizations in National Readmissions Database 2013–2014, of which 1,104,363 (4.0%) were for sepsis and 4,150,998 (15.1%) were cancer related. In-hospital mortality in cancer-related sepsis was 27.9% versus 19.5% in non–cancer-related sepsis. The median count of organ dysfunctions was indistinguishable, but the rate of specific organ dysfunctions differed by small amounts (e.g., hematologic dysfunction 20.1% in cancer-related sepsis vs 16.6% in non–cancer-related sepsis; p < 0.001). Cancer-related sepsis was associated with an adjusted absolute increase in in-hospital mortality ranging from 2.2% to 15.2% compared with non–cancer-related sepsis. The mortality difference was greatest in younger adults and waned with age. Patients (23.2%) discharged from cancer-related sepsis were rehospitalized within 30 days, compared with 20.1% in non–cancer-related sepsis (p < 0.001).Conclusions: In this cohort of over 1 million U.S. sepsis hospitalizations, more than one in five were cancer related. The difference in mortality varies substantially across age spectrum and is greatest in younger adults. Readmissions were more common after cancer-related sepsis.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Declining Mortality of Cirrhotic Variceal Bleeding Requiring Admission to
           Intensive Care: A Binational Cohort Study*
    • Authors: Majeed; Ammar; Majumdar, Avik; Bailey, Michael; Kemp, William; Bellomo, Rinaldo; Pilcher, David; Roberts, Stuart K.
      Abstract: imageObjectives: We aimed to describe changes over time in admissions and outcomes, including length of stay, discharge destinations, and mortality of cirrhotic patients admitted to the ICU for variceal bleeding, and to compare it to the outcomes of those with other causes of ICU admissions.Design: Retrospective analysis of data captured prospectively in the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database.Settings: One hundred eighty-three ICUs in Australia and New Zealand.Patients: Consecutive admissions to these ICUs for upper gastrointestinal bleeding related to varices in patients with cirrhosis between January 1, 2005, and December 31, 2016.Interventions: None.Measurements and Main Results: ICU admissions for variceal bleeding in cirrhotic patients accounted for 4,003 (0.6%) of all 720,425 nonelective ICU admissions. The proportion of ICU admissions for variceal bleeding fell significantly from 0.8% (83/42,567) in 2005 to 0.4% (53/80,388) in 2016 (p < 0.001). Hospital mortality rate was significantly higher within admissions for variceal bleeding compared with nonelective ICU admissions (20.0% vs 15.7%; p < 0.0001), but decreased significantly over time, from 24.6% in 2005 to 15.8% in 2016 (annual decline odds ratio, 0.93; 95% CI, 0.90–0.96). There was no difference in the reduction in mortality from variceal bleeding over time between liver transplant and nontransplant centers (p = 0.26).Conclusions: Admission rate to ICU and mortality of cirrhotic patients with variceal bleeding has declined significantly over time compared with other causes of ICU admissions with the outcomes comparable between liver transplant and nontransplant centers.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • A Core Outcome Set for Critical Care Ventilation Trials
    • Authors: Blackwood; Bronagh; Ringrow, Suzanne; Clarke, Mike; Marshall, John C.; Connolly, Bronwen; Rose, Louise; McAuley, Daniel F.
      Abstract: imageObjectives: Our objective was to obtain international consensus on a set of core outcome measures that should be recorded in all clinical trials of interventions intended to modify the duration of ventilation for invasively mechanically ventilated patients in the ICU.Design: A two-stage consensus process was undertaken between December 2015 and January 2018. Stage 1 included an online three-round Delphi study and three consensus meetings. Stage 2 included three consensus meetings.Setting: The setting was international, including Europe, North and South America, Australia, Asia, and Africa.Participants: Organization members representing intensive care survivors and carers; nursing, allied health professionals, and critical care physicians; clinical trials groups and trial investigators; and industry.Interventions: None.Measurements and Main Results: Delphi study outcomes were scored by participants from one (least important) to nine (most important). Consensus criteria for including the outcome in the core set were more than 70% of responses rating the outcome above seven and not more than 15% rating the outcome less than 3. From 222 participants, 183 from 38 organizations in 27 countries contributed to the consensus process. Stage 1: Delphi response rates from 200 participants ranged from 89% to 90% across three rounds. Forty-seven outcomes were ranked as follows: 19 met consensus criteria for inclusion and were considered at three consensus meetings (33 participants). Six outcomes were agreed for the core set as follows: extubation, reintubation, duration of mechanical ventilation, length of stay, health-related quality of life, and mortality. Stage 2: Three consensus meetings (37 participants) agreed on the measures for each outcome.Conclusions: We used rigorous and well-established methods to develop a core outcome set for use in all clinical trials evaluating interventions intended to modify duration of mechanical ventilation. This core outcome set will inform the design of future trials in this field by strengthening methodological quality and improving comparability across trials.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Implementation of a Bundled Consent Process in the ICU: A Single-Center
           Experience*
    • Authors: Anandaiah; Asha M.; Stevens, Jennifer P.; Sullivan, Amy M.
      Abstract: imageObjectives: A bundled consent process, where patients or surrogates provide consent for all commonly performed procedures on a single form at the time of ICU admission, has been advocated as a method for improving both rates of documented consent and patient/family satisfaction, but there has been little published literature about the use of bundled consent. We sought to determine how residents in an academic medical center with a required bundled consent process actually obtain consent and how they perceive the overall value, efficacy, and effects on families of this approach.Design: Single-center survey study.Setting: Medical ICUs in an urban academic medical center.Subjects: Internal medicine residents.Interventions: We administered an online survey about bundled consent use to all residents. Quantitative and qualitative data were analyzed.Measurements and Main Results: One-hundred two of 164 internal medicine residents (62%) completed the survey. A majority of residents (55%) reported grouping procedures and discussing general risks and benefits; 11% reported conducting a complete informed consent discussion for each procedure. Respondents were divided in their perception of the value of bundled consent, but most (78%) felt it scared or stressed families. A minority (26%) felt confident that they obtained valid informed consent for critical care procedures with the use of bundled consent. An additional theme that emerged from qualitative data was concern regarding the validity of anticipatory consent.Conclusions: Resident physicians experienced with the use of bundled consent in the ICU held variable perceptions of its value but raised concerns about the effect on families and the validity of consent obtained with this strategy. Further studies are necessary to further explore what constitutes best practice for informed consent in critical care.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Randomized Clinical Trial of an ICU Recovery Pilot Program for Survivors
           of Critical Illness*
    • Authors: Bloom; Sarah L.; Stollings, Joanna L.; Kirkpatrick, Olivia; Wang, Li; Byrne, Daniel W.; Sevin, Carla M.; Semler, Matthew W.
      Abstract: imageObjectives: To examine the effect of an interdisciplinary ICU recovery program on process measures and clinical outcomes.Design: A prospective, single-center, randomized pilot trial.Setting: Academic, tertiary-care medical center.Patients: Adult patients admitted to the medical ICU for at least 48 hours with a predicted risk of 30-day same-hospital readmission of at least 15%.Interventions: Patients randomized to the ICU recovery program group were offered a structured 10-intervention program, including an inpatient visit by a nurse practitioner, an informational pamphlet, a 24 hours a day, 7 days a week phone number for the recovery team, and an outpatient ICU recovery clinic visit with a critical care physician, nurse practitioner, pharmacist, psychologist, and case manager. For patients randomized to the usual care group, all aspects of care were determined by treating clinicians.Measurements and Main Results: Among the primary analysis of enrolled patients who survived to hospital discharge, patients randomized to the ICU recovery program (n = 111) and usual care (n = 121) were similar at baseline. Patients in the ICU recovery program group received a median of two interventions compared with one intervention in the usual care group (p < 0.001). A total of 16 patients (14.4%) in the ICU recovery program group and 26 patients (21.5%) in the usual care group were readmitted to the study hospital within 30 days of discharge (p = 0.16). For these patients, the median time to readmission was 21.5 days (interquartile range, 11.5–26.2 d) in the ICU recovery program group and 7 days (interquartile range, 4–21.2 d) in the usual care group (p = 0.03). Four patients (3.6%) in the ICU recovery program and 14 patients (11.6%) in the usual care group were readmitted within 7 days of hospital discharge (p = 0.02). The composite outcome of death or readmission within 30 days of hospital discharge occurred in 20 patients (18%) in the ICU recovery program group and 36 patients (29.8%) in usual care group (p = 0.04).Conclusions: This randomized pilot trial found that a multidisciplinary ICU recovery program could deliver more interventions for post ICU recovery than usual care. The finding of longer time-to-readmission with an ICU recovery program should be examined in future trials.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Practice Patterns and Ethical Considerations in the Management of
           Venovenous Extracorporeal Membrane Oxygenation Patients: An International
           Survey*
    • Authors: Abrams; Darryl; Pham, Tài; Burns, Karen E. A.; Combes, Alain; Curtis, J. Randall; Mueller, Thomas; Prager, Kenneth M.; Serra, Alexis; Slutsky, Arthur S.; Brodie, Daniel; Schmidt, Matthieu; on behalf of the International ECMO Network (ECMONet
      Abstract: imageObjectives: To characterize physicians’ practices and attitudes toward the initiation, limitation, and withdrawal of venovenous extracorporeal membrane oxygenation for severe respiratory failure and evaluate factors associated with these attitudes.Design: Electronic, cross-sectional, scenario-based survey.Setting: Extracorporeal membrane oxygenation centers affiliated with the Extracorporeal Life Support Organization and the International Extracorporeal Membrane Oxygenation Network.Subjects: Attending-level physicians with experience managing adult patients receiving venovenous extracorporeal membrane oxygenation.Interventions: None.Measurements and Main Results: Five-hundred thirty-nine physicians in 39 countries across six continents completed the survey. Factors that influenced the decision to limit extracorporeal membrane oxygenation initiation included older patient age (46.9%), additional organ failures (37.7%), and prolonged mechanical ventilation (35.1%). Patient comorbidities (70.5%), patient’s wishes (56.0%), and etiology of respiratory failure (37.7%) were factors that influenced the decision to withdraw extracorporeal membrane oxygenation. In multivariable analysis, factors associated with increased odds of withdrawing life-sustaining therapies included pulmonary fibrosis, stroke, surrogate’s desire to withdraw, lack of knowledge regarding patient’s or surrogate’s wishes in the setting of fibrosis, not initiating extracorporeal membrane oxygenation in the baseline scenario, and respondent religiosity. Factors associated with decreased odds of withdrawal included practicing in an environment where it is not legally possible to make decisions against patient or surrogate wishes. Most respondents (90.5%) involved other physicians in treatment decisions for extracorporeal membrane oxygenation patients, whereas only 53.2%, 45.3%, and 29.5% of respondents involved surrogates, awake patients, or bedside nurses, respectively.Conclusions: Patient and physician-level factors were associated with decision-making regarding extracorporeal membrane oxygenation initiation and withdrawal, including patient prognosis and knowledge of patient or surrogate wishes. Respondents reported low rates of engaging in shared decision-making when managing patients receiving extracorporeal membrane oxygenation.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Are Peripherally Inserted Central Catheters Suitable for Cardiac Output
           Assessment With Transpulmonary Thermodilution'*
    • Authors: D’Arrigo; Sonia; Sandroni, Claudio; Cacciola, Sofia; Dell’Anna, Antonio Maria; Pittiruti, Mauro; Annetta, Maria Giuseppina; Colosimo, Cesare; Antonelli, Massimo
      Abstract: imageObjectives: Peripherally inserted central catheters are increasingly used in ICU as an alternative to centrally inserted central catheters for IV infusion. However, their reliability for hemodynamic measurements with transpulmonary thermodilution is currently unknown. We investigated the agreement between transpulmonary thermodilution measurements obtained with bolus injection through peripherally inserted central catheter and centrally inserted central catheter (reference standard) using a transpulmonary thermodilution–calibrated Pulse Contour hemodynamic monitoring system (VolumeView/EV1000).Design: Prospective method-comparison study.Setting: Twenty-bed medical-surgical ICU of a teaching hospital.Patients: Twenty adult ICU patients who required hemodynamic monitoring because of hemodynamic instability and had both peripherally inserted central catheter and centrally inserted central catheter in place.Intervention: The hemodynamic measurements obtained by transpulmonary thermodilution after injection of a cold saline bolus via both centrally inserted central catheter and either a single-lumen 4F or a double-lumen 5F peripherally inserted central catheter using were compared. In order to rule out bias related to manual injection, measurements were repeated using an automated rapid injection system.Measurements and Main Results: A total of 320 measurements were made. Cardiac index was significantly higher when measured with double-lumen 5F peripherally inserted central catheter than with centrally inserted central catheter (mean, 4.5 vs 3.3 L/min/m2; p < 0.0001; bias, 1.24 L/min/m2 [0.27, 2.22 L/min/m2]; bias percentage, 31%). Global end-diastolic index, extravascular lung water index, and stroke volume index were also overestimated (853 ± 240 vs 688 ± 175 mL/m2, 12.2 ± 4.2 vs 9.4 ± 2.9 mL/kg, and 49.6 ± 14.9 vs 39.5 ± 9.6 mL/m2, respectively; p < 0.0001). Lower, albeit significant differences were found using single-lumen 4F peripherally inserted central catheter (mean cardiac index, 4.2 vs 3.7 L/min/m2; p = 0.043; bias, 0.51 L/min/m2 [–0.53, 1.55 L/min/m2]; bias percentage, 12.7%). All differences were confirmed, even after standardization of bolus speed with automated injection.Conclusions: Bolus injection through peripherally inserted central catheter for transpulmonary thermodilution using EV1000 led to a significant overestimation of cardiac index, global end-diastolic index, extravascular lung water index, and stroke volume index, especially when double-lumen 5F peripherally inserted central catheter was used (ClinicalTrial.gov NCT03834675).
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Comparing the McGrath Mac Video Laryngoscope and Direct Laryngoscopy for
           Prehospital Emergency Intubation in Air Rescue Patients: A Multicenter,
           Randomized, Controlled Trial*
    • Authors: Kreutziger; Janett; Hornung, Sonja; Harrer, Clemens; Urschl, Wilhelm; Doppler, Reinhard; Voelckel, Wolfgang G.; Trimmel, Helmut
      Abstract: imageObjectives: Tracheal intubation in prehospital emergency care is challenging. The McGrath Mac Video Laryngoscope (Medtronic, Minneapolis, MN) has been proven to be a reliable alternative for in-hospital airway management. This trial compared the McGrath Mac Video Laryngoscope and direct laryngoscopy for the prehospital setting.Design: Multicenter, prospective, randomized, controlled equivalence trial.Setting: Oesterreichischer Automobil- und Touring Club (OEAMTC) Helicopter Emergency Medical Service in Austria, 18-month study period.Patients: Five-hundred fourteen adult emergency patients (≥ 18 yr old).Interventions: Helicopter Emergency Medical Service physicians followed the institutional algorithm, comprising a maximum of two tracheal intubation attempts with each device, followed by supraglottic, then surgical airway access in case of tracheal intubation failure. No restrictions were given for tracheal intubation indication.Measurements Main Results: The Primary outcome was the rate of successful tracheal intubation; equivalence range was ± 6.5% of success rates. Secondary outcomes were the number of attempts to successful tracheal intubation, time to glottis passage and first end-tidal Co2 measurement, degree of glottis visualization, and number of problems. The success rate for the two devices was equivalent: direct laryngoscopy 98.5% (254/258), McGrath Mac Video Laryngoscope 98.1% (251/256) (difference, 0.4%; 99% CI, –2.58 to 3.39). There was no statistically significant difference with regard to tracheal intubation times, number of attempts or difficulty. The view to the glottis was significantly better, but the number of technical problems was increased with the McGrath Mac Video Laryngoscope. After a failed first tracheal intubation attempt, immediate switching of the device was significantly more successful than after the second attempt (90.5% vs 57.1%; p = 0.0003), regardless of the method.Conclusions: Both devices are equivalently well suited for use in prehospital emergency tracheal intubation of adult patients. Switching the device following a failed first tracheal intubation attempt was more successful than a second attempt with the same device.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Patient Outcomes and Cost-Effectiveness of a Sepsis Care Quality
           Improvement Program in a Health System*
    • Authors: Afshar; Majid; Arain, Erum; Ye, Chen; Gilbert, Emily; Xie, Meng; Lee, Josh; Churpek, Matthew M.; Durazo-Arvizu, Ramon; Markossian, Talar; Joyce, Cara
      Abstract: imageObjectives: Assess patient outcomes in patients with suspected infection and the cost-effectiveness of implementing a quality improvement program.Design, Setting, and Participants: We conducted an observational single-center study of 13,877 adults with suspected infection between March 1, 2014, and July 31, 2017. The 18-month period before and after the effective date for mandated reporting of the sepsis bundle was examined. The Sequential Organ Failure Assessment score and culture and antibiotic orders were used to identify patients meeting Sepsis-3 criteria from the electronic health record.Interventions: The following interventions were performed as follows: 1) multidisciplinary sepsis committee with sepsis coordinator and data abstractor; 2) education campaign; 3) electronic health record tools; and 4) a Modified Early Warning System.Main Outcomes and Measures: Primary health outcomes were in-hospital death and length of stay. The incremental cost-effectiveness ratio was calculated and the empirical 95% CI for the incremental cost-effectiveness ratio was estimated from 5,000 bootstrap samples.Results: In multivariable analysis, the odds ratio for in-hospital death in the post- versus pre-implementation periods was 0.70 (95% CI, 0.57–0.86) in those with suspected infection, and the hazard ratio for time to discharge was 1.25 (95% CI, 1.20–1.29). Similarly, a decrease in the odds for in-hospital death and an increase in the speed to discharge was observed for the subset that met Sepsis-3 criteria. The program was cost saving in patients with suspected infection (–$272,645.7; 95% CI, –$757,970.3 to –$79,667.7). Cost savings were also observed in the Sepsis-3 group.Conclusions and Relevance: Our health system’s program designed to adhere to the sepsis bundle metrics led to decreased mortality and length of stay in a cost-effective manner in a much larger catchment than just the cohort meeting the Centers for Medicare and Medicaid Services measures. Our single-center model of interventions may serve as a practice-based benchmark for hospitalized patients with suspected infection.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • End-of-Life Decision-Making for ICU Patients With Limited English
           Proficiency: A Qualitative Study of Healthcare Team Insights
    • Authors: Barwise; Amelia K.; Nyquist, Christina A.; Espinoza Suarez, Nataly R.; Jaramillo, Carolina; Thorsteinsdottir, Bjorg; Gajic, Ognjen; Wilson, Michael E.
      Abstract: imageObjectives: Research indicates that the increasing population of over 25 million people in the United States who have limited English proficiency experience differences in decision-making and subsequent care at end of life in the ICU when compared with the general population. The objective of this study was to assess the perceptions of healthcare team members about the factors that influence discussions and decision-making about end of life for patients and family members with limited English proficiency in the ICU.Design: Qualitative study using semistructured interviews with ICU physicians, nurses, and interpreters.Setting: Three ICUs at Mayo Clinic Rochester.Subjects: Sixteen ICU physicians, 12 ICU nurses, and 12 interpreters.Intervention: None.Measurements and Main Results: We conducted 40 semistructured interviews. We identified six key differences in end-of-life decision-making for patients with limited English proficiency compared with patients without limited English proficiency: 1) clinician communication is modified and less frequent; 2) clinician ability to assess patient and family understanding is impaired; 3) relationship building is impaired; 4) patient and family understanding of decision-making concepts (e.g., palliative care) is impaired; 5) treatment limitations are often perceived to be unacceptable due to faith-based and cultural beliefs; and 6) patient and family decision-making styles are different. Facilitators of high-quality decision-making in patients with limited English proficiency included: 1) premeeting between clinician and interpreter; 2) interpretation that communicates empathy and caring; 3) bidirectional communication of cultural perspectives; 4) interpretation that improves messaging including appropriate word choice; and 5) clinician cultural humility.Conclusions: End-of-life decision-making is significantly different for ICU patients with limited English proficiency. Participants identified several barriers and facilitators to high-quality end-of-life decision-making for ICU patients and families with limited English proficiency. Awareness of these factors can facilitate interventions to improve high-quality, compassionate, and culturally sensitive decision-making for patients and families with limited English proficiency.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Supply Chain Delays in Antimicrobial Administration After the Initial
           Clinician Order and Mortality in Patients With Sepsis*
    • Authors: Kashiouris; Markos G.; Zemore, Zachary; Kimball, Zachary; Stefanou, Christos; Fowler, Alpha A. III; Fisher, Bernard; de Wit, Marjolein; Pedram, Sammy; Sessler, Curtis N.
      Abstract: imageObjectives: There is mounting evidence that delays in appropriate antimicrobial administration are responsible for preventable deaths in patients with sepsis. Herein, we examine the association between potentially modifiable antimicrobial administration delays, measured by the time from the first order to the first administration (antimicrobial lead time), and death among people who present with new onset of sepsis.Design: Observational cohort and case-control study.Setting: The emergency department of an academic, tertiary referral center during a 3.5-year period.Patients: Adult patients with new onset of sepsis or septic shock.Interventions: None.Measurements and Main Results: We enrolled 4,429 consecutive patients who presented to the emergency department with a new diagnosis of sepsis. We defined 0–1 hour as the gold standard antimicrobial lead time for comparison. Fifty percent of patients had an antimicrobial lead time of more than 1.3 hours. For an antimicrobial lead time of 1–2 hours, the adjusted odds ratio of death at 28 days was 1.28 (95% CI, 1.07–1.54; p = 0.007); for an antimicrobial lead time of 2–3 hours was 1.07 (95% CI, 0.85–1.36; p = 0.6); for an antimicrobial lead time of 3–6 hours was 1.57 (95% CI, 1.26–1.95; p < 0.001); for an antimicrobial lead time of 6–12 hours was 1.36 (95% CI, 0.99–1.86; p = 0.06); and for an antimicrobial lead time of more than 12 hours was 1.85 (95% CI, 1.29–2.65; p = 0.001).Conclusions: Delays in the first antimicrobial execution, after the initial clinician assessment and first antimicrobial order, are frequent and detrimental. Biases inherent to the retrospective nature of the study apply. Known biologic mechanisms support these findings, which also demonstrate a dose-response effect. In contrast to the elusive nature of sepsis onset and sepsis onset recognition, antimicrobial lead time is an objective, measurable, and modifiable process.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Agreement With Consensus Statements on End-of-Life Care: A Description of
           Variability at the Level of the Provider, Hospital, and Country*
    • Authors: Long; Ann C.; Brumback, Lyndia C.; Curtis, J. Randall; Avidan, Alexander; Baras, Mario; De Robertis, Edoardo; Efferen, Linda; Engelberg, Ruth A.; Kross, Erin K.; Michalsen, Andrej; Mularski, Richard A.; Sprung, Charles L.; for the Worldwide End-of-Life Practice for Patients in ICUs (WELPICUS Investigators
      Abstract: imageObjectives: To develop an enhanced understanding of factors that influence providers’ views about end-of-life care, we examined the contributions of provider, hospital, and country to variability in agreement with consensus statements about end-of-life care.Design and Setting: Data were drawn from a survey of providers’ views on principles of end-of-life care obtained during the consensus process for the Worldwide End-of-Life Practice for Patients in ICUs study.Subjects: Participants in Worldwide End-of-Life Practice for Patients in ICUs included physicians, nurses, and other providers. Our sample included 1,068 providers from 178 hospitals and 31 countries.Interventions: None.Measurements and Main Results: We examined views on cardiopulmonary resuscitation and withholding/withdrawing life-sustaining treatments, using a three-level linear mixed model of responses from providers within hospitals within countries. Of 1,068 providers from 178 hospitals and 31 countries, 1% strongly disagreed, 7% disagreed, 11% were neutral, 44% agreed, and 36% strongly agreed with declining to offer cardiopulmonary resuscitation when not indicated. Of the total variability in those responses, 98%, 0%, and 2% were explained by differences among providers, hospitals, and countries, respectively. After accounting for provider characteristics and hospital size, the variance partition was similar. Results were similar for withholding/withdrawing life-sustaining treatments.Conclusions: Variability in agreement with consensus statements about end-of-life care is related primarily to differences among providers. Acknowledging the primary source of variability may facilitate efforts to achieve consensus and improve decision-making for critically ill patients and their family members at the end of life.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Association Between the Use of Sodium Bicarbonate and Mortality in Acute
           Kidney Injury Using Marginal Structural Cox Model
    • Authors: Zhang; Zhongheng; Mo, Lei; Ho, Kwok M.; Hong, Yucai
      Abstract: imageObjective: Acute kidney injury with metabolic acidosis is common in critically ill patients. This study assessed the associations between the use of IV sodium bicarbonate and mortality of patients with acute kidney injury and acidosis.Design: The study was conducted by using data from Beth Israel Deaconess Medical Center, which included several ICUs such as coronary care unit, cardiac surgery recovery unit, medical ICU, surgical ICU, and trauma-neuro ICU. Marginal structural Cox model was used to assess the relationship between receipt of sodium bicarbonate and hospital mortality, allowing pH, Paco2, creatinine, and bicarbonate concentration as time-varying predictors of sodium bicarbonate exposure while adjusting for baseline characteristics of age, gender, Sequential Organ Failure Assessment score, acute kidney injury stage, Elixhauser score, quick Sequential Organ Failure Assessment, and Simplified Acute Physiology Score II.Setting: A large U.S.-based critical care database named Medical Information Mart for Intensive Care.Patients: Patients with Kidney Disease: Improving Global Outcomes acute kidney injury stage greater than or equal to 1 (> 1.5 JOURNAL/ccme/04.03/00003246-201910000-00016/inline-graphic1/v/2019-09-16T181613Z/r/image-tiff baseline creatinine) and one measurement of acidosis (pH ≤ 7.2). Baseline creatinine was estimated using the Chronic Kidney Disease Epidemiology Collaboration equation.Interventions: None.Measurements and Main Results: Of the 3,406 eligible patients, 836 (24.5%) had received sodium bicarbonate treatment. Patients who received sodium bicarbonate treatment had a higher Sequential Organ Failure Assessment (9 vs 7; p < 0.001), lower pH (7.16 vs 7.18; p < 0.001), and bicarbonate concentration (16.51 ± 7.04 vs 20.57 ± 6.29 mmol/L; p < 0.001) compared with those who did not receive sodium bicarbonate. In the marginal structural Cox model by weighing observations with inverse probability of receiving sodium bicarbonate, sodium bicarbonate treatment was not associated with mortality in the overall population (hazard ratio, 1.16; 95% CI, 0.98–1.42; p = 0.132), but it appeared to be beneficial in subgroups of pancreatitis (hazard ratio, 0.53; 95% CI, 0.28–0.98; p = 0.044) and severe acidosis (pH < 7.15; hazard ratio, 0.75; 95% CI, 0.58–0.96; p = 0.024). Furthermore, sodium bicarbonate appeared to be beneficial in patients with severe bicarbonate deficit (< –50 kg·mmol/L).Conclusions: In the analysis by adjusting for potential confounders, there is no evidence that IV sodium bicarbonate is beneficial for patients with acute kidney injury and acidosis. Although the study suggested potential beneficial effects in some highly selected subgroups, the results need to be validated in experimental trials.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Optimizing Mean Arterial Pressure in Acutely Comatose Patients Using
           Cerebral Autoregulation Multimodal Monitoring With Near-Infrared
           Spectroscopy*
    • Authors: Rivera-Lara; Lucia; Geocadin, Romergryko; Zorrilla-Vaca, Andres; Healy, Ryan J.; Radzik, Batya R.; Palmisano, Caitlin; Mirski, Marek; White, Mirinda Anderson; Suarez, Jose; Brown, Charles; Hogue, Charles W.; Ziai, Wendy
      Abstract: imageObjectives: This study investigated whether comatose patients with greater duration and magnitude of clinically observed mean arterial pressure outside optimal mean arterial blood pressure have worse outcomes than those with mean arterial blood pressure closer to optimal mean arterial blood pressure calculated by bedside multimodal cerebral autoregulation monitoring using near-infrared spectroscopy.Design: Prospective observational study.Setting: Neurocritical Care Unit of the Johns Hopkins Hospital.Subjects: Acutely comatose patients secondary to brain injury.Interventions: None.Measurements and Main Results: The cerebral oximetry index was continuously monitored with near-infrared spectroscopy for up to 3 days. Optimal mean arterial blood pressure was defined as that mean arterial blood pressure at the lowest cerebral oximetry index (nadir index) for each 24-hour period of monitoring. Kaplan-Meier analysis and proportional hazard regression models were used to determine if survival at 3 months was associated with a shorter duration of mean arterial blood pressure outside optimal mean arterial blood pressure and the absolute difference between clinically observed mean arterial blood pressure and optimal mean arterial blood pressure. A total 91 comatose patients were enrolled in the study. The most common etiology was intracerebral hemorrhage. Optimal mean arterial blood pressure could be calculated in 89 patients (97%), and the median optimal mean arterial blood pressure was 89.7 mm Hg (84.6–100 mm Hg). In multivariate proportional hazard analysis, duration outside optimal mean arterial blood pressure of greater than 80% of monitoring time (adjusted hazard ratio, 2.13; 95% CI, 1.04–4.41; p = 0.04) and absolute difference between clinically observed mean arterial blood pressure and optimal mean arterial blood pressure of more than 10 mm Hg (adjusted hazard ratio, 2.44; 95% CI, 1.21–4.92; p = 0.013) were independently associated with mortality at 3 months, after adjusting for brain herniation, admission Glasgow Coma Scale, duration on vasopressors and midline shift at septum.Conclusions: Comatose neurocritically ill adults with an absolute difference between clinically observed mean arterial blood pressure and optimal mean arterial blood pressure greater than 10 mm Hg and duration outside optimal mean arterial blood pressure greater than 80% had increased mortality at 3 months. Noninvasive near-infrared spectroscopy-based bedside calculation of optimal mean arterial blood pressure is feasible and might be a promising tool for cerebral autoregulation oriented-therapy in neurocritical care patients.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Quantitative Electroencephalogram Trends Predict Recovery in
           Hypoxic-Ischemic Encephalopathy*
    • Authors: Ghassemi; Mohammad M.; Amorim, Edilberto; Alhanai, Tuka; Lee, Jong W.; Herman, Susan T.; Sivaraju, Adithya; Gaspard, Nicolas; Hirsch, Lawrence J.; Scirica, Benjamin M.; Biswal, Siddharth; Moura Junior, Valdery; Cash, Sydney S.; Brown, Emery N.; Mark, Roger G.; Westover, M. Brandon; for the Critical Care Electroencephalogram Monitoring Research Consortium
      Abstract: imageObjectives: Electroencephalogram features predict neurologic recovery following cardiac arrest. Recent work has shown that prognostic implications of some key electroencephalogram features change over time. We explore whether time dependence exists for an expanded selection of quantitative electroencephalogram features and whether accounting for this time dependence enables better prognostic predictions.Design: Retrospective.Setting: ICUs at four academic medical centers in the United States.Patients: Comatose patients with acute hypoxic-ischemic encephalopathy.Interventions: None.Measurements and Main Results: We analyzed 12,397 hours of electroencephalogram from 438 subjects. From the electroencephalogram, we extracted 52 features that quantify signal complexity, category, and connectivity. We modeled associations between dichotomized neurologic outcome (good vs poor) and quantitative electroencephalogram features in 12-hour intervals using sequential logistic regression with Elastic Net regularization. We compared a predictive model using time-varying features to a model using time-invariant features and to models based on two prior published approaches. Models were evaluated for their ability to predict binary outcomes using area under the receiver operator curve, model calibration (how closely the predicted probability of good outcomes matches the observed proportion of good outcomes), and sensitivity at several common specificity thresholds of interest. A model using time-dependent features outperformed (area under the receiver operator curve, 0.83 ± 0.08) one trained with time-invariant features (0.79 ± 0.07; p < 0.05) and a random forest approach (0.74 ± 0.13; p < 0.05). The time-sensitive model was also the best-calibrated.Conclusions: The statistical association between quantitative electroencephalogram features and neurologic outcome changed over time, and accounting for these changes improved prognostication performance.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Outcome Prediction in Postanoxic Coma With Deep Learning*
    • Authors: Tjepkema-Cloostermans; Marleen C.; da Silva Lourenço, Catarina; Ruijter, Barry J.; Tromp, Selma C.; Drost, Gea; Kornips, Francois H. M.; Beishuizen, Albertus; Bosch, Frank H.; Hofmeijer, Jeannette; van Putten, Michel J. A. M.
      Abstract: imageObjectives: Visual assessment of the electroencephalogram by experienced clinical neurophysiologists allows reliable outcome prediction of approximately half of all comatose patients after cardiac arrest. Deep neural networks hold promise to achieve similar or even better performance, being more objective and consistent.Design: Prospective cohort study.Setting: Medical ICU of five teaching hospitals in the Netherlands.Patients: Eight-hundred ninety-five consecutive comatose patients after cardiac arrest.Interventions: None.Measurements and Main Results: Continuous electroencephalogram was recorded during the first 3 days after cardiac arrest. Functional outcome at 6 months was classified as good (Cerebral Performance Category 1–2) or poor (Cerebral Performance Category 3–5). We trained a convolutional neural network, with a VGG architecture (introduced by the Oxford Visual Geometry Group), to predict neurologic outcome at 12 and 24 hours after cardiac arrest using electroencephalogram epochs and outcome labels as inputs. Output of the network was the probability of good outcome. Data from two hospitals were used for training and internal validation (n = 661). Eighty percent of these data was used for training and cross-validation, the remaining 20% for independent internal validation. Data from the other three hospitals were used for external validation (n = 234). Prediction of poor outcome was most accurate at 12 hours, with a sensitivity in the external validation set of 58% (95% CI, 51–65%) at false positive rate of 0% (CI, 0–7%). Good outcome could be predicted at 12 hours with a sensitivity of 48% (CI, 45–51%) at a false positive rate of 5% (CI, 0–15%) in the external validation set.Conclusions: Deep learning of electroencephalogram signals outperforms any previously reported outcome predictor of coma after cardiac arrest, including visual electroencephalogram assessment by trained electroencephalogram experts. Our approach offers the potential for objective and real time, bedside insight in the neurologic prognosis of comatose patients after cardiac arrest.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Persistent Mitochondrial Dysfunction Linked to Prolonged Organ Dysfunction
           in Pediatric Sepsis
    • Authors: Weiss; Scott L.; Zhang, Donglan; Bush, Jenny; Graham, Kathryn; Starr, Jonathan; Tuluc, Florin; Henrickson, Sarah; Kilbaugh, Todd; Deutschman, Clifford S.; Murdock, Deborah; McGowan, Francis X. Jr; Becker, Lance; Wallace, Douglas C.
      Abstract: imageObjectives: Limited data exist about the timing and significance of mitochondrial alterations in children with sepsis. We therefore sought to determine if alterations in mitochondrial respiration and content within circulating peripheral blood mononuclear cells were associated with organ dysfunction in pediatric sepsis.Design: Prospective observational studySetting: Single academic PICU.Patients: One-hundred sixty-seven children with sepsis/septic shock and 19 PICU controls without sepsis, infection, or organ dysfunction.Interventions: None.Measurements and Main Results: Mitochondrial respiration and content were measured in peripheral blood mononuclear cells on days 1–2, 3–5, and 8–14 after sepsis recognition or once for controls. Severity and duration of organ dysfunction were determined using the Pediatric Logistic Organ Dysfunction score and organ failure-free days through day 28. Day 1–2 maximal uncoupled respiration (9.7 ± 7.7 vs 13.7 ± 4.1 pmol O2/s/106 cells; p = 0.02) and spare respiratory capacity (an index of bioenergetic reserve: 6.2 ± 4.3 vs 9.6 ± 3.1; p = 0.005) were lower in sepsis than controls. Mitochondrial content, measured by mitochondrial DNA/nuclear DNA, was higher in sepsis on day 1–2 than controls (p = 0.04) and increased in sepsis patients who had improving spare respiratory capacity over time (p = 0.005). Mitochondrial respiration and content were not associated with day 1–2 Pediatric Logistic Organ Dysfunction score, but low spare respiratory capacity was associated with higher Pediatric Logistic Organ Dysfunction score on day 3–5. Persistently low spare respiratory capacity was predictive of residual organ dysfunction on day 14 (area under the receiver operating characteristic, 0.72; 95% CI, 0.61–0.84) and trended toward fewer organ failure-free days although day 28 (β coefficient, –0.64; 95% CI, –1.35 to 0.06; p = 0.08).Conclusions: Mitochondrial respiration was acutely decreased in peripheral blood mononuclear cells in pediatric sepsis despite an increase in mitochondrial content. Over time, a rise in mitochondrial DNA tracked with improved respiration. Although initial mitochondrial alterations in peripheral blood mononuclear cells were unrelated to organ dysfunction, persistently low respiration was associated with slower recovery from organ dysfunction.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Nurse Practitioners and Physician Assistants in Acute and Critical Care: A
           Concise Review of the Literature and Data 2008–2018
    • Authors: Kleinpell; Ruth M.; Grabenkort, W. Robert; Kapu, April N.; Constantine, Roy; Sicoutris, Corinna
      Abstract: imageObjectives: To provide a concise review of the literature and data pertaining to the use of nurse practitioners and physician assistants, collectively called advanced practice providers, in ICU and acute care settings.Data Sources: Detailed search strategy using the databases PubMed, Ovid MEDLINE, and the Cumulative Index of Nursing and Allied Health Literature for the time period from January 2008 to December 2018.Study Selection: Studies addressing nurse practitioner, physician assistant, or advanced practice provider care in the ICU or acute care setting.Data Extraction: Relevant studies were reviewed, and the following aspects of each study were identified, abstracted, and analyzed: study population, study design, study aims, methods, results, and relevant implications for critical care practice.Data Synthesis: Five systematic reviews, four literature reviews, and 44 individual studies were identified, reviewed, and critiqued. Of the research studies, the majority were retrospective with others being observational, quasi-experimental, or quality improvement, along with two randomized control trials. Overall, the studies assessed a variety of effects of advanced practice provider care, including on length of stay, mortality, and quality-related metrics, with a majority demonstrating similar or improved patient care outcomes.Conclusions: Over the past 10 years, the number of studies assessing the impact of advanced practice providers in acute and critical care settings continue to increase. Collectively, these studies identify the value of advanced practice providers in patient care management, continuity of care, improved quality and safety metrics, patient and staff satisfaction, and on new areas of focus including enhanced educational experience of residents and fellows.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Implementation of Sepsis Bundles: Just Do It!!*
    • Authors: Levy; Mitchell M.
      Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Cancer and Sepsis: Adding Insult to Injury—As if Either Alone Were
           Not Enough'*
    • Authors: Parker; Robert I.
      Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Mortality of Cirrhosis Induced Variceal Hemorrhage Is Declining: Can We Do
           More'*
    • Authors: Appavu; Samuel K.
      Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Optimal Informed Consent for the Critically Ill Patient—Difficult to
           Define, but We Know It When We See It*
    • Authors: Albert; Ben D.; Burns, Jeffrey P.
      Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • How to Recover From Critical Illness—Is It All in the Brochure'*
    • Authors: Boyd; Owen
      Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Painting a Fuller Picture*
    • Authors: Kumar Puri; Nitin; Conrad, Steven A.
      Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Should We Dismiss Peripherally Inserted Central Catheters for Monitoring
           Cardiac Output' Maybe Not*
    • Authors: Chiumello; Davide; Coppola, Silvia
      Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Redundant Safety and Videolaryngoscopy*
    • Authors: Manoach; Seth; Peterson, Lars-Kristofer N.
      Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • More Than We Bargained For: The “Dominating” Cost Effectiveness of
           Sepsis Quality Improvement'*
    • Authors: Peltan; Ithan D.; Liu, Vincent X.
      Abstract: imageNo abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Antibiotic Order-to-Infusion Time for Patients With Septic Shock: A
           Potential New Quality Metric*
    • Authors: Klompas; Michael; Rhee, Chanu
      Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • A Consensus: Everyone Agrees Collectively but No One Believes
           Individually*
    • Authors: Nadig; Nandita R.; Ford, Dee W.
      Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • In a Search of Pressure Which Optimizes Autoregulation of Cerebral Blood
           Flow*
    • Authors: Czosnyka; Marek
      Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Machine Learning to Decode the Electroencephalography for Post Cardiac
           Arrest Neuroprognostication*
    • Authors: Stevens; Robert D.
      Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Lactated Ringer’s Versus 4% Albumin on Lactated Ringer’s in Early
           
    • Authors: Park; Clarice Hyesuk Lee; de Almeida, Juliano Pinheiro; de Oliveira, Gisele Queiroz; Rizk, Stéphanie Itala; Fukushima, Julia Tizue; Nakamura, Rosana Ely; Mourão, Matheus Moraes; Galas, Filomena Regina Barbosa Gomes; Abdala, Edson; Pinheiro Freire, Maristela; Kalil Filho, Roberto; Costa Auler, Jose Otavio Jr; Nardelli, Pasquale; Martin, Greg S.; Landoni, Giovanni; Hajjar, Ludhmila Abrahao
      Abstract: imageObjective: To investigate the effects of the administration of 4% albumin on lactated Ringer’s, when compared with lactated Ringer’s alone, in the early phase of sepsis in cancer patients.Design: Single-center, randomized, double-blind, controlled-parallel trial.Setting: A tertiary care university cancer hospital.Patients: Cancer patients with severe sepsis or septic shock.Interventions: Between October 2014 and December 2016, patients were randomly assigned to receive either bolus of albumin in a lactated Ringer’s solution or lactated Ringer’s solution alone during the first 6 hours of fluid resuscitation after intensive care medicine (ICU) admission. Primary outcome was defined as death from any cause at 7 days. Secondary outcomes were defined as death from any cause within 28 days, change in Sequence Organ Failure Assessment scores from baseline to day 7, days alive and free of mechanical ventilation, days alive and free of vasopressor, renal replacement therapy during ICU stay, and length of ICU and hospital stay.Measurements and Main Results: A total of 360 patients were enrolled in the trial. At 7 days, 46 of 180 patients (26%) died in the albumin group and 40 of 180 (22%) died in the lactated Ringer’s group (p = 0.5). At 28 days, 96 of 180 patients (53%) died in the albumin group and 83 of 180 (46%) died in the lactated Ringer’s group (p = 0.2). No significant differences in secondary outcomes were observed.Conclusions: Adding albumin to early standard resuscitation with lactated Ringer’s in cancer patients with sepsis did not improve 7-day survival.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Continuous Renal Replacement Therapy in Pediatric Severe Sepsis: A
           
    • Authors: Miao; Huijie; Shi, Jingyi; Wang, Chunxia; Lu, Guoping; Zhu, Xiaodong; Wang, Ying; Cui, Yun; Zhang, Yucai
      Abstract: imageObjectives: Continuous renal replacement therapy becomes available utilization for pediatric critically ill, but the impact of mortality rate in severe sepsis remains no consistent conclusion. The aim of the study is to assess the effect of continuous renal replacement therapy in pediatric patients with severe sepsis and the impact this therapy may have on their mortality.Design: Propensity score-matched cohort study analyzing data prospectively collected by the PICUs over 2 years (2016–2018).Setting: Four PICUs of tertiary university children’s hospital in China.Patients: The consecutive patients with severe sepsis admitted to study PICUs were enrolled from July 2016 to June 2018.Interventions: The patients were divided into the continuous renal replacement therapy group and the conventional (noncontinuous renal replacement therapy) group.Measurements and Main Results: A total of 324 patients with severe sepsis were enrolled. The hospital mortality rate was 35.6% (64/180) in the continuous renal replacement therapy group and 47.9% (69/144) in the noncontinuous renal replacement therapy group. After propensity score adjustment, the hospital mortality rate was 21.3% (29/136) in the continuous renal replacement therapy group and 32.4% (44/136) in the noncontinuous renal replacement therapy group. In subgroup analysis, the relative risk of dying was 0.447 (95% CI, 0.208–0.961) only in patients complicated by acute respiratory distress syndrome (p = 0.037), but not in patients with shock, acute kidney injury, acute liver dysfunction, encephalopathy, and fluid overload greater than 10%. The mean duration of continuous renal replacement therapy was 45 hours (26–83 hr) with an ultrafiltration rate of 50 mL/kg/hr. The level of interleukin-6 was decreased, and the percent of natural killer cells (%) was improved in the continuous renal replacement therapy group compared with the noncontinuous renal replacement therapy group. Furthermore, continuous renal replacement therapy was an independently significant risk factor for hospital mortality in pediatric patients with severe sepsis, and the interval between continuous renal replacement therapy initiation and PICU admission was an independent risk factor for hospital mortality in patients receiving continuous renal replacement therapy.Conclusions: Continuous renal replacement therapy with an ultrafiltration rate of 50 mL/kg/hr decreases hospital mortality rate in pediatric severe sepsis, especially in patients with acute respiratory distress syndrome.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Discharge Destination As a Marker of Mobility Impairment in Survivors of
           Acute Respiratory Distress Syndrome
    • Authors: Jolley; Sarah E.; Angus, Derek C.; Clermont, Gilles; Hough, Catherine L.
      Abstract: imageObjectives: Discharge destination is a commonly used surrogate for long-term recovery in rehabilitation studies. We determined the accuracy of discharge destination as a surrogate marker for 6-month mobility impairment in acute respiratory distress syndrome survivors.Design/Setting: Secondary analysis of the Economic Analysis of Pulmonary Artery Catheters study, a long-term observational sub-study of the National Institutes of Health/National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network Fluid and Catheter Treatment Trial.Patients: Patients underwent functional assessment using the Health Utilities Index-2 mobility domains at 6 months. A score greater than or equal to 3 (i.e., need for assistive device) defined mobility impairment. Discharge to any institutional care constituted a care facility discharge. We used logistic regression to explore the association between discharge destination and mobility impairment. We generated test characteristics and receiver operating characteristics to assess the accuracy of discharge destination as a surrogate for mobility impairment.Interventions: None.Measurements and Main Results: A total of 591 patients were enrolled in Economic Analysis of Pulmonary Artery Catheters in whom 328 had functional measurements at 6 months with 116 (35%) of these patients discharged to a care facility. Care facility patients were older (mean age 53 vs 44 yr; p < 0.001) and had longer hospital durations (length of stay 29 vs 17 d; p < 0.001). Care facility discharge was associated with greater 6-month mobility impairment. Sensitivity and specificity of discharge to a care facility for mobility impairment were 40.5% (95% CI, 32.0–49.6%) and 79.3% (95% CI, 73.3–84.2%) at 6 months. Discharge destination alone was a poor discriminator of long-term mobility impairment (receiver operating characteristic area under the curve: 0.61 at 6 mo).Conclusions: Discharge to a care facility was strongly associated with mobility impairment 6 months after acute respiratory distress syndrome but discharge destination alone performed poorly as a surrogate for mobility impairment.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Use of Cell Cycle Arrest Biomarkers in Conjunction With Classical Markers
           of Acute Kidney Injury
    • Authors: Joannidis; Michael; Forni, Lui G.; Haase, Michael; Koyner, Jay; Shi, Jing; Kashani, Kianoush; Chawla, Lakhmir S.; Kellum, John A.; on behalf of the Sapphire Investigators
      Abstract: imageObjectives: Decreased urine output and/or increased serum creatinine may herald the development of acute kidney injury or reflect normal physiology. In this secondary analysis of the Sapphire study, we examined biomarkers of cell cycle arrest in the settings of oliguria and/or azotemia to improve risk assessment when used with conventional indices in predicting severe acute kidney injury (Kidney Disease: Improving Global Outcomes 3 defined by the need for renal replacement therapy or changes in urine output, serum creatinine or both) or death.Design: Prospective, international, Sapphire study.Setting: Academic Medical Center.Patients: Patients without acute kidney injury Kidney Disease: Improving Global Outcomes stage 2 or 3.Interventions: None.Measurements and Main Results: The primary endpoint being development of severe acute kidney injury or death within 1 week. Secondary analysis examined the relationship between tissue inhibitor of metalloproteinases-2 ([TIMP-2]) and insulin growth factor binding protein 7 ([IGFBP7]) and 9-month death or dialysis conditioned on progression to stage 2–3 acute kidney injury within 1 week. Seventy-nine patients reached the primary endpoint and were more likely to be surgical, with higher nonrenal Acute Physiology and Chronic Health Evaluation III scores and more chronic kidney disease. Stage 1 urine output, serum creatinine, and urinary [TIMP-2]•[IGFBP7] greater than 2.0 were all predictive of progression to the primary endpoint independent from nonrenal Acute Physiology and Chronic Health Evaluation III score. Combinations of predictors increased the hazard ratios considerably (from 2.17 to 4.14 to 10.05, respectively). In the presence of acute kidney injury (stage 1), [TIMP-2]•[IGFBP7] greater than 2.0 leads to an increased risk of death or dialysis at 9 months even in the absence of progression of acute kidney injury (stage 2–3) within 7 days.Conclusions: Cell cycle arrest biomarkers, TIMP-2 and IGFBP7, improve risk stratification for severe outcomes in patients with stage 1 acute kidney injury by urine output, serum creatinine or both, with risk increasing with each acute kidney injury indicator. Longer term outcomes demonstrate that the associated risks of a [TIMP-2]•[IGFBP7] greater than 2.0 is equivalent to acute kidney injury progression even where no progression from stage 1 acute kidney injury is observed.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • External Validation of Two Models to Predict Delirium in Critically Ill
           Adults Using Either the Confusion Assessment Method-ICU or the Intensive
           Care Delirium Screening Checklist for Delirium Assessment
    • Authors: Wassenaar; Annelies; Schoonhoven, Lisette; Devlin, John W.; van Haren, Frank M. P.; Slooter, Arjen J. C.; Jorens, Philippe G.; van der Jagt, Mathieu; Simons, Koen S.; Egerod, Ingrid; Burry, Lisa D.; Beishuizen, Albertus; Matos, Joaquim; Donders, A. Rogier T.; Pickkers, Peter; van den Boogaard, Mark
      Abstract: imageObjectives: To externally validate two delirium prediction models (early prediction model for ICU delirium and recalibrated prediction model for ICU delirium) using either the Confusion Assessment Method-ICU or the Intensive Care Delirium Screening Checklist for delirium assessment.Design: Prospective, multinational cohort study.Setting: Eleven ICUs from seven countries in three continents.Patients: Consecutive, delirium-free adults admitted to the ICU for greater than or equal to 6 hours in whom delirium could be reliably assessed.Interventions: None.Measurements and Main Results: The predictors included in each model were collected at the time of ICU admission (early prediction model for ICU delirium) or within 24 hours of ICU admission (recalibrated prediction model for ICU delirium). Delirium was assessed using the Confusion Assessment Method-ICU or the Intensive Care Delirium Screening Checklist. Discrimination was determined using the area under the receiver operating characteristic curve. The predictive performance was determined for the Confusion Assessment Method-ICU and Intensive Care Delirium Screening Checklist cohort, and compared with both prediction models’ original reported performance. A total of 1,286 Confusion Assessment Method-ICU–assessed patients and 892 Intensive Care Delirium Screening Checklist–assessed patients were included. Compared with the area under the receiver operating characteristic curve of 0.75 (95% CI, 0.71–0.79) in the original study, the area under the receiver operating characteristic curve of the early prediction model for ICU delirium was 0.67 (95% CI, 0.64–0.71) for delirium as assessed using the Confusion Assessment Method-ICU and 0.70 (95% CI, 0.66–0.74) using the Intensive Care Delirium Screening Checklist. Compared with the original area under the receiver operating characteristic curve of 0.77 (95% CI, 0.74–0.79), the area under the receiver operating characteristic curve of the recalibrated prediction model for ICU delirium was 0.75 (95% CI, 0.72–0.78) for assessing delirium using the Confusion Assessment Method-ICU and 0.71 (95% CI, 0.67–0.75) using the Intensive Care Delirium Screening Checklist.Conclusions: Both the early prediction model for ICU delirium and recalibrated prediction model for ICU delirium are externally validated using either the Confusion Assessment Method-ICU or the Intensive Care Delirium Screening Checklist for delirium assessment. Per delirium prediction model, both assessment tools showed a similar moderate-to-good statistical performance. These results support the use of either the early prediction model for ICU delirium or recalibrated prediction model for ICU delirium in ICUs around the world regardless of whether delirium is evaluated with the Confusion Assessment Method-ICU or Intensive Care Delirium Screening Checklist.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Ultrasonographic Detection of Micro-Bubbles in the Right Atrium to Confirm
           Peripheral Venous Catheter Position in Children
    • Authors: Takeshita; Jun; Nakajima, Yasufumi; Kawamura, Atsushi; Taniguchi, Masashi; Shimizu, Yoshiyuki; Takeuchi, Muneyuki; Shime, Nobuaki
      Abstract: imageObjectives: In pediatric patients, indwelling peripheral venous catheters are sometimes displaced to extravascular positions, causing infiltration or extravasation. No reliable techniques are available to confirm accurate IV catheterization. However, ultrasonographic detection of micro-bubble turbulence in the right atrium after saline injection has been reported to be useful in confirming central venous catheter positions in both adults and children. This study evaluated whether this micro-bubble detection test can offer better confirmation of peripheral venous catheter positions compared with the smooth saline injection technique in pediatric patients.Design: Randomized controlled study.Setting: Single tertiary PICU.Patients: Pediatric patients (weighing < 15 kg) who already had or required a peripheral venous catheter.Interventions: Patients were randomly allocated to either of the two groups (150 patients per group): undergoing either the micro-bubble detection test (M group) or the smooth saline injection test (S group).Measurements and Main Results: The peripheral venous catheters were confirmed to be IV located in the final position in 137 and 139 patients in the M and S groups, respectively. In properly located catheters, the tests were positive in 100% (n = 137/137; sensitivity, 100%; 95% CI, 97.8–100), and in 89% (n = 124/139; 95% CI, 82.8–93.8) of the M and S groups, respectively (p = 0.0001). Among the catheters located in extravascular positions, the tests were negative in 100% (n = 13/13; specificity, 100%; 95% CI, 79.4–100), and in 64% (n = 7/11; 95% CI, 30.8–89.1) of the M and S groups, respectively (p = 0.017).Conclusions: The micro-bubble detection test is a useful technique for detecting extravasation and confirming proper positioning of peripheral IV catheters in pediatric patients.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • B-Mode Ultrasound Findings in a Patient With Suspected Pulmonary Gangrene
    • Authors: Echivard; Mathieu; Lichtenstein, Daniel A.; Lala, Adrian; Sanchez, Anais Perez; Girerd, Nicolas
      Abstract: imageObjectives: Lung ultrasound has shown increasing diagnostic value in many lung diseases and has become an efficient tool in the management of dyspnea. In the present case report, we describe a new ultrasound feature of potential interest.Data Sources: Clinical observation of a patient.Study Selection: Case report.Data Extraction: Data were extracted from medical records, after obtaining consent from the patient’s family. Illustrations were extracted from the imaging software and a video device.Data Synthesis: A 56-year-old man was admitted with pneumonia of adverse outcome. Lung ultrasound, a method increasingly considered as a bedside gold standard in critically ill patients due to its overwhelming advantages, was the only tool able to specify the lung injuries. We describe herein a distinctive sign unequivocally evoking a destructive process suggestive of pulmonary gangrene, a variant of the fractal sign combining a lung consolidation with an underlying heterogeneous free fluid.Conclusions: Lung ultrasound may help highlight pulmonary gangrene, a poorly-known disease, with this new ultrasonographic description. The next step will be to ascertain the relation between this new ultrasound feature and pulmonary gangrene and to assess how this bedside diagnosis could impact the prognosis of the disease.
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Continuation of Newly Initiated Midodrine Therapy: Appropriate in Patients
           With Heart Failure'
    • Authors: Reed; Brent N.; Gale, Stormi E.; Ramani, Gautam
      Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • The authors reply
    • Authors: Rizvi; Mahrukh S.; Gajic, Ognjen; Nei, Andrea M.; Barreto, Erin F.
      Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • High Flow Versus Standard Oxygen Therapy After Noninvasive Ventilation
           Withdrawal
    • Authors: Lazo; Kevin G.; Birnbaum, Brian; Esquinas, Antonio; Mina, Bushra A.
      Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • The authors reply
    • Authors: Longhini; Federico; Pisani, Lara; Nava, Stefano; Navalesi, Paolo
      Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Nonlinear Association Between Fluid Intake and Clinical Outcomes in
           Subarachnoid Hemorrhage
    • Authors: Du; Kailei; Cheng, Xuping; Zhang, Weimin
      Abstract: imageNo abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • The authors reply
    • Authors: Rass; Verena; Gaasch, Max; Ianosi, Bogdan-Andrei; Helbok, Raimund
      Abstract: imageNo abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • The “Underwater Part of the Iceberg” of Insulin Administration for
           Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State: Electrolytics
           Disorders
    • Authors: Jamme; Matthieu; Ben Hadj Salem, Omar; Mesnard, Laurent; Robert, Thomas
      Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • The authors reply
    • Authors: Firestone; Rachelle L.; Duby, Jeremiah J.
      Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Mortality Risk in Ventilator-Acquired Bacterial Pneumonia and
           Nonventilator ICU-Acquired Bacterial Pneumonia: Impact of Antimicrobial
           Timing and Associated Healthcare Cost
    • Authors: Olanipekun; Titilope; Snyder, Richard
      Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • Thromboelastography Predicts Thromboembolism in Critically Ill
           Coagulopathic Patients: Erratum
    • Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
  • The Effectiveness of α2 Agonists As Sedatives in Pediatric Critical Care:
           A Propensity Score-Matched Cohort Study: Erratum
    • Abstract: No abstract available
      PubDate: Tue, 01 Oct 2019 00:00:00 GMT-
       
 
 
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