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Critical Care Medicine
Journal Prestige (SJR): 3.116
Citation Impact (citeScore): 3
Number of Followers: 308  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0090-3493
Published by LWW Wolters Kluwer Homepage  [311 journals]
  • Cost-Effectiveness Studies in the ICU: A Systematic Review*
    • Authors: Wilcox; M. Elizabeth; Vaughan, Kelsey; Chong, Christopher A. K. Y.; Neumann, Peter J.; Bell, Chaim M.
      Abstract: imageObjectives: Cost-effectiveness analyses are increasingly used to aid decisions about resource allocation in healthcare; this practice is slow to translate into critical care. We sought to identify and summarize original cost-effectiveness studies presenting cost per quality-adjusted life year, incremental cost-effectiveness ratios, or cost per life-year ratios for treatments used in ICUs.Design: We conducted a systematic search of the English-language literature for cost-effectiveness analyses published from 1993 to 2018 in critical care. Study quality was assessed using the Drummond checklist.Setting: Critical care units.Patients or Subjects: Critical care patients.Interventions: Identified studies with cost-effectiveness analyses.Measurements and Main Results: We identified 97 studies published through 2018 with 156 cost-effectiveness ratios. Reported incremental cost-effectiveness ratios ranged from –$119,635 (hypothetical cohort of patients requiring either intermittent or continuous renal replacement therapy) to $876,539 (data from an acute renal failure study in which continuous renal replacement therapy was the most expensive therapy). Many studies reported favorable cost-effectiveness profiles (i.e., below $50,000 per life year or quality-adjusted life year). However, several therapies have since been proven harmful. Over 2 decades, relatively few cost-effectiveness studies in critical care have been published (average 4.6 studies per year). There has been a more recent trend toward using hypothetical cohorts and modeling scenarios without proven clinical data (2014–2018: 19/33 [58%]).Conclusions: Despite critical care being a significant healthcare cost burden there remains a paucity of studies in the literature evaluating its cost effectiveness.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Monocyte Distribution Width: A Novel Indicator of Sepsis-2 and Sepsis-3 in
           High-Risk Emergency Department Patients*
    • Authors: Crouser; Elliott D.; Parrillo, Joseph E.; Seymour, Christopher W.; Angus, Derek C.; Bicking, Keri; Esguerra, Vincent G.; Peck-Palmer, Octavia M.; Magari, Robert T.; Julian, Mark W.; Kleven, Jennifer M.; Raj, Paarth J.; Procopio, Gabrielle; Careaga, Diana; Tejidor, Liliana
      Abstract: imageObjectives: Most septic patients are initially encountered in the emergency department where sepsis recognition is often delayed, in part due to the lack of effective biomarkers. This study evaluated the diagnostic accuracy of peripheral blood monocyte distribution width alone and in combination with WBC count for early sepsis detection in the emergency department.Design: An Institutional Review Board approved, blinded, observational, prospective cohort study conducted between April 2017 and January 2018.Setting: Subjects were enrolled from emergency departments at three U.S. academic centers.Patients: Adult patients, 18–89 years, with complete blood count performed upon presentation to the emergency department, and who remained hospitalized for at least 12 hours. A total of 2,212 patients were screened, of whom 2,158 subjects were enrolled and categorized per Sepsis-2 criteria, such as controls (n = 1,088), systemic inflammatory response syndrome (n = 441), infection (n = 244), and sepsis (n = 385), and Sepsis-3 criteria, such as control (n = 1,529), infection (n = 386), and sepsis (n = 243).Interventions: The primary outcome determined whether an monocyte distribution width of greater than 20.0 U, alone or in combination with WBC, improves early sepsis detection by Sepsis-2 criteria. Secondary endpoints determined monocyte distribution width performance for Sepsis-3 detection.Measurements and Main Results: Monocyte distribution width greater than 20.0 U distinguished sepsis from all other conditions based on either Sepsis-2 criteria (area under the curve, 0.79; 95% CI, 0.76–0.82) or Sepsis-3 criteria (area under the curve, 0.73; 95% CI, 0.69–0.76). The negative predictive values for monocyte distribution width less than or equal to 20 U for Sepsis-2 and Sepsis-3 were 93% and 94%, respectively. Monocyte distribution width greater than 20.0 U combined with an abnormal WBC further improved Sepsis-2 detection (area under the curve, 0.85; 95% CI, 0.83–0.88) and as reflected by likelihood ratio and added value analyses. Normal WBC and monocyte distribution width inferred a six-fold lower sepsis probability.Conclusions: An monocyte distribution width value of greater than 20.0 U is effective for sepsis detection, based on either Sepsis-2 criteria or Sepsis-3 criteria, during the initial emergency department encounter. In tandem with WBC, monocyte distribution width is further predicted to enhance medical decision making during early sepsis management in the emergency department.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • National Performance on the Medicare SEP-1 Sepsis Quality Measure
    • Authors: Barbash; Ian J.; Davis, Billie; Kahn, Jeremy M.
      Abstract: imageObjectives: The Centers for Medicare and Medicaid Services requires hospitals to report compliance with a sepsis treatment bundle as part of its Inpatient Quality Reporting Program. We used recently released data from this program to characterize national performance on the sepsis measure, known as SEP-1.Design: Cross-sectional study of United States hospitals participating in the Centers for Medicare and Medicaid Services Hospital Inpatient Quality Reporting Program linked to Centers for Medicare and Medicaid Services’ Healthcare Cost Reporting Information System.Setting: General, short-stay, acute-care hospitals in the United States.Measurements and Main Results: We examined the hospital factors associated with reporting SEP-1 data, the hospital factors associated with performance on the SEP-1 measure, and the relationship between SEP-1 performance and performance on other quality measures related to time-sensitive medical conditions. A total of 3,283 hospitals were eligible for the analysis, of which 2,851 (86.8%) reported SEP-1 performance data. SEP-1 reporting was more common in larger, nonprofit hospitals. The most common reason for nonreporting was an inadequate case volume. Among hospitals reporting SEP-1 performance data, overall bundle compliance was generally low, but it varied widely across hospitals (mean and sd: 48.9% ± 19.4%). Compared with hospitals with worse SEP-1 performance, hospitals with better SEP-1 performance tended to be smaller, for-profit, nonteaching, and with intermediate-sized ICUs. Better hospital performance on SEP-1 was associated with higher rates of timely head CT interpretation for stroke patients (rho = 0.16; p < 0.001), more frequent aspirin administration for patients with chest pain or heart attacks (rho = 0.24; p < 0.001) and shorter median time to electrocardiogram for patients with chest pain (rho = –0.12; p < 0.001).Conclusions: The majority of eligible hospitals reported SEP-1 data, and overall bundle compliance was highly variable. SEP-1 performance was associated with structural hospital characteristics and performance on other measures of hospital quality, providing preliminary support for SEP-1 performance as a marker of timely hospital sepsis care.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Effect of Increasing Blood Pressure With Noradrenaline on the
           Microcirculation of Patients With Septic Shock and Previous Arterial
           Hypertension
    • Authors: Fiorese Coimbra; Karla Tuanny; de Freitas, Flávio Geraldo Rezende; Bafi, Antônio Tonete; Pinheiro, Tuanny Teixeira; Nunes, Nathaly Fonseca; de Azevedo, Luciano César Pontes; Machado, Flávia Ribeiro
      Abstract: imageObjectives: To assess whether an increase in mean arterial pressure in patients with septic shock and previous systemic arterial hypertension changes microcirculatory and systemic hemodynamic variables compared with patients without arterial hypertension (control).Design: Prospective, nonblinded, interventional study.Setting: Three ICUs in two teaching hospitals.Patients: After informed consent, we included patients older than 18 years with septic shock for at least 6 hours, sedated, and under mechanical ventilation. We paired patients with and without arterial hypertension by age.Interventions: After obtaining systemic and microcirculation baseline hemodynamic variables (time 0), we increased noradrenaline dose to elevate mean arterial pressure up to 85–90 mm Hg before collecting a new set of measurements (time 1).Measurements and Main Results: We included 40 patients (20 in each group). There was no significant difference in age between the groups. After the rise in mean arterial pressure, there was a significant increase in cardiac index and a slight but significant reduction in lactate in both groups. We observed a significant improvement in the proportion of perfused vessels (control: 57.2 ± 14% to 66 ± 14.8%; arterial hypertension: 61.4 ± 12.3% to 70.8 ± 7.1%; groups: p = 0.29; T0 and T1: p < 0.001; group and time interaction: p = 0.85); perfused vessels density (control: 15.6 ± 4 mm/mm2 to 18.6 ± 4.5 mm/mm2; arterial hypertension: 16.4 ± 3.5 mm/mm2 to 19.1 ± 3 mm/mm2; groups: p = 0.51; T0 and T1: p < 0.001; group and time interaction: p = 0.70), and microcirculatory flow index (control: 2.1 ± 0.6 to 2.4 ± 0.6; arterial hypertension: 2.1 ± 0.5 to 2.6 ± 0.2; groups: p = 0.71; T0 and T1: p = 0.002; group and time interaction: p = 0.45) in both groups.Conclusions: Increasing mean arterial pressure with noradrenaline in septic shock patients improves density and flow in small vessels of sublingual microcirculation. However, this improvement occurs both in patients with previous arterial hypertension and in those without arterial hypertension.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • At-Risk Drinking Is Independently Associated With Acute Kidney Injury in
           Critically Ill Patients
    • Authors: Gacouin; Arnaud; Lesouhaitier, Mathieu; Frerou, Aurelien; Painvin, Benoit; Reizine, Florian; Rafi, Sonia; Maamar, Adel; Le Tulzo, Yves; Tadié, Jean Marc
      Abstract: imageObjectives: Unhealthy use of alcohol and acute kidney injury are major public health problems, but little is known about the impact of excessive alcohol consumption on kidney function in critically ill patients. We aimed to determine whether at-risk drinking is independently associated with acute kidney injury in the ICU and at ICU discharge.Design: Prospective observational cohort study.Setting: A 21-bed polyvalent ICU in a university hospital.Patients: A total of 1,107 adult patients admitted over a 30-month period who had an ICU stay of greater than or equal to 3 days and in whom alcohol consumption could be assessed.Interventions: None.Measurements and Main Results: We assessed Kidney Disease Improving Global Outcomes stages 2–3 acute kidney injury in 320 at-risk drinkers (29%) and 787 non–at-risk drinkers (71%) at admission to the ICU, within 4 days after admission and at ICU discharge. The proportion of patients with stages 2–3 acute kidney injury at admission to the ICU (42.5% vs 18%; p < 0.0001) was significantly higher in at-risk drinkers than in non–at-risk drinkers. Within 4 days and after adjustment on susceptible and predisposing factors for acute kidney injury was performed, at-risk drinking was significantly associated with acute kidney injury for the entire population (odds ratio, 2.15; 1.60–2.89; p < 0.0001) in the subgroup of 832 patients without stages 2–3 acute kidney injury at admission to the ICU (odds ratio, 1.44; 1.02–2.02; p = 0.04) and in the subgroup of 971 patients without known chronic kidney disease (odds ratio, 1.92; 1.41–2.61; p < 0.0001). Among survivors, 22% of at-risk drinkers and 9% of non–at-risk drinkers were discharged with stages 2–3 acute kidney injury (p < 0.001).Conclusions: Our results suggest that chronic and current alcohol misuse in critically ill patients is associated with kidney dysfunction. The systematic and accurate identification of patients with alcohol misuse may allow for the prevention of acute kidney injury.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Recommendation of New Medical Alarms Based on Audibility, Identifiability,
           and Detectability in a Randomized, Simulation-Based Study
    • Authors: Bennett; Christopher; Dudaryk, Roman; Crenshaw, Nichole; Edworthy, Judy; McNeer, Richard
      Abstract: imageObjectives: Accurate and timely identification of existing audible medical alarms is not adequate in clinical settings. New alarms that are easily heard, quickly identifiable, and discernable from one another are indicated. The “auditory icons” (brief sounds that serve as metaphors for the events they represent) have been proposed as a replacement to the current international standard. The objective was to identify the best performing icons based on audibility and performance in a simulated clinical environment.Design: Three sets of icon alarms were designed using empirical methods. Subjects participated in a series of clinical simulation experiments that examined the audibility, identification accuracy, and response time of each of these icon alarms. A statistical model that combined the outcomes was used to rank the alarms in overall efficacy. We constructed the “best” and “worst” performing sets based on this ranking and prospectively validated these sets in a subsequent experiment with a new subject sample.Setting: Experiments were conducted in simulated ICU settings at the University of Miami.Subjects: Medical trainees were recruited from a convenience sample of nursing students and anesthesia residents at the institution.Interventions: In Experiment 1 (formative testing), subjects were exposed to one of the three sets of alarms; identical setting and instruments were used throughout. In Experiment 2 (summative testing), subjects were exposed to one of the two sets of alarms, assembled from the best and worst performing alarms from Experiment 1.Measurements and Main Results: For each alarm, we determined the minimum sound level to reach audibility threshold in the presence of background clinical noise, identification accuracy (percentage), and response time (seconds). We enrolled 123 medical trainees and professionals for participation (78 with < 6 yr of training). We identified the best performing icon alarms for each category, which matched or exceeded the other candidate alarms in identification accuracy and response time.Conclusions: We propose a set of eight auditory icon alarms that were selected through formative testing and validated through summative testing for adoption by relevant regulatory bodies and medical device manufacturers.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • A 360° Rotational Positioning Protocol of Organ Donors May Increase Lungs
           Available for Transplantation*
    • Authors: Mendez; Marissa A.; Fesmire, Alyssa J.; Johnson, Scott S.; Neel, Dustin R.; Markham, Lori E.; Olson, Jody C.; Ott, Melissa; Sangha, Harbaksh; Vasquez, Donald G.; Whitt, Stevan P.; Wilkins, Harry E. III; Moncure, Michael
      Abstract: imageObjectives: To evaluate the improvement in lung donation and immediate lung function after the implementation of a 360° rotational positioning protocol within an organ procurement organization in the Midwest.Design: Retrospective observational study.Setting: The Midwest Transplant Network from 2005 to 2017. Rotational positioning of donors began in 2008.Subjects: Potential deceased lung donors.Interventions: A 360° rotational protocol. Presence of immediate lung function in recipients, change in Pao2:Fio2 ratio during donor management, initial and final Pao2:Fio2 ratio, and proportion of lungs donated were measured. Outcomes were compared between rotated and nonrotated donors.Measurements and Main Results: A total of 693 donors were analyzed. The proportion of lung donations increased by 10%. The difference between initial Pao2:Fio2 ratio and final Pao2:Fio2 ratio was significantly different between rotated and nonrotated donors (36 ± 116 vs 104 ± 148; p < 0.001). Lungs transplanted from rotated donors had better immediate function than those from nonrotated donors (99.5% vs 68%; p < 0.001).Conclusions: There was a statistically significant increase in lung donations after implementing rotational positioning of deceased donors. Rotational positioning significantly increased the average difference in Pao2:Fio2 ratios. There was also superior lung function in the rotated group. The authors recommend that organ procurement organizations consider adopting a rotational positioning protocol for donors to increase the lungs available for transplantation.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Mitochondrial DNA Haplogroups and Delirium During Sepsis
    • Authors: Samuels; David C.; Hulgan, Todd; Fessel, Joshua P.; Billings, Frederic T. IV; Thompson, Jennifer L.; Chandrasekhar, Rameela; Girard, Timothy D.
      Abstract: imageObjectives: Studies suggest that mitochondrial dysfunction underlies some forms of sepsis-induced organ failure. We sought to test the hypothesis that variations in mitochondrial DNA haplogroup affect susceptibility to sepsis-associated delirium, a common manifestation of acute brain dysfunction during sepsis.Design: Retrospective cohort study.Setting: Medical and surgical ICUs at a large tertiary care center.Patients: Caucasian and African American adults with sepsis.Measurements and Main Results: We determined each patient’s mitochondrial DNA haplogroup using single-nucleotide polymorphisms genotyping data in a DNA databank and extracted outcomes from linked electronic medical records. We then used zero-inflated negative binomial regression to analyze age-adjusted associations between mitochondrial DNA haplogroups and duration of delirium, identified using the Confusion Assessment Method for the ICU. Eight-hundred ten patients accounted for 958 sepsis admissions, with 802 (84%) by Caucasians and 156 (16%) by African Americans. In total, 795 patient admissions (83%) involved one or more days of delirium. The 7% of Caucasians belonging to mitochondrial DNA haplogroup clade IWX experienced more delirium than the 49% in haplogroup H, the most common Caucasian haplogroup (age-adjusted rate ratio for delirium 1.36; 95% CI, 1.13–1.64; p = 0.001). Alternatively, among African Americans the 24% in haplogroup L2 experienced less delirium than those in haplogroup L3, the most common African haplogroup (adjusted rate ratio for delirium 0.60; 95% CI, 0.38–0.94; p = 0.03).Conclusions: Variations in mitochondrial DNA are associated with development of and protection from delirium in Caucasians and African Americans during sepsis. Future studies are now required to determine whether mitochondrial DNA and mitochondrial dysfunction contribute to the pathogenesis of delirium during sepsis so that targeted treatments can be developed.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Early Enteral Nutrition in Patients Undergoing Sustained Neuromuscular
           Blockade: A Propensity-Matched Analysis Using a Nationwide Inpatient
           Database*
    • Authors: Ohbe; Hiroyuki; Jo, Taisuke; Matsui, Hiroki; Fushimi, Kiyohide; Yasunaga, Hideo
      Abstract: imageObjectives: Whether enteral nutrition should be postponed in patients undergoing sustained treatment with neuromuscular blocking agents remains unclear. We evaluated the association between enteral nutrition initiated within 2 days of sustained neuromuscular blocking agent treatment and in-hospital mortality.Design: Retrospective administrative database study from July 2010 to March 2016.Setting: More than 1,200 acute care hospitals covering approximately 90% of all tertiary-care emergency hospitals in Japan.Patients: Mechanically ventilated patients, who had undergone sustained treatment with neuromuscular blocking agents in an ICU, were retrospectively reviewed. We defined patients who received sustained treatment with neuromuscular blocking agents as those who received either rocuronium at greater than or equal to 250 mg/d or vecuronium at greater than or equal to 50 mg/d for at least 2 consecutive days.Interventions: Enteral nutrition started within 2 days from the initiation of neuromuscular blocking agents (defined as early enteral nutrition).Measurements and Main Results: We identified 2,340 eligible patients during the 69-month study period. Of these, 378 patients (16%) had received early enteral nutrition. One-to-three propensity score matching created 374–1,122 pairs. The in-hospital mortality rate was significantly lower in the early than late enteral nutrition group (risk difference, –6.3%; 95% CI, –11.7% to –0.9%). There was no significant difference in the rate of hospital pneumonia between the two groups (risk difference, 2.8%; 95% CI, –2.7% to 8.3%). Length of hospital stay among survivors was significantly shorter in the early compared with the late enteral nutrition group (risk difference, –11.4 d; 95% CI, –19.1 to –3.7 d). There was no significant difference between the two groups in length of ICU stay or length of mechanical ventilation among survivors.Conclusions: According to this retrospective database study, early enteral nutrition may be associated with lower in-hospital mortality with no increase in-hospital pneumonia in patients undergoing sustained treatment with neuromuscular blocking agents.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Predictive Accuracy of Quick Sequential Organ Failure Assessment for
           Hospital Mortality Decreases With Increasing Comorbidity Burden Among
           Patients Admitted for Suspected Infection*
    • Authors: Parks Taylor; Stephanie; McWilliams, Andrew; Taylor, Brice T.; Heffner, Alan C.; Chou, Shih-Hsiung; Runyon, Michael; Cunningham, Kyle; Evans, Susan L.; Gibbs, Michael; Russo, Mark; Rossman, Whitney; Murphy, Stephanie E.; Kowalkowski, Marc A.; Atrium Health Acute Care Outcomes Research Network Investigators
      Abstract: imageObjectives: Evaluate the accuracy of the quick Sequential Organ Failure Assessment tool to predict mortality across increasing levels of comorbidity burden.Design: Retrospective observational cohort study.Setting: Twelve acute care hospitals in the Southeastern United States.Patients: A total of 52,187 patients with suspected infection presenting to the Emergency Department between January 2014 and September 2017.Interventions: None.Measurements and Main Results: The primary outcome was hospital mortality. We used electronic health record data to calculate quick Sequential Organ Failure Assessment risk scores from vital signs and laboratory values documented during the first 24 hours. We calculated Charlson Comorbidity Index scores to quantify comorbidity burden. We constructed logistic regression models to evaluate differences in the performance of quick Sequential Organ Failure Assessment greater than or equal to 2 to predict hospital mortality in patients with no documented (Charlson Comorbidity Index = 0), low (Charlson Comorbidity Index = 1–2), moderate (Charlson Comorbidity Index = 3–4), or high (Charlson Comorbidity Index ≥ 5) comorbidity burden. Among the cohort, 2,030 patients died in the hospital (4%). No comorbidities were documented for 5,038 patients (10%), 9,235 patients (18%) had low comorbidity burden, 12,649 patients (24%) had moderate comorbidity burden, and 25,265 patients (48%) had high comorbidity burden. Overall model discrimination for quick Sequential Organ Failure Assessment greater than or equal to 2 was the area under the receiver operating characteristic curve of 0.71 (95% CI, 0.69–0.72). A model including both quick Sequential Organ Failure Assessment and Charlson Comorbidity Index had improved discrimination compared with Charlson Comorbidity Index alone (area under the receiver operating characteristic curve, 0.77; 95% CI, 0.76–0.78 vs area under the curve, 0.61; 95% CI, 0.59–0.62). Discrimination was highest among patients with no documented comorbidities (quick Sequential Organ Failure Assessment area under the receiver operating characteristic curve, 0.84; 95% CI; 0.79–0.89) and lowest among high comorbidity patients (quick Sequential Organ Failure Assessment area under the receiver operating characteristic curve, 0.67; 95% CI, 0.65–0.68). The strength of association between quick Sequential Organ Failure Assessment and mortality ranged from 30.5-fold increased likelihood in patients with no comorbidities to 4.7-fold increased likelihood in patients with high comorbidity.Conclusions: The accuracy of quick Sequential Organ Failure Assessment to predict hospital mortality diminishes with increasing comorbidity burden. Patients with comorbidities may have baseline abnormalities in quick Sequential Organ Failure Assessment variables that reduce predictive accuracy. Additional research is needed to better understand quick Sequential Organ Failure Assessment performance across different comorbid conditions with modification that incorporates the context of changes to baseline variables.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Association of Elevated Plasma Interleukin-18 Level With Increased
           Mortality in a Clinical Trial of Statin Treatment for Acute Respiratory
           Distress Syndrome*
    • Authors: Rogers; Angela J.; Guan, Jiazhen; Trtchounian, Anna; Hunninghake, Gary M.; Kaimal, Rajani; Desai, Manisha; Kozikowski, Lori-Ann; DeSouza, Lesley; Mogan, Susan; Liu, Kathleen D.; Matthay, Michael A.; Steingrub, Jay; Wheeler, Art; Yoon, Joo Heon; Nakahira, Kiichi; Choi, Augustine M.; Baron, Rebecca M.
      Abstract: imageObjective: A high plasma level of inflammasome mediator interleukin-18 was associated with mortality in observational acute respiratory distress syndrome cohorts. Statin exposure increases both inflammasome activation and lung injury in mouse models. We tested whether randomization to statin therapy correlated with increased interleukin-18 in the ARDS Network Statins for Acutely Injured Lungs from Sepsis trial.Design: Retrospective analysis of randomized controlled clinical trial.Setting: Multicenter North American clinical trial, the ARDS Network Statins for Acutely Injured Lungs from Sepsis.Patients: Six hundred eighty-three subjects with infection-related acute respiratory distress syndrome, representing 92% of the original trial population.Interventions: Random assignment of rosuvastatin or placebo for up to 28 days or 3 days after ICU discharge.Measurements and Main Results: We measured plasma interleukin-18 levels in all Statins for Acutely Injured Lungs from Sepsis patients with sample available at day 0 (baseline, n = 683) and day 3 (after randomization, n = 588). We tested the association among interleukin-18 level at baseline, rising interleukin-18, and the impact of statin therapy on 60-day mortality, adjusting for severity of illness. Baseline plasma interleukin-18 level greater than or equal to 800 pg/mL was highly associated with 60-day mortality, with a hazard of death of 2.3 (95% CI, 1.7–3.1). Rising plasma interleukin-18 was also associated with increased mortality. For each unit increase in log2 (interleukin-18) at day 3 compared with baseline, the hazard of death increased by 2.3 (95% CI, 1.5–3.5). Subjects randomized to statin were significantly more likely to experience a rise in plasma interleukin-18 levels. Subjects with acute kidney injury, shock, low baseline interleukin-18, and those not receiving systemic corticosteroids were more likely to experience rising interleukin-18. Randomization to statin therapy was associated with rising in interleukin-18 in all of those subsets, however.Conclusions: Elevated baseline plasma interleukin-18 was associated with higher mortality in sepsis-induced acute respiratory distress syndrome. A rise in plasma interleukin-18 was also associated with increased mortality and was more common in subjects randomized to statin therapy in this clinical trial.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Extracorporeal Membrane Oxygenation for Septic Shock
    • Authors: Falk; Lars; Hultman, Jan; Broman, Lars Mikael
      Abstract: imageObjectives: Septic shock carries a high mortality risk. Studies have indicated that patients with septic shock may benefit from extracorporeal membrane oxygenation. In most studies, patients exhibited shock due to myocardial dysfunction rather than distributive/vasoplegic shock. One proposed theory is that venoarterial extracorporeal membrane oxygenation alleviates a failing myocardial function.Design: Retrospective observational study.Setting: Single-center, high-volume extracorporeal membrane oxygenation unit.Patients: All patients treated for septic shock between 2012 and 2017 with an age greater than 18 years old, fulfilling septic shock criteria according to “Sepsis-3” at acceptance for extracorporeal membrane oxygenation, presence of cardiocirculatory failure requiring a support equivalent to a Vasoactive Inotropic Score greater than 50 to reach a mean arterial pressure greater than 65 mm Hg despite adequate fluid resuscitation, were included.Interventions: None.Measurements and Main Results: Thirty-seven patients, mean age 54.7 years old, were included. Median Simplified Acute Physiology Score-3 score was 86 and Sequential Organ Failure Assessment 16. Twenty-seven patients were submitted to venoarterial and 10 patients to venovenous extracorporeal membrane oxygenation. Hospital survival was 90% for septic shock with left ventricular failure and 64.7% in patients with distributive shock. At long-term follow-up at 46.1 months, total survival was 59.5%. Commencement of venovenous extracorporeal membrane oxygenation and more organ failures at admission showed a less favorable outcome in terms of hospital and long-term survival.Conclusions: The current results add not only to the growing evidence of the benefit of venoarterial extracorporeal membrane oxygenation for septic cardiomyopathy but also indicate improved hospital survival in distributive septic shock.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Calorie Intake During Status Epilepticus and Outcome: A 5-Year Cohort
           Study
    • Authors: Rybitschka; Anja; Semmlack, Saskia; Kaplan, Peter W.; De Marchis, Gian Marco; Rüegg, Stephan; Marsch, Stephan; Sutter, Raoul
      Abstract: imageObjectives: Recommendations regarding nutrition during status epilepticus are lacking, and it is unclear whether restriction of calorie intake would result in beneficial effects or potential harm. We thus aimed to investigate associations between daily calorie intake and outcome in adult status epilepticus patients deriving from a 5-year cohort with a systematic and prospective collection of nutritional data.Design: Retrospective observational study.Setting: Medical ICUs at a tertiary academic medical care center.Patients: Consecutive patients with status epilepticus treated at the ICUs from 2012 to 2016 were included.Interventions: None.Measurements and Main Results: All patients with status epilepticus were monitored regarding nutrition support provided according to the guidelines. Relative risks of no return to baseline were estimated by Poisson regression with robust error variance and adjusted for potential confounders. Of 203 patients, 86 (42%) had return to baseline. Metabolic characteristics of patients with and without return to baseline did not differ. Patients without return to baseline received more calories and proteins per status epilepticus day, and increasing nutritional support was associated with ventilator-associated pneumonia (relative risk, 1.19; 95% CI, 1.09–1.28). Multivariable regression analysis revealed significant increases in relative risks for no return to baseline with every percent of days with nutrition (relative risk, 1.35; 95% CI, 1.05–1.74), with every 100 kcal (relative risk, 1.01; 95% CI, 1.002–1.01), and gram of protein intake (relative risk, 1.01; 95% CI, 1.001–1.01) per status epilepticus day, independent of potential confounders (including fatal etiology, duration and severity of status epilepticus, Charlson comorbidity index, and treatment with anesthetics).Conclusions: Our results indicate that increased calorie intake during status epilepticus is independently associated with unfavorable outcome. These findings require further validation and investigations into potential mediators, such as induction of ketogenesis, immunomodulating effects, and/or reduction of ICU-associated complications, such as infections.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Association Between Critical Care Admissions and Cognitive Trajectories in
           Older Adults*
    • Authors: Schulte; Phillip J.; Warner, David O.; Martin, David P.; Deljou, Atousa; Mielke, Michelle M.; Knopman, David S.; Petersen, Ronald C.; Weingarten, Toby N.; Warner, Matthew A.; Rabinstein, Alejandro A.; Hanson, Andrew C.; Schroeder, Darrell R.; Sprung, Juraj
      Abstract: imageObjectives: Patients requiring admission to an ICU may subsequently experience cognitive decline. Our objective was to investigate longitudinal cognitive trajectories in older adults hospitalized in ICUs. We hypothesized that individuals hospitalized for critical illness develop greater cognitive decline compared with those who do not require ICU admission.Design: A retrospective cohort study using prospectively collected cognitive scores of participants enrolled in the Mayo Clinic Study of Aging and ICU admissions retrospectively ascertained from electronic medical records. A covariate-adjusted linear mixed effects model with random intercepts and slopes assessed the relationship between ICU admissions and the slope of global cognitive z scores and domains scores (memory, attention/executive, visuospatial, and language).Setting: ICU admissions and cognitive scores in the Mayo Clinic Study of Aging from October 1, 2004, to September 11, 2017.Patients: Nondemented participants age 50 through 91 at enrollment in the Mayo Clinic Study of Aging with an initial cognitive assessment and at least one follow-up visit.Interventions: None.Measurements and Main Results: Of 3,673 participants, 372 had at least one ICU admission with median (25–75th percentile) follow-up after first ICU admission of 2.5 years (1.2–4.4 yr). For global cognitive z score, admission to an ICU was associated with greater decline in scores over time compared with participants not requiring ICU admission (difference in annual slope = –0.028; 95% CI, –0.044 to –0.012; p < 0.001). ICU admission was associated with greater declines in memory (–0.029; 95% CI, –0.047 to –0.011; p = 0.002), attention/executive (–0.020; 95% CI, –0.037 to –0.004; p = 0.016), and visuospatial (–0.013; 95% CI, –0.026 to –0.001; p = 0.041) domains. ICU admissions with delirium were associated with greater declines in memory (interaction p = 0.006) and language (interaction p = 0.002) domains than ICU admissions without delirium.Conclusions: In older adults, ICU admission was associated with greater long-term cognitive decline compared with patients without ICU admission. These findings were more pronounced in those who develop delirium while in the ICU.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Intracranial Hypertension and Cerebral Perfusion Pressure Insults in Adult
           Hypertensive Intraventricular Hemorrhage: Occurrence and Associations With
           Outcome
    • Authors: Ziai; Wendy C.; Thompson, Carol B.; Mayo, Steven; McBee, Nichol; Freeman, William D.; Dlugash, Rachel; Ullman, Natalie; Hao, Yi; Lane, Karen; Awad, Issam; Hanley, Daniel F.; for the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR III Investigators
      Abstract: imageObjectives: Elevated intracranial pressure and inadequate cerebral perfusion pressure may contribute to poor outcomes in hypertensive intraventricular hemorrhage. We characterized the occurrence of elevated intracranial pressure and low cerebral perfusion pressure in obstructive intraventricular hemorrhage requiring extraventricular drainage.Design: Prospective observational cohort.Setting: ICUs of 73 academic hospitals.Patients: Four hundred ninety-nine patients enrolled in the CLEAR III trial, a multicenter, randomized study to determine if extraventricular drainage plus intraventricular alteplase improved outcome versus extraventricular drainage plus saline.Interventions: Intracranial pressure and cerebral perfusion pressure were recorded every 4 hours, analyzed over a range of thresholds, as single readings or spans (≥ 2) of readings after adjustment for intracerebral hemorrhage severity. Impact on 30- and 180-days modified Rankin Scale scores was assessed, and receiver operating curves were analyzed to identify optimal thresholds.Measurements and Main Results: Of 21,954 intracranial pressure readings, median interquartile range 12 mm Hg (8–16), 9.7% were greater than 20 mm Hg and 1.8% were greater than 30 mm Hg. Proportion of intracranial pressure readings from greater than 18 to greater than 30 mm Hg and combined intracranial pressure greater than 20 plus cerebral perfusion pressure less than 70 mm Hg were associated with day-30 mortality and partially mitigated by intraventricular alteplase. Proportion of cerebral perfusion pressure readings from less than 65 to less than 90 mm Hg and intracranial pressure greater than 20 mm Hg in spans were associated with both 30-day mortality and 180-day mortality. Proportion of cerebral perfusion pressure readings from less than 65 to less than 90 mm Hg and combined intracranial pressure greater than 20 plus cerebral perfusion pressure less than 60 mm Hg were associated with poor day-30 modified Rankin Scale, whereas cerebral perfusion pressure less than 65 and less than 75 mm Hg were associated with poor day-180 modified Rankin Scale.Conclusions: Elevated intracranial pressure and inadequate cerebral perfusion pressure are not infrequent during extraventricular drainage for severe intraventricular hemorrhage, and level and duration predict higher short-term mortality and long-term mortality. Burden of low cerebral perfusion pressure was also associated with poor short- and long-term outcomes and may be more significant than intracranial pressure. Adverse consequences of intracranial pressure-time burden and cerebral perfusion pressure-time burden should be tested prospectively as potential thresholds for therapeutic intervention.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Growth and Changing Characteristics of Pediatric Intensive Care
           2001–2016
    • Authors: Horak; Robin V.; Griffin, John F.; Brown, Ann-Marie; Nett, Sholeen T.; Christie, LeeAnn M.; Forbes, Michael L.; Kubis, Sherri; Li, Simon; Singleton, Marcy N.; Verger, Judy T.; Markovitz, Barry P.; Burns, Jeffrey P.; Chung, Sarita A.; Randolph, Adrienne G.; on behalf of the Pediatric Acute Lung Injury Sepsis Investigator’s (PALISI Network
      Abstract: imageObjectives: We assessed the growth, distribution, and characteristics of pediatric intensive care in 2016.Design: Hospitals with PICUs were identified from prior surveys, databases, online searching, and clinician networking. A structured web-based survey was distributed in 2016 and compared with responses in a 2001 survey.Setting: PICUs were defined as a separate unit, specifically for the treatment of children with life-threatening conditions. PICU hospitals contained greater than or equal to 1 PICU.Subjects: Physician medical directors and nurse managers.Interventions: None.Measurements and Main Results: PICU beds per pediatric population (< 18 yr), PICU bed distribution by state and region, and PICU characteristics and their relationship with PICU beds were measured. Between 2001 and 2016, the U.S. pediatric population grew 1.9% to greater than 73.6 million children, and PICU hospitals decreased 0.9% from 347 to 344 (58 closed, 55 opened). In contrast, PICU bed numbers increased 43% (4,135 to 5,908 beds); the median PICU beds per PICU hospital rose from 9 to 12 (interquartile range 8, 20 beds). PICU hospitals with greater than or equal to 15 beds in 2001 had significant bed growth by 2016, whereas PICU hospitals with less than 15 beds experienced little average growth. In 2016, there were eight PICU beds per 100,000 U.S. children (5.7 in 2001), with U.S. census region differences in bed availability (6.8 to 8.8 beds/100,000 children). Sixty-three PICU hospitals (18%) accounted for 47% of PICU beds. Specialized PICUs were available in 59 hospitals (17.2%), 48 were cardiac (129% growth). Academic affiliation, extracorporeal membrane oxygenation availability, and 24-hour in-hospital intensivist staffing increased with PICU beds per hospital.Conclusions: U.S. PICU bed growth exceeded pediatric population growth over 15 years with a relatively small percentage of PICU hospitals containing almost half of all PICU beds. PICU bed availability is variable across U.S. states and regions, potentially influencing access to care and emergency preparedness.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Should Patients With Acute Respiratory Distress Syndrome on Venovenous
           Extracorporeal Membrane Oxygenation Have Ventilatory Support Reduced to
           the Lowest Tolerable Settings' Yes
    • Authors: Zakhary; Bishoy; Fan, Eddy; Slutsky, Arthur
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Should Patients With Acute Respiratory Distress Syndrome on Venovenous
           Extracorporeal Membrane Oxygenation Have Ventilatory Support Reduced to
           the Lowest Tolerable Settings' No
    • Authors: Shekar; Kiran; Brodie, Daniel
      Abstract: No abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Nudges in the Care of the Critically Ill*
    • Authors: Wallace; David J.; Drake, Coleman; Mohan, Deepika
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Sepsis: From Little Findings Big Ideas Grow*
    • Authors: Parker; Robert I.
      Abstract: No abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Changing the Position: Iterative Improvements in the Chain of Lung
           Transplantation*
    • Authors: Ball; Jonathan
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • To Feed or Not to Feed: What to Do for Patients Receiving Sustained
           Neuromuscular Blockade'*
    • Authors: Gerlach; Anthony T.
      Abstract: No abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Risk Stratification Tools in Sepsis: From Acute Physiology and Chronic
           Health Evaluation to Quick Sequential Organ Failure Assessment*
    • Authors: Lee; Jessica T.; Mikkelsen, Mark E.
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Inflammasomes Assemble: Cytoplasmic Guardians or Fallen Heroes'*
    • Authors: Sinha; Pratik; Calfee, Carolyn S.
      Abstract: No abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Understanding Cognitive Outcome Trajectories After Critical Illness*
    • Authors: Hopkins; Ramona O.
      Abstract: No abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Training for Competence in Central Venous Catheter Placement in Pediatric
           Patients—What Are We Missing'*
    • Authors: Mariscalco; M. Michele
      Abstract: No abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Biphasic Release of the Alarmin High Mobility Group Box 1 Protein Early
           After Trauma Predicts Poor Clinical Outcome
    • Authors: Ottestad; William; Rognes, Ingrid N.; Pischke, Soeren E.; Mollnes, Tom E.; Andersson, Ulf; Eken, Torsten
      Abstract: imageObjectives: The causal role of the prototype alarmin high mobility group box 1 protein in systemic inflammation and remote organ injury after trauma and shock is established in animal models but not in humans. Our aim was therefore to determine high mobility group box 1 protein concentration kinetics with high time resolution during the first hours after trauma in individual patients and investigate the association with outcome.Design: Prospective single-center observational study.Setting: University hospital Level I trauma center.Patients: Convenience recruitment of 136 trauma patients.Interventions: None.Measurements and Main Results: Total plasma high mobility group box 1 protein levels were analyzed with enzyme-linked immunosorbent assay in repeated samples. Relationships between predefined predictor variables and outcome were examined in multivariable linear regression models. Ventilator-free days was used as primary outcome measure. Two distinct high mobility group box 1 protein release phases were identified. An initial exponential decay phase with half-life 26 minutes was not correlated with outcome. In contrast, a second high mobility group box 1 protein wave peaking 3–6 hours after trauma in the most severely injured and physiologically deranged patients was consistently the most important predictor of outcome in our multivariable models, rendering all other predictor variables insignificant except for smaller contributions from age and sex, and of admission base excess for maximal creatinine concentration.Conclusions: High mobility group box 1 protein was released in two consecutive phases. Only the second high mobility group box 1 protein wave was a significant predictor of outcome. Patients with a high high mobility group box 1 protein concentration between 3 and 6 hours after trauma might hypothetically benefit from high mobility group box 1 protein-specific antagonist therapy.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Glomerular Hyper- and Hypofiltration During Acute Circulatory Failure:
           Iohexol-Based Gold-Standard Descriptive Study
    • Authors: Salmon Gandonnière; Charlotte; Helms, Julie; Le Tilly, Olivier; Benz-de Bretagne, Isabelle; Bretagnol, Anne; Bodet-Contentin, Laetitia; Mercier, Emmanuelle; Halimi, Jean-Michel; Benzékri-Lefèvre, Dalila; Meziani, Ferhat; Barin-Le Guellec, Chantal; Ehrmann, Stephan; on behalf of the Clinical Research in Intensive Care Research in SEPsis (CRICS-TriggerSep Network
      Abstract: imageObjective: To assess glomerular filtration rate in the early phase of acute circulatory failure by measuring iohexol plasma clearance.Design: Interventional prospective multicentric study.Setting: Three French ICUs in tertiary teaching hospitals.Patients: Patients with acute circulatory failure within 12 hours after ICU admission.Interventions: IV administration of a nontoxic 5-mL dose of iohexol. Collection of nine arterial blood samples over 24 hours for iohexol plasma concentration measurements. Iohexol clearance calculation with a population pharmacokinetic model. Iohexol clearance was an estimation of the mean glomerular filtration rate over 24 hours.Measurements and Main Results: Among 99 included patients, we could calculate iohexol clearance for 85. The median iohexol clearance was 31 mL/min (interquartile range, 16–44). According to iohexol clearance, 41 patients (48%) had severe hypofiltration (clearance, < 30 mL/min), 29 (34%) had moderate hypofiltration, and 10 (12%) had mild hypofiltration (clearance, 30–60 and 60–90 mL/min, respectively). Four patients (5%) had normal glomerular filtration rate, and only one (1%) showed hyperfiltration (clearance,> 130 mL/min). Urinary creatinine clearance underestimated renal impairment in one patient out of two; the bias of iohexol clearance toward 24-hour urinary creatinine clearance over the same period was –18.1 mL/min (limits of agreement, –73.5 to 37.4).Conclusions: We demonstrated the feasibility of iohexol clearance measurement in unstable critically ill patients. Normal kidney function is exceptional during the early phase of acute circulatory failure. Glomerular filtration rate estimation by urinary creatinine clearance frequently fails to detect renal impairment. Hyperfiltration is very infrequent.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Trends and Outcomes in Sepsis Hospitalizations With and Without Atrial
           Fibrillation: A Nationwide Inpatient Analysis
    • Authors: Desai; Rupak; Hanna, Bishoy; Singh, Sandeep; Omar, Ahmed; Deshmukh, Abhishek; Kumar, Gautam; Foreman, Marilyn G.; Sachdeva, Rajesh
      Abstract: imageObjectives: Atrial fibrillation is frequently seen in sepsis-related hospitalizations. However, large-scale contemporary data from the United States comparing outcomes among sepsis-related hospitalizations with versus without atrial fibrillation are limited. The aim of our study was to assess the frequency of atrial fibrillation and its impact on outcomes of sepsis-related hospitalizations.Design: Retrospective cohort study.Setting: The National Inpatient Sample databases (2010–2014).Patients: Primary discharge diagnosis of sepsis with and without atrial fibrillation were identified using prior validated International Classification of Diseases, 9th Edition, Clinical Modification codes.Interventions: None.Measurements and Main Results: Overall, 5,808,166 hospitalizations with the primary diagnosis of sepsis, of which 19.4% (1,126,433) were associated with atrial fibrillation. The sepsis-atrial fibrillation cohort consisted of older (median [interquartile range] age of 79 yr [70–86 yr] vs 67 yr [53–79 yr]; p < 0.001) white (80.9% vs 68.8%; p < 0.001) male (51.1% vs 47.5%; p < 0.001) patients with an extended length of stay (median [interquartile range] 6 d [4–11 d] vs 5 d [3–9 d]; p < 0.001) and higher hospitalization charges (median [interquartile range] $44,765 [$23,234–$88,657] vs $35,737 [$18,767–$72,220]; p < 0.001) as compared with the nonatrial fibrillation cohort. The all-cause mortality rate in the sepsis-atrial fibrillation cohort was significantly higher (18.4% and 11.9%; p = 0.001) as compared with those without atrial fibrillation. Although all-cause mortality (20.4% vs 16.6%) and length of stay (median [interquartile range] 7 d [4–11 d] vs 6 d [4–10 d]) decreased between 2010 and 2014, hospitalization charges increased (median [interquartile range] $41,783 [$21,430–$84,465] vs $46,251 [$24,157–$89,995]) in the sepsis-atrial fibrillation cohort. The greatest predictors of mortality in the atrial fibrillation-sepsis cohort were African American race, female gender, advanced age, and the presence of medical comorbidities.Conclusions: The presence of atrial fibrillation among sepsis-related hospitalizations is a marker of poor prognosis and increased mortality. Although we observed rising trends in sepsis and sepsis-atrial fibrillation–related hospitalizations during the study period, the rate and odds of mortality progressively decreased.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Intra-Abdominal Hypertension Is Responsible for False Negatives to the
           Passive Leg Raising Test
    • Authors: Beurton; Alexandra; Teboul, Jean-Louis; Girotto, Valentina; Galarza, Laura; Anguel, Nadia; Richard, Christian; Monnet, Xavier
      Abstract: imageObjectives: To compare the passive leg raising test ability to predict fluid responsiveness in patients with and without intra-abdominal hypertension.Design: Observational study.Setting: Medical ICU.Patients: Mechanically ventilated patients monitored with a PiCCO2 device (Pulsion Medical Systems, Feldkirchen, Germany) in whom fluid expansion was planned, with (intra-abdominal hypertension+) and without (intra-abdominal hypertension–) intra-abdominal hypertension, defined by an intra-abdominal pressure greater than or equal to 12 mm Hg (bladder pressure).Interventions: We measured the changes in cardiac index during passive leg raising and after volume expansion. The passive leg raising test was defined as positive if it increased cardiac index greater than or equal to 10%. Fluid responsiveness was defined by a fluid-induced increase in cardiac index greater than or equal to 15%.Measurements and Main Results: We included 60 patients, 30 without intra-abdominal hypertension (15 fluid responders and 15 fluid nonresponders) and 30 with intra-abdominal hypertension (21 fluid responders and nine fluid nonresponders). The intra-abdominal pressure at baseline was 4 ± 3 mm Hg in intra-abdominal hypertension– and 20 ± 6 mm Hg in intra-abdominal hypertension+ patients (p < 0.01). In intra-abdominal hypertension– patients with fluid responsiveness, cardiac index increased by 25% ± 19% during passive leg raising and by 35% ± 14% after volume expansion. The passive leg raising test was positive in 14 patients. The passive leg raising test was negative in all intra-abdominal hypertension– patients without fluid responsiveness. In intra-abdominal hypertension+ patients with fluid responsiveness, cardiac index increased by 10% ± 14% during passive leg raising (p = 0.01 vs intra-abdominal hypertension– patients) and by 32% ± 18% during volume expansion (p = 0.72 vs intra-abdominal hypertension– patients). Among these patients, the passive leg raising test was negative in 15 patients (false negatives) and positive in six patients (true positives). Among the nine intra-abdominal hypertension+ patients without fluid responsiveness, the passive leg raising test was negative in all but one patient. The area under the receiver operating characteristic curve of the passive leg raising test for detecting fluid responsiveness was 0.98 ± 0.02 (p < 0.001 vs 0.5) in intra-abdominal hypertension– patients and 0.60 ± 0.11 in intra-abdominal hypertension+ patients (p = 0.37 vs 0.5).Conclusions: Intra-abdominal hypertension is responsible for some false negatives to the passive leg raising test.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Continuation of Newly Initiated Midodrine Therapy After Intensive Care and
           Hospital Discharge: A Single-Center Retrospective Study
    • Authors: Rizvi; Mahrukh S.; Nei, Andrea M.; Gajic, Ognjen; Mara, Kristin C.; Barreto, Erin F.
      Abstract: imageObjectives: Midodrine is an α1-agonist approved for orthostatic hypotension. Recently, it has received attention as an oral vasopressor to facilitate ICU discharge. The purpose of this study was to identify the incidence of continuation of newly initiated midodrine upon ICU and hospital discharge and identify risk factors associated with its occurrence.Design: Single-center retrospective study.Setting: ICU patients from January 2011 to October 2016 at Mayo Clinic, Rochester.Patients: Adult patients admitted to any ICU who received new midodrine for hypotension and survived to discharge.Interventions: None.Measurements and Main Results: During the study period, 1,010 patients were newly started on midodrine and survived to ICU discharge. Midodrine was continued in 67% (672/1,010) of patients at ICU discharge. Admission to cardiovascular surgery ICU and mixed medical/surgical ICU was a risk factor for midodrine continuation at ICU discharge (odds ratio, 3.94 [2.50–6.21] and 2.03 [1.29–3.20], respectively). At hospital discharge, 34% (311/909) of patients were continued on midodrine therapy. History of congestive heart failure predicted midodrine continuation at hospital discharge (odds ratio, 1.49 [1.05–2.12]). Hypertension and use of mechanical ventilation were associated with a decreased odds of midodrine prescription at both ICU and hospital discharge. Of those discharged from the ICU or hospital on midodrine, 50% were concomitantly prescribed antihypertensives. Discharge from the ICU on midodrine was associated with a significantly shorter ICU length of stay (7.5 ± 8.9 vs 10.6 ± 13.4 d) and reduced risk of in-hospital mortality (hazard ratio, 0.47 [95% CI, 0.32–0.70]; p < 0.001), despite no difference in baseline severity of illness scores. In contrast, patients discharged from the hospital on midodrine had a higher risk of 1-year mortality (hazard ratio, 1.60 [95% CI, 1.26–2.04]; p < 0.001).Conclusions: This study established a high prevalence of midodrine continuation in transitions of care. The risks and benefits of this practice remain unclear. Future studies should explore the impact of this practice on patient outcomes and resource utilization. These insights could be used to model interventions for proper tapering, discontinuation, or follow-up of new start midodrine.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Assessing Competence in Central Venous Catheter Placement by Pediatric
           Critical Care Fellows: A National Survey Study*
    • Authors: Boyer; Donald L.; Zurca, Adrian D.; Mason, Katherine; Mink, Richard; Petrillo, Toni; Schuette, Jennifer; Tcharmtchi, M. Hossein; Winkler, Margaret; Fleming, Geoffrey M.; Turner, David A.; for the Education in Pediatric Intensive Care (E.P.I.C. Investigators
      Abstract: imageObjectives: To describe the current approach to initial training, ongoing skill maintenance, and assessment of competence in central venous catheter placement by pediatric critical care medicine fellows, a subset of trainees in whom this skill is required.Design: Cross-sectional internet-based survey with deliberate sampling.Setting: United States pediatric critical care medicine fellowship programs.Subjects: Pediatric critical care medicine program directors of Accreditation Council for Graduate Medical Education-accredited fellowship programs.Interventions: None.Measurements and Main Results: A working group of the Education in Pediatric Intensive Care Investigators research collaborative conducted a national study to assess the degree of standardization of training and competence assessment of central venous catheter placement across pediatric critical care medicine fellowship programs. After piloting, the survey was sent to all program directors (n = 67) of Accreditation Council for Graduate Medical Education-accredited pediatric critical care medicine programs between July 2017 and September 2017. The response rate was 85% (57/67). Although 98% of programs provide formalized central venous catheter placement training for first-year fellows, only 42% of programs provide ongoing maintenance training as part of fellowship. Over half (55%) of programs use a global assessment tool and 33% use a checklist-based tool when evaluating fellow central venous catheter placement competence under direct supervision. Only two programs (4%) currently use an assessment tool previously published and validated by the Education in Pediatric Intensive Care group. A majority (82%) of responding program directors believe that a standardized approach to assessment of central venous catheter competency across programs is important.Conclusions: Despite national mandates for skill competence by many accrediting bodies, no standardized system currently exists across programs for assessing central venous catheter placement. Most pediatric critical care medicine programs use a global assessment and decisions around the ability of a fellow to place a central venous catheter under indirect supervision are largely based upon subjective assessment of performance. Further investigation is needed to determine if this finding is consistent in other specialties/subspecialties, if utilization of standardized assessment methods can improve program directors’ abilities to ensure trainee competence in central venous catheter insertion in the setting of variable training approaches, and if these findings are consistent with other procedures across critical care medicine training programs, adult and pediatric.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Adjusting for Disease Severity Across ICUs in Multicenter Studies
    • Authors: Brakenhoff; Timo B.; Plantinga, Nienke L.; Wittekamp, Bastiaan H. J.; Cremer, Olaf; de Lange, Dylan W.; de Keizer, Nicolet F.; Bakhshi-Raiez, Ferishta; Groenwold, Rolf H. H.; Peelen, Linda M.
      Abstract: imageObjectives: To compare methods to adjust for confounding by disease severity during multicenter intervention studies in ICU, when different disease severity measures are collected across centers.Design: In silico simulation study using national registry data.Setting: Twenty mixed ICUs in The Netherlands.Subjects: Fifty-five–thousand six-hundred fifty-five ICU admissions between January 1, 2011, and January 1, 2016.Interventions: None.Measurements and Main Results: To mimic an intervention study with confounding, a fictitious treatment variable was simulated whose effect on the outcome was confounded by Acute Physiology and Chronic Health Evaluation IV predicted mortality (a common measure for disease severity). Diverse, realistic scenarios were investigated where the availability of disease severity measures (i.e., Acute Physiology and Chronic Health Evaluation IV, Acute Physiology and Chronic Health Evaluation II, and Simplified Acute Physiology Score II scores) varied across centers. For each scenario, eight different methods to adjust for confounding were used to obtain an estimate of the (fictitious) treatment effect. These were compared in terms of relative (%) and absolute (odds ratio) bias to a reference scenario where the treatment effect was estimated following correction for the Acute Physiology and Chronic Health Evaluation IV scores from all centers. Complete neglect of differences in disease severity measures across centers resulted in bias ranging from 10.2% to 173.6% across scenarios, and no commonly used methodology—such as two-stage modeling or score standardization—was able to effectively eliminate bias. In scenarios where some of the included centers had (only) Acute Physiology and Chronic Health Evaluation II or Simplified Acute Physiology Score II available (and not Acute Physiology and Chronic Health Evaluation IV), either restriction of the analysis to Acute Physiology and Chronic Health Evaluation IV centers alone or multiple imputation of Acute Physiology and Chronic Health Evaluation IV scores resulted in the least amount of relative bias (0.0% and 5.1% for Acute Physiology and Chronic Health Evaluation II, respectively, and 0.0% and 4.6% for Simplified Acute Physiology Score II, respectively). In scenarios where some centers used Acute Physiology and Chronic Health Evaluation II, regression calibration yielded low relative bias too (relative bias, 12.4%); this was not true if these same centers only had Simplified Acute Physiology Score II available (relative bias, 54.8%).Conclusions: When different disease severity measures are available across centers, the performance of various methods to control for confounding by disease severity may show important differences. When planning multicenter studies, researchers should make contingency plans to limit the use of or properly incorporate different disease measures across centers in the statistical analysis.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Frailty and Associated Outcomes and Resource Utilization Among Older ICU
           Patients With Suspected Infection
    • Authors: Fernando; Shannon M.; McIsaac, Daniel I.; Perry, Jeffrey J.; Rochwerg, Bram; Bagshaw, Sean M.; Thavorn, Kednapa; Seely, Andrew J. E.; Forster, Alan J.; Fiest, Kirsten M.; Dave, Chintan; Tran, Alexandre; Reardon, Peter M.; Tanuseputro, Peter; Kyeremanteng, Kwadwo
      Abstract: imageObjectives: Suspected infection and sepsis are common conditions seen among older ICU patients. Frailty has prognostic importance among critically ill patients, but its impact on outcomes and resource utilization in older patients with suspected infection is unknown. We sought to evaluate the association between patient frailty (defined as a Clinical Frailty Scale ≥ 5) and outcomes of critically ill patients with suspected infection. We also evaluated the association between frailty and the quick Sequential Organ Failure Assessment score.Design: Analysis of a prospectively collected registry.Setting: Two hospitals within a single tertiary care level hospital system between 2011 and 2016.Patients: We analyzed 1,510 patients 65 years old or older (at the time of ICU admission) and with suspected infection at the time of ICU admission. Of these, 507 (33.6%) were categorized as “frail” (Clinical Frailty Scale ≥ 5).Interventions: None.Measurements and Main Results: The primary outcome was in-hospital mortality. A total of 558 patients (37.0%) died in-hospital. Frailty was associated with increased risk of in-hospital death (adjusted odds ratio, 1.81 [95% CIs, 1.34–2.49]). Frailty was also associated with higher likelihood of discharge to long-term care (adjusted odds ratio, 2.06 [95% CI, 1.50–2.64]) and higher likelihood of readmission within 30 days (adjusted odds ratio, 1.83 [95% CI, 1.38–2.34]). Frail patients had increased ICU resource utilization and total costs. The combination of frailty and quick Sequential Organ Failure Assessment greater than or equal to 2 further increased the risk of death (adjusted odds ratio, 7.54 [95% CI, 5.82–9.90]).Conclusions: The presence of frailty among older ICU patients with suspected infection is associated with increased mortality, discharge to long-term care, hospital readmission, resource utilization, and costs. This work highlights the importance of clinical frailty in risk stratification of older ICU patients with suspected infection.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Circulating Histones Are Major Mediators of Multiple Organ Dysfunction
           Syndrome in Acute Critical Illnesses
    • Authors: Cheng; Zhenxing; Abrams, Simon T.; Alhamdi, Yasir; Toh, Julien; Yu, Weiping; Wang, Guozheng; Toh, Cheng-Hock
      Abstract: imageObjectives: Multiple organ dysfunction syndrome is characterized by simultaneous multiple organ failure, which is the leading cause of death in acute critically ill patients. However, what mediates multiple organ dysfunction syndrome is not fully understood. The discovery of toxic effects by extracellular histones on different individual organs strongly suggests their involvement in multiple organ dysfunction syndrome. In this study, we investigate whether circulating histones are major mediators of multiple organ dysfunction syndrome in acute critical illnesses.Design: Combination of retrospective clinical studies and animal models with intervention.Setting: ICU in a tertiary hospital and research laboratories.Patients: Four hundred and twenty ICU patients, including sepsis (140), severe trauma (63), severe pancreatitis (89), and other admission diagnoses (128).Laboratory Investigation: Cells from major organs are treated with calf thymus histones or histone-containing sera. Animal models for sepsis, trauma, and acute pancreatitis are treated with antihistone reagents.Intervention: Antihistone reagents in in vitro, ex vivo, and animal models.Measurement and Main Results: Retrospective analysis of a prospectively recruited ICU cohort demonstrated a strong correlation between circulating histones and organ injury markers and Sequential Organ Failure Assessment scores. Ex vivo experiments showed that patient sera containing high histone levels were toxic to cultured cells from different origins, suggesting their universal toxicity to multiple organs. Animal models of sepsis, trauma, and pancreatitis further demonstrated a temporal correlation between histone levels and disease severity and multiple organ injury. Importantly, antihistone reagents, that is, antihistone single-chain variable fragment and nonanticoagulant heparin, could dramatically reduce multiple organ injury, particularly of the heart and lungs, and improve survival in mouse models.Conclusions: High levels of circulating histones are major mediators of multiple organ dysfunction syndrome. Our results indicate that monitoring upon ICU admission could inform on disease severity and developing antihistone therapy holds great potential of reducing multiple organ dysfunction syndrome and improving survival of critically ill patients.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Neurologic Complications of Infective Endocarditis: A Joint Model for a
           Septic Thromboembolism and Inflammatory Small Vessel Disease
    • Authors: Cantier; Marie; Sabben, Candice; Adle-Biassette, Homa; Louedec, Liliane; Delbosc, Sandrine; Desilles, Jean-Philippe; Journé, Clément; Diallo, Devy; Ou, Phalla; Klein, Isabelle; Chau, Françoise; Lefort, Agnès; Iung, Bernard; Duval, Xavier; Olivot, Jean-Marc; Ho-Tin-Noe, Benoit; Michel, Jean-Baptiste; Sonneville, Romain; Mazighi, Mikael
      Abstract: imageObjectives: Embolic events from vegetations are commonly accepted as the main mechanism involved in neurologic complications of infective endocarditis. The pathophysiology may imply other phenomena, including vasculitis. We aimed to define the cerebral lesion spectrum in an infective endocarditis rat model.Design: Experimental model of Staphylococcus aureus or Enterococcus faecalis infective endocarditis. Neurologic lesions observed in the infective endocarditis model were compared with three other conditions, namely bacteremia, nonbacterial thrombotic endocarditis, and healthy controls.Setting: Research laboratory of a university hospital.Subjects: Male Wistar rats.Interventions: Brain MRI, neuropathology, immunohistochemistry for astrocyte and microglia, and bacterial studies on brain tissue were used to characterize neurologic lesions.Measurements and Main Results: In the infective endocarditis group, MRI revealed at least one cerebral lesion in 12 of 23 rats (52%), including brain infarctions (n = 9/23, 39%) and cerebral microbleeds (n = 8/23, 35%). In the infective endocarditis group, neuropathology revealed brain infarctions (n = 12/23, 52%), microhemorrhages (n = 10/23, 44%), and inflammatory processes (i.e., cell infiltrates including abscesses, vasculitis, meningoencephalitis, and/or ependymitis; n = 11/23, 48%). In the bacteremia group, MRI studies were normal and neuropathology revealed only hemorrhages (n = 2/11, 18%). Neuropathologic patterns observed in the nonbacterial thrombotic endocarditis group were similar to those observed in the infective endocarditis group. Immunochemistry revealed higher microglial activation in the infective endocarditis group (n = 11/23, 48%), when compared with the bacteremia (n = 1/11, 9%; p = 0.03) and nonbacterial thrombotic endocarditis groups (n = 0/7, 0%; p = 0.02).Conclusions: This original model of infective endocarditis recapitulates the neurologic lesion spectrum observed in humans and suggests synergistic mechanisms involved, including thromboembolism and cerebral vasculitis, promoted by a systemic bacteremia-mediated inflammation.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Argon Inhalation for 24 Hours After Onset of Permanent Focal Cerebral
           
    • Authors: Ma; Shuang; Chu, Dongmei; Li, Litao; Creed, Jennifer A.; Ryang, Yu-Mi; Sheng, Huaxin; Yang, Wei; Warner, David S.; Turner, Dennis A.; Hoffmann, Ulrike
      Abstract: imageObjectives: We tested the hypothesis that prolonged inhalation of 70% argon for 24 hours after in vivo permanent or temporary stroke provides neuroprotection and improves neurologic outcome and overall recovery after 7 days.Design: Controlled, randomized, double-blinded laboratory study.Setting: Animal research laboratories.Subjects: Adult Wistar male rats (n = 110).Interventions: Rats were subjected to permanent or temporary focal cerebral ischemia via middle cerebral artery occlusion, followed by inhalation of 70% argon or nitrogen in 30% oxygen for 24 hours. On postoperative day 7, a 48-point neuroscore and histologic lesion size were assessed.Measurements and Main Results: After argon inhalation for 24 hours immediately following “severe permanent ischemia” induction, neurologic outcome (neuroscore, p = 0.034), overall recovery (body weight, p = 0.02), and infarct volume (total infarct volume, p = 0.0001; cortical infarct volume, p = 0.0003; subcortical infarct volume, p = 0.0001) were significantly improved. When 24-hour argon treatment was delayed for 2 hours after permanent stroke induction or until after postischemic reperfusion treatment, neurologic outcomes remained significantly improved (neuroscore, p = 0.043 and p = 0.014, respectively), as was overall recovery (body weight, p = 0.015), compared with nitrogen treatment. However, infarct volume and 7-day mortality were not significantly reduced when argon treatment was delayed.Conclusions: Neurologic outcome (neuroscore), overall recovery (body weight), and infarct volumes were significantly improved after 24-hour inhalation of 70% argon administered immediately after severe permanent stroke induction. Neurologic outcome and overall recovery were also significantly improved even when argon treatment was delayed for 2 hours or until after reperfusion.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Myeloid-Derived Suppressor Cells Mediate Immunosuppression After
           Cardiopulmonary Bypass
    • Authors: Hübner; Max; Tomasi, Roland; Effinger, David; Wu, Tingting; Klein, Gregor; Bender, Martin; Kilger, Erich; Juchem, Gerd; Schwedhelm, Edzard; Kreth, Simone
      Abstract: imageObjectives: Cardiopulmonary bypass is associated with severe immune dysfunctions. Particularly, a cardiopulmonary bypass–related long-lasting immunosuppressive state predisposes patients to a higher risk of postoperative complications, such as persistent bacterial infections. This study was conducted to elucidate mechanisms of post-cardiopulmonary bypass immunosuppression.Design: In vitro studies with human peripheral blood mononuclear cells.Setting: Cardiosurgical ICU, University Research Laboratory.Patients: Seventy-one patients undergoing cardiac surgery with cardiopulmonary bypass (enrolled May 2017 to August 2018).Interventions: Peripheral blood mononuclear cells before and after cardiopulmonary bypass were analyzed for the expression of immunomodulatory cell markers by real-time quantitative reverse transcription polymerase chain reaction. T cell effector functions were determined by enzyme-linked immunosorbent assay, carboxyfluorescein succinimidyl ester staining, and cytotoxicity assays. Expression of cell surface markers was assessed by flow cytometry. CD15+ cells were depleted by microbead separation. Serum arginine was measured by mass spectrometry. Patient peripheral blood mononuclear cells were incubated in different arginine concentrations, and T cell functions were tested.Measurements and Main Results: After cardiopulmonary bypass, peripheral blood mononuclear cells exhibited significantly reduced levels of costimulatory receptors (inducible T-cell costimulator, interleukin 7 receptor), whereas inhibitory receptors (programmed cell death protein 1 and programmed cell death 1 ligand 1) were induced. T cell effector functions (interferon γ secretion, proliferation, and CD8+-specific cell lysis) were markedly repressed. In 66 of 71 patients, a not yet described cell population was found, which could be characterized as myeloid-derived suppressor cells. Myeloid-derived suppressor cells are known to impair immune cell functions by expression of the arginine-degrading enzyme arginase-1. Accordingly, we found dramatically increased arginase-1 levels in post-cardiopulmonary bypass peripheral blood mononuclear cells, whereas serum arginine levels were significantly reduced. Depletion of myeloid-derived suppressor cells from post-cardiopulmonary bypass peripheral blood mononuclear cells remarkably improved T cell effector function in vitro. Additionally, in vitro supplementation of arginine enhanced T cell immunocompetence.Conclusions: Cardiopulmonary bypass strongly impairs the adaptive immune system by triggering the accumulation of myeloid-derived suppressor cells. These myeloid-derived suppressor cells induce an immunosuppressive T cell phenotype by increasing serum arginine breakdown. Supplementation with L-arginine may be an effective measure to counteract the onset of immunoparalysis in the setting of cardiopulmonary bypass.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Impact of Structured Pathways for Postcardiac Arrest Care: A Systematic
           Review and Meta-Analysis
    • Authors: Storm; Christian; Leithner, Christoph; Krannich, Alexander; Suarez, Jose I.; Stevens, Robert D.
      Abstract: imageObjectives: Recent research has demonstrated value in selected therapeutic and prognostic interventions delivered to patients following cardiac arrest. The aim of this work was to determine if the implementation of a structured care pathway, which combines different interventions, could improve outcomes in survivors of cardiac arrest.Data Sources: PubMed and review of citations in retrieved articles.Study Selection: Randomized trials and prospective observational studies conducted in adult cardiac arrest patients, which evaluated the impact on outcome of a structured care pathway, defined as an organized set of interventions designed specifically for postcardiac arrest patients.Data Extraction: Data collected included study characteristics and methodologic quality, populations enrolled, interventions that were part of the cardiac arrest structured care pathway, and outcomes. The principal outcome was favorable functional status defined as a Cerebral Performance Category score of 1–2 at or after hospital discharge.Data Synthesis: The systematic search retrieved 481 articles of which nine (total, 1,994 patients) were selected for systematic review, and six (1,422 patients) met criteria for meta-analysis. Interventions in the care pathways included early coronary angiography with or without percutaneous coronary intervention (eight studies), targeted temperature management (nine studies), and protocolized management in the ICU (seven studies). Neurologic prognostication was not a part of any of the structured pathways. Meta-analysis found significantly higher odds of achieving a favorable functional outcome in patients who were treated in a structured care pathway, when compared with standard care (odds ratio, 2.35; 95% CI, 1.46–3.81).Conclusions: Following cardiac arrest, patients treated in a structured care pathway may have a substantially higher likelihood of favorable functional outcome than those who receive standard care. These findings suggest benefit of a highly organized approach to postcardiac arrest care, in which a cluster of evidence-based interventions are delivered by a specialized interdisciplinary team. Given the overall low certainty of evidence, definitive recommendations will need confirmation in additional high-quality studies.
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Severe Sepsis and Septic Shock Early Management Bundle Risks Aiding
           Vasopressor Misuse
    • Authors: Gazmuri; Raúl J.; Añez de Gomez, Cristina Isabel; Siddiqui, Mahwash; Schechtman, Jeffrey; Nadeem, Amin Ur Rehman
      Abstract: No abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • The authors reply
    • Authors: Rhee; Chanu; Klompas, Michael
      Abstract: No abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • The Role of Pharmacist in Scientific Antimicrobial Management Strategy in
           the ICU
    • Authors: Ji; Hongjian; Zhang, Yajun
      Abstract: No abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • The authors reply
    • Authors: Morris; Andrew M.; Bai, Anthony; Burry, Lisa; Dresser, Linda D.; McIntyre, Mark; Nelson, Sandra; So, Miranda; Bell, Chaim
      Abstract: No abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Food and Drink and the Mitochondrion: Is Less Really More'
    • Authors: Papadimos; Thomas John; Satyapriya, S. Veena
      Abstract: No abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • The authors reply
    • Authors: McKeever; Liam; Peterson, Sarah J.; Braunschweig, Carol A.
      Abstract: No abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • Use of Dexmedetomidine for Deep Sedation and Reduction of Vasopressor
           Requirement'
    • Authors: Park; Jung Hoon; Hampton, Scott R.; Derry, Katrina L.
      Abstract: No abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • The authors reply
    • Authors: Morelli; Andrea; Sanfilippo, Filippo; Rehberg, Sebastian; Ertmer, Christian
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • It Is Time to Treat the Patient and Not Just the Ventilator
    • Authors: Habashi; Nader M.; Andrews, Penny; Satalin, Joshua; Gatto, Louis A.; Nieman, Gary F.
      Abstract: No abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • The authors reply
    • Authors: Hirshberg; Eliotte L.; Lanspa, Michael J.; Brown, Samuel M.; Dean, Nathan C.; Grissom, Colin K.
      Abstract: No abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • ICU Utilization for Patients With Acute Exacerbations of Chronic
           Obstructive Pulmonary Disease Receiving Noninvasive Ventilation. Seeking
           Answers to the Questions of Utilization: Does Perception Reflect
           Reality'
    • Authors: Soo Hoo; Guy W.; Dilken, Olcay; Esquinas, Antonio M.
      Abstract: No abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
  • The authors reply
    • Authors: Myers; Laura C.; Camargo, Carlos A. Jr
      Abstract: No abstract available
      PubDate: Thu, 01 Aug 2019 00:00:00 GMT-
       
 
 
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