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EMERGENCY AND INTENSIVE CRITICAL CARE (121 journals)                     

Showing 1 - 124 of 124 Journals sorted alphabetically
AACN Advanced Critical Care     Full-text available via subscription   (Followers: 36)
Academic Emergency Medicine     Hybrid Journal   (Followers: 90)
Acta Colombiana de Cuidado Intensivo     Full-text available via subscription   (Followers: 1)
Acute and Critical Care     Open Access   (Followers: 9)
Acute Cardiac Care     Hybrid Journal   (Followers: 11)
Acute Medicine     Full-text available via subscription   (Followers: 8)
Advances in Emergency Medicine     Open Access   (Followers: 16)
Advances in Neonatal Care     Hybrid Journal   (Followers: 43)
African Journal of Anaesthesia and Intensive Care     Full-text available via subscription   (Followers: 7)
African Journal of Emergency Medicine     Open Access   (Followers: 7)
AINS - Anasthesiologie - Intensivmedizin - Notfallmedizin - Schmerztherapie     Hybrid Journal   (Followers: 5)
American Journal of Emergency Medicine     Hybrid Journal   (Followers: 54)
Annals of Emergency Medicine     Hybrid Journal   (Followers: 126)
Annals of Intensive Care     Open Access   (Followers: 37)
Annals of the American Thoracic Society     Full-text available via subscription   (Followers: 15)
Archives of Academic Emergency Medicine     Open Access   (Followers: 6)
Archives of Trauma Research     Open Access   (Followers: 4)
ASAIO Journal     Hybrid Journal   (Followers: 2)
Australasian Journal of Paramedicine     Open Access   (Followers: 7)
Australian Critical Care     Full-text available via subscription   (Followers: 21)
Bangladesh Critical Care Journal     Open Access   (Followers: 1)
BMC Emergency Medicine     Open Access   (Followers: 25)
BMJ Quality & Safety     Hybrid Journal   (Followers: 65)
Burns Open     Open Access  
Canadian Journal of Respiratory, Critical Care, and Sleep Medicine     Hybrid Journal   (Followers: 2)
Case Reports in Acute Medicine     Open Access   (Followers: 3)
Case Reports in Critical Care     Open Access   (Followers: 13)
Case Reports in Emergency Medicine     Open Access   (Followers: 19)
Chronic Wound Care Management and Research     Open Access   (Followers: 7)
Clinical and Applied Thrombosis/Hemostasis     Open Access   (Followers: 32)
Clinical Intensive Care     Hybrid Journal   (Followers: 6)
Clinical Medicine Insights : Trauma and Intensive Medicine     Open Access   (Followers: 3)
Clinical Risk     Hybrid Journal   (Followers: 5)
Crisis: The Journal of Crisis Intervention and Suicide Prevention     Hybrid Journal   (Followers: 15)
Critical Care     Open Access   (Followers: 74)
Critical Care and Resuscitation     Full-text available via subscription   (Followers: 29)
Critical Care Clinics     Full-text available via subscription   (Followers: 34)
Critical Care Explorations     Open Access   (Followers: 3)
Critical Care Medicine     Hybrid Journal   (Followers: 279)
Critical Care Research and Practice     Open Access   (Followers: 13)
Current Emergency and Hospital Medicine Reports     Hybrid Journal   (Followers: 5)
Current Opinion in Critical Care     Hybrid Journal   (Followers: 73)
Disaster and Emergency Medicine Journal     Open Access   (Followers: 12)
Egyptian Journal of Critical Care Medicine     Open Access   (Followers: 2)
EMC - Urgenze     Full-text available via subscription  
Emergency Care Journal     Open Access   (Followers: 7)
Emergency Medicine (Medicina neotložnyh sostoânij)     Open Access  
Emergency Medicine Australasia     Hybrid Journal   (Followers: 17)
Emergency Medicine Clinics of North America     Full-text available via subscription   (Followers: 19)
Emergency Medicine International     Open Access   (Followers: 8)
Emergency Medicine Journal     Hybrid Journal   (Followers: 53)
Emergency Medicine News     Full-text available via subscription   (Followers: 7)
Emergency Nurse     Full-text available via subscription   (Followers: 17)
Enfermería Intensiva (English ed.)     Full-text available via subscription  
European Burn Journal     Open Access   (Followers: 10)
European Journal of Emergency Medicine     Hybrid Journal   (Followers: 23)
Frontiers in Emergency Medicine     Open Access   (Followers: 8)
Global Journal of Transfusion Medicine     Open Access   (Followers: 1)
Hong Kong Journal of Emergency Medicine     Full-text available via subscription   (Followers: 5)
Indian Journal of Burns     Open Access   (Followers: 2)
Injury     Hybrid Journal   (Followers: 20)
Intensive Care Medicine     Hybrid Journal   (Followers: 82)
Intensive Care Medicine Experimental     Open Access   (Followers: 2)
Intensivmedizin up2date     Hybrid Journal   (Followers: 4)
International Journal of Critical Illness and Injury Science     Open Access   (Followers: 1)
International Journal of Emergency Medicine     Open Access   (Followers: 9)
International Journal of Emergency Mental Health and Human Resilience     Open Access   (Followers: 2)
International Paramedic Practice     Full-text available via subscription   (Followers: 14)
Iranian Journal of Emergency Medicine     Open Access  
Irish Journal of Paramedicine     Open Access   (Followers: 2)
Journal Européen des Urgences et de Réanimation     Hybrid Journal   (Followers: 1)
Journal of Acute Care Physical Therapy     Hybrid Journal   (Followers: 3)
Journal of Cardiac Critical Care TSS     Open Access   (Followers: 1)
Journal Of Cardiovascular Emergencies     Open Access  
Journal of Concussion     Open Access  
Journal of Critical Care     Hybrid Journal   (Followers: 48)
Journal of Critical Care Medicine     Open Access   (Followers: 18)
Journal of Education and Teaching in Emergency Medicine     Open Access   (Followers: 1)
Journal of Emergencies, Trauma and Shock     Open Access   (Followers: 13)
Journal of Emergency Medical Services     Full-text available via subscription   (Followers: 12)
Journal of Emergency Medicine     Hybrid Journal   (Followers: 53)
Journal of Emergency Medicine, Trauma and Acute Care     Open Access   (Followers: 25)
Journal of Emergency Practice and Trauma     Open Access   (Followers: 6)
Journal of Intensive Care     Open Access   (Followers: 9)
Journal of Intensive Care Medicine     Hybrid Journal   (Followers: 22)
Journal of Intensive Medicine     Open Access  
Journal of Neuroanaesthesiology and Critical Care     Open Access   (Followers: 3)
Journal of Stroke Medicine     Hybrid Journal  
Journal of the American College of Emergency Physicians Open     Open Access   (Followers: 1)
Journal of the Intensive Care Society     Hybrid Journal   (Followers: 4)
Journal of the Royal Army Medical Corps     Hybrid Journal   (Followers: 6)
Journal of Thrombosis and Haemostasis     Hybrid Journal   (Followers: 81)
Journal of Translational Critical Care Medicine     Open Access   (Followers: 5)
Journal of Trauma and Acute Care Surgery, The     Hybrid Journal   (Followers: 34)
La Presse Médicale Open     Open Access  
Médecine de Catastrophe - Urgences Collectives     Hybrid Journal  
Medicina Intensiva     Open Access   (Followers: 3)
Medicina Intensiva (English Edition)     Hybrid Journal   (Followers: 1)
Mediterranean Journal of Emergency Medicine & Acute Care : MedJEM     Open Access  
Notfall + Rettungsmedizin     Hybrid Journal   (Followers: 3)
OA Critical Care     Open Access   (Followers: 3)
OA Emergency Medicine     Open Access   (Followers: 2)
Open Access Emergency Medicine     Open Access   (Followers: 6)
Open Journal of Emergency Medicine     Open Access   (Followers: 2)
Palliative Care : Research and Treatment     Open Access   (Followers: 19)
Palliative Medicine     Hybrid Journal   (Followers: 54)
Prehospital Emergency Care     Hybrid Journal   (Followers: 19)
Regulatory Toxicology and Pharmacology     Hybrid Journal   (Followers: 41)
Research and Opinion in Anesthesia and Intensive Care     Open Access   (Followers: 3)
Resuscitation     Hybrid Journal   (Followers: 54)
Resuscitation Plus     Open Access   (Followers: 2)
Saudi Critical Care Journal     Open Access   (Followers: 2)
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine     Open Access   (Followers: 11)
Seminars in Thrombosis and Hemostasis     Hybrid Journal   (Followers: 46)
Shock : Injury, Inflammation, and Sepsis : Laboratory and Clinical Approaches     Hybrid Journal   (Followers: 10)
Sklifosovsky Journal Emergency Medical Care     Open Access  
The Journal of Trauma Injury Infection and Critical Care     Full-text available via subscription   (Followers: 24)
Therapeutics and Clinical Risk Management     Open Access   (Followers: 2)
Transplant Research and Risk Management     Open Access  
Trauma Case Reports     Open Access   (Followers: 1)
Trauma Monthly     Open Access   (Followers: 3)
Visual Journal of Emergency Medicine     Full-text available via subscription   (Followers: 1)
Western Journal of Emergency Medicine     Open Access   (Followers: 11)
 AEM Education and Training : A Global Journal of Emergency Care     Open Access   (Followers: 1)

           

Similar Journals
Journal Cover
Journal of Intensive Care Medicine
Journal Prestige (SJR): 0.82
Citation Impact (citeScore): 2
Number of Followers: 22  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0885-0666 - ISSN (Online) 1525-1489
Published by Sage Publications Homepage  [1174 journals]
  • Inhaled Pulmonary Vasodilators in COVID-19 Infection: A Systematic Review
           and Meta-Analysis

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      Authors: Waleed Khokher, Saif-Eddin Malhas, Azizullah Beran, Saffa Iftikhar, Cameron Burmeister, Mohammed Mhanna, Omar Srour, Rakin Rashid, Nithin Kesireddy, Ragheb Assaly
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Introduction: Inhaled pulmonary vasodilators (IPVD) have been previously studied in patients with non-coronavirus disease-19 (COVID-19) related acute respiratory distress syndrome (ARDS). The use of IPVD has been shown to improve the partial pressure of oxygen in arterial blood (PaO2), reduce fraction of inspired oxygen (FiO2) requirements, and ultimately increase PaO2/FiO2 (P/F) ratios in ARDS patients. However, the role of IPVD in COVID-19 ARDS is still unclear. Therefore, we performed this meta-analysis to evaluate the role of IPVD in COVID-19 patients. Methods: Comprehensive literature search of PubMed, Embase, Web of Science and Cochrane Library databases from inception through April 22, 2022 was performed for all published studies that utilized IPVD in COVID-19 ARDS patients. The single arm studies and case series were combined for a 1-arm meta-analysis, and the 2-arm studies were combined for a 2-arm meta-analysis. Primary outcomes for the 1-arm and 2-arm meta-analyzes were change in pre- and post-IPVD P/F ratios and mortality, respectively. Secondary outcomes for the 1-arm meta-analysis were change in pre- and post-IPVD positive end-expiratory pressure (PEEP) and lung compliance, and for the 2-arm meta-analysis the secondary outcomes were need for endotracheal intubation and hospital length of stay (LOS). Results: 13 single arm retrospective studies and 5 case series involving 613 patients were included in the 1-arm meta-analysis. 3 studies involving 640 patients were included in the 2-arm meta-analysis. The pre-IPVD P/F ratios were significantly lower compared to post-IPVD, but there was no significant difference between pre- and post-IPVD PEEP and lung compliance. The mortality rates, need for endotracheal intubation, and hospital LOS were similar between the IPVD and standard therapy groups. Conclusion: Although IPVD may improve oxygenation, our investigation showed no benefits in terms of mortality compared to standard therapy alone. However, randomized controlled trials are warranted to validate our findings.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-08-02T07:14:53Z
      DOI: 10.1177/08850666221118271
       
  • 90-day Case-Fatality in Critically ill Patients with Chronic Liver Disease
           Influenced by Presence of Portal Hypertension, Results from a Multicentre
           Retrospective Cohort Study

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      Authors: Kyle White, Alexis Tabah, Mahesh Ramanan, Kiran Shekar, Felicity Edwards, Kevin B. Laupland
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundCritical illness in patients with chronic liver disease (CLD) is increasing in occurrence, and by virtue of its adverse effect on prognosis, its presence may influence the decision to offer admission to intensive care units (ICU). Our objective was to examine the determinants and outcome of patients with CLD admitted to ICU.MethodsA retrospective cohort of patients admitted to four adult ICUs in Queensland, Australia from 2017 to 2019. Patients with mild or moderate-severe CLD were defined by the absence and presence of portal hypertension, respectively, and were was determined using granular ICU and state-wide administrative databases. The primary outcome was 90-day all cause case-fatality.ResultsWe included 3836 patients in the analysis, of which, 60 (2%) had mild liver disease and 132 (3%) had moderate-severe liver disease . Patients with CLD had higher incidence of other co-morbidities with the median adjusted-Charlson co-morbidity index (CCI) was 1 (interquartile range; IQR 0-3) for no CLD, 2 (IQR 1.5-4) for mild CLD, and 3 (IQR 2-5) for moderate-severe CLD. Case-fatality rates at 90 days was 17% for no CLD, 25% for mild CLD, and 41% for moderate-severe CLD. Among those with mild and moderate-severe CLD, an increased co-morbidity burden as measured by an adjusted CCI score of low (0-3), medium (4-5), high (6-7) and very high (>7) resulted in increasing case-fatality rates of 24–40%, 11–28.5%, 33–62%, and 50% respectively. Moderate-severe CLD, but not mild CLD, was independently associated with increased case-fatality at 90 days (Odds Ratio 1.58; 95% confidence interval 1.01-2.48; p = 0.004) after adjusting for medical co-morbidities and severity of illness using logistic regression analysis.ConclusionsAlthough patients with moderate-severe CLD have an increased risk for 90-day case-fatality, patients with mild CLD are not at higher risk for death following ICU admission.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-07-27T06:42:32Z
      DOI: 10.1177/08850666221100408
       
  • E-CPR in Cardiac Arrest due to Accidental Hypothermia Using Intensivist
           Cannulators: A Case Series of Nine Consecutive Patients

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      Authors: Erik Kraai, Trenton C. Wray, Emily Ball, Isaac Tawil, Jessica Mitchell, Sundeep Guliani, Todd Dettmer, Jonathan Marinaro
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Background: Severe accidental hypothermia (AH) accounts for over 1300 deaths/year in the United States. Early extracorporeal life support (ECLS) is recommended for hypothermic cardiac arrest. We describe the use of a rapid-deployment extracorporeal cardiopulmonary resuscitation (E-CPR) team using intensivist physicians (IPs) as cannulators and report the outcomes of consecutive patients cannulated for ECLS to manage cardiac arrest due to AH. Methods: We reviewed all patients managed with veno-arterial (V-A) ECLS for hypothermic cardiac arrest between January 1, 2017 and November 1, 2021. For each patient- age, sex, cause of hypothermia, initial core temperature, initial rhythm, time from arrest to cannulation, cannula configuration, pH, lactate, potassium, cannulation complications, duration of ECLS, hospital length of stay, mortality, and cerebral performance category (CPC) at discharge were reviewed. Results: Nine consecutive patients were identified that underwent V-A ECLS for cardiac arrest due to AH. Seven (78%) were witnessed arrests. Initial rhythm was ventricular fibrillation (VF) in eight patients and pulseless electrical activity (PEA) in one. The mean initial core temperature was 23.8 degrees Celsius. The mean time from arrest to cannulation was 58 min (range 17 to 251 min). There were no complications related to cannulation. The mean duration of ECLS was 39.1 h. All nine patients were discharged alive with a Cerebral Performance score of one or two. Conclusion: In this case series of consecutive patients reporting intensivist-deployed E-CPR for cardiac arrest due to AH, all patients survived to discharge with a favorable neurologic outcome. A rapidly available E-CPR team utilizing intensivist cannulators may improve outcomes in patients with cardiac arrest due to AH.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-07-25T11:46:29Z
      DOI: 10.1177/08850666221116594
       
  • Malignant Catatonia: A Review for the Intensivist

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      Authors: Jennifer Connell, Mark Oldham, Pratik Pandharipande, Robert S Dittus, Amanda Wilson, Matthew Mart, Stephan Heckers, E. Wes Ely, Jo Ellen Wilson
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Catatonia is a clinical syndrome characterized by psychomotor, neurological and behavioral changes. The clinical picture of catatonia ranges from akinetic stupor to severe motoric excitement. Catatonia can occur in the setting of a primary psychiatric condition such as bipolar disorder or secondary to a general medical illness like autoimmune encephalitis. Importantly, it can co-occur with delirium or coma. Malignant catatonia describes catatonia that presents with clinically significant autonomic abnormalities including change in temperature, blood pressure, heart rate, and respiratory rate. It is a life-threatening form of acute brain dysfunction that has several motoric manifestations and occurs secondary to a primary psychiatric condition or a medical cause. Many of the established predisposing and precipitating factors for catatonia such as exposure to neuroleptic medications or withdrawal states are common in the setting of critical illness. Catatonia typically improves with benzodiazepines and treatment of its underlying psychiatric or medical conditions, with electroconvulsive therapy reserved for catatonia refractory to benzodiazepines or for malignant catatonia. However, some forms of catatonia, such as catatonia secondary to a general medical condition or catatonia comorbid with delirium, may be less responsive to traditional treatments. Prompt recognition and treatment of catatonia are crucial because malignant catatonia may be fatal without treatment. Given the high morbidity and mortality associated with malignant catatonia, intensivists should familiarize themselves with this important and under-recognized condition.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-07-21T03:20:27Z
      DOI: 10.1177/08850666221114303
       
  • Fentanyl-Induced Rigid Chest Syndrome in Critically Ill Patients

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      Authors: Alison J. Tammen, Donald Brescia, Dan Jonas, Jeremy L. Hodges, Philip Keith
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundOpioid induced chest wall rigidity was first described in the early 1950s during surgical anesthesia and has often been referred to as fentanyl induced rigid chest syndrome (FIRCS). It has most commonly been described in the setting of procedural sedation and bronchoscopy, characterized by pronounced abdominal and thoracic rigidity, asynchronous ventilation, and respiratory failure. FIRCS has been infrequently described in the setting of continuous analgesia in critically ill adult patients. We postulate that FIRCS can occur in this setting and is likely under recognized, leading to increased morbidity and mortality.MethodsPatients admitted to the intensive care unit with suspected FIRCS were included in this retrospective analysis. The objective of this analysis is to describe the clinical presentation and treatment strategies for FIRCS.ResultsForty-two patients exhibiting symptoms of FIRCS were included in this analysis. Twenty-two of the forty-two patients with descriptive documentation had evidence of thoracic or abdominal rigidity on examination (52.4%). Twelve of sixteen (75%) patients treated solely with naloxone had documented ventilator compliance following intervention, compared to six of eleven (55%) managed with cisatracurium alone. Nine of twelve patients who ultimately received naloxone after initial treatment with cisatracurium had documented ventilator compliance following naloxone administration (75%). Standard interventions, including sedation optimization and ventilator adjustments were attempted to rule out and treat other potential causes of dyssynchrony. In most cases, the administration of naloxone resulted in appropriate compliance with both ventilator and patient-initiated breaths, suggesting the ventilator dyssynchrony was due to fentanyl.ConclusionsThis is the largest case series to date describing FIRCS in the intensive care setting. Recognition and prompt management is necessary for improved patient outcomes. Research is needed to increase awareness and recognition, identify patient risk factors, and analyze the efficacy and safety of interventions.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-07-20T04:00:00Z
      DOI: 10.1177/08850666221115635
       
  • Prognostic Implication of Pre-Cannulation Cardiac Arrest in Patients
           Undergoing Extracorporeal Membrane Oxygenation for the Management of
           Cardiogenic Shock

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      Authors: Hoyle L. Whiteside, Dustin Hillerson, Ahmed Abdel-Latif, Vedant A. Gupta
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundThe application of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in contemporary management of cardiogenic shock (CS) has dramatically increased. Despite increased utilization, few predictive models exist to estimate patient survival based on pre-ECMO characteristics. Furthermore, the prognostic implications of pre-ECMO cardiac arrest are not well defined.MethodsUtilizing an institutional VA-ECMO database, all consecutive patients undergoing VA-ECMO for the management of CS from January 1, 2014, to July 1, 2019, were identified. Survival to hospital discharge was analyzed based on cannulation indication in patients with and without pre-ECMO cardiac arrest. Patients who received extracorporeal cardiopulmonary resuscitation (eCPR) were analyzed separately.ResultsOf the 214 patients identified, 110 did not suffer a cardiac arrest prior to cannulation (cohort 1), 57 patients had a cardiac arrest with sustained ROSC (cohort 2), and 47 were cannulated as a component of eCPR (cohort 3). Despite sustained ROSC (cohort 2), the presence of pre-ECMO cardiac arrest was associated with a significant reduction in survival to hospital discharge (22.8% vs. 55.5% in cohort 1; p 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-07-20T03:59:50Z
      DOI: 10.1177/08850666221115606
       
  • Indications, Clinical Impact, and Complications of Critical Care
           Transesophageal Echocardiography: A Scoping Review

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      Authors: Ross Prager, Joshua Bowdridge, Michael Pratte, Jason Cheng, Matthew DF McInnes, Robert Arntfield
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundCritical care transesophageal echocardiography (ccTEE) is an increasingly popular tool used by intensivists to characterize and manage hemodynamics at the bedside. Its usage appears to be driven by expanded diagnostic scope as well as the limitations of transthoracic echocardiography (TTE) – lack of acoustic windows, patient positioning, and competing clinical interests (eg, the need to perform chest compressions). The objectives of this scoping review were to determine the indications, clinical impact, and complications of ccTEE.MethodsMEDLINE, EMBASE, Cochrane, and six major conferences were searched without a time or language restriction on March 31st, 2021. Studies were included if they assessed TEE performed for adult critically ill patients by intensivists, emergency physicians, or anesthesiologists. Intraoperative or post-cardiac surgical TEE studies were excluded. Study demographics, indication for TEE, main results, and complications were extracted in duplicate.ResultsOf the 4403 abstracts screened, 289 studies underwent full-text review, with 108 studies (6739 patients) included. Most studies were retrospective (66%), performed in academic centers (84%), in the intensive care unit (73%), and were observational (55%). The most common indications for ccTEE were hemodynamic instability, trauma, cardiac arrest, respiratory failure, and procedural guidance. Across multiple indications, ccTEE was reported to change the diagnosis in 52% to 78% of patients and change management in 32% to79% patients. During cardiac arrest, ccTEE identified the cause of arrest in 25% to 35% of cases. Complications of ccTEE included two cases of significant gastrointestinal bleeding requiring intervention, but no other major complications (death or esophageal perforation) reported.ConclusionsThe use of ccTEE has been described for the diagnosis and management of a broad range of clinical problems. Overall, ccTEE was commonly reported to offer additional diagnostic yield beyond TTE with a low observed complication rate. Additional high quality ccTEE studies will permit stronger conclusions and a more precise understanding of the trends observed in this scoping review.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-07-20T03:59:39Z
      DOI: 10.1177/08850666221115348
       
  • The Early Detection of Hypovolemic Shock and Shifting the Focus to
           Compensation

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      Authors: Mithun R. Suresh
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.

      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-07-19T04:52:19Z
      DOI: 10.1177/08850666221114267
       
  • Efficacy and Safety of Cisatracurium Compared to Vecuronium for
           Neuromuscular Blockade in Acute Respiratory Distress Syndrome

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      Authors: Priya Vallabh, Michael Ha, Krystina Ahern
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      PurposePrevious studies analyzing neuromuscular blocking agents (NMBAs) in acute respiratory distress syndrome (ARDS) have evaluated the benefit of cisatracurium with conflicting results, and data evaluating other NMBAs remains limited. The objective of this study was to compare the efficacy and safety of cisatracurium to vecuronium in ARDS.Materials and methodsA single-center, retrospective, propensity matched review of patients who received cisatracurium or vecuronium continuous infusions between October 1, 2017 and June 30, 2020 for ARDS was conducted. The primary endpoint was duration of mechanical ventilation. Secondary endpoints included change in PaO2/FiO2 ratio at 48 h, intensive care unit (ICU) and hospital mortality, and ICU and hospital length of stay (LOS). Safety endpoints included newly developed myopathy, presence of bradycardia or hypotension, and newly developed barotrauma or volutrauma.ResultsTwenty-nine patients were included in each group. There was no statistically significant difference in the primary endpoint of ventilator days between cisatracurium and vecuronium groups (mean 15.9 vs. 20.5 days respectively; p = .2). No statistically significant differences were found in secondary endpoints of ICU mortality (51.7% vs. 51.7%) or length of stay (18.7 vs. 23.9 days, p = .19), hospital mortality (51.7% vs. 55.2%, p = .79) or length of stay (22 vs. 30.6 days, p = .08), or mean change in PaO2/FiO2 (29.8 vs. 36.6; p = .74). Statistically significant differences were not observed in safety endpoints of myopathy (37.9% vs. 37.9%), barotrauma or volutrauma (13.8% vs. 3.5%; p = .16), bradycardia (31% vs. 13.8%; p = .12), or hypotension (96.6% vs. 82.8%; p = .08)ConclusionsNo significant differences were seen in efficacy or safety endpoints between cisatracurium or vecuronium groups, suggesting that vecuronium may be a safe alternative agent for neuromuscular blockade in ARDS. Results of this analysis warrant confirmation in a larger, randomized study.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-07-13T03:44:49Z
      DOI: 10.1177/08850666221113504
       
  • Serum Ferritin as a Predictor of Outcomes in Hospitalized Patients with
           Covid-19 Pneumonia

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      Authors: Dania A. Shakaroun, Michael H. Lazar, Jeffrey C. Horowitz, Jeffrey H. Jennings
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Purpose: Elevated ferritin levels are associated with poor outcomes in Covid-19 patients. Optimal timing of ferritin assessment and the merit of longitudinal values remains unclear. Methods: Patients admitted to Henry Ford Hospital with confirmed SARS-CoV-2 were studied. Regression models were used to determine the relation between ferritin and mortality, need for mechanical ventilation, ICU admission, and days on the ventilator. Results: 2265 patients were evaluated. Patients with an initial ferritin of> 490 ng/mL had an increased risk of death (OR 3.4, P 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-07-11T11:58:39Z
      DOI: 10.1177/08850666221113252
       
  • A Controlled Study in CPR—Survival in Propensity Score Matched Full-Code
           and Do-Not-Resuscitate ICU Patients

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      Authors: Daniel J. Baldor, Nicholas A. Smyrnios, Khaldoun Faris, Yurima Guilarte-Walker, Ugur Celik, Ulises Torres
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundCardiopulmonary Resuscitation (CPR) causes significant injuries and increased cost among transiently resuscitated patients that do not survive their hospitalizations. Descriptive studies show zero and near-zero percent survival for CPR recipients with high Apache II scores. Despite these factors, no controlled studies exist in CPR to guide patient selection for CPR candidacy. Our objective was therefore to perform a controlled study in CPR to inform recommendations for CPR candidacy. We hypothesize that the protective effects of CPR decrease as illness severity increases, and that Full-Code status provides no survival benefit over Do-Not-Resuscitate (DNR) status for patients with the highest predicted mortality by Apache IV score.MethodsWe performed propensity-score matched survival analyzes between Full-Code and DNR patients after stratifying by predicted mortality quartiles using Apache IV scores. Primary outcomes were mortality hazard ratios. Secondary outcomes were Median Survival Differences, ICU LOS, and tracheostomy rates.ResultsAmong 17,710 propensity-score matched ICU encounters, DNR status was associated with greater mortality in the first through third predicted mortality quartiles. There was no difference in survival outcomes in the fourth quartile (HR 0.99, p = .96). There was a stepwise decrease in the mortality hazard ratio for DNR patients as quartiles increased.ConclusionFull-Code status provides no survival benefit over DNR status in individuals with greater than 75% predicted mortality by Apache IV score. There is a stepwise decrease in survival benefit for Full-Code patients as predicted mortality increases. We propose that it is reasonable to consider a very high predicted mortality by Apache IV score a contraindication to CPR given the lack of survival benefit seen in these patients. Larger studies with similar methods should be performed to reinforce or refute these findings.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-07-11T11:58:09Z
      DOI: 10.1177/08850666221114052
       
  • To Wean or Not to Wean: A Practical Patient Focused Guide to Ventilator
           Weaning

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      Authors: Padmastuti Akella, Louis P. Voigt, Sanjay Chawla
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Since the inception of critical care medicine and artificial ventilation, literature and research on weaning has transformed daily patient care in intensive care units (ICU). As our knowledge of mechanical ventilation (MV) improved, so did the need to study patient-ventilator interactions and weaning predictors. Randomized trials have evaluated the use of protocol-based weaning (vs. usual care) to study the duration of MV in ICUs, different techniques to conduct spontaneous breathing trials (SBT), and strategies to eventually extubate a patient whose initial SBT failed. Despite considerable milestones in the management of multiple diseases contributing to reversible respiratory failure, in the application of early rehabilitative interventions to preserve muscle integrity, and in ventilator technology that mitigates against ventilator injury and dyssynchrony, major barriers to successful liberation from MV persist. This review provides a broad encompassing view of weaning classification, causes of weaning failure, and evidence behind weaning predictors and weaning modes.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-07-11T11:57:54Z
      DOI: 10.1177/08850666221095436
       
  • Resource Utilization in Children who Receive a Pediatric Intensive Care
           Unit Consult in the Emergency Department: A Retrospective Cohort Study

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      Authors: Samantha Boggs, Genevieve de Caen, Anna-Theresa Lobos, Amy C Plint, Kristina Krmpotic
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      ObjectivesTo describe the characteristics, critical care resource requirements, and outcomes of children who were hospitalized after a Pediatric Intensive Care Unit (PICU) consult in the Emergency Department (ED).MethodsIn this single-centre retrospective cohort study, we conducted chart reviews for children (
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-07-07T06:52:19Z
      DOI: 10.1177/08850666221109176
       
  • Pre-Existing Right Ventricular Dysfunction as an Independent Risk Factor
           for Post Intubation Cardiac Arrest and Hemodynamic Instability in
           Critically Ill Patients: A Retrospective Observational Study

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      Authors: Mukhtar A Al-Saadi, Behnam Heidari, Kevin R Donahue, Emily M Shipman, Kush N Kinariwala, Faisal N Masud
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundPost intubation cardiac arrest and hemodynamic instability are serious adverse events encountered in critically ill patients. The association of pre-existing right ventricular (RV) dysfunction with post intubation cardiac arrest and hemodynamic instability in critically ill patients is unknown.MethodsThis is a retrospective matched cohort study of adult critically ill patients who underwent intubation from July 2016 to December 2019. The study was conducted at a quaternary medical center in Houston, Texas. A total of 340 critically ill patients who underwent intubation in the intensive care units, wards, and the emergency room were included. The study cohort was categorized into 4 groups based on the pre-existing RV function: normal function, mild dysfunction, moderate dysfunction, and severe dysfunction. Cardiac arrest and/or hemodynamic instability within one hour post intubation were the primary study outcomes. Secondary outcomes included in hospital and 60-day mortality.ResultsStudy patients were of mean age of 61.95 ± 14.28 years, including 132 (39%) females and 208 (61%) males. The primary outcomes were significantly worse in mild, moderate, and severe RV dysfunction groups compared to the normal RV function group (34.12%-P = 0.014, 47.06%-P 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-07-04T05:53:24Z
      DOI: 10.1177/08850666221111776
       
  • Hospital Variation in Mortality and Ventilator Management among
           Mechanically Ventilated Patients with ARDS

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      Authors: Mallory N. LeSieur, Nicholas A. Bosch, Allan J. Walkey
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      RationaleAcute Respiratory Distress Syndrome (ARDS) is associated with significant mortality. Despite the mortality benefits of lung protective ventilation, adherence rates to evidence-based ventilator practice have remained low and ARDS mortality has remained high.ObjectiveDetermine variation in ARDS mortality and adherence to low tidal volume ventilation (LTV) across US hospitals.Materials and MethodsWe identified mechanically ventilated patients with ARDS using data from Philips eICU (2014-2015). We then used multi-variable hierarchical logistic regression models with hospital site as the random effect and patient and hospital level factors as fixed effects to assess the hospital risk adjusted mortality rate and median odds ratio for the association between mortality and hospital site. We then assessed associations between adherence to LTV (defined as 4-8 mL/kg PBW) and hospital risk adjusted mortality rates using Spearman correlation.ResultsAmong 4441 patients admitted at 110 hospitals with ARDS, the hospital risk-adjusted mortality rate ranged from 19% to 39%, and the MOR for hospital of admission was 1.33 (95% CI 1.25-1.41). Among 3070 patients at 72 hospitals with available ventilator data, 73% of patients had a median set Vt between 4 to 8 mL/kg PBW; hospital adherence rates to LTV ranged from 13% to 95%. There was no association between hospital adherence to LTV and risk-adjusted mortality rate (spearman correlation coefficient −0.01, p = .93). Similarly, among 956 patients who started with a Vt> 8 mL/kg PBW, there was no association between the percent of patients at each hospital whose Vt was decreased to ≤ 8 mL/kg PBW and risk adjusted mortality rate (spearman correlation coefficient .05, p = .73).ConclusionRisk adjusted mortality and use of LTV for patients with ARDS varied widely across hospitals. However, hospital adherence to LTV was not associated with ARDS mortality rates. Further evaluation of hospital practices associated with lower ARDS mortality are warranted.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-07-04T05:53:09Z
      DOI: 10.1177/08850666221111748
       
  • Airway Pressure Release Ventilation for Acute Respiratory Failure Due to
           Coronavirus Disease 2019: A Systematic Review and Meta-Analysis

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      Authors: Ashraf Roshdy, Ahmad Samy Elsayed, Ahmad Sabry Saleh
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      ObjectiveTo explore the evidence surrounding the use of Airway Pressure Release Ventilation (APRV) in patients with coronavirus disease 2019 (COVID-19). Methods: A Systematic electronic search of PUBMED, EMBASE, and the WHO COVID-19 database. We also searched the grey literature via Google and preprint servers (medRxive and research square). Eligible studies included randomised controlled trials and observational studies comparing APRV to conventional mechanical ventilation (CMV) in adults with acute hypoxemic respiratory failure due to COVID-19 and reporting at least one of the following outcomes; in-hospital mortality, ventilator free days (VFDs), ICU length of stay (LOS), changes in gas exchange parameters, and barotrauma. Two authors independently screened and selected articles for inclusion and extracted data in a pre-specified form. Results: Of 181 articles screened, seven studies (one randomised controlled trial, two cohort studies, and four before-after studies) were included comprising 354 patients. APRV was initiated at a mean of 1.2-13 days after intubation. APRV wasn’t associated with improved mortality compared to CMV (relative risk [RR], 1.20; 95% CI 0.70-2.05; I2, 61%) neither better VFDs (ratio of means [RoM], 0.80; 95% CI, 0.52-1.24; I2, 0%) nor ICU LOS (RoM, 1.10; 95% CI, 0.79-1.51; I2, 57%). Compared to CMV, APRV was associated with a 33% increase in PaO2/FiO2 ratio (RoM, 1.33; 95% CI, 1.21-1.48; I2, 29%) and a 9% decrease in PaCO2 (RoM, 1.09; 95% CI, 1.02-1.15; I2, 0%). There was no significant increased risk of barotrauma compared to CMV (RR, 1.55; 95% CI, 0.60-4.00; I2, 0%). Conclusions: In adult patients with COVID-19 requiring mechanical ventilation, APRV is associated with improved gas exchange but not mortality nor VFDs when compared with CMV. The results were limited by high uncertainty given the low quality of the available studies and limited number of patients. Adequately powered and well-designed clinical trials to define the role of APRV in COVID-19 patients are still needed. Registration: PROSPERO; CRD42021291234.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-06-23T05:55:08Z
      DOI: 10.1177/08850666221109779
       
  • A Survey of Implementation of ABCDE Protocols

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      Authors: Rita N. Bakhru, Kathleen J. Propert, Steven M. Kawut, William D. Schweickert
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundSpontaneous awakening trials (SATs), spontaneous breathing trials (SBTs), delirium assessment/management, early mobility have been termed the ABCDE bundle. The ABCDE bundle has been proven to improve patient outcomes. However, there is often a long gap in dissemination and implementation of evidence-based medicine.ObjectivesTo determine the prevalent implementation of and determinants for ABCDE protocol adoption in Pennsylvania.MethodsWe developed a survey of ABCDE bundle protocols. We surveyed factors around implementation including written protocol presence, standardized assessments to guide protocols, timing of creation of protocols, and estimated adherence to protocols. We also collected data on factors that might be determinants for protocol adoption including ICU staffing models, hospital and ICU level factors. We validated the survey tool using the Michigan Health and Hospital Association Keystone ICU collaborative. We then administered the validated survey to a leader of the medical ICU or mixed medical-surgical ICU of all Pennsylvania Hospitals. Multivariable logistic and ordinal regression were used to determine associations between ICU staffing models and hospital and ICU level factors with the presence of ABCDE bundle protocols.ResultsIn the study cohort of Pennsylvania ICUs (n = 144), we had 100 respondents (69% response). The median number of hospital beds among the respondents was 185 (IQR 111-355) with a median of 14 ICU beds (IQR 10-20). 86% reported spontaneous awakening trial protocols, 60% reported spontaneous breathing trial protocols, 43% reported delirium assessment/management protocols, and 27% reported early mobility protocols. Being a medical ICU compared to a mixed medical-surgical ICU (OR 3.48, 95% CI 1.19-10.21, P = .02) and presence of multidisciplinary rounds (OR 4.97, 95% CI 2.07-11.94, P 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-06-22T04:39:19Z
      DOI: 10.1177/08850666221109157
       
  • Biomarkers of Glycocalyx Injury and Endothelial Activation are Associated
           with Clinical Outcomes in Patients with Sepsis: A Systematic Review and
           Meta-Analysis

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      Authors: Jaime Fernández-Sarmiento, Carlos Federico Molina, Lina María Salazar-Pelaez, Steffanie Flórez, Laura Carolina Alarcón-Forero, Mauricio Sarta, Ricardo Hernández-Sarmiento, Juan Carlos Villar
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      ObjectiveSepsis is one of the main causes of morbidity and mortality worldwide. Microcirculatory impairment, especially damage to the endothelium and glycocalyx, is often not assessed. The objective of this systematic review and meta-analysis was to summarize the available evidence of the risk of unsatisfactory outcomes in patients with sepsis and elevated glycocalyx injury and endothelial activation biomarkers.DesignA systematic search was carried out on PubMed/MEDLINE, Embase, Cochrane and Google Scholar up to December 31, 2021, including studies in adults and children with sepsis which measured glycocalyx injury and endothelial activation biomarkers within 48 hours of hospital admission. The primary outcome was the risk of mortality from all causes and the secondary outcomes were the risk of developing respiratory failure (RF) and multiple organ dysfunction syndrome (MODS) in patients with elevations of these biomarkers.Measurements and Main ResultsA total of 17 studies (3,529 patients) were included: 11 evaluated syndecan-1 (n=2,397) and 6 endocan (n=1,132). Syndecan-1 was higher in the group of patients who died than in those who survived [255 ng/mL (IQR: 139-305) vs. 83 ng/mL (IQR:40-111); p=0.014]. Patients with elevated syndecan-1 had a greater risk of death (OR 2.32; 95% CI 1.89, 3.10: p
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-06-20T04:02:57Z
      DOI: 10.1177/08850666221109186
       
  • The Impact of Chronic Medical Conditions on Mortality in Acute Respiratory
           Distress Syndrome

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      Authors: Saqib H. Baig, Urvashi Vaid, Erika J. Yoo
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      PurposeTo examine the impact of chronic comorbidities on mortality in Acute Respiratory Distress Syndrome (ARDS).Materials and MethodsRetrospective cohort study of adults with ARDS (ICD-10-CM code J80) from the National Inpatient Sample between January, 2016 and December, 2018. For the primary outcome of mortality, we conducted weighted logistic regression adjusting for factors identified on univariate analysis as potentially significant or differing between the two groups at baseline. We used negative binomial regression adjusting for the same comorbidities to identify risk factors for longer length of stay (LOS) among ARDS survivors.ResultsAfter exclusions, 1046 records were analyzed (3355 ARDS survivors and 1875 non-survivors.) The comorbidities examined included hypertension, diabetes mellitus, obesity, hypothyroidism, alcohol and drug use, chronic kidney disease (CKD), cardiovascular disease, chronic liver disease, chronic pulmonary disease and malignancy. In multivariate analysis, we found that malignancy (OR 2.26, 95% CI 1.84-2.78, p 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-06-20T04:02:42Z
      DOI: 10.1177/08850666221108079
       
  • Clinical Practices in Central Venous Catheter Mechanical Adverse Events

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      Authors: Enyo A. Ablordeppey, Wendy Huang, Ian Holley, Michael Willman, Richard Griffey, Daniel L. Theodoro
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Background: Over 5 million central venous catheters (CVCs) are placed annually. Pneumothorax and catheter malpositioning are common adverse events (AE) that requires attention. This study aims to evaluate local practices of mechanical complication frequency, type, and subsequent intervention(s) related to mechanical AE with an emphasis on catheter malpositioning. Methods: This is a retrospective review of CVC placements in a tertiary hospital setting from 1/2013 to 12/2013. Pneumothorax and CVC positioning were evaluated on post-insertion chest x-ray (CXR). Malposition was defined as unintended placement of the catheter in a vessel other than the intended superior vena cava on CXR. Catheter reposition was defined as radiographic evidence of a new catheter with removal of the old catheter less than 24hrs after initial placement. Data points analyzed included pneumothorax and thoracostomy rate, CVC malposition frequency, catheter reposition rate, catheter duration, and incidence of complications such as catheter associated venous thrombosis. Result: Among 2045 eligible CVC insertions, pneumothoraces occurred in 14 (0.7%; 95%CI 0.38, 1.17) and malpositions were identified in 275 (13.4%; 95% CI 12.3, 15.3). The proportion of pneumothoraces that required tube thoracostomy was 57%. The proportion of CVCs with malposition that were removed or replaced within 24h was 32.7%. "Malpositioned" catheters that were left in place by the clinical team (n = 185) had an average catheter duration of 8.2 days (95% CI 7.2, 9.3) versus 7.2 days (95% CI 6.17, 8.23) for catheters that were replaced after initial malposition (p = 0.14, t test). The incidence of venous thrombosis in repositioned “malpositioned” catheters was 7.8% versus 4.9% for “malpositioned” catheters that were left in place. Conclusions: Clinically significant catheter malposition and pneumothorax after CVC insertion are low. In this study, replaced and non-replaced “malpositioned” catheters had similar catheter duration and rates of complications, challenging the current dogma of CVC malposition practice.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-06-20T02:24:12Z
      DOI: 10.1177/08850666221076798
       
  • Potential Interaction Between Sepsis and Acute Respiratory Distress
           Syndrome and Effect on the 6-Month Clinical Outcomes: A Preliminary
           Secondary Analysis of a Prospective Observational Study

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      Authors: Tomoya Okazaki, Daisuke Kawakami, Shigeki Fujitani, Natsuyo Shinohara, Kenya Kawakita, Yasuhiro Kuroda
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundThis study aimed to investigate the effect of the potential interaction between sepsis and acute respiratory distress syndrome (ARDS) on the 6-month clinical outcomes.MethodsThis secondary analysis of a prospective multicenter observational study included patients who were expected to receive mechanical ventilation for more than 48 h. Patients were stratified based on the incidence of sepsis and further subdivided according to the presence of ARDS. The primary endpoints for patients whose follow-up information was available included mortality (n = 162) and the occurrence of PICS (n = 96) at six months. The diagnosis of PICS was based on any of the following criteria: (1) decrease ≥ 10 points in the physical component score of the 36-item Short Form (SF36) questionnaire; (2) decrease ≥ 10 points in the mental component score of the SF-36; or (3) decline in the Short Memory Questionnaire (SMQ) score and SMQ score < 40 at six months after ICU admission. We conducted multivariate logistic regression analyses to assess the effect of the potential interaction between ARDS and sepsis on the 6-month clinical outcomes.ResultsThe mortality in the ARDS sub-group was higher than that in the non-ARDS subgroup [47% (7/15) versus 21% (18/85)] in the non-sepsis group. However, the mortality in the ARDS and non-ARDS subgroups was similar in the sepsis group. Multivariate logistic regression analyses revealed that ARDS was significantly associated with mortality in the non-sepsis group (adjusted OR: 5.25; 95% CI: 1.45-19.09; p = .012), but not in the sepsis group (P for interaction = .087). Multivariate logistic regression analyses showed ARDS was not associated with PICS occurrence in the non-sepsis and sepsis groups (P-value for the interaction = .039).ConclusionsThis hypothesis-generating study suggested that the effect of ARDS on the 6-month outcomes depended on the presence or absence of sepsis.Trial registrationNot applicable
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-06-17T08:16:26Z
      DOI: 10.1177/08850666221107559
       
  • Intensivist -Driven Ventilator Management Shortens Duration of Mechanical
           Ventilation in Coronary Artery Bypass Graft Surgery Patients

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      Authors: Yonatan Dollin, Brian Elliott, Ronald Markert, Angela Morman, Matthew Koroscil
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundProlonged mechanical ventilation in post Coronary Artery Bypass Graft Surgery (CABG) is associated with deleterious effects including, increased ICU and hospital length of stay (LOS), infectious complications, and mortality. Standardized ventilator weaning protocols and the utilization of critical care physicians in post CABG patient care vary substantially among institutions. The purpose of this study was to evaluate if intensivist consultation in conjunction with a multidisciplinary, standardized ventilator weaning protocol improves outcomes in CABG patients.Materials and MethodsWe performed a single-center, retrospective, before-after cohort analysis at Miami Valley Hospital in Dayton, OH, a 970-bed community hospital. Patients were divided into two arms: the before cohort or delayed-consult group (critical care consult after six hours on ventilator) and after cohort or immediate-consult group (immediate critical care consult). All patients were weaned from ventilator using a standardized weaning protocol.ResultsA total of 764 patients were enrolled, 411 in the delayed-consult group and 353 in the immediate-consult group. The immediate-consult group had less time on initial mechanical ventilation than the delayed-consult group (5.86 ± 4.75 h vs. 6.00 ± 6.64 h, P = 0.038). The small advantages to immediate critical care consultation for higher percent of early extubations, fewer re-intubations, shorter ICU LOS, and lower rate of ICU readmission were not statistically significant. The two groups had similar ventilator free days, prolonged mechanical ventilation, hospital LOS, and in-hospital mortality.ConclusionOur study suggests that intensivist-driven ventilator management in conjunction with a multidisciplinary standardized weaning protocol shortens duration of mechanical ventilation in coronary artery bypass graft surgery patients.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-06-17T06:09:27Z
      DOI: 10.1177/08850666221109181
       
  • Evaluation of Procalcitonin's Utility to Predict Concomitant Bacterial
           Pneumonia in Critically Ill COVID-19 Patients

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      Authors: Nandini Patel, Christopher Adams, Luigi Brunetti, Christopher Bargoud, Amanda L. Teichman, Rachel L. Choron
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Background: Historically, procalcitonin(PCT) has been used as a predictor of bacterial infection and to guide antibiotic therapy in hospitalized patients. The purpose of this study was to determine PCT's diagnostic utility in predicting secondary bacterial pneumonia in critically ill patients with severe COVID-19 pneumonia. Methods: A retrospective cohort study was conducted in COVID-19 adults admitted to the ICU between March 2020, and March 2021. All included patients had a PCT level within 72 h of presentation and serum creatinine of  0.05). While there was no difference in bacterial pneumonia in low versus high groups (34(26.8%) versus 12(31.6%), p = 0.562), more patients in the high PCT group had bacteremia (19(15%) versus 11(28.9%), p = 0.050). Sensitivity was 26.1% and specificity was 78.2% for PCT to predict bacterial pneumonia coinfection in ICU patients with COVID-19 pneumonia. ROC yielded an AUC 0.54 (p = 0.415). After adjusting for LDH>350U/L and creatinine in multivariable regression, PCT did not enhance performance of the regression model. Conclusions: PCT offers little to no predictive utility in diagnosing concomitant bacterial pneumonia in critically ill patients with COVID-19 nor in predicting increased severity of disease or worse outcomes including mortality.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-06-17T06:09:21Z
      DOI: 10.1177/08850666221108636
       
  • Subjective Assessment of Motor Function by the Bedside Nurses in
           Mechanically Ventilated Surgical Intensive Care Unit Patients Predicts
           Tracheostomy

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      Authors: Sabine Friedrich, Bijan Teja, Nicola Latronico, Jay Berger, Sandra Muse, Karen Waak, Philipp Fassbender, Omid Azimaraghi, Matthias Eikermann, Karuna Wongtangman
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      ObjectiveIn many institutions, intensive care unit (ICU) nurses assess their patients’ muscle function as part of their routine bedside examination. We tested the research hypothesis that this subjective examination of muscle function prior to extubation predicts tracheostomy requirement.MethodsAdult, mechanically ventilated patients admitted to 7 ICUs at Beth Israel Deaconess Medical Center (BIDMC) between 2008 and 2019 were included in this observational study. Assessment of motor function was performed every four hours by ICU nurses. Multivariable logistic regression analysis controlled for acute disease severity, delirium risk assessment through the confusion assessment method for the ICU (CAM-ICU), and pre-defined predictors of extubation failure was applied to examine the association of motor function and tracheostomy within 30 days after extubation.ResultsWithin 30 days after extubation, 891 of 9609 (9.3%) included patients required a tracheostomy. The inability to spontaneously move and hold extremities against gravity within 24 h prior to extubation was associated with significantly higher odds of 30-day tracheostomy (adjusted OR 1.56, 95% CI 1.27−1.91, p 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-06-13T06:30:18Z
      DOI: 10.1177/08850666221107839
       
  • Relationship Between the Anion Gap and Serum Lactate in Hypovolemic Shock

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      Authors: Scott E. Rudkin, Tristan R. Grogan, Richard M. Treger
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Background and objectives: Previous studies evaluating patients in the Intensive Care Unit with established lactic acidosis determined that the anion gap is an insensitive screening tool for elevated blood lactate. No prior study has examined the relationship between anion gap and serum lactate within the first hours of the development of lactic acidosis. Design, setting, participants, & measurements: Data were obtained prospectively from a convenience sample of adult trauma patients at a single level 1 trauma center. Venous samples were drawn prior to initiation of intravenous fluid resuscitation. A linear regression model was constructed to assess the relationship between serum lactate and anion gap, and 95% prediction intervals were computed. Logistic regression models were constructed to determine the sensitivity and specificity for several different anion gap and lactate cutpoints. Results: 128 patients with elevated serum lactate levels (>2.1 mmol/L) and 63 patients with normal serum lactate levels (< 2.1 mmol/L) were included. The sensitivity of an elevated anion gap (> 10) to reveal hyperlactatemia was only 43% whereas specificity was 84%. Sensitivity improved if the upper limit of normal anion gap was lowered and with increasing levels of serum lactate. The coefficient of determination between serum lactate level and AG yielded an R2 of 0.30 (p < 0.001) and the slope of this relationship was 2.185 with a 95% confidence interval of 2.011–2.359. The mean 95% prediction interval was + 8.9. Conclusions: Within the first hour of the development of lactic acidosis due to hypovolemic shock, the anion gap was not a sensitive indicator of an elevated serum lactate level, but it was fairly specific. The anion gap increased to a greater extent than the serum lactate, the 95% mean prediction interval was wide and approximately 70% of the change in anion gap could not be explained by increases in serum lactate, suggesting that other anions contribute to the anion gap in lactic acidosis.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-06-07T05:26:43Z
      DOI: 10.1177/08850666221106413
       
  • Echocardiographic Characteristics of Cardiogenic Shock Patients with and
           Without Cardiac Arrest

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      Authors: Meir Tabi, Narayana Sarma V. Singam, Brandon Wiley, Nandan Anavekar, Gregory Barsness, Jacob C. Jentzer
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundCardiac arrest (CA) is associated with worse outcomes in patients with cardiogenic shock (CS). To better understand the contribution of CA on CS, we evaluated transthoracic echocardiography (TTE) parameters in CS patients with and without CA. Methods: We retrospectively identified CS patients with a TTE performed near cardiac intensive care unit admission between 2007 to 2018. We compared TTE measurements of left ventricular (LV) and right ventricular (RV) function in patients with and without CA. The primary outcome was all-cause in-hospital mortality, as determined using multivariable logistic regression. Results: We included 1085 patients, 35% of whom had CA. Median age was 70 years and 37% were females. CA patients had higher severity of illness, more invasive mechanical ventilation and greater vasopressor/inotrope use. In-hospital mortality was 31% and was higher in CA patients (45% vs. 23%, p
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-06-03T08:05:59Z
      DOI: 10.1177/08850666221105236
       
  • Hourly Analysis of Mechanical Ventilation Parameters in Critically Ill
           Adult Covid-19 Patients: Association with Mortality

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      Authors: Tomás F. Fariña-González, Antonio Núñez-Reiz, Viktor Yordanov-Zlatkov, Julieta Latorre, Maria Calle-Romero, Patricia Alonso-Martinez, Sara Domingo-Marín, Miguel Sánchez-García
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Objective: There exists controversy about the pathophysiology and lung mechanics of COVID-19 associated acute respiratory distress syndrome (ARDS), because some report severe hypoxemia with preserved respiratory system mechanics, contrasting with “classic” ARDS. We performed a detailed hourly analysis of the characteristics and time course of lung mechanics and biochemical analysis of patients requiring invasive mechanical ventilation (IMV) for COVID-19-associated ARDS, comparing survivors and non-survivors. Methods: Retrospective analysis of the data stored in the ICU information system of patients admitted in our hospital ICU that required IMV due to confirmed SARS-CoV-2 pneumonia between March 5th and April 30th, 2020. We compare respiratory system mechanics and gas exchange during the first ten days of IMV, discriminating volume and pressure controlled modes, between ICU survivors and non-survivors. Results: 140 patients were included, analyzing 11 138 respiratory mechanics recordings. Global mortality was 38.6%. Multivariate analysis showed that age (OR 1.092, 95% (CI 1.014-1.176)) and need of renal replacement therapies (OR 10.15, (95% CI 1.58-65.11)) were associated with higher mortality. Previous use of Angiotensin Converting Enzyme inhibitor (ACEI)/angiotensin-receptor blockers (ARBs) also seemed to show an increased mortality (OR 4.612, (95% CI 1.19-17.84)) although this significance was lost when stratifying by age. Respiratory variables start to diverge significantly between survivors and non-survivors after the 96 to 120 hours (hs) from mechanical ventilation initiation, particularly respiratory system compliance. In non survivors, mechanical power at 24 and 96 hs was higher regardless ventilatory mode. Conclusions: In patients admitted for SARS-CoV-2 pneumonia and requiring mechanical ventilation, non survivors have different respiratory system mechanics than survivors in the first 10 days of ICU admission. We propose a checkpoint at 96–120 hs to assess patients improvement or worsening in order to consider escalating to extracorporeal therapies.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-06-01T05:56:22Z
      DOI: 10.1177/08850666221105423
       
  • Association Between Glycemic Gap and Mortality in Critically Ill Patients
           with Diabetes

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      Authors: Ran Lou, Li Jiang, Meiping Wang, Bo Zhu, Qi Jiang, Peng Wang
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      ObjectivesDysglycemia is associated with poor outcomes in critically ill patients,which is uncertain in patients with diabetes regarding to the situation of glucose control before hospitalization. This study was aimed to investigate the effect of the difference between the level of blood glucose during ICU stay and before admission to ICU upon the outcomes of critically ill patients with diabetes.MethodPatients with diabetes expected to stay for more than 24hs were enrolled, HbA1c was converted to A1C-derived average glucose (ADAG) by the equation: ADAG  =  [ (HbA1c * 28.7) – 46.7 ] * 18−1, blood glucose were measured four times a day during the first 7 days after admission, the mean glucose level(MGL) and SOFA (within 3, 5, and 7days) were calculated for each person, GAPadm and GAPmean was calculated as admission blood glucose and MGL minus ADAG, the incidence of moderate hypoglycemia(MH), severe hypoglycemia (SH), total dosage of glucocorticoids and average daily dosage of insulin, duration of renal replacement therapy(RRT), ventilator-free hours, and non-ICU days were also collected. Patients were divided into survival group and nonsurvival group according to survival or not at 28-day, the relationship between GAP and mortality were analyzed.Results431 patients were divided into survival group and nonsurvival group. The two groups had a comparable level of HbA1c, the nonsurvivors had greater APACHE II, SOFA, GAPadm, GAPmean-3, GAPmean-5, GAPmean-7 and higher MH and SH incidences. Less duration of ventilator-free, non-ICU stay and longer duration of RRT were recorded in the nonsurvival group. GAPmean-5 had the greatest predictive power with an AUC of 0.807(95%CI: 0.762-0.851), the cut-off value was 3.6 mmol/L (sensitivity 77.7% and specificity 76.6%). The AUC was increased to 0.852(95%CI: 0.814-0.889) incorporated with SOFA5 (NRI  =  11.34%).ConclusionGlycemic GAP between the MGL within 5 days and ADAG was independently associated with 28-day mortality of critically ill patients with diabetes. The predictive power was optimized with addition of SOFA5.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-05-25T07:07:00Z
      DOI: 10.1177/08850666221101856
       
  • Incidence, Risk Factors, and Prognosis of Bloodstream Infections in
           COVID-19 Patients in Intensive Care: A Single-Center Observational Study

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      Authors: Ahmet Furkan Kurt, Bilgul Mete, Seval Urkmez, Oktay Demirkiran, Guleren Yartas Dumanli, Suha Bozbay, Olcay Dilken, Ridvan Karaali, Ilker Inanç Balkan, Nese Saltoğlu, Yalim Dikmen, Fehmi Tabak, Gokhan Aygun
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundCritically ill COVID-19 patients are prone to bloodstream infections (BSIs).AimTo evaluate the incidence, risk factors, and prognosis of BSIs developing in COVID-19 patients in the intensive care unit (ICU).MethodsPatients staying at least 48 h in ICU from 22 March 2020 to 25 May 2021 were included. Demographic, clinical, and laboratory data were analyzed.ResultsThe median age of the sample (n  =  470) was 66 years (IQR 56.0-76.0), and 64% were male. The three most common comorbidities were hypertension (49.8%), diabetes mellitus (32.8%), and coronary artery disease (25.7%). Further, 252 BSI episodes developed in 179 patients, and the BSI incidence rate was 50.2 (95% CI 44.3-56.7) per 1000 patient-days. The source of BSI is central venous catheter in 42.5% and lower respiratory tract in 38.9% of the episodes. Acinetobacter baumannii (40%) and carbapenem-resistant Klebsiella pneumoniae (21%) were the most common pathogens. CRP levels were lower in patients receiving tocilizumab. Multivariable analysis revealed that continuous renal replacement therapy, extracorporeal membrane oxygenation, and treatment with a combination of methylprednisolone and tocilizumab were independent risk factors for BSI. The estimated cumulative risk of developing first BSI episode was 50% after 6 days and 100% after 25 days. Of the 179 patients, 149 (83.2%) died, and a statistically significant difference (p 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-05-24T05:33:41Z
      DOI: 10.1177/08850666221103495
       
  • Racial and Ethnic Differences in the Prevalence of Do-Not-Resuscitate
           Orders among Older Adults with Severe Traumatic Brain Injury

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      Authors: Jordan Hatfield, Megan Fah, Alex Girden, Brianna Mills, Tetsu Ohnuma, Krista Haines, Julien Cobert, Jordan Komisarow, Theresa Williamson, Raquel Bartz, Monica Vavilala, Karthik Raghunathan, Anwen Tobalske, Joshua Ward, Vijay Krishnamoorthy
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundOlder adults suffering from traumatic brain injury (TBI) are subject to higher injury burden and mortality. Do Not Resuscitate (DNR) orders are used to provide care aligned with patient wishes, but they may not be equitably distributed across racial/ethnic groups. We examined racial/ethnic differences in the prevalence of DNR orders at hospital admission in older patients with severe TBI.MethodsWe conducted a retrospective cohort study using the National Trauma Databank (NTDB) between 2007 to 2016. We examined patients ≥ 65 years with severe TBI. For our primary aim, the exposure was race/ethnicity and outcome was the presence of a documented DNR at hospital admission. We conducted an exploratory analysis of hospital outcomes including hospital mortality, discharge to hospice, and healthcare utilization (intracranial pressure monitor placement, hospital LOS, and duration of mechanical ventilation).ResultsCompared to White patients, Black patients (OR 0.48, 95% CI 0.35-0.64), Hispanic patients (OR 0.54, 95% CI 0.40-0.70), and Asian patients (OR 0.63, 95% CI 0.44-0.90) had decreased odds of having a DNR order at hospital admission. Patients with DNRs had increased odds of hospital mortality (OR 2.16, 95% CI 1.94-2.42), discharge to hospice (OR 2.08, 95% CI 1.75-2.46), shorter hospital LOS (−2.07 days, 95% CI −3.07 to −1.08) and duration of mechanical ventilation (−1.09 days, 95% CI −1.52 to −0.67). There was no significant difference in the utilization of ICP monitoring (OR 0.94, 95% CI 0.78-1.12).ConclusionsWe found significant racial and ethnic differences in the utilization of DNR orders among older patients with severe TBI. Additionally. DNR orders at hospital admission were associated with increased in-hospital mortality, increased hospice utilization, and decreased healthcare utilization. Future studies should examine mechanisms underlying race-based differences in DNR utilization.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-05-23T05:49:47Z
      DOI: 10.1177/08850666221103780
       
  • Measuring Social Health Following Pediatric Critical Illness: A Scoping
           Review and Conceptual Framework

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      Authors: Hannah Daughtrey, Katherine N. Slain, Sabrina Derrington, Idris V. R. Evans, Denise M. Goodman, LeeAnn M. Christie, Simon Li, John C. Lin, Debbie A. Long, Maureen A. Madden, Sara VandenBranden, McKenna Smith, Neethi P. Pinto, Aline B. Maddux, Ericka L. Fink, R. Scott Watson, Leslie A. Dervan
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      ObjectiveSocial health is an important component of recovery following critical illness as modeled in the pediatric Post-Intensive Care Syndrome framework. We conducted a scoping review of studies measuring social outcomes (measurable components of social health) following pediatric critical illness and propose a conceptual framework of the social outcomes measured in these studies.Data sourcesPubMed, EMBASE, PsycINFO, CINAHL, and the Cochrane RegistryStudy selectionWe identified studies evaluating social outcomes in pediatric intensive care unit (PICU) survivors or their families from 1970–2017 as part of a broader scoping review of outcomes after pediatric critical illness.Data extractionWe identified articles by dual review and dual-extracted study characteristics, instruments, and instrument validation and administration information. For instruments used in studies evaluating a social outcome, we collected instrument content and described it using qualitative methods adapted to a scoping review.Data synthesisOf 407 articles identified in the scoping review, 223 (55%) evaluated a social outcome. The majority were conducted in North America and the United Kingdom, with wide variation in methodology and population. Among these studies, 38 unique instruments were used to evaluate a social outcome. Specific social outcomes measured included individual (independence, attachment, empathy, social behaviors, social cognition, and social interest), environmental (community perceptions and environment), and network (activities and relationships) characteristics, together with school and family outcomes. While many instruments assessed more than one social outcome, no instrument evaluated all areas of social outcome.ConclusionsThe full range of social outcomes reported following pediatric critical illness were not captured by any single instrument. The lack of a comprehensive instrument focused on social outcomes may contribute to under-appreciation of the importance of social outcomes and their under-representation in PICU outcomes research. A more comprehensive evaluation of social outcomes will improve understanding of overall recovery following pediatric critical illness.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-05-23T05:49:27Z
      DOI: 10.1177/08850666221102815
       
  • Interaction Between Altered Gut Microbiota and Sepsis: A Hypothesis or an
           Authentic Fact'

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      Authors: Edris Nabizadeh, Javid Sadeghi, Mohammad Ahangarzadeh Rezaee, Alka Hasani, Hossein Samadi Kafil, Anahita Ghotaslou, Hiva Kadkhoda, Reza Ghotaslou
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Sepsis, as an important public health concern, is one of the leading causes of death in hospitals around the world, accounting for 25% of all deaths. Nowadays, several factors contribute to the development of sepsis. The role of the gut microbiota and the response state of the aberrant immune system is dominant. The effect of the human microbiome on health is undeniable, and gut microbiota is even considered a body organ. It is now clear that the alteration in the normal balance of the microbiota (dysbiosis) is associated with a change in the status of immune system responses. Owing to the strong association between the gut microbiota and its metabolites particularly short-chain fatty acids with many illnesses, the gut microbiota has a unique position in the research of microbiologists and even clinicians. This review aimed to analyze studies’ results on the association between microbiota and sepsis, with a substantial understanding of their relationship. As a result, an extensive and comprehensive search was conducted on this issue in existing databases.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-05-23T05:49:12Z
      DOI: 10.1177/08850666221102796
       
  • Acute Stress in Parents of Patients Admitted to the Pediatric Intensive
           Care Unit: A Two-Center Cross-Sectional Observational Study

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      Authors: Daniel Kaplan, Mekela Whyte Nesfield, Peter S Eldridge, WIlliam Cuddy, Nadia Ansari, Pamela Siller, Simon Li
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      ObjectiveTo examine medical and psychosocial risk factors associated with the development of acute stress in parents of patients unexpectedly admitted to the PICU.DesignCross-sectional observational study.SettingTwo tertiary care children's hospitals with mixed medical/surgical/cardiac PICU.PatientsParents of patients unexpectedly admitted to the PICU.InterventionNone.Measurements and Main Results265 parents of 188 children were enrolled of whom 49 parents (18%) met ASD qualification and 108 (41%) parents developed ASD symptoms as determined by the ASDS-5 scale. Risk factors making parents likely to meet ASD qualification include parents from area served by Penn State (p 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-05-20T08:20:37Z
      DOI: 10.1177/08850666221100482
       
  • Multi-inflammatory Index as a Novel Mortality Predictor in Critically Ill
           COVID-19 Patients

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      Authors: Hasan Tahsin Gozdas, Seyit Ali Kayis, Tugce Damarsoy, Emine Ozsari, Mustafa Turkoglu, Isa Yildiz, Abdullah Demirhan
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      AimSystemic inflammation has a crucial role in the pathogenesis and mortality of Coronavirus disease 2019 (COVID-19). Multi-inflammatory index (MII) is a novel index related with systemic inflammation. In this study, we investigated the relationship between MII and in-hospital mortality in COVID-19 patients admitted to the intensive care unit (ICU).MethodsWe retrospectively analyzed the medical records of COVID-19 patients followed-up in the ICU of our institution between 01.04.2020 and 01.10.2021. Patients were classified into two groups according to mortality status as survivors and non-survivors. Various inflammatory parameters of the groups were compared and their efficacy in predicting mortality was investigated.ResultsOut of 348 study patients, 86 cases (24.7%) were in the survived group and 262 cases (75.3%) were in the dead group. The median age of the mortal group was significantly higher than that of the survived group (65.5 vs 76, P 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-05-11T07:33:02Z
      DOI: 10.1177/08850666221100411
       
  • Effect of High Altitude on the Survival of COVID-19 Patients in Intensive
           Care Unit: A Cohort Study

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      Authors: Manuel Jibaja, Estefania Roldan-Vasquez, Jordi Rello, Hua Shen, Nelson Maldonado, Michelle Grunauer, Ana María Díaz, Fernanda García, Vanessa Ramírez, Hernán Sánchez, José Luis Barberán, Juan Pablo Paredes, Mónica Cevallos, Francisco Montenegro, Soraya Puertas, Killen Briones, Marlon Martínez, Jorge Vélez-Páez, Mario Montalvo-Villagómez, Luis Herrera, Santiago Garrido, Ivan Sisa
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Purpose: The effect of high altitude ( ≥ 1500 m) and its potential association with mortality by COVID-19 remains controversial. We assessed the effect of high altitude on the survival/discharge of COVID-19 patients requiring intensive care unit (ICU) admission for mechanical ventilation compared to individuals treated at sea level. Methods: A retrospective cohort multi-center study of consecutive adults patients with a positive RT-PCR test for COVID-19 who were mechanically ventilated between March and November 2020. Data were collected from two sea-level hospitals and four high-altitude hospitals in Ecuador. The primary outcome was ICU and hospital survival/discharge. Survival analysis was conducted using semi-parametric Cox proportional hazards models. Results: Of the study population (n = 670), 35.2% were female with a mean age of 58.3 ± 12.6 years. On admission, high-altitude patients were more likely to be younger (57.2 vs. 60.5 years old), presented with less comorbidities such as hypertension (25.9% vs. 54.9% with p-value
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-05-09T11:21:49Z
      DOI: 10.1177/08850666221099827
       
  • Clinical Outcomes of Early Versus Late Tracheostomy in Coronavirus Disease
           2019 Patients: A Systematic Review and Meta-Analysis

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      Authors: Woon Hean Chong, Chee Keat Tan
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundA significant proportion of Coronavirus Disease 2019 (COVID-19) patients require admission to the intensive care unit (ICU) and invasive mechanical ventilation (IMV). Tracheostomy is increasingly performed when a prolonged course of IMV is anticipated.ObjectivesTo determine clinical and resource utilization benefits of early versus late tracheostomy among COVID-19 patients.MethodsPubmed, Cochrane Library, Scopus, and Embase were used to identify relevant studies comparing outcomes of COVID-19 patients undergoing early and late tracheostomy from January 1, 2020, to December 1, 2021.ResultsTwelve studies were selected, and 2222 critically ill COVID-19 patients hospitalized between January to December 2020 were included. Among the included patients, 34.5% and 65.5% underwent early and late tracheostomy, respectively. Among the included studies, 58.3% and 41.7% defined early tracheostomy using cutoffs of 14 and 10 days, respectively. All-cause in-hospital mortality was not different between the early and late tracheostomy groups (32.9% vs. 33.1%; OR = 1.00; P = 0.98). Sensitivity analysis demonstrated a similar mortality rate in studies using a cutoff of 10 days (34.6% vs. 35.5%; OR = 0.97; P = 0.89) or 14 days (31.2% vs. 27.7%; OR = 1.05; P = 0.78). The early tracheostomy group had shorter ICU length of stay (LOS) (mean: 23.18 vs. 30.51 days; P 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-05-04T02:20:11Z
      DOI: 10.1177/08850666221098930
       
  • Comparisons of Continuous-wave Doppler Ultrasound Monitor and
           Echocardiography in Cardiac Postoperative Pediatric Patients

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      Authors: Eran Shostak, Elchanan Nahum, Tzippy Shochat, Orit Manor, Ovadia Dagan, Ofer Schiller
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Rational and ObjectivesNon-invasive cardiac output (CO) measurements are essential during the immediate post-operative course of young, congenital heart repaired patients. The use of the Ultrasonic Cardiac Output Monitor (USCOM) in pediatric intensive care units (PICU) is increasing. The literature on accuracy of USCOM in young, critically ill, mechanically ventilated, hemodynamically supported patients is scarce. We aimed to assess agreement between the USCOM device and echocardiography for measurements of CO in this population.Materials (Patients) and MethodsA prospective observational study in a pediatric cardiac intensive care unit (PCICU). Paired CO measurements were taken in young, mechanically ventilated, immediate post-operative patients with exclusion of unrepaired or residual intra-cardiac shunt, using USCOM and echocardiography, by two separate senior performers. Agreement between echocardiography and USCOM was assessed by percentage error and Bland-Altman analysis.ResultsOne hundred and thirteen comparison scans were performed on 61 patients: mean age 94 ± 111 d, weight 4.7 ± 2.1 kg, vaso-inotropic score 15.3 ± 11, and STAT score 3–4 (46%). Mean USCOM cardiac index (CI) percent difference was −9.6% (45.6) and velocity-time-integral (VTI) 8.9% (34.7). Bland–Altman analyzes demonstrated poor agreement comparing USCOM to echocardiography with regard to CI, stroke volume (SV), VTI and aortic diameter (AO) measurements.ConclusionOur study shows that USCOM underestimates CI in comparison with echocardiography; therefore USCOM should be used with great caution as an absolute estimate or surrogate of CI in neonates and infants in the immediate post-operative, congenital heart surgery period.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-05-03T03:57:58Z
      DOI: 10.1177/08850666221099830
       
  • Relationship Between Glucose Time in Range in Diabetic and Non-Diabetic
           Patients and Mortality in Critically Ill Patients

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      Authors: Mahmoud A. Ammar, Abdalla A. Ammar, Timothy Wee, Ranjit Deshpande, Matthew Band, Shamsuddin Akhtar
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Background: Shorter time spent in specific blood glucose ranges is associated with mortality benefit in critically ill patients. However, various time in range values are reported, each based on a specific blood glucose range. Objective: To evaluate relationship between percentage of time spent at various blood glucose ranges (TIR) and mortality in critically ill patients. Methods: Single-center, retrospective, cohort study that included adult patients admitted to ICU for at least one day. We evaluated the relationship between TIR at prespecified blood glucose ranges and hospital mortality in diabetic and non-diabetic patients Results: Of the 5287 patients included, 3705 (70.0%) were non-diabetic and 1582 were diabetic (29.9%). Diabetic patients had higher in-hospital mortality rate (15.8%) compared to non-diabetic patients (11.3%), p 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-05-02T07:21:18Z
      DOI: 10.1177/08850666221098383
       
  • Mobilization and Rehabilitation Practice in ICUs During the COVID-19
           Pandemic

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      Authors: Keibun Liu, Kensuke Nakamura, Sapna R. Kudchadkar, Hajime Katsukawa, Peter Nydahl, Eugene Wesley Ely, Kunihiko Takahashi, Shigeaki Inoue, Osamu Nishida
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundMobilization and acute rehabilitation are essential in the intensive care unit (ICU), with substantial evidence supporting their benefits. This study aimed to characterize ICU mobilization practices during the COVID-19 pandemic for patients with and without COVID-19.MethodsThis was a secondary analysis of an international point prevalence study. All ICUs across the world were eligible to participate and were required to enroll all patients in each ICU on the survey date, 27 January 2021. The primary outcome was the achievement of mobilization at the level of sitting over the edge of the bed. Independent factors associated with mobilization, including COVID-19 infection, were analyzed by multivariable analysis.ResultsA total of 135 ICUs in 33 countries participated, for inclusion of 1229 patients. Among patients who were not receiving mechanical ventilation (MV), those with COVID-19 infection were mobilized more than those without COVID-19 (60% vs. 34%, p 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-04-27T08:41:55Z
      DOI: 10.1177/08850666221097644
       
  • Length of Stay and Hospital Cost Reductions After Implementing Bedside
           Percutaneous Ultrasound Gastrostomy (PUG) in a Critical Care Unit

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      Authors: Jeffrey D. Marshall, Jason J. Heavner, Peter P. Olivieri, Hannah K. Van Ryzin, Janelle Thomas, Youssef Annous, R. Gentry Wilkerson
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Background: Critical care patients receive 50% of gastrostomy tubes placed in the United States. Several gastrostomy placement methods exist, however care processes remain variable and often lack health system cost effectiveness. No data exists on efficiency or cost impact of performing bedside percutaneous ultrasound gastrostomy (PUG) on patients with ventilator-dependent respiratory failure. This study's objective was to determine if implementing bedside PUG would positively impact efficiency and cost outcomes in intensive care unit (ICU) patients compared to usual care gastrostomy. Design and Methods: This is a retrospective cohort study of patients with ventilator-dependent respiratory failure who received a gastrostomy consult or procedure in the ICU. Patients received PUG or usual care gastrostomy, determined by the presiding attending's skillset, and both groups were compared across patients’ demographics, clinical characteristics and outcomes. Primary outcomes were length of stay (LOS) and total hospital costs. Results: A total of 88 patients were included in the analysis, 45 patients in the PUG group and 43 in the usual care gastrostomy group. No differences were observed in demographic and clinical characteristics. Patients who received PUG had a significantly shorter mean ICULOS and hospital LOS, with reductions of 5.0 and 8.7 days, respectively. Total hospital costs were significantly reduced in the PUG group, with a cost savings of US $26,621 per patient. No differences in mortality or discharge disposition were observed. PUG patients received concomitant percutaneous dilatation tracheostomy (PDT) and PUG (“TPUG”) 70% of the time, whereas no usual care patients received concomitant procedures. Off-hour procedures occurred in 53.3% of PUG and 4.6% of usual care gastrostomy. Conclusions: This study demonstrates bedside PUG leads to decreased LOS and total hospital costs in patients with ventilator-dependent respiratory failure. Hospital costs were significantly reduced with a per patient savings of $26,621 compared to usual care gastrostomy.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-04-27T07:54:27Z
      DOI: 10.1177/08850666221097018
       
  • Severe Multi-inflammatory Syndrome in Children Temporally Related to COVID
           19—Clinical Course, Laboratory Profile and Outcomes from a North Indian
           PICU

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      Authors: Arpita Chattopadhyay, Karnika Saigal Kalra, Diganta Saikia, Varshanjali Yadav, Juhi Chouksey, Mamta Jajoo, B. L. Sherwal
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Objective: We describe the trajectory of clinical course, laboratory markers and outcomes in children with severe multi—inflammatory syndrome temporally related to COVID-19 (MIS-C) admitted to our pediatric intensive care unit (PICU). Methods: This was a prospective case series of children admitted to PICU between May 1, 2020 and January 31, 2021, fulfilling the case definition of MIS-C published by World Health Organization (WHO) or Centers for Disease Control and Prevention (CDC). We analyzed demographic, clinical, laboratory data and echocardiographic findings. We also plotted the variation in trends between survivors and nonsurvivors. Results: Of the 34 critically ill children referred to PICU with diagnosis of MIS-C only 17 fulfilled the WHO/CDC classification of MIS-C, rest were MISC mimickers albeit other tropical infections. Median age at admission was 4 years (range 1y 6 mo-8 years). Fever, rash and conjunctival redness were most prominent symptoms. Myocardial involvement was seen in 70.5% while 76.4% developed shock; Invasive mechanical ventilation was required in 64.7% cases. Inflammatory markers showed a downward trend such as—median C- reactive protein (mg/L) had a serial reduction in levels—from (median/IQR) 210 (132.60, 246.90) at admission to 52.3 (42, 120) on Day 3. Median Ferritin (ng/ml) (n = 12) was 690 (203, 1324), serum LDH (IU/L) (n = 12) was 505 (229.5, 1032) and Mean D-dimer (ng/ml) (n = 7) was 5093.85 (1991.65), suggestive of hyperinflammatory syndrome. Twelve patients received intravenous immune globulin, with adjunctive steroid therapy used in two third of the cases. Six children died, 4 of them were under—5 years of age. Tocilizumab was prescribed in two children with high vasotrope inotrope score (VIS), cardiogenic shock and oxygenation index more than 15, both survived. Conclusions: Severe MIS-C has a heterogenous presentation, local or regional outbreaks of prevalent infectious diseases often lead to confusion and overdiagnosis. Higher proportion of mortality was seen in Under −5 children with MISC. Shock—like presentation, presence of myocardial dysfunction or nonsurvivor status is associated with higher trend of inflammatory markers and more profound multi-organ dysfunction. If disease progresses rapidly despite first line therapy (IvIg and steroids), use of Tocilizumab should be considered—as a rescue therapy under resource limitations in the absence of extracorporeal support.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-04-26T07:03:14Z
      DOI: 10.1177/08850666221092302
       
  • Evaluation of Low-Dose Aspirin use among Critically Ill Patients with
           COVID-19: A Multicenter Propensity Score Matched Study

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      Authors: Abdullah F. Al Harthi, Ohoud Aljuhani, Ghazwa B. Korayem, Ali F. Altebainawi, Raghdah S. Alenezi, Shmeylan Al Harbi, Jawaher Gramish, Raed Kensara, Awattif Hafidh, Huda Al Enazi, Ahad Alawad, Rand Alotaibi, Abdulaziz Alshehri, Omar Alhuthaili, Ramesh Vishwakarma, Khalid bin Saleh, Thamer Alsulaiman, Rahaf Ali Alqahtani, Sajid Hussain, Saja Almazrou, Khalid Al Sulaiman
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundAspirin is widely used as a cardioprotective agent due to its antiplatelet and anti-inflammatory properties. The literature has assessed and evaluated its role in hospitalized COVID-19 patients. However, no data are available regarding its role in COVID-19 critically ill patients. This study aimed to evaluate the use of low-dose aspirin (81-100 mg) and its impact on outcomes in critically ill patients with COVID-19.MethodA multicenter, retrospective cohort study of all critically ill adult patients with confirmed COVID-19 admitted to intensive care units (ICUs) between March 1, 2020, and March 31, 2021. Eligible patients were classified into two groups based on aspirin use during ICU stay. The primary outcome was in-hospital mortality, and other outcomes were considered secondary. Propensity score matching was used (1:1 ratio) based on the selected criteria.ResultsA total of 1033 patients were eligible, and 352 patients were included after propensity score matching. The in-hospital mortality (HR 0.73 [0.56, 0.97], p = 0.03) was lower in patients who received aspirin during stay. Conversely, patients who received aspirin had a higher odds of major bleeding than those in the control group (OR 2.92 [0.91, 9.36], p = 0.07); however, this was not statistically significant. Additionally, subgroup analysis showed a possible mortality benefit for patients who used aspirin therapy prior to hospitalization and continued during ICU stay (HR 0.72 [0.52, 1.01], p = 0.05), but not with the new initiation of aspirin (HR 1.22 [0.68, 2.20], p = 0.50).ConclusionContinuation of aspirin therapy during ICU stay in critically ill patients with COVID-19 who were receiving it prior to ICU admission may have a mortality benefit; nevertheless, it may be associated with an increased risk of significant bleeding. Appropriate evaluation for safety versus benefits of utilizing aspirin therapy during ICU stay in COVID19 critically ill patients is highly recommended.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-04-22T06:31:07Z
      DOI: 10.1177/08850666221093229
       
  • A Retrospective Observational Study of Anticoagulation Practices in
           Critically ill Patients with Atrial Fibrillation Admitted to the Intensive
           Care Unit

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      Authors: NHC Miller, BW Johnston, A Hampden-Martin, AAC Waite, V Waugh, ID Welters
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundAtrial Fibrillation (AF) is the most common arrhythmia in critically ill patients. AF precipitates thromboembolic (TE) events. International guidelines recommend long-term anticoagulation for AF patients dependent upon the risk of TE versus major bleeding events. The CHA2DS2VASc and HAS-BLED scores are used to calculate these risks, but have not been validated in intensive care. Little is known about the risk/benefit ratio of prescribing anticoagulation to patients with AF in the intensive care setting.MethodsThis observational study included patients who were admitted to intensive care and had AF episodes during admission. We aimed to 1) describe the anticoagulation strategies used in critically ill patients with AF, 2) determine the percentage of patients who received guideline-compliant anticoagulation and 3) compare anticoagulation strategies in patients with new onset AF (NOAF) and known AF. Demographic data was extracted from electronic health records. Therapeutic anticoagulation prescribed during AF episodes and outcomes were collected. CHA2DS2VASc and HAS-BLED scores were calculated and correlated with TE and bleeding events.ResultsThe incidence of AF in our cohort was 13.8%. Anticoagulation was administered in 34.0% of patients. Anticoagulation use did not affect morbidity or mortality outcomes. Patients with pre-existing AF were anticoagulated more often compared to patients with NOAF. CHA2DS2VASc scores and TE events, and HAS-BLED scores and bleeding events did not correlate well.ConclusionAF is common in critical care. Current guidelines on anticoagulation in AF may not be directly transferable to the critical care setting.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-04-22T06:31:01Z
      DOI: 10.1177/08850666221092997
       
  • Ten Influential Point-of-Care Ultrasound Papers: 2021 in Review

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      Authors: Scott J. Millington, Robert T. Arntfield, Seth J. Koenig, Paul H. Mayo, Antoine Vieillard-Baron
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      The ongoing rapid expansion of point-of-care ultrasound (POCUS) and its corresponding supporting literature leaves the frontline clinician in a difficult position when trying to keep abreast of the latest developments. Our group of POCUS experts has selected ten influential POCUS-related papers from the past twelve months and provided a short summary of each. Our aim is to give to emergency physicians, intensivists, and other acute care providers key information, helping them to keep up to date on rapidly evolving POCUS literature.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-04-20T06:24:43Z
      DOI: 10.1177/08850666221095050
       
  • Hospital Academic Status and the Volume-Outcome Association in
           Postoperative Patients Requiring Intensive Care: Results of a Nationwide
           Analysis of Intensive Care Units in the United States

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      Authors: Leon Naar, Lydia R. Maurer, Ander Dorken Gallastegi, Majed W. El Hechi, Sowmya R. Rao, Catherine Coughlin, Senan Ebrahim, Adesh Kadambi, April E. Mendoza, Noelle N. Saillant, B. Christian B. Renne, George C. Velmahos, Haytham M.A. Kaafarani, Jarone Lee
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Objective: To determine whether the outcomes of postoperative patients admitted directly to an intensive care unit (ICU) differ based on the academic status of the institution and the total operative volume of the unit. Methods: This was a retrospective analysis using the eICU Collaborative Research Database v2.0, a national database from participating ICUs in the United States. All patients admitted directly to the ICU from the operating room were included. Transfer patients and patients readmitted to the ICU were excluded. Patients were stratified based on admission to an ICU in an academic medical center (AMC) versus non-AMC, and to ICUs with different operative volume experience, after stratification in quartiles (high, medium-high, medium-low, and low volume). Primary outcomes were ICU and hospital mortality. Secondary outcomes included the need for continuous renal replacement therapy (CRRT) during ICU stay, ICU length of stay (LOS), and 30-day ventilator free days. Results: Our analysis included 22,180 unique patients; the majority of which (15,085[68%]) were admitted to ICUs in non-AMCs. Cardiac and vascular procedures were the most common types of procedures performed. Patients admitted to AMCs were more likely to be younger and less likely to be Hispanic or Asian. Multivariable logistic regression indicated no meaningful association between academic status and ICU mortality, hospital mortality, initiation of CRRT, duration of ICU LOS, or 30-day ventilator-free-days. Contrarily, medium-high operative volume units had higher ICU mortality (OR = 1.45, 95%CI = 1.10-1.91, p-value = 0.040), higher hospital mortality (OR = 1.33, 95%CI = 1.07-1.66, p-value = 0.033), longer ICU LOS (Coefficient = 0.23, 95%CI = 0.07-0.39, p-value = 0.038), and fewer 30-day ventilator-free-days (Coefficient = -0.30, 95%CI = -0.48 – −0.13, p-value = 0.015) compared to their high operative volume counterparts. Conclusions: This study found that a volume-outcome association in the management of postoperative patients requiring ICU level of care immediately after a surgical procedure may exist. The academic status of the institution did not affect the outcomes of these patients.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-04-19T07:25:41Z
      DOI: 10.1177/08850666221094506
       
  • A Cavitary Lesion in a Patient with Antineutrophilic Cytoplasmic Antibody
           (ANCA) Associated Vasculitis: A Case Report and Review of the Literature

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      Authors: Sofia Lakhdar, Mahmoud Nassar, Shabnam Shatabdi, Chandan Buttar, Adriana Abrudescu, Theo Trandafirescu
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Patients with antineutrophilic cytoplasmic antibody (ANCA) associated vasculitis who were on immunosuppressive therapy with corticosteroids may be susceptible to cavitary lesions. Only a few cases have been reported in the literature to date. Immunosuppression was shown to improve prognosis in patients with vasculitis. However, adverse therapy events and the risk of opportunistic infections become a major cause of morbidity and mortality in this specific patient population. We present a case of a 75-year-old female who was diagnosed and treated in our hospital for ANCA-associated vasculitis and returned within a few weeks of medical therapy and was found to have developed cavitation concerning for worsening vasculitis or an opportunistic fungal infection or combination of both. Given the risk of severe complications from opportunistic fungal infections, close monitoring and prophylactic antifungal therapy should be considered. Further studies are needed to evaluate the benefit of prophylaxis in this patient population.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-04-19T06:04:50Z
      DOI: 10.1177/08850666221095498
       
  • Predictive Factors of Extubation Failure in COVID-19 Mechanically
           Ventilated Patients

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      Authors: Natália Godoy Guzatti, Fernanda Klein, Julia Almeida Oliveira, Gustavo Bruno Rático, Marcos Freitas Cordeiro, Luana Patrícia Marmitt, Diego de Carvalho, João Rogério Nunes Filho, Antuani Rafael Baptistella
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Purpose: We investigated whether COVID-19 patients on mechanical ventilation (MV) had a different extubation outcome compared to non-COVID-19 patients while identifying predictive factors of extubation failure in the former. Methods: A retrospective, single-center, and observational study was done on 216 COVID-19 patients admitted to an intensive care unit (ICU) between March 2020 and March 2021, aged ≥ 18 years, in use of invasive MV for more than 24 h, which progressed to weaning. The primary outcome that was evaluated was extubation failure during ICU stay. A statistical analysis was performed to evaluate the association of patient characteristics with extubation outcome, and a Poisson regression model determined the predictive value. Results: Seventy-seven patients were extubated; the mean age was 57.2 years, 52.5% were male, and their mean APACHE II score at admission was 17.8. On average, MV duration until extubation was 8.7 ± 3.7 days, with 14.9 ± 10.1 days of ICU stay and 24.6 ± 14.0 days with COVID-19 symptoms. The rate of extubation failure (ie, the patient had to be reintubated during their ICU stay) was 22.1% (n = 17), while extubation was successful in 77.9% (n = 60) of cases. Failure was observed in only 7.8% of cases when evaluated 48 hours after extubation. The mean reintubation time was 4.28 days. After adjusting the analysis for age, sex, during of symptoms, days under MV, dialysis, and PaO2/FiO2 ratio, some parameters independently predicted extubation failure: age ≥ 66 years (APR = 5.12 [1.35-19.46]; p = 0.016), ≥ 31 days of symptoms (APR = 5.45 [0.48-62.19]; p = 0.016), and need for dialysis (APR = 5.10 [2.00-13.00]; p = 0.001), while a PaO2/FiO2 ratio>300 decreased the probability of extubation failure (APR = 0.14 [0.04-0.55]; p = 0.005). The presence of three predictors (ie, age ≥ 66 years, time of symptoms ≥ 31 days, need of dialysis, and PaO2/FiO2 ratio < 200) increased the risk of extubation failure by a factor of 23.0 (95% CI, 3.34-158.5). Conclusion: COVID-19 patients had an extubation failure risk that was almost three times higher than non-COVID-19 patients, with the extubation of the former being delayed compared to the latter. Furthermore, an age ≥ 66 years, time of symptoms ≥ 31 days, need of dialysis, and PaO2/FiO2 ratio> 200 were independent predictors for extubation failure, and the presence of three of these characteristics increased the risk of failure by a factor of 23.0.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-04-15T05:52:45Z
      DOI: 10.1177/08850666221093946
       
  • Long-term Safety of Directly Discharging Patients Home from the ICU
           Compared to Ward Transfer

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      Authors: Eric Sy, Chiraag Gupta, Zunaira Shahab, Nathan Fortin, Sandy Kassir, Jonathan F. Mailman, Vincent I. Lau
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Purpose: To evaluate the long-term safety of directly discharging intensive care unit (ICU) survivors to their home. Methods: A retrospective observational cohort of 341 ICU survivors who were directly discharged home from the ICU (“direct discharge”) or discharged home ≤72 hours after ICU transfer to the ward (“ward transfer”) was conducted in Regina, Saskatchewan ICUs between September 1, 2016 and September 30, 2018. The primary outcome was 90-day hospital readmission. Secondary outcomes included 30-day, 90-day, and 365-day emergency department (ED) visits, 30-day and 365-day hospital readmissions, and 365-day mortality. All outcomes were evaluated by multivariable Cox regression after adjustment for demographic and clinical characteristics. Results: Of 341 survivors (25.5% of total ICU visits), 148 (43.4%) patients were direct discharges and 193 (56.6%) were ward transfers. The median age was 46 years (interquartile range, 34-62), 38.4% were female, and 61.8% resided in Regina. Compared to the ward transfer cohort, more patients in the direct discharge cohort had at least one 90-day hospital readmission (30.4% versus 17.1% of patients, adjusted hazard ratio 2.09, 95% confidence interval 1.28-3.40, P = .003), after adjustment. Additionally, there were more 90-day ED visits (P = .045), and 30-day (P = .049) and 365-day hospital readmissions (P = .03), after adjustment. Conclusions: In Saskatchewan, direct discharge compared to ward transfer was associated with an increase in 90-day hospital readmissions, and potentially other clinical outcomes. Further study is necessary.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-03-30T06:52:48Z
      DOI: 10.1177/08850666221090459
       
  • A Single-Centered Randomized Controlled Trial of Primary Pediatric
           Intensivists and Nurses

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      Authors: Jeffrey D Edwards, Erin P Williams, Elizabeth K Wagman, Brittany L McHale, Caryn T Malone, Steven G Kernie
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Background: For long-stay patients (LSP) in pediatric intensive care units (PICU), frequently rotating providers can lead to ineffective information sharing and retention, varying goals and timelines, and delayed decisions, likely contributing to prolonged admissions. Primary intensivists (one physician serves as a consistent resource for the patient/family and PICU providers) and primary nurses (a small team of PICU nurses provide consistent bedside care) seek to augment usual transitory PICU care, by enhancing continuity and, potentially, decreasing length of stay (LOS). Methods: A single-centered, partially blinded randomized controlled trial of primary intensivists and nurses versus usual care. PICU patients admitted for or expected to be admitted for>10 days and who had ≥1 complex chronic condition were eligible. A block randomization with 1:1 allocation was used. The primary outcome was PICU LOS. Multiple secondary outcomes were explored. Results: Two hundred LSPs were randomized—half to receive primaries and half to usual care. The two groups were not significantly different in their baseline and admission characteristics. LSPs randomized to receive primaries had a shorter, but non-significant, mean LOS than those randomized to usual care (32.5 vs. 37.1 days, respectively, p = .19). Compared to LSPs in the usual care group, LSPs in the primary group had fewer unplanned intubations. Among LSPs that died, DNR orders were more prevalent in the primary group. Other secondary outcome and balance metrics were not significantly different between the two groups. Conclusion: Primary intensivists and nurses may be an effective strategy to counteract transitory PICU care and serve the distinctive needs of LSPs. However, additional studies are needed to determine the ways and to what extent they may accomplish this.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-03-30T06:51:37Z
      DOI: 10.1177/08850666221090421
       
  • Prognosis of Chronically Ventilated Patients in a Long-Term Ventilation
           Facility: Association with Age, Consciousness and Cognitive State

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      Authors: David Stein, Sigal Sviri, Michael Beil, Ilana Stav, Esther-Lee Marcus
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Background: The number of adults requiring prolonged mechanical ventilation (PMV) including those with cognitive impairment or disorders of consciousness is escalating. We aimed to compare in a long-term acute care hospital (LTACH) mortality and length of stay (LOS) among three age groups (40-59y, 60-79y, ≥80y) of hospitalized PMV patients, and according to consciousness and cognitive state at admission. Methods: We obtained data from the health records of 308 adults aged ≥40 years requiring PMV hospitalized at a Chronic Ventilator Dependent Unit in a LTACH between 01/01/2015 to 06/30/2019 and followed-up until discharge or death or until 12/31/2019. Results: At admission to LTACH, 42.2% of PMV patients were in a vegetative state/ minimally conscious state (VS/MCS); 32.5% were severely cognitively impaired, 11.0% were mildly to moderately cognitively impaired, 12.3% had no cognitive impairment, and 1.9% had intellectual disability/psychiatric disorder. In-LTACH LOS (months) decreased from 34.6 ± 42.6 at age 40–59y, 19.1 ± 22.3 at 60–79y to 14.4 ± 19.3 at age ≥80y (p = .006). In-LTACH mortality was 30.6% for 40–59y, 41.1% for 60–79y and 54.8% for age ≥80y. In-LTACH LOS (months) was 23.8 ± 30.7 for VS/MCS, 15.1 ± 19.5 for the severely cognitively impaired, 10.0 ± 12.8 for mild to moderate cognitive impairment and 18.9 ± 21.9 for those without cognitive impairment (p = .02). In-LTACH mortality was 50.8% for VS/MCS, 58.0% for the severely cognitively impaired, 26.5% for mild to moderate cognitive impairment and 13.2% for those without cognitive impairment (p 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-03-30T06:51:08Z
      DOI: 10.1177/08850666221088800
       
  • Safe Positioning of Central Venous Catheters

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      Authors: Asad Khan, William T McGee
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.

      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-03-29T07:52:25Z
      DOI: 10.1177/08850666221085486
       
  • “Novel Management of Depression Using Ketamine in the Intensive Care
           Unit”

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      Authors: Abhishek R. Giri, Nirmaljot Kaur, Siva Naga S. Yarrarapu, Kathleen A. Rottman Pietrzak, Christan Santos, Philip E. Lowman, Shehzad Niaz, Pablo Moreno Franco, Devang K. Sanghavi
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Background: Ketamine, a dissociative anesthetic, induces improvement in depressive symptoms by antagonizing glutaminergic NMDA receptors. Ketamine has been used previously in outpatient setting for treatment-resistant depression, but we showcase its utility in depression management at the Intensive Care Unit (ICU). Research Question: Can ketamine be used for depression treatment in ICU patients' Study Design and Methods: A retrospective chart review of ICU patients was done at a tertiary center from 2018 to 2021, to assess the ketamine usage. Among the patients reviewed, ketamine was used for depression in 12, and for analgesia & sedation in 2322 patients. Ketamine was administered in doses of 0.5mg/kg & 0.75mg/kg for depression. Each course consisted of 3 doses of ketamine administered over 3 days, and 7 in 12 patients received a single course of ketamine. The rest received 3–4 courses 1 week apart. Results: Ketamine was found to improve mood and affect in most of the patients with depression. 11 in 12 patients had a positive response with better sleep. It has a major advantage over conventional anti-depressants since it takes only a few hours to induce clinical improvement. Patients who were observably withdrawn from care team and family, were administered ketamine. Conclusion: A major drawback of ketamine is that the duration of clinical improvement is short, with the response lasting only up to seven days after a single dose. Hence, all the patients in our study were weaned off ketamine with a supporting antidepressant. Ketamine has been documented to cause cardio-neurotoxicity; however, only one patient had worsening lethargy in our study. To conclude, ketamine has a marked benefit in treating depression in the ICU. Although our study was associated with positive outcomes, there is a need for prospective studies with long-term follow-up assessments.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-03-22T06:55:37Z
      DOI: 10.1177/08850666221088220
       
  • Capillary Refill Technology to Enhance the Accuracy of Peripheral
           Perfusion Evaluation in Sepsis

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      Authors: Jordan Gillespie, Matthew Hansen, Ravi Samatham, Steven D. Baker, Scott Filer, David C. Sheridan
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Background: Monitoring of capillary refill time (CRT) is a common bedside assessment used to ascertain peripheral perfusion in a patient for a vast array of conditions. The literature has shown that a change in CRT can be used to recognize life-threatening conditions that cause decreased perfusion, such as sepsis, and aid in resuscitation. The current practice for calculating CRT invites subjectivity and produces a highly variable result. Innovative technology may be able to standardize this process and provide a reliable and accurate value for use in diagnostics and treatment. This study aimed to assess a new technology (DCR by ProMedix Inc.) for rapid, bedside, and noninvasive detection of CRT. Methods: This was a secondary analysis of a prospective observational study evaluating the accuracy of new technology towards CRT-guided diagnosis of sepsis. It was carried out in the adult emergency departments (ED) of an academic tertiary care medical center. Patients seeking care in the ED were determined eligible if they were> 18 years in age and exhibited chief complaints suggestive of possible sepsis. The CRT produced by the technology was compared to the gold standard manual waveform assessment. Results: 218 consecutive subject enrollments were included and multiple measurements were made on each patient. Data with irregular waveforms were excluded. A total of 692 waveforms were evaluated for CRT values by a pair of trained PhD biomedical engineers. The average age of the cohort was 50.62 and 51.4% female. Results showed a Pearson correlation coefficient of 0.91 for the device CRT compared to the CRT gold standard. The Pearson correlation coefficient for the two independent engineering review of the waveform data was 0.98. This device produces accurate, consistent results and eliminates the subjectivity of CRT measurements that is in practice currently.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-03-21T08:29:13Z
      DOI: 10.1177/08850666221087685
       
  • Intravenous Brivaracetam in the Management of Acute Seizures in the
           Hospital Setting: A Scoping Review

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      Authors: Kiwon Lee, Pavel Klein, Prashant Dongre, Eun Jung Choi, Denise H. Rhoney
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundClinical considerations for drug treatment of acute seizures involve variables such as safety, tolerability, drug-drug interactions, dosage, route of administration, and alterations in pharmacokinetics because of critical illness. Therapy options that are easily and quickly administered without dilution, well tolerated, and effective are needed for the treatment of acute seizures. The objective of this review is to focus on the clinical considerations relating to the use of intravenous brivaracetam (IV BRV) for the treatment of acute seizures in the hospital, focusing on critically ill patients.MethodsThis was a scoping literature review of PubMed from inception to April 13, 2021, and search of the American Academy of Neurology (AAN) 2021 Annual Meeting website for English language publications/conference abstracts reporting the results of IV BRV use in hospitalized patients, particularly in the critical care setting. Outcomes of interest relating to the clinical pharmacology, safety, tolerability, efficacy, and effectiveness of IV BRV were reviewed and are discussed.ResultsTwelve studies were included for analysis. One study showed that plasma concentrations of IV BRV 15 min after the first dose were similar between patients receiving IV BRV as bolus or infusion. IV BRV was generally well tolerated in patients with acute seizures in the hospital setting, with a low incidence of individual TEAEs classified as behavioral disorders. IV BRV demonstrated efficacy and effectiveness and had a rapid onset, with clinical and electrophysiological improvement in seizures observed within minutes. Although outside of the approved label, findings from several studies suggest that IV BRV reduces seizures and is generally well tolerated in patients with status epilepticus.ConclusionsIV BRV shows effectiveness, and is generally well tolerated in the management of acute seizures in hospitalized patients where rapid administration is needed, representing a clinically relevant antiseizure medication for potential use in the critical care setting.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-03-21T08:28:59Z
      DOI: 10.1177/08850666211073598
       
  • A Standardized Step-by-Step Approach for the Diagnosis and Treatment of
           Sepsis

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      Authors: Yang Gao, Hong liang Wang, Zhao jin Zhang, Chang Kun Pan, Ying Wang, Yu cheng Zhu, Feng jie Xie, Qiu yuan Han, Jun bo Zheng, Qing qing Dai, Yuan yuan Ji, Xue Du, Peng fei Chen, Chuang shi Yue, Ji han Wu, Kai Kang, Kai jiang Yu
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Sepsis is the major culprit of death among critically ill patients who are hospitalized in intensive care units (ICUs). Although sepsis-related mortality is steadily declining year-by-year due to the continuous understanding of the pathophysiological mechanism on sepsis and improvement of the bundle treatment, sepsis-associated hospitalization is rising worldwide. Surviving Sepsis Campaign (SSC) guidelines are continuously updating, while their content is extremely complex and comprehensive for a precisely implementation in clinical practice. As a consequence, a standardized step-by-step approach for the diagnosis and treatment of sepsis is particularly important. In the present study, we proposed a standardized step-by-step approach for the diagnosis and treatment of sepsis using our daily clinical experience and the latest researches, which is close to clinical practice and is easy to implement. The proposed approach may assist clinicians to more effectively diagnose and treat septic patients and avoid the emergence of adverse clinical outcomes.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-03-14T12:59:59Z
      DOI: 10.1177/08850666221085181
       
  • A Comparative Analysis of Catheter Directed Thrombolysis with
           Anticoagulation Alone or Systemic tPA in Acute Pulmonary Embolism with Cor
           Pulmonale

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      Authors: Anand Muthu Krishnan, Naga Vaishnavi Gadela, Rudra Ramanathan, Anil Jha, Michael E. Perkins, Mark L. Metersky
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundPulmonary embolism (PE) with cor pulmonale causes considerable mortality and morbidity. Randomized trials have failed to show a mortality difference between treatment modalities including anticoagulation (AC), Catheter directed thrombolysis (CDT) and systemic tPA (tissue plasminogen activator).MethodsThis is a cross-sectional retrospective case-control study utilizing the 2017 National Inpatient Sample (NIS). Patients admitted with acute PE with cor pulmonale were divided into groups based on whether they received anticoagulation, CDT or systemic tPA based on appropriate ICD-10 PCS codes. The AC group and CDT group were compared using univariate and multivariate analyses after adjusting for age, gender, race, comorbidities, insurance status and Charlson comorbidity index (CCI). Secondary outcomes included factors influencing length of stay (LOS) and total charges incurred. Similar analyses were done to compare the CDT group with the tPA group.ResultsIn 2017, 13240 patients were admitted with acute PE and cor pulmonale, of whom 18% underwent CDT, 10% underwent systemic tPA and 72% underwent AC alone. Patients who received CDT over AC alone were significantly younger (61.5 vs. 65.5, p = 0.00). Mortality rate overall was 4.8% with tPA group, CDT group and AC alone group having a 11.2%, 3.0% and 4.4% mortality rate respectively. On multivariate analyses, there was no significant mortality difference between the CDT and AC groups (aOR 0.61, 0.34-1.1 95%CI, p = 0.103). Patients with liver disease had significantly higher mortality while obese patients had a significantly lower mortality after adjusting for treatment strategy and confounders. Length of stay (LOS) was not significantly different between the groups however, compared to AC alone, patients who underwent CDT or tPA incurred significantly higher total hospital charges.ConclusionsCDT offers an attractive alternative to tPA therapy; however, our study does not show an in-hospital mortality benefit. More studies are required to guide patient selection prior to establishing treatment protocols.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-03-14T12:57:58Z
      DOI: 10.1177/08850666221083241
       
  • Cause of In-Hospital Death After Weaning from Venoarterial-Extracorporeal
           Membrane Oxygenation

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      Authors: Milica Bjelic, Neil Kumar, Yang Gu, Karin Chase, Frane Paic, Igor Gosev
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      PurposeA survival gap between weaning from venoarterial-extracorporeal membrane oxygenation (VA-ECMO) and the hospital discharge has been consistently reported. The aim of this study is to investigate the clinical features of patients who underwent successful VA-ECMO decannulation at our institution and to identify the major contributors responsible for adverse outcomes.MethodsWe retrospectively reviewed all patients supported with VA-ECMO in our institution between January 2013 and June 2020. Only patients that survived VA-ECMO and underwent successful decannulation were included and dichotomized based on survival to hospital discharge: non-survivors versus survivors. The primary study outcome was the cause of death after successful VA-ECMO decannulation.ResultsOf the 262 adult patients who underwent VA-ECMO decannulation, 72 (27.5%) patients did not survive to hospital discharge. Non-survivors were older (62 vs. 54 years, p 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-03-14T01:00:13Z
      DOI: 10.1177/08850666221086839
       
  • Burnout among Respiratory Therapists and Perception of Leadership: A Cross
           Sectional Survey Over Eight Intensive Care Units

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      Authors: Amr Salah Omar, Samy Hanoura, Ahmed Labib, Rasha Kaddoura, Alaa Rahhal, Mohammed Mousa Al-Zubi, Ruzzel Dorado Galvez, Shiny Shiju, Mohammed Jamil Al Jonidi, Hany Ragab, Abdul Aziz Al Hashemi, Abdelwahid Alumlla
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundBurnout syndrome (BOS) is a job-related stress disorder featured by three main cardinal manifestations: emotional exhaustion (EE), reduced personal accomplishment (PA), and depersonalization (DP).AimWe aimed to report the prevalence of burnout and the impact of leadership and work condition on the burnout among respiratory therapists (RT) are front-line practitioners in many critical settings.MethodsWe surveyed RT in eight intensive care units (ICU) at five tertiary hospitals, under one medical corporation, using three instruments: the Maslach Burnout Inventory Human Services Survey for Medical Personnel, Condition of Work Effectiveness Questionnaire (CWEQ), and Leadership behaviours scale. We used a group of other health care practitioners (ie, physicians and nurses) as the control group.ResultsOf a sampling frame of 1222 ICU practitioners, 445 (36.4%) responded with completed surveys. Eighty-four (17.3%) and 361 (82.7%) participants were in the RT and the control group, respectively. The overall burnout score was significantly lower in the RT group (53.6% vs. 67%, p = 0.02). The EE and DP scores were significantly lower in the RT group [(26.2% vs. 37.7, p = 0.048) and (9.5% vs. 19.9%, p = 0.025), respectively], but the PA score did not show significant difference between the groups. A significant negative relationship was found between CWEQ score and both EE and DP scores (rs = −0. 0.557, p 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-03-14T01:00:01Z
      DOI: 10.1177/08850666221086208
       
  • Cytokine Adsorption in Critically Ill COVID-19 Patients, a Case-Control
           Study

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      Authors: Ruslan Abdullayev, Fethi Gul, Beliz Bilgili, Seda Seven, Ismail Cinel
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Aim: New coronavirus disease (COVID-19) has become an international emergency. As many of the intensive care unit (ICU) patients with the disease also present multiple organ failure, blood purification techniques might be a good choice in their treatment. In this study we aimed to investigate the role of cytokine removal in COVID-19 patients managed in ICUs. Methods: For this case-control study we have investigated the role of the cytokine removal by means of two resin membranes (HA330 and Mediasorb) in COVID-19 patients managed in ICUs. Particularly, we investigated the overtime variation in clinical severity scores, laboratory variables, and effects on hospital and ICU stay and mortality. Results: Seventy-two patients have been evaluated, of which half constituted Cytokine Filtration (CF) Group, and other half the Case-Control (CC) Group. Mortality was 55.6% and 50% in CF and CC groups, respectively. In the CF Group, there was decrease in C-reactive protein (CRP) and fibrinogen levels measured at the end of cytokine adsorption; lymphocyte count and ratio were increased, whereas neutrophile ratio was decreased. There were no differences between the groups regarding other laboratory variables, SOFA scores and vasopressor uses. Conclusions: We have demonstrated decrease in CRP, fibrinogen and increase in lymphocyte count in the patients having cytokine adsorption, but there was no clinical reflection of these benefits, and no decrease in mortality as well. Even though there is physio-pathologic rationale to use cytokine adsorption techniques for immunomodulation in critically ill COVID-19 patients, it is early to make strong suggestions about their benefits.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-03-11T03:45:18Z
      DOI: 10.1177/08850666221085185
       
  • Effects of Timing of Invasive Mechanical Ventilation in Patients with
           Shock. An Analysis of the Multicenter Prospective Observational
           VOLUME–CHASERS Cohort

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      Authors: Neha N. Goel, Jen–Ting Chen, Russel Roberts, Jonathan Sevransky, Michelle N. Gong, Kusum S. Mathews
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Objectives: Describe the variation in practice and identify predictors of invasive mechanical ventilation (IMV) use in shock. Explore the association between the timing of IMV initiation (“Early” vs. “Delayed”) on shock duration. Design: Multicenter, prospective, observational cohort study between September 2017 and February 2018 Setting: 34 hospitals in the United States and Jordan. Patients: Consecutive, adult, critically ill patients with shock, defined as a systolic blood pressure less than or equal to 90mm Hg, mean arterial pressure less than or equal to 65mm Hg, or need for a vasopressor medication. Interventions: None. Measurements and Main Results: “Early” IMV was defined as starting IMV 0–6 hours of shock onset and “Delayed” IMV was defined as starting IMV between 6 and 48 hours of shock onset. The primary outcome was shock–free days, defined as the number of days without shock after the first 48 hours of shock onset. Variation and predictors of IMV use were examined within the whole cohort as well as the subgroup of those intubated within 0–48 hours of shock onset. Mixed effects modeling with hospital site as a random effect showed that there was 7% variation by site in the use and timing of IMV in this shock cohort. In a propensity–matched model for the timing of IMV, “Early” IMV after shock onset was associated with more shock–free days when compared to “Delayed” IMV in those intubated within 0–48 hours of shock onset (Beta coefficient 0.65 days, 95% CI 0.14-1.16 days). Conclusions: Timing of IMV initiation for patients in shock has potentially important implications for patient outcomes and merits further study.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-03-07T04:22:40Z
      DOI: 10.1177/08850666221081102
       
  • Hypotension Prediction Score for Endotracheal Intubation in Critically Ill
           Patients: A Post Hoc Analysis of the HEMAIR Study*

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      Authors: Nathan J. Smischney, Salim R. Surani, Ashley Montgomery, Pablo Moreno Franco, Cynthia Callahan, Gozde Demiralp, Rudy Tedja, Sarah Lee, Santhi I. Kumar, Ashish K. Khanna
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundHypotension with endotracheal intubation (ETI) is common and associated with adverse outcomes. We sought to evaluate whether a previously described hypotension prediction score (HYPS) for ETI is associated with worse patient outcomes and/or clinical conditions.MethodsThis study is a post hoc analysis of a prospective observational multicenter study involving adult (age ≥18 years) intensive care unit (ICU) patients undergoing ETI in which the HYPS was derived and validated on the entire cohort and a stable subset (ie, patients in stable condition). We evaluated the association between increasing HYPSs in both subsets and several patient-centered outcomes and clinical conditions.ResultsComplete data for HYPS calculations were available for 783 of 934 patients (84%). Logistic regression analysis showed increasing odds ratios (ORs) for the highest risk category for new-onset acute kidney injury (OR, 7.37; 95% CI, 2.58-21.08); new dialysis need (OR, 8.13; 95% CI, 1.74-37.91); ICU mortality (OR, 16.39; 95% CI, 5.99-44.87); and hospital mortality (OR, 18.65; 95% CI, 6.81-51.11). Although not increasing progressively, the OR for the highest risk group was significantly associated with new-onset hypovolemic shock (OR, 6.06; 95% CI, 1.47-25.00). With increasing HYPSs, median values (interquartile ranges) decreased progressively (lowest risk vs. highest risk) for ventilator-free days (23 [18-26] vs. 1 [0-21], P 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-03-04T01:22:57Z
      DOI: 10.1177/08850666221085256
       
  • Sepsis, Septic Shock, and Differences in Cardiovascular Event Occurrence

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      Authors: Grace E. Falk, Jerad Rogers, Liuqiang Lu, Elizabeth Ablah, Hayrettin Okut, Mohinder R. Vindhyal
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Introduction: Mortality estimates from sepsis and septic shock ranged from 18% to 35% and 40% to 60%, respectively, prior to 2014. Sepsis patients who experience subsequent cardiovascular events have increased mortality; however, data are limited among septic shock patients. This study reports in-hospital mortality, incident cardiovascular events, and cardiovascular procedures among sepsis patients with and without subsequent septic shock. Methods: Patients with a primary diagnosis of sepsis with and without a secondary diagnosis of septic shock were identified from the 2016 and 2017 National Readmissions Database. These patients were then evaluated for the occurrence of cardiovascular events and procedures. Results: A total of 2,127,137 patients were included in the study, with a mean age of 66 years. Twenty percent of patients (n = 420,135) developed subsequent septic shock. In-hospital mortality among patients with a primary diagnosis of sepsis was 5.3%, and it was 31.2% for those with subsequent septic shock. Notable cardiovascular events occurring among sepsis patients with and without subsequent septic shock, respectively, included: acute kidney injury (65.1% vs. 32.8%, P < .0001), acute systolic heart failure (9.8% vs. 5.1%, P < .0001), NSTEMI (8.8% vs. 3.2%, P < .0001), and ischemic stroke (2.3% vs. 0.9%, P < .0001). Similarly, the most common cardiovascular procedures between the two groups were: percutaneous coronary intervention (0.37% vs. 0.20%, P < .0001), intra-aortic balloon pump (0.19% vs. 0.02%, P < .0001), and extracorporeal membrane oxygenation (0.18% vs. 0.01%, P < .0001). Conclusions: Sepsis with subsequent septic shock is associated with an increased frequency of in-hospital cardiovascular events and procedures.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-03-03T08:19:18Z
      DOI: 10.1177/08850666221083644
       
  • Dexamethasone for Pediatric Critical Asthma: A Multicenter Descriptive
           Study

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      Authors: Austin R. Sellers, Meghan R. Roddy, Kristina K. Darville, Beatriz Sanchez-Teppa, Scott D. McKinley, Anthony A. Sochet
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundSystemic corticosteroids are vital to critical asthma management. While intravenous methylprednisolone is routinely used in the pediatric intensive care unit (PICU) setting, recent data supports dexamethasone as an alternative. Using the Pediatric Health Information System (PHIS) registry, we assessed trends and variation in corticosteroid prescribing among children hospitalized for critical asthma.MethodsWe performed a multicenter retrospective cohort study using PHIS data among children 3-17 years of age admitted for critical asthma from 2011 through 2019. Primary outcomes were corticosteroid prescribing rates by year and participating sites. Exploratory outcomes were corticosteroid-related adverse effects, rates of adjunctive pharmaceutical and respiratory interventions, mortality and length of stay.ResultsOf the 49 children's hospitals assessed, 26 907 encounters were included for study. Mean dexamethasone exposure rates were 18.1 ± 2.4% where 2.4 ± 1.2% represented dexamethasone-alone prescribing. Dexamethasone alone prescribing exhibited a linear trend (annual increase of 0.5 ± 0.1% annually R2 = 0.845) without correlation to cumulative site critical asthma admission rates. Compared to encounters prescribed solely methylprednisolone or a combination of dexamethasone and methylprednisolone, subjects provided dexamethasone alone had reduced asthma severity indices, length of stay, and exposure rates to adjunctive asthma interventions. Adverse events were rare and the dexamethasone-alone group less frequently experienced gastritis and hyperglycemia.ConclusionsIn this multicenter retrospective study from 49 children's hospitals, dexamethasone prescribing rates appear increasing for pediatric critical asthma. Observed variability in corticosteroid prescribing implies a continued need for controlled prospective comparative analyses to define ideal corticosteroid regimens for pediatric critical asthma.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-03-03T08:19:08Z
      DOI: 10.1177/08850666221082540
       
  • Varying Estimates of Sepsis among Adults Presenting to US Emergency
           Departments: Estimates from a National Dataset from 2002-2018

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      Authors: Sriram Ramgopal, Christopher M Horvat, Mark D Adler
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundA variety of approaches to defining sepsis using administrative datasets have been previously reported. We aimed to compare estimates, demographics, treatment factors, outcomes and longitudinal trends of patients identified with sepsis in United States emergency departments (EDs) using differing sets of sepsis criteria.MethodsWe performed a cross-sectional study using the National Healthcare Ambulatory Medical Care Survey, a complex survey of nonfederal US ED encounters between 2002 to 2018. We obtained survey-weighted population-adjusted encounters of sepsis using the following criteria: explicit sepsis, severe sepsis, and quick Sequential Organ Failure Assessment (qSOFA) score combined with the presence of infection.ResultsAge-adjusted for US adults, 18.6, 16.1 and 8.9 encounters per 10 000 population were identified when using the explicit, severe sepsis and qSOFA definitions, respectively. A higher proportion of the explicit cohort was hospitalized and had blood cultures performed, compared to cohorts ascertained using severe sepsis and qSOFA criteria, though confidence intervals overlapped. Antibiotic use was highest in encounters meeting qSOFA criteria. When inspecting unweighted encounters meeting each set of criteria, there was minimal overlap, with only 3% meeting all three. Encounters meeting the explicit and severe sepsis criteria were increasing over time.ConclusionThe explicit, severe sepsis and qSOFA criteria generated similar annual rates of presentation when applied to US ED encounters, with some evidence of the explicit sepsis cohort being higher acuity. There was minimal overlap of cases and instability in estimates when assessed longitudinally. Our findings inform research efforts to accurately identify sepsis among ED encounters using administrative data.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-02-28T03:57:36Z
      DOI: 10.1177/08850666221080060
       
  • Influence of Timing and Catecholamine Requirements on Vasopressin
           Responsiveness in Critically ill Patients with Septic Shock

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      Authors: Nicholas D. Jakowenko, Joseph Murata, Brian J. Kopp, Brian L. Erstad
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Introduction: Despite its widespread use, there is a paucity of data to guide the optimal use of arginine vasopressin (AVP) in critically ill patients with septic shock. Methods: This multicenter retrospective cohort study conducted in critically ill adults sought to evaluate the role of catecholamine requirements and timing on responsiveness to AVP. Responsiveness was defined as both a decrease in ≥ 50% of catecholamine requirements and no decrease in mean arterial pressure (MAP) at 4 hours post-AVP initiation. Primary outcomes of interest included the proportion of patients who started AVP within 4 hours after starting catecholamine therapy, as well as baseline norepinephrine (NE) equivalents (< 15, 15-39, or ≥ 40 mcg/min). Multivariate analyses and logistic regression were performed to identify other factors associated with AVP responsiveness. Results: There were 300 patients included in this study, with 74 patients being responders and 226 being non-responders. There was no significant difference in the number of patients who received AVP within 4 hours from catecholamine initiation between responders and non-responders (35% vs. 42%, P = 0.29). There were more patients in the non-responder group requiring ≥ 40 mcg/min of NE equivalents at AVP initiation (30% vs. 16%, P = 0.023). Stress dose steroid use was less common in responders (35% vs. 52%, P = 0.011), which was consistent with logistic regression analysis (OR 0.56, 95% 0.32-0.98, P = 0.044). Clinical outcomes between responders and non-responders were similar, apart from ICU (5.4% vs. 19.5%) and hospital (5.4% vs. 20.4%) mortality being lower in responders (P = 0.0032 and P = 0.0002, respectively). Conclusion: Shorter times to AVP initiation was not associated with responsiveness at 4 hours post-catecholamine initiation, although non-responders tended to require higher doses of NE equivalents at time of AVP initiation. Concomitant corticosteroids were associated with a lower likelihood of AVP responsiveness.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-02-23T02:22:20Z
      DOI: 10.1177/08850666221081836
       
  • Predicting Ventriculoperitoneal Shunt Dependence in High Grade Aneurysmal
           Subarachnoid Hemorrhage

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      Authors: Steve Bibu, Alessandro Iliceto, Florence Chukwuneke, Sean Munier, Madeline Stecy, Bryan Green, Kiwon Lee
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      IntroductionAneurysmal subarachnoid hemorrhage (aSAH) commonly presents with hydrocephalus due to obstruction of cerebrospinal fluid (CSF) passage across the ventricular system in the brain. Placement of an external ventricular device (EVD) and in some cases ventriculoperitoneal shunt (VPS) are often necessary for patients requiring prolonged CSF diversion. The study aimed at evaluating critical factors that play a role in determining the need for extended extraventricular drainage.MethodsWe performed a retrospective observational cohort study of two groups of patients with radiological imaging confirmed high grade aSAH (Hunt & Hess grades 3-5) who required VPS placement, shunt-dependent group, and who did not require long term CSF diversion, non-shunt-dependent group. We collected and analyzed data regarding the daily CSF output for 10 days following EVD placement, daily EVD height, intracranial pressure (ICP) and cerebral perfusion pressure (CPP), indicators of hydrocephalus, and CSF characteristics.ResultsThe cohort, comprising of 8 patients in the shunt-dependent group and 32 patients in the non-shunt-dependent group, displayed median daily CSF output of 275.1 mL/day and 193.4 mL/day, respectively (P = .0005). ROC curve for CSF drainage for the two groups showed an area under the curve (AUC) of 0.71 with a 95% confidence interval (CI) 0.65 to 0.77. Qualitative analysis of CSF characteristics revealed that the shunt-dependent group had more proteinaceous, darker red color, and greater proportion of red blood cells (RBCs) although not statistically significant.ConclusionsDeterminants of prolonged CSF drainage requirements in patients with high grade aSAH are not fully elucidated to this date and there is no standardized protocol for CSF diversion. Our study revealed potential markers that can be used in the assessment for the need for long term CSF diversion. Our limited sample size necessitates further research to establish clear correlations and cutoffs of these parameters in predicting long term CSF diversion requirements.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-02-16T06:23:05Z
      DOI: 10.1177/08850666221080073
       
  • Prognostic Value of Sequential Organ Failure Assessment (SOFA) Score in
           Critically-Ill Combat-Injured Patients

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      Authors: Shannon L. McCarthy, Laveta Stewart, Faraz Shaikh, Clinton K. Murray, David R. Tribble, Dana M. Blyth
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Background: Infection is a frequent and serious complication after combat-related trauma. The Sequential Organ Failure Assessment (SOFA) score has been shown to have predictive value for outcomes, including sepsis and mortality, among various populations. We evaluated the prognostic ability of SOFA score in a combat-related trauma population. Methods: Combat casualties (2009–2014) admitted to Landstuhl Regional Medical Center (LRMC; Germany) intensive care unit (ICU) within 4 days post-injury followed by transition to ICUs in military hospitals in the United States were included. Multivariate logistic regression was used to determine predictive effect of selected variables and receiver operating characteristic (ROC) curve analysis was used to evaluate overall accuracy of SOFA score for infection prediction. Results: Of the 748 patients who met inclusion criteria, 436 (58%) were diagnosed with an infection (32% bloodstream, 63% skin and soft tissue, and 40% pulmonary) and were predominantly young (median 24 years) males. Penetrating trauma accounted for 95% and 86% of injuries among those with and without infections, respectively (p 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-02-16T03:48:07Z
      DOI: 10.1177/08850666221078196
       
  • Association of Arterial Metabolic Content with Cerebral Blood Flow
           Regulation and Cerebral Energy Metabolism–A Multimodality Analysis in
           Aneurysmal Subarachnoid Hemorrhage

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      Authors: Teodor Svedung Wettervik, Anders Hånell, Timothy Howells, Elisabeth Ronne-Engström, Per Enblad, Anders Lewén
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundIn this study, the association of the arterial content of oxygen, carbon dioxide, glucose, and lactate with cerebral pressure reactivity, energy metabolism and clinical outcome after aneurysmal subarachnoid hemorrhage (aSAH) was investigated.MethodsIn this retrospective study, 60 patients with aSAH, treated at the neurointensive care (NIC), Uppsala University Hospital, Sweden, between 2016 and 2021 with arterial blood gas (ABG), intracranial pressure, and cerebral microdialysis (MD) monitoring were included. The first 10 days were divided into an early phase (day 1 to 3) and a vasospasm phase (day 4 to 10).ResultsHigher arterial lactate was independently associated with higher/worse pressure reactivity index (PRx) in the early phase (β = 0.32, P = .02), whereas higher pO2 had the opposite association in the vasospasm phase (β = −0.30, P = .04). Arterial glucose and pCO2 were not associated with PRx. Higher arterial lactate (β = 0.29, P = .05) was independently associated with higher MD-glucose in the vasospasm phase, whereas higher pO2 had the opposite association in the vasospasm phase (β = −0.33, P = .03). Arterial glucose and pCO2 were not associated with MD-glucose. Higher pCO2 in the early phase, lower arterial glucose in both phases, and lower arterial lactate in the vasospasm phase were associated (P 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-02-16T03:47:42Z
      DOI: 10.1177/08850666221080054
       
  • Incidence of Seizure and Associated Risk Factors in Patients in the
           Medical Intensive Care Unit (ICU) at Memorial Sloan Kettering Cancer
           Center (MSK) from 2016–2017

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      Authors: Saeedeh Azary, Christopher Caravanos, Anne S. Reiner, Katherine S. Panageas, Vikram Dhawan, Edward K. Avila
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Background: Seizures and status epilepticus are common neurologic complications in the intensive care unit (ICU) but the incidence in a cancer ICU is unknown. It is important to understand seizure risk factors in cancer patients to properly diagnose the seizure type to ensure appropriate therapy. Methods: We identified patients admitted to the medical ICU at Memorial Sloan Kettering Cancer Center (MSK) from January 2016 to December 2017 who had continuous or routine electroencephalography (EEG) and identified clinical and electrographic seizures by chart review. Results: Of the 1059 patients admitted to the ICU between 2016 and 2017, 50 patients had clinical and/or electrographic seizures (incidence of 4.7%, 95% CI: 3.4-6.0). The incidences of clinical and electrographic seizure were 4.1% and 1.1%, respectively. In a multivariable stepwise regression model, history of seizure (OR: 2.9, 95% CI: 1.1-7.8, P: .03), brain metastasis (OR: 2.5, 95% CI: 1.1-5.8, P: .03), vasopressor requirement (OR: 2.2, 95% CI: 1.0-4.9, P: .05), and age  24 h significantly increased the chances of both clinical and electrographic seizure detection, (OR: 2.6 [95% CI: 1.2-5.7] and 15.0 [95% CI: 2.7-82.5], respectively). Conclusions: We identified known and cancer-related risk factors which can aid clinicians in diagnosing seizures in cancer ICUs. Long-term video EEG monitoring should be considered, particularly given the treatable and reversible nature of seizures.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-02-07T10:13:03Z
      DOI: 10.1177/08850666211066080
       
  • Handheld Point-of-Care Ultrasound: Safety Considerations for Creating
           Guidelines

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      Authors: Adam Hsieh, Maxwell B Baker, Joseph M Phalen, Julio Mejias-Garcia, Alan Hsieh, Alex Hsieh, Robert Canelli
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundCompared to traditional ultrasound machines, emerging handheld point-of-care-ultrasound (HPOCUS) systems exhibit superior portability and affordability. Thus, they have been increasingly embraced in the intensive care setting. However, there is scarce data on patient safety and current regulatory body guidelines are lacking. Here, we critically appraise the literature with a focus on the merits, concerns, and framework of existing POCUS guidelines. Subsequently, we provide recommendations for future regulatory guidelines. MethodsA comprehensive literature review was conducted using the PubMed database employing the key words “point-of-care/handheld/portable ultrasound” and “guidelines” alone, in combination, and using thesaurus terms. Eligible articles were scrutinized for description of potential benefits and concerns of HPOCUS, especially from a patient safety perspective, as well as currently existing POCUS practice guidelines. Data was extracted, reported thematically using a narrative synthesis approach, then subsequently used to guide our proposed guidelines. ResultsThe most widely reported benefits of HPOCUS include superior portability, affordability, imaging, facilitation of expedited diagnosis and management, and integration with medical workplace flow. However, major barriers to adoption include device security/patient confidentiality and patient safety. Furthermore, except for a policy published by the American College of Emergency Physicians (ACEP) in 2018, there are few other national regulatory guidelines pertaining to handheld POCUS. In light of this, we propose a framework for HPOCUS guideline development to address these and other concerns. Such guidelines include training and credentialing, bioengineering approval, and strategic integration with electronic medical record systems. ConclusionHPOCUS can be a powerful tool for expedited diagnosis and management guidance. However, there is limited data regarding patient safety and current regulatory body guidelines are lacking. Our assessment illuminates that there remain many unsolved problems about HPOCUS, and in turn, we propose guidelines to address safe regulation and implementation.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-02-04T01:10:30Z
      DOI: 10.1177/08850666221076041
       
  • Models of Intermediate Care Organization and Staffing at an Academic
           Medical Center: Considerations of an Inpatient Planning Committee

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      Authors: David N. Hager, Rebecca Dezube, Sarah M. Disney, Eleni Flanagan, Shanshan Huang, Kinjal Kakadiya, Ronald Langlotz, Matthew B Lautzenheiser, Lara Street, Andrew Michalek, Lee D. Biddison, Sanjay V. Desai, Carrie A. Herzke
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Rationale: Geographic co-localization of patients and provider teams (geography) may improve care efficiency and quality. Patients requiring intermediate care present a unique challenge to the geographic model. Objective: Identify the best organizational and staffing model for intermediate care at our academic medical center. Methods: A modified nominal group technique was employed to assess the benefits and limitations of an existing model of intermediate care, identify and review potential alternative models, and choose a new model. Results: In addition to the institution's current model, the benefits and limitations of six alternative organizational and staffing models were characterized. The anticipated impact of each model on nurse: provider communication, maintenance of nursing competencies, nurse satisfaction, efficient utilization of technical and human resources, triage of patients to the unit, care continuity, and the impact on trainee education are described. After considering these features, stakeholders ranked a closed provider staffing model on a unit dedicated to intermediate care highest of the six alternative models. Important outcomes to monitor following transition to a closed staffing model included patient outcomes, nursing job satisfaction and retention, provider and trainee experience, unexpected patient transfers to higher or lower levels of care, and administrative costs. Conclusions: After considering six alternative staffing models for intermediate care, stakeholders ranked a closed provider staffing model highest. Further qualitative and quantitative comparisons to determine optimal models of intermediate care are needed.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-01-24T04:18:58Z
      DOI: 10.1177/08850666211062151
       
  • The Growth of Palliative Practice and End of Life Care in an Academic
           Teaching Intensive Care Unit

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      Authors: Daniel King, Erica Schockett, Ghazi Rizvi, Daniel Fischer, Richard Amdur, Ivy Benjenk, David Yamane, Benjamin DelPrete, Danielle Davison, Michael Seneff
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      ObjectiveDying in the intensive care unit (ICU) has changed over the last twenty years due to increased utilization of palliative care. We sought to examine how palliative medicine (PM) integration into critical care medicine has changed outcomes in end of life including the utilization of do not resuscitate (no cardiopulmonary resuscitation but continue treatment) and comfort care orders (No resuscitation, only comfort medication). Design: Retrospective observational review of critical care patients who died during admission between two decades, 2008 to 09 and 2018 to 19. Setting: Single urban tertiary care academic medical center in Washington, D.C. Patients: Adult patients who were treated in any ICU during the admission which they died.Interventions and MeasurementsWe sought to measure PM involvement across the two decades and its association with end of life care including do not resuscitate (DNR) and comfort care (CC) orders. Main Results: 571 cases were analyzed. Mean age was 65 ± 15, 46% were female. In univariate analysis significantly more patients received PM in 2018 to 19 (40% vs. 27%, p = .002). DNR status increased significantly over time (74% to 84%, p = .002) and was significantly more common in patients who were receiving PM (96% vs. 72%, p 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-01-10T02:14:02Z
      DOI: 10.1177/08850666211069031
       
  • Kidney and Mortality Outcomes Associated with Ondansetron in Critically
           Ill Patients

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      Authors: Matthew Gray, Priyanka Priyanka, Sandra Kane-Gill, Lirong Wang, John A. Kellum
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Background: Ondansetron is a preferred anti-emetic in critical care to treat nausea and vomiting, and has historically been considered a largely safe option. A recent pharmacoepidemiology study reported that ondansetron may be associated with an increased risk for acute kidney injury (AKI). Methods: We interrogated the High-Density Intensive Care (HiDenIC-15) database containing intensive care data for 13 hospitals across Western Pennsylvania between Oct 2008-Dec 2014. AKI was defined using the Kidney Disease, Improving Global Outcomes 2012 guidelines. Ondansetron use was considered as receiving any form of ondansetron within 24 h of admission. The subsequent 48 h (hours 25-72 after admission) were analyzed for outcomes. Primary outcome was development of AKI; secondary outcomes included 90-day mortality and time to AKI. Propensity-matched, multivariate logistic regression was applied for both outcomes. Comparator groups were metoclopramide and prochlorperazine using the same exposure criteria. Results:AKI occurred in 965 (5.6%), 12 (3.0%), and 61 (6.5%) patients receiving ondansetron, prochlorperazine, and metoclopramide, respectively. In the adjusted analysis, no anti-emetic was associated with a significant change in the odds of developing AKI. Ondansetron was associated with a 5.48% decrease (CI −6.17–−4.79) in death within 90 days of ICU-admission, which was independent of AKI status; an effect not seen with other anti-emetics. Anti-emetic usage was not associated with a change in the time to first AKI. Conclusion:Anti-emetic usage did not alter AKI risk. Ondansetron was associated with a significant decrease in 90-day mortality that was not seen by other anti-emetics, which requires further exploration.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-01-08T01:07:28Z
      DOI: 10.1177/08850666211073582
       
  • Predicting Impact of Prone Position on Oxygenation in Mechanically
           Ventilated Patients with COVID-19

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      Authors: Jacob Bell, C. William Pike, Charles Kreisel, Rajiv Sonti, Nathan Cobb
      First page: 883
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      ObjectivesProne positioning is widely used in mechanically ventilated patients with COVID-19; however, the specific clinical scenario in which the individual is most poised to benefit is not fully established. In patients with COVID-19 respiratory failure requiring mechanical ventilation, how effective is prone positioning in improving oxygenation and can that response be predicted'DesignThis is a retrospective observational study from two tertiary care centers including consecutive patients mechanically ventilated for COVID-19 from 3/1/2020 – 7/1/2021. The primary outcome is improvement in oxygenation as measured by PaO2/FiO2. We describe oxygenation before, during and after prone episodes with a focus on identifying patient, respiratory or ventilator variables that predict prone positioning success.Setting2 Tertiary Care Academic HospitalsPatients125 patients mechanically ventilated for COVID-19 respiratory failure.InterventionsProne positioningMain ResultsOne hundred twenty-five patients underwent prone positioning a total of 309 times for a median duration of 23 hours IQR (14 – 49). On average, PaO2/FiO2 improved 19%: from 115 mm Hg (80 – 148) immediately before proning to 137 mm Hg (95 – 197) immediately after returning to the supine position. Prone episodes were more successful if the pre-prone PaO2/FiO2 was lower and if the patient was on inhaled epoprostenol (iEpo). For individuals with severe acute respiratory distress syndrome (ARDS) (PaO2/FiO2 < 100 prior to prone positioning) and on iEpo, the median improvement in PaO2/FiO2 was 27% in both instances.ConclusionsProne positioning in mechanically ventilated patients with COVID-19 is generally associated with sustained improvements in oxygenation, which is made more likely by the concomitant use of iEpo and is more impactful in those who are more severely hypoxemic prior to prone positioning.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-02-23T02:22:03Z
      DOI: 10.1177/08850666221081757
       
  • Patients Surviving Critical COVID-19 have Impairments in Dual-task
           Performance Related to Post-intensive Care Syndrome

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      Authors: Nathan Morelli, Selina M. Parry, Angela Steele, Megan Lusby, Ashley A. Montgomery-Yates, Peter E. Morris, Kirby P. Mayer
      First page: 890
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      ObjectiveThe purpose was to examine Dual Task (DT) performance in patients surviving severe and critical COVID-19 compared to patients with chronic lung disease (CLD). Secondarily, we aimed to determine the psychometric properties of the Timed Up and Go (TUG) test in patients surviving COVID-19.DesignProspective, cross-sectional, observational study.SettingAcademic medical center within United States.PatientsNinety-two patients including 36 survivors of critical COVID-19 that required mechanical ventilation (critical-COVID), 20 patients recovering from COVID-19 that required supplemental oxygen with hospitalization (severe-COVID), and 36 patients with CLD serving as a control group.Measurements and Main ResultsPatients completed the TUG, DT-TUG, Short Physical Performance Battery (SPPB), and Six Minute Walk Test (6MWT) 1-month after hospital discharge. A subset of patients returned at 3-months and repeated testing to determine the minimal detectable change (MDC). Critical-COVID group (16.8 ± 7.3) performed the DT-TUG in significantly slower than CLD group (13.9 ± 4.8 s; P = .024) and Severe-COVID group (13.1 ± 5.1 s; P = .025). Within-subject difference between TUG and DT-TUG was also significantly worse in critical-COVID group (−21%) compared to CLD (−10%; P = .012), even despite CLD patients having a higher comorbid burden (P 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-01-24T04:19:14Z
      DOI: 10.1177/08850666221075568
       
  • Intensive Care Unit- Acquired Weakness and Hospital Functional Mobility
           Outcomes Following Invasive Mechanical Ventilation in Patients with
           COVID-19: A Single-Centre Prospective Cohort Study

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      Authors: Maria N. Núñez-Seisdedos, Irene Lázaro-Navas, Luís López-González, Lorena López-Aguilera
      First page: 1005
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Background: Acute physical function outcomes in ICU survivors of COVID-19 pneumonia has received little attention. Critically ill patients with COVID-19 infection who require invasive mechanical ventilation may undergo greater exposure to some risk factors for ICU-acquired weakness (ICUAW). Purpose: To determine incidence and factors associated with ICUAW at ICU discharge and gait dependence at hospital discharge in mechanically ventilated patients with COVID-19 pneumonia. Methods: Single-centre, prospective cohort study conducted at a tertiary hospital in Madrid, Spain. We evaluated ICUAW with the Medical Research Council Summary Score (MRC-SS). Gait dependence was assessed with the Functional Status Score for the ICU (FSS-ICU) walking subscale. Results: During the pandemic second wave, between 27 July and 15 December, 2020, 70 patients were enrolled. ICUAW incidence was 65.7% and 31.4% at ICU discharge and hospital discharge, respectively. Gait dependence at hospital discharge was observed in 66 (54.3%) patients, including 9 (37.5%) without weakness at ICU discharge. In univariate analysis, ICUAW was associated with the use of neuromuscular blockers (crude odds ratio [OR] 9.059; p = 0.01) and duration of mechanical ventilation (OR 1.201; p = 0.001), but not with the duration of neuromuscular blockade (OR 1.145, p = 0.052). There was no difference in corticosteroid use between patients with and without weakness. Associations with gait dependence were lower MRC-SS at ICU discharge (OR 0.943; p = 0.015), older age (OR 1.126; p = 0.001), greater Charlson Comorbidity Index (OR 1.606; p = 0.011), longer duration of mechanical ventilation (OR 1.128; p = 0.001) and longer duration of neuromuscular blockade (OR 1.150; p = 0.029). Conclusions: In critically ill COVID-19 patients, the incidence of ICUAW and acute gait dependence were high. Our study identifies factors influencing both outcomes. Future studies should investigate optimal COVID-19 ARDS management and impact of dyspnea on acute functional outcomes of COVID-19 ICU survivors.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-05-17T05:09:31Z
      DOI: 10.1177/08850666221100498
       
  • Incidence and Clinical Features of Pneumomediastinum and Pneumothorax in
           COVID-19 Pneumonia

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      Authors: Ambreen Iqbal Muhammad, Meera Mehta, Michael Shaw, Nafisa Hussain, Stephen Joseph, Rama Vancheeswaran
      First page: 1015
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundPneumothorax (PTX) and pneumomediastinum (PM), collectively termed here “air leak”, are now well described complications of severe COVID-19 pneumonia across several case series. The incidence is thought to be approximately 1% but is not definitively known.ObjectivesTo report the incidence and describe the demographic features, risk factors and outcomes of patients with air leak as a complication of COVID-19.MethodsA retrospective observational study on all adult patients with COVID-19 admitted to Watford General Hospital, West Hertfordshire NHS Trust between March 1st 2020 and Feb 28th 2021. Patients with air leak were identified after reviewing both chest radiographs (CXRs) and axial imaging (CT Thorax) with confirmatory radiology reports inclusive of the terms PTX and/or PM.ResultsAir leak occurred with an incidence of 0.56%. Patients with air leak were younger and had evidence of more severe disease at presentation, including a higher median CRP and number of abnormal zones affected on chest radiograph. Asthma was a significant risk factor in the development of air leak (OR 13.4 [4.7-36.4]), both spontaneously and following positive pressure ventilation. CPAP and IMV were also associated with a greater than six fold increase in the risk of air leak (OR 6.4 [2.5-16.6] and 9.8 [3.7-27.8] respectively). PTX, with or without PM, in the context of COVID-19 pneumonia was almost universally fatal whereas those with alone PM had a lower risk of death.ConclusionDespite the global vaccination programme, patients continue to develop severe COVID-19 disease and may require respiratory support. This study demonstrates the importance of identifying that deterioration in such patients may be resultant from PTX or PM, particularly in asthmatics and those managed with positive pressure ventilation.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-04-01T06:24:09Z
      DOI: 10.1177/08850666221091441
       
  • Survival After Severe COVID-19: Long-Term Outcomes of Patients Admitted to
           an Intensive Care Unit

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      Authors: Thanh H. Neville, Ron D. Hays, Chi-Hong Tseng, Cynthia A. Gonzalez, Lucia Chen, Ashley Hong, Myrtle Yamamoto, Laura Santoso, Alina Kung, Kristin Schwab, Steve Y. Chang, Nida Qadir, Tisha Wang, Neil S. Wenger
      First page: 1019
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundUnderstanding the long-term sequelae of severe COVID-19 remains limited, particularly in the United States.ObjectiveTo examine long-term outcomes of patients who required intensive care unit (ICU) admission for severe COVID-19.Design, Patients, and Main MeasuresThis is a prospective cohort study of patients who had severe COVID-19 requiring an ICU admission in a two-hospital academic health system in Southern California. Patients discharged alive between 3/21/2020 and 12/31/2020 were surveyed approximately 6 months after discharge to assess health-related quality of life using Patient-Reported Outcomes Measurement Information System (PROMIS®)-29 v2.1, post-traumatic stress disorder (PTSD) and loneliness scales. A preference-based health utility score (PROPr) was estimated using 7 PROMIS domain scores. Patients were also asked their attitude about receiving aggressive ICU care.Key ResultsOf 275 patients admitted to the ICU for severe COVID-19, 205 (74.5%) were discharged alive and 132 (64%, median age 59, 46% female) completed surveys a median of 182 days post-discharge. Anxiety, depression, fatigue, sleep disturbance, ability to participate in social activities, pain interference, and cognitive function were not significantly different from the U.S. general population, but physical function (44.2, SD 11.0) was worse. PROPr mean score of 0.46 (SD 0.30, range −0.02 to 0.96 [
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-04-06T06:06:55Z
      DOI: 10.1177/08850666221092687
       
  • Early Post-Hospitalization Hemoglobin Recovery and Clinical Outcomes in
           Survivors of Critical Illness: A Population-Based Cohort Study

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      Authors: Matthew A Warner, Andrew C. Hanson, Phillip J. Schulte, Nareg H. Roubinian, Curt Storlie, Gabriel Demuth, Ognjen Gajic, Daryl J. Kor
      First page: 1067
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Anemia is common during critical illness, is associated with adverse clinical outcomes, and often persists after hospitalization. The goal of this investigation is to assess the relationships between post-hospitalization hemoglobin recovery and clinical outcomes after survival of critical illness. This is a population-based observational study of adults (≥18 years) surviving hospitalization for critical illness between January 1, 2010 and December 31, 2016 in Olmsted County, Minnesota, United States with hemoglobin concentrations and clinical outcomes assessed through one-year post-hospitalization. Multi-state proportional hazards models were utilized to assess the relationships between 1-month post-hospitalization hemoglobin recovery and hospital readmission or death through one-year after discharge. Among 6460 patients that survived hospitalization for critical illness during the study period, 2736 (42%) were alive, not hospitalized, and had available hemoglobin concentrations assessed at 1-month post-index hospitalization. Median (interquartile range) age was 69 (56, 80) years with 54% of male gender. Overall, 86% of patients had anemia at the time of hospital discharge, with median discharge hemoglobin concentrations of 10.2 (9.1, 11.6) g/dL. In adjusted analyses, each 1 g/dL increase in 1-month hemoglobin recovery was associated with decreased instantaneous hazard for hospital readmission (HR 0.87 [95% CI 0.84-0.90]; p 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-02-01T02:25:28Z
      DOI: 10.1177/08850666211069098
       
  • Increased Mortality and Costs Associated with Adverse Events in Intensive
           Care Unit Patients

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      Authors: Nathan Cantor, Kevin M. Durr, Kylie McNeill, Laura H. Thompson, Shannon M. Fernando, Peter Tanuseputro, Kwadwo Kyeremanteng
      First page: 1075
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      Background: Adverse events (AEs) are defined as unintended complications occurring to patients as a result of medical care. AEs are especially prevalent in the intensive care unit (ICU) setting and may lead to negative patient outcomes. Although many studies have examined the impact of AEs on patient outcomes, few have investigated their associated costs. Methods: The study population consisted of 17 173 adult patients (≥18 years of age) who were admitted to the ICU at The Ottawa Hospital (TOH) between 2011 and 2016. AEs were categorized using an established International Classification of Diseases 10th revision (ICD-10) patient safety indicators (PSI) system for AE detection. Logistic regression was performed to determine the association between AEs and in-hospital outcomes, including mortality. In addition, we constructed a generalized linear model to assess the independent association between AEs and total hospital costs. Results: Patients who experienced an AE had longer total hospital and ICU lengths of stay, required more invasive ICU interventions, had more complex discharge plans, and experienced higher rates of in-hospital mortality compared to those who did not experience an AE. Average total hospital costs and ICU-specific costs were higher among patients who experienced an AE ($72 718; $46 715) relative to their counterparts ($20 543; $16 217), but the per day cost was comparable in both groups. After controlling for age, sex, patient comorbidities, and illness severity, AEs were significantly associated with an increased odds of mortality (OR = 1.13, 95% CIs = 1.04, 1.22) and total average costs (Cost Ratio = 1.04, 95% CIs = 1.06, 1.08). The most impactful AE subtypes from a cost- and patient-perspective were hospital-acquired infections (HAI) and cardiac-related AEs. Conclusion: Incidence of AEs among ICU patients is associated with higher patient mortality and elevated costs. Specific causes of these AEs should be investigated, with further protocols and interventions developed to reduce their occurrence.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-03-03T04:12:30Z
      DOI: 10.1177/08850666221084908
       
  • Critical Care Randomized Trials Demonstrate Power Failure: A Low Positive
           Predictive Value of Findings in the Critical Care Research Field

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      Authors: Sarah Nostedt, Ari R Joffe
      First page: 1082
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundWe aimed to determine the post-hoc power of randomized controlled trials (RCTs) in critical care, and describe the implications for long-term positive (PPV) and negative predictive value (NPV) of statistically significant and non-significant findings respectively in the research field.MethodsWe reviewed three cohorts of RCTs. “Adult-RCTs” were 216 multicenter RCTs with a mortality outcome from a published systematic review. “Pediatric-RCTs” were 120 RCTs with a mortality outcome, obtained by search of picutrials.net. “Consecutive-RCTs” were 90 recent RCTs obtained by screening publications in 6 journals. Post-hoc power for each study was calculated at α 0.05 and 0.005, for measures of small, medium, and large effect-size, using G*Power software. Long-run expected PPV and NPV of critical care research field findings were then calculated.ResultsWith α 0.05, post-hoc power for small effect-size was very low in all RCT-cohorts (eg, median 24% in Adult-RCTs). For medium effect-size, post-hoc power was low, except for Adult-RCTs (eg, median 9% in Pediatric-RCTs). For large effect-size, post-hoc power for non-human-animal Consecutive-RCTs was low (median 32%). With α 0.005, post-hoc power was even lower. The corollary was that both PPV and NPV were poor for small effect-size, unless α 0.005 was used. Even with α 0.005, with realistic (vs. optimistic) prior probability of the alternative hypothesis, the PPV was low (eg, in Adult-RCTs 57.1% vs. 92.3%). Adding mild bias (0.1) reduced the PPV even further. For medium effect-size both PPV and NPV were better; nevertheless, with α 0.05 and realistic prior probability of the alternative hypothesis the PPV was poor, and with α 0.005 and mild bias (0.1) the PPV was very low (eg, Adult-RCTs median 44.1%).ConclusionsTo improve the predictive value of findings in the critical care research field, RCTs should be designed to have 80% power for realistic effect-size at α 0.005.
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-02-18T03:38:50Z
      DOI: 10.1177/08850666221077203
       
  • Compassionate use of Pulmonary Vasodilators in Acute Severe Hypoxic
           Respiratory Failure due to COVID-19

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      Authors: Lewis Matthews, Laurence Baker, Matteo Ferrari, Weronika Sanchez, John Pappachan, Mike PW Grocott, Ahilanandan Dushianthan
      First page: 1101
      Abstract: Journal of Intensive Care Medicine, Ahead of Print.
      BackgroundThere have been over 200 million cases and 4.4 million deaths from COVID-19 worldwide. Despite the lack of robust evidence one potential treatment for COVID-19 associated severe hypoxaemia is inhaled pulmonary vasodilator (IPVD) therapy, using either nitric oxide (iNO) or prostaglandins. We describe the implementation of, and outcomes from, a protocol using IPVDs in a cohort of patients with severe COVID-19 associated respiratory failure receiving maximal conventional support.MethodsProspectively collected data from adult patients with SARS-CoV-2 admitted to the intensive care unit (ICU) at a large teaching hospital were analysed for the period 14th March 2020 - 11th February 2021. An IPVD was considered if the PaO2/FiO2 (PF) ratio was less than 13.3kPa despite maximal conventional therapy. Nitric oxide was commenced at 20ppm and titrated to response. If oxygenation improved Iloprost nebulisers were commenced and iNO weaned. The primary outcome was percentage changes in PF ratio and Alveolar-arterial (A-a) gradient.ResultsFifty-nine patients received IPVD therapy during the study period. The median PF ratio before IPVD therapy was commenced was 11.33kPa (9.93-12.91). Patients receiving an IPVD had a lower PF ratio (14.37 vs. 16.37kPa, p = 0.002) and higher APACHE-II score (17 vs. 13, p = 0.028) at ICU admission. At 72 hours after initiating an IPVD the median improvement in PF ratio was 33.9% (-4.3-84.1). At 72 hours changes in PF ratio (70.8 vs. −4.1%, p 
      Citation: Journal of Intensive Care Medicine
      PubDate: 2022-04-04T08:33:59Z
      DOI: 10.1177/08850666221086521
       
 
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