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Critical Care Medicine
Journal Prestige (SJR): 3.116
Citation Impact (citeScore): 3
Number of Followers: 386  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0090-3493 - ISSN (Online) 1530-0293
Published by LWW Wolters Kluwer Homepage  [301 journals]
  • International Critical Care—From an Indulgence of the Best-Funded
           Healthcare Systems to a Core Need for the Provision of Equitable Care

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      Authors: Lumb; Philip D.; Adler, Diane C.; Al Rahma, Hussain; Amin, Pravin; Bakker, Jan; Bhagwanjee, Satish; Du, Bin; Bryan-Brown, Christopher W.; Dobb, Geoffrey; Gingles, Bruce; Jacobi, Judith; Koh, Younsuck; Razek, Assem Abdel; Peden, Carol; Shrestha, Gentle S.; Shukri, Khalid; Singer, Mervyn; Taylor, Phil; Williams, Ged
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • 50 Years of Sepsis Investigation/Enlightenment Among Adults—The Long
           and Winding Road

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      Authors: Dellinger; R. Phillip; Levy, Mitchell M.; Schorr, Christa A.; Townsend, Sean R.
      Abstract: imageNo abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Palliative and End-of-Life Care: Prioritizing Compassion Within the ICU
           and Beyond

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      Authors: Aslakson; Rebecca A.; Cox, Christopher E.; Baggs, Judith G.; Curtis, J. Randall
      Abstract: imageNo abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Hemodynamic Monitoring and Support

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      Authors: Vincent; Jean-Louis; Joosten, Alexandre; Saugel, Bernd
      Abstract: imageNo abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Discriminating Bacterial and Viral Infection Using a Rapid Host Gene
           Expression Test*

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      Authors: Tsalik; Ephraim L.; Henao, Ricardo; Montgomery, Jesse L.; Nawrocki, Jeff W.; Aydin, Mert; Lydon, Emily C.; Ko, Emily R.; Petzold, Elizabeth; Nicholson, Bradly P.; Cairns, Charles B.; Glickman, Seth W.; Quackenbush, Eugenia; Kingsmore, Stephen F.; Jaehne, Anja K.; Rivers, Emanuel P.; Langley, Raymond J.; Fowler, Vance G.; McClain, Micah T.; Crisp, Robert J.; Ginsburg, Geoffrey S.; Burke, Thomas W.; Hemmert, Andrew C.; Woods, Christopher W.; for The Antibacterial Resistance Leadership Group
      Abstract: imageOBJECTIVES: Host gene expression signatures discriminate bacterial and viral infection but have not been translated to a clinical test platform. This study enrolled an independent cohort of patients to describe and validate a first-in-class host response bacterial/viral test.DESIGN: Subjects were recruited from 2006 to 2016. Enrollment blood samples were collected in an RNA preservative and banked for later testing. The reference standard was an expert panel clinical adjudication, which was blinded to gene expression and procalcitonin results.SETTING: Four U.S. emergency departments.PATIENTS: Six-hundred twenty-three subjects with acute respiratory illness or suspected sepsis.INTERVENTIONS: Forty-five–transcript signature measured on the BioFire FilmArray System (BioFire Diagnostics, Salt Lake City, UT) in ~45 minutes.MEASUREMENTS AND MAIN RESULTS: Host response bacterial/viral test performance characteristics were evaluated in 623 participants (mean age 46 yr; 45% male) with bacterial infection, viral infection, coinfection, or noninfectious illness. Performance of the host response bacterial/viral test was compared with procalcitonin. The test provided independent probabilities of bacterial and viral infection in ~45 minutes. In the 213-subject training cohort, the host response bacterial/viral test had an area under the curve for bacterial infection of 0.90 (95% CI, 0.84–0.94) and 0.92 (95% CI, 0.87–0.95) for viral infection. Independent validation in 209 subjects revealed similar performance with an area under the curve of 0.85 (95% CI, 0.78–0.90) for bacterial infection and 0.91 (95% CI, 0.85–0.94) for viral infection. The test had 80.1% (95% CI, 73.7–85.4%) average weighted accuracy for bacterial infection and 86.8% (95% CI, 81.8–90.8%) for viral infection in this validation cohort. This was significantly better than 68.7% (95% CI, 62.4–75.4%) observed for procalcitonin (p < 0.001). An additional cohort of 201 subjects with indeterminate phenotypes (coinfection or microbiology-negative infections) revealed similar performance.CONCLUSIONS: The host response bacterial/viral measured using the BioFire System rapidly and accurately discriminated bacterial and viral infection better than procalcitonin, which can help support more appropriate antibiotic use.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • A Novel 29-Messenger RNA Host-Response Assay From Whole Blood Accurately
           Identifies Bacterial and Viral Infections in Patients Presenting to the
           Emergency Department With Suspected Infections: A Prospective
           Observational Study*

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      Authors: Bauer; Wolfgang; Kappert, Kai; Galtung, Noa; Lehmann, Dana; Wacker, James; Cheng, Henry K.; Liesenfeld, Oliver; Buturovic, Ljubomir; Luethy, Roland; Sweeney, Timothy E.; Tauber, Rudolf; Somasundaram, Rajan
      Abstract: imageOBJECTIVES: The rapid diagnosis of acute infections and sepsis remains a serious challenge. As a result of limitations in current diagnostics, guidelines recommend early antimicrobials for suspected sepsis patients to improve outcomes at a cost to antimicrobial stewardship. We aimed to develop and prospectively validate a new, 29-messenger RNA blood-based host-response classifier Inflammatix Bacterial Viral Non-Infected version 2 (IMX-BVN-2) to determine the likelihood of bacterial and viral infections.DESIGN: Prospective observational study.SETTING: Emergency Department, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Germany.PATIENTS: Three hundred twelve adult patients presenting to the emergency department with suspected acute infections or sepsis with at least one vital sign change.INTERVENTIONS: None (observational study only).MEASUREMENTS AND MAIN RESULTS: Gene expression levels from extracted whole blood RNA was quantified on a NanoString nCounter SPRINT (NanoString Technologies, Seattle, WA). Two predicted probability scores for the presence of bacterial and viral infection were calculated using the IMX-BVN-2 neural network classifier, which was trained on an independent development set. The IMX-BVN-2 bacterial score showed an area under the receiver operating curve for adjudicated bacterial versus ruled out bacterial infection of 0.90 (95% CI, 0.85–0.95) compared with 0.89 (95% CI, 0.84–0.94) for procalcitonin with procalcitonin being used in the adjudication. The IMX-BVN-2 viral score area under the receiver operating curve for adjudicated versus ruled out viral infection was 0.83 (95% CI, 0.77–0.89).CONCLUSIONS: IMX-BVN-2 demonstrated accuracy for detecting both viral infections and bacterial infections. This shows the potential of host-response tests as a novel and practical approach for determining the causes of infections, which could improve patient outcomes while upholding antimicrobial stewardship.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Application of Full-Spectrum Rapid Clinical Genome Sequencing Improves
           Diagnostic Rate and Clinical Outcomes in Critically Ill Infants in the
           China Neonatal Genomes Project*

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      Authors: Wu; Bingbing; Kang, Wenqing; Wang, Yingyuan; Zhuang, Deyi; Chen, Liping; Li, Long; Su, Yajie; Pan, Xinnian; Wei, Qiufen; Tang, Zezhong; Li, Yangfang; Gao, Jin; Cheng, Rui; Zhou, Wei; Wang, Zhangxing; Qiu, Gang; Wang, Jian; Yang, Lin; Zhang, Ping; Zhao, Xuemei; Wang, Yao; Gan, Mingyu; Li, Gang; Liu, Renchao; Ni, Qi; Xiao, Feifan; Yan, Kai; Cao, Yun; Lu, Guoping; Lu, Yulan; Wang, Huijun; Zhou, Wenhao
      Abstract: imageOBJECTIVES: To determine the diagnostic and clinical utility of trio-rapid genome sequencing in critically ill infants.DESIGN: In this prospective study, samples from critically ill infants were analyzed using both proband-only clinical exome sequencing and trio-rapid genome sequencing (proband and biological parents). The study occurred between April 2019 and December 2019.SETTING: Thirteen member hospitals of the China Neonatal Genomes Project spanning 10 provinces were involved.PARTICIPANTS: Critically ill infants (n = 202), from birth up until 13 months of life were enrolled based on eligibility criteria (e.g., CNS anomaly, complex congenital heart disease, evidence of metabolic disease, recurrent severe infection, suspected immune deficiency, and multiple malformations).INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: Of the 202 participants, neuromuscular (45%), respiratory (22%), and immunologic/infectious (18%) were the most commonly observed phenotypes. The diagnostic yield of trio-rapid genome sequencing was higher than that of proband-only clinical exome sequencing (36.6% [95% CI, 30.1–43.7%] vs 20.3% [95% CI, 15.1–26.6%], respectively; p = 0.0004), and the average turnaround time for trio-rapid genome sequencing (median: 7 d) was faster than that of proband-only clinical exome sequencing (median: 20 d) (p < 2.2 × 10–16). The metagenomic analysis identified pathogenic or likely pathogenic microbes in six infants with symptoms of sepsis, and these results guided the antibiotic treatment strategy. Sixteen infants (21.6%) experienced a change in clinical management following trio-rapid genome sequencing diagnosis, and 24 infants (32.4%) were referred to a new subspecialist.CONCLUSIONS: Trio-rapid genome sequencing provided higher diagnostic yield in a shorter period of time in this cohort of critically ill infants compared with proband-only clinical exome sequencing. Precise and fast molecular diagnosis can alter medical management and positively impact patient outcomes.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Design of Clinical Trials Evaluating Sedation in Critically Ill Adults
           Undergoing Mechanical Ventilation: Recommendations From Sedation
           Consortium on Endpoints and Procedures for Treatment, Education, and
           Research (SCEPTER) Recommendation III

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      Authors: Ward; Denham S.; Absalom, Anthony R.; Aitken, Leanne M.; Balas, Michele C.; Brown, David L.; Burry, Lisa; Colantuoni, Elizabeth; Coursin, Douglas; Devlin, John W.; Dexter, Franklin; Dworkin, Robert H.; Egan, Talmage D.; Elliott, Doug; Egerod, Ingrid; Flood, Pamela; Fraser, Gilles L.; Girard, Timothy D.; Gozal, David; Hopkins, Ramona O.; Kress, John; Maze, Mervyn; Needham, Dale M.; Pandharipande, Pratik; Riker, Richard; Sessler, Daniel I.; Shafer, Steven L.; Shehabi, Yahya; Spies, Claudia; Sun, Lena S.; Tung, Avery; Urman, Richard D.
      Abstract: imageOBJECTIVES: Clinical trials evaluating the safety and effectiveness of sedative medication use in critically ill adults undergoing mechanical ventilation differ considerably in their methodological approach. This heterogeneity impedes the ability to compare results across studies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations convened a meeting of multidisciplinary experts to develop recommendations for key methodologic elements of sedation trials in the ICU to help guide academic and industry clinical investigators.DESIGN: A 2-day in-person meeting was held in Washington, DC, on March 28–29, 2019, followed by a three-round, online modified Delphi consensus process.PARTICIPANTS: Thirty-six participants from academia, industry, and the Food and Drug Administration with expertise in relevant content areas, including two former ICU patients attended the in-person meeting, and the majority completed an online follow-up survey and participated in the modified Delphi process.MEASUREMENTS AND MAIN RESULTS: The final recommendations were iteratively refined based on the survey results, participants’ reactions to those results, summaries written by panel moderators, and a review of the meeting transcripts made from audio recordings. Fifteen recommendations were developed for study design and conduct, subject enrollment, outcomes, and measurement instruments. Consensus recommendations included obtaining input from ICU survivors and/or their families, ensuring adequate training for personnel using validated instruments for assessments of sedation, pain, and delirium in the ICU environment, and the need for methodological standardization.CONCLUSIONS: These recommendations are intended to assist researchers in the design, conduct, selection of endpoints, and reporting of clinical trials involving sedative medications and/or sedation protocols for adult ICU patients who require mechanical ventilation. These recommendations should be viewed as a starting point to improve clinical trials and help reduce methodological heterogeneity in future clinical trials.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Identifying High-Risk Subphenotypes and Associated Harms From Delayed
           Antibiotic Orders and Delivery*

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      Authors: Han; Xuan; Spicer, Alexandra; Carey, Kyle A.; Gilbert, Emily R.; Laiteerapong, Neda; Shah, Nirav S.; Winslow, Christopher; Afshar, Majid; Kashiouris, Markos G.; Churpek, Matthew M.
      Abstract: imageOBJECTIVES: Early antibiotic administration is a central component of sepsis guidelines, and delays may increase mortality. However, prior studies have examined the delay to first antibiotic administration as a single time period even though it contains two distinct processes: antibiotic ordering and antibiotic delivery, which can each be targeted for improvement through different interventions. The objective of this study was to characterize and compare patients who experienced order or delivery delays, investigate the association of each delay type with mortality, and identify novel patient subphenotypes with elevated risk of harm from delays.DESIGN: Retrospective analysis of multicenter inpatient data.SETTING: Two tertiary care medical centers (2008–2018, 2006–2017) and four community-based hospitals (2008–2017).PATIENTS: All patients admitted through the emergency department who met clinical criteria for infection.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: Patient demographics, vitals, laboratory values, medication order and administration times, and in-hospital survival data were obtained from the electronic health record. Order and delivery delays were calculated for each admission. Adjusted logistic regression models were used to examine the relationship between each delay and in-hospital mortality. Causal forests, a machine learning method, was used to identify a high-risk subgroup. A total of 60,817 admissions were included, and delays occurred in 58% of patients. Each additional hour of order delay (odds ratio, 1.04; 95% CI, 1.03–1.05) and delivery delay (odds ratio, 1.05; 95% CI, 1.02–1.08) was associated with increased mortality. A patient subgroup identified by causal forests with higher comorbidity burden, greater organ dysfunction, and abnormal initial lactate measurements had a higher risk of death associated with delays (odds ratio, 1.07; 95% CI, 1.06–1.09 vs odds ratio, 1.02; 95% CI, 1.01–1.03).CONCLUSIONS: Delays in antibiotic ordering and drug delivery are both associated with a similar increase in mortality. A distinct subgroup of high-risk patients exist who could be targeted for more timely therapy.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Limiting Acute Kidney Injury Progression In Sepsis: Study Protocol and
           Trial Simulation*

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      Authors: Molinari; Luca; Heskia, Fabienne; Peerapornratana, Sadudee; Ronco, Claudio; Guzzi, Louis; Toback, Seth; Birch, Robert; Beyhaghi, Hadi; Kwan, Thomas; Kampf, J. Patrick; Yealy, Donald M.; Kellum, John A.; for the Sapphire Protocolized Care for Early Septic Shock (ProCESS Investigators
      Abstract: imageOBJECTIVES: To describe study design considerations and to simulate a trial of biomarker-guided sepsis management aimed to reduce acute kidney injury (acute kidney injury). Tissue inhibitor of metalloproteinases-2 and insulin-like growth factor-binding protein 7, urinary biomarkers of cell-cycle arrest, and indicators of kidney stress can detect acute kidney injury before clinical manifestations. We sought to determine the event rates for acute kidney injury as a function of serial measurements of urinary (tissue inhibitor of metalloproteinases-2)•(insulin-like growth factor-binding protein 7) in patients at risk of sepsis-associated acute kidney injury, so that an escalating series of kidney-sparing sepsis bundles based on international guidelines could be applied.DESIGN: We described the study protocol of “Limiting acute kidney injury Progression In Sepsis,” a phase 4, multicenter, adaptive, randomized controlled trial. We performed simulations to estimate the rates for the trial’s primary endpoint using patient-level data from two previous studies (Sapphire and Protocolized Care for Early Septic Shock).SETTING: Academic and community ICUs.PATIENTS: Critically ill patients with sepsis or septic shock, without evidence of stage 2/3 acute kidney injury at enrollment.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: Our primary endpoint is progression of two or more stages of acute kidney injury, death, or dialysis within 72 hours after enrollment. In the Sapphire simulation, 45 of 203 patients (22%) with sepsis met the endpoint. In Protocolized Care for Early Septic Shock, 144 of 607 patients (24%) with septic shock met the endpoint. In both simulations, (tissue inhibitor of metalloproteinases-2)•(insulin-like growth factor-binding protein 7) patterns, suggested by Limiting acute kidney injury Progression In Sepsis protocol, stratified the risk for the endpoint from 6% (three negative tests) to 41% (for patients eligible for the highest level of kidney-sparing sepsis bundle) in Sapphire, and 14% (two negative tests) to 46% (for the highest level of kidney-sparing sepsis bundle) in Protocolized Care for Early Septic Shock.CONCLUSIONS: Findings of our Limiting acute kidney injury Progression In Sepsis trial simulation confirmed that (tissue inhibitor of metalloproteinases-2)•(insulin-like growth factor-binding protein 7) could identify patients with different rates of progression to moderate/severe acute kidney injury, death, or dialysis in 72 hours. The Limiting acute kidney injury Progression In Sepsis protocol algorithm is therefore feasible in terms of identifying suitably high-risk individuals for kidney-sparing sepsis bundle.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Comparison of Circulating Immune Cells Profiles and Kinetics Between
           Coronavirus Disease 2019 and Bacterial Sepsis*

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      Authors: de Roquetaillade; Charles; Mansouri, Sehmi; Brumpt, Caren; Neuwirth, Marie; Voicu, Sébastian; Le Dorze, Matthieu; Fontaine, Candice; Barthélémy, Romain; Gayat, Etienne; Megarbane, Bruno; Mebazaa, Alexandre; Chousterman, Benjamin Glenn
      Abstract: imageOBJECTIVES: Although clinical presentation of coronavirus disease 2019 has been extensively described, immune response to severe acute respiratory syndrome coronavirus 2 remains yet not fully understood. Similarities with bacterial sepsis were observed; however, few studies specifically addressed differences of immune response between both conditions. Here, we report a longitudinal analysis of the immune response in coronavirus disease 2019 patients, its correlation with outcome, and comparison between severe coronavirus disease 2019 patients and septic patients.DESIGN: Longitudinal, retrospective observational study.SETTING: Tertiary-care hospital during the first 2020 coronavirus disease 2019 outbreak in France.PATIENTS: All successive patients with confirmed severe acute respiratory syndrome coronavirus 2 infection admitted to the emergency department, medical ward, and ICU with at least one available immunophenotyping performed during hospital stay.MEASUREMENTS AND MAIN RESULTS: Between March and April 2020, 247 patients with coronavirus disease 2019 were included and compared with a historical cohort of 108 severe septic patients. Nonsevere coronavirus disease 2019 patients (n = 153) presented normal or slightly altered immune profiles. Severe coronavirus disease 2019 (n = 94) immune profile differed from sepsis. Coronavirus disease 2019 exhibited profound and prolonged lymphopenia (mostly on CD3, CD4, CD8, and NK cells), neutrophilia, and human leukocyte antigen D receptor expression on CD14+ monocytes down-regulation. Surprisingly, coronavirus disease 2019 patients presented a unique profile of B cells expansion, basophilia, and eosinophilia. Lymphopenia, human leukocyte antigen D receptor expression on CD14+ monocytes down-regulation, and neutrophilia were associated with a worsened outcome, whereas basophilia and eosinophilia were associated with survival. Circulating immune cell kinetics differed between severe coronavirus disease 2019 and sepsis, lack of correction of immune alterations in coronavirus disease 2019 patients during the first 2 weeks of ICU admission was associated with death and nosocomial infections.CONCLUSIONS: Circulating immune cells profile differs between mild and severe coronavirus disease 2019 patients. Severe coronavirus disease 2019 is associated with a unique immune profile as compared with sepsis. Several immune features are associated with outcome. Thus, immune monitoring of coronavirus disease 2019 might be of help for patient management.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Functional Outcomes and Their Association With Physical Performance in
           Mechanically Ventilated Coronavirus Disease 2019 Survivors at 3 Months
           Following Hospital Discharge: A Cohort Study

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      Authors: van Gassel; Rob J. J.; Bels, Julia; Remij, Loes; van Bussel, Bas C. T.; Posthuma, Rein; Gietema, Hester A.; Verbunt, Jeanine; van der Horst, Iwan C. C.; Olde Damink, Steven W. M.; van Santen, Susanne; van de Poll, Marcel C. G.
      Abstract: imageOBJECTIVES: We performed a comprehensive health assessment in mechanically ventilated coronavirus disease 2019 survivors to assess the impact of respiratory and skeletal muscle injury sustained during ICU stay on physical performance at 3 months following hospital discharge.DESIGN: Preregistered prospective observational cohort study.SETTING: University hospital ICU.PATIENTS: All mechanically ventilated coronavirus disease 2019 patients admitted to our ICU during the first European pandemic wave.MEASUREMENTS AND MAIN RESULTS: At 3 months after hospital discharge, 46 survivors underwent a comprehensive physical assessment (6-min walking distance, Medical Research Council sum score and handgrip strength), a full pulmonary function test, and a chest CT scan which was used to analyze skeletal muscle architecture. In addition, patient-reported outcomes measures were collected. Physical performance assessed by 6-minute walking distance was below 80% of predicted in 48% of patients. Patients with impaired physical performance had more muscle weakness (Medical Research Council sum score 53 [51–56] vs 59 [56–60]; p < 0.001), lower lung diffusing capacity (54% [44–66%] vs 68% of predicted [61–72% of predicted]; p = 0.002), and higher intermuscular adipose tissue area (p = 0.037). Reduced lung diffusing capacity and increased intermuscular adipose tissue were independently associated with physical performance.CONCLUSIONS: Physical disability is common at 3 months in severe coronavirus disease 2019 survivors. Lung diffusing capacity and intermuscular adipose tissue assessed on CT were independently associated with walking distance, suggesting a key role for pulmonary function and muscle quality in functional disability.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Validation of a Crisis Standards of Care Model for Prioritization of
           Limited Resources During the Coronavirus Disease 2019 Crisis in an Urban,
           Safety-Net, Academic Medical Center*

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      Authors: Nadjarian; Albert; LeClair, Jessica; Mahoney, Taylor F.; Awtry, Eric H.; Bhatia, Jasvinder S.; Caruso, Lisa B.; Clay, Alexis; Greer, David; Hingorani, Karan S.; Horta, L. F. B.; Ibrahim, Michel; Ieong, Michael H.; James, Thea; Kulke, Matthew H.; Lim, Remington; Lowe, Robert C.; Moses, James M.; Murphy, Jaime; Nozari, Ala; Patel, Anuj D.; Silver, Brent; Theodore, Arthur C.; Wang, Ryan Shufei; Weinstein, Ellen; Wilson, Stephen A.; Cervantes-Arslanian, Anna M.
      Abstract: imageOBJECTIVES: The coronavirus disease 2019 pandemic has overwhelmed healthcare resources even in wealthy nations, necessitating rationing of limited resources without previously established crisis standards of care protocols. In Massachusetts, triage guidelines were designed based on acute illness and chronic life-limiting conditions. In this study, we sought to retrospectively validate this protocol to cohorts of critically ill patients from our hospital.DESIGN: We applied our hospital-adopted guidelines, which defined severe and major chronic conditions as those associated with a greater than 50% likelihood of 1- and 5-year mortality, respectively, to a critically ill patient population. We investigated mortality for the same intervals.SETTING: An urban safety-net hospital ICU.PATIENTS: All adults hospitalized during April of 2015 and April 2019 identified through a clinical database search.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: Of 365 admitted patients, 15.89% had one or more defined chronic life-limiting conditions. These patients had higher 1-year (46.55% vs 13.68%; p < 0.01) and 5-year (50.00% vs 17.22%; p < 0.01) mortality rates than those without underlying conditions. Irrespective of classification of disease severity, patients with metastatic cancer, congestive heart failure, end-stage renal disease, and neurodegenerative disease had greater than 50% 1-year mortality, whereas patients with chronic lung disease and cirrhosis had less than 50% 1-year mortality. Observed 1- and 5-year mortality for cirrhosis, heart failure, and metastatic cancer were more variable when subdivided into severe and major categories.CONCLUSIONS: Patients with major and severe chronic medical conditions overall had 46.55% and 50.00% mortality at 1 and 5 years, respectively. However, mortality varied between conditions. Our findings appear to support a crisis standards protocol which focuses on acute illness severity and only considers underlying conditions carrying a greater than 50% predicted likelihood of 1-year mortality. Modifications to the chronic lung disease, congestive heart failure, and cirrhosis criteria should be refined if they are to be included in future models.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Impact of Nonpharmaceutical Interventions on ICU Admissions During
           Lockdown for Coronavirus Disease 2019 in New Zealand—A Retrospective
           Cohort Study

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      Authors: Gonzenbach; Tobias P.; McGuinness, Shay P.; Parke, Rachael L.; Merz, Tobias M.
      Abstract: imageOBJECTIVES: Nonpharmaceutical interventions are implemented internationally to mitigate the spread of severe acute respiratory syndrome coronavirus 2 with the aim to reduce coronavirus disease 2019–related deaths and to protect the health system, particularly intensive care facilities from being overwhelmed. The aim of this study is to describe the impact of nonpharmaceutical interventions on ICU admissions of non–coronavirus disease 2019–related patients.DESIGN: Retrospective cohort study.SETTING: Analysis of all reported adult patient admissions to New Zealand ICUs during Level 3 and Level 4 lockdown restrictions from March 23, to May 13, 2020, in comparison with equivalent periods from 5 previous years (2015–2019).SUBJECTS: Twelve-thousand one-hundred ninety-two ICU admissions during the time periods of interest were identified.MEASUREMENTS: Patient data were obtained from the Australian and New Zealand Intensive Care Society Adult Patient Database, Australian and New Zealand Intensive Care Society critical care resources registry, and Statistics New Zealand. Study variables included patient baseline characteristics and ICU resource use.MAIN RESULTS: Nonpharmaceutical interventions in New Zealand were associated with a 39.1% decrease in ICU admission rates (p < 0.0001). Both elective (–44.2%) and acute (–36.5%) ICU admissions were significantly reduced when compared with the average of the previous 5 years (both p < 0.0001). ICU occupancy decreased from a mean of 64.3% (2015–2019) to 39.8% in 2020. Case mix, ICU resource use per patient, and ICU and hospital mortality remained unchanged.CONCLUSIONS: The institution of nonpharmaceutical interventions was associated with a significant decrease in elective and acute ICU admissions and ICU resource use. These findings may help hospitals and health authorities planning for surge capacities and elective surgery management in future pandemics.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Right Ventricular Dysfunction and Its Association With Mortality in
           Coronavirus Disease 2019 Acute Respiratory Distress Syndrome*

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      Authors: Chotalia; Minesh; Ali, Muzzammil; Alderman, Joseph E.; Kalla, Manish; Parekh, Dhruv; Bangash, Mansoor N.; Patel, Jaimin M.
      Abstract: imageOBJECTIVES: To assess whether right ventricular dilation or systolic impairment is associated with mortality and/or disease severity in invasively ventilated patients with coronavirus disease 2019 acute respiratory distress syndrome.DESIGN: Retrospective cohort study.SETTING: Single-center U.K. ICU.PATIENTS: Patients with coronavirus disease 2019 acute respiratory distress syndrome undergoing invasive mechanical ventilation that received a transthoracic echocardiogram between March and December 2020.INTERVENTION: None.MEASUREMENTS AND MAIN RESULTS: Right ventricular dilation was defined as right ventricular:left ventricular end-diastolic area greater than 0.6, right ventricular systolic impairment as fractional area change less than 35%, or tricuspid annular plane systolic excursion less than 17 mm. One hundred seventy-two patients were included, 59 years old (interquartile range, 49–67), with mostly moderate acute respiratory distress syndrome (n = 101; 59%). Ninety-day mortality was 41% (n = 70): 49% in patients with right ventricular dilation, 53% in right ventricular systolic impairment, and 72% in right ventricular dilation with systolic impairment. The right ventricular dilation with systolic impairment phenotype was independently associated with mortality (odds ratio, 3.11 [95% CI, 1.15–7.60]), but either disease state alone was not. Right ventricular fractional area change correlated with Pao2:Fio2 ratio, Paco2, chest radiograph opacification, and dynamic compliance, whereas right ventricular:left ventricle end-diastolic area correlated negatively with urine output.CONCLUSIONS: Right ventricular systolic impairment correlated with pulmonary pathophysiology, whereas right ventricular dilation correlated with renal dysfunction. Right ventricular dilation with systolic impairment was the only right ventricular phenotype that was independently associated with mortality.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Association of Early Multiple Organ Dysfunction With Clinical and
           Functional Outcomes Over the Year Following Traumatic Brain Injury: A
           Transforming Research and Clinical Knowledge in Traumatic Brain Injury
           Study

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      Authors: Krishnamoorthy; Vijay; Temkin, Nancy; Barber, Jason; Foreman, Brandon; Komisarow, Jordan; Korley, Fred K.; Laskowitz, Daniel T.; Mathew, Joseph P.; Hernandez, Adrian; Sampson, John; James, Michael L.; Bartz, Raquel; Raghunathan, Karthik; Goldstein, Benjamin A.; Markowitz, Amy J.; Vavilala, Monica S.; Knowledge in TBI (TRACK-TBI Investigators
      Abstract: imageOBJECTIVES: Traumatic brain injury is a leading cause of death and disability in the United States. While the impact of early multiple organ dysfunction syndrome has been studied in many critical care paradigms, the clinical impact of early multiple organ dysfunction syndrome in traumatic brain injury is poorly understood. We examined the incidence and impact of early multiple organ dysfunction syndrome on clinical, functional, and disability outcomes over the year following traumatic brain injury.DESIGN: Retrospective cohort study.SETTING: Patients enrolled in the Transforming Clinical Research and Knowledge in Traumatic Brain Injury study, an 18-center prospective cohort study of traumatic brain injury patients evaluated in participating level 1 trauma centers.SUBJECTS: Adult (age> 17 yr) patients with moderate-severe traumatic brain injury (Glasgow Coma Scale < 13). We excluded patients with major extracranial injury (Abbreviated Injury Scale score ≥ 3).INTERVENTIONS: Development of early multiple organ dysfunction syndrome, defined as a maximum modified Sequential Organ Failure Assessment score greater than 7 during the initial 72 hours following admission.MEASUREMENTS AND MAIN RESULTS: The main outcomes were: hospital mortality, length of stay, 6-month functional and disability domains (Glasgow Outcome Scale-Extended and Disability Rating Scale), and 1-year mortality. Secondary outcomes included: ICU length of stay, 3-month Glasgow Outcome Scale-Extended, 3-month Disability Rating Scale, 1-year Glasgow Outcome Scale-Extended, and 1-year Disability Rating Scale. We examined 373 subjects with moderate-severe traumatic brain injury. The mean (sd) Glasgow Coma Scale in the emergency department was 5.8 (3.2), with 280 subjects (75%) classified as severe traumatic brain injury (Glasgow Coma Scale 3–8). Among subjects with moderate-severe traumatic brain injury, 252 (68%) developed early multiple organ dysfunction syndrome. Subjects that developed early multiple organ dysfunction syndrome had a 75% decreased odds of a favorable outcome (Glasgow Outcome Scale-Extended 5–8) at 6 months (adjusted odds ratio, 0.25; 95% CI, 0.12–0.51) and increased disability (higher Disability Rating Scale score) at 6 months (adjusted mean difference, 2.04; 95% CI, 0.92–3.17). Subjects that developed early multiple organ dysfunction syndrome experienced an increased hospital length of stay (adjusted mean difference, 11.4 d; 95% CI, 7.1–15.8), with a nonsignificantly decreased survival to hospital discharge (odds ratio, 0.47; 95% CI, 0.18–1.2).CONCLUSIONS: Early multiple organ dysfunction following moderate-severe traumatic brain injury is common and independently impacts multiple domains (mortality, function, and disability) over the year following injury. Further research is necessary to understand underlying mechanisms, improve early recognition, and optimize management strategies.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Adherence to Lung-Protective Ventilation Principles in Pediatric Acute
           Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress
           Syndrome Incidence and Epidemiology Study*

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      Authors: Bhalla; Anoopindar K.; Klein, Margaret J.; Emeriaud, Guillaume; Lopez-Fernandez, Yolanda M.; Napolitano, Natalie; Fernandez, Analia; Al-Subu, Awni M.; Gedeit, Rainer; Shein, Steven L.; Nofziger, Ryan; Hsing, Deyin Doreen; Briassoulis, George; Ilia, Stavroula; Baudin, Florent; Piñeres-Olave, Byron Enrique; Maria Izquierdo, Ledys; Lin, John C.; Cheifetz, Ira M.; Kneyber, Martin C. J.; Smith, Lincoln; Khemani, Robinder G.; Newth, Christopher J. L.; on behalf of Pediatric Acute Respiratory Distress Syndrome Incidence Pediatric Acute Lung Injury and
      Abstract: imageOBJECTIVES: To describe mechanical ventilation management and factors associated with nonadherence to lung-protective ventilation principles in pediatric acute respiratory distress syndrome.DESIGN: A planned ancillary study to a prospective international observational study. Mechanical ventilation management (every 6 hr measurements) during pediatric acute respiratory distress syndrome days 0–3 was described and compared with Pediatric Acute Lung Injury Consensus Conference tidal volume recommendations (< 7 mL/kg in children with impaired respiratory system compliance, < 9 mL/kg in all other children) and the Acute Respiratory Distress Syndrome Network lower positive end-expiratory pressure/higher Fio2 grid recommendations.SETTING: Seventy-one international PICUs.PATIENTS: Children with pediatric acute respiratory distress syndrome.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: Analyses included 422 children. On pediatric acute respiratory distress syndrome day 0, median tidal volume was 7.6 mL/kg (interquartile range, 6.3–8.9 mL/kg) and did not differ by pediatric acute respiratory distress syndrome severity. Plateau pressure was not recorded in 97% of measurements. Using delta pressure (peak inspiratory pressure – positive end-expiratory pressure), median tidal volume increased over quartiles of median delta pressure (p = 0.007). Median delta pressure was greater than or equal to 18 cm H2O for all pediatric acute respiratory distress syndrome severity levels. In severe pediatric acute respiratory distress syndrome, tidal volume was greater than or equal to 7 mL/kg 62% of the time, and positive end-expiratory pressure was lower than recommended by the positive end-expiratory pressure/Fio2 grid 70% of the time. In multivariable analysis, tidal volume nonadherence was more common with severe pediatric acute respiratory distress syndrome, fewer PICU admissions/yr, non-European PICUs, higher delta pressure, corticosteroid use, and pressure control mode. Adherence was associated with underweight stature and cuffed endotracheal tubes. In multivariable analysis, positive end-expiratory pressure/Fio2 grid nonadherence was more common with higher pediatric acute respiratory distress syndrome severity, ventilator decisions made primarily by the attending physician, pre-ICU cardiopulmonary resuscitation, underweight stature, and age less than 2 years. Adherence was associated with respiratory therapist involvement in ventilator management and longer time from pediatric acute respiratory distress syndrome diagnosis. Higher nonadherence to tidal volume and positive end-expiratory pressure recommendations were independently associated with higher mortality and longer duration of ventilation after adjustment for confounding variables. In stratified analyses, these associations were primarily influenced by children with severe pediatric acute respiratory distress syndrome.CONCLUSIONS: Nonadherence to lung-protective ventilation principles is common in pediatric acute respiratory distress syndrome and may impact outcome. Modifiable factors exist that may improve adherence.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Neuroprognostic Accuracy of Quantitative Versus Standard Pupillary Light
           Reflex for Adult Postcardiac Arrest Patients: A Systematic Review and
           Meta-Analysis*

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      Authors: Wang; Chih-Hung; Wu, Cheng-Yi; Liu, Carolyn Chia-Yu; Hsu, Tzu-Chun; Liu, Michael A.; Wu, Meng-Che; Tsai, Min-Shan; Chang, Wei-Tien; Huang, Chien-Hua; Lee, Chien-Chang; Chen, Shyr-Chyr; Chen, Wen-Jone
      Abstract: imageOBJECTIVES: An automated infrared pupillometer measures quantitative pupillary light reflex using a calibrated light stimulus. We examined whether the timing of performing quantitative pupillary light reflex or standard pupillary light reflex may impact its neuroprognostic performance in postcardiac arrest comatose patients and whether quantitative pupillary light reflex may outperform standard pupillary light reflex in early postresuscitation phase.DATA SOURCES: PubMed and Embase databases from their inception to July 2020.STUDY SELECTION: We selected studies providing sufficient data of prognostic values of standard pupillary light reflex or quantitative pupillary light reflex to predict neurologic outcomes in adult postcardiac arrest comatose patients.DATA EXTRACTION: Quantitative data required for building a 2 × 2 contingency table were extracted, and study quality was assessed using standard criteria.DATA SYNTHESIS: We used the bivariate random-effects model to estimate the pooled sensitivity and specificity of standard pupillary light reflex or quantitative pupillary light reflex in predicting poor neurologic outcome during early (< 72 hr), middle (between 72 and 144 hr), and late (≧ 145 hr) postresuscitation periods, respectively. We included 39 studies involving 17,179 patients. For quantitative pupillary light reflex, the cut off points used in included studies to define absent pupillary light reflex ranged from 0% to 13% (median: 7%) and from zero to 2 (median: 2) for pupillary light reflex amplitude and Neurologic Pupil index, respectively. Late standard pupillary light reflex had the highest area under the receiver operating characteristic curve (0.98, 95% CI [CI], 0.97–0.99). For early standard pupillary light reflex, the area under the receiver operating characteristic curve was 0.80 (95% CI, 0.76–0.83), with a specificity of 0.91 (95% CI, 0.85–0.95). For early quantitative pupillary light reflex, the area under the receiver operating characteristic curve was 0.83 (95% CI, 0.79–0.86), with a specificity of 0.99 (95% CI, 0.91–1.00).CONCLUSIONS: Timing of pupillary light reflex examination may impact neuroprognostic accuracy. The highest prognostic performance was achieved with late standard pupillary light reflex. Early quantitative pupillary light reflex had a similar specificity to late standard pupillary light reflex and had better specificity than early standard pupillary light reflex. For postresuscitation comatose patients, early quantitative pupillary light reflex may substitute for early standard pupillary light reflex in the neurologic prognostication algorithm.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Association Between Lack of Blinding and Mortality Results in Critical
           Care Randomized Controlled Trials: A Meta-Epidemiological Study*

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      Authors: Martin; Guillaume L.; Trioux, Théo; Gaudry, Stéphane; Tubach, Florence; Hajage, David; Dechartres, Agnès
      Abstract: imageOBJECTIVES: To investigate whether intervention effect estimates for mortality differ between blinded and nonblinded randomized controlled trials conducted in critical care. We used a meta-epidemiological approach, comparing effect estimates between blinded and nonblinded randomized controlled trials for the same research question.DATA SOURCES: Systematic reviews and meta-analyses of randomized controlled trials evaluating a therapeutic intervention on mortality in critical care, published between January 2009 and March 2019 in high impact factor general medical or critical care journals and by Cochrane.DATA EXTRACTION: For each randomized controlled trial included in eligible meta-analyses, we evaluated whether the trial was blinded (i.e., double-blinded and/or reporting adequate methods) or not (i.e., open-label, single-blinded, or unclear). We collected risk of bias evaluated by the review authors and extracted trial results.DATA SYNTHESIS: Within each meta-analysis, we compared intervention effect estimates between blinded and nonblinded randomized controlled trials by using a ratio of odds ratio (< 1 indicates larger estimates in nonblinded than blinded randomized controlled trials). We then combined ratio of odds ratios across meta-analyses to obtain the average relative difference between nonblinded and blinded trials. Among 467 randomized controlled trials included in 36 meta-analyses, 267 (57%) were considered blinded and 200 (43%) nonblinded. Intervention effect estimates were statistically significantly larger in nonblinded than blinded trials (combined ratio of odds ratio, 0.91; 95% CI, 0.84–0.99). We found no heterogeneity across meta-analyses (p = 0.72; I2 = 0%; τ2 = 0). Sensitivity analyses adjusting the main analysis on risk of bias items yielded consistent results.CONCLUSIONS: Intervention effect estimates of mortality were slightly larger in nonblinded than blinded randomized controlled trials conducted in critical care, but confounding cannot be excluded. Blinding of both patients and personnel is important to consider when possible in critical care trials, even when evaluating mortality.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • A Host of Host Assays: The Clinical Accuracy of Two Host Gene Expression
           Assays in Acute Infection*

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      Authors: Vlasschaert; Caitlyn; Rauh, Michael J.
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Whole Genome Sequencing as a First-Line Clinical Test: Almost Ready for
           Prime Time*

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      Authors: Dahmer; Mary K.
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Antibiotic Administration and Timing: Risks, Delay, Zombies*

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      Authors: Townsend; Sean R.
      Abstract: imageNo abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • The Journey Begins: Personalized Acute Kidney Injury Therapy*

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      Authors: Zarbock; Alexander
      Abstract: imageNo abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Utility of Coronavirus Disease 2019 Immune Profiling for the Clinician at
           the Bedside*

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      Authors: Minkove; Samuel J.; Torabi-Parizi, Parizad
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Assessing Accuracy and Equity in Crisis Standards of Care*

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      Authors: Peterson; Lars-Kristofer Nelson; Green, Adam
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Coronavirus Disease 2019: There Is a Heart Between the Lungs*

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      Authors: Michard; Frederic; Gonzalez, Filipe
      Abstract: imageNo abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Adherence to Lung-Protective Ventilation in Pediatric Acute Respiratory
           Distress Syndrome: Principles Versus Explicit Targets*

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      Authors: Bergmann; Jules P.; Brower, Roy G.
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Quantitative Pupillometry Following Cardiac Arrest: Is It Time to Throw
           Away Our Penlight'*

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      Authors: Sadan; Ofer
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Seeing Interventions in a Favorable Light: The Consequences of Unblinded
           Trials*

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      Authors: Yarnell; Christopher J.
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • New Ways to Skin a Cat or Still a Cat Chasing Its Tail' Bayesian
           Vancomycin Monitoring in the ICU*

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      Authors: Flannery; Alexander H.; Landmesser, Katherine B.; Mynatt, Ryan P.
      Abstract: imageNo abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Prospective Validation of the Preschool Confusion Assessment Method for
           the ICU to Screen for Delirium in Infants Less Than 6 Months Old

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      Authors: Canter; Marguerite O.; Tanguturi, Yasas C.; Ellen Wilson, Jo; Williams, Stacey R.; Exum, Sylvia A.; Umrania, Hiren M.; Betters, Kristina A.; Raman, Rameela; Ely, E. Wesley; Pandharipande, Pratik P.; Fuchs, D. Catherine; Smith, Heidi A. B.
      Abstract: imageOBJECTIVES: ICU delirium is a predictor of greater morbidity and higher mortality in the pediatric population. The diagnostic obstacles and validity of delirium monitoring among neonates and young infants have yet to be fully delineated. We sought to validate the Preschool Confusion Assessment Method for the ICU in neonates and young infants and determine delirium prevalence in this young population.DESIGN: Prospective cohort study to validate the Preschool Confusion Assessment Method for the ICU for the assessment of ICU delirium in neonates and young infants compared with the reference standard, Child and Adolescent Psychiatry.SETTING: Tertiary medical center PICU, including medical, surgical, and cardiac patients.PARTICIPANTS: Infants less than 6 months old admitted to the PICU regardless of admission diagnosis.MEASUREMENTS AND MAIN RESULTS: We enrolled 49 patients with a median age of 1.8 months (interquartile range, 0.7–4.1 mo), 82% requiring mechanical ventilation. Enrolled patients were assessed for delirium in blinded-fashion by the research team using the Preschool Confusion Assessment Method for the ICU and independently assessed by the psychiatry reference rater using Diagnostic and Statistical Manual of Mental Disorders-5 criteria. A total of 189 paired assessments were completed, and the Preschool Confusion Assessment Method for the ICU performed with a sensitivity of 95% (95% CI, 89–100%), specificity of 81% (68–90%), “negative and positive predictive values” of 97% (94–100%) and 69% (55–79%), respectively, compared with the reference rater. Delirium prevalence was 47%, with higher rates of 61% observed among neonates (< 1 mo old) and 39% among infants 1–6 months old.CONCLUSIONS: The Preschool Confusion Assessment Method for the ICU is a valid screening tool for delirium monitoring in infants less than 6 months old. Delirium screening was feasible in this population despite evolving neurocognition and arousal architecture. ICU delirium was prevalent among infants. The consequence of acute brain dysfunction during crucial neurocognitive development remains unclear. Future studies are necessary to determine the long-term impact of ICU delirium and strategies to reduce associated harm in critically ill infants.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Effect of Hyperbaric Oxygen Therapy Initiation Time in Acute Carbon
           Monoxide Poisoning

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      Authors: Lee; Yoonsuk; Cha, Yong Sung; Kim, Sung Hwa; Kim, Hyun
      Abstract: imageOBJECTIVES: Hyperbaric oxygen therapy (HBO2) is recommended for symptomatic patients within 24-hour postcarbon monoxide poisoning. Previous studies have reported significantly better outcomes with treatment administered within 6 hours after carbon monoxide poisoning. Thus, we aimed to compare the neurocognitive outcomes according to HBO2 delay intervals.DESIGN: Retrospective analysis of data from our prospectively collected carbon monoxide poisoning registry.SETTING: A single academic medical center in Wonju, Republic of Korea.PATIENTS: We analyzed the data of 706 patients older than 16 years treated with HBO2 with propensity score matching. Based on carbon monoxide exposure-to-HBO2 delay intervals, we classified patients into the early (control, less than or equal to 6 hr) and late (case, 6–24 hr) groups. The late group was further divided into Case-1 (6–12 hr) and Case-2 (12–24 hr) groups. We also compared mild (nonintubated) and severe (intubated) groups.INTERVENTIONS: HBO2.MEASUREMENTS AND MAIN RESULTS: After propensity score matching, Global Deterioration Scale scores at 6 months postcarbon monoxide exposure showed significantly fewer poor outcome patients in the early than in the late group (p = 0.027). The early group had significantly fewer patients with poor outcomes than the Case-2 group (p = 0.035) at 1 month and than the Case-1 (p = 0.033) and Case-2 (p = 0.004) groups at 6 months. There were significantly more patients with poor prognoses at 6 months as treatment interval increased (p = 0.008). In the mild cohort, the early group had significantly fewer patients with poor 6-month outcomes than the late group (p = 0.033).CONCLUSIONS: Patients who received HBO2 within 6 hours of carbon monoxide exposure had a better 6-month neurocognitive prognosis than those treated within 6–24 hours. An increase in the interval to treatment led to an increase in poor outcomes.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Stratification for Identification of Prognostic Categories In the Acute
           RESpiratory Distress Syndrome (SPIRES) Score

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      Authors: Villar; Jesús; González-Martín, Jesús M.; Ambrós, Alfonso; Mosteiro, Fernando; Martínez, Domingo; Fernández, Lorena; Soler, Juan A.; Parra, Laura; Solano, Rosario; Soro, Marina; del Campo, Rafael; González-Luengo, Raúl I.; Civantos, Belén; Montiel, Raquel; Pita-García, Lidia; Vidal, Anxela; Añón, José M.; Ferrando, Carlos; Díaz-Domínguez, Francisco J.; Mora-Ordoñez, Juan M.; Fernández, M. Mar; Fernández, Cristina; Fernández, Rosa L.; Rodríguez-Suárez, Pedro; Steyerberg, Ewout W.; Kacmarek, Robert M.; for the Spanish Initiative for Epidemiology, Stratification Therapies of ARDS (SIESTA Network
      Abstract: imageOBJECTIVES: To develop a scoring model for stratifying patients with acute respiratory distress syndrome into risk categories (Stratification for identification of Prognostic categories In the acute RESpiratory distress syndrome score) for early prediction of death in the ICU, independent of the underlying disease and cause of death.DESIGN: A development and validation study using clinical data from four prospective, multicenter, observational cohorts.SETTING: A network of multidisciplinary ICUs.PATIENTS: One-thousand three-hundred one patients with moderate-to-severe acute respiratory distress syndrome managed with lung-protective ventilation.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: The study followed Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis guidelines for prediction models. We performed logistic regression analysis, bootstrapping, and internal-external validation of prediction models with variables collected within 24 hours of acute respiratory distress syndrome diagnosis in 1,000 patients for model development. Primary outcome was ICU death. The Stratification for identification of Prognostic categories In the acute RESpiratory distress syndrome score was based on patient’s age, number of extrapulmonary organ failures, values of end-inspiratory plateau pressure, and ratio of Pao2 to Fio2 assessed at 24 hours of acute respiratory distress syndrome diagnosis. The pooled area under the receiver operating characteristic curve across internal-external validations was 0.860 (95% CI, 0.831–0.890). External validation in a new cohort of 301 acute respiratory distress syndrome patients confirmed the accuracy and robustness of the scoring model (area under the receiver operating characteristic curve = 0.870; 95% CI, 0.829–0.911). The Stratification for identification of Prognostic categories In the acute RESpiratory distress syndrome score stratified patients in three distinct prognostic classes and achieved better prediction of ICU death than ratio of Pao2 to Fio2 at acute respiratory distress syndrome onset or at 24 hours, Acute Physiology and Chronic Health Evaluation II score, or Sequential Organ Failure Assessment scale.CONCLUSIONS: The Stratification for identification of Prognostic categories In the acute RESpiratory distress syndrome score represents a novel strategy for early stratification of acute respiratory distress syndrome patients into prognostic categories and for selecting patients for therapeutic trials.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Pattern of Brain Injury in Patients With Thrombotic Thrombocytopenic
           Purpura in the Precaplacizumab Era

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      Authors: Mirouse; Adrien; Legriel, Stéphane; Dumas, Guillaume; Labro, Guylaine; Veyradier, Agnès; Zafrani, Lara; Valade, Sandrine; Hourmant, Yannick; Boutboul, David; Darmon, Michael; Coppo, Paul; Mariotte, Eric; Azoulay, Elie
      Abstract: imageOBJECTIVES: To describe short- and long-term neurologic prognosis of patients with thrombotic thrombocytopenic purpura and to identify clusters associated with evolution.DESIGN: Prospective French cohort.SETTING: ICU in a reference center.PATIENTS: All consecutive patients with newly diagnosed thrombocytopenic purpura.INTERVENTION: Comprehensive clinical, biological, and radiological evaluation at admission. Neurocognitive recovery was assessed using Glasgow Outcome Scale (range 1–5, with 1 representing death and 5 representing no or minimal neurologic deficit).MEASUREMENTS AND MAIN RESULTS: Among the 130 newly diagnosed patients with thrombocytopenic purpura, 108 (83%; age 43 [30–52]; 73% women) presented with neurologic signs, including headaches (51%), limb weakness, paresthesia, and/or aphasia (49%), pyramidal syndrome (30%), decreased consciousness (20%), seizure (19%), cognitive impairment (34%), cerebellar syndrome (18%), and visual symptoms (20%). A hierarchical cluster analysis identified three distinct groups of patients. Cluster 1 included younger patients (37 [27–48], 41 [32–52], and 48 [35–54], in clusters 1, 2 and 3, respectively; p = 0.045), with a predominance of headaches (75%, 27%, and 36%; p < 0.0001). Cluster 2 patients had ataxic gait and cerebellar syndrome (77%, 0%, and 0%; p < 0.0001) and dizziness (50%, 0%, and 0%; p < 0.0001). Cluster 3 included patients with delirium (36%, 0%, and 9%; p < 0.0001), obtundation (58%, 0%, and 24%; p < 0.0001), and seizure (36%, 0%, and 14%; p < 0.0001). Acute kidney injury was 32%, 68%, and 77%, in clusters 1, 2, and 3, respectively (p < 0.0001). The three clusters did not differ for other biological or brain imaging. After a median follow-up of 34 months (12–71 mo), 100 patients (93%) were alive with full neurocognitive recovery (i.e., Glasgow Outcome Scale score 5) in 89 patients (89%). Patients from cluster 1 more frequently exhibited full recovery (Glasgow Outcome Scale score of 5) compared with clusters 2 and 3, (44 [98%], 13 [65%], and 21 [60%] at 3 mo; p < 0.0001), (44 [100%], 15 [68%], and 23 [69%] at 6 mo; p < 0.0001), and (40 [100%], 15 [79%], and 20 [57%] at 1 yr; p < 0.0001).CONCLUSIONS: Initial clinical neurologic evaluation in thrombocytopenic purpura patients distinguishes three groups of patients with different clinical and functional outcomes.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Epidemiology of Acute Kidney Injury After Neonatal Cardiac Surgery: A
           Report From the Multicenter Neonatal and Pediatric Heart and Renal
           Outcomes Network

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      Authors: Alten; Jeffrey A.; Cooper, David S.; Blinder, Joshua J.; Selewski, David T.; Tabbutt, Sarah; Sasaki, Jun; Gaies, Michael G.; Bertrandt, Rebecca A.; Smith, Andrew H.; Reichle, Garrett; Gist, Katja M.; Banerjee, Mousumi; Zhang, Wenying; Hock, Kristal M.; Borasino, Santiago; on behalf of the Neonatal Renal Outcomes Network (NEPHRON Investigators
      Abstract: imageOBJECTIVES: Cardiac surgery–associated acute kidney injury occurs commonly following congenital heart surgery and is associated with adverse outcomes. This study represents the first multicenter study of neonatal cardiac surgery–associated acute kidney injury. We aimed to describe the epidemiology, including perioperative predictors and associated outcomes of this important complication.DESIGN: This Neonatal and Pediatric Heart and Renal Outcomes Network study is a multicenter, retrospective cohort study of consecutive neonates less than 30 days. Neonatal modification of The Kidney Disease Improving Global Outcomes criteria was used. Associations between cardiac surgery–associated acute kidney injury stage and outcomes (mortality, length of stay, and duration of mechanical ventilation) were assessed through multivariable regression.SETTING: Twenty-two hospitals participating in Pediatric Cardiac Critical Care Consortium.PATIENTS: Twenty-two–thousand forty neonates who underwent major cardiac surgery from September 2015 to January 2018.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: Cardiac surgery–associated acute kidney injury occurred in 1,207 patients (53.8%); 983 of 1,657 in cardiopulmonary bypass patients (59.3%) and 224 of 583 in noncardiopulmonary bypass patients (38.4%). Seven-hundred two (31.3%) had maximum stage 1, 302 (13.5%) stage 2, 203 (9.1%) stage 3; prevalence of cardiac surgery–associated acute kidney injury peaked on postoperative day 1. Cardiac surgery–associated acute kidney injury rates varied greatly (27–86%) across institutions. Preoperative enteral feeding (odds ratio = 0.68; 0.52–0.9) and open sternum (odds ratio = 0.76; 0.61–0.96) were associated with less cardiac surgery–associated acute kidney injury; cardiopulmonary bypass was associated with increased cardiac surgery–associated acute kidney injury (odds ratio = 1.53; 1.01–2.32). Duration of cardiopulmonary bypass was not associated with cardiac surgery–associated acute kidney injury in the cardiopulmonary bypass cohort. Stage 3 cardiac surgery–associated acute kidney injury was independently associated with hospital mortality (odds ratio = 2.44; 1.3–4.61). No cardiac surgery–associated acute kidney injury stage was associated with duration of mechanical ventilation or length of stay.CONCLUSIONS: Cardiac surgery–associated acute kidney injury occurs frequently after neonatal cardiac surgery in both cardiopulmonary bypass and noncardiopulmonary bypass patients. Rates vary significantly across hospitals. Only stage 3 cardiac surgery–associated acute kidney injury is associated with mortality. Cardiac surgery–associated acute kidney injury was not associated with any other outcomes. Kidney Disease Improving Global Outcomes criteria may not precisely define a clinically meaningful renal injury phenotype in this population.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Predictive Performance of Bayesian Vancomycin Monitoring in the Critically
           Ill*

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      Authors: Narayan; Sujita W.; Thoma, Yann; Drennan, Philip G.; Yejin Kim, Hannah; Alffenaar, Jan-Willem; Van Hal, Sebastiaan; Patanwala, Asad E.
      Abstract: imageOBJECTIVES: It is recommended that therapeutic monitoring of vancomycin should be guided by 24-hour area under the curve concentration. This can be done via Bayesian models in dose-optimization software. However, before these models can be incorporated into clinical practice in the critically ill, their predictive performance needs to be evaluated. This study assesses the predictive performance of Bayesian models for vancomycin in the critically ill.DESIGN: Retrospective cohort study.SETTING: Single-center ICU.PATIENTS: Data were obtained for all patients in the ICU between 1 January, and 31 May 2020, who received IV vancomycin. The predictive performance of three Bayesian models were evaluated based on their availability in commercially available software. Predictive performance was assessed via bias and precision. Bias was measured as the mean difference between observed and predicted vancomycin concentrations. Precision was measured as the sd of bias, root mean square error, and 95% limits of agreement based on Bland-Altman plots.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: A total of 466 concentrations from 188 patients were used to evaluate the three models. All models showed low bias (–1.7 to 1.8 mg/L), which was lower with a posteriori estimate (–0.7 to 1.8 mg/L). However, all three models showed low precision in terms of sd (4.7–8.8 mg/L) and root mean square error (4.8–8.9 mg/L). The models underpredicted at higher observed vancomycin concentrations (bias 0.7–3.2 mg/L for < 20 mg/L; –5.1 to –2.3 for ≥ 20 mg/L) and the Bland-Altman plots showed a great deviation between observed and predicted concentrations.CONCLUSIONS: Bayesian models of vancomycin show not only low bias, but also low precision in the critically ill. Thus, Bayesian-guided dosing of vancomycin in this population should be used cautiously.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • A Trend-Based Early Warning Score Can Be Implemented in a Hospital
           Electronic Medical Record to Effectively Predict Inpatient Deterioration

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      Authors: Bell; David; Baker, John; Williams, Chris; Bassin, Levi
      Abstract: imageOBJECTIVES: To determine whether a statistically derived, trend-based, deterioration index is superior to other early warning scores at predicting adverse events and whether it can be integrated into an electronic medical record to enable real-time alerts.DESIGN: Forty-three variables and their trends from cases and controls were used to develop a logistic model and deterioration index to predict patient deterioration greater than or equal to 1 hour prior to an adverse event.SETTING: Two large Australian teaching hospitals.PATIENTS: Cases were considered as patients who suffered adverse events (unexpected death, unplanned ICU transfer, urgent surgery, and rapid-response alert) between August 1, 2016, and April 1, 2019.INTERVENTIONS: The logistic model and deterioration index were tested on historical data and then integrated into an electronic medical record for a 6-month prospective “silent” validation.MEASUREMENTS AND MAIN RESULTS: Data were acquired from 258,732 admissions. There were 8,002 adverse events. The addition of vital sign and laboratory trend values to the logistic model increased the area under the curve from 0.84 to 0.89 and the sensitivity to predict an adverse event 1–48 hours prior from 0.35 to 0.41. A 48-hour simulation showed that the logistic model had a higher area under the curve than the Modified Early Warning Score and National Early Warning Score (0.87 vs 0.74 vs 0.71). During the silently run prospective trial, the sensitivity of the deterioration index to detect adverse event any time prior to the adverse event was 0.474, 0.369 1 hour prior, and 0.327 4 hours prior, with a specificity of 0.972.CONCLUSIONS: A deterioration prediction model was developed using patient demographics, ward-based observations, laboratory values, and their trends. The model’s outputs were converted to a deterioration index that was successfully integrated into a live hospital electronic medical record. The sensitivity and specificity of the tool to detect inpatient deterioration were superior to traditional early warning scores.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Duration of Hyperoxia and Neurologic Outcomes in Patients Undergoing
           Extracorporeal Membrane Oxygenation

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      Authors: Al-Kawaz; Mais N.; Canner, Joseph; Caturegli, Giorgio; Kannapadi, Nivedha; Balucani, Clotilde; Shelley, Leah; Kim, Bo Soo; Choi, Chun Woo; Geocadin, Romergryko G.; Whitman, Glenn; Cho, Sung-Min
      Abstract: imageOBJECTIVES: To evaluate the impact of duration of hyperoxia on neurologic outcome and mortality in patients undergoing venoarterial extracorporeal membrane oxygenation.DESIGN: A retrospective analysis of venoarterial extracorporeal membrane oxygenation patients admitted to the Johns Hopkins Hospital. The primary outcome was neurologic function at discharge defined by modified Rankin Scale, with a score of 0–3 defined as a good neurologic outcome, and a score of 4–6 defined as a poor neurologic outcome. Multivariable logistic regression analysis was performed to evaluate the association between hyperoxia and neurologic outcomes.SETTING: The Johns Hopkins Hospital Cardiovascular ICU and Cardiac Critical Care Unit.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: We measured first and maximum Pao2 values, area under the curve per minute over the first 24 hours, and duration of mild, moderate, and severe hyperoxia. Of 132 patients on venoarterial extracorporeal membrane oxygenation, 127 (96.5%) were exposed to mild hyperoxia in the first 24 hours. Poor neurologic outcomes were observed in 105 patients (79.6%) (102 with vs 3 without hyperoxia; p = 0.14). Patients with poor neurologic outcomes had longer exposure to mild (19.1 vs 15.2 hr; p = 0.01), moderate (14.6 vs 9.2 hr; p = 0.003), and severe hyperoxia (9.1 vs 4.0 hr; p = 0.003). In a multivariable analysis, patients with worse neurologic outcome experienced longer durations of mild (adjusted odds ratio, 1.10; 95% CI, 1.01–1.19; p = 0.02), moderate (adjusted odds ratio, 1.12; 95% CI, 1.04–1.22; p = 0.002), and severe (adjusted odds ratio, 1.19; 95% CI, 1.06–1.35; p = 0.003) hyperoxia. Additionally, duration of severe hyperoxia was independently associated with inhospital mortality (adjusted odds ratio, 1.18; 95% CI, 1.08–1.29; p < 0.001).CONCLUSIONS: In patients undergoing venoarterial extracorporeal membrane oxygenation, duration and severity of early hyperoxia were independently associated with poor neurologic outcomes at discharge and mortality.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • ICU Memories and Patient Outcomes in a Low Middle–Income Country: A
           Longitudinal Cohort Study

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      Authors: Tripathy; Swagata; Kar, Nilamadhab; Acharya, Swati P.; Singh, Santosh Kumar
      Abstract: imageOBJECTIVES: To study memories of ICU following discharge, their associations, and impact on mental health and quality of life in a low- and middle-income country.DESIGN: Prospective observational cohort; data on memories (pain, fear, nightmare, factual), clinical and demographic variables, anxiety-depression, posttraumatic stress symptoms, and quality of life were collected 0, 7, 14, 30, 90, and 180 days post discharge. Home visits for assessment minimized loss to follow-up. Linear mixed-models and regression analyses were used to estimate adjusted effects of memories controlling for age, sex, time, and severity of illness.SETTING: Twenty-five bedded ICU of a tertiary care center in East India.PATIENTS: Adult ICU survivors between January 2017 and July 2018 able to communicate their memories.INTERVENTIONS: Not applicable.MEASUREMENTS AND MAIN RESULTS: Final sample consisted of 322 patients who completed 180 days follow-up. Pain, fear, factual, and nightmare memories dropped from 85%, 56%, 55%, and 45% at discharge to less than or equal to 5% at 180 days. Patients with gaps in ICU memory had worse anxiety-depression, posttraumatic stress symptoms, and quality of life at all follow-up points. Sedation (odds ratio, 0.54; CI, 0.4–0.7), steroids (odds ratio, 0.47; CI, 0.3–0.8), benzodiazepines (odds ratio, 1.74; CI, 1–3.04), and mechanical ventilation (odds ratio, 0.43; CI, 0.2–0.8) were independently associated with gaps in memory. Non-ICU factor such as substance addiction (odds ratio, 5.38; CI, 2–14) was associated with memories affecting mental health and quality of life.CONCLUSIONS: Gaps in memory and various memory types were common after ICU admission, whose prevalence waned over time. Compared with nightmares and fearful memories, gaps in memories were most strongly associated with poor mental health and quality of life. Identifying patients with gaps in memories might be an objective way of planning interventions to improve their long-term outcomes.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Admission Features Associated With Paroxysmal Sympathetic Hyperactivity
           After Traumatic Brain Injury: A Case-Control Study

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      Authors: Podell; Jamie E.; Miller, Serenity S.; Jaffa, Matthew N.; Pajoumand, Mehrnaz; Armahizer, Michael; Chen, Huanwen; Tripathi, Hemantkumar; Schwartzbauer, Gary T.; Chang, Wan-Tsu W.; Parikh, Gunjan Y.; Hu, Peter; Badjatia, Neeraj
      Abstract: imageOBJECTIVES: Paroxysmal sympathetic hyperactivity occurs in a subset of critically ill traumatic brain injury patients and has been associated with worse outcomes after traumatic brain injury. The goal of this study was to identify admission risk factors for the development of paroxysmal sympathetic hyperactivity in traumatic brain injury patients.DESIGN: Retrospective case-control study of age- and Glasgow Coma Scale–matched traumatic brain injury patients.SETTING: Neurotrauma ICU at the R. Adams Cowley Shock Trauma Center of the University of Maryland Medical System, January 2016 to July 2018.PATIENTS: Critically ill adult traumatic brain injury patients who underwent inpatient monitoring for at least 14 days were included. Cases were identified based on treatment for paroxysmal sympathetic hyperactivity with institutional first-line therapies and were confirmed by retrospective tabulation of established paroxysmal sympathetic hyperactivity diagnostic and severity criteria. Cases were matched 1:1 by age and Glasgow Coma Scale to nonparoxysmal sympathetic hyperactivity traumatic brain injury controls, yielding 77 patients in each group.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: Admission characteristics independently predictive of paroxysmal sympathetic hyperactivity included male sex, higher admission systolic blood pressure, and initial CT evidence of diffuse axonal injury, intraventricular hemorrhage/subarachnoid hemorrhage, complete cisternal effacement, and absence of contusion. Paroxysmal sympathetic hyperactivity cases demonstrated significantly worse neurologic outcomes upon hospital discharge despite being matched for injury severity at admission.CONCLUSIONS: Several anatomical, epidemiologic, and physiologic risk factors for clinically relevant paroxysmal sympathetic hyperactivity can be identified on ICU admission. These features help characterize paroxysmal sympathetic hyperactivity as a clinical-pathophysiologic phenotype associated with worse outcomes after traumatic brain injury.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Prone Positioning of Nonintubated Patients With Coronavirus Disease
           2019—A Systematic Review and Meta-Analysis

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      Authors: Ponnapa Reddy; Mallikarjuna; Subramaniam, Ashwin; Afroz, Afsana; Billah, Baki; Lim, Zheng Jie; Zubarev, Alexandr; Blecher, Gabriel; Tiruvoipati, Ravindranath; Ramanathan, Kollengode; Wong, Suei Nee; Brodie, Daniel; Fan, Eddy; Shekar, Kiran
      Abstract: imageOBJECTIVES: Several studies have reported prone positioning of nonintubated patients with coronavirus diseases 2019–related hypoxemic respiratory failure. This systematic review and meta-analysis evaluated the impact of prone positioning on oxygenation and clinical outcomes.DESIGN AND SETTING: We searched PubMed, Embase, and the coronavirus diseases 2019 living systematic review from December 1, 2019, to November 9, 2020.SUBJECTS AND INTERVENTION: Studies reporting prone positioning in hypoxemic, nonintubated adult patients with coronavirus diseases 2019 were included.MEASUREMENTS AND MAIN RESULTS: Data on prone positioning location (ICU vs non-ICU), prone positioning dose (total minutes/d), frequency (sessions/d), respiratory supports during prone positioning, relative changes in oxygenation variables (peripheral oxygen saturation, Pao2, and ratio of Pao2 to the Fio2), respiratory rate pre and post prone positioning, intubation rate, and mortality were extracted. Twenty-five observational studies reporting prone positioning in 758 patients were included. There was substantial heterogeneity in prone positioning location, dose and frequency, and respiratory supports provided. Significant improvements were seen in ratio of Pao2 to the Fio2 (mean difference, 39; 95% CI, 25–54), Pao2 (mean difference, 20 mm Hg; 95% CI, 14–25), and peripheral oxygen saturation (mean difference, 4.74%; 95% CI, 3–6%). Respiratory rate decreased post prone positioning (mean difference, –3.2 breaths/min; 95% CI, –4.6 to –1.9). Intubation and mortality rates were 24% (95% CI, 17–32%) and 13% (95% CI, 6–19%), respectively. There was no difference in intubation rate in those receiving prone positioning within and outside ICU (32% [69/214] vs 33% [107/320]; p = 0.84). No major adverse events were recorded in small subset of studies that reported them.CONCLUSIONS: Despite the significant variability in frequency and duration of prone positioning and respiratory supports applied, prone positioning was associated with improvement in oxygenation variables without any reported serious adverse events. The results are limited by a lack of controls and adjustments for confounders. Whether this improvement in oxygenation results in meaningful patient-centered outcomes such as reduced intubation or mortality rates requires testing in well-designed randomized clinical trials.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Diminishing Efficacy of Prone Positioning With Late Application in
           Evolving Lung Injury

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      Authors: Xin; Yi; Martin, Kevin; Morais, Caio C. A.; Delvecchio, Paolo; Gerard, Sarah E.; Hamedani, Hooman; Herrmann, Jacob; Abate, Nicholas; Lenart, Austin; Humayun, Shiraz; Sidhu, Uday; Petrov, Mihail; Reutlinger, Kristan; Mandelbaum, Tal; Duncan, Ian; Tustison, Nicholas; Kadlecek, Stephen; Chatterjee, Shampa; Gee, James C.; Rizi, Rahim R.; Berra, Lorenzo; Cereda, Maurizio
      Abstract: imageOBJECTIVES: It is not known how lung injury progression during mechanical ventilation modifies pulmonary responses to prone positioning. We compared the effects of prone positioning on regional lung aeration in late versus early stages of lung injury.DESIGN: Prospective, longitudinal imaging study.SETTING: Research imaging facility at The University of Pennsylvania (Philadelphia, PA) and Medical and Surgical ICUs at Massachusetts General Hospital (Boston, MA).SUBJECTS: Anesthetized swine and patients with acute respiratory distress syndrome (acute respiratory distress syndrome).INTERVENTIONS: Lung injury was induced by bronchial hydrochloric acid (3.5 mL/kg) in 10 ventilated Yorkshire pigs and worsened by supine nonprotective ventilation for 24 hours. Whole-lung CT was performed 2 hours after hydrochloric acid (Day 1) in both prone and supine positions and repeated at 24 hours (Day 2). Prone and supine images were registered (superimposed) in pairs to measure the effects of positioning on the aeration of each tissue unit. Two patients with early acute respiratory distress syndrome were compared with two patients with late acute respiratory distress syndrome, using electrical impedance tomography to measure the effects of body position on regional lung mechanics.MEASUREMENTS AND MAIN RESULTS: Gas exchange and respiratory mechanics worsened over 24 hours, indicating lung injury progression. On Day 1, prone positioning reinflated 18.9% ± 5.2% of lung mass in the posterior lung regions. On Day 2, position-associated dorsal reinflation was reduced to 7.3% ± 1.5% (p < 0.05 vs Day 1). Prone positioning decreased aeration in the anterior lungs on both days. Although prone positioning improved posterior lung compliance in the early acute respiratory distress syndrome patients, it had no effect in late acute respiratory distress syndrome subjects.CONCLUSIONS: The effects of prone positioning on lung aeration may depend on the stage of lung injury and duration of prior ventilation; this may limit the clinical efficacy of this treatment if applied late.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Andexanet Alfa or Prothrombin Complex Concentrate for Factor Xa Inhibitor
           Reversal in Acute Major Bleeding: A Systematic Review and Meta-Analysis

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      Authors: Nederpelt; Charlie J.; Naar, Leon; Krijnen, Pieta; le Cessie, Saskia; Kaafarani, Haytham M. A.; Huisman, Menno V.; Velmahos, George C.; Schipper, Inger B.
      Abstract: imageOBJECTIVES: To combine evidence on andexanet alfa and prothrombin complex concentrates for factor Xa inhibitor-associated bleeding to guide clinicians on reversal strategies.DATA SOURCES: Embase, Pubmed, Web of Science, and the Cochrane Library.STUDY SELECTION: Observational studies and randomized clinical trials studying hemostatic effectiveness of andexanet alfa or prothrombin complex concentrate for acute reversal of factor Xa inhibitor-associated hemorrhage.DATA EXTRACTION: Two independent reviewers extracted the data from the studies. Visualization and comparison of hemostatic effectiveness using Sarode et al or International Society of Thrombosis and Hemostasis Scientific and Standardization Committee criteria at 12 and 24 hours, (venous) thrombotic event rates, and inhospital mortality were performed by constructing Forest plots. Exploratory analysis using a logistic mixed model analysis was performed to identify factors associated with effectiveness and venous thromboembolic event.DATA SYNTHESIS: A total of 21 studies were included (andexanet: 438 patients; prothrombin complex concentrate: 1,278 patients). The (weighted) mean effectiveness for andexanet alfa was 82% at 12 hours and 71% at 24 hours. The (weighted) mean effectiveness for prothrombin complex concentrate was 88% at 12 hours and 76% at 24 hours. The mean 30-day symptomatic venous thromboembolic event rates were 5.0% for andexanet alfa and 1.9% for prothrombin complex concentrate. The mean 30-day total thrombotic event rates for andexanet alfa and prothrombin complex concentrate were 10.7% and 3.1%, respectively. Mean inhospital mortality was 23.3% for andexanet versus 15.8% for prothrombin complex concentrate. Exploratory analysis controlling for potential confounders did not demonstrate significant differences between both reversal agents.CONCLUSIONS: Currently, available evidence does not unequivocally support the clinical effectiveness of andexanet alfa or prothrombin complex concentrate to reverse factor Xa inhibitor-associated acute major bleeding, nor does it permit conventional meta-analysis of potential superiority. Neither reversal agent was significantly associated with increased effectiveness or a higher rate of venous thromboembolic event. These results underscore the importance of randomized controlled trials comparing the two reversal agents and may provide guidance in designing institutional guidelines.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Coronavirus Disease 2019 Policy Restricting Family Presence May Have
           Delayed End-of-Life Decisions for Critically Ill Patients

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      Authors: Azad; Tej D.; Al-Kawaz, Mais N.; Turnbull, Alison E.; Rivera-Lara, Lucia
      Abstract: imageOBJECTIVES: To determine if a restrictive visitor policy inadvertently lengthened the decision-making process for dying inpatients without coronavirus disease 2019.DESIGN: Regression discontinuity and time-to-event analysis.SETTING: Two large academic hospitals in a unified health system.PATIENTS OR SUBJECTS: Adult decedents who received greater than or equal to 1 day of ICU care during their terminal admission over a 12-month period.INTERVENTIONS: Implementation of a visit restriction policy.MEASUREMENTS AND MAIN RESULTS: We identified 940 adult decedents without coronavirus disease 2019 during the study period. For these patients, ICU length of stay was 0.8 days longer following policy implementation, although this effect was not statistically significant (95% CI, –2.3 to 3.8; p = 0.63). After excluding patients admitted before the policy but who died after implementation, we observed that ICU length of stay was 2.9 days longer post-policy (95% CI, 0.27–5.6; p = 0.03). A time-to-event analysis revealed that admission after policy implementation was associated with a significantly longer time to first do not resuscitate/do not intubate/comfort care order (adjusted hazard ratio, 2.2; 95% CI, 1.6–3.1; p < 0.0001).CONCLUSIONS: Policies restricting family presence may lead to longer ICU stays and delay decisions to limit treatment prior to death. Further policy evaluation and programs enabling access to family-centered care and palliative care during the ongoing coronavirus disease 2019 pandemic are imperative.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • An Update on Temperature Management Following Cardiac Arrest in Australian
           and New Zealand ICUs

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      Authors: Young; Paul J.; Bailey, Michael; Bellomo, Rinaldo
      Abstract: imageNo abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Intracranial Hemorrhage in Venovenous Extracorporeal Membrane Oxygenation:
           The Hunt for Modifiable Risk Factors

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      Authors: Bermea; Rene S.; Raz, Yuval; Bermudez, Christian; Shelton, Kenneth T.
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
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      Authors: Graw; Jan Adriaan; Hunsicker, Oliver; Menk, Mario
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • The Effect of Prone Position on Hemodynamics in Patients With Acute
           Respiratory Distress Syndrome

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      Authors: Izumida; Toshihide; Imamura, Teruhiko
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
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      Authors: Lai; Christopher; Teboul, Jean-Louis; Monnet, Xavier
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Plausibility Limits Imagination

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      Authors: Zijlstra; Jan G.; van Meurs, Matijs; Moser, Jill
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
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      Authors: DeMerle; Kimberley M.; Seymour, Christopher W.
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • The Janus Face of Coronavirus Disease 2019–Associated Coagulopathy

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      Authors: Stahl; Klaus; Seeliger, Benjamin; Hofmaenner, Daniel A.; Doebler, Michael; Bode, Christian; David, Sascha
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
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      Authors: Doyle; Andrew J.; Retter, Andrew
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Postcoronavirus Disease Chronic Fatigue Is Frequent and Not Only
           Restricted to Hospitalized Patients

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      Authors: Reuken; Philipp A.; Scherag, André; Stallmach, Andreas
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
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      Authors: Martillo; Miguel A.
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Aerosol Generating Procedure, Aerosol, and Personal Protective Equipment:
           The Link Is Still Missing

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      Authors: Cheung; Jonathan Chun-Hei; Ho, Lap Tin; Yip, Yu-Yeung; Lam, Koon Ngai
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
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      Authors: Teoh; Jeremy Yuen-Chun; Chan, Vinson Wai-Shun
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Bivalirudin Superior to Heparin for Extracorporeal Membrane Oxygenation:
           Not So Fast

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      Authors: Mazzeffi; Michael A.; Plazak, Michael; Dalton, Heidi
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
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      Authors: Rivosecchi; Ryan M.; Sanchez, Pablo G.
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • Diagnostic Criteria for Chronic Critical Illness Should Be Standardized

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      Authors: Li; Sicheng; Wu, Xiuwen; Ren, Jianan
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
  • What Is the Best Extracorporeal Carbon Dioxide Removal Blood Flow to Help
           Treating Patients With Severe Status Asthmaticus!

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      Authors: Honore; Patrick M.; Redant, Sebastien; Preseau, Thierry; Kaefer, Keitiane; Barreto Gutierrez, Leonel; Attou, Rachid; Gallerani, Andrea; De Bels, David
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT+
       
 
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