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Critical Care Medicine
Journal Prestige (SJR): 3.116
Citation Impact (citeScore): 3
Number of Followers: 252  
 
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ISSN (Print) 0090-3493
Published by LWW Wolters Kluwer Homepage  [285 journals]
  • Noninvasive Ventilation in Patients With Do-Not-Intubate and
           Comfort-Measures-Only Orders: A Systematic Review and Meta-Analysis*
    • Authors: Wilson; Michael E.; Majzoub, Abdul M.; Dobler, Claudia C.; Curtis, J. Randall; Nayfeh, Tarek; Thorsteinsdottir, Bjorg; Barwise, Amelia K.; Tilburt, Jon C.; Gajic, Ognjen; Montori, Victor M.; Murad, M. Hassan
      Abstract: imageObjectives: To assess the effectiveness of noninvasive ventilation in patients with acute respiratory failure and do-not-intubate or comfort-measures-only orders.Data Sources: MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science from inception to January 1, 2017.Study Selection: Studies of all design types that enrolled patients in the ICU or hospital ward who received noninvasive ventilation and had preset do-not-intubate or comfort-measures-only orders.Data Extraction: Data abstraction followed Meta-analysis of Observational Studies in Epidemiology guidelines. Data quality was assessed using a modified Newcastle-Ottawa Scale.Data Synthesis: Twenty-seven studies evaluating 2,020 patients with do-not-intubate orders and three studies evaluating 200 patients with comfort-measures-only orders were included. In patients with do-not-intubate orders, the pooled survival was 56% (95% CI, 49–64%) at hospital discharge and 32% (95% CI, 21–45%) at 1 year. Hospital survival was 68% for chronic obstructive pulmonary disease, 68% for pulmonary edema, 41% for pneumonia, and 37% for patients with malignancy. Survival was comparable for patients treated in a hospital ward versus an ICU. Quality of life of survivors was not reduced compared with baseline, although few studies evaluated this. No studies evaluated quality of dying in nonsurvivors. In patients with comfort-measures-only orders, a single study showed that noninvasive ventilation was associated with mild reductions in dyspnea and opioid requirements.Conclusions: A large proportion of patients with do-not-intubate orders who received noninvasive ventilation survived to hospital discharge and at 1 year, with limited data showing no decrease in quality of life in survivors. Provision of noninvasive ventilation in a well-equipped hospital ward may be a viable alternative to the ICU for selected patients. Crucial questions regarding quality of life in survivors, quality of death in nonsurvivors, and the impact of noninvasive ventilation in patients with comfort-measures-only orders remain largely unanswered.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Insidious Harm of Medication Diluents as a Contributor to Cumulative
           Volume and Hyperchloremia: A Prospective, Open-Label, Sequential Period
           Pilot Study*
    • Authors: Magee; Carolyn A.; Bastin, Melissa L. Thompson; Laine, Melanie E.; Bissell, Brittany D.; Howington, Gavin T.; Moran, Peter R.; McCleary, Emily J.; Owen, Gary D.; Kane, Lauren E.; Higdon, Emily A.; Pierce, Cathy A.; Morris, Peter E.; Flannery, Alexander H.
      Abstract: imageObjectives: Although the potential dangers of hyperchloremia from resuscitation fluids continue to emerge, no study to date has considered the contribution of medication diluents to cumulative volume and hyperchloremia. This study compares saline versus dextrose 5% in water as the primary medication diluent and the occurrence of hyperchloremia in critically ill patients.Design: Prospective, open-label, sequential period pilot study.Setting: Medical ICU of a large academic medical center.Patients: Adult patients admitted to the medical ICU were eligible for inclusion. Patients who were admitted for less than 48 hours, less than 18 years old, pregnant, incarcerated, or who had brain injury were excluded.Interventions: Saline as the primary medication diluent for 2 months followed by dextrose 5% in water as the primary medication diluent for 2 months.Measurements and Main Results: A total of 426 patients were included, 216 in the saline group and 210 in the dextrose 5% in water group. Medication diluents accounted for 63% of the total IV volume over the observation period. In the saline group, 17.9% developed hyperchloremia compared with 10.5% in the dextrose 5% in water group (p = 0.037), which was statistically significant in multivariable analysis (odds ratio, 0.50; 95% CI, 0.26–0.94; p = 0.031). In the saline group, 34.2% developed acute kidney injury versus 24.5% in the dextrose 5% in water group (p = 0.035); however, this was not statistically significant when adjusting for baseline covariates. No other significant differences in dysnatremias, insulin requirements, glucose control, ICU length of stay, or ICU mortality were observed.Conclusions: This study identified that medication diluents contribute substantially to the total IV volume received by critically ill patients. Saline as the primary medication diluent compared with dextrose 5% in water is associated with hyperchloremia, a possible risk factor for acute kidney injury.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Near-Continuous Glucose Monitoring Makes Glycemic Control Safer in ICU
           Patients*
    • Authors: Preiser; Jean-Charles; Lheureux, Olivier; Thooft, Aurelie; Brimioulle, Serge; Goldstein, Jacques; Vincent, Jean-Louis
      Abstract: imageObjectives: Tight glycemic control using intermittent blood glucose measurements is associated with a risk of hypoglycemia. Glucose concentrations can now be measured near continuously (every 5–15 min). We assessed the quality and safety of glycemic control guided by a near-continuous glucose monitoring system in ICU patients.Design: Prospective, cluster-randomized, crossover study.Setting: Thirty-five–bed medico-surgical department of intensive care with four separate ICUs.Patients: Adult patients admitted to the department and expected to stay for at least 3 days were considered for inclusion if they had persistent hyperglycemia (blood glucose> 150 mg/dL) up to 6 hours after admission and/or were receiving insulin therapy.Interventions: A peripheral venous catheter was inserted in all patients and connected to a continuous glucose monitoring sensor (GlucoClear; Edwards Lifesciences, Irvine, CA). The four ICUs were randomized in pairs in a crossover design to glycemic control using unblinded or blinded continuous glucose monitoring monitors. The insulin infusion rate was adjusted to keep blood glucose between 90 and 150 mg/dL using the blood glucose values displayed on the continuous glucose monitor (continuous glucose monitoring group—unblinded units) or according to intermittent blood glucose readings (intermittent glucose monitoring group—blinded units).Measurements and Main Results: The quality and safety of glycemic control were assessed using the proportion of time in range, the frequency of blood glucose less than 70 mg/dL, and the time spent with blood glucose less than 70 mg/dL (TB70), using blood glucose values measured by the continuous glucose monitoring device. Seventy-seven patients were enrolled: 39 in the continuous glucose monitoring group and 38 in the intermittent glucose monitoring group. A total of 43,107 blood glucose values were recorded. The time in range was similar in the two groups. The incidence of hypoglycemia (8/39 [20.5%] vs 15/38 [39.5%]) and the TB70 (0.4% ± 0.9% vs 1.6% ± 3.4%; p < 0.05) was lower in the continuous glucose monitoring than in the intermittent glucose monitoring group.Conclusions: Use of a continuous glucose monitoring–based strategy decreased the incidence and severity of hypoglycemia, thus improving the safety of glycemic control.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • National Trends (2009–2013) for Palliative Care Utilization for Patients
           Receiving Prolonged Mechanical Ventilation*
    • Authors: Chatterjee; Kshitij; Goyal, Abhinav; Kakkera, Krishna; Harrington, Sarah; Corwin, Howard L.
      Abstract: imageObjectives: Patients requiring mechanical ventilation have high morbidity and mortality. Providing palliative care services has been suggested as a way to improve comprehensive management of critically ill patients. We examined the trend in the utilization of palliative care among adults who require prolonged mechanical ventilation. Primary objectives were to determine the trend in palliative care utilization over time, predictors for palliative care utilization, and palliative care impact on hospital length of stay.Design: Retrospective, cross-sectional study.Setting: The National Inpatient Sample data between 2009 and 2013 was used for this study.Patients: Adults (age ≥ 18 yr) who underwent prolonged mechanical ventilation (≥ 96 consecutive hr) were studied.Measurements and Main Results: Palliative care and mechanical ventilation were identified using the corresponding International Classification of Diseases, 9th revision, Clinical Modification, codes. A total of 1,751,870 hospitalizations with prolonged mechanical ventilation were identified between 2009 and 2013. The utilization of palliative care increased yearly from 6.5% in 2009 to 13.1% in 2013 (p < 0.001). Among the mechanically ventilated patients who died, palliative care increased from 15.9% in 2009 to 33.3% in 2013 (p < 0.001). Median hospital length of stay for patients with and without palliative care was 13 and 17 days, respectively (p < 0.001). Patients discharged to either short- or long-term care facilities had a shorter length of stay if palliative care was provided (15 vs 19 d; p < 0.001). The factors associated with a higher palliative care utilization included older age, malignancy, larger hospitals in urban areas, and teaching hospitals. Non-Caucasian race was associated with lower palliative care utilization.Conclusions: Among patients who undergo prolonged mechanical ventilation, palliative care utilization is increasing, particularly in patients who die during hospitalization. Using palliative care for mechanically ventilated patients who are discharged to either short- or long-term care facilities is associated with a shorter hospital length of stay.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Evaluating Muscle Mass in Survivors of Acute Respiratory Distress
           Syndrome: A 1-Year Multicenter Longitudinal Study*
    • Authors: Chan; Kitty S.; Mourtzakis, Marina; Aronson Friedman, Lisa; Dinglas, Victor D.; Hough, Catherine L.; Ely, E. Wesley; Morris, Peter E.; Hopkins, Ramona O.; Needham, Dale M.; for the National Institutes of Health National Heart, Lung, Blood Institute (NHLBI Acute Respiratory Distress Syndrome (ARDS Network
      Abstract: imageObjectives: Rapid muscle wasting occurs during acute respiratory failure, resulting in muscle weakness and functional impairments. This study examines survivors’ body composition in the year after acute respiratory distress syndrome and tests associations of patient characteristics, hospital exposures, and survivors’ strength and physical functioning with whole body percent lean mass.Design: Prospective cohort study with 6- and 12-month follow-up.Setting: National study enrolling patients from five study centers.Patients: Acute respiratory distress syndrome survivors (n = 120).Interventions: None.Measurements and Main Results: Lean and fat mass from dual energy x-ray absorptiometry. On average, survivors gained whole body total mass (+1.4 kg; 0.1–2.7) and fat mass (+1.2 kg; 0.2–2.2) and maintained lean mass (+0.2 kg; –0.4 to 0.8) between 6 and 12 months. Proportionally, percent fat mass increased and percent lean mass decreased for the whole body, trunk, and legs (p < 0.05). Greater whole body percent lean mass was associated with younger age, male sex, and lower baseline body mass index, but not other patient characteristics or ICU/hospital exposures. Greater percent lean mass was also significantly associated with gait speed and 6-minute walk distance, but not volitional strength or self-reported functional status.Conclusions: In the first year after acute respiratory distress syndrome, patients gained fat mass and maintained lean mass. We found no association of whole body percent lean mass with commonly hypothesized hospital risk factors. Direct measurement of body composition and performance-based functional measures may be helpful for understanding functional recovery in ICU survivors.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Mortality Measures to Profile Hospital Performance for Patients With
           Septic Shock*
    • Authors: Walkey; Allan J.; Shieh, Meng-Shiou; Liu, Vincent X.; Lindenauer, Peter K.
      Abstract: imageObjectives: Sepsis care is becoming a more common target for hospital performance measurement, but few studies have evaluated the acceptability of sepsis or septic shock mortality as a potential performance measure. In the absence of a gold standard to identify septic shock in claims data, we assessed agreement and stability of hospital mortality performance under different case definitions.Design: Retrospective cohort study.Setting: U.S. acute care hospitals.Patients: Hospitalized with septic shock at admission, identified by either implicit diagnosis criteria (charges for antibiotics, cultures, and vasopressors) or by explicit International Classification of Diseases, 9th revision, codes.Interventions: None.Measurements and Main Results: We used hierarchical logistic regression models to determine hospital risk–standardized mortality rates and hospital performance outliers. We assessed agreement in hospital mortality rankings when septic shock cases were identified by either explicit International Classification of Diseases, 9th revision, codes or implicit diagnosis criteria. Kappa statistics and intraclass correlation coefficients were used to assess agreement in hospital risk–standardized mortality and hospital outlier status, respectively. Fifty-six thousand six-hundred seventy-three patients in 308 hospitals fulfilled at least one case definition for septic shock, whereas 19,136 (33.8%) met both the explicit International Classification of Diseases, 9th revision, and implicit septic shock definition. Hospitals varied widely in risk-standardized septic shock mortality (interquartile range of implicit diagnosis mortality: 25.4–33.5%; International Classification of Diseases, 9th revision, diagnosis: 30.2–38.0%). The median absolute difference in hospital ranking between septic shock cohorts defined by International Classification of Diseases, 9th revision, versus implicit criteria was 37 places (interquartile range, 16–70), with an intraclass correlation coefficient of 0.72, p value of less than 0.001; agreement between case definitions for identification of outlier hospitals was moderate (kappa, 0.44 [95% CI, 0.30–0.58]).Conclusions: Risk-standardized septic shock mortality rates varied considerably between hospitals, suggesting that septic shock is an important performance target. However, efforts to profile hospital performance were sensitive to septic shock case definitions, suggesting that septic shock mortality is not currently ready for widespread use as a hospital quality measure.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • A Multicenter Observational Study of Family Participation in ICU Rounds
    • Authors: Au; Selena S.; Roze des Ordons, Amanda L.; Parsons Leigh, Jeanna; Soo, Andrea; Guienguere, Simon; Bagshaw, Sean M.; Stelfox, Henry T.
      Abstract: imageObjectives: Guidelines recommend offering family members of critically ill patients the option to attend interdisciplinary team rounds as a way to improve communication and satisfaction. Uncertainty remains around the benefits and risks.Design: We conducted an observational study to describe family participation in ICU rounds and its association with rounding processes.Setting: Rounds conducted under the leadership of 33 attending physicians in seven hospitals across three Canadian cities.Patients: Three hundred two individual rounds on 210 unique patients were observed.Interventions: Quantitative and qualitative data were collected using standardized observational tools.Measurements and Main Results: Among the 302 rounds observed, family attended in 68 rounds (23%), were present in ICU but did not attend in 59 rounds (20%), and were absent from the ICU in 175 rounds (58%). The median duration of rounds respectively for these three groups of patients was 20 minutes (interquartile range, 14–26 min), 16 minutes (interquartile range, 13–22 min), and 16 minutes (interquartile range, 10–23 min) (p = 0.01). There were no significant differences in prognostic discussions (35% vs 36% vs 36%; p = 0.99) or bedside teaching (35% vs 37% vs 34%; p = 0.88). The quality of rounds was not significantly associated with family attendance in rounds or presence in the ICU (quality score [1 (low) to 10 (high)] median 8 [interquartile range, 7–8] vs 7 [interquartile range, 6–9] vs 7 [interquartile range, 6–9]; p = 0.11). Qualitative analyses suggested that family attendance may influence relationship building, information gathering, patient and family education, team dynamics, future family meetings, workflow, and shared clinical decision-making.Conclusions: Our results suggest family attendance in ICU rounds is associated with longer duration of rounds, but not the frequency of trainee teaching, discussions of prognosis, or quality of rounds. Family attendance in rounds may enhance communication and complement family conferences.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Duration of Respiratory Failure After Trauma Is Not Associated With
           Increased Long-Term Mortality
    • Authors: Cook; Mackenzie R.; O’Connell, Kathleen; Qiu, Qian; Riggle, Andrew J.; Shoultz, Thomas H.; Maine, Rebecca G.; Arbabi, Saman; O’Keefe, Grant E.; Cuschieri, Joseph; Maier, Ronald V.; Robinson, Bryce R. H.
      Abstract: imageObjectives: Although 1-year survival in medically critically ill patients with prolonged mechanical ventilation is less than 50%, the relationship between respiratory failure after trauma and 1-year mortality is unknown. We hypothesize that respiratory failure duration in trauma patients is associated with decreased 1-year survival.Design: Retrospective cohort of trauma patients.Setting: Single center, level 1 trauma center.Patients: Trauma patients admitted from 2011 to 2014; respiratory failure is defined as mechanical ventilation greater than or equal to 48 hours, excluded head Abbreviated Injury Score greater than or equal to 4.Interventions: None.Measurements and Main Results: Mortality was calculated from the Washington state death registry. Cohort was divided into short (≤ 14 d) and long (> 14 d) ventilation groups. We compared survival with a Cox proportional hazard model and generated a receiver operator characteristic to describe the respiratory failure and mortality relationship. Data are presented as medians with interquartile ranges and hazard ratios with 95% CIs. We identified 1,503 patients with respiratory failure; median age was 51 years (33–65 yr) and Injury Severity Score was 19 (11–29). Median respiratory failure duration was 3 days (2–6 d) with 10% of patients in the long respiratory failure group. Cohort mortality at 1 year was 16%, and there was no difference in mortality between short and long duration of respiratory failure. Predictions for 1-year mortality based on respiratory failure duration demonstrated an area under the receiver operator characteristic curve of 0.57. We determined that respiratory failure patients greater than or equal to 75 years had an increased hazard of death at 1 year, hazard ratio, 6.7 (4.9–9.1), but that within age cohorts, respiratory failure duration did not influence 1-year mortality.Conclusions: Duration of mechanical ventilation in the critically injured is not associated with 1-year mortality. Duration of ventilation following injury should not be used to predict long-term survival.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Long-Term Survival of Young Patients Surviving ICU Admission With Severe
           Sepsis*
    • Authors: Abu-Kaf; Heba; Mizrakli, Yuval; Novack, Victor; Dreiher, Jacob
      Abstract: imageObjectives: Sepsis remains a disease with a high mortality rate. The study goal was to assess long-term survival of severe sepsis in young patients.Design: Retrospective cohort study.Setting: Patients admitted with sepsis to ICUs in seven tertiary hospitals between 2003 and 2011.Patients: A total of 409 patients less than 45 years who survived to hospital discharge were age and sex matched with 818 patients with infectious disease without sepsis selected from internal medicine or surgical department admissions.Interventions: None.Measurements and Main Results: The median age in sepsis patients and the comparison group was 31 and 32 years, respectively. The proportions of patients surviving after hospital discharge were significantly lower in the sepsis group compared with the control group; among survivors, 6-month, 1-year, and 3-year mortality rates were 0.7% versus 0%, 4.5% versus 0.7%, 7.9% versus 1.2%, and 10.8% versus 1.8%, respectively (p < 0.001 for all). In a multivariate Cox proportional hazards regression model, sepsis was associated with an increased risk of mortality (hazard ratio, 3.79; 95% CI, 2.27–6.32), while controlling for age, Charlson Comorbidity Index, history of stroke, and congestive heart failure. Past the 24-month landmark, sepsis was not found to be an independent risk for mortality (hazard ratio, 1.79; 95% CI, 0.67–4.79). Based on cause of death analysis, chronic underlying comorbidities might explain the excess mortality in patients with sepsis.Conclusions: Young patients experiencing an episode of severe sepsis continue to be at higher risk of long-term mortality. The highest mortality rates were observed during the first 24 months following discharge.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Predictive Validity of Sepsis-3 Definitions and Sepsis Outcomes in
           Critically Ill Patients: A Cohort Study in 49 ICUs in Argentina
    • Authors: Estenssoro; Elisa; Kanoore Edul, Vanina S.; Loudet, Cecilia I.; Osatnik, Javier; Ríos, Fernando G.; Vázquez, Daniela N.; Pozo, Mario O.; Lattanzio, Bernardo; Pálizas, Fernando; Klein, Francisco; Piezny, Damián; Rubatto Birri, Paolo N.; Tuhay, Graciela; Díaz, Anatilde; Santamaría, Analía; Zakalik, Graciela; Dubin, Arnaldo; on behalf of SATISEPSIS Investigators
      Abstract: imageObjectives: The new Sepsis-3 definitions have been scarcely assessed in low- and middle-income countries; besides, regional information of sepsis outcomes is sparse. Our objective was to evaluate Sepsis-3 definition performance in Argentina.Design: Cohort study of 3-month duration beginning on July 1, 2016.Settings: Forty-nine ICUs.Patients: Consecutive patients admitted to the ICU with suspected infection that triggered blood cultures and antibiotic administration.Interventions: None.Measurements and Main Results: Patients were classified as having infection, sepsis (infection + change in Sequential Organ Failure Assessment ≥ 2 points), and septic shock (vasopressors + lactate> 2 mmol/L). Patients on vasopressors and lactate less than or equal to 2 mmol/L (cardiovascular dysfunction) were analyzed separately, as those on vasopressors without serum lactate measurement. Systemic inflammatory response syndrome was also recorded. Main outcome was hospital mortality. Of 809 patients, 6% had infection, 29% sepsis, 20% cardiovascular dysfunction, 40% septic shock, and 3% received vasopressors with lactate unmeasured. Hospital mortality was 13%, 20%, 39%, 51%, and 41%, respectively (p = 0.000). Independent predictors of outcome were lactate, Sequential Organ Failure Assessment score, comorbidities, prior duration of symptoms (hr), mechanical ventilation requirement, and infection by highly resistant microorganisms. Area under the receiver operating characteristic curves for mortality for systemic inflammatory response syndrome and Sequential Organ Failure Assessment were 0.53 (0.48–0.55) and 0.74 (0.69–0.77), respectively (p = 0.000).Conclusions: Increasing severity of Sepsis-3 categories adequately tracks mortality; cardiovascular dysfunction subgroup, not included in Sepsis-3, has distinct characteristics. Sequential Organ Failure Assessment score shows adequate prognosis accuracy─contrary to systemic inflammatory response syndrome. This study supports the predictive validity of Sepsis-3 definitions.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Dynamic Contrast-Enhanced Ultrasound Identifies Microcirculatory
           Alterations in Sepsis-Induced Acute Kidney Injury
    • Authors: Lima; Alexandre; van Rooij, Tom; Ergin, Bulent; Sorelli, Michele; Ince, Yasin; Specht, Patricia A. C.; Mik, Egbert G.; Bocchi, Leonardo; Kooiman, Klazina; de Jong, Nico; Ince, Can
      Abstract: imageObjectives: We developed quantitative methods to analyze microbubble kinetics based on renal contrast-enhanced ultrasound imaging combined with measurements of sublingual microcirculation on a fixed area to quantify early microvascular alterations in sepsis-induced acute kidney injury.Design: Prospective controlled animal experiment study.Setting: Hospital-affiliated animal research institution.Subjects: Fifteen female pigs.Interventions: The animals were instrumented with a renal artery flow probe after surgically exposing the kidney. Nine animals were given IV infusion of lipopolysaccharide to induce septic shock, and six were used as controls.Measurements and Main Results: Contrast-enhanced ultrasound imaging was performed on the kidney before, during, and after having induced shock. Sublingual microcirculation was measured continuously using the Cytocam on the same spot. Contrast-enhanced ultrasound effectively allowed us to develop new analytical methods to measure dynamic variations in renal microvascular perfusion during shock and resuscitation. Renal microvascular hypoperfusion was quantified by decreased peak enhancement and an increased ratio of the final plateau intensity to peak enhancement. Reduced intrarenal blood flow could be estimated by measuring the microbubble transit times between the interlobar arteries and capillary vessels in the renal cortex. Sublingual microcirculation measured using the Cytocam in a fixed area showed decreased functional capillary density associated with plugged sublingual capillary vessels that persisted during and after fluid resuscitation.Conclusions: In our lipopolysaccharide model, with resuscitation targeted at blood pressure, contrast-enhanced ultrasound imaging can identify renal microvascular alterations by showing prolonged contrast enhancement in microcirculation during shock, worsened by resuscitation with fluids. Concomitant analysis of sublingual microcirculation mirrored those observed in the renal microcirculation.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • The Effect of IV Amino Acid Supplementation on Mortality in ICU Patients
           May Be Dependent on Kidney Function: Post Hoc Subgroup Analyses of a
           Multicenter Randomized Trial
    • Authors: Zhu; Ran; Allingstrup, Matilde J.; Perner, Anders; Doig, Gordon S.; for the Nephro-Protective Trial Investigators Group
      Abstract: imageObjectives: We investigated whether preexisting kidney function determines if ICU patients may benefit from increased (2.0 g/kg/d) protein intake.Design: Post hoc, hypothesis-generating, subgroup analysis of a multicenter, phase 2, randomized clinical trial. All analyses were conducted by intention to treat and maintained group allocation. Ninety-day mortality was the primary outcome.Setting: ICUs of 16 hospitals throughout Australia and New Zealand.Patients: Adult critically ill patients expected to remain in the study ICU for longer than 2 days.Interventions: Random allocation to receive a daily supplement of up to 100 g of IV amino acids to achieve a total protein intake of 2.0 g/kg/d or standard nutrition care.Measurements and Main Results: A total of 474 patients were randomized: 235 to standard care and 239 to IV amino acid supplementation. There was a statistically significant interaction between baseline kidney function and supplementation with study amino acids (p value for interaction = 0.026). Within the subgroup of patients with normal kidney function at randomization, patients who were allocated to receive the study amino acid supplement were less likely to die before study day 90 (covariate-adjusted risk difference, –7.9%; 95% CI, –15.1 to –0.7; p = 0.034). Furthermore, amino acid supplementation significantly increased estimated glomerular filtration rate in these patients (repeated-measures treatment × time interaction p = 0.009). Within the subgroup of patients with baseline kidney dysfunction and/or risk of progression of acute kidney injury, a significant effect of the study intervention on mortality was not found (covariate-adjusted risk difference, –0.6%; 95% CI, –16.2 to 15.2; p = 0.95).Conclusions: In this post hoc, hypothesis-generating, subgroup analysis, we observed reduced mortality and improved estimated glomerular filtration rate in ICU patients with normal kidney function who were randomly allocated to receive increased protein intake (up to 2.0 g/kg/d). We strongly recommend confirmation of these results in trials with low risk of bias before this treatment is recommended for routine care.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Clinical Factors Associated With ICU-Specific Care Following Supratentoral
           Brain Tumor Resection and Validation of a Risk Prediction Score
    • Authors: Franko; Lynze R.; Hollon, Todd; Linzey, Joseph; Roark, Christopher; Rajajee, Venkatakrishna; Sheehan, Kyle; Teig, Magnus; Hervey-Jumper, Shawn; Heth, Jason; Orringer, Daniel; Williamson, Craig A.
      Abstract: imageObjectives: The postoperative management of patients who undergo brain tumor resection frequently occurs in an ICU. However, the routine admission of all patients to an ICU following surgery is controversial. This study seeks to identify the frequency with which patients undergoing elective supratentorial tumor resection require care, aside from frequent neurologic checks, that is specific to an ICU and to determine the frequency of new complications during ICU admission. Additionally, clinical predictors of ICU-specific care are identified, and a scoring system to discriminate patients most likely to require ICU-specific treatment is validated.Design: Retrospective observational cohort study.Setting: Academic neurosurgical center.Patients: Two-hundred consecutive adult patients who underwent supratentorial brain tumor surgery. An additional 100 consecutive patients were used to validate the prediction score.Interventions: None.Measurements and Main Results: Univariate statistics and multivariable logistic regression were used to identify clinical characteristics associated with ICU-specific treatment. Eighteen patients (9%) received ICU-specific care, and 19 (9.5%) experienced new complications or underwent emergent imaging while in the ICU. Factors significantly associated with ICU-specific care included nonelective admission, preoperative Glasgow Coma Scale, and volume of IV fluids. A simple clinical scoring system that included Karnofsky Performance Status less than 70 (1 point), general endotracheal anesthesia (1 point), and any early postoperative complications (2 points) demonstrated excellent ability to discriminate patients who required ICU-specific care in both the derivation and validation cohorts.Conclusions: Less than 10% of patients required ICU-specific care following supratentorial tumor resection. A simple clinical scoring system may aid clinicians in stratifying the risk of requiring ICU care and could inform triage decisions when ICU bed availability is limited.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Platelet Transfusion Practices in Critically Ill Children
    • Authors: Nellis; Marianne E.; Karam, Oliver; Mauer, Elizabeth; Cushing, Melissa M.; Davis, Peter J.; Steiner, Marie E.; Tucci, Marisa; Stanworth, Simon J.; Spinella, Philip C.;
      Abstract: imageObjectives: Little is known about platelet transfusions in pediatric critical illness. We sought to describe the epidemiology, indications, and outcomes of platelet transfusions among critically ill children.Design: Prospective cohort study.Setting: Multicenter (82 PICUs), international (16 countries) from September 2016 to April 2017.Patients: Children ages 3 days to 16 years prescribed a platelet transfusion in the ICU during screening days.Interventions: None.Measurements and Main Results: Over 6 weeks, 16,934 patients were eligible, and 559 received at least one platelet transfusion (prevalence, 3.3%). The indications for transfusion included prophylaxis (67%), minor bleeding (21%), and major bleeding (12%). Thirty-four percent of prophylactic platelet transfusions were prescribed when the platelet count was greater than or equal to 50 × 109 cells/L. The median (interquartile range) change in platelet count post transfusion was 48 × 109 cells/L (17–82 × 109 cells/L) for major bleeding, 42 × 109 cells/L (16–80 × 109 cells/L) for prophylactic transfusions to meet a defined threshold, 38 × 109 cells/L (17–72 × 109 cells/L) for minor bleeding, and 25 × 109 cells/L (10–47 × 109 cells/L) for prophylaxis in patients at risk of bleeding from a device. Overall ICU mortality was 25% but varied from 18% to 35% based on indication for transfusion. Upon adjusted analysis, total administered platelet dose was independently associated with increased ICU mortality (odds ratio for each additional 1 mL/kg platelets transfused, 1.002; 95% CI, 1.001–1.003; p = 0.005).Conclusions: The majority of platelet transfusions are given as prophylaxis to nonbleeding children, and significant variation in platelet thresholds exists. Studies are needed to clarify appropriate indications, with focus on prophylactic transfusions.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Criteria to Identify a Potential Deceased Organ Donor: A Systematic Review
           
    • Authors: Squires; Janet E.; Coughlin, Mary; Dorrance, Kristin; Linklater, Stefanie; Chassé, Michaël; Grimshaw, Jeremy M.; Shemie, Sam D.; Dhanani, Sonny; Knoll, Gregory A.
      Abstract: imageObjectives: To systematically review the global published literature defining a potential deceased organ donor and identifying clinical triggers for deceased organ donation identification and referral.Data Sources: Medline and Embase databases from January 2006 to September 2017.Study Selection: All published studies containing a definition of a potential deceased organ donor and/or clinical triggers for referring a potential deceased organ donor were eligible for inclusion. Dual, independent screening was conducted of 3,857 citations.Data Extraction: Data extraction was completed by one team member and verified by a second team member. Thematic content analysis was used to identify clinical criteria for potential deceased organ donation identification from the published definitions and clinical triggers.Data Synthesis: One hundred twenty-four articles were included in the review. Criteria fell into four categories: Neurological, Medical Decision, Cardiorespiratory, and Administrative. Distinct and globally consistent sets of clinical criteria by type of deceased organ donation (neurologic death determination, controlled donation after circulatory determination of death, and uncontrolled donation after circulatory determination of death) are reported.Conclusions: Use of the clinical criteria sets reported will reduce ambiguity associated with the deceased organ donor identification and the subsequent referral process, potentially reducing the number of missed donors and saving lives globally through increased transplantation.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Early Interventions for the Prevention of Posttraumatic Stress Symptoms in
           Survivors of Critical Illness: A Qualitative Systematic Review
    • Authors: Roberts; Michael B.; Glaspey, Lindsey J.; Mazzarelli, Anthony; Jones, Christopher W.; Kilgannon, Hope J.; Trzeciak, Stephen; Roberts, Brian W.
      Abstract: imageObjectives: Posttraumatic stress disorder among survivors of critical illness is of public health importance, as it is common and reduces patient quality of life. The objective of this systematic review was to collate the world’s literature on interventions aimed at preventing posttraumatic stress disorder among survivors of critical illness.Data Sources: We performed a search of CENTRAL, MEDLINE, EMBASE, CINAHL, and clinical trials registry platforms, with no restriction to language using a comprehensive strategy.Study Selection: Study inclusion criteria were as follows: 1) adult human subjects, 2) patients treated in an ICU setting, 3) intervention arm aimed at reducing posttraumatic stress disorder symptoms, 4) use of a control arm, and 5) an outcome measure assessing development of acute stress or posttraumatic stress disorder symptoms.Data Extraction: We performed a qualitative analysis to collate and summarize effects of identified interventions according to the recommended methodology from the Cochrane Handbook.Data Synthesis: Seventeen studies met all inclusion and no exclusion criteria. There was heterogeneity in interventions and outcome measures used. All studies had some concern for risk of bias as per the Cochrane tool for assessing risk of bias. In eight of 12 studies (67%) testing early interventions (i.e., initiated in the ICU course) and one of five studies (20%) testing delayed interventions following ICU discharge, posttraumatic stress disorder symptoms were decreased among the intervention group compared with controls.Conclusions: Despite a paucity of high-quality clinical investigations, the preponderance of evidence to date suggests that 1) posttraumatic stress disorder among survivors of critical illness may be preventable and 2) early interventions may be the most effective.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Surviving Sepsis Campaign: Research Priorities for Sepsis and Septic Shock
           
    • Authors: Coopersmith; Craig M.; De Backer, Daniel; Deutschman, Clifford S.; Ferrer, Ricard; Lat, Ishaq; Machado, Flavia R.; Martin, Greg S.; Martin-Loeches, Ignacio; Nunnally, Mark E.; Antonelli, Massimo; Evans, Laura E.; Hellman, Judith; Jog, Sameer; Kesecioglu, Jozef; Levy, Mitchell M.; Rhodes, Andrew
      Abstract: imageObjective: To identify research priorities in the management, epidemiology, outcome and underlying causes of sepsis and septic shock.Design: A consensus committee of 16 international experts representing the European Society of Intensive Care Medicine and Society of Critical Care Medicine was convened at the annual meetings of both societies. Subgroups had teleconference and electronic-based discussion. The entire committee iteratively developed the entire document and recommendations.Methods: Each committee member independently gave their top five priorities for sepsis research. A total of 88 suggestions (Supplemental Table 1, Supplemental Digital Content 2, http://links.lww.com/CCM/D636) were grouped into categories by the committee co-chairs, leading to the formation of seven subgroups: infection, fluids and vasoactive agents, adjunctive therapy, administration/epidemiology, scoring/identification, post-intensive care unit, and basic/translational science. Each subgroup had teleconferences to go over each priority followed by formal voting within each subgroup. The entire committee also voted on top priorities across all subgroups except for basic/translational science.Results: The Surviving Sepsis Research Committee provides 26 priorities for sepsis and septic shock. Of these, the top six clinical priorities were identified and include the following questions: 1) can targeted/personalized/precision medicine approaches determine which therapies will work for which patients at which times?; 2) what are ideal endpoints for volume resuscitation and how should volume resuscitation be titrated?; 3) should rapid diagnostic tests be implemented in clinical practice?; 4) should empiric antibiotic combination therapy be used in sepsis or septic shock?; 5) what are the predictors of sepsis long-term morbidity and mortality?; and 6) what information identifies organ dysfunction?Conclusions: While the Surviving Sepsis Campaign guidelines give multiple recommendations on the treatment of sepsis, significant knowledge gaps remain, both in bedside issues directly applicable to clinicians, as well as understanding the fundamental mechanisms underlying the development and progression of sepsis. The priorities identified represent a roadmap for research in sepsis and septic shock.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Increasing Evidence-Based Interventions in Patients with Acute Infections
           in a Resource-Limited Setting: A Before-and-After Feasibility Trial in
           Gitwe, Rwanda
    • Authors: Urayeneza; Olivier; Mujyarugamba, Pierre; Rukemba, Zacharie; Nyiringabo, Vincent; Ntihinyurwa, Polyphile; Baelani, John I.; Kwizera, Arthur; Bagenda, Danstan; Mer, Mervyn; Musa, Ndidiamaka; Hoffman, Julia T.; Mudgapalli, Ashok; Porter, Austin M.; Kissoon, Niranjan; Ulmer, Hanno; Harmon, Lori A.; Farmer, Joseph C.; Dünser, Martin W.; Patterson, Andrew J.; for the Sepsis in Resource-Limited Nations Workgroup of the Surviving Sepsis Campaign
      Abstract: imageObjective: To evaluate whether a focused education program and implementation of a treatment bundle increases the rate of early evidence-based interventions in patients with acute infections.Design: Single-center, prospective, before-and-after feasibility trial.Setting: Emergency department of a sub-Saharan African district hospital.Patients: Patients> 28 days of life admitted to the study hospital for an acute infection.Interventions: The trial had three phases (each of four months). Interventions took place during the second (educational program followed by implementation of the treatment bundle) and third (provision of resources to implement treatment bundle) phases.Measurements and Main Results: Demographic, clinical, and laboratory data were collected at study enrollment; 24, 48, and 72 hours after hospital admission; and at discharge. A total of 1,594 patients were enrolled (pre-intervention, n = 661; intervention I, n = 531; intervention II, n = 402). The rate of early evidence-based interventions per patient during Intervention Phase I was greater than during the pre-intervention phase (74 ± 17 vs. 79 ± 15%, p < 0.001). No difference was detected when data were compared between Intervention Phases I and II (79 ± 15 vs. 80 ± 15%, p = 0.58). No differences in the incidence of blood transfusion (pre-intervention, 6%; intervention I, 7%; intervention II, 7%) or severe adverse events in the first 24 hours (allergic reactions: pre-intervention, 0.2%; intervention I, 0%; intervention II, 0%; respiratory failure: pre-intervention, 2%; intervention I, 2%; intervention II, 2%; acute renal failure: pre-intervention, 2%; intervention I, 2%; intervention II, 1%) were observed.Conclusions: Our results indicate that a focused education program and implementation of an infection treatment bundle in clinical practice increased the rate of early evidence-based interventions in patients with acute infections (mostly malaria) admitted to a sub-Saharan African district hospital. Provision of material resources did not further increase this rate. While no safety issues were detected, this could be related to the very low disease severity of the enrolled patient population (www.clinicaltrials.gov: NCT02697513).
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • What Matters Most When Considering Noninvasive Ventilation for Patients
           With Do-Not-Intubate or Comfort-Measures-Only Orders'*
    • Authors: Esbensen; Kari L.
      Abstract: imageNo abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Making the Medicine Go Down: Salt or Sugar'*
    • Authors: Brown; Ryan M.; Stollings, Joanna L.; Semler, Matthew W.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Glucose Monitoring in the ICU: What Is Really Needed'*
    • Authors: Long; Micah T.; Rice, Mark J.; Coursin, Douglas B.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Trends for Palliative Care Use in the Prolonged Mechanically Ventilated
           Patient: Are We Moving Toward a Proactive Approach'*
    • Authors: Schorr; Christa; Angelo, Mark
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Body Composition After Critical Illness: Fat in All the Wrong Places'*
           
    • Authors: Griffith; David M.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Sepsis Redefined…Again*
    • Authors: Gaughan; John
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Sepsis—The “Gift” That Keeps on Giving, Regardless of
           Age*
    • Authors: Simpson; Steven Q.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Improving Evidence-Based Medical Care in Developing Countries*
    • Authors: Rimawi; Ramzy Husam; Kalaji, Wael
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Blue Light Illuminates a Novel Sepsis Treatment*
    • Authors: Pannu; Sonal; Crouser, Elliott D.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • The Potential Role of Steroid-Induced Cerebral Vasospasm in the
           Pathogenesis of Delayed Cerebral Injury in Bacterial Meningitis*
    • Authors: Eisenhut; Michael
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Effect of Body Temperature on Cerebral Autoregulation in Acutely Comatose
           Neurocritically Ill Patients
    • Authors: Adatia; Krishma; Geocadin, Romergryko G.; Healy, Ryan; Ziai, Wendy; Ponce-Mejia, Luciano; Anderson-White, Mirinda; Shah, Dhaval; Radzik, Batya R.; Palmisano, Caitlin; Hogue, Charles W.; Brown, Charles; Rivera-Lara, Lucia
      Abstract: imageObjectives: Impaired cerebral autoregulation following neurologic injury is a predictor of poor clinical outcome. We aimed to assess the relationship between body temperature and cerebral autoregulation in comatose patients.Design: Retrospective analysis of prospectively collected data.Setting: Neurocritical care unit of the Johns Hopkins Hospital.Patients: Eighty-five acutely comatose patients (Glasgow Coma Scale score of ≤ 8) admitted between 2013 and 2017.Interventions: None.Measurement and Main Results: Cerebral autoregulation was monitored using multimodal monitoring with near-infrared spectroscopy–derived cerebral oximetry index. Cerebral oximetry index was calculated as a Pearson correlation coefficient between low-frequency changes in regional cerebral oxygenation saturation and mean arterial pressure. Patients were initially analyzed together, then stratified by temperature pattern over the monitoring period: no change (< 1°C difference between highest and lowest temperatures; n = 11), increasing (≥ 1°C; n = 9), decreasing (≥ 1°C; n = 9), and fluctuating (≥ 1°C difference but no sustained direction of change; n = 56). Mixed random effects models with random intercept and multivariable logistic regression analysis were used to assess the association between hourly temperature and cerebral oximetry index, as well as between temperature and clinical outcomes. Cerebral oximetry index showed a positive linear relationship with temperature (β = 0.04 ± 0.10; p = 0.29). In patients where a continual increase or decrease in temperature was seen during the monitoring period, every 1°C change in temperature resulted in a cerebral oximetry index change in the same direction by 0.04 ± 0.01 (p < 0.001) and 0.02 ± 0.01 (p = 0.12), respectively, after adjusting for PaCO2, hemoglobin, mean arterial pressure, vasopressor and sedation use, and temperature probe location. There was no significant difference in mortality or poor outcome (modified Rankin Scale score of 4–6) between temperature pattern groups at discharge, 3, or 6 months.Conclusions: In acute coma patients, increasing body temperature is associated with worsening cerebral autoregulation as measured by cerebral oximetry index. More studies are needed to clarify the impact of increasing temperature on cerebral autoregulation in patients with acute brain injury.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Effect of a Perioperative Intra-Aortic Balloon Pump in High-Risk Cardiac
           Surgery Patients: A Randomized Clinical Trial
    • Authors: Rocha Ferreira; Graziela Santos; de Almeida, Juliano Pinheiro; Landoni, Giovanni; Vincent, Jean Louis; Fominskiy, Evgeny; Gomes Galas, Filomena Regina Barbosa; Gaiotto, Fabio A.; Dallan, Luís Oliveira; Franco, Rafael Alves; Lisboa, Luiz Augusto; Palma Dallan, Luis Roberto; Fukushima, Julia Tizue; Rizk, Stephanie Itala; Park, Clarice Lee; Strabelli, Tânia Mara; Gelas Lage, Silvia Helena; Camara, Ligia; Zeferino, Suely; Jardim, Jaquelline; Calvo Arita, Elisandra Cristina Trevisan; Caldas Ribeiro, Juliana; Ayub-Ferreira, Silvia Moreira; Costa Auler, Jose Otavio Jr; Filho, Roberto Kalil; Jatene, Fabio Biscegli; Hajjar, Ludhmila Abrahao
      Abstract: imageObjectives: The aim of this study was to evaluate the efficacy of perioperative intra-aortic balloon pump use in high-risk cardiac surgery patients.Design: A single-center randomized controlled trial and a meta-analysis of randomized controlled trials.Setting: Heart Institute of São Paulo University.Patients: High-risk patients undergoing elective coronary artery bypass surgery.Intervention: Patients were randomized to receive preskin incision intra-aortic balloon pump insertion after anesthesia induction versus no intra-aortic balloon pump use.Measurements and Main Results: The primary outcome was a composite endpoint of 30-day mortality and major morbidity (cardiogenic shock, stroke, acute renal failure, mediastinitis, prolonged mechanical ventilation, and a need for reoperation). A total of 181 patients (mean [SD] age 65.4 [9.4] yr; 32% female) were randomized. The primary outcome was observed in 43 patients (47.8%) in the intra-aortic balloon pump group and 42 patients (46.2%) in the control group (p = 0.46). The median duration of inotrope use (51 hr [interquartile range, 32–94 hr] vs 39 hr [interquartile range, 25–66 hr]; p = 0.007) and the ICU length of stay (5 d [interquartile range, 3–8 d] vs 4 d [interquartile range, 3–6 d]; p = 0.035) were longer in the intra-aortic balloon pump group than in the control group. A meta-analysis of 11 randomized controlled trials confirmed a lack of survival improvement in high-risk cardiac surgery patients with perioperative intra-aortic balloon pump use.Conclusions: In high-risk patients undergoing cardiac surgery, the perioperative use of an intra-aortic balloon pump did not reduce the occurrence of a composite outcome of 30-day mortality and major complications compared with usual care alone.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Cardiac Arrest in Patients Managed for Convulsive Status Epilepticus:
           Characteristics, Predictors, and Outcome
    • Authors: Legriel; Stephane; Bresson, Edouard; Deye, Nicolas; Grimaldi, David; Sauneuf, Bertrand; Lesieur, Olivier; Lascarrou, Jean-Baptiste; Argaud, Laurent; Chelly, Jonathan; Beuret, Pascal; Schnell, David; Chateauneuf, Anne-Laure; Holleville, Mathilde; Perier, François; Lemiale, Virginie; Bruel, Cedric; Cronier, Pierrick; Pichon, Nicolas; Mongardon, Nicolas; de-Prost, Nicolas; Dumas, Florence; Cariou, Alain
      Abstract: imageObjectives: Cardiac arrest is a catastrophic event that may arise during the management of convulsive status epilepticus. We aimed to report the clinical characteristics, outcomes, and early predictors of convulsive status epilepticus–related cardiac arrest.Design: Retrospective multicenter study.Setting: Seventeen university or university affiliated participating ICUs in France and Belgium.Patients: Consecutive patients admitted to the participating ICUs for management of successfully resuscitated out-of-hospital cardiac arrest complicating the initial management of convulsive status epilepticus between 2000 and 2015. Patients were compared with controls without cardiac arrest identified in a single-center registry of convulsive status epilepticus patients, regarding characteristics, management, and outcome.Interventions: None.Measurements and Main Results: We included 49 cases with convulsive status epilepticus–cardiac arrest and 235 controls. In the cases, median time from medical team arrival to cardiac arrest was 25 minutes (interquartile range, 5–85 min). First recorded rhythm was asystole in 25 patients (51%) and pulseless electrical activity in 13 patients (27%). A significantly larger proportion of patients had a favorable 1-year outcome (Glasgow Outcome Scale score of 5) among controls (90/235; 38%) than among cases (10/49; 21%; p = 0.02). By multivariate analysis, independent predictors of cardiac arrest were pulse oximetry less than 97% on scene (odds ratio, 2.66; 95% CI, 1.03–7.26; p = 0.04), drug poisoning as the cause of convulsive status epilepticus (odds ratio, 4.13; 95% CI, 1.27–13.53; p = 0.02), and complications during early management (odds ratio, 11.98; 95% CI, 4.67–34.69; p < 0.0001). Having at least one comorbidity among cardiac, respiratory, and neurologic (other than epilepsy) conditions predicted absence of cardiac arrest (odds ratio, 0.28; 95% CI, 0.10–0.80; p = 0.02).Conclusions: In patients managed for convulsive status epilepticus, relative hypoxemia, on-scene management complications, and drug poisoning as the cause of convulsive status epilepticus were strong early predictors of cardiac arrest, suggesting areas for improvement.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Changes in MicroRNA Expression Level of Circulating Platelets Contribute
           to Platelet Defect After Cardiopulmonary Bypass
    • Authors: Mukai; Nobuhiro; Nakayama, Yoshinobu; Ishi, Sachiyo; Ogawa, Satoru; Maeda, Sachiko; Anada, Natuki; Murakami, Satoshi; Mizobe, Toshiki; Sawa, Teiji; Nakajima, Yasufumi
      Abstract: imageObjectives: Platelet defect mechanisms after cardiopulmonary bypass remain unclear. Our hypothesis microRNA expressions in circulating platelets significantly change between pre and post cardiopulmonary bypass, and consequent messenger RNA and protein expression level alterations cause postcardiopulmonary bypass platelet defect.Design: Single-center prospective observational study.Setting: Operating room of Kyoto Prefectural University of Medicine.Patients: Twenty-five adult patients scheduled for elective cardiac surgeries under cardiopulmonary bypass.Interventions: None.Measurements and Main Results: In the initial phase, changes in microRNA expression between pre and post cardiopulmonary bypass underwent next generation sequencing analysis (10 patients). Based on the results, we focused on changes in mir-10b and mir-96, which regulate glycoprotein 1b and vesicle-associated membrane protein 8, respectively, and followed them until messenger RNA and protein syntheses (15 patients) using quantitative polymerase chain reaction and Western blotting. Seven microRNAs including mir-10b and mir-96 exhibited significant differences in the initial phase. In the subsequent phase, mir-10b-5p and mir-96-5p overexpressions were confirmed, and glycoprotein 1b and vesicle-associated membrane protein 8 messenger RNA levels were significantly decreased after cardiopulmonary bypass: fold differences (95% CI): mir-10b-5p: 1.35 (1.05–2.85), p value equals to 0.01; mir-96-5p: 1.59 (1.06–2.13), p value equals to 0.03; glycoprotein 1b messenger RNA: 0.46 (0.32–0.60), p value of less than 0.001; and vesicle-associated membrane protein messenger RNA: 0.70 (0.56–0.84), p value of less than 0.001. Glycoprotein 1b and vesicle-associated membrane protein 8 were also significantly decreased after cardiopulmonary bypass: glycoprotein 1b: 82.6% (71.3–93.8%), p value equals to 0.005; vesicle-associated membrane protein 8: 79.0% (70.7–82.3%), p value of less than 0.001.Conclusions: Expressions of several microRNAs in circulating platelets significantly changed between pre and post cardiopulmonary bypass. Overexpressions of mir-10b and mir-96 decreased glycoprotein 1b and vesicle-associated membrane protein 8 messenger RNA as well as protein, possibly causing platelet defect after cardiopulmonary bypass.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Adjunct Ketamine Use in the Management of Severe Ethanol Withdrawal
    • Authors: Pizon; Anthony F.; Lynch, Michael J.; Benedict, Neal J.; Yanta, Joseph H.; Frisch, Adam; Menke, Nathan B.; Swartzentruber, Greg S.; King, Andrew M.; Abesamis, Michael G.; Kane-Gill, Sandra L.
      Abstract: imageObjectives: Ketamine offers a plausible mechanism with favorable kinetics in treatment of severe ethanol withdrawal. The purpose of this study is to determine if a treatment guideline using an adjunctive ketamine infusion improves outcomes in patients suffering from severe ethanol withdrawal.Design: Retrospective observational cohort study.Setting: Academic tertiary care hospital.Patients: Patients admitted to the ICU and diagnosed with delirium tremens by Diagnostic and Statistical Manual of Mental Disorders V criteria.Interventions: Pre and post guideline, all patients were treated in a symptom-triggered fashion with benzodiazepines and/or phenobarbital. Postguideline, standard symptom-triggered dosing continued as preguideline, plus, the patient was initiated on an IV ketamine infusion at 0.15–0.3 mg/kg/hr continuously until delirium resolved. Based upon withdrawal severity and degree of agitation, a ketamine bolus (0.3 mg/kg) was provided prior to continuous infusion in some patients.Measurements and Main Results: A total of 63 patients were included (29 preguideline; 34 postguideline). Patients treated with ketamine were less likely to be intubated (odds ratio, 0.14; p < 0.01; 95% CI, 0.04–0.49) and had a decreased ICU stay by 2.83 days (95% CI, –5.58 to –0.089; p = 0.043). For ICU days outcome, correlation coefficients were significant for alcohol level and total benzodiazepine dosing. For hospital days outcome, correlation coefficients were significant for patient age, aspartate aminotransferase, and alanine aminotransferase level. Regression revealed the use of ketamine was associated with a nonsignificant decrease in hospital stay by 3.66 days (95% CI, –8.40 to 1.08; p = 0.13).Conclusions: Mechanistically, adjunctive therapy with ketamine may attenuate the demonstrated neuroexcitatory contribution of N-methyl-D-aspartate receptor stimulation in severe ethanol withdrawal, reduce the need for excessive gamma-aminobutyric acid agonist mediated–sedation, and limit associated morbidity. A ketamine infusion in patients with delirium tremens was associated with reduced gamma-aminobutyric acid agonist requirements, shorter ICU length of stay, lower likelihood of intubation, and a trend toward a shorter hospitalization.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Reversible Microvascular Hyporeactivity to Acetylcholine During Diabetic
           Ketoacidosis
    • Authors: Joffre; Jérémie; Bourcier, Simon; Hariri, Geoffroy; Miailhe, Arnaud-Felix; Bigé, Naike; Dumas, Guillaume; Dubée, Vincent; Boelle, Pierre-Yves; Abdallah, Idriss; Baudel, Jean-Luc; Guidet, Bertrand; Maury, Eric; Ait-Oufella, Hafid
      Abstract: imageObjectives: Metabolic acidosis is commonly observed in critically ill patients. Experimental studies suggested that acidosis by itself could impair vascular function, but this has been poorly investigated in human.Design: Prospective observational study.Setting: Medical ICU in a tertiary teaching hospital.Patients: To assess the relationship between metabolic acidosis severity and microvascular reactivity, we included adult diabetic patients admitted in ICU for ketoacidosis. Microvascular response to acetylcholine iontophoresis was measured at admission (baseline) and after correction of metabolic acidosis (24 hr).Interventions: None.Measurements and Main Results: Thirty-nine patients with diabetic ketoacidosis were included (68% male), with a median age of 43 (31–57) years. At admission, microvascular reactivity negatively correlated with acidosis severity (R = –0.53; p < 0.001). Microvascular response was strongly depressed at pH less than 7.20 (area under the curve, 1,779 [740–3,079] vs 12,944 [4,874–21,596] at pH> 7.20; p < 0.0001). In addition, acidosis severity was significantly correlated with capillary refill time (R = 0.50; p = 0.02). At H24, after rehydration and insulin infusion, clinical and biological disorders were fully corrected. After acidosis correction, microvascular reactivity increased more in patients with severe baseline acidosis (pH < 7.20) than in those with mild baseline acidosis (area under the curve, +453% [213%–1,470%] vs +121% [79%–312%]; p < 0.01).Conclusions: We identified an alteration of microvascular reactivity during metabolic acidosis in critically ill patients with diabetic ketoacidosis. Microvascular hyporeactivity recovered after acidosis correction.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Blue Light Enhances Bacterial Clearance and Reduces Organ Injury During
           Sepsis*
    • Authors: Lewis; Anthony J.; Zhang, Xianghong; Griepentrog, John E.; Yuan, Du; Collage, Richard D.; Waltz, Paul K.; Angus, Derek C.; Zuckerbraun, Brian S.; Rosengart, Matthew R.
      Abstract: imageObjectives: The physiology of nearly all mammalian organisms are entrained by light and exhibit circadian rhythm. The data derived from animal studies show that light influences immunity, and these neurophysiologic pathways are maximally entrained by the blue spectrum. Here, we hypothesize that bright blue light reduces acute kidney injury by comparison with either bright red or standard, white fluorescent light in mice subjected to sepsis. To further translational relevance, we performed a pilot clinical trial of blue light therapy in human subjects with appendicitis.Design: Laboratory animal research, pilot human feasibility trial.Setting: University basic science laboratory and tertiary care hospital.Subjects: Male C57BL/6J mice, adult (> 17 yr) patients with acute appendicitis.Interventions: Mice underwent cecal ligation and puncture and were randomly assigned to a 24-hour photoperiod of bright blue, bright red, or ambient white fluorescent light. Subjects with appendicitis were randomized to receive postoperatively standard care or standard care plus high-illuminance blue light.Measurements and Main Results: Exposure to bright blue light enhanced bacterial clearance from the peritoneum, reduced bacteremia and systemic inflammation, and attenuated the degree of acute kidney injury. The mechanism involved an elevation in cholinergic tone that augmented tissue expression of the nuclear orphan receptor REV-ERBα and occurred independent of alterations in melatonin or corticosterone concentrations. Clinically, exposure to blue light after appendectomy was feasible and reduced serum interleukin-6 and interleukin-10 concentrations.Conclusions: Modifying the spectrum of light may offer therapeutic utility in sepsis.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Niacin and Selenium Attenuate Brain Injury After Cardiac Arrest in Rats by
           Up-Regulating DJ-1-Akt Signaling
    • Authors: Kwon; Woon Yong; Suh, Gil Joon; Kim, Kyung Su; Jung, Yoon Sun; Kim, Sung Hee; Lee, A Rum; You, Kyoung Min; Park, Min Ji
      Abstract: imageObjectives: To determine neuroprotective effects and mechanism of the combination therapy of niacin and selenium in cardiac arrest rats.Design: Prospective laboratory study.Setting: University laboratory.Subjects: Rat cortex neurons and male Sprague-Dawley rats (n = 68).Interventions: In rat cortex neurons underwent 90 minutes of oxygen-glucose deprivation and 22.5 hours of reoxygenation, effects of the combination therapy of niacin (0.9 mM) and selenium (1.5 μM) were investigated. The role of DJ-1 was determined using DJ-1 knockdown cells. In cardiac arrest rats, posttreatment effects of the combination therapy of niacin (360 mg/kg) and selenium (60 μg/kg) were evaluated.Measurements and Main Results: In oxygen-glucose deprivation and 22.5 hours of reoxygenation cells, combination therapy synergistically activated the glutathione redox cycle by a niacin-induced increase in glutathione reductase and a selenium-induced increase in glutathione peroxidase activities and reduced hydrogen peroxide level. It increased phosphorylated Akt and intranuclear Nuclear factor erythroid 2–related factor 2 expression and attenuated neuronal injury. However, these benefits were negated by DJ-1 knockdown. In cardiac arrest rats, combination therapy increased DJ-1, phosphorylated Akt, and intranuclear nuclear factor erythroid 2–related factor 2 expression, suppressed caspase 3 cleavage, and attenuated histologic injury in the brain tissues. It also improved the 7-day Neurologic Deficit Scales from 71.5 (66.0–74.0) to 77.0 (74.–80.0) (p = 0.02).Conclusions: The combination therapy of clinically relevant doses of niacin and selenium attenuated brain injury and improved neurologic outcome in cardiac arrest rats. Its benefits were associated with reactive oxygen species reduction and subsequent DJ-1-Akt signaling up-regulation.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Cecal Ligation and Puncture Alters Glucocorticoid Receptor Expression
    • Authors: Abraham; Mabel N.; Jimenez, Daniela M.; Fernandes, Tiago D.; Deutschman, Clifford S.
      Abstract: imageObjectives: Interventional trials on glucocorticoids in sepsis have yielded capricious results. Recent studies have identified multiple glucocorticoid receptor isoforms. The relative abundance of these isoforms in septic patients and following murine cecal ligation and puncture is unknown. The objective of this study is to determine the effects of cecal ligation and puncture on glucocorticoid receptor isoform abundance.Design: Determination of effects of cecal ligation and puncture on glucocorticoid receptor isoform subtype abundance in C57BL/6 mice. Examination of glucocorticoid receptor isoform abundance in tissues harvested from patients immediately after death from sepsis or nonseptic critical illness.Setting: Research laboratory.Subjects: C57BL/6 mice and human tissue sections from recently deceased critically ill patients.Interventions: C57BL/6 mice were subjected to cecal ligation and puncture or sham operation. Abundance of the activating glucocorticoid receptor α and the inactivating glucocorticoid receptor β isoforms was determined in mouse and human tissue using immunoblotting. Cardiac output with or without stimulation with dexamethasone was assessed using echocardiography. The expression of the gene encoding the glucocorticoid-dependent enzyme glucose-6-phosphatase was identified using polymerase chain reaction. Statistical significance (p < 0.05) was determined using analysis of variance.Measurements and Main Results: Results in baseline and sham operation mice were identical. At baseline, glucocorticoid receptor αA predominated in heart, lung, and skeletal muscle; abundance was decreased post cecal ligation and puncture. All glucocorticoid receptor α subtypes were identified in liver. Cecal ligation and puncture decreased the summed abundance of hepatic glucocorticoid receptor α subtypes and those of glucocorticoid receptors αA, B, and D. However, glucocorticoid receptor αC abundance was unchanged. Cecal ligation and puncture increased glucocorticoid receptor β protein abundance in the heart and lung. Relative to T0, cecal ligation and puncture decreased cardiac output and attenuated the cardiac output response to dexamethasone. Cecal ligation and puncture also decreased expression of glucose-6-phosphatase. Compared with nonseptic patients, human sepsis decreased the abundance of glucocorticoid receptor α and increased the abundance of glucocorticoid receptor β in heart and liver biopsies.Conclusions: Cecal ligation and puncture altered glucocorticoid receptor α and glucocorticoid receptor β isoform expression in tissues and decreased functional responses in heart and liver. Decreases in glucocorticoid receptor α and increases in glucocorticoid receptor β might explain the diminished glucocorticoid responsiveness observed in sepsis.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Inhibition of Vascular Endothelial Cell Leak Following Escherichia coli
           Attachment in an Experimental Model of Sepsis
    • Authors: McHale; Tony M.; Garciarena, Carolina D.; Fagan, Robert P.; Smith, Stephen G. J.; Martin-Loches, Ignacio; Curley, Gerard F.; Fitzpatrick, Fidelma; Kerrigan, Steve W.
      Abstract: imageObjectives: The vascular endothelium is a major target of sepsis-induced events, and endothelial activation accounts for much of the pathology of sepsis. Urinary tract infections and pneumonia caused by Escherichia coli are among of the most common infections causing sepsis in both community and hospital settings. Currently, there are no approved drugs on the market to treat the underlying pathophysiology of sepsis. The aim of this study is to elucidate the molecular mechanism by which E. coli induces endothelial injury as a result of attachment.Design: Laboratory research using a hemodynamic perfusion ex vivo model.Setting: Research Laboratories of Royal College of Surgeons in Ireland and Beaumont Hospital.Patients: Ex vivo human vascular endothelial cells.Interventions: Addition of αVβ3 antagonist, cilengitide.Measurements and Main Results: Clinical strains of E. coli isolated from patients with sepsis bound to sheared human endothelial cells under static and hemodynamic shear conditions. Binding was dependent on E. coli cell membrane protein outer membrane protein A attaching directly to endothelial cell integrin αVβ3. Attachment resulted in disturbances in endothelial barrier integrity, as determined by loss of tight junction protein staining, permeability changes, and ultimately cell death by apoptosis. Using a low concentration of the αVβ3 antagonist cilengitide or using a strain deficient in outer membrane protein A resulted in a significant reduction in endothelial dysfunction following infection.Conclusions: Inhibition of E. coli binding to endothelial cell αVβ3 by cilengitide prevents endothelial dysfunction and may, therefore, present as a novel early therapeutic for the treatment of sepsis.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Delayed Cerebral Injury in Adults With Bacterial Meningitis: A Novel
           Complication of Adjunctive Steroids'*
    • Authors: Gallegos; Cinthia; Tobolowsky, Farrell; Nigo, Masayuki; Hasbun, Rodrigo
      Abstract: imageObjectives: To report the prevalence of delayed cerebral injury in adults with bacterial meningitis and explore its association with adjunctive steroids.Design: Retrospective analysis of adults with bacterial meningitis between 2005 and 2016.Setting: Ten hospitals in the Greater Houston area.Patients: Consecutive subjects with culture proven community-acquired bacterial meningitis.Intervention: Subjects were categorized as receiving or not adjunctive steroids within 4 hours.Measurements and Main Results: A total of 120 patients were identified who were admitted with community-acquired bacterial meningitis. Delayed cerebral injury was seen in five of 120 patients (4.1%); all five patients had fever and abnormal neurologic examinations. Adjunctive steroids within 4 hours were more likely given to those with delayed cerebral injury (5/5,100% vs 43/115, 37.5%; p = 0.01). Of the patients who developed delayed cerebral injury, three had Streptococcus pneumoniae, one had methicillin-resistant Staphylococcus aureus, and one had Listeria monocytogenes isolated. We observed an adverse clinical outcome as defined by the Glasgow Outcome Scale in four of the five patients (80%).Conclusions: Delayed cerebral injury occurred in 4.1% of adults with bacterial meningitis, and it was associated with the use of adjunctive steroids. Future studies should explore the etiology and prevention of this devastating complication.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • When Simply Informing May Not Suffice
    • Authors: Sharma; Achyut; Khanal, Kishor; Aryal, Diptesh
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • The authors reply
    • Authors: Brehaut; Jamie; Atwere, Pearl; Carroll, Kelly
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Fluid Responsiveness: Goal-Directed Care or Resuscitative Guide to Salt
           Water Drowning'
    • Authors: Spiegel; Rory J.; Kappler, Shane B.; McCurdy, Michael T.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • The authors reply
    • Authors: Leisman; Daniel E.; Doerfler, Martin E.; Schneider, Sandra M.; D’Amore, Jason A.; D’Angelo, John K.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Is the Tail Wagging the Dog in Sepsis'
    • Authors: Haniffa; Rashan; Beane, Abi; Dondorp, Arjen M.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • The authors reply
    • Authors: Azevedo; Luciano Cesar Pontes; Machado, Flavia Ribeiro
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Uncertainty in Diagnosis Leads to Underestimates of Performance
    • Authors: McHugh; Leo C.; Davis, Roy F.; Yager, Thomas D.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • The authors reply
    • Authors: Koster-Brouwer; Maria E.; Verboom, Diana M.; Bonten, Marc J. M.; Cremer, Olaf L.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Prevent Thrombus Formation: What We Are Doing
    • Authors: Cui; Yongchao; Wang, Hong; Hou, Xiaotong
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • The authors reply
    • Authors: Grübler; Martin R.; Hunziker, Lukas
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • How Would You Evaluate the Quality of Uncontrolled Studies in a
           Meta-Analysis'
    • Authors: Wang; Liangshan; Gu, Chengxiong
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • The authors reply
    • Authors: Pavasini; Rita; Campo, Gianluca
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Outcomes in Patients with Vasodilatory Shock and Renal Replacement Therapy
           Treated with Intravenous Angiotensin II: Erratum
    • Abstract: imageNo abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
 
 
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