for Journals by Title or ISSN
for Articles by Keywords
help
Followed Journals
Journal you Follow: 0
 
Sign Up to follow journals, search in your chosen journals and, optionally, receive Email Alerts when new issues of your Followed Journals are published.
Already have an account? Sign In to see the journals you follow.
Journal Cover Critical Care Medicine
  [SJR: 3.748]   [H-I: 220]   [242 followers]  Follow
    
   Full-text available via subscription Subscription journal
   ISSN (Print) 0090-3493
   Published by LWW Wolters Kluwer Homepage  [290 journals]
  • Should We Manage All Septic Patients Based on a Single Definition' An
           Alternative Approach
    • Authors: Kalil; Andre C.; Sweeney, Daniel A.
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Prevention of Ventilator-Associated Pneumonia: The Multimodal Approach of
           the Spanish ICU “Pneumonia Zero” Program*
    • Authors: Álvarez-Lerma; Francisco; Palomar-Martínez, Mercedes; Sánchez-García, Miguel; Martínez-Alonso, Montserrat; Álvarez-Rodríguez, Joaquín; Lorente, Leonardo; Arias-Rivera, Susana; García, Rosa; Gordo, Federico; Añón, José M.; Jam-Gatell, Rosa; Vázquez-Calatayud, Mónica; Agra, Yolanda
      Abstract: imageObjectives: The “Pneumonia Zero” project is a nationwide multimodal intervention based on the simultaneous implementation of a comprehensive evidence-based bundle measures to prevent ventilator-associated pneumonia in critically ill patients admitted to the ICU.Design: Prospective, interventional, and multicenter study.Setting: A total of 181 ICUs throughout Spain.Patients: All patients admitted for more than 24 hours to the participating ICUs between April 1, 2011, and December 31, 2012.Intervention: Ten ventilator-associated pneumonia prevention measures were implemented (seven were mandatory and three highly recommended). The database of the National ICU-Acquired Infections Surveillance Study (Estudio Nacional de Vigilancia de Infecciones Nosocomiales [ENVIN]) was used for data collection. Ventilator-associated pneumonia rate was expressed as incidence density per 1,000 ventilator days. Ventilator-associated pneumonia rates from the incorporation of the ICUs to the project, every 3 months, were compared with data of the ENVIN registry (April–June 2010) as the baseline period. Ventilator-associated pneumonia rates were adjusted by characteristics of the hospital, including size, type (public or private), and teaching (postgraduate) or university-affiliated (undergraduate) status.Measurements and Main Results: The 181 participating ICUs accounted for 75% of all ICUs in Spain. In a total of 171,237 ICU admissions, an artificial airway was present on 505,802 days (50.0% of days of stay in the ICU). A total of 3,474 ventilator-associated pneumonia episodes were diagnosed in 3,186 patients. The adjusted ventilator-associated pneumonia incidence density rate decreased from 9.83 (95% CI, 8.42–11.48) per 1,000 ventilator days in the baseline period to 4.34 (95% CI, 3.22–5.84) after 19–21 months of participation.Conclusions: Implementation of the bundle measures included in the “Pneumonia Zero” project resulted in a significant reduction of more than 50% of the incidence of ventilator-associated pneumonia in Spanish ICUs. This reduction was sustained 21 months after implementation.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Predictors, Prevalence, and Outcomes of Early Crystalloid Responsiveness
           Among Initially Hypotensive Patients With Sepsis and Septic Shock*
    • Authors: Leisman; Daniel E.; Doerfler, Martin E.; Schneider, Sandra M.; Masick, Kevin D.; D’Amore, Jason A.; D’Angelo, John K.
      Abstract: imageObjectives: The prevalence of responsiveness to initial fluid challenge among hypotensive sepsis patients is unclear. To avoid fluid overload, and unnecessary treatment, it is important to differentiate these phenotypes. We aimed to 1) determine the proportion of hypotensive sepsis patients sustaining favorable hemodynamic response after initial fluid challenge, 2) determine demographic and clinical risk factors that predicted refractory hypotension, and 3) assess the association between timeliness of fluid resuscitation and refractoriness.Design: Secondary analysis of a prospective, multisite, observational, consecutive-sample cohort.Setting: Nine tertiary and community hospitals over 1.5 years.Patients: Inclusion criteria 1) suspected or confirmed infection, 2) greater than or equal to two systemic inflammatory response syndrome criteria, 3) systolic blood pressure less than 90 mm Hg, greater than 40% decrease from baseline, or mean arterial pressure less than 65 mm Hg.Measurements and Main Results: Sex, age, heart failure, renal failure, immunocompromise, source of infection, initial lactate, coagulopathy, temperature, altered mentation, altered gas exchange, and acute kidney injury were used to generate a risk score. The primary outcome was sustained normotension after fluid challenge without vasopressor titration. Among 3,686 patients, 2,350 (64%) were fluid responsive. Six candidate risk factors significantly predicted refractoriness in multivariable analysis: heart failure (odds ratio, 1.43; CI, 1.20–1.72), hypothermia (odds ratio, 1.37; 1.10–1.69), altered gas exchange (odds ratio, 1.33; 1.12–1.57), initial lactate greater than or equal to 4.0 mmol/L (odds ratio, 1.28; 1.08–1.52), immunocompromise (odds ratio, 1.23; 1.03–1.47), and coagulopathy (odds ratio, 1.23; 1.03–1.48). High-risk patients (≥ three risk factors) had 70% higher (CI, 48–96%) refractory risk (19% higher absolute risk; CI, 14–25%) versus low-risk (zero risk factors) patients. Initiating fluids in greater than 2 hours also predicted refractoriness (odds ratio, 1.96; CI, 1.49–2.58). Mortality was 15% higher (CI, 10-18%) for refractory patients.Conclusions: Two in three hypotensive sepsis patients were responsive to initial fluid resuscitation. Heart failure, hypothermia, immunocompromise, hyperlactemia, and coagulopathy were associated with the refractory phenotype. Fluid resuscitation initiated after the initial 2 hours more strongly predicted refractoriness than any patient factor tested.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Impact of Quality Bundle Enforcement by a Critical Care Pharmacist on
           Patient Outcome and Costs*
    • Authors: Leguelinel-Blache; Géraldine; Nguyen, Tri-Long; Louart, Benjamin; Poujol, Hélène; Lavigne, Jean-Philippe; Roberts, Jason A.; Muller, Laurent; Kinowski, Jean-Marie; Roger, Claire; Lefrant, Jean-Yves
      Abstract: imageObjectives: Surgical and medical ICU patients are at high risk of mortality and provide a significant cost to the healthcare system. The aim of this study is to describe the effect of pharmacist-led interventions on drug therapy and clinical strategies on ICU patient outcome and hospital costs.Design: Before and after study in two French ICUs (16 and 10 beds).Patients: ICU patients.Intervention: From January 1, 2013, to June 30, 2015, a pharmacist observation period was compared with an intervention period in which a critical care pharmacist provided recommendations to clinicians regarding sedative drugs and doses, choice of mechanical ventilation mode and related settings, antimicrobial de-escalation, and central venous and urinary catheters removal. Differences in ICU and hospital length of stay, duration of mechanical ventilation, mortality rate, and hospital costs per patient were quantified between groups with patients matched for severity of illness (Simplified Acute Physiology Score II) at admission.Measurements and Main Results: From the 1,519 and 1,268 admitted patients during the observation and intervention periods, respectively, 1,164 patients were evaluable in both groups after matching for Simplified Acute Physiology Score II score. The intervention period was associated with mean (95% CI) reductions in patient hospital length of stay (3.7 d [5.2–2.3 d]; p < 0.001), ICU length of stay (1.4 d [2.3–0.5 d]; p < 0.005), duration of mechanical ventilation (1.2 d [2.1–0.3 d]; p < 0.01), and hospital costs per stay (2,560 euros [3,728–1,392 euros]; p < 0.001). The overall cost savings were 10,840 euros (10,727–10,952 euros) per month, mostly due to reduced consumption of sedatives and antimicrobials. No impact on mortality rate was identified.Conclusions: Critical care pharmacist-led interventions were associated with decreases in ICU and hospital length of stays and ICU drug costs.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Predictors of Intubation in Patients With Acute Hypoxemic Respiratory
           Failure Treated With a Noninvasive Oxygenation Strategy*
    • Authors: Frat; Jean-Pierre; Ragot, Stéphanie; Coudroy, Rémi; Constantin, Jean-Michel; Girault, Christophe; Prat, Gwénael; Boulain, Thierry; Demoule, Alexandre; Ricard, Jean-Damien; Razazi, Keyvan; Lascarrou, Jean-Baptiste; Devaquet, Jérôme; Mira, Jean-Paul; Argaud, Laurent; Chakarian, Jean-Charles; Fartoukh, Muriel; Nseir, Saad; Mercat, Alain; Brochard, Laurent; Robert, René; Thille, Arnaud W.; for the REVA network
      Abstract: imageObjectives: In patients with acute hypoxemic respiratory failure, noninvasive ventilation and high-flow nasal cannula oxygen are alternative strategies to conventional oxygen therapy. Endotracheal intubation is frequently needed in these patients with a risk of delay, and early predictors of failure may help clinicians to decide early. We aimed to identify factors associated with intubation in patients with acute hypoxemic respiratory failure treated with different noninvasive oxygenation techniques.Design: Post hoc analysis of a randomized clinical trial.Setting: Twenty-three ICUs.Patients: Patients with a respiratory rate greater than 25 breaths/min and a PaO2/FIO2 ratio less than or equal to 300 mm Hg.Intervention: Patients were treated with standard oxygen, high-flow nasal cannula oxygen, or noninvasive ventilation.Measurement and Main Results: Respiratory variables one hour after treatment initiation. Under standard oxygen, patients with a respiratory rate greater than or equal to 30 breaths/min were more likely to need intubation (odds ratio, 2.76; 95% CI, 1.13–6.75; p = 0.03). One hour after high-flow nasal cannula oxygen initiation, increased heart rate was the only factor associated with intubation. One hour after noninvasive ventilation initiation, a PaO2/FIO2 ratio less than or equal to 200 mm Hg and a tidal volume greater than 9 mL/kg of predicted body weight were independent predictors of intubation (adjusted odds ratio, 4.26; 95% CI, 1.62–11.16; p = 0.003 and adjusted odds ratio, 3.14; 95% CI, 1.22–8.06; p = 0.02, respectively). A tidal volume above 9 mL/kg during noninvasive ventilation remained independently associated with 90-day mortality.Conclusions: In patients with acute hypoxemic respiratory failure breathing spontaneously, the respiratory rate was a predictor of intubation under standard oxygen, but not under high-flow nasal cannula oxygen or noninvasive ventilation. A PaO2/FIO2 below 200 mm Hg and a high tidal volume greater than 9 mL/kg were the two strong predictors of intubation under noninvasive ventilation.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Renal Decapsulation Prevents Intrinsic Renal Compartment Syndrome in
           Ischemia-Reperfusion–Induced Acute Kidney Injury: A Physiologic
           Approach*
    • Authors: Cruces; Pablo; Lillo, Pablo; Salas, Camila; Salomon, Tatiana; Lillo, Felipe; González, Carlos; Pacheco, Alejandro; Hurtado, Daniel E.
      Abstract: imageObjectives: Acute kidney injury is a serious complication with unacceptably high mortality that lacks of specific curative treatment. Therapies focusing on the hydraulic behavior have shown promising results in preventing structural and functional renal impairment, but the underlying mechanisms remain understudied. Our goal is to assess the effects of renal decapsulation on regional hemodynamics, oxygenation, and perfusion in an ischemic acute kidney injury experimental model.Methods: In piglets, intra renal pressure, renal tissue oxygen pressure, and dysoxia markers were measured in an ischemia-reperfusion group with intact kidney, an ischemia-reperfusion group where the kidney capsule was removed, and in a sham group.Results: Decapsulated kidneys displayed an effective reduction of intra renal pressure, an increment of renal tissue oxygen pressure, and a better performance in the regional delivery, consumption, and extraction of oxygen after reperfusion, resulting in a marked attenuation of acute kidney injury progression due to reduced structural damage and improved renal function.Conclusions: Our results strongly suggest that renal decapsulation prevents the onset of an intrinsic renal compartment syndrome after ischemic acute kidney injury.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Temperature Variability in a Modern Targeted Temperature Management Trial
    • Authors: Abu-Arafeh; Ahmad; Rodriguez, Aryelly; Paterson, Ross L.; Andrews, Peter J. D.
      Abstract: imageObjectives: The Eurotherm3235 trial showed that therapeutic hypothermia was deleterious in patients with raised intracranial pressure following traumatic brain injury. We sought to ascertain if increased temperature variability within the first 48 hours, or for 7 days post randomization, were modifiable risk factors associated with poorer outcome.Design: Eurotherm3235 was a multicenter randomized controlled trial. Patients were randomized to receive either therapeutic hypothermia in addition to standard care or the later only. Mean moving range (mr) was used to stratify subjects into tertiles by the variability present in their core temperature within the first 48 hours post randomization and within 7 days post randomization. The primary outcome measure was a collapsed Glasgow Outcome Scale-Extended at 6 months post randomization. The temperature variability effect was estimated with ordinal logistic regression adjusted for baseline covariates and treatment effect.Setting: Forty-seven critical care units in 18 countries.Patients: Patients enrolled in the Eurotherm3235 trial to either therapeutic hypothermia or control treatments only.Measurements and Main Results: Three hundred eighty-six patients were included in our study. High level of temperature variability during the first 48 hours was associated with poorer collapsed Glasgow Outcome Scale-Extended. This effect remained statistically significant when only the control arm of the study was analyzed. No statistically significant effect was seen within the first 48 hours in the hypothermia group or within 7 days in either group.Conclusions: When targeting normothermia, temperature variability may be a statistically significant variable in an ordinal analysis adjusted for baseline covariates.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Acute Physiologic Stress and Subsequent Anxiety Among Family Members of
           ICU Patients
    • Authors: Beesley; Sarah J.; Hopkins, Ramona O.; Holt-Lunstad, Julianne; Wilson, Emily L.; Butler, Jorie; Kuttler, Kathryn G.; Orme, James; Brown, Samuel M.; Hirshberg, Eliotte L.
      Abstract: imageObjectives: The ICU is a complex and stressful environment and is associated with significant psychologic morbidity for patients and their families. We sought to determine whether salivary cortisol, a physiologic measure of acute stress, was associated with subsequent psychologic distress among family members of ICU patients.Design: This is a prospective, observational study of family members of adult ICU patients.Setting: Adult medical and surgical ICU in a tertiary care center.Subjects: Family members of ICU patients.Interventions: Participants provided five salivary cortisol samples over 24 hours at the time of the patient ICU admission. The primary measure of cortisol was the area under the curve from ground; the secondary measure was the cortisol awakening response. Outcomes were obtained during a 3-month follow-up telephone call. The primary outcome was anxiety, measured by the Hospital Anxiety and Depression Scale-Anxiety. Secondary outcomes included depression and posttraumatic stress disorder.Measurements and Main Results: Among 100 participants, 92 completed follow-up. Twenty-nine participants (32%) reported symptoms of anxiety at 3 months, 15 participants (16%) reported depression symptoms, and 14 participants (15%) reported posttraumatic stress symptoms. In our primary analysis, cortisol level as measured by area under the curve from ground was not significantly associated with anxiety (odds ratio, 0.94; p = 0.70). In our secondary analysis, however, cortisol awakening response was significantly associated with anxiety (odds ratio, 1.08; p = 0.02).Conclusions: Roughly one third of family members experience anxiety after an ICU admission for their loved one, and many family members also experience depression and posttraumatic stress. Cortisol awakening response is associated with anxiety in family members of ICU patients 3 months following the ICU admission. Physiologic measurements of stress among ICU family members may help identify individuals at particular risk of adverse psychologic outcomes.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Prolonged Infusion Piperacillin-Tazobactam Decreases Mortality and
           Improves Outcomes in Severely Ill Patients: Results of a Systematic Review
           and Meta-Analysis*
    • Authors: Rhodes; Nathaniel J.; Liu, Jiajun; O’Donnell, J. Nicholas; Dulhunty, Joel M.; Abdul-Aziz, Mohd H.; Berko, Patsy Y.; Nadler, Barbara; Lipman, Jeffery; Roberts, Jason A.
      Abstract: imageObjective: Piperacillin-tazobactam is a commonly used antibiotic in critically ill patients; however, controversy exists as to whether mortality in serious infections can be decreased through administration by prolonged infusion compared with intermittent infusion. The purpose of this systematic review and meta-analysis was to describe the impact of prolonged infusion piperacillin-tazobactam schemes on clinical endpoints in severely ill patients.Design: We conducted a systematic literature review and meta-analysis searching MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library from inception to April 1, 2017, for studies.Interventions: Mortality rates were compared between severely ill patients receiving piperacillin-tazobactam via prolonged infusion or intermittent infusion. Included studies must have reported severity of illness scores, which were transformed into average study-level mortality probabilities.Measurements and Main Results: Two investigators independently screened titles, abstracts, and full texts of studies meeting inclusion criteria for this systematic review and meta-analysis. Variables included author name, publication year, study design, demographics, total daily dose(s), average estimated creatinine clearance, type of prolonged infusion, prevalence of combination therapy, severity of illness scores, infectious sources, all-cause mortality, clinical cure, microbiological cure, and hospital and ICU length of stay. The review identified 18 studies including 3,401 patients who received piperacillin-tazobactam, 56.7% via prolonged infusion. Across all studies, the majority of patients had an identified primary infectious source. Receipt of prolonged infusion was associated with a 1.46-fold lower odds of mortality (95% CI, 1.20–1.77) in the pooled analysis. Patients receiving prolonged infusion had a 1.77-fold higher odds of clinical cure (95% CI, 1.24–2.54) and a 1.22-fold higher odds of microbiological cure (95% CI, 0.84–1.77). Subanalyses were conducted according to high (≥ 20%) and low (< 20%) average study-level mortality probabilities. In studies reporting higher mortality probabilities, effect sizes were variable but similar to the pooled results.Conclusions: Receipt of prolonged infusion of piperacillin-tazobactam was associated with reduced mortality and improved clinical cure rates across diverse cohorts of severely ill patients.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Multicohort Analysis of Whole-Blood Gene Expression Data Does Not Form a
           Robust Diagnostic for Acute Respiratory Distress Syndrome
    • Authors: Sweeney; Timothy E.; Thomas, Neal J.; Howrylak, Judie A.; Wong, Hector R.; Rogers, Angela J.; Khatri, Purvesh
      Abstract: imageObjectives: To identify a novel, generalizable diagnostic for acute respiratory distress syndrome using whole-blood gene expression arrays from multiple acute respiratory distress syndrome cohorts of varying etiologies.Data Sources: We performed a systematic search for human whole-blood gene expression arrays of acute respiratory distress syndrome in National Institutes of Health Gene Expression Omnibus and ArrayExpress. We also included the Glue Grant gene expression cohorts.Study Selection: We included investigator-defined acute respiratory distress syndrome within 48 hours of diagnosis and compared these with relevant critically ill controls.Data Extraction: We used multicohort analysis of gene expression to identify genes significantly associated with acute respiratory distress syndrome, both with and without adjustment for clinical severity score. We performed gene ontology enrichment using Database for Annotation, Visualization and Integrated Discovery and cell type enrichment tests for both immune cells and pneumocyte gene expression. Finally, we selected a gene set optimized for diagnostic power across the datasets and used leave-one-dataset-out cross validation to assess robustness of the model.Data Synthesis: We identified datasets from three adult cohorts with sepsis, one pediatric cohort with acute respiratory failure, and two datasets of adult patients with trauma and burns, for a total of 148 acute respiratory distress syndrome cases and 268 critically ill controls. We identified 30 genes that were significantly associated with acute respiratory distress syndrome (false discovery rate < 20% and effect size>1.3), many of which had been previously associated with sepsis. When metaregression was used to adjust for clinical severity scores, none of these genes remained significant. Cell type enrichment was notable for bands and neutrophils, suggesting that the gene expression signature is one of acute inflammation rather than lung injury per se. Finally, an attempt to develop a generalizable diagnostic gene set for acute respiratory distress syndrome showed a mean area under the receiver-operating characteristic curve of only 0.63 on leave-one-dataset-out cross validation.Conclusions: The whole-blood gene expression signature across a wide clinical spectrum of acute respiratory distress syndrome is likely confounded by systemic inflammation, limiting the utility of whole-blood gene expression studies for uncovering a generalizable diagnostic gene signature.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Should Transfusion Trigger Thresholds Differ for Critical Care Versus
           Perioperative Patients' A Meta-Analysis of Randomized Trials
    • Authors: Chong; Matthew A.; Krishnan, Rohin; Cheng, Davy; Martin, Janet
      Abstract: imageObjective: To address the significant uncertainty as to whether transfusion thresholds for critical care versus surgical patients should differ.Design: Meta-analysis of randomized controlled trials.Setting: Medline, EMBASE, and Cochrane Library searches were performed up to 15 June 2016.Patients: Trials had to enroll adult surgical or critically ill patients for inclusion.Interventions: Studies had to compare a liberal versus restrictive threshold for the transfusion of allogeneic packed RBCs.Measurements and Main Results: The primary outcome was 30-day all-cause mortality, sub-grouped by surgical and critical care patients. Secondary outcomes included myocardial infarction, stroke, renal failure, allogeneic blood exposure, and length of stay. Odds ratios and weighted mean differences were calculated using random effects meta-analysis. To assess whether subgroups were significantly different, tests for subgroup interaction were used. Subgroup analysis by trials enrolling critically ill versus surgical patients was performed. Twenty-seven randomized controlled trials (10,797 patients) were included. In critical care patients, restrictive transfusion resulted in significantly reduced 30-day mortality compared with liberal transfusion (odds ratio, 0.82; 95% CI, 0.70–0.97). In surgical patients, a restrictive transfusion strategy led to the opposite direction of effect for mortality (odds ratio, 1.31; 95% CI, 0.94–1.82). The subgroup interaction test was significant (p = 0.04), suggesting that the effect of restrictive transfusion on mortality is statistically different for critical care (decreased risk) versus surgical patients (potentially increased risk or no difference). Regarding secondary outcomes, for critically ill patients, a restrictive strategy resulted in reduced risk of stroke/transient ischemic attack, packed RBC exposure, transfusion reactions, and hospital length of stay. In surgical patients, restrictive transfusion resulted in reduced packed RBC exposure.Conclusions: The safety of restrictive transfusion strategies likely differs for critically ill patients versus perioperative patients. Further trials investigating transfusion strategies in the perioperative setting are necessary.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Numeracy and Interpretation of Prognostic Estimates in Intracerebral
           Hemorrhage Among Surrogate Decision Makers in the Neurologic ICU
    • Authors: Leiter; Nikita; Motta, Melissa; Reed, Robert M.; Adeyeye, Temitope; Wiegand, Debra L.; Shah, Nirav G.; Verceles, Avelino C.; Netzer, Giora
      Abstract: imageObjective: Clinicians caring for patients with intracerebral hemorrhage must often discuss prognosis and goals of care with their patients’ surrogate decision makers, and may make numeric estimates of likelihood of survival and functional independence, informed by validated prediction models. Surrogates’ prognostic estimates are often discordant with physicians’, suggesting that physicians’ numeric statements may not be accurately interpreted. We sought to assess the relationship between numeracy and interpretation of prognostic estimates in intracerebral hemorrhage among surrogate decision makers. We also assessed surrogates’ application of prognostic estimates to decisions regarding goals of care.Design: Single-center, survey-based, cross-sectional study.Setting: Twenty-two–bed neurologic ICU at an urban, academic hospital.Subjects: Surrogate decision makers for patients admitted to the neurologic ICU.Interventions: Participants completed a survey containing five clinical vignettes describing patients with nontraumatic intracerebral hemorrhage. For each patient, numerical estimates of survival and functional independence were explicitly provided, based on the validated outcome risk stratification scale (intracerebral hemorrhage score) and the Prediction of Functional Outcome in Patients with Primary Intracerebral Hemorrhage score.Measurements and Main Results: Participants were asked to make their own prognostic estimates, as well as to describe their preferred goals of care for each hypothetical patient. Respondent demographics were collected, and numeracy was assessed using a modified Lipkus 11-item scale. Poor numeracy was common (42 of 96 total subjects) in this relatively highly educated population. Most prognostic estimates (55%) made by surrogates were discordant with the provided estimates. High numeracy correlated with better concordance (odds ratio, 23.9 [5.57–97.64]; p < 0.001), independent of several factors, including level of education and religion. Numeracy also affected goals-of-care decisions made by surrogates.Conclusions: Poor numeracy is common among surrogate decision makers in an intensive care setting and poses a barrier to communication between surrogates and clinicians regarding prognosis and goals of care.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • β-lactam Therapeutic Drug Management in the PICU*
    • Authors: Cies; Jeffrey J.; Moore, Wayne S. II; Enache, Adela; Chopra, Arun
      Abstract: imageObjectives: To determine whether contemporary β-lactam anti-infective dosing recommendations in critically ill children achieve concentrations associated with maximal anti-infective activity. The secondary objective was to describe the microbiological and clinical outcomes associated with β-lactam therapeutic drug management.Design: Electronic Medical Record Review.Setting: A 189-bed, freestanding children’s tertiary care teaching hospital in Philadelphia, PA.Patients: Patients admitted to the PICU from September 1, 2014, to May 31, 2017, with sepsis and those receiving extracorporal therapy with either extracorporeal membrane oxygenation or continuous renal replacement therapy that had routine β-lactam therapeutic drug management.Interventions: None.Measurements and Main Results: Eighty-two patients were in the total cohort and 23 patients in the infected cohort accounting for 248 samples for therapeutic drug management analysis. The median age was 1 year (range, 4 d to 18 yr) with a mean weight of 19.7 ± 22.3 kg (range, 2.7–116 kg). Twenty-three patients (28%) had growth of an identified pathogen from a normally sterile site. Seventy-eight of 82 patients (95%) had subtherapeutic anti-infective concentrations and did not attain the primary pharmacodynamic endpoint. All patients in the infected cohort achieved a microbiological response, and 22 of 23 (95.7%) had a positive clinical response.Conclusions: Overall, 95% of patients had subtherapeutic anti-infective concentrations and did not achieve the requisite pharmacodynamic exposure with current pediatric dosing recommendations. All patients achieved a microbiological response, and 95.7% achieved clinical response with active β-lactam therapeutic drug management. These data suggest β-lactam therapeutic drug management is a potentially valuable intervention to optimize anti-infective pharmacokinetics and the pharmacodynamic exposure. Further, these data also suggest the need for additional research in specific pediatric populations and assessing clinical outcomes associated with β-lactam therapeutic drug management in a larger cohort of pediatric patients.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Osmotic Shifts, Cerebral Edema, and Neurologic Deterioration in Severe
           Hepatic Encephalopathy
    • Authors: Liotta; Eric Michael; Romanova, Anna L.; Lizza, Bryan D.; Rasmussen-Torvik, Laura J.; Kim, Minjee; Francis, Brandon; Sangha, Rajbeer Singh; Carroll, Timothy J.; Ganger, Daniel; Ladner, Daniela P.; Naidech, Andrew M.; Paparello, James J.; Prabhakaran, Shyam; Sorond, Farzaneh A.; Maas, Matthew B.
      Abstract: imageObjectives: We sought to determine the effect of acute electrolyte and osmolar shifts on brain volume and neurologic function in patients with liver failure and severe hepatic encephalopathy.Design: Retrospective analysis of brain CT scans and clinical data.Setting: Tertiary care hospital ICUs.Patients: Patients with acute or acute-on-chronic liver failure and severe hepatic encephalopathy.Interventions: Clinically indicated CT scans and serum laboratory studies.Measurements and Main Results: Change in intracranial cerebrospinal fluid volume between sequential CT scans was measured as a biomarker of acute brain volume change. Corresponding changes in serum osmolality, chemistry measurements, and Glasgow Coma Scale were determined. Associations with cerebrospinal fluid volume change and Glasgow Coma Scale change for initial volume change assessments were identified by Spearman’s correlations (rs) and regression models. Consistency of associations with repeated assessments was evaluated using generalized estimating equations. Forty patients were included. Median baseline osmolality was elevated (310 mOsm/Kg [296–321 mOsm/Kg]) whereas sodium was normal (137 mEq/L [134–142 mEq/L]). Median initial osmolality change was 9 mOsm/kg (5–17 mOsm/kg). Neuroimaging consistent with increased brain volume occurred in 27 initial assessments (68%). Cerebrospinal fluid volume change was more strongly correlated with osmolality (r = 0.70; p = 4 × 10–7) than sodium (r = 0.28; p = 0.08) change. Osmolality change was independently associated with Glasgow Coma Scale change (p = 1 × 10–5) and cerebrospinal fluid volume change (p = 2.7 × 10–5) in initial assessments and in generalized estimating equations using all 103 available assessments.Conclusions: Acute decline in osmolality was associated with brain swelling and neurologic deterioration in severe hepatic encephalopathy. Minimizing osmolality decline may avoid neurologic deterioration.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • The Effect of ICU Out-of-Hours Admission on Mortality: A Systematic Review
           and Meta-Analysis*
    • Authors: Galloway; Megan; Hegarty, Aoife; McGill, Sarah; Arulkumaran, Nishkantha; Brett, Stephen J; Harrison, David
      Abstract: imageObjectives: Organizational factors are associated with outcome of critically ill patients and may vary by time of day and day of week. We aimed to identify the association between out-of-hours admission to critical care and mortality.Data Sources: MEDLINE (via Ovid) and EMBASE (via Ovid).Study Selection: We performed a systematic search of the literature for studies on out-of-hours adult general ICU admission on patient mortality.Data Extraction: Meta-analyses were performed and Forest plots drawn using RevMan software. Data are presented as odds ratios ([95% CIs], p values).Data Synthesis: A total of 16 studies with 902,551 patients were included in the analysis with a crude mortality of 18.2%. Fourteen studies with 717,331 patients reported mortality rates by time of admission and 11 studies with 835,032 patients by day of admission. Admission to ICU at night was not associated with an increased odds of mortality compared with admissions during the day (odds ratio, 1.04 [0.98–1.11]; p = 0.18). However, admissions during the weekend were associated with an increased odds of death compared with ICU admissions during weekdays (1.05 [1.01–1.09]; p = 0.006). Increased mortality associated with weekend ICU admissions compared with weekday ICU admissions was limited to North American countries (1.08 [1.03–1.12]; p = 0.0004). The absence of a routine overnight on-site intensivist was associated with increased mortality among weekend ICU admissions compared with weekday ICU admissions (1.11 [1.00–1.22]; p = 0.04) and nighttime admissions compared with daytime ICU admissions (1.11 [1.00–1.23]; p = 0.05).Conclusions: Adjusted risk of death for ICU admission was greater over the weekends compared with weekdays. The absence of a dedicated intensivist on-site overnight may be associated with increased mortality for acute admissions. These results need to be interpreted in context of the organization of local healthcare resources before changes to healthcare policy are implemented.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Association of Driving Pressure With Mortality Among Ventilated Patients
           With Acute Respiratory Distress Syndrome: A Systematic Review and
           Meta-Analysis*
    • Authors: Aoyama; Hiroko; Pettenuzzo, Tommaso; Aoyama, Kazuyoshi; Pinto, Ruxandra; Englesakis, Marina; Fan, Eddy
      Abstract: imageObjectives: A recent post hoc analysis suggested that driving pressure may be more important than traditional ventilatory variables in determining outcome in mechanically ventilated patients with acute respiratory distress syndrome. We conducted a systematic review and meta-analysis to summarize the risk of mortality for higher versus lower driving pressure.Data Sources: MEDLINE, EMBASE, PubMed, CINAHL, and Cochrane CENTRAL from inception to February 10, 2017.Study Selection: Studies including mechanically ventilated adult patients with acute respiratory distress syndrome, reporting driving pressure and mortality.Data Extraction: Seven studies including five secondary analysis of previous randomized controlled trials and two observational studies (6,062 patients) were eligible for study. All studies were judged as having a low risk of bias. Median (interquartile range) driving pressure between higher and lower driving pressure groups was 15 cm H2O (14–16 cm H2O). Median (interquartile range) mortality of all included studies was 34% (32–38%).Data Synthesis: In the meta-analyses of four studies (3,252 patients), higher driving pressure was associated with a significantly higher mortality (pooled risk ratio, 1.44; 95% [CI], 1.11–1.88; I2 = 85%). A sensitivity analysis restricted to the three studies with similar driving pressure cutoffs (13–15 cm H2O) demonstrated similar results (pooled risk ratio, 1.28; 95% CI, 1.14–1.43; I2 = 0%).Conclusions: Our study confirmed an association between higher driving pressure and higher mortality in mechanically ventilated patients with acute respiratory distress syndrome. These findings suggest a possible range of driving pressure to be evaluated in clinical trials. Future research is needed to ascertain the benefit of ventilatory strategies targeting driving pressure in patients with acute respiratory distress syndrome.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • The Present State of Neurointensivist Training in the United States: A
           Comparison to Other Critical Care Training Programs
    • Authors: Marcolini; Evie G.; Seder, David B.; Bonomo, Jordan B.; Bleck, Thomas P.; Hemphill, J. Claude III; Shutter, Lori; Rincon, Fred; Timmons, Shelly D.; Nyquist, Paul
      Abstract: imageObjective: This manuscript describes the state of neurocritical care fellowship training, compares its written standards to those of other critical care fellowship programs, and discusses how programmatic oversight by the United Council for Neurological Subspecialties should evolve to meet American College of Graduate Medical Education standards. This review is a work product of the Society of Critical Care Medicine Neuroscience section and was reviewed and approved by the Council of the Society of Critical Care Medicine.Data Sources: We evaluated the published training criteria and requirements of American College of Graduate Medical Education Critical Care subspecialty fellowships programs of Internal Medicine, Surgery, and Anesthesia and compared them with the training criteria and required competencies for neurocritical care.Study Selection: We have reviewed the published training standards from American College of Graduate Medical Education as well as the United Council for Neurologic Subspecialties subspecialty training documents and clarified the definition and responsibilities of an intensivist with reference to the Leapfrog Group, the National Quality Forum, and the Joint Commission.Data Extraction: No data at present exist to test the concept of similarity across specialty fellowship critical care training programs.Data Synthesis: Neurocritical care training differs in its exposure to clinical entities that are directly associated to other critical care subspecialties. However, the core critical care knowledge, procedural skills, and competencies standards for neurocritical care appears to be similar with some important differences compared with American College of Graduate Medical Education critical care training programs.Conclusions: The United Council for Neurologic Subspecialties has developed a directed program development strategy to emulate American College of Graduate Medical Education standards with the goal to have standards that are similar or identical to American College of Graduate Medical Education standards.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Prevention of Ventilator-Associated and Early Postoperative Pneumonia
           Through Tapered Endotracheal Tube Cuffs: A Systematic Review and
           Meta-Analysis of Randomized Controlled Trials
    • Authors: Maertens; Bert; Blot, Koen; Blot, Stijn
      Abstract: imageObjective: Microaspiration of subglottic secretions is considered a major pathogenic mechanism of hospital-acquired pneumonia, either early postoperative or ventilator-associated pneumonia. Tapered endotracheal tube cuffs have been proposed to provide a better seal of the extraluminal airway, thereby preventing microaspiration and possibly hospital-acquired pneumonia. We performed a systematic review and meta-analysis to assess the value of endotracheal tubes with tapered cuffs in the prevention of hospital-acquired pneumonia.Data Sources: A systematic search of MEDLINE, EMBASE, CENTRAL/CCTR, ClinicalTrials.gov, and ICTRP was conducted up to March 2017.Study Selection: Eligible trials were randomized controlled clinical trials comparing the impact of tapered cuffs versus standard cuffs on hospital-acquired pneumonia.Data Extraction: Random-effects meta-analysis calculated odds ratio and 95% CI for hospital-acquired pneumonia occurrence rate between groups. Secondary outcome measures included mortality, duration of mechanical ventilation, length of hospital and ICU stay, and cuff underinflation.Data Synthesis: Six randomized controlled clinical trials with 1,324 patients from intensive care and postoperative wards were included. Only two studies concomitantly applied subglottic secretion drainage, and no trial performed continuous cuff pressure monitoring. No significant difference in hospital-acquired pneumonia incidence per patient was found when tapered cuffs were compared with standard cuffs (odds ratio, 0.97; 95% CI, [0.73–1.28]; p = 0.81). There were likewise no differences in secondary outcomes.Conclusions: Application of tapered endotracheal tube cuffs did not reduce hospital-acquired pneumonia incidence among ICU and postoperative patients. Further research should examine the impact of concomitant use of tapered cuffs with continuous cuff pressure monitoring and subglottic secretion drainage.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Can a Multicenter Pneumonia Zero Bundle Reduce Ventilator-Associated
           Pneumonias'*
    • Authors: Rimawi; Ramzy Husam; Murphy, David J.
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • “Judge a Man by His Questions Rather Than by His Answers”
           Voltaire*
    • Authors: Rubulotta; Francesca
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Early Fluid Management in Sepsis: Yes*
    • Authors: Morley; Peter Thomas
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Expanding the Reach of Critical Care Pharmacists Globally*
    • Authors: Devlin; John W.; McKenzie, Catherine
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Noninvasive Treatment of Hypoxemic Respiratory Failure: Give It a Try…
           But Do Not Push Too Hard*
    • Authors: Richard; Jean-Christophe
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Renal Decapsulation to Treat Ischemic Acute Kidney Injury: A New Twist in
           an Old Tale*
    • Authors: Evans; Roger G.
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Prolonged Infusions: The Significance of How*
    • Authors: Colton; Benjamin
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Beta-Lactam Therapeutic Drug Monitoring in the Critically Ill Children:
           Big Solution for Infections in Small People'*
    • Authors: Roberts; Jason A.
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • (Not) Everybody Is Working for the Weekend*
    • Authors: Wheeler; David S.; Hyzy, Robert C.
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Ventilator Management Guided by Driving Pressure: A Better Way to Protect
           the Lungs'*
    • Authors: MacIntyre; Neil
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Old Wine in New Bottles: Continuous Versus Intermittent Renal Replacement
           Therapy in the ICU*
    • Authors: de Pont; Anne-Cornélie; Volbeda, Meint
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Informed or Misinformed Consent'*
    • Authors: Meyfroidt; Geert
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Mesenchymal Stromal Cell Therapy: Does the Source Matter'*
    • Authors: Ghanta; Sailaja; Kwon, Min-Young; Rosas, Ivan O.; Liu, Xiaoli; Perrella, Mark A.
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • From Big Data to Artificial Intelligence: Harnessing Data Routinely
           Collected in the Process of Care*
    • Authors: Rush; Barret; Stone, David J.; Celi, Leo Anthony
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Renal Replacement Therapy Modality in the ICU and Renal Recovery at
           Hospital Discharge*
    • Authors: Bonnassieux; Martin; Duclos, Antoine; Schneider, Antoine G.; Schmidt, Aurélie; Bénard, Stève; Cancalon, Charlotte; Joannes-Boyau, Olivier; Ichai, Carole; Constantin, Jean-Michel; Lefrant, Jean-Yves; Kellum, John A.; Rimmelé, Thomas; for the AzuRéa Group
      Abstract: imageObjectives: Acute kidney injury requiring renal replacement therapy is a major concern in ICUs. Initial renal replacement therapy modality, continuous renal replacement therapy or intermittent hemodialysis, may impact renal recovery. The aim of this study was to assess the influence of initial renal replacement therapy modality on renal recovery at hospital discharge.Design: Retrospective cohort study of all ICU stays from January 1, 2010, to December 31, 2013, with a “renal replacement therapy for acute kidney injury” code using the French hospital discharge database.Setting: Two hundred ninety-one ICUs in France.Patients: A total of 1,031,120 stays: 58,635 with renal replacement therapy for acute kidney injury and 25,750 included in the main analysis.Interventions: None.Measurements Main Results: PPatients alive at hospital discharge were grouped according to initial modality (continuous renal replacement therapy or intermittent hemodialysis) and included in the main analysis to identify predictors of renal recovery. Renal recovery was defined as greater than 3 days without renal replacement therapy before hospital discharge. The main analysis was a hierarchical logistic regression analysis including patient demographics, comorbidities, and severity variables, as well as center characteristics. Three sensitivity analyses were performed. Overall mortality was 56.1%, and overall renal recovery was 86.2%. Intermittent hemodialysis was associated with a lower likelihood of recovery at hospital discharge; odds ratio, 0.910 (95% CI, 0.834–0.992) p value equals to 0.0327. Results were consistent across all sensitivity analyses with odds/hazards ratios ranging from 0.883 to 0.958.Conclusions: In this large retrospective study, intermittent hemodialysis as an initial modality was associated with lower renal recovery at hospital discharge among patients with acute kidney injury, although the difference seems somewhat clinically limited.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Informed Consent Documents Used in Critical Care Trials Often Do Not
           Implement Recommendations*
    • Authors: Atwere; Pearl; McIntyre, Lauralyn; Carroll, Kelly; Hayes, Tavis; Brehaut, Jamie C.
      Abstract: imageObjective: Informed consent documents are often poorly understood by research participants. In critical care, issues such as time pressure, patient capacity, and surrogate decision making complicate the consent process further. Recommendations exist for addressing critical care–specific consent issues; we examined how well existing practice implements these recommendations.Design: We conducted a systematic search of the literature for recommendations specific to critical care informed consent and rated existing informed consent documents on their implementation of 1) 18 of these critical care recommendations and 2) 36 previously developed general informed consent recommendations. Four hundred twelve registered critical care trials were identified and a request sent to the principal investigators for an example of the informed consent document associated with the trial. Each consent document was rated on both set of recommendations.Setting: We evaluated informed consent documents for trials conducted in English or French registered with clinicaltrials.gov.Patients: Not applicable.Interventions: Not applicable.Measurements and Main Results: Independent coders rated implementation of each recommendation on a four-point scale. Of 412 requests, 137 informed consent documents were returned, for a response rate of 34.1%. Of these, 86 met inclusion criteria and were assessed. Overall agreement between raters was 90.6% (weighted κ = 0.79; 0.77–0.81). Implementation of the 18 critical care recommendations was highly variable, ranging between 2% and 96.5%.Conclusions: Critical care studies often do not provide the information recommended for those providing consent for research. These clear recommendations provide testable hypotheses about how to improve the consent process for patients and family members considering trial participation in the critical care setting.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • The Glucagon-Like Peptide-1 Analog Exenatide Increases Blood Glucose
           Clearance, Lactate Clearance, and Heart Rate in Comatose Patients After
           Out-of-Hospital Cardiac Arrest
    • Authors: Wiberg; Sebastian; Kjaergaard, Jesper; Schmidt, Henrik; Thomsen, Jakob Hartvig; Frydland, Martin; Winther-Jensen, Matilde; Lindholm, Matias Greve; Høfsten, Dan Eik; Engstrøm, Thomas; Køber, Lars; Møller, Jacob Eifer; Hassager, Christian
      Abstract: imageObjectives: To investigate the effects of the glucagon-like peptide-1 analog exenatide on blood glucose, lactate clearance, and hemodynamic variables in comatose, resuscitated out-of-hospital cardiac arrest patients.Design: Predefined post hoc analyzes from a double-blind, randomized clinical trial.Setting: The ICU of a tertiary heart center.Patients: Consecutive sample of adult, comatose patients undergoing targeted temperature management after out-of-hospital cardiac arrest from a presumed cardiac cause, irrespective of the initial cardiac rhythm.Interventions: Patients were randomized 1:1 to receive 6 hours and 15 minutes of infusion of either 17.4 μg of the glucagon-like peptide-1 analog exenatide (Byetta; Lilly) or placebo within 4 hours from sustained return of spontaneous circulation. The effects of exenatide were examined on the following prespecified covariates within the first 6 hours from study drug initiation: lactate level, blood glucose level, heart rate, mean arterial pressure, and combined dosage of norepinephrine and dopamine.Measurements and Main Results: The population consisted of 106 patients receiving either exenatide or placebo. During the first 6 hours from study drug initiation, the levels of blood glucose and lactate decreased 17% (95% CI, 8.9–25%; p = 0.0004) and 21% (95% CI, 6.0–33%; p = 0.02) faster in patients receiving exenatide versus placebo, respectively. Exenatide increased heart rate by approximately 10 beats per minute compared to placebo (p < 0.0001). There was no effect of exenatide on other hemodynamic variables.Conclusions: In comatose out-of-hospital cardiac arrest patients, infusion with exenatide lowered blood glucose and resulted in increased clearance of lactate as well as increased heart rate. The clinical importance of these physiologic effects remains to be investigated.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Hospital Differences Drive Antibiotic Delays for Black Patients Compared
           With White Patients With Suspected Septic Shock
    • Authors: Taylor; Stephanie Parks; Karvetski, Colleen H.; Templin, Megan A.; Taylor, Brice T.
      Abstract: imageObjective: Evaluate racial disparities in sepsis processes of care.Design: Observational cohort study.Setting: Nine hospitals in the Southeastern United States between 2014 and 2016.Patients: Two thousand two hundred twenty-one white and 707 black patients treated in the emergency department through “code sepsis” pathway for suspected septic shock.Measurements and Main Results: Black patients were less likely to receive timely antibiotics than were white patients using multiple definitions (1 hr from code sepsis activation [odds ratio, 0.57; 95% CI, [0.44–0.74]; 85.6% vs. 91.2%; p < 0.0001]; 1 hr from triage [odds ratio, 0.83; 95% CI, [0.69–1.00]; 28.0% vs. 31.8%; p = 0.06]; 3 hr from triage [odds ratio, 0.71; 95% CI, [0.57–0.88]; 80.1% vs. 85.0%; p = 0.002]). Focusing on antibiotic administration within 1 hour of triage, these differences were enhanced after adjusting for patient-level factors (adjusted odds ratio, 0.80; 95% CI, [0.66–0.96]; p = 0.02), but attenuated after adjusting for hospital-level differences (adjusted odds ratio, 0.90; 95% CI, [0.81–1.01]; p = 0.07). Black and white patients did not differ on other sepsis quality indicators or adjusted mortality.Conclusions: Black patients appear to be less likely than white patients to receive timely antibiotic therapy for sepsis. These differences were largely explained by variation in care among hospitals, such that hospitals that disproportionately treat black patients were less likely to provide timely antibiotic therapy overall. There were no differences between races in other sepsis quality measures or adjusted mortality.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Mesenchymal Stem Cells From Bone Marrow, Adipose Tissue, and Lung Tissue
           Differentially Mitigate Lung and Distal Organ Damage in Experimental Acute
           Respiratory Distress Syndrome*
    • Authors: Silva; Johnatas D.; Lopes-Pacheco, Miquéias; Paz, Ana H. R.; Cruz, Fernanda F.; Melo, Elga B.; de Oliveira, Milena V.; Xisto, Débora G.; Capelozzi, Vera L.; Morales, Marcelo M.; Pelosi, Paolo; Cirne-Lima, Elizabeth; Rocco, Patricia R. M.
      Abstract: imageObjectives: Mesenchymal stem cells–based therapies have shown promising effects in experimental acute respiratory distress syndrome. Different mesenchymal stem cells sources may result in diverse effects in respiratory diseases; however, there is no information regarding the best source of mesenchymal stem cells to treat pulmonary acute respiratory distress syndrome. We tested the hypothesis that mesenchymal stem cells derived from bone marrow, adipose tissue, and lung tissue would lead to different beneficial effects on lung and distal organ damage in experimental pulmonary acute respiratory distress syndrome.Design: Animal study and primary cell culture.Setting: Laboratory investigation.Subjects: Seventy-five Wistar rats.Interventions: Wistar rats received saline (control) or Escherichia coli lipopolysaccharide (acute respiratory distress syndrome) intratracheally. On day 2, acute respiratory distress syndrome animals were further randomized to receive saline or bone marrow, adipose tissue, or lung tissue mesenchymal stem cells (1 × 105 cells) IV. Lung mechanics, histology, and protein levels of inflammatory mediators and growth factors were analyzed 5 days after mesenchymal stem cells administration. RAW 264.7 cells (a macrophage cell line) were incubated with lipopolysaccharide followed by coculture or not with bone marrow, adipose tissue, and lung tissue mesenchymal stem cells (105 cells/mL medium).Measurements and Main Results: Regardless of mesenchymal stem cells source, cells administration improved lung function and reduced alveolar collapse, tissue cellularity, collagen, and elastic fiber content in lung tissue, as well as decreased apoptotic cell counts in liver. Bone marrow and adipose tissue mesenchymal stem cells administration also reduced levels of tumor necrosis factor–α, interleukin-1β, keratinocyte-derived chemokine, transforming growth factor–β, and vascular endothelial growth factor, as well as apoptotic cell counts in lung and kidney, while increasing expression of keratinocyte growth factor in lung tissue. Additionally, mesenchymal stem cells differently modulated the secretion of biomarkers by macrophages depending on their source.Conclusions: Mesenchymal stem cells from different sources led to variable responses in lungs and distal organs. Bone marrow and adipose tissue mesenchymal stem cells yielded greater beneficial effects than lung tissue mesenchymal stem cells. These findings may be regarded as promising in clinical trials.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Determinants of Long-Term Neurological Recovery Patterns Relative to
           Hospital Discharge Among Cardiac Arrest Survivors
    • Authors: Agarwal; Sachin; Presciutti, Alex; Roth, William; Matthews, Elizabeth; Rodriguez, Ashley; Roh, David J.; Park, Soojin; Claassen, Jan; Lazar, Ronald M.
      Abstract: imageObjective: To explore factors associated with neurological recovery at 1 year relative to hospital discharge after cardiac arrest.Design: Observational, retrospective review of a prospectively collected cohort.Setting: Medical or surgical ICUs in a single tertiary care center.Patients: Older than 18 years, resuscitated following either in-hospital or out-of-hospital cardiac arrest and considered for targeted temperature management between 2007 and 2013.Interventions: None.Measurements and Main Results: Logistic regressions to determine factors associated with a poor recovery pattern after 1 year, defined as persistent Cerebral Performance Category Score 3–4 or any worsening of Cerebral Performance Category Score relative to discharge status. In total, 30% (117/385) of patients survived to hospital discharge; among those discharged with Cerebral Performance Category Score 1, 2, 3, and 4, good recovery pattern was seen in 54.5%, 48.4%, 39.5%, and 0%, respectively. Significant variables showing trends in associations with a poor recovery pattern (62.5%) in a multivariate model were age more than 70 years (odds ratio, 4; 95% CIs, 1.1–15; p = 0.04), Hispanic ethnicity (odds ratio, 4; CI, 1.2–13; p = 0.02), and discharge disposition (home needing out-patient services (odds ratio, 1), home requiring no additional services (odds ratio, 0.15; CI, 0.03–0.8; p = 0.02), acute rehabilitation (odds ratio, 0.23; CI, 0.06–0.9; p = 0.04).Conclusions: Patients discharged with mild or moderate cerebral dysfunction sustained their risk of neurological worsening within 1 year of cardiac arrest. Old age, Hispanic ethnicity, and discharge disposition of home with out-patient services may be associated with a poor 1 year neurological recovery pattern after hospital discharge from cardiac arrest.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • The Association Between Ventilator Dyssynchrony, Delivered Tidal Volume,
           and Sedation Using a Novel Automated Ventilator Dyssynchrony Detection
           Algorithm*
    • Authors: Sottile; Peter D.; Albers, David; Higgins, Carrie; Mckeehan, Jeffery; Moss, Marc M.
      Abstract: imageObjective: Ventilator dyssynchrony is potentially harmful to patients with or at risk for the acute respiratory distress syndrome. Automated detection of ventilator dyssynchrony from ventilator waveforms has been difficult. It is unclear if certain types of ventilator dyssynchrony deliver large tidal volumes and whether levels of sedation alter the frequency of ventilator dyssynchrony.Design: A prospective observational study.Setting: A university medical ICU.Patients: Patients with or at risk for acute respiratory distress syndrome.Interventions: Continuous pressure-time, flow-time, and volume-time data were directly obtained from the ventilator. The level of sedation and the use of neuromuscular blockade was extracted from the medical record. Machine learning algorithms that incorporate clinical insight were developed and trained to detect four previously described and clinically relevant forms of ventilator dyssynchrony. The association between normalized tidal volume and ventilator dyssynchrony and the association between sedation and the frequency of ventilator dyssynchrony were determined.Measurements and Main Results: A total of 4.26 million breaths were recorded from 62 ventilated patients. Our algorithm detected three types of ventilator dyssynchrony with an area under the receiver operator curve of greater than 0.89. Ventilator dyssynchrony occurred in 34.4% (95% CI, 34.41–34.49%) of breaths. When compared with synchronous breaths, double-triggered and flow-limited breaths were more likely to deliver tidal volumes greater than 10 mL/kg (40% and 11% compared with 0.2%; p < 0.001 for both comparisons). Deep sedation reduced but did not eliminate the frequency of all ventilator dyssynchrony breaths (p < 0.05). Ventilator dyssynchrony was eliminated with neuromuscular blockade (p < 0.001).Conclusion: We developed a computerized algorithm that accurately detects three types of ventilator dyssynchrony. Double-triggered and flow-limited breaths are associated with the frequent delivery of tidal volumes of greater than 10 mL/kg. Although ventilator dyssynchrony is reduced by deep sedation, potentially deleterious tidal volumes may still be delivered. However, neuromuscular blockade effectively eliminates ventilator dyssynchrony.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Hospital Variation in Renal Replacement Therapy for Sepsis in the United
           States
    • Authors: Valley; Thomas S.; Nallamothu, Brahmajee K.; Heung, Michael; Iwashyna, Theodore J.; Cooke, Colin R.
      Abstract: imageObjectives: Acute renal replacement therapy in patients with sepsis has increased dramatically with substantial costs. However, the extent of variability in use across hospitals—and whether greater use is associated with better outcomes—is unknown.Design: Retrospective cohort study.Setting: Nationwide Inpatient Sample in 2011.Patients: Eighteen years old and older with sepsis and acute kidney injury admitted to hospitals sampled by the Nationwide Inpatient Sample in 2011.Interventions: We estimated the risk- and reliability-adjusted rate of acute renal replacement therapy use for patients with sepsis and acute kidney injury at each hospital. We examined the association between hospital-specific renal replacement therapy rate and in-hospital mortality and hospital costs after adjusting for patient and hospital characteristics.Measurements and Main Results: We identified 293,899 hospitalizations with sepsis and acute kidney injury at 440 hospitals, of which 6.4% (n = 18,885) received renal replacement therapy. After risk and reliability adjustment, the median hospital renal replacement therapy rate for patients with sepsis and acute kidney injury was 3.6% (interquartile range, 2.9–4.5%). However, hospitals in the top quintile of renal replacement therapy use had rates ranging from 4.8% to 13.4%. There was no significant association between hospital-specific renal replacement therapy rate and in-hospital mortality (odds ratio per 1% increase in renal replacement therapy rate: 1.03; 95% CI, 0.99–1.07; p = 0.10). Hospital costs were significantly higher with increasing renal replacement therapy rates (absolute cost increase per 1% increase in renal replacement therapy rate: $1,316; 95% CI, $157–$2,475; p = 0.03).Conclusions: Use of renal replacement therapy in sepsis varied widely among nationally sampled hospitals without associated differences in mortality. Improving renal replacement standards for the initiation of therapy for sepsis may reduce healthcare costs without increasing mortality.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • PET-CT in Critically Ill Patients: Diagnosing the Unsuspected
    • Authors: Fort; Romain; Ledochowski, Stanislas; Friggeri, Arnaud
      Abstract: imageObjective: Quick identification of septic source is fundamental in patients with severe sepsis of unknown origin. The purpose of this case report was to assess the benefit and feasibility of an early PET-CT in critically ill patients with undiagnosed sepsis.Data Sources: Clinical observations of two patients.Study Selection: Case reports.Data Extraction: Data extracted from medical records, after patient’s consent. Illustrations were collected from the imaging software.Data Synthesis: We admitted two critically ill patients for suspected sepsis and altered mental state. As all bacteriological samples were initially sterile, diagnostic workups in both patients led us to suspect underlying malignant hemopathy. In fact, the lumbar puncture of the first patient revealed a large B-cell lymphoma, and an acquired thrombotic thrombocytopenic purpura was suspected in the second patient. However, PET-CTs performed in both patients displayed infra-clinical underlying infectious foci. Within 48 hours, both patients developed a clearly identified sepsis linked to the described focus, and favorable outcome thanks to the precious information delivered by the PET-CT.Conclusions: PET-CT precisely detected the deep foci of infection about 48 hours prior to the diagnosis of sepsis. The cases reports suggested the use of this image technique in ICU for patients with sepsis of unknown origin.
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Donation After Cardiocirculatory Determination of Death Requires
           “Timely” Rather Than “Early” Referral
    • Authors: Kramer; Andreas H.
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • The authors reply
    • Authors: Krmpotic; Kristina; Dhanani, Sonny
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Extracorporeal Membrane Oxygenation–Associated Infections: Carefully
           Consider Cannula Infections!
    • Authors: Messika; Jonathan; Schmidt, Matthieu; Aubry, Alexandra; Combes, Alain; Ricard, Jean-Damien
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • The authors reply
    • Authors: Grasselli; Giacomo; Scaravilli, Vittorio; Alagna, Laura; Gori, Andrea; Pesenti, Antonio
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Untargeted Antifungal Treatment in the ICU: Changing Definitions and
           Labels Do Not Change the Evidence
    • Authors: Cortegiani; Andrea; Raineri, Santi Maurizio; Giarratano, Antonino
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • The authors reply
    • Authors: Dupont; Hervé; Mahjoub, Yazine; Chouaki, Taieb; Lorne, Emmanuel; Zogheib, Elie
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Individualizing Cerebral Perfusion Pressure Targets
    • Authors: Bernard; Francis; Albert, Martin; Brunette, Véronique
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • The authors reply
    • Authors: Donnelly; Joseph; Smielewski, Peter; Menon, David K.; Ercole, Ari; Aries, Marcel J. H.
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Heparin-Free Regional Anticoagulation: There Are Significant Differences
           
    • Authors: Gubensek; Jakob; Buturovic-Ponikvar, Jadranka
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • The authors reply
    • Authors: Faguer; Stanislas; Kamar, Nassim; Cointault, Olivier
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Impact of Moderate Hyperchloremia on Clinical Outcomes in Intracerebral
           Hemorrhage Patients. Is There Still Room for Continuous Infusion of 3%
           Hypertonic Saline'
    • Authors: Poignant; Simon; Laffon, Marc
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • The authors reply
    • Authors: Jones; G. Morgan; Erdman, Michael J.; Riha, Heidi M.
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Burnout Research: Eyes Wide Shut
    • Authors: Schonfeld; Irvin Sam; Laurent, Eric; Bianchi, Renzo
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • The authors reply
    • Authors: Colville; Gillian A.; Smith, Jared G.
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Is Oxygenation Really an Intrinsic Predictive Factor of Mortality in
           Patients Undergoing Extracorporeal Life Support'
    • Authors: Ishii; Junki; Ohshimo, Shinichiro; Shime, Nobuaki
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • The authors reply
    • Authors: Munshi; Laveena; Fan, Eddy
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Systolic Dysfunction Following Traumatic Brain Injury
    • Authors: Venkata; Chakradhar
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • The authors reply
    • Authors: Krishnamoorthy; Vijay; Rowhani-Rahbar, Ali; Gibbons, Edward F.; Chaikittisilpa, Nophanan; Vavilala, Monica S.
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Noninvasive Ventilation in Acute Respiratory Failure: Who Will
           Benefit'
    • Authors: Cheng; Xuping
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • The authors reply
    • Authors: Xu; Xiu-Ping; Liu, Ling; Pan, Chun; Qiu, Hai-Bo
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Effect of Patient- and Family-Centered Care Interventions on ICU Length of
           Stay
    • Authors: Iftikhar; Imran H.
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • The author replies
    • Authors: Goldfarb; Michael
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Clinical Airway Management: An Illustrated Case-Based Approach
    • Authors: Miller; Lydia K.; Bittner, Edward A.
      Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
  • Severe Burnout Is Common Among Critical Care Physician Assistants:
           Retraction
    • Abstract: No abstract available
      PubDate: Thu, 01 Feb 2018 00:00:00 GMT-
       
 
 
JournalTOCs
School of Mathematical and Computer Sciences
Heriot-Watt University
Edinburgh, EH14 4AS, UK
Email: journaltocs@hw.ac.uk
Tel: +00 44 (0)131 4513762
Fax: +00 44 (0)131 4513327
 
Home (Search)
Subjects A-Z
Publishers A-Z
Customise
APIs
Your IP address: 54.227.17.101
 
About JournalTOCs
API
Help
News (blog, publications)
JournalTOCs on Twitter   JournalTOCs on Facebook

JournalTOCs © 2009-