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Journal Cover Critical Care Medicine
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   ISSN (Print) 0090-3493
   Published by LWW Wolters Kluwer Homepage  [289 journals]
  • Efficacy and Safety of Combination Therapy of Shenfu Injection and
           Postresuscitation Bundle in Patients With Return of Spontaneous
           Circulation After In-Hospital Cardiac Arrest: A Randomized,
           Assessor-Blinded, Controlled Trial*
    • Authors: Zhang; Qian; Li, Chunsheng; Shao, Fei; Zhao, Lianxing; Wang, Miaomiao; Fang, Yingying
      Abstract: imageObjectives: Postresuscitation care bundle treatment after return of spontaneous circulation in patients experiencing in-hospital cardiac arrest can improve patients’ survival and quality of life. The aim of the study was to evaluate the efficacy and safety of combined therapy of Shenfu injection and postresuscitation care bundle in these patients.Design: Prospective, randomized, controlled clinical study.Setting: Fifty hospitals in China.Patients: Adult patients had experienced in-hospital cardiac arrest between 2012 and 2015.Interventions: Based on the standardized postresuscitation care bundle treatment, patients were randomized to a Shenfu injection group (Shenfu injection + postresuscitation care bundle) or control group (postresuscitation care bundle) for 14 days or until hospital discharge. In the Shenfu injection group, 100 mL Shenfu injection was additionally administered via continuous IV infusion, bid.Measurements and Main Results: The primary outcome was 28-day survival after randomization. The secondary outcomes included 90-day survival as well as the duration of mechanical ventilation and the hospital stay and the total cost of hospitalization. Of 1,022 patients enrolled, a total of 978 patients were allocated to the two groups: the control (n = 486) and Shenfu injection (n = 492) groups. The Shenfu injection group had a significantly greater 28-day survival rate (42.7%) than the control group (30.1%). Also, the Shenfu injection group had a significantly higher survival rate at 90 days (39.6%) than the control group (25.9%). Compared with patients in the control group, patients in the Shenfu injection group had lower risks of 28-day mortality (hazard ratio, 0.61; 95% CI, 0.43–0.89; p = 0.009) and 90-day mortality (hazard ratio, 0.55; 95% CI, 0.38–0.79; p = 0.002). In the Shenfu injection group, the duration of mechanical ventilation (8.6 ± 3.2 vs 12.7 ± 7.9 d; p < 0.001) and the hospital stay (8.7 ± 5.9 vs 13.2 ± 8.1 d; p < 0.001) were significantly less than in the control group. Irreversible brain damage was the main cause of death in both groups. No serious drug-related adverse event was recorded.Conclusions: This study demonstrates that Shenfu injection in combination with conventional postresuscitation care bundle treatment is effective at improving clinical outcomes in patients with return of spontaneous circulation after in-hospital cardiac arrest.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Patterns and Outcomes Associated With Timeliness of Initial Crystalloid
           Resuscitation in a Prospective Sepsis and Septic Shock Cohort*
    • Authors: Leisman; Daniel E.; Goldman, Chananya; Doerfler, Martin E.; Masick, Kevin D.; Dries, Susan; Hamilton, Eric; Narasimhan, Mangala; Zaidi, Gulrukh; D’Amore, Jason A.; D’Angelo, John K.
      Abstract: imageObjectives: The objectives of this study were to 1) assess patterns of early crystalloid resuscitation provided to sepsis and septic shock patients at initial presentation and 2) determine the association between time to initial crystalloid resuscitation with hospital mortality, mechanical ventilation, ICU utilization, and length of stay.Design: Consecutive-sample observational cohort.Setting: Nine tertiary and community hospitals over 1.5 years.Patients: Adult sepsis and septic shock patients captured in a prospective quality improvement database inclusion criteria: suspected or confirmed infection, greater than or equal to two systemic inflammatory response criteria, greater than or equal to one organ-dysfunction criteria.Interventions: The primary exposure was crystalloid initiation within 30 minutes or lesser, 31–120 minutes, or more than 120 minutes from sepsis identification.Measurements and Main Results: We identified 11,182 patients. Crystalloid initiation was faster for emergency department patients (β, –141 min; CI, –159 to –125; p < 0.001), baseline hypotension (β, –39 min; CI, –48 to –32; p < 0.001), fever, urinary or skin/soft-tissue source of infection. Initiation was slower with heart failure (β, 20 min; CI, 14–25; p < 0.001), and renal failure (β, 16 min; CI, 10–22; p < 0.001). Five thousand three hundred thirty-six patients (48%) had crystalloid initiated in 30 minutes or lesser versus 2,388 (21%) in 31–120 minutes, and 3,458 (31%) in more than 120 minutes. The patients receiving fluids within 30 minutes had lowest mortality (949 [17.8%]) versus 31–120 minutes (446 [18.7%]) and more than 120 minutes (846 [24.5%]). Compared with more than 120 minutes, the adjusted odds ratio for mortality was 0.76 (CI, 0.64–0.90; p = 0.002) for 30 minutes or lesser and 0.76 (CI, 0.62–0.92; p = 0.004) for 31–120 minutes. When assessed continuously, mortality odds increased by 1.09 with each hour to initiation (CI, 1.03–1.16; p = 0.002). We observed similar patterns for mechanical ventilation, ICU utilization, and length of stay. We did not observe significant interaction for mortality risk between initiation time and baseline heart failure, renal failure, hypotension, acute kidney injury, altered gas exchange, or emergency department (vs inpatient) presentation.Conclusions: Crystalloid was initiated significantly later with comorbid heart failure and renal failure, with absence of fever or hypotension, and in inpatient-presenting sepsis. Earlier crystalloid initiation was associated with decreased mortality. Comorbidities and severity did not modify this effect.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Identifying Distinct Subgroups of ICU Patients: A Machine Learning
           Approach*
    • Authors: Vranas; Kelly C.; Jopling, Jeffrey K.; Sweeney, Timothy E.; Ramsey, Meghan C.; Milstein, Arnold S.; Slatore, Christopher G.; Escobar, Gabriel J.; Liu, Vincent X.
      Abstract: imageObjectives: Identifying subgroups of ICU patients with similar clinical needs and trajectories may provide a framework for more efficient ICU care through the design of care platforms tailored around patients’ shared needs. However, objective methods for identifying these ICU patient subgroups are lacking. We used a machine learning approach to empirically identify ICU patient subgroups through clustering analysis and evaluate whether these groups might represent appropriate targets for care redesign efforts.Design: We performed clustering analysis using data from patients’ hospital stays to retrospectively identify patient subgroups from a large, heterogeneous ICU population.Setting: Kaiser Permanente Northern California, a healthcare delivery system serving 3.9 million members.Patients: ICU patients 18 years old or older with an ICU admission between January 1, 2012, and December 31, 2012, at one of 21 Kaiser Permanente Northern California hospitals.Interventions: None.Measurements and Main Results: We used clustering analysis to identify putative clusters among 5,000 patients randomly selected from 24,884 ICU patients. To assess cluster validity, we evaluated the distribution and frequency of patient characteristics and the need for invasive therapies. We then applied a classifier built from the sample cohort to the remaining 19,884 patients to compare the derivation and validation clusters. Clustering analysis successfully identified six clinically recognizable subgroups that differed significantly in all baseline characteristics and clinical trajectories, despite sharing common diagnoses. In the validation cohort, the proportion of patients assigned to each cluster was similar and demonstrated significant differences across clusters for all variables.Conclusions: A machine learning approach revealed important differences between empirically derived subgroups of ICU patients that are not typically revealed by admitting diagnosis or severity of illness alone. Similar data-driven approaches may provide a framework for future organizational innovations in ICU care tailored around patients’ shared needs.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Molecular Adsorbent Recirculating System Can Reduce Short-Term Mortality
           Among Patients With Acute-on-Chronic Liver Failure—A Retrospective
           Analysis*
    • Authors: Gerth; Hans U.; Pohlen, Michele; Thölking, Gerold; Pavenstädt, Hermann; Brand, Marcus; Hüsing-Kabar, Anna; Wilms, Christian; Maschmeier, Miriam; Kabar, Iyad; Torner, Josep; Pavesi, Marco; Arroyo, Vicente; Banares, Rafael; Schmidt, Hartmut H. J.
      Abstract: imageObjectives: Acute-on-chronic liver failure is associated with numerous consecutive organ failures and a high short-term mortality rate. Molecular adsorbent recirculating system therapy has demonstrated beneficial effects on the distinct symptoms, but the associated mortality data remain controversial.Design: Retrospective analysis of acute-on-chronic liver failure patients receiving either standard medical treatment or standard medical treatment and molecular adsorbent recirculating system. Secondary analysis of data from the prospective randomized Recompensation of Exacerbated Liver Insufficiency with Hyperbilirubinemia and/or Encephalopathy and/or Renal Failure trial by applying the recently introduced Chronic Liver Failure-criteria.Setting: Medical Departments of University Hospital Muenster (Germany).Patients: This analysis was conducted in two parts. First, 101 patients with acute-on-chronic liver failure grades 1–3 and Chronic Liver Failure-C-Organ Failure liver subscore equals to 3 but stable pulmonary function were identified and received either standard medical treatment (standard medical treatment, n = 54) or standard medical treatment and molecular adsorbent recirculating system (n = 47) at the University Hospital Muenster. Second, the results of this retrospective analysis were tested against the Recompensation of Exacerbated Liver Insufficiency with Hyperbilirubinemia and/or Encephalopathy and/or Renal Failure trial.Interventions: Standard medical treatment and molecular adsorbent recirculating system.Measurements and Main Results: Additionally to improved laboratory variables (bilirubin and creatinine), the short-term mortality (up to day 14) of the molecular adsorbent recirculating system group was significantly reduced compared with standard medical treatment. A reduced 14-day mortality rate was observed in the molecular adsorbent recirculating system group (9.5% vs 50.0% with standard medical treatment; p = 0.004), especially in patients with multiple organ failure (acute-on-chronic liver failure grade 2–3). Concerning the affected organ system, this effect of molecular adsorbent recirculating system on mortality was particularly evident among patients with increased kidney, brain, or coagulation Chronic Liver Failure-C-Organ Failure subscores. Subsequent reanalysis of the Recompensation of Exacerbated Liver Insufficiency with Hyperbilirubinemia and/or Encephalopathy and/or Renal Failure dataset with adoption of the Chronic Liver Failure-classification resulted in similar findings.Conclusions: Molecular adsorbent recirculating system treatment was associated with an improved short-term survival of patients with acute-on-chronic liver failure and multiple organ failure. Among these high-risk patients, molecular adsorbent recirculating system treatment might bridge to liver recovery or liver transplantation.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Determinants of Receiving Palliative Care and Ventilator Withdrawal Among
           Patients With Prolonged Mechanical Ventilation*
    • Authors: Chen; Yang-Ching; Fan, Hsien-Yu; Curtis, J. Randall; Lee, Oscar Kuang-Sheng; Liu, Chih-Kuang; Huang, Sheng-Jean
      Abstract: imageObjectives: Increasing numbers of patients with prolonged mechanical ventilation generates a tremendous strain on healthcare systems. Patients with prolonged mechanical ventilation suffer from long-term poor quality of life. However, no study has ever explored the willingness to receive palliative care or terminal withdrawal and the factors influencing willingness.Design: Cross-sectional study.Setting: Five different hospitals of Taipei City Hospital system.Patients: Adult patients with ventilatory support for more than 60 days.Interventions: None.Measurements and Main Results: We identified the family members of 145 consecutive patients with prolonged mechanical ventilation in five hospitals of Taipei City Hospital system and enrolled family members for 106 patients (73.1%). We collected information from patient families’ regarding concepts (knowledge, attitude, and experiences) of palliative care, caregiver burden, family function, patient quality of life, and physician-family communications. From the medical record, we obtained duration of hospitalization, consciousness level, disease severity, medical cost, and the presence of do-not-resuscitate orders. The vast majority of family members agreed with the concept of palliative care (90.4%) with 17.3% of the family members agreeing to ventilator withdrawal currently and 67.5% terminally in anticipation of death. Approximately half of the family members regretted having chosen prolonged mechanical ventilation (56.7%). Reduced patient quality of life and increased family understanding of palliative care significantly associated with increased caregiver willingness to endorse palliative care and withdraw life-sustaining agents in anticipation of death. Longer duration of ventilator usage and hospitalization was associated with increased feelings of regret about choosing prolonged mechanical ventilation.Conclusions: During prolonged mechanical ventilation, physicians should thoroughly discuss its benefits and burdens. Families should be given the opportunity to discuss the circumstances under which they might request the implementation of palliative care or withdrawal of mechanical ventilation in order to avoid prolonging the dying process.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • No Impact of Preadmission Anti-Inflammatory Drug Use on Risk of Depression
           and Anxiety After Critical Illness*
    • Authors: Medici; Clara R.; Gradus, Jaimie L.; Pedersen, Lars; Sørensen, Henrik T.; Østergaard, Søren D.; Christiansen, Christian F.
      Abstract: imageObjectives: Risk of depression and anxiety is elevated after intensive care. Drugs with anti-inflammatory properties may have antidepressant and anxiolytic effects. The aim of this study was to investigate the association between preadmission use of drugs with anti-inflammatory effects and risk of new-onset depression and anxiety among adult patients admitted to an ICU.Design: Propensity score–matched, population-based cohort study.Setting: All ICUs in Denmark from 2005 to 2013.Patients: Adults receiving mechanical ventilation in an ICU.Interventions: None.Measurements and Main Results: A total of 48,207 ICU patients were included. Exposures were preadmission single-agent or combined use of statins, nonsteroidal anti-inflammatory drugs, or glucocorticoids. Outcomes were cumulative incidence (risk) and risk ratio of new-onset psychiatrist-diagnosed depression or anxiety or prescriptions for antidepressants or anxiolytics. Propensity score matching yielded 6,088 statin user pairs, 2,886 nonsteroidal anti-inflammatory drug user pairs, 1,440 glucocorticoid user pairs, and 1,743 combination drug user pairs. The cumulative incidence of anxiety and depression during the 3 years following intensive care was 18.0% (95% CI, 17.0–19.0%) for statin users, 21.3% (95% CI, 19.8–22.9%) for nonsteroidal anti-inflammatory drug users, 17.4% (95% CI, 15.4–19.5%) for glucocorticoid users, and 19.0% (95% CI, 16.3–20.2%) for combination users. The cumulative incidence was similar in nonusers compared with users in all drug groups. The risk ratio of depression and anxiety 3 years after admission to ICU was 1.04 (95% CI, 0.96–1.13) for statin users, 1.00 (95% CI, 0.90–1.11) for nonsteroidal anti-inflammatory drug users, 0.97 (95% CI, 0.82–1.14) for glucocorticoid users, and 1.05 (95% CI, 0.90–1.21) for combination users, compared with nonusers. Results were consistent across subgroups (gender, age, preadmission diseases, type of admission) and sensitivity analyses (depression and anxiety separately).Conclusions: Preadmission use of statins, nonsteroidal anti-inflammatory drugs, glucocorticoids, or combinations did not alter the risk of depression and anxiety after critical illness.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Severe Respiratory Failure, Extracorporeal Membrane Oxygenation, and
           Intracranial Hemorrhage*
    • Authors: Lockie; Christopher J. A.; Gillon, Stuart A.; Barrett, Nicholas A.; Taylor, Daniel; Mazumder, Asif; Paramesh, Kaggere; Rowland, Katie; Daly, Kathleen; Camporota, Luigi; Meadows, Christopher I. S.; Glover, Guy W.; Ioannou, Nicholas; Langrish, Christopher J.; Tricklebank, Stephen; Retter, Andrew; Wyncoll, Duncan L. A.
      Abstract: imageObjectives: For patients supported with veno-venous extracorporeal membrane oxygenation, the occurrence of intracranial hemorrhage is associated with a high mortality. It is unclear whether intracranial hemorrhage is a consequence of the extracorporeal intervention or of the underlying severe respiratory pathology. In a cohort of patients transferred to a regional severe respiratory failure center that routinely employs admission brain imaging, we sought 1) the prevalence of intracranial hemorrhage; 2) survival and neurologic outcomes; and 3) factors associated with intracranial hemorrhage.Design: A single-center, retrospective, observational cohort study.Setting: Tertiary referral severe respiratory failure center, university teaching hospital.Patients: Patients admitted between December 2011 and February 2016.Intervention: None.Measurements and Main Results: Three hundred forty-two patients were identified: 250 managed with extracorporeal support and 92 managed using conventional ventilation. The prevalence of intracranial hemorrhage was 16.4% in extracorporeal membrane oxygenation patients and 7.6% in conventionally managed patients (p = 0.04). Multivariate analysis revealed factors independently associated with intracranial hemorrhage to be duration of ventilation (d) (odds ratio, 1.13 [95% CI, 1.03–1.23]; p = 0.011) and admission fibrinogen (g/L) (odds ratio, 0.73 [0.57–0.91]; p = 0.009); extracorporeal membrane oxygenation was not an independent risk factor (odds ratio, 3.29 [0.96–15.99]; p = 0.088). In patients who received veno-venous extracorporeal membrane oxygenation, there was no significant difference in 6-month survival between patients with and without intracranial hemorrhage (68.3% vs 76.0%; p = 0.350). Good neurologic function was observed in 92%.Conclusions: We report a higher prevalence of intracranial hemorrhage than has previously been described with high level of neurologically intact survival. Duration of mechanical ventilation and admission fibrinogen, but not exposure to extracorporeal support, are independently associated with intracranial hemorrhage.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Quality Improvement Initiatives in Sepsis in an Emerging Country: Does the
           Institution’s Main Source of Income Influence the Results' An
           Analysis of 21,103 Patients*
    • Authors: Machado; Flavia R.; Ferreira, Elaine M.; Sousa, Juliana Lubarino; Silva, Carla; Schippers, Pierre; Pereira, Adriano; Cardoso, Ilusca M.; Salomão, Reinaldo; Japiassu, Andre; Akamine, Nelson; Mazza, Bruno F.; Assunção, Murillo S. C.; Fernandes, Haggeas S.; Bossa, Aline; Monteiro, Mariana B.; Caixeita, Noemi; Azevedo, Luciano C. P.; Silva, Eliezer; on behalf of the Latin American Sepsis Institute Network
      Abstract: imageObjective: We aimed to assess the results of a quality improvement initiative in sepsis in an emerging setting and to analyze it according to the institutions’ main source of income (public or private).Design: Retrospective analysis of the Latin American Sepsis Institute database from 2005 to 2014.Settings: Brazilian public and private institutions.Patients: Patients with sepsis admitted in the participant institutions.Interventions: The quality improvement initiative was based on a multifaceted intervention. The institutions were instructed to collect data on 6-hour bundle compliance and outcomes in patients with sepsis in all hospital settings. Outcomes and compliance was measured for eight periods of 6 months each, starting at the time of the enrollment in the intervention. The primary outcomes were hospital mortality and compliance with 6-hour bundle.Measurements and Main Results: We included 21,103 patients; 9,032 from public institutions and 12,071 from private institutions. Comparing the first period with the eigth period, compliance with the 6-hour bundle increased from 13.5% to 58.2% in the private institutions (p < 0.0001) and from 7.4% to 15.7% in the public institutions (p < 0.0001). Mortality rates significantly decreased throughout the program in private institutions, from 47.6% to 27.2% in the eighth period (adjusted odds ratio, 0.45; 95% CI, 0.32–0.64). However, in the public hospitals, mortality diminished significantly only in the first two periods.Conclusion: This quality improvement initiative in sepsis in an emerging country was associated with a reduction in mortality and with improved compliance with quality indicators. However, this reduction was sustained only in private institutions.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Effectiveness and Safety of an Extended ICU Visitation Model for Delirium
           Prevention: A Before and After Study*
    • Authors: Rosa; Regis Goulart; Tonietto, Tulio Frederico; da Silva, Daiana Barbosa; Gutierres, Franciele Aparecida; Ascoli, Aline Maria; Madeira, Laura Cordeiro; Rutzen, William; Falavigna, Maicon; Robinson, Caroline Cabral; Salluh, Jorge Ibrain; Cavalcanti, Alexandre Biasi; Azevedo, Luciano Cesar; Cremonese, Rafael Viegas; Haack, Tarissa Ribeiro; Eugênio, Cláudia Severgnini; Dornelles, Aline; Bessel, Marina; Teles, José Mario Meira; Skrobik, Yoanna; Teixeira, Cassiano; for the ICU Visits Study Group Investigators
      Abstract: imageObjectives: To evaluate the effect of an extended visitation model compared with a restricted visitation model on the occurrence of delirium among ICU patients.Design: Prospective single-center before and after study.Setting: Thirty-one–bed medical-surgical ICU.Patients: All patients greater than or equal to 18 years old with expected length of stay greater than or equal to 24 hours consecutively admitted to the ICU from May 2015 to November 2015.Interventions: Change of visitation policy from a restricted visitation model (4.5 hr/d) to an extended visitation model (12 hr/d).Measurements and Main Results: Two hundred eighty-six patients were enrolled (141 restricted visitation model, 145 extended visitation model). The primary outcome was the cumulative incidence of delirium, assessed bid using the confusion assessment method for the ICU. Predefined secondary outcomes included duration of delirium/coma; any ICU-acquired infection; ICU-acquired bloodstream infection, pneumonia, and urinary tract infection; all-cause ICU mortality; and length of ICU stay. The median duration of visits increased from 133 minutes (interquartile range, 97.7–162.0) in restricted visitation model to 245 minutes (interquartile range, 175.0–272.0) in extended visitation model (p < 0.001). Fourteen patients (9.6%) developed delirium in extended visitation model compared with 29 (20.5%) in restricted visitation model (adjusted relative risk, 0.50; 95% CI, 0.26–0.95). In comparison with restricted visitation model patients, extended visitation model patients had shorter length of delirium/coma (1.5 d [interquartile range, 1.0–3.0] vs 3.0 d [interquartile range, 2.5–5.0]; p = 0.03) and ICU stay (3.0 d [interquartile range, 2.0–4.0] vs 4.0 d [interquartile range, 2.0–6.0]; p = 0.04). The rate of ICU-acquired infections and all-cause ICU mortality did not differ significantly between the two study groups.Conclusions: In this medical-surgical ICU, an extended visitation model was associated with reduced occurrence of delirium and shorter length of delirium/coma and ICU stay.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Characteristics and Outcome of Cancer Patients Admitted to the ICU in
           England, Wales, and Northern Ireland and National Trends Between 1997 and
           2013*
    • Authors: Ostermann; Marlies; Ferrando-Vivas, Paloma; Gore, Carmen; Power, Sarah; Harrison, David
      Abstract: imageObjective: To describe trends in outcomes of cancer patients with an unplanned admission to the ICU between 1997 and 2013 and to identify risk factors for mortality of those admitted between 2009 and 2013.Design: Retrospective analysis.Setting: Intensive Care National Audit & Research Centre Case Mix Programme Database including data of ICUs in England, Wales, and Northern Ireland.Patients: Patients (99,590) with a solid tumor and 13,538 patients with a hematological malignancy with an unplanned ICU admission between 1997 and 2013; 39,734 solid tumor patients and 6,652 patients with a hematological malignancy who were admitted between 2009 and 2013 were analyzed in depth.Interventions: None.Measurements and Main Results: In solid tumor patients admitted between 2009 and 2013, hospital mortality was 26.4%. Independent risk factors for hospital mortality were metastatic disease (odds ratio, 1.99), cardiopulmonary resuscitation before ICU admission (odds ratio, 1.63), Intensive Care National Audit & Research Centre Physiology score (odds ratio, 1.14), admission for gastrointestinal (odds ratio, 1.12), respiratory (odds ratio, 1.48) or neurological (odds ratio, 1.65) reasons, and previous ICU admission (odds ratio, 1.18). In patients with a hematological malignancy admitted between 2009 and 2013, hospital mortality was 53.6%. Independent risk factors for hospital mortality were age (odds ratio, 1.02), cardiopulmonary resuscitation before ICU admission (odds ratio, 1.90), Intensive Care National Audit & Research Centre Physiology Score (odds ratio, 1.12), admission for hematological (odds ratio, 1.48) or respiratory (odds ratio, 1.56) reasons, bone marrow transplant (odds ratio, 1.53), previous ICU admission (odds ratio, 1.43), and mechanical ventilation within 24 hours of admission (odds ratio, 1.33). Trend analysis showed a significant decrease in ICU and hospital mortality and length of stay between 1997 and 2013 despite little change in severity of illness during this time.Conclusions: Between 1997 and 2013, the outcome of cancer patients with an unplanned admission to ICU improved significantly. Among those admitted between 2009 and 2013, independent risk factors for hospital mortality were age, severity of illness, previous cardiopulmonary resuscitation, previous ICU admission, metastatic disease, and admission for respiratory reasons.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Association Between Survival and Time of Day for Rapid Response Team Calls
           in a National Registry
    • Authors: Churpek; Matthew Michael; Edelson, Dana P.; Lee, Ji Yeon; Carey, Kyle; Snyder, Ashley; for the American Heart Association’s Get With The Guidelines-Resuscitation Investigators
      Abstract: imageObjectives: Decreased staffing at nighttime is associated with worse outcomes in hospitalized patients. Rapid response teams were developed to decrease preventable harm by providing additional critical care resources to patients with clinical deterioration. We sought to determine whether rapid response team call frequency suffers from decreased utilization at night and how this is associated with patient outcomes.Design: Retrospective analysis of a prospectively collected registry database.Setting: National registry database of inpatient rapid response team calls.Patients: Index rapid response team calls occurring on the general wards in the American Heart Association Get With The Guidelines-Medical Emergency Team database between 2005 and 2015 were analyzed.Interventions: None.Measurements and Main Results: The primary outcome was inhospital mortality. Patient and event characteristics between the hours with the highest and lowest mortality were compared, and multivariable models adjusting for patient characteristics were fit. A total of 282,710 rapid response team calls from 274 hospitals were included. The lowest frequency of calls occurred in the consecutive 1 AM to 6:59 AM period, with 266 of 274 (97%) hospitals having lower than expected call volumes during those hours. Mortality was highest during the 7 AM hour and lowest during the noon hour (18.8% vs 13.8%; adjusted odds ratio, 1.41 [1.31–1.52]; p < 0.001). Compared with calls at the noon hour, those during the 7 AM hour had more deranged vital signs, were more likely to have a respiratory trigger, and were more likely to have greater than two simultaneous triggers.Conclusions: Rapid response team activation is less frequent during the early morning and is followed by a spike in mortality in the 7 AM hour. These findings suggest that failure to rescue deteriorating patients is more common overnight. Strategies aimed at improving rapid response team utilization during these vulnerable hours may improve patient outcomes.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Critically Ill Patients With the Middle East Respiratory Syndrome: A
           Multicenter Retrospective Cohort Study
    • Authors: Arabi; Yaseen M.; Al-Omari, Awad; Mandourah, Yasser; Al-Hameed, Fahad; Sindi, Anees A.; Alraddadi, Basem; Shalhoub, Sarah; Almotairi, Abdullah; Al Khatib, Kasim; Abdulmomen, Ahmed; Qushmaq, Ismael; Mady, Ahmed; Solaiman, Othman; Al-Aithan, Abdulsalam M.; Al-Raddadi, Rajaa; Ragab, Ahmed; Al Mekhlafi, Ghaleb. A.; Al Harthy, Abdulrahman; Kharaba, Ayman; Ahmadi, Mashael Al; Sadat, Musharaf; Mutairi, Hanan Al; Qasim, Eman Al; Jose, Jesna; Nasim, Maliha; Al-Dawood, Abdulaziz; Merson, Laura; Fowler, Robert; Hayden, Frederick G.; Balkhy, Hanan H.; for the Saudi Critical Care Trial Group
      Abstract: imageObjectives: To describe patient characteristics, clinical manifestations, disease course including viral replication patterns, and outcomes of critically ill patients with severe acute respiratory infection from the Middle East respiratory syndrome and to compare these features with patients with severe acute respiratory infection due to other etiologies.Design: Retrospective cohort study.Setting: Patients admitted to ICUs in 14 Saudi Arabian hospitals.Patients: Critically ill patients with laboratory-confirmed Middle East respiratory syndrome severe acute respiratory infection (n = 330) admitted between September 2012 and October 2015 were compared to consecutive critically ill patients with community-acquired severe acute respiratory infection of non–Middle East respiratory syndrome etiology (non–Middle East respiratory syndrome severe acute respiratory infection) (n = 222).Interventions: None.Measurements and Main Results: Although Middle East respiratory syndrome severe acute respiratory infection patients were younger than those with non–Middle East respiratory syndrome severe acute respiratory infection (median [quartile 1, quartile 3] 58 yr [44, 69] vs 70 [52, 78]; p < 0.001), clinical presentations and comorbidities overlapped substantially. Patients with Middle East respiratory syndrome severe acute respiratory infection had more severe hypoxemic respiratory failure (PaO2/FIO2: 106 [66, 160] vs 176 [104, 252]; p < 0.001) and more frequent nonrespiratory organ failure (nonrespiratory Sequential Organ Failure Assessment score: 6 [4, 9] vs 5 [3, 7]; p = 0.002), thus required more frequently invasive mechanical ventilation (85.2% vs 73.0%; p < 0.001), oxygen rescue therapies (extracorporeal membrane oxygenation 5.8% vs 0.9%; p = 0.003), vasopressor support (79.4% vs 55.0%; p < 0.001), and renal replacement therapy (48.8% vs 22.1%; p < 0.001). After adjustment for potential confounding factors, Middle East respiratory syndrome was independently associated with death compared to non–Middle East respiratory syndrome severe acute respiratory infection (adjusted odds ratio, 5.87; 95% CI, 4.02–8.56; p < 0.001).Conclusions: Substantial overlap exists in the clinical presentation and comorbidities among patients with Middle East respiratory syndrome severe acute respiratory infection from other etiologies; therefore, a high index of suspicion combined with diagnostic testing is essential component of severe acute respiratory infection investigation for at-risk patients. The lack of distinguishing clinical features, the need to rely on real-time reverse transcription polymerase chain reaction from respiratory samples, variability in viral shedding duration, lack of effective therapy, and high mortality represent substantial clinical challenges and help guide ongoing clinical research efforts.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Is There a Role for Enterohormones in the Gastroparesis of Critically Ill
           Patients'
    • Authors: Santacruz; Carlos A.; Quintairos, Amanda; Righy, Claudia; Crippa, Ilaria A.; Couto, Lucio Jr; Imbault, Virginie; Wasineeart, Mongkolpun; De Ryckere, Mathieu; Preiser, Jean-Charles
      Abstract: imageObjectives: Delayed gastric emptying occurs in critically ill patients and impairs the delivery, digestion, and absorption of enteral feeding. A pathophysiologic role of the enterohormones peptide YY and ghrelin is supported by preclinical data. To compare the circulating plasma levels of peptide YY and ghrelin in control subjects and in critically ill patients, during feeding and fasting, and to search for a correlation with gastric emptying.Design: A prospective observational trial.Settings: Mixed ICU of an academic hospital.Subjects: Healthy volunteers and patients expected to stay in ICU for at least 3 days in whom enteral nutrition was indicated.Interventions: None.Measurements and Main Results: Plasma peptide YY and ghrelin (enzyme-linked immunosorbent assay) were measured once in 10 fasting volunteers (controls) and daily from admission until day 5 of the ICU stay in 30 critically ill patients (median [interquartile range] age 63 [57–67] yr, median [interquartile range] Acute Physiology and Chronic Health Evaluation II score 21 [14–24]). Eight patients could not be fed (fasting group). In fed patients, 13 never had a gastric residual volume higher than 250 mL (low gastric residual volume group), in contrast to the high gastric residual volume group (n = 9). The plasma levels of peptide YY did not differ between patients (6.4 [0–18.1] pg/mL) and controls (4.8 [0.3–17.7] pg/mL). Ghrelin levels were lower in patients than in control (213 [54.4–522.7] vs 1,435 [1,321.9–1,869.3] pg/mL; p < 0.05). Plasma peptide YY or ghrelin did not differ between fasting and fed patients or between the high and low gastric residual volume groups.Conclusions: In critically ill patients, plasma concentration of ghrelin significantly differs from that of controls, irrespective of the feeding status. No correlation was found between the temporal profile of ghrelin or peptide YY plasma concentration with bedside functional assessment of gastric emptying.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Readmissions for Recurrent Sepsis: New or Relapsed Infection'*
    • Authors: DeMerle; Kimberley Marie; Royer, Stephanie C.; Mikkelsen, Mark E.; Prescott, Hallie C.
      Abstract: imageObjectives: Sepsis hospitalizations are frequently followed by hospital readmissions, often for recurrent sepsis. However, it is unclear how often sepsis readmissions are for relapsed/recrudescent versus new infections. The aim of this study was to assess the extent to which 90-day readmissions for recurrent sepsis are due to infection of the same site and same pathogen as the initial episode.Design: Retrospective cohort study.Setting: University of Michigan Health System.Patients: All hospitalizations (May 15, 2013 to May 14, 2015) with a principal International Classification of Diseases, Ninth revision, Clinical Modification diagnosis of septicemia (038.x), severe sepsis (995.92), or septic shock (785.52), as well as all subsequent hospitalizations and sepsis readmissions within 90 days. We determined organism and site of sepsis through manual chart abstraction.Interventions: None.Measurements and Main Results: We identified 472 readmissions within 90 days of sepsis, of which 137 (29.1%) were for sepsis. In sepsis readmissions, the site and organisms were most commonly urinary (29.2%), gastrointestinal (20.4%), Gram negative (29.9%), Gram positive (16.8%), and culture negative (30.7%). Ninety-four readmissions (68.6%) were for infection at the same site as initial sepsis hospitalization. Nineteen percent of readmissions were confirmed to be same site and same organism. However, accounting for the uncertainty from culture-negative sepsis, as many as 53.2% of readmissions could plausibly due to infections with both the same organism and same site.Conclusions: Of the patients readmitted with sepsis within 90 days, two thirds had infection at the same site as their initial admission. Just 19% had infection confirmed to be from the same site and organism as the initial sepsis hospitalization. Half of readmissions were definitively for new infections, whereas an additional 34% were unclear since cultures were negative in one of the hospitalizations.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Prevalence and Prognostic Association of Circulating Troponin in the Acute
           Respiratory Distress Syndrome
    • Authors: Metkus; Thomas S.; Guallar, Eliseo; Sokoll, Lori; Morrow, David; Tomaselli, Gordon; Brower, Roy; Schulman, Steven; Korley, Frederick K.
      Abstract: imageObjective: Circulating cardiac troponin has been associated with adverse prognosis in the acute respiratory distress syndrome in small and single-center studies; however, comprehensive studies of myocardial injury in acute respiratory distress syndrome using modern high-sensitivity troponin assays, which can detect troponin at much lower circulating concentrations, have not been performed.Design: We performed a prospective cohort study.Setting: We included patients enrolled in previously completed trials of acute respiratory distress syndrome.Patients: One thousand fifty-seven acute respiratory distress syndrome patients were included.Interventions: To determine the association of circulating high-sensitivity troponin I (Abbott ARCHITECT), with acute respiratory distress syndrome outcomes, we measured high-sensitivity troponin I within 24 hours of intubation. The primary outcome was 60-day mortality.Measurements and Main Results: Detectable high-sensitivity troponin I was present in 94% of patients; 38% of patients had detectable levels below the 99th percentile of a healthy reference population (26 ng/L), whereas 56% of patients had levels above the 99th percentile cut point. After multivariable adjustment, age, cause of acute respiratory distress syndrome, temperature, heart rate, vasopressor use, Sequential Organ Failure Assessment score, creatinine, and PCO2 were associated with higher high-sensitivity troponin I concentration. After adjustment for age, sex, and randomized trial assignment, the hazard ratio for 60-day mortality comparing the fifth to the first quintiles of high-sensitivity troponin I was 1.61 (95% CI, 1.11–2.32; p trend = 0.003). Adjusting for Sequential Organ Failure Assessment score suggested that this association was not independent of disease severity (hazard ratio, 0.95; 95% CI, 0.64–1.39; p = 0.93).Conclusions: Circulating troponin is detectable in over 90% of patients with acute respiratory distress syndrome and is associated with degree of critical illness. The magnitude of myocardial injury correlated with mortality.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Long-Term Survival in Adult Patients With Severe Acute Lung Failure
           Receiving Veno-Venous Extracorporeal Membrane Oxygenation
    • Authors: Enger; Tone Bull; Philipp, Alois; Lubnow, Matthias; Fischer, Marcus; Camboni, Daniele; Lunz, Dirk; Bein, Thomas; Müller, Thomas
      Abstract: imageObjectives: To assess long-term survival in adult patients with severe acute lung failure receiving veno-venous extracorporeal membrane oxygenation and explore risk factors for long-term mortality.Design: Single-center prospective cohort study.Setting: University Hospital Regensburg, Germany.Patients: All primary cases supported with veno-venous extracorporeal membrane oxygenation from 2007 to 2016 (n = 553).Interventions: None.Measurements and Main Results: Patients were followed until January 2017. Long-term survival and predictors of long-term mortality were assessed using Kaplan-Meier survival analyses and Cox proportional hazards modeling, respectively. Two hundred eighty-six patients (52%) died during follow-up (mean follow-up 4.8 yr). Two hundred seventeen patients (39%) died during hospitalization, whereas another 69 patients (12%) died during later follow-up. Among hospital survivors, the 1-month, 3-month, 1-year, and 5-year survival rates were 99%, 95%, 86%, and 76%, respectively. Higher age, immunocompromised status, and higher Sequential Organ Failure Assessment scores were associated with long-term mortality, whereas patients with out-of-center cannulation showed improved long-term survival. Due to nonproportional hazards over time, the analysis was repeated for hospital survivors only (n = 336). Only age and immunocompromised state remained significant predictors of late mortality among hospital survivors. Lower Glasgow Outcome Scale at hospital discharge and the University Hospital Regensburg pre–extracorporeal membrane oxygenation score for predicting hospital mortality in veno-venous extracorporeal membrane oxygenation patients before extracorporeal membrane oxygenation initiation were associated with late mortality in hospital survivors (p < 0.001).Conclusions: Whereas acute illness factors may be important in prediction of hospital outcomes in veno-venous extracorporeal membrane oxygenation patients, they do not determine late mortality in hospital survivors. Preexisting morbidity and functional ability at hospital discharge may be important determinants of long-term survival in veno-venous extracorporeal membrane oxygenation patients.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Nosocomial Infections During Extracorporeal Membrane Oxygenation:
           Incidence, Etiology, and Impact on Patients’ Outcome
    • Authors: Grasselli; Giacomo; Scaravilli, Vittorio; Di Bella, Stefano; Biffi, Stefano; Bombino, Michela; Patroniti, Nicolò; Bisi, Luca; Peri, Anna Maria; Pesenti, Antonio; Gori, Andrea; Alagna, Laura
      Abstract: imageObjective: To study incidence, type, etiology, risk factors, and impact on outcome of nosocomial infections during extracorporeal membrane oxygenation.Design: Retrospective analysis of prospectively collected data.Setting: Italian tertiary referral center medical-surgical ICU.Patients: One hundred five consecutive patients who were treated with extracorporeal membrane oxygenation from January 2010 to November 2015.Interventions: None.Measurements and Main Results: Ninety-two patients were included in the analysis (48.5 [37–56] years old, simplified acute physiology score II 37 [32–47]) who underwent peripheral extracorporeal membrane oxygenation (87% veno-venous) for medical indications (78% acute respiratory distress syndrome). Fifty-two patients (55%) were infected (50.4 infections/1,000 person-days of extracorporeal membrane oxygenation). We identified 32 ventilator-associated pneumonia, eight urinary tract infections, five blood stream infections, three catheter-related blood stream infections, two colitis, one extracorporeal membrane oxygenation cannula infection, and one pulmonary-catheter infection. G+ infections (35%) occurred earlier compared with G– (48%) (4 [2–10] vs. 13 [7–23] days from extracorporeal membrane oxygenation initiation; p < 0.001). Multidrug-resistant organisms caused 56% of bacterial infections. Younger age (2–35 years old) was independently associated with higher risk for nosocomial infections. Twenty-nine patients (31.5%) died (13.0 deaths/1,000 person-days of extracorporeal membrane oxygenation). Infected patients had higher risk for death (18 vs. 8 deaths/1,000 person-days of extracorporeal membrane oxygenation; p = 0.037) and longer ICU stay (32.5 [19.5–78] vs. 19 [10.5–27.5] days; p = 0.003), mechanical ventilation (36.5 [20–80.5] vs. 16.5 [9–25.5] days; p < 0.001), and extracorporeal membrane oxygenation (25.5 [10.75–54] vs. 10 [5–13] days; p < 0.001). Older age (> 50 years old), reason for connection different from acute respiratory distress syndrome, higher simplified acute physiology score II, diagnosis of ventilator-associated pneumonia, and infection by multidrug-resistant bacteria were independently associated to increased death rate.Conclusions: Infections (especially ventilator-associated pneumonia) during extracorporeal membrane oxygenation therapy are common and frequently involve multidrug-resistant organisms. In addition, they have a negative impact on patients’ outcomes.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Brain-Dead Donors on Extracorporeal Membrane Oxygenation*
    • Authors: Bronchard; Régis; Durand, Louise; Legeai, Camille; Cohen, Johana; Guerrini, Patrice; Bastien, Olivier
      Abstract: imageObjectives: To describe donors after brain death with ongoing extracorporeal membrane oxygenation and to analyze the outcome of organs transplanted from these donors.Design: Retrospective analysis of the national information system run by the French Biomedicine Agency (CRISTAL database).Setting: National registry data of all donors after brain death in France and their organ recipients between 2007 and 2013.Patients: Donors after brain death and their organ recipients.Interventions: None.Measurements and Main Results: During the study period, there were 22,270 brain-dead patients diagnosed in France, of whom 161 with extracorporeal membrane oxygenation. Among these patients, 64 donors on extracorporeal membrane oxygenation and 10,805 donors without extracorporeal membrane oxygenation had at least one organ retrieved. Donors on extracorporeal membrane oxygenation were significantly younger and had more severe intensive care medical conditions (hemodynamic, biological, renal, and liver insults) than donors without extracorporeal membrane oxygenation. One hundred nine kidneys, 37 livers, seven hearts, and one lung were successfully transplanted from donors on extracorporeal membrane oxygenation. We found no significant difference in 1-year kidney graft survival (p = 0.24) and function between recipients from donors on extracorporeal membrane oxygenation (92.7% [85.9–96.3%]) and matching recipients from donors without extracorporeal membrane oxygenation (95.4% [93.0–97.0%]). We also found no significant difference in 1-year liver recipient survival (p = 0.91): 86.5% (70.5–94.1) from donors on extracorporeal membrane oxygenation versus 80.7% (79.8–81.6) from donors without extracorporeal membrane oxygenation.Conclusions: Brain-dead patients with ongoing extracorporeal membrane oxygenation have more severe medical conditions than those without extracorporeal membrane oxygenation. However, kidney graft survival and function were no different than usual. Brain-dead patients with ongoing extracorporeal membrane oxygenation are suitable for organ procurement.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Neurobiologic Correlates of Attention and Memory Deficits Following
           Critical Illness in Early Life*
    • Authors: Schiller; Raisa M.; IJsselstijn, Hanneke; Madderom, Marlous J.; Rietman, André B.; Smits, Marion; van Heijst, Arno F. J.; Tibboel, Dick; White, Tonya; Muetzel, Ryan L.
      Abstract: imageObjectives: Survivors of critical illness in early life are at risk of long-term–memory and attention impairments. However, their neurobiologic substrates remain largely unknown.Design: A prospective follow-up study.Setting: Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands.Patients: Thirty-eight school-age (8–12 yr) survivors of neonatal extracorporeal membrane oxygenation and/or congenital diaphragmatic hernia with an intelligence quotient greater than or equal to 80 and a below average score (z score ≤ –1.5) on one or more memory tests.Interventions: None.Measurements and Main Results: Intelligence, attention, memory, executive functioning, and visuospatial processing were assessed and compared with reference data. White matter microstructure and hippocampal volume were assessed using diffusion tensor imaging and structural MRI, respectively. Global fractional anisotropy was positively associated with selective attention (β = 0.53; p = 0.030) and sustained attention (β = 0.48; p = 0.018). Mean diffusivity in the left parahippocampal region of the cingulum was negatively associated with visuospatial memory, both immediate (β = –0.48; p = 0.030) and delayed recall (β = –0.47; p = 0.030). Mean diffusivity in the parahippocampal region of the cingulum was negatively associated with verbal memory delayed recall (left: β = –0.52, p = 0.021; right: β = –0.52, p = 0.021). Hippocampal volume was positively associated with verbal memory delayed recall (left: β = 0.44, p = 0.037; right: β = 0.67, p = 0.012). Extracorporeal membrane oxygenation treatment or extracorporeal membrane oxygenation type did not influence the structure-function relationships.Conclusions: Our findings indicate specific neurobiologic correlates of attention and memory deficits in school-age survivors of neonatal extracorporeal membrane oxygenation and congenital diaphragmatic hernia. A better understanding of the neurobiology following critical illness, both in early and in adult life, may lead to earlier identification of patients at risk for impaired neuropsychological outcome with the use of neurobiologic markers.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Outcomes of Patient- and Family-Centered Care Interventions in the ICU: A
           Systematic Review and Meta-Analysis
    • Authors: Goldfarb; Michael J.; Bibas, Lior; Bartlett, Virginia; Jones, Heather; Khan, Naureen
      Abstract: imageObjective: To determine whether patient- and family-centered care interventions in the ICU improve outcomes.Data Sources: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library databases from inception until December 1, 2016.Study Selection: We included articles involving patient- and family-centered care interventions and quantitative, patient- and family-important outcomes in adult ICUs.Data Extraction: We extracted the author, year of publication, study design, population, setting, primary domain investigated, intervention, and outcomes.Data Synthesis: There were 46 studies (35 observational pre/post, 11 randomized) included in the analysis. Seventy-eight percent of studies (n = 36) reported one or more positive outcome measures, whereas 22% of studies (n = 10) reported no significant changes in outcome measures. Random-effects meta-analysis of the highest quality randomized studies showed no significant difference in mortality (n = 5 studies; odds ratio = 1.07; 95% CI, 0.95–1.21; p = 0.27; I2 = 0%), but there was a mean decrease in ICU length of stay by 1.21 days (n = 3 studies; 95% CI, –2.25 to –0.16; p = 0.02; I2 = 26%). Improvements in ICU costs, family satisfaction, patient experience, medical goal achievement, and patient and family mental health outcomes were also observed with intervention; however, reported outcomes were heterogeneous precluding formal meta-analysis.Conclusions: Patient- and family-centered care–focused interventions resulted in decreased ICU length of stay but not mortality. A wide range of interventions were also associated with improvements in many patient- and family-important outcomes. Additional high-quality interventional studies are needed to further evaluate the effectiveness of patient- and family-centered care in the intensive care setting.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Treatment of Hyponatremic Encephalopathy in the Critically Ill
    • Authors: Achinger; Steven G.; Ayus, Juan Carlos
      Abstract: imageObjectives: Hyponatremic encephalopathy, symptomatic cerebral edema due to a low osmolar state, is a medical emergency and often encountered in the ICU setting. This article provides a critical appraisal and review of the literature on identification of high-risk patients and the treatment of this life-threatening disorder.Data Sources, Study Selection, and Data Extraction: Online search of the PubMed database and manual review of articles involving risk factors for hyponatremic encephalopathy and treatment of hyponatremic encephalopathy in critical illness.Data Synthesis: Hyponatremic encephalopathy is a frequently encountered problem in the ICU. Prompt recognition of hyponatremic encephalopathy and early treatment with hypertonic saline are critical for successful outcomes. Manifestations are varied, depending on the extent of CNS’s adaptation to the hypoosmolar state. The absolute change in serum sodium alone is a poor predictor of clinical symptoms. However, certain patient specific risks factors are predictive of a poor outcome and are important to identify. Gender (premenopausal and postmenopausal females), age (prepubertal children), and the presence of hypoxia are the three main clinical risk factors and are more predictive of poor outcomes than the rate of development of hyponatremia or the absolute decrease in the serum sodium.Conclusions: In patients with hyponatremic encephalopathy exhibiting neurologic manifestations, a bolus of 100 mL of 3% saline, given over 10 minutes, should be promptly administered. The goal of this initial bolus is to quickly treat cerebral edema. If signs persist, the bolus should be repeated in order to achieve clinical remission. However, the total change in serum sodium should not exceed 5 mEq/L in the initial 1–2 hours and 15–20 mEq/L in the first 48 hours of treatment. It has recently been demonstrated in a prospective fashion that 500 mL of 3% saline at an infusion rate of 100 mL per hour can be given safely. It is critical to recognize the early signs of cerebral edema (nausea, vomiting, and headache) and intervene with IV 3% sodium chloride as this is the time to intervene rather than waiting until more severe symptoms develop. Cerebral demyelination is a rare complication of overly rapid correction of hyponatremia. The principal risk factors for cerebral demyelination are correction of the serum sodium more than 25 mEq/L in the first 48 hours of therapy, correction past the point of 140 mEq/L, chronic liver disease, and hypoxic/anoxic episode.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • The Promise of Traditional Chinese Medicine After Cardiac Arrest: An
           Untapped Resource'*
    • Authors: Morley; Peter Thomas
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Fluid Management in Sepsis—Is There a Golden Hour (or Two)'*
    • Authors: Nugent; Katherine L.; Coopersmith, Craig M.
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Group Therapy in the ICU*
    • Authors: Kramer; Andrew A.
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Life on MARS'*
    • Authors: Warrillow; Stephen
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Determinants of Care—When Is Prolonged Mechanical Ventilation No Longer
           Appropriate and Who Decides'*
    • Authors: Cohen; Neal H.
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • No Luck With Preadmission Anti-Inflammatory Drugs to Prevent Postcritical
           Illness Psychiatric Morbidity*
    • Authors: Bienvenu; O. Joseph
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Intracranial Hemorrhage and Extracorporeal Membrane Oxygenation: Chicken
           or the Egg'*
    • Authors: Dalton; Heidi J.
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • The Importance of Clinical Context on Assessing Outcomes in Sepsis*
    • Authors: Lanspa; Michael J.; Morris, Alan H.
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • When the Letter “F” Meets the Letter “D”: Beneficial Impact of
           Open Visiting and Family Presence on Incidence of Delirium Among ICU
           Patients*
    • Authors: Giannini; Alberto
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Prognostication of Critically Ill Patients With Cancer: A Long Road Ahead*
           
    • Authors: Caruso; Pedro
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Bad Response or Bad Luck' A New Versus Recrudescent Sepsis
           Readmission*
    • Authors: Rimawi; Ramzy Husam
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Expanding the Donor Pool: Organ Donation After Brain Death for
           Extracorporeal Membrane Oxygenation Patients*
    • Authors: Christopher; Derrick A.; Woodside, Kenneth J.
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Evaluating Cognitive Deficits in Childhood After Neonatal Critical Illness
           With MRI*
    • Authors: Thiagarajan; Ravi R.
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Central Venous Catheter Insertion and Bedside Ultrasound: Building a New
           Standard of Care'*
    • Authors: Remerand; Francis; Espitalier, Fabien
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Sedating Children on Extracorporeal Membrane Oxygenation: Achieving More
           With Less*
    • Authors: Argent; Andrew C.
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Hyperoxia in Septic Shock: Crafty Therapeutic Weapon or Double-Edged
           Sword'*
    • Authors: Asfar; Pierre; Schortgen, Frédérique; Huber-Lang, Markus; Radermacher, Peter
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Autonomous Resuscitation on the Horizon'*
    • Authors: Karcutskie; Charles A.; Proctor, Kenneth G.
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Single-Operator Ultrasound-Guided Central Venous Catheter Insertion
           Verifies Proper Tip Placement*
    • Authors: Galante; Ori; Slutsky, Tzachi; Fuchs, Lior; Smoliakov, Alexander; Mizrakli, Yuval; Novack, Victor; Brotfein, Evgeni; Klein, Moti; Frenkel, Amit; Koifman, Leonid; Almog, Yaniv
      Abstract: imageObjectives: To evaluate whether a single-operator ultrasound-guided, right-sided, central venous catheter insertion verifies proper placement and shortens time to catheter utilization.Design: Prospective observational study with historical controls.Setting: Adult ICUs.Patients: Sixty-four consecutive patients undergoing ultrasound-assisted right-sided central venous catheterization compared with 92 serial historic controls who had unassisted central catheter insertion at the same sites.Interventions: Subcostal transthoracic echocardiography during catheter insertion.Measurements and Main Results: The primary outcome was the correct placement of the catheter tip determined by postprocedural chest radiography. The subclavian site was used in 41 patients (64%) (inserted without ultrasound guidance) in the ultrasound-assisted group and 62 (67%) in the control group, whereas the jugular vein was used in the remaining patients. The tip was accurately positioned in 59 of 68 patients (86.7%) in the ultrasound-assisted group compared with 51 of 94 (54.8%) in the control group (p < 0.001). The median time from end of the procedure to catheter utilization after chest radiography approval was 2.4 hours.Conclusions: A single-operator ultrasound-guided central venous catheter insertion is effective in verifying proper tip placement and shortens time to catheter utilization.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Sedation Management in Children Supported on Extracorporeal Membrane
           Oxygenation for Acute Respiratory Failure*
    • Authors: Schneider; James B.; Sweberg, Todd; Asaro, Lisa A.; Kirby, Aileen; Wypij, David; Thiagarajan, Ravi R.; Curley, Martha A. Q.; for the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE Study Investigators
      Abstract: imageObjectives: To describe sedation management in children supported on extracorporeal membrane oxygenation for acute respiratory failure.Design: Secondary analysis of prospectively collected data from a multicenter randomized trial of sedation (Randomized Evaluation of Sedation Titration for Respiratory Failure).Setting: Twenty-one U.S. PICUs.Patients: One thousand two hundred fifty-five children, 2 weeks to 17 years old, with moderate/severe pediatric acute respiratory distress syndrome.Interventions: Sedation managed per usual care or Randomized Evaluation of Sedation Titration for Respiratory Failure protocol.Measurements and Main Results: Sixty-one Randomized Evaluation of Sedation Titration for Respiratory Failure patients (5%) with moderate/severe pediatric acute respiratory distress syndrome were supported on extracorporeal membrane oxygenation, including 29 managed per Randomized Evaluation of Sedation Titration for Respiratory Failure protocol. Most extracorporeal membrane oxygenation patients received neuromuscular blockade (46%) or were heavily sedated with State Behavioral Scale scores –3/–2 (34%) by extracorporeal membrane oxygenation day 3. Median opioid and benzodiazepine doses on the day of cannulation, 0.15 mg/kg/hr (3.7 mg/kg/d) and 0.11 mg/kg/hr (2.8 mg/kg/d), increased by 36% and 58%, respectively, by extracorporeal membrane oxygenation day 3. In the 41 patients successfully decannulated prior to study discharge, patients were receiving 0.40 mg/kg/hr opioids (9.7 mg/kg/d) and 0.39 mg/kg/hr benzodiazepines (9.4 mg/kg/d) at decannulation, an increase from cannulation of 108% and 192%, respectively (both p < 0.001). Extracorporeal membrane oxygenation patients experienced more clinically significant iatrogenic withdrawal than moderate/severe pediatric acute respiratory distress syndrome patients managed without extracorporeal membrane oxygenation support (p < 0.001). Compared to extracorporeal membrane oxygenation patients managed per Randomized Evaluation of Sedation Titration for Respiratory Failure protocol, usual care extracorporeal membrane oxygenation patients received more opioids during the study period (mean cumulative dose of 183.0 vs 89.8 mg/kg; p = 0.02), over 6.5 greater exposure days (p = 0.002) with no differences in wakefulness or agitation.Conclusions: In children, the initiation of extracorporeal membrane oxygenation support is associated with deep sedation, substantial sedative exposure, and increased frequency of iatrogenic withdrawal syndrome. A standardized, goal-directed, nurse-driven sedation protocol may help mitigate these effects.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Transcranial Doppler Microemboli Monitoring for Stroke Risk Stratification
           in Blunt Cerebrovascular Injury
    • Authors: Bonow; Robert H.; Witt, Cordelie E.; Mosher, Bryan P.; Mossa-Basha, Mahmud; Vavilala, Monica S.; Rivara, Frederick P.; Cuschieri, Joseph; Arbabi, Saman; Chesnut, Randall M.
      Abstract: imageObjectives: To assess whether microemboli burden, assessed noninvasively by bedside transcranial Doppler ultrasonography, correlates with risk of subsequent stroke greater than 24 hours after hospital arrival among patients with blunt cerebrovascular injury. The greater than 24-hour time frame provides a window for transcranial Doppler examinations and therapeutic interventions to prevent stroke.Design: Retrospective cohort study.Setting: Level I trauma center.Patients: One thousand one hundred forty-six blunt cerebrovascular injury patients over 10 years.Interventions: None.Measurements and Main Results: We identified 1,146 blunt cerebrovascular injury patients; 54 (4.7%) experienced stroke detected greater than 24 hours after arrival. Among those with isolated internal carotid artery injuries, five of nine with delayed stroke had positive transcranial Dopplers (at least one microembolus detected with transcranial Dopplers) before stroke, compared with 46 of 248 without (risk ratio, 5.05; 95% CI, 1.41–18.13). Stroke risk increased with the number of microemboli (adjusted risk ratio, 1.03/microembolus/hr; 95% CI, 1.01–1.05) and with persistently positive transcranial Dopplers over multiple days (risk ratio, 16.0; 95% CI, 2.00–127.93). Among patients who sustained an internal carotid artery injury with or without additional vessel injuries, positive transcranial Dopplers predicted stroke after adjusting for ipsilateral and contralateral internal carotid artery injury grade (adjusted risk ratio, 2.91; 95% CI, 1.42–5.97). No patients with isolated vertebral artery injuries had positive transcranial Dopplers before stroke, and positive transcranial Dopplers were not associated with delayed stroke among patients who sustained a vertebral artery injury with or without additional vessel injuries (risk ratio, 0.90; 95% CI, 0.21–3.83).Conclusions: Microemboli burden is associated with higher risk of stroke due to internal carotid artery injuries, but monitoring was not useful for vertebral artery injuries.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Faster Blood Flow Rate Does Not Improve Circuit Life in Continuous Renal
           Replacement Therapy: A Randomized Controlled Trial
    • Authors: Fealy; Nigel; Aitken, Leanne; du Toit, Eugene; Lo, Serigne; Baldwin, Ian
      Abstract: imageObjectives: To determine whether blood flow rate influences circuit life in continuous renal replacement therapy.Design: Prospective randomized controlled trial.Setting: Single center tertiary level ICU.Patients: Critically ill adults requiring continuous renal replacement therapy.Interventions: Patients were randomized to receive one of two blood flow rates: 150 or 250 mL/min.Measurements and Main Results: The primary outcome was circuit life measured in hours. Circuit and patient data were collected until each circuit clotted or was ceased electively for nonclotting reasons. Data for clotted circuits are presented as median (interquartile range) and compared using the Mann-Whitney U test. Survival probability for clotted circuits was compared using log-rank test. Circuit clotting data were analyzed for repeated events using hazards ratio. One hundred patients were randomized with 96 completing the study (150 mL/min, n = 49; 250 mL/min, n = 47) using 462 circuits (245 run at 150 mL/min and 217 run at 250 mL/min). Median circuit life for first circuit (clotted) was similar for both groups (150 mL/min: 9.1 hr [5.5–26 hr] vs 10 hr [4.2–17 hr]; p = 0.37). Continuous renal replacement therapy using blood flow rate set at 250 mL/min was not more likely to cause clotting compared with 150 mL/min (hazards ratio, 1.00 [0.60–1.69]; p = 0.68). Gender, body mass index, weight, vascular access type, length, site, and mode of continuous renal replacement therapy or international normalized ratio had no effect on clotting risk. Continuous renal replacement therapy without anticoagulation was more likely to cause clotting compared with use of heparin strategies (hazards ratio, 1.62; p = 0.003). Longer activated partial thromboplastin time (hazards ratio, 0.98; p = 0.002) and decreased platelet count (hazards ratio, 1.19; p = 0.03) were associated with a reduced likelihood of circuit clotting.Conclusions: There was no difference in circuit life whether using blood flow rates of 250 or 150 mL/min during continuous renal replacement therapy.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Diabetes Is Not Associated With Increased 90-Day Mortality Risk in
           Critically Ill Patients With Sepsis
    • Authors: van Vught; Lonneke A.; Holman, Rebecca; de Jonge, Evert; de Keizer, Nicolette F.; van der Poll, Tom
      Abstract: imageObjectives: To determine the association of pre-existing diabetes, hyperglycemia, and hypoglycemia during the first 24 hours of ICU admissions with 90-day mortality in patients with sepsis admitted to the ICU.Design: We used mixed effects logistic regression to analyze the association of diabetes, hyperglycemia, and hypoglycemia with 90-day mortality (n = 128,222).Setting: All ICUs in the Netherlands between January 2009 and 2014 that participated in the Dutch National Intensive Care Evaluation registry.Patients: All unplanned ICU admissions in patients with sepsis.Interventions: The association between 90-day mortality and pre-existing diabetes, hyperglycemia, and hypoglycemia, corrected for other factors, was analyzed using a generalized linear mixed effect model.Measurements and Main Results: In a multivariable analysis, diabetes was not associated with increased 90-day mortality. In diabetes patients, only severe hypoglycemia in the absence of hyperglycemia was associated with increased 90-day mortality (odds ratio, 2.95; 95% CI, 1.19–7.32), whereas in patients without pre-existing diabetes, several combinations of abnormal glucose levels were associated with increased 90-day mortality.Conclusions: In the current retrospective large database review, diabetes was not associated with adjusted 90-day mortality risk in critically ill patients admitted with sepsis.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Wide Disagreement Between Alternative Assessments of Premorbid Physical
           Activity: Subjective Patient and Surrogate Reports and Objective
           Smartphone Data
    • Authors: Gluck; Samuel; Summers, Matthew J.; Goddard, Thomas P.; Andrawos, Alice; Smith, Natalie C.; Lange, Kylie; Iwashyna, Theodore J.; Deane, Adam M.
      Abstract: imageObjectives: Surrogate-decision maker and patient self-reported estimates of the distances walked prior to acute illness are subjective and may be imprecise. It may be possible to extract objective data from a patient’s smartphone, specifically, step and global position system data, to quantify physical activity. The objectives were to 1) assess the agreement between surrogate-decision maker and patient self-reported estimates of distance and time walked prior to resting and daily step-count and 2) determine the feasibility of extracting premorbid physical activity (step and global position system) data from critically ill patients.Design: Prospective cohort study.Setting: Quaternary ICU.Patients: Fifty consecutively admitted adult patients who owned a smartphone, who were ambulatory at baseline, and who remained in ICU for more than 48 hours participated.Measurments and Main Results: There was no agreement between patients and surrogates for all premorbid walking metrics (mean bias 108% [99% lower to 8,700% higher], 83% [97% to 2,100%], and 71% [96% to 1,080%], for distance, time, and steps, respectively). Step and/or global position system data were successfully extracted from 24 of 50 phones (48%; 95% CI, 35–62%). Surrogate-decision makers, but not patient self-reported, estimates of steps taken per day correlated with smartphone data (surrogates: n = 13, ρ = 0.56, p < 0.05; patients: n = 13, ρ = 0.30, p = 0.317).Conclusion: There was a lack of agreement between surrogate-decision maker and patient self-reported subjective estimates of distance walked. Obtaining premorbid physical activity data from the current-generation smartphones was feasible in approximately 50% of patients.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Safety Hazards During Intrahospital Transport: A Prospective Observational
           Study
    • Authors: Bergman; Lina M.; Pettersson, Monica E.; Chaboyer, Wendy P.; Carlström, Eric D.; Ringdal, Mona L.
      Abstract: imageObjective: To identify, classify, and describe safety hazards during the process of intrahospital transport of critically ill patients.Design: A prospective observational study. Data from participant observations of the intrahospital transport process were collected over a period of 3 months.Setting: The study was undertaken at two ICUs in one university hospital.Patients: Critically ill patients transported within the hospital by critical care nurses, unlicensed nurses, and physicians.Interventions: None.Measurements and Main Results: Content analysis was performed using deductive and inductive approaches. We detected a total of 365 safety hazards (median, 7; interquartile range, 4–10) during 51 intrahospital transports of critically ill patients, 80% of whom were mechanically ventilated. The majority of detected safety hazards were assessed as increasing the risk of harm, compromising patient safety (n = 204). Using the System Engineering Initiative for Patient Safety, we identified safety hazards related to the work system, as follows: team (n = 61), tasks (n = 83), tools and technologies (n = 124), environment (n = 48), and organization (n = 49). Inductive analysis provided an in-depth description of those safety hazards, contributing factors, and process-related outcomes.Conclusions: Findings suggest that intrahospital transport is a hazardous process for critically ill patients. We have identified several factors that may contribute to transport-related adverse events, which will provide the opportunity for the redesign of systems to enhance patient safety.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Admission to Intensive Care for Palliative Care or Potential Organ
           Donation: Demographics, Circumstances, Outcomes, and Resource Use
    • Authors: Melville; Andrew; Kolt, Gali; Anderson, David; Mitropoulos, Joanna; Pilcher, David
      Abstract: imageObjectives: To describe the characteristics, circumstances, change over time, resource use, and outcomes of patients admitted to ICUs in Australia and New Zealand for the purposes of “palliative care of a dying patient” or “potential organ donation,” and compare with actively managed ICU patients.Design: A retrospective study of data from the Australian and New Zealand Intensive Care Society Adult Patient Database and a nested cohort analysis of a single center.Setting: One hundred seventy-seven ICUs in Australia and New Zealand and a nested analysis of one university-affiliated hospital ICU in Melbourne, VIC, Australia.Patients: Three thousand seven hundred “palliative care of a dying patient” and 1,115 “potential organ donation” patients from 2007 to 2016. The nested cohort included 192 patients.Interventions: No interventions. Data extracted included patient demographics, diagnoses, length of stay, circumstances, and outcome of admission.Measurements and Main Results: ICU admissions for “palliative care of a dying patient” and “potential organ donation” increased from 179 in 2007 to 551 in 2016 and from 44 in 2007 to 174 in 2016 in each respective group, though only the “potential organ donation” cohort showed an increase in proportion of total ICU admissions. Lengths of stay in ICU were a mean of 33.8 hours (median, 17.5; interquartile range, 6.4–38.8) and 44.7 hours (26.6; 16.0–44.6), respectively, compared with 74.2 hours (41.5; 21.7–77.0) in actively managed patients. Hospital mortality was 86.6% and 95.9%, respectively. In the nested cohort of 192 patients, facilitating family discussions about goals of treatment and organ donation represented the most common reason for ICU admission.Conclusions: Patients admitted to ICU to manage end-of-life care represent a small proportion of overall ICU admissions, with an increasing proportion of “potential organ donation” admissions. They have shorter ICU lengths of stay than actively managed patients, suggesting resource use for these patients is not disproportionate.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Should Hyperoxia Be Avoided During Sepsis' An Experimental Study in
           Ovine Peritonitis*
    • Authors: He; Xinrong; Su, Fuhong; Xie, Keliang; Taccone, Fabio Silvio; Donadello, Katia; Vincent, Jean-Louis
      Abstract: imageObjectives: Optimizing oxygen delivery is an important part of the hemodynamic resuscitation of septic shock, but concerns have been raised over the potentially deleterious effects of hyperoxia. We evaluated the impact of hyperoxia on hemodynamics, the microcirculation, and cerebral and renal metabolism in an ovine model of septic shock.Design: Randomized animal study.Setting: University hospital animal research laboratory.Subjects: Fourteen adult female sheep.Interventions: After induction of fecal peritonitis, sheep were randomized to ventilation with an FIO2 of 100% (n = 7) or an FIO2 adjusted to maintain PaO2 between 90 and 120 mm Hg (n = 7, control). All animals were fluid resuscitated and observed until death.Measurements and Main Results: In addition to hemodynamic measurements, we assessed the sublingual microcirculation, renal and cerebral microdialysis and microvascular perfusion, and brain tissue oxygen pressure. Hyperoxic animals initially had a higher mean arterial pressure than control animals. After onset of shock, hyperoxia blunted the decrease in stroke volume index observed in the control group. Hyperoxia was associated with a higher sublingual microcirculatory flow over time, with higher cerebral perfusion and brain tissue oxygen pressure and with a lower cerebral lactate-to-pyruvate ratio than in control animals. Hyperoxia was also associated with preserved renal microvascular perfusion, lower renal lactate-to-pyruvate ratio, and higher PaO2/FIO2 ratio.Conclusions: In this acute peritonitis model, hyperoxia induced during resuscitation provided better hemodynamics and peripheral microvascular flow and better preserved cerebral metabolism, renal function, and gas exchange. These observations are reassuring with recent concerns about excessive oxygen therapy in acute diseases.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Closed-Loop– and Decision-Assist–Guided Fluid Therapy of Human
           Hemorrhage*
    • Authors: Hundeshagen; Gabriel; Kramer, George C.; Ribeiro Marques, Nicole; Salter, Michael G.; Koutrouvelis, Aristides K.; Li, Husong; Solanki, Daneshvari R.; Indrikovs, Alexander; Seeton, Roger; Henkel, Sheryl N.; Kinsky, Michael P.
      Abstract: imageObjectives: We sought to evaluate the efficacy, efficiency, and physiologic consequences of automated, endpoint-directed resuscitation systems and compare them to formula-based bolus resuscitation.Design: Experimental human hemorrhage and resuscitation.Setting: Clinical research laboratory.Subjects: Healthy volunteers.Interventions: Subjects (n = 7) were subjected to hemorrhage and underwent a randomized fluid resuscitation scheme on separate visits 1) formula-based bolus resuscitation; 2) semiautonomous (decision assist) fluid administration; and 3) fully autonomous (closed loop) resuscitation. Hemodynamic variables, volume shifts, fluid balance, and cardiac function were monitored during hemorrhage and resuscitation. Treatment modalities were compared based on resuscitation efficacy and efficiency.Measurements and Main Results: All approaches achieved target blood pressure by 60 minutes. Following hemorrhage, the total amount of infused fluid (bolus resuscitation: 30 mL/kg, decision assist: 5.6 ± 3 mL/kg, closed loop: 4.2 ± 2 mL/kg; p < 0.001), plasma volume, extravascular volume (bolus resuscitation: 17 ± 4 mL/kg, decision assist: 3 ± 1 mL/kg, closed loop: –0.3 ± 0.3 mL/kg; p < 0.001), body weight, and urinary output remained stable under decision assist and closed loop and were significantly increased under bolus resuscitation. Mean arterial pressure initially decreased further under bolus resuscitation (–10 mm Hg; p < 0.001) and was lower under bolus resuscitation than closed loop at 20 minutes (bolus resuscitation: 57 ± 2 mm Hg, closed loop: 69 ± 4 mm Hg; p = 0.036). Colloid osmotic pressure (bolus resuscitation: 19.3 ± 2 mm Hg, decision assist, closed loop: 24 ± 0.4 mm Hg; p < 0.05) and hemoglobin concentration were significantly decreased after bolus fluid administration.Conclusions: We define efficacy of decision-assist and closed-loop resuscitation in human hemorrhage. In comparison with formula-based bolus resuscitation, both semiautonomous and autonomous approaches were more efficient in goal-directed resuscitation of hemorrhage. They provide favorable conditions for the avoidance of over-resuscitation and its adverse clinical sequelae. Decision-assist and closed-loop resuscitation algorithms are promising technological solutions for constrained environments and areas of limited resources.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Selective Activation of Basal Forebrain Cholinergic Neurons Attenuates
           Polymicrobial Sepsis–Induced Inflammation via the Cholinergic
           Anti-Inflammatory Pathway
    • Authors: Zhai; Qian; Lai, Dengming; Cui, Ping; Zhou, Rui; Chen, Qixing; Hou, Jinchao; Su, Yunting; Pan, Libiao; Ye, Hui; Zhao, Jing-Wei; Fang, Xiangming
      Abstract: imageObjectives: Basal forebrain cholinergic neurons are proposed as a major neuromodulatory system in inflammatory modulation. However, the function of basal forebrain cholinergic neurons in sepsis is unknown, and the neural pathways underlying cholinergic anti-inflammation remain unexplored.Design: Animal research.Setting: University research laboratory.Subjects: Male wild-type C57BL/6 mice and ChAT-ChR2-EYFP (ChAT) transgenic mice.Interventions: The cholinergic neuronal activity of the basal forebrain was manipulated optogenetically. Cecal ligation and puncture was produced to induce sepsis. Left cervical vagotomy and 6-hydroxydopamine injection to the spleen were used.Measurements and Main Results: Photostimulation of basal forebrain cholinergic neurons induced a significant decrease in the levels of tumor necrosis factor-α and interleukin-6 in the serum and spleen. When cecal ligation and puncture was combined with left cervical vagotomy in photostimulated ChAT mice, these reductions in tumor necrosis factor-α and interleukin-6 were partly reversed. Furthermore, photostimulating basal forebrain cholinergic neurons induced a large increase in c-Fos expression in the basal forebrain, the dorsal motor nucleus of the vagus, and the ventral part of the solitary nucleus. Among them, 35.2% were tyrosine hydroxylase positive neurons. Furthermore, chemical denervation showed that dopaminergic neurotransmission to the spleen is indispensable for the anti-inflammation.Conclusions: These results are the first to demonstrate that selectively activating basal forebrain cholinergic neurons is sufficient to attenuate systemic inflammation in sepsis. Specifically, photostimulation of basal forebrain cholinergic neurons activated dopaminergic neurons in dorsal motor nucleus of the vagus/ventral part of the solitary nucleus, and this dopaminergic efferent signal was further transmitted by the vagus nerve to the spleen. This cholinergic-to-dopaminergic neural circuitry, connecting central cholinergic neurons to the peripheral organ, might have mediated the anti-inflammatory effect in sepsis.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Does Admission to the ICU Prevent African American Disparities in
           Withdrawal of Life-Sustaining Treatment'
    • Authors: Chertoff; Jason; Olson, Angela; Alnuaimat, Hassan
      Abstract: imageObjective: We sought to determine whether black patients admitted to an ICU were less likely than white patients to withdraw life-sustaining treatments.Design: We performed a retrospective cohort study of hospital discharges from October 20, 2015, to October 19, 2016, for inpatients 18 years old or older and recorded those patients, along with their respective races, who had an “Adult Comfort Care” order set placed prior to discharge. A two-sample test for equality of two proportions with continuity correction was performed to compare the proportions between blacks and whites.Setting: University of Florida Health.Patients: The study cohort included 29,590 inpatient discharges, with 21,212 Caucasians (71.69%), 5,825 African Americans (19.69%), and 2,546 non-Caucasians/non–African Americans (8.62%).Interventions: Withdrawal of life-sustaining treatments.Measurements and Main Results: Of the total discharges (n = 29,590), 525 (1.77%) had the Adult Comfort Care order set placed. Seventy-eight of 5,825 African American patients (1.34%) had the Adult Comfort Care order set placed, whereas 413 of 21,212 Caucasian patients (1.95%) had this order set placed (p = 0.00251; 95% CI, 0.00248–0.00968). Of the 29,590 patients evaluated, 6,324 patients (21.37%) spent at least one night in an ICU. Of these 6,324 patients, 4,821 (76.24%) were white and 1,056 (16.70%) were black. Three hundred fifty of 6,324 (5.53%) were discharged with an Adult Comfort Care order set. Two hundred seventy-one White patients (5.62%) with one night in an ICU were discharged with an Adult Comfort Care order set, whereas 54 Black patients (5.11%) with one night in an ICU had the order set (p = 0.516).Conclusions: This study suggests that Black patients may be less likely to withdraw life-supportive measures than whites, but that this disparity may be absent in patients who spend time in the ICU during their hospitalization.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Acute Respiratory Distress Syndrome Due To Tuberculosis in a Respiratory
           ICU Over a 16-Year Period
    • Authors: Muthu; Valliappan; Dhooria, Sahajal; Aggarwal, Ashutosh N.; Behera, Digambar; Sehgal, Inderpaul Singh; Agarwal, Ritesh
      Abstract: imageObjective: Whether tuberculosis-related acute respiratory distress syndrome is associated with worse outcomes when compared with acute respiratory distress syndrome secondary to other causes remains unknown. Herein, we compare the outcomes between the two groups.Design: Retrospective analysis of all subjects admitted with acute respiratory distress syndrome over the last 16 years.Setting: Respiratory ICU of a tertiary care hospital in North India.Subjects: Consecutive subjects with acute respiratory distress syndrome.Intervention: Subjects were categorized as tuberculosis-related acute respiratory distress syndrome and acute respiratory distress syndrome-others and were managed with mechanical ventilation using the low tidal volume strategy as per the Acute Respiratory Distress Syndrom Network protocol.Measurements and Main Results: The baseline clinical and demographic characteristics, lung mechanics, and mortality were compared between the two groups. Factors predicting ICU survival were analyzed using multivariate logistic regression analysis. During the study period, 469 patients (18 tuberculosis-related acute respiratory distress syndrome and 451 acute respiratory distress syndrome-others) with acute respiratory distress syndrome were admitted. The mean (SD) age of the study population (52.9% women) was 33.6 years (14.8 yr). The baseline parameters and the lung mechanics were similar between the two groups. There were 132 deaths (28.1%) with no difference between the two groups (tuberculosis-related acute respiratory distress syndrome vs acute respiratory distress syndrome-others; 27.7% vs 28.2%; p = 0.71). There was also no significant difference in the ventilator-free days, ICU, and the hospital length of stay. On multivariate logistic regression analysis, the factors predicting survival were the admission Acute Physiology and Chronic Health Evaluation II score and baseline driving pressure after adjusting for PaO2:FIO2 ratio, gender, and the etiology of acute respiratory distress syndrome.Conclusions: Tuberculosis is an uncommon cause of acute respiratory distress syndrome even in high tuberculosis prevalence countries. Acute respiratory distress syndrome due to tuberculosis behaves like acute respiratory distress syndrome due to other causes and does not affect the ICU survival.
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Updating Evidence for Using Therapeutic Hypothermia in Pediatric Severe
           Traumatic Brain Injury
    • Authors: Tasker; Robert C.; Akhondi-Asl, Alireza
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • The authors reply
    • Authors: Crompton; Ellie; Sharma, Pankaj
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Early Electroencephalography Dynamics After Cardiac Arrest
    • Authors: Hofmeijer; Jeannette; Ruijter, Barry J.; Tjepkema-Cloostermans, Marleen C.; van Putten, Michel J. A. M.
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • The authors reply
    • Authors: Rossetti; Andrea O.; Rabinstein, Alejandro A.
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Interpreting Immune Mediator Dysbalance in Sepsis
    • Authors: Pfortmueller; Carmen Andrea; Meisel, Christian; Schefold, Joerg Christian
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • The authors reply
    • Authors: Frencken; Jos F.; Cremer, Olaf L.
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Primary Outcomes in Acute Respiratory Distress Syndrome Research
    • Authors: Adams; Traci Nicole; Battaile, John T.
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • The authors reply
    • Authors: McKown; Andrew C.; Semler, Matthew W.
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Procalcitonin Clearance and Prognosis in Sepsis: Are There Really an
           Optimal Cutoff and Time Interval'
    • Authors: Vitorio; Daniel; Nassar, Antônio Paulo Jr; Caruso, Pedro
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • The authors reply
    • Authors: Schuetz; Philipp; Ebmeyer, Stefan; Johannes, Sascha; Wiemer, Jan C.; Schwabe, Andrej; Shapiro, Nathan I.
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Hyperchloremia Is Associated With Acute Kidney Injury in Patients With
           Aneurysmal Subarachnoid Hemorrhage: Not Sure
    • Authors: Jiang; Shouyin; Shen, Yehua; Zhao, Xiaogang
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • The authors reply
    • Authors: Sadan; Ofer; Singbartl, Kai; Kandiah, Prem A.; Martin, Kathleen S.; Samuels, Owen B.
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Beneficial Effects of Noninvasive Ventilation in Acute Hypoxemic
           Respiratory Failure: Caution With Findings From Meta-Analyses
    • Authors: Coudroy; Rémi; Marjanovic, Nicolas; Frat, Jean-Pierre; Thille, Arnaud W.
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • The authors reply
    • Authors: Xu; Xiu-Ping; Liu, Ling; Pan, Chun; Qiu, Hai-Bo; Zhang, Xin-Chang
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • The Overlap Between Burnout and Depression in ICU Staff
    • Authors: Colville; Gillian A.; Smith, Jared G.
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Optimal Sampling Frequency of Serum Cortisol Concentrations After Cardiac
           Surgery
    • Authors: Powell; Ben; Nason, Guy P.; Angelini, Gianni D.; Lightman, Stafford L.; Gibbison, Ben
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
  • Neurosurgical Intensive Care, Second Edition
    • Authors: Levy; Zachary David
      Abstract: No abstract available
      PubDate: Sun, 01 Oct 2017 00:00:00 GMT-
       
 
 
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