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Journal Cover Critical Care Medicine
  [SJR: 3.748]   [H-I: 220]   [230 followers]  Follow
    
   Full-text available via subscription Subscription journal
   ISSN (Print) 0090-3493
   Published by LWW Wolters Kluwer Homepage  [290 journals]
  • “It Was the Only Thing I Could Hold Onto, But…”: Receiving a Letter
           of Condolence After Loss of a Loved One in the ICU A Qualitative Study of
           Bereaved Relatives’ Experience*
    • Authors: Kentish-Barnes; Nancy; Cohen-Solal, Zoé; Souppart, Virginie; Galon, Marion; Champigneulle, Benoît; Thirion, Marina; Gilbert, Marion; Lesieur, Olivier; Renault, Anne; Garrouste-Orgeas, Maïté; Argaud, Laurent; Venot, Marion; Demoule, Alexandre; Guisset, Olivier; Vinatier, Isabelle; Troché, Gilles; Massot, Julien; Jaber, Samir; Bornstain, Caroline; Gaday, Véronique; Robert, René; Rigaud, Jean-Philippe; Cinotti, Raphaël; Adda, Mélanie; Thomas, François; Azoulay, Elie
      Abstract: imageObjectives: Family members of patients who die in the ICU often remain with unanswered questions and suffer from lack of closure. A letter of condolence may help bereaved relatives, but little is known about their experience of receiving such a letter. The objective of the study was to understand bereaved family members’ experience of receiving a letter of condolence.Design: Qualitative study using interviews with bereaved family members who received a letter of condolence and letters written by these family members to the ICU team. This study was designed to provide insight into the results of a larger randomized, controlled, multicenter study.Setting: Twenty-two ICUs in France.Subjects: Family members who lost a loved one in the ICU and who received a letter of condolence.Measurements and Main Results: Thematic analysis was used and was based on 52 interviews and 26 letters. Six themes emerged: 1) a feeling of support, 2) humanization of the medical system, 3) an opportunity for reflection, 4) an opportunity to describe their loved one, 5) continuity and closure, and 6) doubts and ambivalence. Possible difficulties emerged, notably the re-experience of the trauma, highlighting the absence of further support.Conclusions: This study describes the benefits of receiving a letter of condolence; mainly, it humanizes the medical institution (feeling of support, confirmation of the role played by the relative, supplemental information). However, this study also shows a common ambivalence about the letter of condolence’s benefit. Healthcare workers must strive to adapt bereavement follow-up to each individual situation.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Effect of Transfusion on Mortality and Other Adverse Events Among
           Critically Ill Septic Patients: An Observational Study Using a Marginal
           Structural Cox Model*
    • Authors: Dupuis; Claire; Garrouste-Orgeas, Maité; Bailly, Sébastien; Adrie, Christophe; Goldgran-Toledano, Dany; Azoulay, Elie; Ruckly, Stéphane; Marcotte, Guillaume; Souweine, Bertrand; Darmon, Michael; Cohen, Yves; Schwebel, Carole; Lacave, Guillaume; Bouadma, Lila; Timsit, Jean-Francois; on behalf of the OUTCOMEREA Study Group
      Abstract: imageObjectives: RBC transfusion is often required in patients with sepsis. However, adverse events have been associated with RBC transfusion, raising safety concerns. A randomized controlled trial validated the 7 g/dL threshold, but previously transfused patients were excluded. Cohort studies led to conflicting results and did not handle time-dependent covariates and history of treatment. Additional data are thus warranted to guide patient’s management.Design: To estimate the effect of one or more RBC within 1 day on three major outcomes (mortality, ICU-acquired infections, and severe hypoxemia) at day 30, we used marginal structural models. A trajectory modeling, based on hematocrit evolution pattern, allowed identification of subgroups. Secondary analyses were performed into each of them.Setting: A prospective French multicenter database.Patients: Patients with sepsis at admission. Patients with hemorrhagic shock at admission were excluded.Interventions: None.Measurements and Main Results: Overall, in our cohort of 6,016 patients, RBC transfusion was not associated with death (hazard ratio, 1.07; 95% CI, 0.88–1.30; p = 0.52). However, RBC transfusion was associated with increased occurrence of ICU-acquired infections (hazard ratio, 2.77; 95% CI, 2.33–3.28; p < 0.01) and of severe hypoxemia (hazard ratio, 1.29; 95% CI, 1.14–1.47; p < 0.01). A protective effect from death by the transfusion was found in the subgroup with the lowest hematocrit level (26 [interquartile range, 24–28]) (hazard ratio, 0.72; 95% CI, 0.55–0.95; p = 0.02).Conclusions: RBC transfusion did not affect overall mortality in critically ill patients with sepsis. Increased occurrence rate of ICU-acquired infection and severe hypoxemia are expected outcomes from RBC transfusion that need to be weighted with its benefits in selected patients.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Effects of High-Flow Nasal Cannula on the Work of Breathing in Patients
           Recovering From Acute Respiratory Failure*
    • Authors: Delorme; Mathieu; Bouchard, Pierre-Alexandre; Simon, Mathieu; Simard, Serge; Lellouche, François
      Abstract: imageObjectives: High-flow nasal cannula is increasingly used in the management of respiratory failure. However, little is known about its impact on respiratory effort, which could explain part of the benefits in terms of comfort and efficiency. This study was designed to assess the effects of high-flow nasal cannula on indexes of respiratory effort (i.e., esophageal pressure variations, esophageal pressure-time product/min, and work of breathing/min) in adults.Design: A randomized controlled crossover study was conducted in 12 patients with moderate respiratory distress (i.e., after partial recovery from an acute episode, allowing physiologic measurements).Setting: Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada.Subjects: Twelve adult patients with respiratory distress symptoms were enrolled in this study.Interventions: Four experimental conditions were evaluated: baseline with conventional oxygen therapy and high-flow nasal cannula at 20, 40, and 60 L/min. The primary outcomes were the indexes of respiratory effort (i.e., esophageal pressure variations, esophageal pressure-time product/min, and work of breathing/min). Secondary outcomes included tidal volume, respiratory rate, minute volume, dynamic lung compliance, inspiratory resistance, and blood gases.Measurements and Main Results: Esophageal pressure variations decreased from 9.8 (5.8–14.6) cm H2O at baseline to 4.9 (2.1–9.1) cm H2O at 60 L/min (p = 0.035). Esophageal pressure-time product/min decreased from 165 (126–179) to 72 (54–137) cm H2O • s/min, respectively (p = 0.033). Work of breathing/min decreased from 4.3 (3.5–6.3) to 2.1 (1.5–5.0) J/min, respectively (p = 0.031). Respiratory pattern variables and capillary blood gases were not significantly modified between experimental conditions. Dynamic lung compliance increased from 38 (24–64) mL/cm H2O at baseline to 59 (43–175) mL/cm H2O at 60 L/min (p = 0.007), and inspiratory resistance decreased from 9.6 (5.5–13.4) to 5.0 (1.0–9.1) cm H2O/L/s, respectively (p = 0.07).Conclusions: High-flow nasal cannula, when set at 60 L/min, significantly reduces the indexes of respiratory effort in adult patients recovering from acute respiratory failure. This effect is associated with an improvement in respiratory mechanics.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • The Epidemiology of Chronic Critical Illness After Severe Traumatic Injury
           at Two Level–One Trauma Centers*
    • Authors: Mira; Juan C.; Cuschieri, Joseph; Ozrazgat-Baslanti, Tezcan; Wang, Zhongkai; Ghita, Gabriela L.; Loftus, Tyler J.; Stortz, Julie A.; Raymond, Steven L.; Lanz, Jennifer D.; Hennessy, Laura V.; Brumback, Babette; Efron, Philip A.; Baker, Henry V.; Moore, Frederick A.; Maier, Ronald V.; Moldawer, Lyle L.; Brakenridge, Scott C.
      Abstract: imageObjective: To determine the incidence and risk factors of chronic critical illness after severe blunt trauma.Design: Prospective observational cohort study (NCT01810328).Setting: Two level–one trauma centers in the United States.Patients: One hundred thirty-five adult blunt trauma patients with hemorrhagic shock who survived beyond 48 hours after injury.Interventions: None.Measurements and Main Results: Chronic critical illness was defined as an ICU stay lasting 14 days or more with evidence of persistent organ dysfunction. Three subjects (2%) died within the first 7 days, 107 (79%) exhibited rapid recovery and 25 (19%) progressed to chronic critical illness. Patients who developed chronic critical illness were older (55 vs 44-year-old; p = 0.01), had more severe shock (base deficit, –9.2 vs –5.5; p = 0.005), greater organ failure severity (Denver multiple organ failure score, 3.5 ± 2.4 vs 0.8 ± 1.1; p < 0.0001) and developed more infectious complications (84% vs 35%; p < 0.0001). Chronic critical illness patients were more likely to be discharged to a long-term care setting (56% vs 34%; p = 0.008) than to a rehabilitation facility/home. At 4 months, chronic critical illness patients had higher mortality (16.0% vs 1.9%; p < 0.05), with survivors scoring lower in general health measures (p < 0.005). Multivariate analysis revealed age greater than or equal to 55 years, systolic hypotension less than or equal to 70 mm Hg, transfusion greater than or equal to 5 units packed red blood cells within 24 hours, and Denver multiple organ failure score at 72 hours as independent predictors of chronic critical illness (area under the receiver operating curve, 0.87; 95% CI, 0.75–0.95).Conclusions: Although early mortality is low after severe trauma, chronic critical illness is a common trajectory in survivors and is associated with poor long-term outcomes. Advancing age, shock severity, and persistent organ dysfunction are predictive of chronic critical illness. Early identification may facilitate targeted interventions to change the trajectory of this morbid phenotype.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Oxygen Thresholds and Mortality During Extracorporeal Life Support in
           Adult Patients*
    • Authors: Munshi; Laveena; Kiss, Alex; Cypel, Marcelo; Keshavjee, Shaf; Ferguson, Niall D.; Fan, Eddy
      Abstract: imageObjectives: Extracorporeal life support can lead to rapid reversal of hypoxemia and shock; however, it can also result in varying degrees of hyperoxia. Recent data have suggested an association between hyperoxia and mortality; however, this conclusion has not been consistent across the literature. We evaluated the association between oxygenation thresholds and mortality in three cohorts of extracorporeal life support patients.Design: We performed a retrospective cohort study using the Extracorporeal Life Support Organization Registry.Setting: We evaluated the relationship between oxygenation measured 24 hours after extracorporeal membrane oxygenation onset and mortality (2010–2015).Patients: The extracorporeal life support cohorts were as follows: 1) veno-venous extracorporeal membrane oxygenation for respiratory failure, 2) veno-arterial extracorporeal membrane oxygenation for cardiogenic shock, and 3) extracorporeal cardiopulmonary resuscitation.Interventions: The relationships between hypoxemia (PaO2 < 60mm Hg), normoxia (PaO2 60–100mm Hg), moderate hyperoxia (PaO2 101–300mm Hg), extreme hyperoxia (PaO2> 300 mm Hg), and mortality were evaluated across three extracorporeal life support cohorts.Measurements and Main Results: Seven hundred sixty-five patients underwent veno-venous extracorporeal membrane oxygenation, 775 patients underwent veno-arterial extracorporeal membrane oxygenation, and 412 underwent extracorporeal cardiopulmonary resuscitation. During veno-venous extracorporeal membrane oxygenation, hypoxemia (odds ratio, 1.68; 95% CI, 1.09–2.57) and moderate hyperoxia (odds ratio, 1.66; 95% CI, 1.11–2.50) were associated with increased mortality compared with normoxia. There was no association between oxygenation and mortality for veno-arterial extracorporeal membrane oxygenation. Moderate hyperoxia was associated with increased mortality during extracorporeal cardiopulmonary resuscitation compared with normoxia (odds ratio, 1.77; 95% CI, 1.03–3.30). An exploratory analysis did not find more specific PaO2 thresholds associated with mortality within moderate hyperoxia.Conclusions: Moderate hyperoxia was associated with increased mortality in patients undergoing veno-venous extracorporeal membrane oxygenation for respiratory failure and extracorporeal cardiopulmonary resuscitation. Hypoxemia was associated with an increased mortality in veno-venous extracorporeal membrane oxygenation. No association was seen between oxygenation and mortality in veno-arterial extracorporeal membrane oxygenation which may be due to early death driven by the underlying disease.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Impact of Missing Physiologic Data on Performance of the Simplified Acute
           Physiology Score 3 Risk-Prediction Model*
    • Authors: Engerström; Lars; Nolin, Thomas; Mårdh, Caroline; Sjöberg, Folke; Karlström, Göran; Fredrikson, Mats; Walther, Sten M.
      Abstract: imageObjectives: The Simplified Acute Physiology 3 outcome prediction model has a narrow time window for recording physiologic measurements. Our objective was to examine the prevalence and impact of missing physiologic data on the Simplified Acute Physiology 3 model’s performance.Design: Retrospective analysis of prospectively collected data.Setting: Sixty-three ICUs in the Swedish Intensive Care Registry.Patients: Patients admitted during 2011–2014 (n = 107,310).Interventions: None.Measurements and Main Results: Model performance was analyzed using the area under the receiver operating curve, scaled Brier’s score, and standardized mortality rate. We used a recalibrated Simplified Acute Physiology 3 model and examined model performance in the original dataset and in a dataset of complete records where missing data were generated (simulated dataset). One or more data were missing in 40.9% of the admissions, more common in survivors and low-risk admissions than in nonsurvivors and high-risk admissions. Discrimination did not decrease with one to two missing variables, but accuracy was highest with no missing data. Calibration was best in the original dataset with a mix of full records and records with some missing values (area under the receiver operating curve was 0.85, scaled Brier 27%, and standardized mortality rate 0.99). With zero, one, and two data missing, the scaled Brier was 31%, 26%, and 21%; area under the receiver operating curve was 0.84, 0.87, and 0.89; and standardized mortality rate was 0.92, 1.05 and 1.10, respectively. Datasets where the missing data were simulated for oxygenation or oxygenation and hydrogen ion concentration together performed worse than datasets with these data originally missing.Conclusions: There is a coupling between missing physiologic data, admission type, low risk, and survival. Increased loss of physiologic data reduced model performance and will deflate mortality risk, resulting in falsely high standardized mortality rates.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Serial Daily Organ Failure Assessment Beyond ICU Day 5 Does Not
           Independently Add Precision to ICU Risk-of-Death Prediction
    • Authors: Holder; Andre L.; Overton, Elizabeth; Lyu, Peter; Kempker, Jordan A.; Nemati, Shamim; Razmi, Fereshteh; Martin, Greg S.; Buchman, Timothy G.; Murphy, David J.
      Abstract: imageObjectives: To identify circumstances in which repeated measures of organ failure would improve mortality prediction in ICU patients.Design: Retrospective cohort study, with external validation in a deidentified ICU database.Setting: Eleven ICUs in three university hospitals within an academic healthcare system in 2014.Patients: Adults (18 yr old or older) who satisfied the following criteria: 1) two of four systemic inflammatory response syndrome criteria plus an ordered blood culture, all within 24 hours of hospital admission; and 2) ICU admission for at least 2 calendar days, within 72 hours of emergency department presentation.Intervention: NoneMeasurements and Main Results: Data were collected until death, ICU discharge, or the seventh ICU day, whichever came first. The highest Sequential Organ Failure Assessment score from the ICU admission day (ICU day 1) was included in a multivariable model controlling for other covariates. The worst Sequential Organ Failure Assessment scores from the first 7 days after ICU admission were incrementally added and retained if they obtained statistical significance (p < 0.05). The cohort was divided into seven subcohorts to facilitate statistical comparison using the integrated discriminatory index. Of the 1,290 derivation cohort patients, 83 patients (6.4%) died in the ICU, compared with 949 of the 8,441 patients (11.2%) in the validation cohort. Incremental addition of Sequential Organ Failure Assessment data up to ICU day 5 improved the integrated discriminatory index in the validation cohort. Adding ICU day 6 or 7 Sequential Organ Failure Assessment data did not further improve model performance.Conclusions: Serial organ failure data improve prediction of ICU mortality, but a point exists after which further data no longer improve ICU mortality prediction of early sepsis.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Emotional Impact of End-of-Life Decisions on Professional Relationships in
           the ICU: An Obstacle to Collegiality'*
    • Authors: Laurent; Alexandra; Bonnet, Magalie; Capellier, Gilles; Aslanian, Pierre; Hebert, Paul
      Abstract: imageObjectives: End-of-life decisions are not only common in the ICU but also frequently elicit strong feelings among health professionals. Even though we seek to develop more collegial interprofessional approaches to care and health decision-making, there are many barriers to successfully managing complex decisions. The aim of this study is to better understand how emotions influence the end-of-life decision-making process among professionals working in ICU.Design: Qualitative study with clinical interviews. All interviews were transcribed verbatim and analyzed thematically using interpretative phenomenological analysis.Setting: Two independent ICUs at the “Centre Hospitalier de l’Université de Montréal.”Subjects: Ten physicians and 10 nurses.Interventions: None.Measurements and Main Results: During the end-of-life decision-making process, families and patients restructure the decision-making frame by introducing a strong emotional dimension. This results in the emergence of new challenges quite different from the immediacy often associated with intensive care. In response to changes in decision frames, physicians rely on their relationship with the patient’s family to assist with advanced care decisions. Nurses, however, draw on their relationship and proximity to the patient to denounce therapeutic obstinacy.Conclusions: Our study suggests that during the end-of-life decision-making process, nurses’ feelings toward their patients and physicians’ feelings toward their patients’ families influence the decisions they make. Although these emotional dimensions allow nurses and physicians to act in a manner that is consistent with their professional ethics, the professionals themselves seem to have a poor understanding of these dimensions and often overlook them, thus hindering collegial decisions.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Time Course of Septic Shock in Immunocompromised and Nonimmunocompromised
           Patients
    • Authors: Jamme; Matthieu; Daviaud, Fabrice; Charpentier, Julien; Marin, Nathalie; Thy, Michaël; Hourmant, Yannick; Mira, Jean-Paul; Pène, Frédéric
      Abstract: imageObjectives: To address the impact of underlying immune conditions on the course of septic shock with respect to both mortality and the development of acute infectious and noninfectious complications.Design: An 8-year (2008–2015) monocenter retrospective study.Setting: A medical ICU in a tertiary care center.Patients: Patients diagnosed for septic shock within the first 48 hours of ICU admission were included. Patients were classified in four subgroups with respect to their immune status: nonimmunocompromised and immunocompromised distributed into hematologic or solid malignancies and nonmalignant immunosuppression. Outcomes were in-hospital death and the development of ischemic and hemorrhagic complications and ICU-acquired infections. The determinants of death and complications were addressed by multivariate competing risk analysis.Interventions: None.Measurements and Main Results: Eight hundred one patients were included. Among them, 305 (38%) were immunocompromised, distributed into solid tumors (122), hematologic malignancies (106), and nonmalignant immunosuppression (77). The overall 3-day, in-ICU, and in-hospital mortality rates were 14.1%, 37.3%, and 41.3%, respectively. Patients with solid tumors displayed increased in-hospital mortality (cause-specific hazard, 2.20 [95% CI, 1.64–2.96]; p < 0.001). ICU-acquired infections occurred in 211 of the 3-day survivors (33%). In addition, 95 (11.8%) and 70 (8.7%) patients exhibited severe ischemic or hemorrhagic complications during the ICU stay. There was no association between the immune status and the occurrence of ICU-acquired infections. Nonmalignant immunosuppression and hematologic malignancies were independently associated with increased risks of severe ischemic events (cause-specific hazard, 2.12 [1.14–3.96]; p = 0.02) and hemorrhage (cause-specific hazard, 3.17 [1.41–7.13]; p = 0.005), respectively.Conclusions: The underlying immune status impacts on the course of septic shock and on the susceptibility to ICU-acquired complications. This emphasizes the complexity of sepsis syndromes in relation with comorbid conditions and raises the question of the relevant endpoints in clinical studies.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Diagnostic Accuracy of Point-of-Care Ultrasound Performed by Pulmonary
           Critical Care Physicians for Right Ventricle Assessment in Patients With
           Acute Pulmonary Embolism*
    • Authors: Filopei; Jason; Acquah, Samuel O.; Bondarsky, Eric E.; Steiger, David J.; Ramesh, Navitha; Ehrlich, Madeline; Patrawalla, Paru
      Abstract: imageObjectives: Risk stratification for acute pulmonary embolism using imaging presence of right ventricular dysfunction is essential for triage; however, comprehensive transthoracic echocardiography has limited availability. We assessed the accuracy and timeliness of Pulmonary Critical Care Medicine Fellow’s performance of goal-directed echocardiograms and intensivists’ interpretations for evaluating right ventricular dysfunction in acute pulmonary embolism.Design: Prospective observational study and retrospective chart review.Setting: Four hundred fifty bed urban teaching hospital.Patients: Adult in/outpatients diagnosed with acute pulmonary embolism.Interventions: Pulmonary critical care fellows performed and documented their goal-directed echocardiogram as normal or abnormal for right ventricular size and function in patients with acute pulmonary embolism. Gold standard transthoracic echocardiography was performed on schedule unless the goal-directed echocardiogram showed critical findings. Attending intensivists blinded to the clinical scenario reviewed these exams at a later date.Measurements and Main Results: Two hundred eighty-seven consecutive patients were evaluated for acute PE. Pulmonary Critical Care Medicine Fellows performed 154 goal-directed echocardiograms, 110 with complete cardiology-reviewed transthoracic echocardiography within 48 hours for comparison. Pulmonary Critical Care Medicine Fellow’s area under the curve for size and function was 0.83 (95% CI, 0.75–0.90) and 0.83 (95% CI, 0.75–0.90), respectively. Intensivists’ 1/2 area under the curve for size and function was (1) 0.87 (95% CI, 0.82–0.94), (1) 0.87 (95% CI, 0.80–0.93) and (2) 0.88 (95% CI, 0.82–0.95), (2) 0.88 (95% CI, 0.82–0.95). Median time difference between goal-directed echocardiogram and transthoracic echocardiography was 21 hours 18 minutes.Conclusions: This is the first study to evaluate pulmonary critical care fellows’ and intensivists’ use of goal-directed echocardiography in diagnosing right ventricular dysfunction in acute pulmonary embolism. Pulmonary Critical Care Medicine Fellows and intensivists made a timely and accurate assessment. Screening for right ventricular dysfunction using goal-directed echocardiography can and should be performed by pulmonary critical care physicians in patients with acute pulmonary embolism.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Racial Differences in Palliative Care Use After Stroke in Majority-White,
           Minority-Serving, and Racially Integrated U.S. Hospitals
    • Authors: Faigle; Roland; Ziai, Wendy C.; Urrutia, Victor C.; Cooper, Lisa A.; Gottesman, Rebecca F.
      Abstract: imageObjectives: Racial/ethnic differences in palliative care resource use after stroke have been recognized, but it is unclear whether patient or hospital characteristics drive this disparity. We sought to determine whether palliative care use after intracerebral hemorrhage and ischemic stroke differs between hospitals serving varying proportions of minority patients.Design: Population-based cross-sectional study.Setting: Inpatient hospital admissions from the Nationwide Inpatient Sample between 2007 and 2011.Patients: A total of 46,735 intracerebral hemorrhage and 331,521 ischemic stroke cases.Interventions: Palliative care use.Measurements and Main Results: Intracerebral hemorrhage and ischemic stroke admissions were identified from the Nationwide Inpatient Sample between 2007 and 2011. Hospitals were categorized based on the percentage of ethnic minority stroke patients (< 25% minorities [“white hospitals”], 25–50% minorities [“mixed hospitals”], or> 50% minorities [“minority hospitals”]). Logistic regression was used to evaluate the association between race/ethnicity and palliative care use within and between the different hospital strata. Stroke patients receiving care in minority hospitals had lower odds of palliative care compared with those treated in white hospitals, regardless of individual patient race/ethnicity (adjusted odds ratio, 0.65; 95% CI, 0.50–0.84 for intracerebral hemorrhage and odds ratio, 0.62; 95% CI, 0.50–0.77 for ischemic stroke). Ethnic minorities had a lower likelihood of receiving palliative care compared with whites in any hospital stratum, but the odds of palliative care for both white and minority intracerebral hemorrhage patients was lower in minority compared with white hospitals (odds ratio, 0.66; 95% CI, 0.50–0.87 for white and odds ratio, 0.64; 95% CI, 0.46–0.88 for minority patients). Similar results were observed in ischemic stroke.Conclusions: The odds of receiving palliative care for both white and minority stroke patients is lower in minority compared with white hospitals, suggesting system-level factors as a major contributor to explain race disparities in palliative care use after stroke.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Outcomes of ICU Patients With a Discharge Diagnosis of Critical Illness
           Polyneuromyopathy: A Propensity-Matched Analysis
    • Authors: Kelmenson; Daniel A.; Held, Natalie; Allen, Richard R.; Quan, Dianna; Burnham, Ellen L.; Clark, Brendan J.; Ho, P. Michael; Kiser, Tyree H.; Vandivier, R. William; Moss, Marc
      Abstract: imageObjectives: To assess the impact of a discharge diagnosis of critical illness polyneuromyopathy on health-related outcomes in a large cohort of patients requiring ICU admission.Design: Retrospective cohort with propensity score–matched analysis.Setting: Analysis of a large multihospital database.Patients: Adult ICU patients without preexisting neuromuscular abnormalities and a discharge diagnosis of critical illness polyneuropathy and/or myopathy along with adult ICU propensity-matched control patients.Interventions: None.Measurements and Main Results: Of 3,567 ICU patients with a discharge diagnosis of critical illness polyneuropathy and/or myopathy, we matched 3,436 of these patients to 3,436 ICU patients who did not have a discharge diagnosis of critical illness polyneuropathy and/or myopathy. After propensity matching and adjusting for unbalanced covariates, we used conditional logistic regression and a repeated measures model to compare patient outcomes. Compared to patients without a discharge diagnosis of critical illness polyneuropathy and/or myopathy, patients with a discharge diagnosis of critical illness polyneuropathy and/or myopathy had fewer 28-day hospital-free days (6 [0.1] vs 7.4 [0.1] d; p < 0.0001), had fewer 28-day ventilator-free days (15.7 [0.2] vs 17.5 [0.2] d; p < 0.0001), had higher hospitalization charges (313,508 [4,853] vs 256,288 [4,470] dollars; p < 0.0001), and were less likely to be discharged home (15.3% vs 32.8%; p < 0.0001) but had lower in-hospital mortality (13.7% vs 18.3%; p < 0.0001).Conclusions: In a propensity-matched analysis of a large national database, a discharge diagnosis of critical illness polyneuropathy and/or myopathy is strongly associated with deleterious outcomes including fewer hospital-free days, fewer ventilator-free days, higher hospital charges, and reduced discharge home but also an unexpectedly lower in-hospital mortality. This study demonstrates the clinical importance of a discharge diagnosis of critical illness polyneuropathy and/or myopathy and the need for effective preventive interventions.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Dysphagia in Mechanically Ventilated ICU Patients (DYnAMICS): A
           Prospective Observational Trial
    • Authors: Schefold; Joerg C.; Berger, David; Zürcher, Patrick; Lensch, Michael; Perren, Andrea; Jakob, Stephan M.; Parviainen, Ilkka; Takala, Jukka
      Abstract: imageObjectives: Swallowing disorders may be associated with adverse clinical outcomes in patients following invasive mechanical ventilation. We investigated the incidence of dysphagia, its time course, and association with clinically relevant outcomes in extubated critically ill patients.Design: Prospective observational trial with systematic dysphagia screening and follow-up until 90 days or death.Settings: ICU of a tertiary care academic center.Patients: One thousand three-hundred four admissions of mixed adult ICU patients (median age, 66.0 yr [interquartile range, 54.0–74.0]; Acute Physiology and Chronic Health Evaluation-II score, 19.0 [interquartile range, 14.0–24.0]) were screened for postextubation dysphagia. Primary ICU admissions (n = 933) were analyzed and followed up until 90 days or death. Patients from an independent academic center served as confirmatory cohort (n = 220).Interventions: Bedside screening for dysphagia was performed within 3 hours after extubation by trained ICU nurses. Positive screening triggered confirmatory specialist bedside swallowing examinations and follow-up until hospital discharge.Measurements and Main Results: Dysphagia screening was positive in 12.4% (n = 116/933) after extubation (18.3% of emergency and 4.9% of elective patients) and confirmed by specialists within 24 hours from positive screening in 87.3% (n = 96/110, n = 6 missing data). The dysphagia incidence at ICU discharge was 10.3% (n = 96/933) of which 60.4% (n = 58/96) remained positive until hospital discharge. Days on feeding tube, length of mechanical ventilation and ICU/hospital stay, and hospital mortality were higher in patients with dysphagia (all p < 0.001). The univariate hazard ratio for 90-day mortality for dysphagia was 3.74 (95% CI, 2.01–6.95; p < 0.001). After adjustment for disease severity and length of mechanical ventilation, dysphagia remained an independent predictor for 28-day and 90-day mortality (excess 90-d mortality 9.2%).Conclusions: Dysphagia after extubation was common in ICU patients, sustained until hospital discharge in the majority of affected patients, and was an independent predictor of death. Dysphagia after mechanical ventilation may be an overlooked problem. Studies on underlying causes and therapeutic interventions seem warranted.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Extracorporeal Membrane Oxygenation Is First-Line Therapy for Acute
           Respiratory Distress Syndrome
    • Authors: Abrams; Darryl; Brodie, Daniel
      Abstract: imageNo abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Extracorporeal Membrane Oxygenation Is Not First-Line Therapy for the
           Acute Respiratory Distress Syndrome
    • Authors: Stephens; R. Scott; Brower, Roy G.
      Abstract: imageNo abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Guidelines for the Diagnosis and Management of Critical Illness-Related
           Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part I):
           Society of Critical Care Medicine (SCCM) and European Society of Intensive
           Care Medicine (ESICM) 2017
    • Authors: Annane; Djillali; Pastores, Stephen M.; Rochwerg, Bram; Arlt, Wiebke; Balk, Robert A.; Beishuizen, Albertus; Briegel, Josef; Carcillo, Joseph; Christ-Crain, Mirjam; Cooper, Mark S.; Marik, Paul E.; Umberto Meduri, Gianfranco; Olsen, Keith M.; Rodgers, Sophia C.; Russell, James A.; Van den Berghe, Greet
      Abstract: imageObjective: To update the 2008 consensus statements for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in adult and pediatric patients.Participants: A multispecialty task force of 16 international experts in critical care medicine, endocrinology, and guideline methods, all of them members of the Society of Critical Care Medicine and/or the European Society of Intensive Care Medicine.Design/Methods: The recommendations were based on the summarized evidence from the 2008 document in addition to more recent findings from an updated systematic review of relevant studies from 2008 to 2017 and were formulated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The strength of each recommendation was classified as strong or conditional, and the quality of evidence was rated from high to very low based on factors including the individual study design, the risk of bias, the consistency of the results, and the directness and precision of the evidence. Recommendation approval required the agreement of at least 80% of the task force members.Results: The task force was unable to reach agreement on a single test that can reliably diagnose CIRCI, although delta cortisol (change in baseline cortisol at 60 min of < 9 μg/dL) after cosyntropin (250 μg) administration and a random plasma cortisol of < 10 μg/dL may be used by clinicians. We suggest against using plasma-free cortisol or salivary cortisol level over plasma total cortisol (conditional, very low quality of evidence). For treatment of specific conditions, we suggest using IV hydrocortisone < 400 mg/day for ≥ 3 days at full dose in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy (conditional, low quality of evidence). We suggest not using corticosteroids in adult patients with sepsis without shock (conditional recommendation, moderate quality of evidence). We suggest the use of IV methylprednisolone 1 mg/kg/day in patients with early moderate to severe acute respiratory distress syndrome (PaO2/FiO2 < 200 and within 14 days of onset) (conditional, moderate quality of evidence). Corticosteroids are not suggested for patients with major trauma (conditional, low quality of evidence).Conclusions: Evidence-based recommendations for the use of corticosteroids in critically ill patients with sepsis and septic shock, acute respiratory distress syndrome, and major trauma have been developed by a multispecialty task force.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Critical Illness-Related Corticosteroid Insufficiency (CIRCI): A Narrative
           Review from a Multispecialty Task Force of the Society of Critical Care
           Medicine (SCCM) and the European Society of Intensive Care Medicine
           (ESICM)
    • Authors: Annane; Djillali; Pastores, Stephen M.; Arlt, Wiebke; Balk, Robert A.; Beishuizen, Albertus; Briegel, Josef; Carcillo, Joseph; Christ-Crain, Mirjam; Cooper, Mark S.; Marik, Paul E.; Meduri, Gianfranco Umberto; Olsen, Keith M.; Rochwerg, Bram; Rodgers, Sophia C.; Russell, James A.; Van den Berghe, Greet
      Abstract: imageObjective: To provide a narrative review of the latest concepts and understanding of the pathophysiology of critical illness-related corticosteroid insufficiency (CIRCI).Participants: A multi-specialty task force of international experts in critical care medicine and endocrinology and members of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine.Data Sources: Medline, Database of s of Reviews of Effects (DARE), Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews.Results: Three major pathophysiologic events were considered to constitute CIRCI: dysregulation of the hypothalamic–pituitary–adrenal (HPA) axis, altered cortisol metabolism, and tissue resistance to glucocorticoids. The dysregulation of the HPA axis is complex, involving multidirectional crosstalk between the CRH/ACTH pathways, autonomic nervous system, vasopressinergic system, and immune system. Recent studies have demonstrated that plasma clearance of cortisol is markedly reduced during critical illness, explained by suppressed expression and activity of the primary cortisol-metabolizing enzymes in the liver and kidney. Despite the elevated cortisol levels during critical illness, tissue resistance to glucocorticoids is believed to occur due to insufficient glucocorticoid alpha-mediated anti-inflammatory activity.Conclusions: Novel insights into the pathophysiology of CIRCI add to the limitations of the current diagnostic tools to identify at-risk patients and may also impact how corticosteroids are used in patients with CIRCI.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Aligning Intention and Effect: What Can We Learn From Family Members’
           Responses to Condolence Letters'*
    • Authors: Long; Ann C.; Curtis, J. Randall
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Is A Hemoglobin Concentration As Low As 7 g/dL Adequate For All
           Critically Ill Patients With Sepsis' Legitimate Doubts Remain!*
    • Authors: Kramer; Andreas H.
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Humidified High-Flow Nasal Cannula Oxygen—More Than Just
           Supplemental Oxygen*
    • Authors: MacIntyre; Neil R.
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Chronic Critical Illness After Trauma: From Description to Treatment'*
           
    • Authors: Meynaar; Iwan A.; Spronk, Peter E.
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Extracorporeal Life Support: What Should We Be Targeting'*
    • Authors: Park; Pauline K.
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Missing Data and ICU Mortality Prediction: Gone But Not to Be Forgotten*
    • Authors: Nagrebetsky; Alexander; Bittner, Edward A.
      Abstract: imageNo abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • A Qualitative Look at End-of-Life Care in the ICU*
    • Authors: Granstein; Justin H.; Creutzfeldt, Claire J.
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • It Just Makes Sense*
    • Authors: Mackay; Fraser; Puri, Nitin
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Critical Care Resources in Mainland China: When More May Not Always Be
           Better*
    • Authors: Du; Bin; Hu, Xiaoyun; Hou, Ming; for the China Critical Care Clinical Trials Group
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Microcirculation First!—Esmolol, a Candidate for the Next Term of
           Office*
    • Authors: Morelli; Andrea; Rehberg, Sebastian
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Racial Disparities in Sepsis-Related In-Hospital Mortality: Using a Broad
           Case Capture Method and Multivariate Controls for Clinical and Hospital
           Variables, 2004–2013
    • Authors: Jones; Jenna M.; Fingar, Kathryn R.; Miller, Melissa A.; Coffey, Rosanna; Barrett, Marguerite; Flottemesch, Thomas; Heslin, Kevin C.; Gray, Darryl T.; Moy, Ernest
      Abstract: imageObjectives: As sepsis hospitalizations have increased, in-hospital sepsis deaths have declined. However, reported rates may remain higher among racial/ethnic minorities. Most previous studies have adjusted primarily for age and sex. The effect of other patient and hospital characteristics on disparities in sepsis mortality is not yet well-known. Furthermore, coding practices in claims data may influence findings. The objective of this study was to use a broad method of capturing sepsis cases to estimate 2004–2013 trends in risk-adjusted in-hospital sepsis mortality rates by race/ethnicity to inform efforts to reduce disparities in sepsis deaths.Design: Retrospective, repeated cross-sectional study.Setting: Acute care hospitals in the Healthcare Cost and Utilization Project State Inpatient Databases for 18 states with consistent race/ethnicity reporting.Patients: Patients diagnosed with septicemia, sepsis, organ dysfunction plus infection, severe sepsis, or septic shock.Measurements and Main Results: In-hospital sepsis mortality rates adjusted for patient and hospital factors by race/ethnicity were calculated. From 2004 to 2013, sepsis hospitalizations for all racial/ethnic groups increased, and mortality rates decreased by 5–7% annually. Mortality rates adjusted for patient characteristics were higher for all minority groups than for white patients. After adjusting for hospital characteristics, sepsis mortality rates in 2013 were similar for white (92.0 per 1,000 sepsis hospitalizations), black (94.0), and Hispanic (93.5) patients but remained elevated for Asian/Pacific Islander (106.4) and “other” (104.7; p < 0.001) racial/ethnic patients.Conclusions: Our results indicate that hospital characteristics contribute to higher rates of sepsis mortality for blacks and Hispanics. These findings underscore the importance of ensuring that improved sepsis identification and management is implemented across all hospitals, especially those serving diverse populations.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Critical Care Resources in Guangdong Province of China: Three Surveys from
           2005 to 2015*
    • Authors: Wu; Jian-Feng; Pei, Fei; Ouyang, Bin; Chen, Juan; Li, Yi-Min; Feng, Yong-Wen; Guo, Fa-Liang; Zhou, Li-Xin; Wang, Zheng; Guo, Ying-Jun; Lin, Qin-Han; Li, Zhan-Peng; Ling, Yun; Li, Li; Deng, Lie-Hua; Zhao, Ying-Ping; Dai, Jian-Wei; Luo, Shu-Yu; Zhou, Dun-Rong; Luo, Wei-Wen; Zhao, Ling; Chen, Wei-Ying; Wang, Wei-Chuan; Cai, Wen-Yang; Luo, Qiong-Xiang; Guan, Xiang-Dong
      Abstract: imageObjectives: Data about the critical care resources in China remain scarce. The purpose of this study was to investigate the variation and distribution of critical care resources in Guangdong province from 2005 to 2015.Design: Data in regard to critical care resources were collected through questionnaires and visits every 5 years from 2005.Setting: All hospitals in Guangdong province were screened and hospitals that provide critical care services were enrolled.Intervention: None.Measurements and Main Results: One hundred eleven, 158, and 284 hospitals that provide critical care services were enrolled in the three consecutive surveys respectively. The number of ICUs, ICU beds, intensivists, and nurses increased to 324, 3,956, 2,470, and 7,695, respectively, by 2015. Adjusted by population, the number of ICU beds per 100,000 (100,000) population increased by 147.7% from 2005 to 2015, and the number of intensivists and nurses per 100,000 population increased by 35.3% and 55.1% from 2011 to 2015. However, the numbers in the Pearl River Delta, a richer area, were higher than those in the non–Pearl River Delta area (ICU beds: 4.64 vs 2.58; intensivists: 2.90 vs 1.61; nurses: 9.30 vs 4.71 in 2015). In terms of staff training, only 17.85% of intensivists and 14.29% of nurses have completed a formal accredited critical care training program by 2015.Conclusions: Our study was the first one to investigate the trend and distribution of critical care resources in China. The quantity of ICU beds and staff has been increasing rapidly, but professional training for staff was inadequate. The distribution of critical care resources was unbalanced. Our study can be beneficial for healthcare policymaking and the allocation of critical care resources in Guangdong province and other provinces in China.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Evaluation of Vasopressin for Septic Shock in Patients on Chronic
           Renin-Angiotensin-Aldosterone System Inhibitors
    • Authors: Erwin; Beth L.; Denaburg, Michael A.; Barker, Andrew B.; McArdle, Philip J.; Windham, Samuel T.; Morgan, Charity J.
      Abstract: imageObjectives: To compare the hemodynamic response in septic shock patients receiving vasopressin who were on chronic renin-angiotensin-aldosterone system inhibitor therapy with those who were not.Design: Single-center, retrospective cohort study.Setting: Medical and surgical ICUs at a 1,100-bed academic medical center.Patients: Medical and surgical ICU patients with septic shock who received vasopressin infusion added to at least one concomitant vasopressor agent between January 2014 and December 2015, then divided into two cohorts: 1) patients who were on chronic renin-angiotensin-aldosterone system inhibitor therapy as outpatients and 2) patients who were not on chronic renin-angiotensin-aldosterone system inhibitor therapy as outpatients.Interventions: None.Measurements and Main Results: Mean arterial pressure at 6 hours was 72.2 mm Hg in the renin-angiotensin-aldosterone system inhibitor group versus 69.7 mm Hg in the non–renin-angiotensin-aldosterone system inhibitor group (p = 0.298). There was no difference in mean arterial pressure at 1, 24, or 48 hours between groups. Total concomitant vasopressor requirements, based on norepinephrine equivalents excluding vasopressin, were significantly lower at 24 hours in the renin-angiotensin-aldosterone system inhibitor group versus the non–renin-angiotensin-aldosterone system inhibitor group (10.7 vs 18.1 µg/min, respectively; p = 0.007), but no significant differences were seen at the other time points assessed. There were no significant differences in ICU or hospital length of stay or mortality.Conclusions: There was no significant difference in the primary outcome of 6-hour mean arterial pressure in septic shock patients receiving vasopressin who were on chronic renin-angiotensin-aldosterone system inhibitor therapy versus those receiving vasopressin who were not on chronic renin-angiotensin-aldosterone system inhibitor therapy. Renin-angiotensin-aldosterone system inhibitor patients had lower total concomitant vasopressor requirements at 24 hours compared with non–renin-angiotensin-aldosterone system inhibitor patients.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Relationship of at Admission Lactate, Unmeasured Anions, and Chloride to
           the Outcome of Critically Ill Patients
    • Authors: Masevicius; Fabio Daniel; Rubatto Birri, Paolo Nahuel; Risso Vazquez, Alejandro; Zechner, Facundo Emanuel; Motta, María Fernanda; Valenzuela Espinoza, Emilio Daniel; Welsh, Sebastián; Guerra Arias, Ernesto Fidel; Furche, Mariano Andrés; Berdaguer, Fernando Daniel; Dubin, Arnaldo
      Abstract: imageObjectives: To investigate the association between the concentration of the causative anions responsible for the main types of metabolic acidosis and the outcome.Design: Prospective observational study.Setting: Teaching ICU.Patients: All patients admitted from January 2006 to December 2014.Interventions: None.Measurements and Main Results: Four thousand nine hundred one patients were admitted throughout the study period; 1,609 met criteria for metabolic acidosis and 145 had normal acid-base values. The association between at admission lactate, unmeasured anions, and chloride concentration with outcome was assessed by multivariate analysis in the whole cohort and in patients with metabolic acidosis. We also compared the mortality of patients with lactic, unmeasured anions, and hyperchloremic metabolic acidosis with that of patients without acid-base disorders. In the whole population, increased lactate and unmeasured anions were independently associated with increased mortality, even after adjusting for potential confounders (odds ratio [95% CI], 1.14 (1.08–1.20); p < 0.0001 and 1.04 (1.02–1.06); p < 0.0001, respectively). In patients with metabolic acidosis, the results were similar. Patients with lactic and unmeasured anions acidosis, but not those with hyperchloremic acidosis, had an increased mortality compared to patients without alterations (17.7%, 12.7%, 4.9%, and 5.8%, respectively; p < 0.05).Conclusions: In this large cohort of critically ill patients, increased concentrations of lactate and unmeasured anions, but not chloride, were associated with increased mortality. In addition, increased unmeasured anions were the leading cause of metabolic acidosis.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Cystic Fibrosis Transmembrane Conductance Regulator Potentiation as a
           Therapeutic Strategy for Pulmonary Edema: A Proof-of-Concept Study in Pigs
           
    • Authors: Li; Xiaopeng; Vargas Buonfiglio, Luis G.; Adam, Ryan J.; Stoltz, David A.; Zabner, Joseph; Comellas, Alejandro P.
      Abstract: imageObjectives: To determine the feasibility of using a cystic fibrosis transmembrane conductance regulator potentiator, ivacaftor (VX-770/Kalydeco, Vertex Pharmaceuticals, Boston, MA), as a therapeutic strategy for treating pulmonary edema.Design: Prospective laboratory animal investigation.Setting: Animal research laboratory.Subjects: Newborn and 3 days to 1 week old pigs.Interventions: Hydrostatic pulmonary edema was induced in pigs by acute volume overload. Ivacaftor was nebulized into the lung immediately after volume overload. Grams of water per grams of dry lung tissue were determined in the lungs harvested 1 hour after volume overload.Measurements and Main Results: Ivacaftor significantly improved alveolar liquid clearance in isolated pig lung lobes ex vivo and reduced edema in a volume overload in vivo pig model of hydrostatic pulmonary edema. To model hydrostatic pressure-induced edema in vitro, we developed a method of applied pressure to the basolateral surface of alveolar epithelia. Elevated hydrostatic pressure resulted in decreased cystic fibrosis transmembrane conductance regulator activity and liquid absorption, an effect which was partially reversed by cystic fibrosis transmembrane conductance regulator potentiation with ivacaftor.Conclusions: Cystic fibrosis transmembrane conductance regulator potentiation by ivacaftor is a novel therapeutic approach for pulmonary edema.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • The β-Blocker Esmolol Restores the Vascular Waterfall Phenomenon
           After Acute Endotoxemia*
    • Authors: Du; Wei; Liu, Dawei; Long, Yun; Wang, Xiaoting
      Abstract: imageBackground: A vascular waterfall occurs when the critical closing pressure is greater than the mean systemic filling pressure. Because the waterfall phenomenon likely exists in the microcirculation, β1-receptor blockers such as esmolol could have some effect on microcirculation and vascular waterfall.Objectives: To determine whether a vascular waterfall exists during septic shock and to assess the effects of vasopressors and β-blockers on vascular waterfall.Design: Sixteen mongrel dogs were mounted with ultrasonic flow probes to measure renal blood flow. The hemodynamic variables of 16 animals were measured at baseline, after induction of acute endotoxemia; then, they underwent volume expansion, and norepinephrine was used to achieve baseline. After achieving septic myocardial depression, the animals were randomly divided into two groups (esmolol vs control groups) after reaching septic myocardial depression.Measurements and Main Results: There was a pressure gap of 41.9 ± 13.9 mm Hg between the arterial critical closing pressure and the mean systemic filling pressure, indicating that a vascular waterfall was present under baseline conditions. Endotoxemia caused a decrease in cardiac output, mean arterial pressure, and critical closing pressure. Endotoxemia also caused the vascular waterfall to disappear. Neither volume expansion nor norepinephrine had any effect on the vascular waterfall. Esmolol infusion restored the vascular waterfall effect following endotoxemia and resuscitation. The 24-hour survival was 75% in the esmolol group versus 12.5% in controls (p = 0.041).Conclusions: Vascular pressure gradients in renal vasculature suggest the presence of a vascular waterfall at baseline. Although this phenomenon disappeared in endotoxemic dogs, it could be restored with β-blocker therapy (esmolol).
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Sepsis Reduces Bone Strength Before Morphologic Changes Are Identifiable
    • Authors: Puthucheary; Zudin A.; Sun, Yao; Zeng, Kaiyang; Vu, Lien Hong; Zhang, Zhi Wei; Lim, Ryan Z. L.; Chew, Nicholas S. Y.; Cove, Matthew E.
      Abstract: imageObjectives: Survivors of critical illness have an increased prevalence of bone fractures. However, early changes in bone strength, and their relationship to structural changes, have not been described. We aimed to characterize early changes in bone functional properties in critical illness and their relationship to changes in bone structure, using a sepsis rodent model.Design: Experimental study.Setting: Animal research laboratory.Subjects: Adult Sprague-Dawley rats.Interventions: Forty Sprague-Dawley rats were randomized to cecal ligation and puncture or sham surgery. Twenty rodents (10 cecal ligation and puncture, 10 sham) were killed at 24 hours, and 20 more at 96 hours.Measurements and Main Results: Femoral bones were harvested for strength testing, microCT imaging, histologic analysis, and multifrequency scanning probe microscopy. Fracture loads at the femoral neck were significantly reduced for cecal ligation and puncture–exposed rodents at 24 hours (83.39 ± 10.1 vs 103.1 ± 17.6 N; p = 0.014) and 96 hours (81.60 ± 14.2 vs 95.66 ± 14.3 N; p = 0.047). Using multifrequency scanning probe microscopy, collagen elastic modulus was lower in cecal ligation and puncture–exposed rats at 24 hours (1.37 ± 0.2 vs 6.13 ± 0.3 GPa; p = 0.001) and 96 hours (5.57 ± 0.5 vs 6.13 ± 0.3 GPa; p = 0.006). Bone mineral elastic modulus was similar at 24 hours but reduced in cecal ligation and puncture–exposed rodents at 96 hours (75.34 ± 13.2 vs 134.4 ± 8.2 GPa; p < 0.001). There were no bone architectural or bone mineral density differences by microCT. Similarly, histologic analysis demonstrated no difference in collagen and elastin staining, and C-X-C chemokine receptor type 4, nuclear factor kappa beta, and tartrate-resistant acid phosphatase immunostaining.Conclusions: In a rodent sepsis model, trabecular bone strength is functionally reduced within 24 hours and is associated with a reduction in collagen and mineral elastic modulus. This is likely to be the result of altered biomechanical properties, rather than increased bone mineral turnover. These data offer both mechanistic insights and may potentially guide development of therapeutic interventions.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Modification of Tracheal Cuff Shape and Continuous Cuff Pressure Control
           to Prevent Microaspiration in an Ex Vivo Pig Tracheal Two-Lung Model
    • Authors: Monsel; Antoine; Le Corre, Marine; Deransy, Romain; Brisson, Hélène; Arbelot, Charlotte; Lu, Qin; Golmard, Jean-Louis; Langeron, Olivier; Rouby, Jean-Jacques
      Abstract: imageObjectives: Microaspiration of subglottic secretions plays a pivotal role in ventilator-associated pneumonia. Impact of endotracheal tube cuff material and shape on tracheal sealing performance remains debated. The primary objective was to compare the tracheal sealing performance of polyvinyl chloride tapered, cylindrical and spherical cuffs. Secondary objectives were to determine the impact of continuous cuff pressure control on sealing performance and pressure variability.Design: Prospective randomized ex vivo animal study.Setting: French research laboratory.Subjects: Seventy-two ex vivo pig tracheal two-lung blocks.Interventions: Blocks were randomly intubated with cylindrical (n = 26), tapered (n = 24), or spherical (n = 22) polyvinyl chloride endotracheal tube cuffs. Two milliliter of methylene blue were instilled above the cuff to quantify microaspirations, and lungs were ventilated for 2 hours. Continuous cuff pressure control was implemented in 33 blocks.Measurements and Main Results: Cuff pressures were continuously recorded, and after 2 hours, a microaspiration score was calculated. Tapered cuffs improved cuff sealing performance compared with spherical cuffs with or without continuous cuff pressure control. Compared with spherical cuffs, tapered cuffs reduced the microaspiration score without and with continuous pressure control by 65% and 72%, respectively. Continuous cuff pressure control did not impact sealing performance. Tapered cuffs generated higher cuff pressures and increased the time spent with overinflation compared with spherical cuffs (median [interquartile range], 77.9% [0–99.8] vs. 0% [0–0.5]; p = 0.03). Continuous cuff pressure control reduced the variability of tapered and spherical cuffs likewise the time spent with overinflation of tapered and cylindrical cuffs.Conclusions: Polyvinyl chloride tapered cuffs sealing enhanced performance at the cost of an increase in cuff pressure and in time spent with overinflation. Continuous cuff pressure control reduced the variability and normalized cuff pressures without impacting sealing performance.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Effects of Hyperoxia During Resuscitation From Hemorrhagic Shock in Swine
           With Preexisting Coronary Artery Disease
    • Authors: Hartmann; Clair; Loconte, Maurizio; Antonucci, Elena; Holzhauser, Michael; Hölle, Tobias; Katzsch, David; Merz, Tamara; McCook, Oscar; Wachter, Ulrich; Vogt, Josef A.; Hoffmann, Andrea; Wepler, Martin; Gröger, Michael; Matejovic, Martin; Calzia, Enrico; Georgieff, Michael; Asfar, Pierre; Radermacher, Peter; Nussbaum, Benedikt L.
      Abstract: imageObjectives: Investigation of the effects of hyperoxia during resuscitation from hemorrhagic shock in swine with preexisting coronary artery disease.Design: Prospective, controlled, randomized trial.Setting: University animal research laboratory.Subjects: Nineteen hypercholesterolemic pigs with preexisting coronary artery disease.Interventions: Anesthetized, mechanically ventilated, and surgically instrumented pigs underwent 3 hours of hemorrhagic shock (removal of 30% of the calculated blood volume and subsequent titration of mean arterial blood pressure ≈40 mm Hg). Postshock resuscitation (48 hr) comprised retransfusion of shed blood, crystalloids (balanced electrolyte solution), and norepinephrine support. Pigs were randomly assigned to “control” (FIO2 0.3, adjusted for arterial oxygen saturation ≥ 90%) and “hyperoxia” (FIO2 1.0 for 24 hr) groups.Measurements and Main Results: Before, at the end of shock and every 12 hours of resuscitation, datasets comprising hemodynamics, calorimetry, blood gases, cytokines, and cardiac and renal function were recorded. Postmortem, organs were sampled for immunohistochemistry, western blotting, and mitochondrial high-resolution respirometry. Survival rates were 50% and 89% in the control and hyperoxia groups, respectively (p = 0.077). Apart from higher relaxation constant τ at 24 hours, hyperoxia did not affect cardiac function. However, troponin values were lower (2.2 [0.9–6.2] vs 6.9 [4.8–9.8] ng/mL; p < 0.05) at the end of the experiment. Furthermore, hyperoxia decreased cardiac 3-nitrotyrosine formation and increased inducible nitric oxide synthase expression. Plasma creatinine values were lower in the hyperoxia group during resuscitation coinciding with significantly improved renal mitochondrial respiratory capacity and lower 3-nitrotyrosine formation.Conclusions: Hyperoxia during resuscitation from hemorrhagic shock in swine with preexisting coronary artery disease reduced renal dysfunction and cardiac injury, potentially resulting in improved survival, most likely due to increased mitochondrial respiratory capacity and decreased oxidative and nitrosative stress. Compared with our previous study, the present results suggest a higher benefit of hyperoxia in comorbid swine due to an increased susceptibility to hemorrhagic shock.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • The Prognostic Value of MRI in Moderate and Severe Traumatic Brain Injury:
           A Systematic Review and Meta-Analysis
    • Authors: Haghbayan; Hourmazd; Boutin, Amélie; Laflamme, Mathieu; Lauzier, François; Shemilt, Michèle; Moore, Lynne; Zarychanski, Ryan; Douville, Vincent; Fergusson, Dean; Turgeon, Alexis F.
      Abstract: imageObjectives: Traumatic brain injury is a major cause of death and disability, yet many predictors of outcome are not precise enough to guide initial clinical decision-making. Although increasingly used in the early phase following traumatic brain injury, the prognostic utility of MRI remains uncertain. We thus undertook a systematic review and meta-analysis of studies evaluating the predictive value of acute MRI lesion patterns for discriminating clinical outcome in traumatic brain injury.Data Sources: MEDLINE, EMBASE, BIOSIS, and CENTRAL from inception to November 2015.Study Selection: Studies of adults who had MRI in the acute phase following moderate or severe traumatic brain injury. Our primary outcomes were all-cause mortality and the Glasgow Outcome Scale.Data Extraction: Two authors independently performed study selection and data extraction. We calculated pooled effect estimates with a random effects model, evaluated the risk of bias using a modified version of Quality in Prognostic Studies and determined the strength of evidence with the Grading of Recommendations, Assessment, Development, and Evaluation.Data Synthesis: We included 58 eligible studies, of which 27 (n = 1,652) contributed data to meta-analysis. Brainstem lesions were associated with all-cause mortality (risk ratio, 1.78; 95% CI, 1.01–3.15; I2 = 43%) and unfavorable Glasgow Outcome Scale (risk ratio, 2.49; 95% CI, 1.72–3.58; I2 = 81%) at greater than or equal to 6 months. Diffuse axonal injury patterns were associated with an increased risk of unfavorable Glasgow Outcome Scale (risk ratio, 2.46; 95% CI, 1.06–5.69; I2 = 74%). MRI scores based on lesion depth demonstrated increasing risk of unfavorable neurologic outcome as more caudal structures were affected. Most studies were at high risk of methodological bias.Conclusions: MRI following traumatic brain injury yields important prognostic information, with several lesion patterns significantly associated with long-term survival and neurologic outcome. Given the high risk of bias in the current body of literature, large well-controlled studies are necessary to better quantify the prognostic role of early MRI in moderate and severe traumatic brain injury.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Pediatric Sepsis Endotypes Among Adults With Sepsis
    • Authors: Wong; Hector R.; Sweeney, Timothy E.; Hart, Kimberly W.; Khatri, Purvesh; Lindsell, Christopher J.
      Abstract: imageObjectives: Recent transcriptomic studies describe two subgroups of adults with sepsis differentiated by a sepsis response signature. The implied biology and related clinical associations are comparable with recently reported pediatric sepsis endotypes, labeled “A” and “B.” We classified adults with sepsis using the pediatric endotyping strategy and the sepsis response signature and determined how endotype assignment, sepsis response signature membership, and age interact with respect to mortality.Design: Retrospective analysis of publically available transcriptomic data representing critically ill adults with sepsis from which the sepsis response signature groups were derived and validated.Setting: Multiple ICUs.Patients: Adults with sepsis.Interventions: None.Measurements and Main Results: Transcriptomic data were conormalized into a single dataset yielding 549 unique cases with sepsis response signature assignments. Each subject was assigned to endotype A or B using the expression data for the 100 endotyping genes. There were 163 subjects (30%) assigned to endotype A and 386 to endotype B. There was a weak, positive correlation between endotype assignment and sepsis response signature membership. Mortality rates were similar between patients assigned endotype A and those assigned endotype B. A multivariable logistic regression model fit to endotype assignment, sepsis response signature membership, age, and the respective two-way interactions revealed that endotype A, sepsis response signature 1 membership, older age, and the interactions between them were associated with mortality. Subjects coassigned to endotype A, and sepsis response signature 1 had the highest mortality.Conclusions: Combining the pediatric endotyping strategy with sepsis response signature membership might provide complementary, age-dependent, biological, and prognostic information.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Personal and Professional Characteristics of U.S. Dual-Boarded Critical
           Care Cardiologists in 2015
    • Authors: Blumenthal; Daniel M.; Mikhael, Bassem; Lawler, Patrick R.; Yeh, Robert W.; Metlay, Joshua P.; Dudzinski, David M.
      Abstract: imageObjectives: Evaluate the characteristics of U.S. physicians who are board certified in cardiology and critical care medicine (“dual-boarded cardiologists”).Design: Retrospective cross-sectional study using a comprehensive database of licensed U.S. physicians linked to Medicare claims.Setting: The United States.Subjects: Dual-boarded cardiologists.Measurements and Main Results: We used a comprehensive physician database to identify all physicians who were board certified in cardiology and critical care medicine before July 2015. We assessed physicians’ characteristics and compared dual-boarded cardiologists with and without active board certification in critical care medicine and estimated the maximum proportion of 2014 Medicare Cardiac ICU admissions treated by dual-boarded cardiologists. Among 473 dual-boarded cardiologists, 16 (3.4%) were women; 468 (99%) and 85 (18%) maintained active board certification in cardiology and critical care medicine, respectively. Overall, 98 dual-boarded cardiologists (21%) submitted 1,215 total claims for critical care services in 2014. Compared to dual-boarded cardiologists without active board certification in critical care medicine, those with active certification had more publications (median publications: 6.5 vs 3.0; p = 0.002), were more likely to be professors (22.3% vs 9.5%; p = 0.003), and were more likely to bill Medicare for critical care services (29% vs 17.8%; p = 0.002). We estimated that no more than 0.47% of all 2014 Medicare Cardiac ICU admissions were treated by a dual-boarded cardiologist.Conclusions: Dual-boarded cardiologists appear to deliver a small proportion of all Cardiac ICU services received by Medicare beneficiaries. Optimizing the modern Cardiac ICU workforce will require greater efforts to promote and support the training of dual-boarded cardiologists.
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Could the Outcome of Septic Patients Be Improved by a Prehospital
           Emergency Medical Service With Physician on Scene'
    • Authors: Jouffroy; Romain; Carli, Pierre; Vivien, Benoît
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Physicians’ Variation in Care: The Practical Balance of Warranted Versus
           Unwarranted Variation
    • Authors: Peabody; John W.; Hauck, Loran D.
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • The authors reply
    • Authors: Peltan; Ithan D.; Hough, Catherine L.; Brown, Samuel M.
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Gender Bias and Cardiopulmonary Rescue: The Context of No Context
    • Authors: Gali; Bhargavi; Moeschler, Susan M.; Hyder, Joseph A.
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • The authors reply
    • Authors: Amacher; Simon Adrian; Marsch, Stephan; Hunziker, Sabina
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Leadership in Medical Emergencies Is “Highly Teachable”
    • Authors: Sell; Rebecca E.; Meier, Angela; Sundararajan, Radhika; Beitler, Jeremy R.
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • The authors reply
    • Authors: Amacher; Simon Adrian; Marsch, Stephan; Hunziker, Sabina
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Determinants of Ventilator Withdrawal Among Patients With Prolonged
           Mechanical Ventilation
    • Authors: Oud; Lavi
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • The authors reply
    • Authors: Chen; Yang-Ching; Fan, Hsien-Yu; Curtis, J. Randall; Lee, Oscar Kuang-Sheng; Liu, Chih-Kuang; Huang, Sheng-Jean
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Respiratory Muscle Weakness, a Major Contributor to Pediatric Extubation
           Failure: Does Low Serum Phosphorus Contribute to Muscle Weakness'
    • Authors: Shah; Satish; Lodha, Rakesh
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • The authors reply
    • Authors: Khemani; Robinder G.; Ross, Patrick A.; Typpo, Katri
      Abstract: imageNo abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Awake Bronchoscopic Intubation With a Noninvasive Positive Pressure
           Support in Critically Ill Patients
    • Authors: Xue; Fu-Shan; Yang, Gui-Zhen; Wen, Chao
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • The authors reply
    • Authors: Johannes; Jimmy; Berlin, David; Patel, Parimal; Schenck, Edward J.; West, Frances Mae; Saggar, Rajan; Barjaktarevic, Igor
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • First Recognition, Then Education
    • Authors: Medeiros; Daniela Nasu Monteiro; Pizarro, Cristiane Freitas; Cardoso, Marta Pessoa; Ogawa Shibata, Audrey Rie; Troster, Eduardo Juan
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • The author replies
    • Authors: Carcillo; Joseph A.; on behalf of the ACCM Taskforce for Guidelines on Hemodynamic Support of Septic Shock
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Quality: A Bridge From Guidelines to Practice
    • Authors: Medeiros; Daniela Nasu Monteiro; Pizarro, Cristiane Freitas; Cardoso, Marta Pessoa; Ogawa Shibata, Audrey Rie; Troster, Eduardo Juan
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • The author replies
    • Authors: Carcillo; Joseph A.; on behalf of the ACCM Taskforce for Guidelines on Hemodynamic Support of Septic Shock
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Confounders Affecting the Prognosis in Patients With Acute Decompensated
           Heart Failure Who Underwent Extracorporeal Membrane Oxygenation
    • Authors: Kyo; Michihito; Ohshimo, Shinichiro; Shime, Nobuaki
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • The authors reply
    • Authors: Luyt; Charles Edouard; Dangers, Laurence
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Potential Confounders of Procalcitonin-Guided Antibiotic Therapy for
           Sepsis
    • Authors: Kikutani; Kazuya; Ohshimo, Shinichiro; Shime, Nobuaki
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Pediatric Arrhythmias and EKGs for the Health Care Provider
    • Authors: Olive; Mary K.
      Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
  • Challenging Authority During an Emergency-the Effect of a Teaching
           Intervention: Erratum
    • Abstract: No abstract available
      PubDate: Fri, 01 Dec 2017 00:00:00 GMT-
       
 
 
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