Critical
Care Medicine: October 2015 - Volume 43 - Issue 10 - p 2133–2140
Zhang,
D
Objective:
To assess the timing of appropriate antibiotic therapy as a determinant of
postinfection hospital and ICU lengths of stay in patients with sepsis. Design:
Single-center retrospective cohort study (January 2008–December 2012). Setting:
One thousand two hundred fifty–bed academic hospital. Patients: One thousand
fifty-eight consecutive blood culture positive patients. Interventions: We
retrospectively identified adult patients with severe sepsis or septic shock.
Timing of appropriate antibiotic therapy was determined from blood culture
collection time to the administration of the first dose of antibiotic therapy
with documented in vitro susceptibility against the identified pathogen. We
constructed generalized linear models to examine the determinants of
attributable lengths of stay. Measurements and Main Results: The median
(interquartile range) time from blood culture collection to the administration
of appropriate antibiotic therapy was 6.7 hours (0.0–23.3 hr). Linear
regression analysis adjusting for severity of illness and comorbid conditions
identified time to appropriate antibiotic therapy to be an independent
determinant of postinfection ICU length of stay (0.095-d increase per hr of
time to deliver appropriate antibiotic therapy; 95% CI, 0.057–0.132 d; p <
0.001) and postinfection hospital length of stay (0.134-d increase per hr of
time to deliver appropriate antibiotic therapy; 95% CI, 0.074–0.194 d; p <
0.001). Other independent determinants associated with increasing ICU length of
stay and hospital length of stay were mechanical ventilation (both ICU and
hospital lengths of stay) and incremental peak WBC counts (hospital length of
stay only). Incremental changes in severity of illness assessed by Acute
Physiology and Chronic Health Evaluation II scores and comorbidity burden
assessed by the Charlson comorbidity score were independently associated with
decreases in ICU length of stay and hospital length of stay. Conclusions: We
identified time to appropriate antibiotic therapy in patients with sepsis to be
an independent determinant of postinfection ICU and hospital lengths of stay.
Clinicians should implement local strategies aimed at timely delivery of
appropriate antibiotic therapy to improve outcomes and reduce length of stay.
Critical
Care Medicine: October 2015 - Volume 43 - Issue 10 - p 2141–2146
Fawzy,
A et al
Objectives:
Clinical guidelines recommend norepinephrine as initial vasopressor of choice
for septic shock, with dopamine suggested as an alternative vasopressor in
selected patients with low risk of tachyarrhythmias and absolute or relative
bradycardia. We sought to determine practice patterns and outcomes associated
with vasopressor selection in a large, population-based cohort of patients with
septic shock that allows for assessment of outcomes in clinically important
subgroups. Design: We performed a retrospective cohort study to determine
factors associated with choice of dopamine as compared with norepinephrine as
initial vasopressor for patients with septic shock. We used propensity score
matching to compare risk of hospital mortality based on initial vasopressor. We
performed multiple sensitivity analyses using alternative methods to address
confounding and hospital-level clustering. We investigated interaction between
vasopressor selection and mortality in clinical subgroups based on arrhythmia
and cardiovascular risk. Setting: Enhanced administrative data (Premier,
Charlotte, NC) from 502 U.S. hospitals during the years 2010–2013. Subjects: A
total of 61,122 patients admitted with septic shock who received dopamine or
norepinephrine as initial vasopressor during the first 2 days of
hospitalization. Interventions: None. Measurements and Main Results:
Norepinephrine (77.6%) was the most frequently used initial vasopressor during
septic shock. Dopamine was preferentially selected by cardiologists, in the
Southern United States, at nonteaching hospitals, for older patients with more
cardiovascular comorbidities and was used less frequently over time. Patients
receiving dopamine experienced greater hospital mortality (propensity-matched cohort:
n = 38,788; 25% vs 23.7%; odds ratio, 1.08; 95% CI, 1.02–1.14). Sensitivity
analyses showed similar results. Subgroup analyses showed no evidence for
effect modification based on arrhythmia risk or underlying cardiovascular
disease. Conclusions: In a large population-based sample of patients with
septic shock in the United States, use of dopamine as initial vasopressor was
associated with increased mortality among multiple clinical subgroups. Areas
where use of dopamine as initial vasopressor is more common represent potential
targets for quality improvement intervention.
Critical
Care Medicine: October 2015 - Volume 43 - Issue 10 - p 2155–2163
Neto,
AS et al
Objective:
Protective mechanical ventilation with low tidal volumes is standard of care
for patients with acute respiratory distress syndrome. The aim of this
individual patient data analysis was to determine the association between tidal
volume and the occurrence of pulmonary complications in ICU patients without
acute respiratory distress syndrome and the association between occurrence of
pulmonary complications and outcome in these patients. Design: Individual
patient data analysis. Patients: ICU patients not fulfilling the consensus
criteria for acute respiratory distress syndrome at the onset of ventilation.
Interventions: Mechanical ventilation with low tidal volume. Measurements and
Main Results: The primary endpoint was development of a composite of acute
respiratory distress syndrome and pneumonia during hospital stay. Based on the
tertiles of tidal volume size in the first 2 days of ventilation, patients were
assigned to a “low tidal volume group” (tidal volumes≤ 7 mL/kg predicted body
weight), an “intermediate tidal volume group” (> 7 and < 10 mL/kg
predicted body weight), and a “high tidal volume group” (≥ 10 mL/kg predicted
body weight). Seven investigations (2,184 patients) were included. Acute
respiratory distress syndrome or pneumonia occurred in 23% of patients in the
low tidal volume group, in 28% of patients in the intermediate tidal volume
group, and in 31% of the patients in the high tidal volume group (adjusted odds
ratio [low vs high tidal volume group], 0.72; 95% CI, 0.52–0.98; p = 0.042).
Occurrence of pulmonary complications was associated with a lower number of
ICU-free and hospital-free days and alive at day 28 (10.0 ± 10.9 vs 13.8 ± 11.6
d; p < 0.01 and 6.1 ± 8.1 vs 8.9 ± 9.4 d; p < 0.01) and an increased
hospital mortality (49.5% vs 35.6%; p < 0.01). Conclusions: Ventilation with
low tidal volumes is associated with a lower risk of development of pulmonary
complications in patients without acute respiratory distress syndrome.
Critical
Care Medicine: October 2015 - Volume 43 - Issue 10 - p 2076–2084
Objective:
Clinical protocols may decrease unnecessary variation in care and improve
compliance with desirable therapies. We evaluated whether highly protocolized
ICUs have superior patient outcomes compared with less highly protocolized
ICUs. Design: Observational study in which participating ICUs completed a
general assessment and enrolled new patients 1 day each week. Patients: A total
of 6,179 critically ill patients. Setting: Fifty-nine ICUs in the United States
Critical Illness and Injury Trials Group Critical Illness Outcomes Study.
Interventions: None. Measurements and Main Results: The primary exposure was
the number of ICU protocols; the primary outcome was hospital mortality. A
total of 5,809 participants were followed prospectively, and 5,454 patients in
57 ICUs had complete outcome data. The median number of protocols per ICU was
19 (interquartile range, 15–21.5). In single-variable analyses, there were no
differences in ICU and hospital mortality, length of stay, use of mechanical
ventilation, vasopressors, or continuous sedation among individuals in ICUs
with a high versus low number of protocols. The lack of association was
confirmed in adjusted multivariable analysis (p = 0.70). Protocol compliance
with two ventilator management protocols was moderate and did not differ
between ICUs with high versus low numbers of protocols for lung protective
ventilation in acute respiratory distress syndrome (47% vs 52%; p = 0.28) and
for spontaneous breathing trials (55% vs 51%; p = 0.27). Conclusions: Clinical
protocols are highly prevalent in U.S. ICUs. The presence of a greater number
of protocols was not associated with protocol compliance or patient mortality.
Critical
Care 2015, 19:340
Garnero
A et al
Introduction: Lung recruitment maneuvers followed by an individually titrated positive
end-expiratory pressure (PEEP) are the key components of the open lung
ventilation strategy in acute respiratory distress syndrome (ARDS). The
staircase recruitment maneuver is a step-by-step increase in PEEP followed by a
decremental PEEP trial. The duration of each step is usually 2 minutes without
physiologic rationale.
Methods: In this prospective study, we measured the
dynamic end-expiratory lung volume changes (ΔEELV) during an increase and
decrease in PEEP to determine the optimal duration for each step. PEEP was
progressively increased from 5 to 40 cmH 2 O and then decreased from 40 to 5
cmH 2 O in steps of 5 cmH 2 O every 2.5 minutes. The dynamic of ΔEELV was
measured by direct spirometry as the difference between inspiratory and
expiratory tidal volumes over 2.5 minutes following each increase and decrease
in PEEP. ΔEELV was separated between the expected increased volume, calculated
as the product of the respiratory system compliance by the change in PEEP, and
the additional volume.
Results: Twenty-six early onset moderate or severe ARDS
patients were included. Data are expressed as median [25th-75th quartiles].
During the increase in PEEP, the expected increased volume was achieved within
2[2-2] breaths. During the decrease in PEEP, the expected decreased volume was
achieved within 1 [1–1] breath, and 95 % of the additional decreased volume was
achieved within 8 [2–15] breaths. Completion of volume changes in 99 % of both
increase and decrease in PEEP events required 29 breaths.
Conclusions: In early
ARDS, most of the ΔEELV occurs within the first minute, and change is completed
within 2 minutes, following an increase or decrease in PEEP.
Critical
Care 2015, 19:329
Palacio
de Azevedo R et al
Introduction
Constipation is a common problem in intensive care units. We assessed the
efficacy and safety of laxative therapy aiming to promote daily defecation in
reducing organ dysfunction in mechanically ventilated patients.
Methods: We
conducted a prospective, randomized, controlled, nonblinded phase II clinical
trial at two general intensive care units. Patients expected to remain
ventilated for over 3 days were randomly assigned to daily defecation or
control groups. The intervention group received lactulose and enemas to produce
1–2 defecations per day. In the control group, absence of defecation was
tolerated up to 5 days. Primary outcome was the change in Sequential Organ
Failure Assessment (SOFA) score between the date of enrollment and intensive
care unit discharge, death or day 14.
Results: We included 88 patients.
Patients in the treatment group had a higher number of defecations per day (1.3
± 0.42 versus 0.7 ± 0.56, p < 0.0001) and lower percentage of days without
defecation (33.1 ± 15.7 % versus 62.3 ±24.5 %, p < 0.0001). Patients in the
intervention group had a greater reduction in SOFA score (–4.0 (–6.0 to 0)
versus –1.0 (–4.0 to 1.0), p = 0.036) with no difference in mortality rates or
in survival time. Adverse events were more frequent in the treatment group (4.5
(3.0–8.0) versus 3.0 (1.0–5.7), p = 0.016), including more days with diarrhea
(2.0 (1.0–4.0) versus 1.0 (0–2.0) days, p < 0.0001). Serious adverse events
were rare and did not significantly differ between groups.
Conclusions:
Laxative therapy improved daily defecation in ventilated patients and was
associated with a greater reduction in SOFA score.
Critical
Care 2015, 19:335
Gattarello
S et al
Introduction: We
aimed to compare intensive care unit mortality due to non-pneumococcal severe
community-acquired pneumonia between the periods 2000–2002 and 2008–2014, and
the impact of the improvement in antibiotic strategies on outcomes. Methods:
This was a matched case–control study enrolling 144 patients with
non-pneumococcal severe pneumonia: 72 patients from the 2000–2002 database
(CAPUCI I group) were paired with 72 from the 2008–2014 period (CAPUCI II
group), matched by the following variables: microorganism, shock at admission,
invasive mechanical ventilation, immunocompromise, chronic obstructive
pulmonary disease, and age over 65 years. Results: The most frequent
microorganism was methicillin-susceptible Staphylococcus aureus (22.1 %)
followed by Legionella pneumophila and Haemophilus influenzae (each 20.7 %);
prevalence of shock was 59.7 %, while 73.6 % of patients needed invasive
mechanical ventilation. Intensive care unit mortality was significantly lower
in the CAPUCI II group (34.7 % versus 16.7 %; odds ratio (OR) 0.78, 95 %
confidence interval (CI) 0.64–0.95; p = 0.02). Appropriate therapy according to
microorganism was 91.5 % in CAPUCI I and 92.7 % in CAPUCI II, while combined
therapy and early antibiotic treatment were significantly higher in CAPUCI II (76.4
versus 90.3 % and 37.5 versus 63.9 %; p < 0.05). In the multivariate
analysis, combined antibiotic therapy (OR 0.23, 95 % CI 0.07–0.74) and early
antibiotic treatment (OR 0.07, 95 % CI 0.02–0.22) were independently associated
with decreased intensive care unit mortality. Conclusions: In non-pneumococcal
severe community-acquired pneumonia , early antibiotic administration and use
of combined antibiotic therapy were both associated with increased intensive
care unit survival during the study period.
Critical
Care 2015, 19:337
Lorente
JA
Kao et al. have reported in Critical Care the histological findings of
101 patients with acute respiratory distress syndrome (ARDS) undergoing open
lung biopsy. Diffuse alveolar damage (DAD), the histological hallmark of ARDS,
was present in only 56.4 % of cases. The presence of DAD was associated with
higher mortality. Evidence from this and other studies indicates that the
clinical criteria for the diagnosis of ARDS identify DAD in only about half of
the cases. On the contrary, there is evidence that the clinical course and
outcome of ARDS differs in patients with DAD and in patients without DAD. The
discovery of biomarkers for the physiological (increased alveolocapillary
permeability) or histological (DAD) hallmarks of ARDS is thus of paramount
importance.
Critical
Care 2015, 19:324
Leteurtre
S et al
Introduction: Daily or serial evaluation of multiple organ dysfunction
syndrome (MODS) scores may provide useful information. We aimed to validate the
daily (d) PELOD-2 score using the set of seven days proposed with the previous
version of the score.
Methods: In all consecutive patients admitted to nine
pediatric intensive care units (PICUs) we prospectively measured the dPELOD-2
score at day 1, 2, 5, 8, 12, 16, and 18. PICU mortality was used as the outcome
dependent variable. The discriminant power of the dPELOD-2 scores was estimated
using the area under the ROC curve and the calibration using the
Hosmer-Lemeshow chi-square test. We used a logistic regression to investigate
the relationship between the dPELOD-2 scores and outcome, and between the
change in PELOD-2 score from day1 and outcome. Results: We included 3669 patients (median age 15.5 months, mortality rate 6.1
%, median length of PICU stay 3 days). Median dPELOD-2 scores were
significantly higher in nonsurvivors than in survivors (p < 0.0001). The
dPELOD-2 score was available at least at day 2 in 2057 patients: among the 796
patients without MODS on day1, 186 (23.3 %) acquired the syndrome during their
PICU stay (mortality 4.9 % vs. 0.3 % among the 610 who did not; p < 0.0001).
Among the1261 patients with MODS on day1, the syndrome worsened in 157 (12.4 %)
and remained unchanged or improved in 1104 (87.6 %) (mortality 22.9 % vs. 6.6
%; p < 0.0001). The AUC of the dPELOD-2 scores ranged from 0.75 (95 % CI:
0.67-0.83) to 0.89 (95 % CI: 0.86-0.91). The calibration was good with a
chi-square test between 13.5 (p = 0.06) and 0.9 (p = 0.99). The PELOD-2 score
on day1 was a significant prognostic factor; the serial evaluation of the
change in the dPELOD-2 score from day1, adjusted for baseline value,
demonstrated a significant odds ratio of death for each of the 7 days. Conclusion: This study suggests that the progression of the severity of organ
dysfunctions can be evaluated by measuring the dPELOD-2 score during a set of 7
days in PICU, providing useful information on outcome in critically ill
children. Its external validation would be useful
Critical
Care 2015, 19:336
Harrold
ME et al
Introduction:
Mobilisation of patients in the intensive care unit (ICU) is an area of growing
research. Currently, there is little data on baseline mobilisation practises
and the barriers to them for patients of all admission diagnoses.
Methods: The
objectives of the study were to (1) quantify and benchmark baseline levels of
mobilisation in Australian and Scottish ICUs, (2) compare mobilisation
practises between Australian and Scottish ICUs and (3) identify barriers to
mobilisation in Australian and Scottish ICUs. We conducted a prospective,
observational, cohort study with a 4-week inception period. Patients were
censored for follow-up upon ICU discharge or after 28 days, whichever occurred
first. Patients were included if they were >18 years of age, admitted to an
ICU and received mechanical ventilation in the ICU.
Results: Ten tertiary ICUs
in Australia and nine in Scotland participated in the study. The Australian
cohort had a large proportion of patients admitted for cardiothoracic surgery
(43.3 %), whereas the Scottish cohort had none. Therefore, comparison analysis
was done after exclusion of patients admitted for cardiothoracic surgery. In
total, 60.2 % of the 347 patients across 10 Australian ICUs and 40.1 % of the
167 patients across 9 Scottish ICUs mobilised during their ICU stay
(p < 0.001). Patients in the Australian cohort were more likely to mobilise
than patients in the Scottish cohort (hazard ratio 1.83, 95 % confidence
interval 1.38–2.42). However, the percentage of episodes of mobilisation where
patients were receiving mechanical ventilation was higher in the Scottish
cohort (41.1 % vs 16.3 %, p < 0.001). Sedation was the most commonly
reported barrier to mobilisation in both the Australian and Scottish cohorts.
Physiological instability and the presence of an endotracheal tube were also
frequently reported barriers.
Conclusions: This is the first study to benchmark
baseline practise of early mobilisation internationally, and it demonstrates
variation in early mobilisation practises between Australia and Scotland.
Critical
Care Medicine, September 2015 - Volume 43 - Issue 9 - p 1898–1906
Haneya,
A et al
Objectives:
Extracorporeal lung support is currently used in the treatment of patients with
severe respiratory failure until organ recovery and as a bridge to further
therapeutic modalities. The aim of our study was to evaluate the impact of
acute kidney injury on outcome in patients with acute respiratory distress
syndrome under venovenous extracorporeal membrane oxygenation support and to
analyze the association between prognosis and the time of occurrence of acute
kidney injury and renal replacement therapy initiation. Design: Retrospective
observational study. Setting: A large European extracorporeal membrane
oxygenation center, University Medical Center Regensburg, Germany. Patients: A total
of 262 consecutive adult patients with acute respiratory distress syndrome have
been treated with extracorporeal membrane oxygenation between January 2007 and
May 2012.
Critical
Care 2015, 19:322
Kitamura,
N et al
Introduction:
Previous studies evaluating whether subsequent conversion to shockable rhythms
in patients who had initially non-shockable rhythms was associated with altered
clinical outcome reported inconsistent results. Therefore, we hypothesized that
subsequent shock delivery by emergency medical service (EMS) providers altered
clinical outcomes in patients with initially non-shockable rhythms.
Methods: We tested for an association between subsequent shock delivery in EMS
resuscitation and clinical outcomes in patients with initially non-shockable
rhythms (n = 11,481) through a survey of patients after out-of-hospital cardiac
arrest in the Kanto region (SOS-KANTO) 2012 study cohort, Japan. The primary
investigated outcome was 1-month survival with favorable neurological
functions. The secondary outcome variable was the presence of subsequent shock
delivery. We further evaluated the association of interval from initiation of
cardiopulmonary resuscitation to shock with clinical outcomes. Results: In the
univariate analysis of initially non-shockable rhythms, patients who received
subsequent shock delivery had significantly increased frequency of return of
spontaneous circulation, 24-hour survival, 1-month survival, and favorable
neurological outcomes compared to the subsequent not shocked group (P
<0 .0001="" 1-month="" 1.45="" 2.78="" 95="" activity="" adjusted="" age="" analysis="" and="" arrest="" associated="" by="" cardiac="" conclusions:="" confidence="" defibrillation="" early="" electrical="" ems="" etiology="" favorable="" had="" in="" increased="" initial="" initially="" interval="" logistic="" multivariate="" neurological="" non-shockable="" not="" o:p="" odds="" of="" outcomes.="" outcomes="" p="0.0020," patients="" presence="" providers="" pulseless="" ratio="" received="" regression="" rhythms.="" rhythms="" shock="" shocked="" significantly="" study="" subsequent="" the="" this="" vs.="" was="" were="" who="" with="" witnessed="" younger="">
Critical
Care 2015, 19:321
Schwarzer
P et al
Introduction:
Ionized calcium (iCa) concentration is often used in critical care and measured
using blood gas analyzers at the point of care. Controlling and adjusting
regional citrate anticoagulation (RCA) for continuous renal replacement therapy
(CRRT) involves measuring the iCa concentration in two samples: systemic with
physiological iCa concentrations and post filter samples with very low iCa
concentrations. However, modern blood gas analyzers are optimized for
physiological iCa concentrations which might make them less suitable for measuring
low iCa in blood with a high concentration of citrate. We present results of
iCa measurements from six different blood gas analyzers and the impact on
clinical decisions based on the recommendations of the dialysis’ device
manufacturer.MethodThe iCa concentrations of systemic and post filter samples
were measured using six distinct, frequently used blood gas analyzers. We
obtained iCa results of 74 systemic and 84 post filter samples from patients
undergoing RCA for CRRT at the University Medicine of Greifswald. Results: The
systemic samples showed concordant results on all analyzers with median iCa
concentrations ranging from 1.07 to 1.16 mmol/L. The medians of iCa
concentrations for post filter samples ranged from 0.21 to 0.50 mmol/L. Results
of >70 % of the post filter samples would lead to major differences in
decisions regarding citrate flow depending on the instrument used. Conclusion:
Measurements of iCa in post filter samples may give misleading information in
monitoring the RCA. Recommendations of the dialysis manufacturer need to be
revised. Meanwhile, little weight should be given to post filter iCa. Reference
methods for low iCa in whole blood containing citrate should be established.
Critical
Care 2015, 19:318
Chapuis
C et al
Introduction:
To evaluate the economic impact of automated-drug dispensing systems (ADS) in surgical
intensive care units (ICUs). A financial analysis was conducted in three adult
ICUs of one university hospital, where ADS were implemented, one in each unit,
to replace the traditional floor stock system.
Method:
Costs were estimated before and after implementation of the ADS on the basis of
floor stock inventories, expired drugs, and time spent by nurses and pharmacy
technicians on medication-related work activities. A financial analysis was
conducted that included operating cash flows, investment cash flows, global
cash flow and net present value.
Results:
After ADS implementation, nurses spent less time on medication-related
activities with an average of 14.7 hours saved per day/33 beds. Pharmacy
technicians spent more time on floor-stock activities with an average of 3.5
additional hours per day across the three ICUs. The cost of drug storage was
reduced by €44,298 and the cost of expired drugs was reduced by €14,772 per
year across the three ICUs. Five years after the initial investment, the global
cash flow was €148,229 and the net present value of the project was positive by
€510,404.
Conclusion:
The financial modeling of the ADS implementation in three ICUs showed a high
return on investment for the hospital. Medication-related costs and nursing
time dedicated to medications are reduced with ADS.
Critical
Care 2015, 19:319
Klein
Klouwenberg, PMC et al
Introduction:
A clinical suspicion of infection is mandatory for diagnosing sepsis in
patients with a systemic inflammatory response syndrome. Yet, the accuracy of
categorizing critically ill patients presenting to the intensive care unit
(ICU) as being infected or not is unknown. We therefore assessed the likelihood
of infection in patients who were treated for sepsis upon admission to the ICU,
and quantified the association between plausibility of infection and mortality.
Methods: We studied a cohort of critically ill patients admitted with
clinically suspected sepsis to two tertiary ICUs in the Netherlands between
January 2011 and December 2013. The likelihood of infection was categorized as
none, possible, probable or definite by post-hoc assessment. We used
multivariable competing risks survival analyses to determine the association of
the plausibility of infection with mortality.
Results: Among 2579 patients treated for sepsis, 13% had a post-hoc infection
likelihood of “none”, and an additional 30% of only “possible”. These
percentages were largely similar for different suspected sites of infection. In
crude analyses, the likelihood of infection was associated with increased
length of stay and complications. In multivariable analysis, patients with an
unlikely infection had a higher mortality rate compared to patients with a
definite infection (subdistribution hazard ratio 1.23; 95% confidence interval
1.03-1.49).
Conclusions: This study is the first prospective analysis to show that the
clinical diagnosis of sepsis upon ICU admission corresponds poorly with the presence
of infection on post-hoc assessment. A higher likelihood of infection does not
adversely influence outcome in this population.