Other bulletins in this series include:

Breast Surgery

Sunday 26 November 2017

Effects of High-Flow Nasal Cannula on the Work of Breathing in Patients Recovering From Acute Respiratory Failure

Effects of High-Flow Nasal Cannula on the Work of Breathing in Patients Recovering From Acute Respiratory Failure

Delorme, M et al
Critical Care Medicine: December 2017 - Volume 45 - Issue 12 - p 1981–1988

Objectives: 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.

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)

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)

Annane, D et al
Critical Care Medicine: December 2017 - Volume 45 - Issue 12 - p 2089–2098

Objective: 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 Abstracts 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.

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

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

Annane, D et al
Critical Care Medicine: December 2017 - Volume 45 - Issue 12 - p 2078–2088

Objective: 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.

Effect of Transfusion on Mortality and Other Adverse Events Among Critically Ill Septic Patients: An Observational Study Using a Marginal Structural Cox Model

Effect of Transfusion on Mortality and Other Adverse Events Among Critically Ill Septic Patients: An Observational Study Using a Marginal Structural Cox Model

Dupuis, C et al
Critical Care Medicine: December 2017 - Volume 45 - Issue 12 - p 1972–1980

Objectives: 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.

A qualitative study of factors that influence active family involvement with patient care in the ICU: Survey of critical care nurses

A qualitative study of factors that influence active family involvement with patient care in the ICU: Survey of critical care nurses

Hetland, B et al
Intensive and Critical Care Nursing:  Article in Press

Family caregiver involvement may improve patient and family outcomes in the intensive care unit. This study describes critical care nurses’ approaches to involving family caregivers in direct patient care.

Interventions to Improve Hand Hygiene Compliance in the ICU: A Systematic Review

Interventions to Improve Hand Hygiene Compliance in the ICU: A Systematic Review

Lydon, S et al

Critical Care Medicine:  November 2017 - Volume 45 - Issue 11 - p e1165–e1172

Objectives: To synthesize the literature describing interventions to improve hand hygiene in ICUs, to evaluate the quality of the extant research, and to outline the type, and efficacy, of interventions described. 
Data Sources: Systematic searches were conducted in November 2016 using five electronic databases: Medline, CINAHL, PsycInfo, Embase, and Web of Science. Additionally, the reference lists of included studies and existing review papers were screened. 
Study Selection: English language, peer-reviewed studies that evaluated an intervention to improve hand hygiene in an adult ICU setting, and reported hand hygiene compliance rates collected via observation, were included. 
Data Extraction: Data were extracted on the setting, participant characteristics, experimental design, hand hygiene measurement, intervention characteristics, and outcomes. Interventional components were categorized using the Behavior Change Wheel. Methodological quality was examined using the Downs and Black Checklist. 
Data Synthesis: Thirty-eight studies were included. The methodological quality of studies was poor, with studies scoring a mean of 8.6 of 24 (SD= 2.7). Over 90% of studies implemented a bundled intervention. The most frequently employed interventional strategies were education (78.9%), enablement (71.1%), training (68.4%), environmental restructuring (65.8%), and persuasion (65.8%). Intervention outcomes were variable, with a mean relative percentage change of 94.7% (SD= 195.7; range, 4.3–1155.4%) from pre to post intervention. 
Conclusions: This review demonstrates that best practice for improving hand hygiene in ICUs remains unestablished. Future research employing rigorous experimental designs, careful statistical analysis, and clearly described interventions is important.

Advanced Percutaneous Mechanical Circulatory Support Devices for Cardiogenic Shock

Advanced Percutaneous Mechanical Circulatory Support Devices for Cardiogenic Shock

Miller, P. et al

Critical Care Medicine: November 2017 - Volume 45 - Issue 11 - p 1922–1929


To review temporary percutaneous mechanical circulatory support devices for the treatment of cardiogenic shock, including current evidence, contraindications, complications, and future directions. Data Sources: A MEDLINE search was conducted with MeSH terms: cardiogenic shock, percutaneous mechanical circulatory support, extracorporeal membrane oxygenation, Impella, and TandemHeart. 
Study Selection: Selected publications included randomized controlled trial data and observational studies describing experience with percutaneous mechanical circulatory support in cardiogenic shock. 
Data Extraction: Studies were chosen based on strength of association with and relevance to cardiogenic shock. 
Data Synthesis: Until recently, there were few options if cardiogenic shock was refractory to vasopressors or intra-aortic balloon pump counterpulsation. Now, several percutaneous mechanical circulatory support devices, including Impella (Abiomed, Danvers, MA), TandemHeart (CardiacAssist, Pittsburgh, PA), and extracorporeal membrane oxygenation, are more accessible. Compared with intra-aortic balloon pump, Impella provides greater hemodynamic support but no reduction in mortality. Similarly, TandemHeart improves hemodynamic variables but not survival. Comparative studies have been underpowered for mortality because of small sample size. Veno-arterial extracorporeal membrane oxygenation offers the advantage of biventricular circulatory support and oxygenation, but there are significant vascular complications. Comparative studies with extracorporeal membrane oxygenation have not been completed. Despite lack of randomized controlled data, there has been a substantial increase in use of percutaneous mechanical circulatory support. Several ongoing prospective studies with larger sample sizes may provide answers, and newer devices may become smaller, easier to insert, and more effective. Conclusions: Mortality from cardiogenic shock remains unacceptably high despite early coronary revascularization or other therapies. Although evidence is lacking and complications rates are high, improvements and experience with percutaneous mechanical circulatory support may offer the prospect of better outcomes.

Brain Oxygen Optimization in Severe Traumatic Brain Injury Phase-II: A Phase II Randomized Trial

Brain Oxygen Optimization in Severe Traumatic Brain Injury Phase-II: A Phase II Randomized Trial

Okonkwo, D et al

Critical Care Medicine: November 2017 - Volume 45 - Issue 11 - p 1907–1914

Objectives: A relationship between reduced brain tissue oxygenation and poor outcome following severe traumatic brain injury has been reported in observational studies. We designed a Phase II trial to assess whether a neurocritical care management protocol could improve brain tissue oxygenation levels in patients with severe traumatic brain injury and the feasibility of a Phase III efficacy study. Design: Randomized prospective clinical trial. Setting: Ten ICUs in the United States. Patients: One hundred nineteen severe traumatic brain injury patients. Interventions: Patients were randomized to treatment protocol based on intracranial pressure plus brain tissue oxygenation monitoring versus intracranial pressure monitoring alone. Brain tissue oxygenation data were recorded in the intracranial pressure –only group in blinded fashion. Tiered interventions in each arm were specified and impact on intracranial pressure and brain tissue oxygenation measured. Monitors were removed if values were normal for 48 hours consecutively, or after 5 days. Outcome was measured at 6 months using the Glasgow Outcome Scale–Extended. 

Prevention of Exposure Keratopathy in Critically Ill Patients: A Single-Center, Randomized, Pilot Trial Comparing Ocular Lubrication With Bandage Contact Lenses and Punctal Plugs

Prevention of Exposure Keratopathy in Critically Ill Patients: A Single-Center, Randomized, Pilot Trial Comparing Ocular Lubrication With Bandage Contact Lenses and Punctal Plugs

Bendavid, I et al

Critical Care Medicine: November 2017 - Volume 45 - Issue 11 - p 1880–1886

To compare the effectiveness of bandage contact lenses and punctal plugs with ocular lubricants in preventing corneal damage in mechanically ventilated and sedated critically ill patients. Design: Single-center, prospective, randomized, pilot study. Setting: Sixteen-bed, general ICU at a tertiary academic medical center. Patients: Adults admitted to the ICU and anticipated to require mechanical ventilation and continuous sedation for greater than or equal to 4 days. Interventions: Patients were randomized to receive eye care with ocular lubricants (n = 38), bandage contact lenses (n = 33), or punctal plugs (n = 33). The bandage contact lenses were changed every 4 days, whereas the punctal plugs remained in situ for the entire study. Measurements and Main Results: The primary endpoint was the presence or absence of corneal damage as assessed by the grade of keratopathy. Patients were examined by an ophthalmologist blinded to the study group every 4 days and at the time of withdrawal from the study, due to cessation of sedation, discharge from the ICU, or death. The mean duration of the study was 8.6 ± 6.2 days. The grade of keratopathy in the ocular lubricant group increased significantly in both eyes (p = 0.01 for both eyes) while no worsening was noted in either the lens or punctal plugs groups. In a post hoc analysis of patients with an initially abnormal ophthalmic examination, significant healing of keratopathy was noted in the lens group (p = 0.02 and 0.018 for left and right eyes, respectively) and in the right eye of the plugs group (p = 0.005); no improvement was noted in the ocular lubricant group. Conclusions: Compared with ocular lubrication, bandage contact lenses and punctal plugs were more effective in limiting keratopathy, and their use, particularly of bandage contact lenses, was associate
with significant healing of existing lesions.

Monday 23 October 2017

Investigating the Impact of Different Suspicion of Infection Criteria on the Accuracy of Quick Sepsis-Related Organ Failure Assessment, Systemic Inflammatory Response Syndrome, and Early Warning Scores

Investigating the Impact of Different Suspicion of Infection Criteria on the Accuracy of Quick Sepsis-Related Organ Failure Assessment, Systemic Inflammatory Response Syndrome, and Early Warning Scores

Churpek, M M et al
Critical Care Medicine: November 2017 - Volume 45 - Issue 11 - p 1805–1812
Abstract

Objective: Objective:Studies in sepsis are limited by heterogeneity regarding what constitutes suspicion of infection. We sought to compare potential suspicion criteria using antibiotic and culture order combinations in terms of patient characteristics and outcomes. We further sought to determine the impact of differing criteria on the accuracy of sepsis screening tools and early warning scores. Design: Design:Observational cohort study. Setting: Setting:Academic center from November 2008 to January 2016. Patients: Patients:Hospitalized patients outside the ICU. Interventions: Interventions:None. Measurements and Main Results: Measurements and Main Results:Six criteria were investigated: 1) any culture, 2) blood culture, 3) any culture plus IV antibiotics, 4) blood culture plus IV antibiotics, 5) any culture plus IV antibiotics for at least 4 of 7 days, and 6) blood culture plus IV antibiotics for at least 4 of 7 days. Accuracy of the quick Sepsis-related Organ Failure Assessment score, Sepsis-related Organ Failure Assessment score, systemic inflammatory response syndrome criteria, the National and Modified Early Warning Score, and the electronic Cardiac Arrest Risk Triage score were calculated for predicting ICU transfer or death within 48 hours of meeting suspicion criteria. A total of 53,849 patients met at least one infection criteria. Mortality increased from 3% for group 1 to 9% for group 6 and percentage meeting Angus sepsis criteria increased from 20% to 40%. Across all criteria, score discrimination was lowest for systemic inflammatory response syndrome (median area under the receiver operating characteristic curve, 0.60) and Sepsis-related Organ Failure Assessment score (median area under the receiver operating characteristic curve, 0.62), intermediate for quick Sepsis-related Organ Failure Assessment (median area under the receiver operating characteristic curve, 0.65) and Modified Early Warning Score (median area under the receiver operating characteristic curve 0.67), and highest for National Early Warning Score (median area under the receiver operating characteristic curve 0.71) and electronic Cardiac Arrest Risk Triage (median area under the receiver operating characteristic curve 0.73). Conclusions: Conclusions:The choice of criteria to define a potentially infected population significantly impacts prevalence of mortality but has little impact on accuracy. Systemic inflammatory response syndrome was the least predictive and electronic Cardiac Arrest Risk Triage the most predictive regardless of how infection was defined.

Quick Sequential Organ Failure Assessment and Systemic Inflammatory Response Syndrome Criteria as Predictors of Critical Care Intervention Among Patients With Suspected Infection

Quick Sequential Organ Failure Assessment and Systemic Inflammatory Response Syndrome Criteria as Predictors of Critical Care Intervention Among Patients With Suspected Infection

Moskowitz, A et al
Critical Care Medicine: November 2017 - Volume 45 - Issue 11 - p 1813–1819

Objectives: Objectives:The Sepsis III clinical criteria for the diagnosis of sepsis rely on scores derived to predict inhospital mortality. In this study, we introduce the novel outcome of “received critical care intervention” and investigate the related predictive performance of both the quick Sequential Organ Failure Assessment and the Systemic Inflammatory Response Syndrome criteria.
Design:This was a single-center, retrospective analysis of electronic health records. Setting: Setting:Tertiary care hospital in the United States. Patients: Patients:Patients with suspected infection who presented to the emergency department and were admitted to the hospital between January 2010 and December 2014. Interventions: Interventions:Systemic Inflammatory Response Syndrome and quick Sequential Organ Failure Assessment scores were calculated, and their relationships to the receipt of critical care intervention and inhospital mortality were determined. 
Measurement and Main Results:A total of 24,164 patients were included of whom 6,693 (27.7%) were admitted to an ICU within 48 hours; 4,453 (66.5%) patients admitted to the ICU received a critical care intervention. Among those with quick Sequential Organ Failure Assessment less than 2, 13.4% received a critical care intervention and 3.5% died compared with 48.2% and 13.4%, respectively, for quick Sequential Organ Failure Assessment greater than or equal to 2. The area under the receiver operating characteristic was similar whether quick Sequential Organ Failure Assessment was used to predict receipt of critical care intervention or inhospital mortality (0.74 [95% CI, 0.73–0.74] vs 0.71 [0.69–0.72]). The area under the receiver operating characteristic of Systemic Inflammatory Response Syndrome for critical care intervention (0.69) and mortality (0.66) was lower than that for quick Sequential Organ Failure Assessment (p < 0.001 for both outcomes). The sensitivity of quick Sequential Organ Failure Assessment for predicting critical care intervention was 38%. 
Conclusions: Emergency department patients with suspected infection and low quick Sequential Organ Failure Assessment scores frequently receive critical care interventions. The misclassification of these patients as “low risk,” in combination with the low sensitivity of quick Sequential Organ Failure Assessment greater than or equal to 2, may diminish the clinical utility of the quick Sequential Organ Failure Assessment score for patients with suspected infection in the emergency department.

Severe Respiratory Failure, Extracorporeal Membrane Oxygenation, and Intracranial Hemorrhage

Severe Respiratory Failure, Extracorporeal Membrane Oxygenation, and Intracranial Hemorrhage
Lockie, CJ et al
Critical Care Medicine: October 2017 - Volume 45 - Issue 10 - p 1642–1649

Objectives: For patients supported with veno-venous extracorporeal membrane oxygenation, the occurrence of intracranial hemorrhage is associated with a high mortality. It is unclear whether intracranial hemorrhage is a consequence of the extracorporeal intervention or of the underlying severe respiratory pathology. In a cohort of patients transferred to a regional severe respiratory failure center that routinely employs admission brain imaging, we sought 1) the prevalence of intracranial hemorrhage; 2) survival and neurologic outcomes; and 3) factors associated with intracranial hemorrhage. 
Design: A single-center, retrospective, observational cohort study. Setting: Tertiary referral severe respiratory failure center, university teaching hospital. Patients: Patients admitted between December 2011 and February 2016. Intervention: None. Measurements and Main Results: Three hundred forty-two patients were identified: 250 managed with extracorporeal support and 92 managed using conventional ventilation. The prevalence of intracranial hemorrhage was 16.4% in extracorporeal membrane oxygenation patients and 7.6% in conventionally managed patients (p = 0.04). Multivariate analysis revealed factors independently associated with intracranial hemorrhage to be duration of ventilation (d) (odds ratio, 1.13 [95% CI, 1.03–1.23]; p = 0.011) and admission fibrinogen (g/L) (odds ratio, 0.73 [0.57–0.91]; p = 0.009); extracorporeal membrane oxygenation was not an independent risk factor (odds ratio, 3.29 [0.96–15.99]; p = 0.088). In patients who received veno-venous extracorporeal membrane oxygenation, there was no significant difference in 6-month survival between patients with and without intracranial hemorrhage (68.3% vs 76.0%; p = 0.350). Good neurologic function was observed in 92%. Conclusions: We report a higher prevalence of intracranial hemorrhage than has previously been described with high level of neurologically intact survival. Duration of mechanical ventilation and admission fibrinogen, but not exposure to extracorporeal support, are independently associated with intracranial hemorrhage.

Outcomes of Patient- and Family-Centered Care Interventions in the ICU: A Systematic Review and Meta-Analysis

Outcomes of Patient- and Family-Centered Care Interventions in the ICU: A Systematic Review and Meta-Analysis

Goldfarb, M J et al
Critical Care Medicine: October 2017 - Volume 45 - Issue 10 - p 1751–1761

Objective: To determine whether patient- and family-centered care interventions in the ICU improve outcomes. Data Sources: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library databases from inception until December 1, 2016. Study Selection: We included articles involving patient- and family-centered care interventions and quantitative, patient- and family-important outcomes in adult ICUs. Data Extraction: We extracted the author, year of publication, study design, population, setting, primary domain investigated, intervention, and outcomes. 
Data Synthesis: There were 46 studies (35 observational pre/post, 11 randomized) included in the analysis. Seventy-eight percent of studies (n = 36) reported one or more positive outcome measures, whereas 22% of studies (n = 10) reported no significant changes in outcome measures. Random-effects meta-analysis of the highest quality randomized studies showed no significant difference in mortality (n = 5 studies; odds ratio = 1.07; 95% CI, 0.95–1.21; p = 0.27; I2 = 0%), but there was a mean decrease in ICU length of stay by 1.21 days (n = 3 studies; 95% CI, –2.25 to –0.16; p = 0.02; I2 = 26%). Improvements in ICU costs, family satisfaction, patient experience, medical goal achievement, and patient and family mental health outcomes were also observed with intervention; however, reported outcomes were heterogeneous precluding formal meta-analysis. 
Conclusions: Patient- and family-centered care–focused interventions resulted in decreased ICU length of stay but not mortality. A wide range of interventions were also associated with improvements in many patient- and family-important outcomes. Additional high-quality interventional studies are needed to further evaluate the effectiveness of patient- and family-centered care in the intensive care setting.

Reading between the lines, the key to successfully implementing early rehabilitation in critical care

Reading between the lines, the key to successfully implementing early rehabilitation in critical care

McWilliams DJ
Intensive and Critical Care Nursing , October 2017 Volume 42, Pages 5–7

The number of critically ill individuals, complexity of illness, and cost of critical care has continued to increase over time (Bauman and Hyzy, 2014). Although this represents an older critical care population than previously seen, presenting with a variety of pre-existing comorbidities, improvements in intensive care services and delivery have meant survival rates have improved in recent years (Esteban et al., 2013; Kaukonen et al., 2014). When considering successful outcomes from critical illness, it is now acknowledged that it is no longer sufficient or appropriate to consider survival alone (Desai et al., 2011).

Pressure ulcers in critically ill patients – Preventable by non-sedation? A substudy of the NONSEDA-trial

Pressure ulcers in critically ill patients – Preventable by non-sedation? A substudy of the NONSEDA-trial

Nedergaard HK et al
Intensive and Critical Care Nursing , Article in Press

Pressure ulcers still pose a significant clinical challenge to critically ill patients. This study is a substudy of the multicenter NONSEDA-trial, where critically ill patients were randomised to sedation or non-sedation during mechanical ventilation. The objective of this substudy was to assess if non-sedation affected the occurrence of pressure ulcers.

Patterns and Outcomes Associated With Timeliness of Initial Crystalloid Resuscitation in a Prospective Sepsis and Septic Shock Cohort

Patterns and Outcomes Associated With Timeliness of Initial Crystalloid Resuscitation in a Prospective Sepsis and Septic Shock Cohort

Leisman, D et al
Critical Care Medicine: October 2017 - Volume 45 - Issue 10 -  p 1596–1606

Objectives: The objectives of this study were to 1) assess patterns of early crystalloid resuscitation provided to sepsis and septic shock patients at initial presentation and 2) determine the association between time to initial crystalloid resuscitation with hospital mortality, mechanical ventilation, ICU utilization, and length of stay. 
Design: Consecutive-sample observational cohort. Setting: Nine tertiary and community hospitals over 1.5 years. Patients: Adult sepsis and septic shock patients captured in a prospective quality improvement database inclusion criteria: suspected or confirmed infection, greater than or equal to two systemic inflammatory response criteria, greater than or equal to one organ-dysfunction criteria. Interventions: The primary exposure was crystalloid initiation within 30 minutes or lesser, 31–120 minutes, or more than 120 minutes from sepsis identification. Measurements and Main Results: We identified 11,182 patients. Crystalloid initiation was faster for emergency department patients (β, –141 min; CI, –159 to –125; p < 0.001), baseline hypotension (β, –39 min; CI, –48 to –32; p < 0.001), fever, urinary or skin/soft-tissue source of infection. Initiation was slower with heart failure (β, 20 min; CI, 14–25; p < 0.001), and renal failure (β, 16 min; CI, 10–22; p < 0.001). Five thousand three hundred thirty-six patients (48%) had crystalloid initiated in 30 minutes or lesser versus 2,388 (21%) in 31–120 minutes, and 3,458 (31%) in more than 120 minutes. The patients receiving fluids within 30 minutes had lowest mortality (949 [17.8%]) versus 31–120 minutes (446 [18.7%]) and more than 120 minutes (846 [24.5%]). Compared with more than 120 minutes, the adjusted odds ratio for mortality was 0.76 (CI, 0.64–0.90; p = 0.002) for 30 minutes or lesser and 0.76 (CI, 0.62–0.92; p = 0.004) for 31–120 minutes. When assessed continuously, mortality odds increased by 1.09 with each hour to initiation (CI, 1.03–1.16; p = 0.002). We observed similar patterns for mechanical ventilation, ICU utilization, and length of stay. We did not observe significant interaction for mortality risk between initiation time and baseline heart failure, renal failure, hypotension, acute kidney injury, altered gas exchange, or emergency department (vs inpatient) presentation. 
Conclusions: Crystalloid was initiated significantly later with comorbid heart failure and renal failure, with absence of fever or hypotension, and in inpatient-presenting sepsis. Earlier crystalloid initiation was associated with decreased mortality. Comorbidities and severity did not modify this effect.

Treatment of Hyponatremic Encephalopathy in the Critically Ill

Treatment of Hyponatremic Encephalopathy in the Critically Ill

Achinger, SG et al
Critical Care Medicine: October 2017 - Volume 45 - Issue 10 - p 1762–1771

Objectives: Hyponatremic encephalopathy, symptomatic cerebral edema due to a low osmolar state, is a medical emergency and often encountered in the ICU setting. This article provides a critical appraisal and review of the literature on identification of high-risk patients and the treatment of this life-threatening disorder. Data Sources, Study Selection, and Data Extraction: Online search of the PubMed database and manual review of articles involving risk factors for hyponatremic encephalopathy and treatment of hyponatremic encephalopathy in critical illness. Data Synthesis: Hyponatremic encephalopathy is a frequently encountered problem in the ICU. Prompt recognition of hyponatremic encephalopathy and early treatment with hypertonic saline are critical for successful outcomes. Manifestations are varied, depending on the extent of CNS’s adaptation to the hypoosmolar state. The absolute change in serum sodium alone is a poor predictor of clinical symptoms. However, certain patient specific risks factors are predictive of a poor outcome and are important to identify. Gender (premenopausal and postmenopausal females), age (prepubertal children), and the presence of hypoxia are the three main clinical risk factors and are more predictive of poor outcomes than the rate of development of hyponatremia or the absolute decrease in the serum sodium. 
Conclusions: In patients with hyponatremic encephalopathy exhibiting neurologic manifestations, a bolus of 100 mL of 3% saline, given over 10 minutes, should be promptly administered. The goal of this initial bolus is to quickly treat cerebral edema. If signs persist, the bolus should be repeated in order to achieve clinical remission. However, the total change in serum sodium should not exceed 5 mEq/L in the initial 1–2 hours and 15–20 mEq/L in the first 48 hours of treatment. It has recently been demonstrated in a prospective fashion that 500 mL of 3% saline at an infusion rate of 100 mL per hour can be given safely. It is critical to recognize the early signs of cerebral edema (nausea, vomiting, and headache) and intervene with IV 3% sodium chloride as this is the time to intervene rather than waiting until more severe symptoms develop. Cerebral demyelination is a rare complication of overly rapid correction of hyponatremia. The principal risk factors for cerebral demyelination are correction of the serum sodium more than 25 mEq/L in the first 48 hours of therapy, correction past the point of 140 mEq/L, chronic liver disease, and hypoxic/anoxic episode.
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Preventing central venous line related bloodstream infections in adult ICUs: Start from the basics and bundle

Preventing central venous line related bloodstream infections in adult ICUs: Start from the basics and bundle

Arvaniti K
Intensive and Critical Care Nursing Article in Press

In the Intensive Care Unit (ICU), central venous line associated bloodstream infections (CLABSIs) represent an important component of healthcare-associated infections and are linked to increased morbidity, mortality and overall hospital-associated cost (Warren et al., 2006; Stevens et al., 2014). CLABSIs are considered a preventable cause of healthcare-associated patient’s adverse events. Despite major scientific advances in pathogenesis, surveillance methods and treatment approach, the most appropriate interventions to prevent and control CLABSIs remain debatable.

Barriers to delirium assessment in the intensive care unit: A literature review


Barriers to delirium assessment in the intensive care unit: A literature review 

Rowley-Conwy G

Intensive and Critical Care Nursing Article in Press

Delirium is a common syndrome that has both short and long-term negative outcomes for critically ill patients. Many studies over several years have found a knowledge gap and lack of evidence-based practice from critical care personnel, but there has been little exploration of the reasons for this.

Role strain among male RNs in the critical care setting: Perceptions of an unfriendly workplace

Role strain among male RNs in the critical care setting: Perceptions of an unfriendly workplace

Carte NS, Williams C
Intensive and Critical Care Nursing Article in Press

Traditionally, nursing has been a female-dominated profession. Men employed as registered nurses have been in the minority and little is known about the experiences of this demographic. The purpose of this descriptive, quantitative study was to understand the relationship between the variables of demographics and causes of role strain among male nurses in critical care settings. The Sherrod Role Strain Scale assesses role strain within the context of role conflict, role overload, role ambiguity and role incongruity.

Monday 18 September 2017

Evaluating the past to improve the future – A qualitative study of ICU patients’ experiences

Evaluating the past to improve the future – A qualitative study of ICU patients’ experiences
Dahle Olsen K et al
Intensive and Critical Care Nursing, Article in Press

Background:The recovery period for patients who have been in an intensive care unitis often prolonged and suboptimal. Anxiety, depression and post-traumatic stress disorder are common psychological problems. Intensive care staff offer various types of intensive aftercare. Intensive care follow-up aftercare services are not standard clinical practice in Norway.
Objective:The overall aim of this study is to investigate how adult patients experience their intensive care stay their recovery period, and the usefulness of an information pamphlet.
Method:A qualitative, exploratory research with semi-structured interviews of 29 survivors after discharge from intensive care and three months after discharge from the hospital.
Results:Two main themes emerged: “Being on an unreal, strange journey” and “Balancing between who I was and who I am” Patients’ recollection of their intensive care stay differed greatly. Continuity of care and the nurse’s ability to see and value individual differences was highlighted. The information pamphlet helped intensive care survivors understand that what they went through was normal.
Conclusions:Continuity of care and an individual approach is crucial to meet patients’ uniqueness and different coping mechanisms. Intensive care survivors and their families must be included when information material and rehabilitation programs are designed and evaluated.

The early diagnosis and management of mixed delirium in a patient placed on ECMO and with difficult sedation: A case report

The early diagnosis and management of mixed delirium in a patient placed on ECMO and with difficult sedation: A case report
Acevedo-Nuevo, M et al
Intensive and Critical Care Nursing, Article in Press

Delirium represents a serious problem that impacts the physical and cognitive prognosis of patients admitted to intensive care units and requires prompt diagnosis and management. This article describes the case and progress of a patient placed on Extracorporeal Membrane Oxygenation with difficult sedation criteria and an early diagnosis of mixed delirium. During the case report, we reflect on the pharmacological and non-pharmacological strategies employed to cope with delirium paying special attention to the non-use of physical restraint measures in order to preserve vital support devices (endotracheal tube or Extracorporeal Membrane Oxygenation cannula).

Intubation-associated pneumonia: An integrative review

Intubation-associated pneumonia: An integrative review
Sabrina Sousa, A et al
Intensive and Critical Care Nursing, Article in Press

Objective
This article aims to characterise intubation-associated pneumonia regarding its diagnosis, causes, risk factors, consequences and incidence.
Research methodology
Integrative literature review using database Pubmed and B-on and webpages of organisations dedicated to this area of study.
Setting
The research took place between May and July 2015. After selection of the articles, according to established criteria, their quality was assessed and 17 documents were included.
Results
Evidence has demonstrated that intubation associated pneumonia has a multifactorial aetiology and one of its main causes is micro-aspiration of gastric and oropharynx contents. Risk factors can be internal or external. The diagnostic criteria are based on clinical, radiological and microbiological data, established by several organisations, including the European Centres for Disease Control and Prevention, which are, however, still not accurate. In recent years, there has been a downward trend in the incidence in Europe. Nevertheless, it continues to have significant economic impact, as well as affecting health and human lives.
Conclusions
Several European countries are committed to addressing this phenomenon through infection control and microbial resistance programmes; however there is a much to be done in order to minimise its effects. The lack of consensus in the literature regarding diagnosis criteria, risk factors and incidence rates is a limitation of this study.

The Impact of Mortality on Total Costs Within the ICU

The Impact of Mortality on Total Costs Within the ICU

Kramer, A A et al
Critical Care Medicine:  September 2017 - Volume 45 - Issue 9 - p 1457–1463

Objectives: The high cost of critical care has engendered research into identifying influential factors. However, existing studies have not considered patient vital status at ICU discharge. This study sought to determine the effect of mortality upon the total cost of an ICU stay. Design: Retrospective cohort study. 
Setting: Twenty-six ICUs at 13 hospitals in the United States. Patients: 58,344 admissions from January 1, 2012, to June 30, 2016, obtained from a commercial ICU database. Interventions: None. 
Measurements and Main Results: The median observed cost of a unit stay was $9,619 (mean = $16,353). A multivariable regression model was developed on the log of total costs for a unit stay, using severity of illness, unit admitting diagnosis, mortality in the unit, daily unit occupancy (occupying a bed at midnight), and length of mechanical ventilation. This model had an r2 of 0.67 and a median difference between observed and expected costs of $437. The first few days of care and the first day receiving mechanical ventilation had the largest effect on total costs. Patients dying before unit discharge had 12.4% greater costs than survivors (p < 0.01; 99% CI = 9.3–15.5%) after multivariable adjustment. This effect was most pronounced for patients with an extended ICU stay who were receiving mechanical ventilation. 
Conclusions: While the largest drivers of ICU costs at the patient level are day 1 room occupancy and day 1 mechanical ventilation, mortality before unit discharge is associated with substantially higher costs. The increase was most evident for patients with an extended ICU stay who were receiving mechanical ventilation. Studies evaluating costs among ICUs need to take mortality into account.

A Technique of Awake Bronchoscopic Endotracheal Intubation for Respiratory Failure in Patients With Right Heart Failure and Pulmonary Hypertension

A Technique of Awake Bronchoscopic Endotracheal Intubation for Respiratory Failure in Patients With Right Heart Failure and Pulmonary Hypertension
Johannes, J et al
Critical Care Medicine:  September 2017 - Volume 45 - Issue 9 - p e980–e984

Objective: Patients with pulmonary hypertension and right heart failure have a high risk of clinical deterioration and death during or soon after endotracheal intubation. The effects of sedation, hypoxia, hypoventilation, and changes in intrathoracic pressure can lead to severe hemodynamic instability. In search for safer approach to endotracheal intubation in this cohort of patients, we evaluate the safety and feasibility of an alternative intubation technique. Data Sources: Retrospective data analysis. Study Selection: Two medical ICUs in large university hospitals in the United States. Data Extraction: We report a case series of nine nonconsecutive patients with compromised right heart function, pulmonary hypertension, and severe acute hypoxemic respiratory failure who underwent endotracheal intubation with a novel technique combining awake bronchoscopic intubation supported with nasally delivered noninvasive positive pressure ventilation or high-flow nasal cannula. Data Synthesis: All patients were intubated in the first attempt without major complications and eight patients (88%) were alive 24 hours after intubation. Systemic hypotension was the most frequent complication following the procedure. Conclusions: Awake bronchoscopic intubation supported with a noninvasive positive pressure delivery systems may be feasible alternative to standard direct laryngoscopy approach. Further studies are needed to better assess its safety and applicability.

Preventing Harm in the ICU—Building a Culture of Safety and Engaging Patients and Families

Preventing Harm in the ICU—Building a Culture of Safety and Engaging Patients and Families
Thornton, K C et al

Critical Care Medicine:  September 2017 - Volume 45 - Issue 9 - p 1531–1537

Objective: Preventing harm remains a persistent challenge in the ICU despite evidence-based practices known to reduce the prevalence of adverse events. This review seeks to describe the critical role of safety culture and patient and family engagement in successful quality improvement initiatives in the ICU. We review the evidence supporting the impact of safety culture and provide practical guidance for those wishing to implement initiatives aimed at improving safety culture and more effectively integrate patients and families in such efforts. 
Data Sources: Literature review using PubMed including evaluation of key studies assessing large-scale quality improvement efforts in the ICU, impact of safety culture on patient outcomes, methodologies for quality improvement commonly used in healthcare, and patient and family engagement. Print and web-based resources from leading patient safety organizations were also searched. Study Selection: Our group completed a review of original studies, review articles, book chapters, and recommendations from leading patient safety organizations. 
Data Extraction: Our group determined by consensus which resources would best inform this review. 
Data Synthesis: A strong safety culture is associated with reduced adverse events, lower mortality rates, and lower costs. Quality improvement efforts have been shown to be more effective and sustainable when paired with a strong safety culture. Different methodologies exist for quality improvement in the ICU; a thoughtful approach to implementation that engages frontline providers and administrative leadership is essential for success. Efforts to substantively include patients and families in the processes of quality improvement work in the ICU should be expanded. Conclusions: Efforts to establish a culture of safety and meaningfully engage patients and families should form the foundation for all safety interventions in the ICU. This review describes an approach that integrates components of several proven quality improvement methodologies to enhance safety culture in the ICU and highlights opportunities to include patients and families.

Statin and Its Association With Delirium in the Medical ICU

Statin and Its Association With Delirium in the Medical ICU

Statin and Its Association With Delirium in the Medical ICU
Mather, J F. et al

Critical Care Medicine:  September 2017 - Volume 45 - Issue 9 - p 1515–1522

Objectives: To examine the association between statin use and the risk of delirium in hospitalized patients with an admission to the medical ICU. Design: Retrospective propensity-matched cohort analysis with accrual from September 1, 2012, to September 30, 2015. Setting: Hartford Hospital, Hartford, CT. Patients: An initial population of patients with an admission to a medical ICU totaling 10,216 visits were screened for delirium by means of the Confusion Assessment Method. After exclusions, a population of 6,664 was used to match statin users and nonstatin users. The propensity-matched cohort resulted in a sample of 1,475 patients receiving statin matched 1:1 with control patients not using statin. Interventions: None. Measurements and Main Results: Delirium defined as a positive Confusion Assessment Method assessment was the primary end point. The prevalence of delirium was 22.3% in the unmatched cohort and 22.8% in the propensity-matched cohort. Statin use was associated with a significant decrease in the risk of delirium (odds ratio, 0.47; 95% CI, 0.38–0.56). Considering the type of statin used, atorvastatin (0.51; 0.41–0.64), pravastatin (0.40; 0.28–0.58), and simvastatin (0.33; 0.21–0.52) were all significantly associated with a reduced frequency of delirium. Conclusions: The use of statins was independently associated with a reduction in the risk of delirium in hospitalized patients. When considering types of statins used, this reduction was significant in patients using atorvastatin, pravastatin, and simvastatin. Randomized trials of various statin types in hospitalized patients prone to delirium should validate their use in protection from delirium.

The Impact of the Sepsis-3 Septic Shock Definition on Previously Defined Septic Shock Patients


The Impact of the Sepsis-3 Septic Shock Definition on Previously Defined Septic Shock Patients
Sterling, S A. et al
Critical Care Medicine:  September 2017 - Volume 45 - Issue 9 - p 1436–1442

Objective: The Third International Consensus Definitions Task Force (Sepsis-3) recently recommended changes to the definitions of sepsis. The impact of these changes remains unclear. Our objective was to determine the outcomes of patients meeting Sepsis-3 septic shock criteria versus patients meeting the “old” (1991) criteria of septic shock only. Design: Secondary analysis of two clinical trials of early septic shock resuscitation. 
Setting: Large academic emergency departments in the United States. Patients: Patients with suspected infection, more than or equal to two systemic inflammatory response syndrome criteria, and systolic blood pressure less than 90 mm Hg after fluid resuscitation. Interventions: Patients were further categorized as Sepsis-3 septic shock if they demonstrated hypotension, received vasopressors, and exhibited a lactate greater than 2 mmol/L. We compared in-hospital mortality in patients who met the old definition only with those who met the Sepsis-3 criteria. Measurements and Main 
Results: Four hundred seventy patients were included in the present analysis. Two hundred (42.5%) met Sepsis-3 criteria, whereas 270 (57.4%) met only the old definition. Patients meeting Sepsis-3 criteria demonstrated higher severity of illness by Sequential Organ Failure Assessment score (9 vs 5; p < 0.001) and mortality (29% vs 14%; p < 0.001). Subgroup analysis of 127 patients meeting only the old definition demonstrated significant mortality benefit following implementation of a quantitative resuscitation protocol (35% vs 10%; p = 0.006). 
Conclusion: In this analysis, 57% of patients meeting old definition for septic shock did not meet Sepsis-3 criteria. Although Sepsis-3 criteria identified a group of patients with increased organ failure and higher mortality, those patients who met the old criteria and not Sepsis-3 criteria still demonstrated significant organ failure and 14% mortality rate.

Clinical Practice Guideline: Safe Medication Use in the ICU

Clinical Practice Guideline: Safe Medication Use in the ICU

Kane-Gill, S L et al
Critical Care Medicine:  September 2017 - Volume 45 - Issue 9 - p e877–e915

Objective: To provide ICU clinicians with evidence-based guidance on safe medication use practices for the critically ill. Data Sources: PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and ISI Web of Science for relevant material to December 2015.
Study Selection: Based on three key components: 1) environment and patients, 2) the medication use process, and 3) the patient safety surveillance system. The committee collectively developed Population, Intervention, Comparator, Outcome questions and quality of evidence statements pertaining to medication errors and adverse drug events addressing the key components. A total of 34 Population, Intervention, Comparator, Outcome questions, five quality of evidence statements, and one commentary on disclosure was developed.
Data Extraction: Subcommittee members were assigned selected Population, Intervention, Comparator, Outcome questions or quality of evidence statements. Subcommittee members completed their Grading of Recommendations Assessment, Development, and Evaluation of the question with his/her quality of evidence assessment and proposed strength of recommendation, then the draft was reviewed by the relevant subcommittee. The subcommittee collectively reviewed the evidence profiles for each question they developed. After the draft was discussed and approved by the entire committee, then the document was circulated among all members for voting on the quality of evidence and strength of recommendation.
Data Synthesis: The committee followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation system to determine quality of evidence and strength of recommendations. Conclusions: This guideline evaluates the ICU environment as a risk for medication-related events and the environmental changes that are possible to improve safe medication use. Prevention strategies for medication-related events are reviewed by medication use process node (prescribing, distribution, administration, monitoring). Detailed considerations to an active surveillance system that includes reporting, identification, and evaluation are discussed. Also, highlighted is the need for future research for safe medication practices that is specific to critically ill patients.

Wednesday 2 August 2017

Hyperchloremia Is Associated With Acute Kidney Injury in Patients With Subarachnoid Hemorrhage

Hyperchloremia Is Associated With Acute Kidney Injury in Patients With Subarachnoid Hemorrhage

Sadan, O et al
Critical Care Medicine: August 2017 - Volume 45 - Issue 8 - p 1382–1388


Objective: To assess the prevalence of acute kidney injury in patients with subarachnoid hemorrhage patients. Design: Retrospective analysis of all subarachnoid hemorrhage admissions. Settings: Neurocritical care unit. Patients: All patients with a diagnosis of subarachnoid hemorrhage between 2009 and 2014. Interventions: None. 
Measurements and Main Results: Of 1,267 patients included in this cohort, 16.7% developed acute kidney injury, as defined by Kidney Disease Improving Global Outcome criteria (changes in creatinine only). Compared to patients without acute kidney injury, patients with acute kidney injury had a higher prevalence of diabetes mellitus (21.2% vs 9.8%; p < 0.001) and hypertension (70.3% vs 50.5%; p < 0.001) and presented with higher admission creatinine concentrations (1.21 ± 0.09 vs 0.81 ± 0.01 mg/dL [mean ± SD], respectively; p < 0.001). Patients with acute kidney injury also had higher mean serum chloride and sodium concentrations during their ICU stay (113.4 ± 0.6 vs 107.1 ± 0.2 mmol/L and 143.3 ± 0.4 vs 138.8 ± 0.1 mmol/L, respectively; p < 0.001 for both), but similar chloride exposure. The mortality rate was also significantly higher in patients with acute kidney injury (28.3% vs 6.1% in the non-acute kidney injury group [p < 0.001]). Logistic regression analysis revealed that only male gender (odds ratio, 1.82; 95% CI, 1.28–2.59), hypertension (odds ratio, 1.64; 95% CI, 1.11–2.43), diabetes mellitus (odds ratio, 1.88; 95% CI, 1.19–2.99), abnormal baseline creatinine (odds ratio, 2.48; 95% CI, 1.59–3.88), and increase in mean serum chloride concentration (per 10 mmol/L; odds ratio, 7.39; 95% CI, 3.44–18.23), but not sodium, were associated with development of acute kidney injury. Kidney recovery was noted in 78.8% of the cases. Recovery reduced mortality compared to non-recovering subgroup (18.6% and 64.4%, respectively; p < 0.001). 
Conclusions: Critically ill patients with subarachnoid hemorrhage show a strong association between hyperchloremia and acute kidney injury as well as acute kidney injury and mortality.

Nonlinear Imputation of PaO2/FIO2 From SpO2/FIO2 Among Mechanically Ventilated Patients in the ICU: A Prospective, Observational Study

Nonlinear Imputation of PaO2/FIO2 From SpO2/FIO2 Among Mechanically Ventilated Patients in the ICU: A Prospective, Observational Study

Brown, S et al
Critical Care Medicine: August 2017 - Volume 45 - Issue 8 - p 1317–1324

Objectives: In the contemporary ICU, mechanically ventilated patients may not have arterial blood gas measurements available at relevant timepoints. Severity criteria often depend on arterial blood gas results. Retrospective studies suggest that nonlinear imputation of PaO2/FIO2 from SpO2/FIO2 is accurate, but this has not been established prospectively among mechanically ventilated ICU patients. The objective was to validate the superiority of nonlinear imputation of PaO2/FIO2 among mechanically ventilated patients and understand what factors influence the accuracy of imputation. 
Design: Simultaneous SpO2, oximeter characteristics, receipt of vasopressors, and skin pigmentation were recorded at the time of a clinical arterial blood gas. Acute respiratory distress syndrome criteria were recorded. For each imputation method, we calculated both imputation error and the area under the curve for patients meeting criteria for acute respiratory distress syndrome (PaO2/FIO2 ≤ 300) and moderate-severe acute respiratory distress syndrome (PaO2/FIO2 ≤ 150). Setting: Nine hospitals within the Prevention and Early Treatment of Acute Lung Injury network. Patients: We prospectively enrolled 703 mechanically ventilated patients admitted to the emergency departments or ICUs of participating study hospitals. Interventions: None. Measurements and Main Results: We studied 1,034 arterial blood gases from 703 patients; 650 arterial blood gases were associated with SpO2 less than or equal to 96%. Nonlinear imputation had consistently lower error than other techniques. Among all patients, nonlinear had a lower error (p < 0.001) and higher (p < 0.001) area under the curve (0.87; 95% CI, 0.85–0.90) for PaO2/FIO2 less than or equal to 300 than linear/log-linear (0.80; 95% CI, 0.76–0.83) imputation. All imputation methods better identified moderate-severe acute respiratory distress syndrome (PaO2/FIO2 ≤ 150); nonlinear imputation remained superior (p < 0.001). For PaO2/FIO2 less than or equal to 150, the sensitivity and specificity for nonlinear imputation were 0.87 (95% CI, 0.83–0.90) and 0.91 (95% CI, 0.88–0.93), respectively. Skin pigmentation and receipt of vasopressors were not associated with imputation accuracy. 
Conclusions: In mechanically ventilated patients, nonlinear imputation of PaO2/FIO2 from SpO2/FIO2 seems accurate, especially for moderate-severe hypoxemia. Linear and log-linear imputations cannot be recommended.

Key factors for hand hygiene promotion in intensive care units

Key factors for hand hygiene promotion in intensive care units

De Wandel D et al
Critical Care Medicine: Article in Press

Hand hygiene remains a cornerstone in the fight against healthcare-associated infections and multidrug resistance (Blot, 2008). Hand hygiene behaviour is deep-rooted and difficult to change. According to a recently published Intensive & Critical Care Nursing article by Battistella et al. (2017), professional hand hygiene behaviour in intensive care settings is influenced by habits of social handwashing in everyday life. Therefore, they plead for the creation of specific professional hand hygiene habits (washing hands should become ‘a routine inside a habit’).

Extracorporeal Membrane Oxygenation for Acute Decompensated Heart Failure

Extracorporeal Membrane Oxygenation for Acute Decompensated Heart Failure

Dangers, L et al
Critical Care Medicine: August 2017 - Volume 45 - Issue 8 - p 1359–1366

Objective: Long-term outcomes of patients treated with venoarterial-extracorporeal membrane oxygenation for acute decompensated heart failure (i.e., cardiogenic shock complicating chronic cardiomyopathy) have not yet been reported. This study was undertaken to describe their outcomes and determine mortality-associated factors. Design: Retrospective analysis of data prospectively collected. Setting: Twenty-six–bed tertiary hospital ICU. Patients: One hundred five patients implanted with venoarterial-extracorporeal membrane oxygenation for acute decompensated heart failure. Intervention: None. 
Measurements and Main Results: From March 2007 to January 2015, 105 patients were implanted with venoarterial-extracorporeal membrane oxygenation for acute decompensated heart failure in our ICU (67% of them had an intraaortic balloon pump to unload the left ventricle). Their 1-year survival rate was 42%; most of the survivors were transplanted either directly or after switching to central bilateral centrifugal pump, ventricular-assist device, or total artificial heart. Most deaths occurred early after multiple organ failure. Multivariable analyses retained (odds ratio [95% CI]) pre–extracorporeal membrane oxygenation Sequential Organ Failure Assessment score of more than 11 (3.3 [1.3–8.3]), idiopathic cardiomyopathy (0.4 [0.2–1]), cardiac disease duration greater than 2 years pre–extracorporeal membrane oxygenation (2.8 [1.2–6.9]), and pre–extracorporeal membrane oxygenation blood lactate greater than 4 mmol/L (2.6 [1.03–6.4]) as independent predictors of 1-year mortality. Only 17% of patients with pre–extracorporeal membrane oxygenation Sequential Organ Failure Assessment scores of 14 or more survived, whereas 52% of those with scores less than 7 and 60% of those with scores 7 or more and less than 11 were alive 1 year later. 
Conclusions: Among this selected cohort of 105 patients implanted with venoarterial-extracorporeal membrane oxygenation for acute decompensated heart failure, 1-year survival was 42%, but better for patients with pre–extracorporeal membrane oxygenation Sequential Organ Failure Assessment scores of less than 11. Venoarterial-extracorporeal membrane oxygenation should be considered for patients with acute decompensated heart failure, but timing of implantation is crucial.

Should All Massively Transfused Patients Be Treated Equally? An Analysis of Massive Transfusion Ratios in the Nontrauma Setting

Should All Massively Transfused Patients Be Treated Equally? An Analysis of Massive Transfusion Ratios in the Nontrauma Setting

Etchill, E et al
Critical Care Medicine: August 2017 - Volume 45 - Issue 8 - Issue 8 - p 1311–1316

Objectives: Although balanced resuscitation has become integrated into massive transfusion practice, there is a paucity of evidence supporting the delivery of high ratios of plasma and platelet to RBCs in the nontrauma setting. This study investigated the administration of blood component ratios in the massively transfused nontrauma demographic. 
Design: Retrospective analysis of a prospective, observational cohort of massively bleeding patients. Setting: Surgical and critically ill patients at a tertiary medical center between 2011 and 2015. Patients: Massively transfused nontrauma patients. Interventions: Patients receiving plasma, platelet, and RBC transfusions were categorized into high and low ratio groups and analyzed for differences in characteristics and clinical outcomes. Measurements and Main Results: The primary outcome was 30-day mortality. Secondary outcomes included 48-hour mortality, hospital length of stay, ICU length of stay, and ventilator-free days. Among 601 massively transfused nontrauma patients, cardiothoracic surgery and gastrointestinal or hepato-pancreatico-biliary bleeds were the most common indications for massive transfusion. Higher fresh frozen plasma ratios (> 1:2) were not associated with increased 30-day mortality. A high platelets-to-packed RBCs ratio (> 1:2) was associated with decreased 48-hour mortality (10.5% vs 19.3%; p = 0.032), but not 30-day mortality. Fresh frozen plasma-to-packed RBCs and platelets-to-packed RBCs ratios were not associated with 30-day mortality hazard ratios after controlling for baseline characteristics and disease severity. 
Conclusions: The benefits of higher ratios of fresh frozen plasma-to-packed RBCs and platelets-to-packed RBCs described in trials of trauma patients were not observed in this analysis of a nontrauma, massively transfused population. These data suggest that greater than 1:2 ratio transfusion in the setting of massive hemorrhage may not be appropriate for all patients, and that further research to guide appropriate resuscitation strategies in nontrauma patients is warranted.

Antibiotic Therapy in Comatose Mechanically Ventilated Patients Following Aspiration: Differentiating Pneumonia From Pneumonitis

Antibiotic Therapy in Comatose Mechanically Ventilated Patients Following Aspiration: Differentiating Pneumonia From Pneumonitis

Lascarrou, JB et al
Critical Care Medicine: August 2017 - Volume 45 - Issue 8 - p 1268–1275

Objectives: To determine the proportion of patients with documented bacterial aspiration pneumonia among comatose ICU patients with symptoms suggesting either bacterial aspiration pneumonia or non-bacterial aspiration pneumonitis. Design: Prospective observational study. Setting: University-affiliated 30-bed ICU. Patients: Prospective cohort of 250 patients admitted to the ICU with coma (Glasgow Coma Scale score ≤ 8) and treated with invasive mechanical ventilation. Interventions: None. Measurements and Main Results: The primary outcome was the proportion of patients with microbiologically documented bacterial aspiration pneumonia. Patients meeting predefined criteria for aspiration syndrome routinely underwent telescopic plugged catheter sampling during bronchoscopy before starting probabilistic antibiotic treatment. When cultures were negative, the antibiotic treatment was stopped. Of 250 included patients, 98 (39.2%) had aspiration syndrome, including 92 before mechanical ventilation discontinuation. Telescopic plugged catheter in these 92 patients showed bacterial aspiration pneumonia in 43 patients (46.7%). Among the remaining 49 patients, 16 continued to receive antibiotics, usually for infections other than pneumonia; of the 33 patients whose antibiotics were discontinued, only two subsequently showed signs of lung infection. In the six patients with aspiration syndrome after mechanical ventilation, and therefore without telescopic plugged catheter, antibiotic treatment was continued for 7 days. Mechanical ventilation duration, ICU length of stay, and mortality did not differ between the 43 patients with bacterial aspiration pneumonia and the 49 patients with non-bacterial aspiration pneumonitis. The 152 patients without aspiration syndrome did not receive antibiotics. Conclusions: Among comatose patients receiving mechanical ventilation, those without clinical, laboratory, or radiologic evidence of bacterial aspiration pneumonia did not require antibiotics. In those with suspected bacterial aspiration pneumonia, stopping empirical antibiotic therapy when routine telescopic plugged catheter sampling recovered no microorganisms was nearly always effective. This strategy may be a valid alternative to routine full-course antibiotic therapy. Only half the patients with suspected bacterial aspiration pneumonia had this diagnosis confirmed by telescopic plugged catheter sampling.

Repeated Critical Illness and Unplanned Readmissions Within 1 Year to PICUs

Repeated Critical Illness and Unplanned Readmissions Within 1 Year to PICUs

Edwards, J et al
Critical Care Medicine: August 2017 - Volume 45 - Issue 8 - p 1276–1284

Objectives: To determine the occurrence rate of unplanned readmissions to PICUs within 1 year and examine risk factors associated with repeated readmission. 
Design: Retrospective cohort analysis. Setting: Seventy-six North American PICUs that participated in the Virtual Pediatric Systems, LLC (VPS, LLC, Los Angeles, CA). Patients: Ninety-three thousand three hundred seventy-nine PICU patients discharged between 2009 and 2010. Interventions: None. 
Measurements and Main Results: Index admissions and unplanned readmissions were characterized and their outcomes compared. Time-to-event analyses were performed to examine factors associated with readmission within 1 year. Eleven percent (10,233) of patients had 15,625 unplanned readmissions within 1 year to the same PICU; 3.4% had two or more readmissions. Readmissions had significantly higher PICU mortality and longer PICU length of stay, compared with index admissions (4.0% vs 2.5% and 2.5 vs 1.6 d; all p < 0.001). Median time to readmission was 30 days for all readmissions, 3.5 days for readmissions during the same hospitalization, and 66 days for different hospitalizations. Having more complex chronic conditions was associated with earlier readmission (adjusted hazard ratio, 2.9 for one complex chronic condition; hazard ratio, 4.8 for two complex chronic conditions; hazard ratio, 9.6 for three or more complex chronic conditions; all p < 0.001 compared no complex chronic condition). Most specific complex chronic condition conferred a greater risk of readmission, and some had considerably higher risk than others. 
Conclusions: Unplanned readmissions occurred in a sizable minority of PICU patients. Patients with complex chronic conditions and particular conditions were at much higher risk for readmission.

Disassociating Lung Mechanics and Oxygenation in Pediatric Acute Respiratory Distress Syndrome

Disassociating Lung Mechanics and Oxygenation in Pediatric Acute Respiratory Distress Syndrome

Yehya, N, Thomas, N J. 
Critical Care Medicine: July 2017 - Volume 45 - Issue 7 - p 1232–1239

Objectives: Both oxygenation and peak inspiratory pressure are associated with mortality in pediatric acute respiratory distress syndrome. Since oxygenation and respiratory mechanics are linked, it is difficult to identify which variables, pressure or oxygenation, are independently associated with outcome. We aimed to determine whether respiratory mechanics (peak inspiratory pressure, positive end-expiratory pressure, ΔP [PIP minus PEEP], tidal volume, dynamic compliance [Cdyn]) or oxygenation (PaO2/FIO2) was associated with mortality. Design: Prospective, observational, cohort study. Setting: University affiliated PICU. Patients: Mechanically ventilated children with acute respiratory distress syndrome (Berlin). Interventions: None. Measurements and Main Results: Peak inspiratory pressure, positive end-expiratory pressure, ΔP, tidal volume, Cdyn, and PaO2/FIO2 were collected at acute respiratory distress syndrome onset and at 24 hours in 352 children between 2011 and 2016. At acute respiratory distress syndrome onset, neither mechanical variables nor PaO2/FIO2 were associated with mortality. At 24 hours, peak inspiratory pressure, positive end-expiratory pressure, ΔP were higher, and Cdyn and PaO2/FIO2 lower, in nonsurvivors. In multivariable logistic regression, PaO2/FIO2 at 24 hours and ΔPaO2/FIO2 (change in PaO2/FIO2 over the first 24 hr) were associated with mortality, whereas pressure variables were not. Both oxygenation and pressure variables were associated with duration of ventilation in multivariable competing risk regression. Conclusions: Improvements in oxygenation, but not in respiratory mechanics, were associated with lower mortality in pediatric acute respiratory distress syndrome. Future trials of mechanical ventilation in children should focus on oxygenation (higher PaO2/FIO2) rather than lower peak inspiratory pressure or ΔP, as oxygenation was more consistently associated with outcome.