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Friday, 14 December 2018

A Comparison of the Quick Sequential (Sepsis-Related) Organ Failure Assessment Score and the National Early Warning Score in Non-ICU Patients With/Without Infection

 by Redfern, Oliver C.; Smith, Gary B.; Prytherch, David R.; Meredith, Paul; Inada-Kim, Matthew; Schmidt, Paul E.  

Objectives: The Sepsis-3 task force recommended the quick Sequential (Sepsis-Related) Organ Failure Assessment score for identifying patients with suspected infection who are at greater risk of poor outcomes, but many hospitals already use the National Early Warning Score to identify high-risk patients, irrespective of diagnosis. We sought to compare the performance of quick Sequential (Sepsis-Related) Organ Failure Assessment and National Early Warning Score in hospitalized, non-ICU patients with and without an infection. Design: Retrospective cohort study.
Setting: Large U.K. General Hospital. Patients: Adults hospitalized between January 1, 2010, and February 1, 2016. Interventions: None.
Measurements and Main Results: We applied the quick Sequential (Sepsis-Related) Organ Failure Assessment score and National Early Warning Score to 5,435,344 vital signs sets (241,996 hospital admissions). Patients were categorized as having no infection, primary infection, or secondary infection using International Classification of Diseases, 10th Edition codes. National Early Warning Score was significantly better at discriminating in-hospital mortality, irrespective of infection status (no infection, National Early Warning Score 0.831 [0.825–0.838] vs quick Sequential [Sepsis-Related] Organ Failure Assessment 0.688 [0.680–0.695]; primary infection, National Early Warning Score 0.805 [0.799–0.812] vs quick Sequential [Sepsis-Related] Organ Failure Assessment 0.677 [0.670–0.685]). Similarly, National Early Warning Score performed significantly better in all patient groups (all admissions, emergency medicine admissions, and emergency surgery admissions) for all outcomes studied. Overall, quick Sequential (Sepsis-Related) Organ Failure Assessment performed no better, and often worse, in admissions with infection than without.
Conclusions: The National Early Warning Score outperforms the quick Sequential (Sepsis-Related) Organ Failure Assessment score, irrespective of infection status. These findings suggest that quick Sequential (Sepsis-Related) Organ Failure Assessment should be reevaluated as the system of choice for identifying non-ICU patients with suspected infection who are at greater risk of poor outcome.

Laryngeal Injury and Upper Airway Symptoms After Oral Endotracheal Intubation With Mechanical Ventilation During Critical Care: A Systematic Review*

by Brodsky, Martin B.; Levy, Matthew J.; Jedlanek, Erin; Pandian, Vinciya; Blackford, Brendan; Price, Carrie; Cole, Gai; Hillel, Alexander T.; Best, Simon R.; Akst, Lee M.  

Objectives: To systematically review the symptoms and types of laryngeal injuries resulting from endotracheal intubation in mechanically ventilated patients in the ICU.
Data Sources: PubMed, Embase, CINAHL, and Cochrane Library from database inception to September 2017. Study Selection: Studies of adult patients who were endotracheally intubated with mechanical ventilation in the ICU and completed postextubation laryngeal examinations with either direct or indirect visualization.
Data Extraction: Independent, double-data extraction and risk of bias assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias assessment followed the Cochrane Collaboration’s criteria.
Data Synthesis: Nine studies (seven cohorts, two cross-sectional) representing 775 patients met eligibility criteria. The mean (SD; 95% CI) duration of intubation was 8.2 days (6.0 d; 7.7–8.7 d). A high prevalence (83%) of laryngeal injury was found. Many of these were mild injuries, although moderate to severe injuries occurred in 13–31% of patients across studies. The most frequently occurring clinical symptoms reported post extubation were dysphonia (76%), pain (76%), hoarseness (63%), and dysphagia (49%) across studies.
Conclusions: Laryngeal injury from intubation is common in the ICU setting. Guidelines for laryngeal assessment and postextubation surveillance do not exist. A systematic approach to more robust investigations could increase knowledge of the association between particular injuries and corresponding functional impairments, improving understanding of both time course and prognosis for resolution of injury. Our findings identify targets for future research and highlight the long-known, but understudied, clinical outcomes from endotracheal intubation with mechanical ventilation in ICU.

Incidence and Prevalence of Delirium Subtypes in an Adult ICU: A Systematic Review and Meta-Analysis*

by Krewulak, Karla D.; Stelfox, Henry T.; Leigh, Jeanna Parsons; Ely, E. Wesley; Fiest, Kirsten M.  

Objectives: Use systematic review and meta-analytic methodology to estimate the pooled incidence, prevalence, and proportion of delirium cases for each delirium subtype (hypoactive, hyperactive, and mixed) in an adult ICU population.
Data Sources: We conducted a search of the MEDLINE, EMBASE, CINAHL, SCOPUS, Web of Science, and PsycINFO databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards from database inception until October 22, 2017, with no restrictions. Study Selection: We included original research conducted in adults admitted to any medical, surgical, or speciality ICU that reported incidence or prevalence estimates of delirium according to delirium subtype.
Data Extraction: Data were extracted on sample size, population demographics, condition information, and reported delirium estimates.
Data Synthesis: Forty-eight studies (27,342 patients; 4,550 with delirium) with an overall pooled prevalence of 31% (95% CI, 24–41; I2 = 99%) met inclusion criteria. The pooled incidence (n = 18 studies) of delirium subtypes were hyperactive (4% [95% CI, 2–6]; I2 = 92%]), hypoactive (11% [95% CI, 8–17; I2 = 97%]), and mixed (7% [95% CI, 4–11; I2 = 97%]). The pooled prevalence (n = 31 studies) of delirium subtypes were hyperactive (4% [95% CI, 3–6; I2 = 94%]), hypoactive (17% [95% CI, 13–22; I2 = 97%]), and mixed (10% [95% CI, 6–16; I2 = 99%]). The pooled prevalence of hypoactive delirium in study populations with a similarly high severity of illness or mechanically ventilated was higher (severity of illness: 29% [95% CI, 18–46%; I2 = 95%], 100% mechanically ventilated: 35% [95% CI, 23–55%; I2 = 93%]) compared with the pooled prevalence of hypoactive delirium.
Conclusions: Despite significant heterogeneity between studies, these data show the majority of delirious ICU patients to have hypoactive delirium, a finding with potential monitoring, management, and prognostic implications. The prevalence of hypoactive delirium varies between-study populations and is higher in patients with greater severity of illness.

Complication and Failures of Central Vascular Access Device in Adult Critical Care Settings*

 by Takashima, Mari; Schults, Jessica; Mihala, Gabor; Corley, Amanda; Ullman, Amanda  

Objectives: To examine the proportion and rate of central venous access device failure and complications across central venous access device types in adult intensive care.
Data Sources: A systematic search was undertaken in the electronic databases Cochrane Central Register of Controlled Trials, Embase, U.S. National Library of Medicine National Institutes of Health, and Cumulative Index to Nursing and Allied Health in September 2017.
Study Selection: Included studies were of observational (prospective and retrospective) or interventional design and reported central venous access device failure and complications in adult ICU settings. Studies were excluded if they were published prior to November 2006 or not reported in English. Two reviewers independently screened articles, assessed eligibility, extracted data, and assessed risk of bias.
Data Extraction: Data were extracted on the primary outcome, central venous access device failure, and secondary outcomes: central venous access device complications (central line-associated bloodstream infection, catheter-related bloodstream infection, catheter-related thrombosis, occlusion, catheter removal due to suspected infection, dislodgement, breakage, and local infection). Patient and device data and study details to assess the study quality were also extracted. 
Data Synthesis: A total of 63 studies involving 50,000 central venous access devices (396,951 catheter days) were included. Central venous access device failure was 5% (95% CI, 3–6%), with the highest rates and proportion of failure in hemodialysis catheters. Overall central line-associated bloodstream infection rate was 4.59 per 1,000 catheter days (95% CI, 2.31–6.86), with the highest rate in nontunneled central venous access devices. Removal of central venous access device due to suspected infection was high (17%; 20.4 per 1,000 catheter days; 95% CI, 15.7–25.2).
Conclusions: Central venous access device complications and device failure is a prevalent and significant problem in the adult ICU, leading to substantial patient harm and increased healthcare costs. The high proportion of central venous access devices removed due to suspicion of infection, despite low overall central line-associated bloodstream infection and catheter-related bloodstream infection rates, indicates a need for robust practice guidelines to inform decision-making surrounding removal of central venous access devices suspected of infection.

Evaluation of Repeated Quick Sepsis-Related Organ Failure Assessment Measurements Among Patients With Suspected Infection*

by Kievlan, Daniel R.; Zhang, Li A.; Chang, Chung-Chou H.; Angus, Derek C.; Seymour, Christopher W.  

Objectives: Among patients with suspected infection, a single measurement of the quick Sepsis-related Organ Failure Assessment has good predictive validity for sepsis, yet the increase in validity from repeated measurements is unknown. We sought to determine the incremental predictive validity for sepsis of repeated quick Sepsis-related Organ Failure Assessment measurements over 48 hours compared with the initial measurement.
Design: Retrospective cohort study. Setting: Twelve hospitals in southwestern Pennsylvania in 2012. Patients: All adult medical and surgical encounters in the emergency department, hospital ward, postanesthesia care unit, and ICU. Interventions: None.
Measurements and Main Results: Among 1.3 million adult encounters, we identified those with a first episode of suspected infection. Using the maximum quick Sepsis-related Organ Failure Assessment score in each 6-hour epoch from onset of suspected infection until 48 hours later, we characterized repeated quick Sepsis-related Organ Failure Assessment with: 1) summary measures (e.g., mean over 48 hr), 2) crude trajectory groups, and 3) group-based trajectory modeling. We measured the predictive validity of repeated quick Sepsis-related Organ Failure Assessment using incremental changes in the area under the receiver operating characteristic curve for in-hospital mortality beyond that of baseline risk (age, sex, race/ethnicity, and comorbidity). Of 37,591 encounters with suspected infection, 1,769 (4.7%) died before discharge. Both the mean quick Sepsis-related Organ Failure Assessment at 48 hours (area under the receiver operating characteristic, 0.86 [95% CI, 0.85–0.86]) and crude trajectory groups (area under the receiver operating characteristic, 0.83 [95% CI, 0.83–0.83]) improved predictive validity compared with initial quick Sepsis-related Organ Failure Assessment (area under the receiver operating characteristic, 0.79 [95% CI, 0.78–0.80]) (p < 0.001 for both). Group-based trajectory modeling found five trajectories (quick Sepsis-related Organ Failure Assessment always low, increasing, decreasing, moderate, and always high) with greater predictive validity than the initial measurement (area under the receiver operating characteristic, 0.85 [95% CI, 0.84–0.85]; p < 0.001).
Conclusions: Repeated measurements of quick Sepsis-related Organ Failure Assessment improve predictive validity for sepsis using in-hospital mortality compared with a single measurement of quick Sepsis-related Organ Failure Assessment at the time a clinician suspects infection.

Randomized Feasibility Trial of a Low Tidal Volume-Airway Pressure Release Ventilation Protocol Compared With Traditional Airway Pressure Release Ventilation and Volume Control Ventilation Protocols

Hirshberg, Eliotte L.; Lanspa, Michael J.; Peterson, Juhee; Carpenter, Lori; Wilson, Emily L.; Brown, Samuel M.; Dean, Nathan C.; Orme, James; Grissom, Colin K.

Objectives: Low tidal volume (= tidal volume ≤ 6 mL/kg, predicted body weight) ventilation using volume control benefits patients with acute respiratory distress syndrome. Airway pressure release ventilation is an alternative to low tidal volume-volume control ventilation, but the release breaths generated are variable and can exceed tidal volume breaths of low tidal volume-volume control. We evaluate the application of a low tidal volume-compatible airway pressure release ventilation protocol that manages release volumes on both clinical and feasibility endpoints.
Design: We designed a prospective randomized trial in patients with acute hypoxemic respiratory failure. We randomized patients to low tidal volume-volume control, low tidal volume-airway pressure release ventilation, and traditional airway pressure release ventilation with a planned enrollment of 246 patients. The study was stopped early because of low enrollment and inability to consistently achieve tidal volumes less than 6.5 mL/kg in the low tidal volume-airway pressure release ventilation arm. Although the primary clinical study endpoint was PaO2/FIO2 on study day 3, we highlight the feasibility outcomes related to tidal volumes in both arms. Setting: Four Intermountain Healthcare tertiary ICUs.
Patients: Adult ICU patients with hypoxemic respiratory failure anticipated to require prolonged mechanical ventilation. Interventions: Low tidal volume-volume control, airway pressure release ventilation, and low tidal volume-airway pressure release ventilation.
Measurements and Main Results: We observed wide variability and higher tidal (release for airway pressure release ventilation) volumes in both airway pressure release ventilation (8.6 mL/kg; 95% CI, 7.8–9.6) and low tidal volume-airway pressure release ventilation (8.0; 95% CI, 7.3–8.9) than volume control (6.8; 95% CI, 6.2–7.5; p = 0.005) with no difference between airway pressure release ventilation and low tidal volume-airway pressure release ventilation (p = 0.58). Recognizing the limitations of small sample size, we observed no difference in 52 patients in day 3 PaO2/ FIO2 (p = 0.92). We also observed no significant difference between arms in sedation, vasoactive medications, or occurrence of pneumothorax.
Conclusions: Airway pressure release ventilation resulted in release volumes often exceeding 12 mL/kg despite a protocol designed to target low tidal volume ventilation. Current airway pressure release ventilation protocols are unable to achieve consistent and reproducible delivery of low tidal volume ventilation goals. A large-scale efficacy trial of low tidal volume-airway pressure release ventilation is not feasible at this time in the absence of an explicit, generalizable, and reproducible low tidal volume-airway pressure release ventilation protocol.

ICU Management of Trauma Patients

By Tisherman, Samuel A.; Stein, Deborah M.  

Objectives: To describe the current state of the art regarding management of the critically ill trauma patient with an emphasis on initial management in the ICU.
Data Sources and Study Selection: A PubMed literature review was performed for relevant articles in English related to the management of adult humans with severe trauma. Specific topics included airway management, hemorrhagic shock, resuscitation, and specific injuries to the chest, abdomen, brain, and spinal cord.
Data Extraction and Data Synthesis: The basic principles of initial management of the critically ill trauma patients include rapid identification and management of life-threatening injuries with the goal of restoring tissue oxygenation and controlling hemorrhage as rapidly as possible. The initial assessment of the patient is often truncated for procedures to manage life-threatening injuries. Major, open surgical procedures have often been replaced by nonoperative or less-invasive approaches, even for critically ill patients. Consequently, much of the early management has been shifted to the ICU, where the goal is to continue resuscitation to restore homeostasis while completing the initial assessment of the patient and watching closely for failure of nonoperative management, complications of procedures, and missed injuries.
Conclusions: The initial management of critically ill trauma patients is complex. Multiple, sometimes competing, priorities need to be considered. Close collaboration between the intensivist and the surgical teams is critical for optimizing patient outcomes.

Evaluation of a Measurement System to Assess ICU Team Performance*

by Dietz, Aaron S.; Salas, Eduardo; Pronovost, Peter J.; Jentsch, Florian; Wyskiel, Rhonda; Mendez-Tellez, Pedro Alejandro; Dwyer, Cynthia; Rosen, Michael A.  

Objective: Measuring teamwork is essential in critical care, but limited observational measurement systems exist for this environment. The objective of this study was to evaluate the reliability and validity of a behavioral marker system for measuring teamwork in ICUs.
 Design: Instances of teamwork were observed by two raters for three tasks: multidisciplinary rounds, nurse-to-nurse handoffs, and retrospective videos of medical students and instructors performing simulated codes. Intraclass correlation coefficients were calculated to assess interrater reliability. Generalizability theory was applied to estimate systematic sources of variance for the three observed team tasks that were associated with instances of teamwork, rater effects, competency effects, and task effects.
Setting: A 15-bed surgical ICU at a large academic hospital.
Subjects: One hundred thirty-eight instances of teamwork were observed. Specifically, we observed 88 multidisciplinary rounds, 25 nurse-to-nurse handoffs, and 25 simulated code exercises. Interventions: No intervention was conducted for this study.
Measurements and Main Results: Rater reliability for each overall task ranged from good to excellent correlation (intraclass correlation coefficient, 0.64–0.81), although there were seven cases where reliability was fair and one case where it was poor for specific competencies. Findings from generalizability studies provided evidence that the marker system dependably distinguished among teamwork competencies, providing evidence of construct validity.
Conclusions: Teamwork in critical care is complex, thereby complicating the judgment of behaviors. The marker system exhibited great potential for differentiating competencies, but findings also revealed that more context specific guidance may be needed to improve rater reliability.

Extracorporeal Membrane Oxygenation Can Successfully Support Patients With Severe Acute Respiratory Distress Syndrome in Lieu of Mechanical Ventilation

 by Kurihara, Chitaru; Walter, James M.; Singer, Benjamin D.; Cajigas, Hector; Shayan, Shahriar; Al-Qamari, Abbas; DeCamp, Malcolm M.; Wunderink, Rich; Budinger, GR Scott; Bharat, Ankit  

Objectives: Extracorporeal membrane oxygenation is increasingly used in the management of severe acute respiratory distress syndrome. With extracorporeal membrane oxygenation, select patients with acute respiratory distress syndrome can be managed without mechanical ventilation, sedation, or neuromuscular blockade. Published experience with this approach, specifically with attention to a patient’s respiratory drive following cannulation, is limited.
Design: We describe our experience with three consecutive patients with severe acute respiratory distress syndrome supported with right jugular-femoral configuration of venovenous extracorporeal membrane oxygenation without therapeutic anticoagulation as an alternative to lung-protective mechanical ventilation. Outcomes are reported including daily respiratory rate, vital capacities, and follow-up pulmonary function testing.
 Results: Following cannulation, patients were extubated within 24 hours. During extracorporeal membrane oxygenation support, all patients were able to maintain a normal respiratory rate and experienced steady improvements in vital capacities. Patients received oral nutrition and ambulated daily. At follow-up, no patients required supplemental oxygen.
Conclusions: Our results suggest that venovenous extracorporeal membrane oxygenation can provide a safe and effective alternative to lung-protective mechanical ventilation in carefully selected patients. This approach facilitates participation in physical therapy and avoids complications associated with mechanical ventilation.