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Breast Surgery

Tuesday, 25 February 2020

The global survival rate among adult out-of-hospital cardiac arrest patients who received cardiopulmonary resuscitation: a systematic review and meta-analysis

by Shijiao Yan, Yong Gan, Nan Jiang, Rixing Wang, Yunqiang Chen, Zhiqian Luo, Qiao Zong, Song Chen and Chuanzhu Lv

Critical Care volume 24, Article number: 61 (2020) Published: 22 February 2020

To quantitatively summarize the available epidemiological evidence on the survival rate of out-of-hospital cardiac arrest (OHCA) patients who received cardiopulmonary resuscitation (CPR).
We systematically searched the PubMed, Embase, and Web of Science databases, and the references of retrieved articles were manually reviewed to identify studies reporting the outcome of OHCA patients who received CPR. The overall incidence and outcome of OHCA were assessed using a random-effects meta-analysis.
A total of 141 eligible studies were included in this meta-analysis. The pooled incidence of return of spontaneous circulation (ROSC) was 29.7% (95% CI 27.6–31.7%), the rate of survival to hospital admission was 22.0% (95% CI 20.7–23.4%), the rate of survival to hospital discharge was 8.8% (95% CI 8.2–9.4%), the pooled 1-month survival rate was 10.7% (95% CI 9.1–13.3%), and the 1-year survival rate was 7.7% (95% CI 5.8–9.5%). Subgroup analysis showed that survival to hospital discharge was more likely among OHCA patients whose cardiac arrest was witnessed by a bystander or emergency medical services (EMS) (10.5%; 95% CI 9.2–11.7%), who received bystander CPR (11.3%, 95% CI 9.3–13.2%), and who were living in Europe and North America (Europe 11.7%; 95% CI 10.5–13.0%; North America: 7.7%; 95% CI 6.9–8.6%). The survival to discharge (8.6% in 1976–1999 vs. 9.9% in 2010–2019), 1-month survival (8.0% in 2000–2009 vs. 13.3% in 2010–2019), and 1-year survival (8.0% in 2000–2009 vs. 13.3% in 2010–2019) rates of OHCA patients who underwent CPR significantly increased throughout the study period. The Egger’s test did not indicate evidence of publication bias for the outcomes of OHCA patients who underwent CPR.
The global survival rate of OHCA patients who received CPR has increased in the past 40 years. A higher survival rate post-OHCA is more likely among patients who receive bystander CPR and who live in Western countries.

Biomarkers of Delirium Duration and Delirium Severity in the ICU*

by Khan, Babar A.; Perkins, Anthony J.; Prasad, Nagendra K.; Shekhar, Anantha; Campbell, Noll L.; Gao, Sujuan; Wang, Sophia; Khan, Sikandar H.; Marcantonio, Edward R.; Twigg, Homer L. III; Boustani, Malaz A.

Objectives: Both delirium duration and delirium severity are associated with adverse patient outcomes. Serum biomarkers associated with delirium duration and delirium severity in ICU patients have not been reliably identified. We conducted our study to identify peripheral biomarkers representing systemic inflammation, impaired neuroprotection, and astrocyte activation associated with delirium duration, delirium severity, and in-hospital mortality.
Design: Observational study.
Setting: Three Indianapolis hospitals.
Patients: Three-hundred twenty-one critically ill delirious patients.
Interventions: None.
Measurements and Main Results: We analyzed the associations between biomarkers collected at delirium onset and delirium-/coma-free days assessed through Richmond Agitation-Sedation Scale/Confusion Assessment Method for the ICU, delirium severity assessed through Confusion Assessment Method for the ICU-7, and in-hospital mortality. After adjusting for age, gender, Acute Physiology and Chronic Health Evaluation II score, Charlson comorbidity score, sepsis diagnosis and study intervention group, interleukin-6, -8, and -10, tumor necrosis factor-α, C-reactive protein, and S-100β levels in quartile 4 were negatively associated with delirium-/coma-free days by 1 week and 30 days post enrollment. Insulin-like growth factor-1 levels in quartile 4 were not associated with delirium-/coma-free days at both time points. Interleukin-6, -8, and -10, tumor necrosis factor-α, C-reactive protein, and S-100β levels in quartile 4 were also associated with delirium severity by 1 week. At hospital discharge, interleukin-6, -8, and -10 retained the association but tumor necrosis factor-α, C-reactive protein, and S-100β lost their associations with delirium severity. Insulin-like growth factor-1 levels in quartile 4 were not associated with delirium severity at both time points. Interleukin-8 and S-100β levels in quartile 4 were also associated with higher in-hospital mortality. Interleukin-6 and -10, tumor necrosis factor-α, and insulin-like growth factor-1 were not found to be associated with in-hospital mortality.
Conclusions: Biomarkers of systemic inflammation and those for astrocyte and glial activation were associated with longer delirium duration, higher delirium severity, and in-hospital mortality. Utility of these biomarkers early in delirium onset to identify patients at a higher risk of severe and prolonged delirium, and delirium related complications during hospitalization needs to be explored in future studies.

Critical care response to a hospital outbreak of the 2019-nCoV infection in Shenzhen, China

by Yong Liu, Jinxiu Li and Yongwen Feng 

Critical Care volume 24, Article number: 56 (2020)

Beginning at early December 2019, there is an outbreak of a novel 2019-nCoV in Wuhan, China. Then, Public Health Emergency of International Concern (PHEIC) was declared on 30 January 2020, by the World Health Organization (WHO) Emergency Committee. The 2019-nCoV pandemic could lead to an influx of critically ill into the already strained hospital systems in mainland China. Dealing with the pandemic requires a robust hospital- and city-wide command and control structure that could make quick and informed decisions among Chinese hospitals. We recommend that a proper plan can enable the local government, healthcare systems, hospitals, and healthcare workers to better cope with such public eventuality. The response should be flexible and adjustable according to the size of the population impacted.

Humanizing Intensive Care: Toward a Human-Centered Care ICU Model

by Nin Vaeza, Nicolas; Martin Delgado, María Cruz; Heras La Calle, Gabriel 

“If you could choose, how would you like the Intensive Care Units (ICUs) to be?” The Humanization of Intensive Care movement (Proyecto HU-CI) arose after we asked this simple question in our blog, receiving suggestions from more 10,000 people (1). Created in Spain on February 2014, the Humanization of Intensive Care movement is an international research project that seeks, using evidence-based medicine, to answer that same question, thus creating a paradigm shift in the way we deliver our care toward a more friendly and human-centered model (2). Although many may be surprised and feel a contradiction toward this humanistic model, is an essential skill in health professionals that should have never been lost. When professionals are face with the reality of being patients or a family member of critically ill patient, it is then, when they appreciate how it works. “Yet many professionals cite lack of humanistic care as a cause for burnout, an epidemic among health professions today” (3).
Displaying kindness and concern for all the individuals that are part of the healthcare environment, not only patients and its families, is a necessity and the path toward building an excellent healthcare system. We will not be able to cure all people, but surely, we can improve the care we provide by focusing on the dignity of people…

Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Cardiovascular, Endocrine, Hematologic, Pulmonary, and Renal Considerations

To develop evidence-based recommendations for clinicians caring for adults with acute or acute on chronic liver failure in the ICU.
The guideline panel comprised 29 members with expertise in aspects of care of the critically ill patient with liver failure and/or methodology. The Society of Critical Care Medicine standard operating procedures manual and conflict-of-interest policy were followed throughout. Teleconferences and electronic-based discussion among the panel, as well as within subgroups, served as an integral part of the guideline development.
The panel was divided into nine subgroups: cardiovascular, hematology, pulmonary, renal, endocrine and nutrition, gastrointestinal, infection, perioperative, and neurology.
We developed and selected population, intervention, comparison, and outcomes questions according to importance to patients and practicing clinicians. For each population, intervention, comparison, and outcomes question, we conducted a systematic review aiming to identify the best available evidence, statistically summarized the evidence whenever applicable, and assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence to decision framework to facilitate recommendations formulation as strong or conditional. We followed strict criteria to formulate best practice statements.
Measurements and Main Results: 
In this article, we report 29 recommendations (from 30 population, intervention, comparison, and outcomes questions) on the management acute or acute on chronic liver failure in the ICU, related to five groups (cardiovascular, hematology, pulmonary, renal, and endocrine). Overall, six were strong recommendations, 19 were conditional recommendations, four were best-practice statements, and in two instances, the panel did not issue a recommendation due to insufficient evidence.
Multidisciplinary international experts were able to formulate evidence-based recommendations for the management acute or acute on chronic liver failure in the ICU, acknowledging that most recommendations were based on low-quality indirect evidence.

The exsecutive summary can be found here: https://journals.lww.com/ccmjournal/Fulltext/2020/03000/Guidelines_for_the_Management_of_Adult_Acute_and.17.aspx

Neurally adjusted ventilatory assist vs. pressure support to deliver protective mechanical ventilation in patients with acute respiratory distress syndrome: a randomized crossover trial

by Fabia Diniz-Silva, Henrique T. Moriya, Adriano M. Alencar, Marcelo B. P. Amato, Carlos R. R. Carvalho and Juliana C. Ferreira

Annals of Intensive Care volume 10, Article number: 18 (2020)

Protective mechanical ventilation is recommended for patients with acute respiratory distress syndrome (ARDS), but it usually requires controlled ventilation and sedation. Using neurally adjusted ventilatory assist (NAVA) or pressure support ventilation (PSV) could have additional benefits, including the use of lower sedative doses, improved patient–ventilator interaction and shortened duration of mechanical ventilation. We designed a pilot study to assess the feasibility of keeping tidal volume (VT) at protective levels with NAVA and PSV in patients with ARDS.
We conducted a prospective randomized crossover trial in five ICUs from a university hospital in Brazil and included patients with ARDS transitioning from controlled ventilation to partial ventilatory support. NAVA and PSV were applied in random order, for 15 min each, followed by 3 h in NAVA. Flow, peak airway pressure (Paw) and electrical activity of the diaphragm (EAdi) were captured from the ventilator, and a software (Matlab, Mathworks, USA), automatically detected inspiratory efforts and calculated respiratory rate (RR) and VT. Asynchrony events detection was based on waveform analysis.
We randomized 20 patients, but the protocol was interrupted for five (25%) patients for whom we were unable to maintain VT below 6.5 mL/kg in PSV due to strong inspiratory efforts and for one patient for whom we could not detect EAdi signal. For the 14 patients who completed the protocol, VT was 5.8 ± 1.1 mL/kg for NAVA and 5.6 ± 1.0 mL/kg for PSV (p = 0.455) and there were no differences in RR (24 ± 7 for NAVA and 23 ± 7 for PSV, p = 0.661). Paw was greater in NAVA (21 ± 3 cmH2O) than in PSV (19 ± 3 cmH2O, p = 0.001). Most patients were under continuous sedation during the study. NAVA reduced triggering delay compared to PSV (p = 0.020) and the median asynchrony Index was 0.7% (0–2.7) in PSV and 0% (0–2.2) in NAVA (p = 0.6835).
It was feasible to keep VT in protective levels with NAVA and PSV for 75% of the patients. NAVA resulted in similar VT, RR and Paw compared to PSV. Our findings suggest that partial ventilatory assistance with NAVA and PSV is feasible as a protective ventilation strategy in selected ARDS patients under continuous sedation.
Trial registration ClinicalTrials.gov (NCT01519258). Registered 26 January 2012, https://clinicaltrials.gov/ct2/show/NCT01519258

Investigating Swallowing and Tracheostomy Following Critical Illness: A Scoping Review

by Skoretz, Stacey A.; Riopelle, Stephanie J.; Wellman, Leslie; Dawson, Camilla 

Objectives: Tracheostomy and dysphagia often coexist during critical illness; however, given the patient’s medical complexity, understanding the evidence to optimize swallowing assessment and intervention is challenging. The objective of this scoping review is to describe and explore the literature surrounding swallowing and tracheostomy in the acute care setting.
Data Sources: Eight electronic databases were searched from inception to May 2017 inclusive, using a search strategy designed by an information scientist. We conducted manual searching of 10 journals, nine gray literature repositories, and forward and backward citation chasing.
Study Selection: Two blinded reviewers determined eligibility according to inclusion criteria: English-language studies reporting on swallowing or dysphagia in adults (≥ 17 yr old) who had undergone tracheostomy placement while in acute care. Patients with head and/or neck cancer diagnoses were excluded.
Data Extraction: We extracted data using a form designed a priori and conducted descriptive analyses.
Data Synthesis: We identified 6,396 citations, of which 725 articles were reviewed and 85 (N) met inclusion criteria. We stratified studies according to content domains with some featuring in multiple categories: dysphagia frequency (n = 38), swallowing physiology (n = 27), risk factors (n = 31), interventions (n = 21), and assessment comparisons (n = 12) and by patient etiology. Sample sizes (with tracheostomy) ranged from 10 to 3,320, and dysphagia frequency ranged from 11% to 93% in studies with consecutive sampling. Study design, sampling method, assessment methods, and interpretation approach varied significantly across studies.
Conclusions: The evidence base surrounding this subject is diverse, complicated by heterogeneous patient selection methods, design, and reporting. We suggest ways the evidence base may be developed.

Higher glycemic variability within the first day of ICU admission is associated with increased 30-day mortality in ICU patients with sepsis

by Wen-Cheng Chao, Chien-Hua Tseng, Chieh-Liang Wu, Sou-Jen Shih, Chi-Yuan Yi and Ming-Cheng Chan 

Annals of Intensive Care volume 10, Article number: 17 (2020)

High glycemic variability (GV) is common in critically ill patients; however, the prevalence and mortality association with early GV in patients with sepsis remains unclear.
This retrospective cohort study was conducted in a medical intensive care unit (ICU) in central Taiwan. Patients in the ICU with sepsis between January 2014 and December 2015 were included for analysis. All of these patients received protocol-based management, including blood sugar monitoring every 2 h for the first 24 h of ICU admission. Mean amplitude of glycemic excursions (MAGE) and coefficient of variation (CoV) were used to assess GV.
A total of 452 patients (mean age 71.4 ± 14.7 years; 76.7% men) were enrolled for analysis. They were divided into high GV (43.4%, 196/452) and low GV (56.6%, 256/512) groups using MAGE 65 mg/dL as the cut-off point. Patients with high GV tended to have higher HbA1c (6.7 ± 1.8% vs. 5.9 ± 0.9%, p < 0.01) and were more likely to have diabetes mellitus (DM) (50.0% vs. 23.4%, p < 0.01) compared with those in the low GV group. Kaplan–Meier analysis showed that a high GV was associated with increased 30-day mortality (log-rank test, p = 0.018). The association remained strong in the non-DM (log-rank test, p = 0.035), but not in the DM (log-rank test, p = 0.254) group. Multivariate Cox proportional hazard regression analysis identified that high APACHE II score (adjusted hazard ratio (aHR) 1.045, 95% confidence interval (CI) 1.013–1.078), high serum lactate level at 0 h (aHR 1.009, 95% CI 1.003–1.014), having chronic airway disease (aHR 0.478, 95% CI 0.302–0.756), high mean day 1 glucose (aHR 1.008, 95% CI 1.000–1.016), and high MAGE (aHR 1.607, 95% CI 1.008–2.563) were independently associated with increased 30-day mortality. The association with 30-day mortality remained consistent when using CoV to assess GV.
We found that approximately 40% of the septic patients had a high early GV, defined as MAGE > 65 mg/dL. Higher GV within 24 h of ICU admission was independently associated with increased 30-day mortality. These findings highlight the need to monitor GV in septic patients early during an ICU admission.

Nutrition therapy in critical illness: a review of the literature for clinicians

by Kate J. Lambell, Oana A. Tatucu-Babet, Lee-anne Chapple, Dashiell Gantner and Emma J. Ridley

Critical Care volume 24, Article number: 35 (2020)

Nutrition therapy during critical illness has been a focus of recent research, with a rapid increase in publications accompanied by two updated international clinical guidelines. However, the translation of evidence into practice is challenging due to the continually evolving, often conflicting trial findings and guideline recommendations. This narrative review aims to provide a comprehensive synthesis and interpretation of the adult critical care nutrition literature, with a particular focus on continuing practice gaps and areas with new data, to assist clinicians in making practical, yet evidence-based decisions regarding nutrition management during the different stages of critical illness.

Novel coronavirus infection during the 2019–2020 epidemic: preparing intensive care units—the experience in Sichuan Province, China

Intensive Care Medicine volume 46, pages 357–360(2020)

Up to 31 January 2020, there have been 9811 officially reported confirmed cases of 2019-novel coronavirus (nCoV) infection in China since the epidemic began in December 2019 (updated data available at https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6).

With the rapid transmission, the epidemic has spread throughout the country, and 177 cases have been reported in Sichuan Province. As nCoV infection is a highly contagious disease with high mortality (3–15%) [1,2,3] and West China Hospital (WCH) is the largest hospital in the southwest of China and the referral medical center in Sichuan Province, it is our responsibility to prepare for admission of additional critically ill patients as a matter of emergency. We have held several expert meetings and have reviewed the related literature to develop a plan to respond to the epidemic [45]. The purpose of the plan is to enable us to provide the maximum level of care to critically ill patients while ensuring the protection of medical staff…

Ventilatory support and mechanical properties of the fibrotic lung acting as a “squishy ball”

by Alessandro Marchioni, Roberto Tonelli, Giulio Rossi, Paolo Spagnolo, Fabrizio Luppi, Stefania Cerri, Elisabetta Cocconcelli, Maria Rosaria Pellegrino, Riccardo Fantini, Luca Tabbì, Ivana Castaniere, Lorenzo Ball, Manu L. N. G. Malbrain, Paolo Pelosi and Enrico Clini

Annals of Intensive Care volume 10, Article number: 13 (2020)

Protective ventilation is the cornerstone of treatment of patients with the acute respiratory distress syndrome (ARDS); however, no studies have yet established the best ventilatory strategy to adopt when patients with acute exacerbation of interstitial lung disease (AE-ILD) are admitted to the intensive care unit. Due to the severe impairment of the respiratory mechanics, the fibrotic lung is at high risk of developing ventilator-induced lung injury, regardless of the lung fibrosis etiology. The purpose of this review is to analyze the effects of mechanical ventilation in AE-ILD and to increase the knowledge on the characteristics of fibrotic lung during artificial ventilation, introducing the concept of “squishy ball lung”. The role of positive end-expiratory pressure is discussed, proposing a “lung resting strategy” as opposed to the “open lung approach”. The review also discusses the practical management of AE-ILD patients discussing illustrative clinical cases.

Methylnaltrexone for the treatment of opioid-induced constipation and gastrointestinal stasis in intensive care patients. Results from the MOTION trial

Constipation can be a significant problem in critically unwell patients, associated with detrimental outcomes. Opioids are thought to contribute to the mechanism of bowel dysfunction. We tested if methylnaltrexone, a pure peripheral mu-opioid receptor antagonist, could reverse opioid-induced constipation.
The MOTION trial is a multi-centre, double blind, randomised placebo-controlled trial to investigate whether methylnaltrexone alleviates opioid-induced constipation (OIC) in critical care patients. Eligibility criteria included adult ICU patients who were mechanically ventilated, receiving opioids and were constipated (had not opened bowels for a minimum 48 h) despite prior administration of regular laxatives as per local bowel management protocol. The primary outcome was time to significant rescue-free laxation. Secondary outcomes included gastric residual volume, tolerance of enteral feeds, requirement for rescue laxatives, requirement for prokinetics, average number of bowel movements per day, escalation of opioid dose due to antagonism/reversal of analgesia, incidence of ventilator-associated pneumonia, incidence of diarrhoea and Clostridium difficile infection and finally 28 day, ICU and hospital mortality.
A total of 84 patients were enrolled and randomized (41 to methylnaltrexone and 43 to placebo). The baseline demographic characteristics of the two groups were generally well balanced. There was no significant difference in time to rescue-free laxation between the groups (Hazard ratio 1.42, 95% CI 0.82–2.46, p = 0.22). There were no significant differences in the majority of secondary outcomes, particularly days 1–3. However, during days 4–28, there were fewer median number of bowel movements per day in the methylnaltrexone group, (p = 0.01) and a greater incidence of diarrhoea in the placebo group (p = 0.02). There was a marked difference in mortality between the groups, with ten deaths in the methylnaltrexone group and two in the placebo group during days 4–28 (p = 0.007).
We found no evidence to support the addition of methylnaltrexone to regular laxatives for the treatment of opioid-induced constipation in critically ill patients; however, the confidence interval was wide and a clinically important difference cannot be excluded.

Effects of endovascular and surface cooling on resuscitation in patients with cardiac arrest and a comparison of effectiveness, stability, and safety: a systematic review and meta-analysis

by Xueli Liao, Ziyu Zhou, Manhong Zhou, Hui Tang, Menglong Feng, Bujin Kou, Ni Zhu, Futuan Liao and Liaozhang Wu

Critical Care volume 24, Article number: 27 (2020)

This study conducted a meta-analysis to assess the effectiveness, stability, and safety of mild therapeutic hypothermia (TH) induced by endovascular cooling (EC) and surface cooling (SC) and its effect on ICU, survival rate, and neurological function integrity in adult CA patients.
We developed inclusion criteria, intervention protocols, results, and data collection. The results included outcomes during target temperature management as well as ICU stay, survival rate, and neurological functional integrity. The characteristics of the included population and each study were analyzed.
Four thousand nine hundred thirteen participants met the inclusion criteria. Those receiving EC had a better cooling efficiency (cooling rates MD = 0.31[0.13, 0.50], p < 0.01; induced cooling times MD = − 90.45[− 167.57, − 13.33], p = 0.02; patients achieving the target temperature RR = 1.60[1.19, 2.15], p < 0.01) and thermal stability during the maintenance phase (maintenance time MD = 2.35[1.22, 3.48], p < 0.01; temperature fluctuation MD = − 0.68[− 1.03, − 0.33], p < 0.01; overcooling RR = 0.33[0.23, 0.49], p < 0.01). There were no differences in ICU survival rate (RR = 1.22[0.98, 1.52], p = 0.07, I2 = 0%) and hospital survival rate (RR = 1.02 [0.96, 1.09], p = 0.46, I2 = 0%), but EC reduced the length of stay in ICU (MD = − 1.83[− 3.45, − 0.21], p = 0.03, I2 = 49%) and improved outcome of favorable neurological function at discharge (RR = 1.15[1.04, 1.28], p < 0.01, I2 = 0%). EC may delay the hypothermia initiation time, and there was no significant difference between the two cooling methods in the time from the start of patients’ cardiac arrest to achieve the target temperature (MD = − 46.64[− 175.86, 82.58]). EC was superior to non-ArcticSun in terms of cooling efficiency. Although there was no statistical difference in ICU survival rate, ICU length of stay, and hospitalization survival rate, in comparison to non-ArcticSun, EC improved rates of neurologically intact survival (RR = 1.16 [1.01, 1.35], p = 0.04, I2 = 0%).
Among adult patients receiving cardiopulmonary resuscitation, although there is no significant difference between the two cooling methods in the time from the start of cardiac arrest to achieve the target temperature, the faster cooling rate and more stable cooling process in EC shorten patients’ ICU hospitalization time and help more patients obtain good neurological prognosis compared with patients receiving SC. Meanwhile, although EC has no significant difference in patient outcomes compared with ArcticSun, EC has improved rates of neurologically intact survival.