Monitoring and optimising outcomes of survivors of critical illness. Intensive and Critical Care Nursing, 2015, 31: p.1-9
Aitken, L.M. and Marshall, A.P.
http://www.intensivecriticalcarenursing.com/article/S0964-3397(14)00093-7/pdf
Recovery after critical illness can be protracted and challenging. Compromise of physical, psychological, cognitive and social function is experienced by some patients and may persist for a number of years. Measurement of recovery outcomes at regular time points throughout the critical illness and recovery pathway is necessary to identify problems and guide selection of interventions to prevent, minimise or overcome that compromise. Optimisation of factors that enhance recovery, such as sleep, nutrition and memories of intensive care, will also assist with promotion of recovery. Effective assessment of recovery requires integration of assessment of outcomes into routine clinical practice by all members of the interdisciplinary team. There must be agreement of appropriate measures and measurement timeframes alongside relevant education and training to ensure optimal assessment and use of the information gained. Assessment outcomes need to be communicated to interdisciplinary team members across the critical illness and recovery trajectory. Adequate resourcing for both the assessment activities and subsequent care is essential to improve patient outcomes after critical illness.
Thursday, 18 December 2014
The experience of communication difficulties in critically ill patients in and beyond intensive care
The experience of communication difficulties in critically ill patients in and beyond intensive care: findings from a larger phenomenological study. Intensive and Critical Care Nursing, Dec. 2014 [in press].
Tembo, A.C., et al.
http://www.intensivecriticalcarenursing.com/article/S0964-3397(14)00091-3/abstract?rss=yes
Communication difficulties in intensive care units (ICU) with critically ill patients have been well documented for more than three decades. However, there is only a paucity of literature that has explored communication difficulties beyond the ICU environment. This paper discusses the experience of communication difficulties in critically ill patients in ICU and beyond as part of findings from a larger study that explored the lived experiences of critically ill patients in ICU in the context of daily sedation interruption
Tembo, A.C., et al.
http://www.intensivecriticalcarenursing.com/article/S0964-3397(14)00091-3/abstract?rss=yes
Communication difficulties in intensive care units (ICU) with critically ill patients have been well documented for more than three decades. However, there is only a paucity of literature that has explored communication difficulties beyond the ICU environment. This paper discusses the experience of communication difficulties in critically ill patients in ICU and beyond as part of findings from a larger study that explored the lived experiences of critically ill patients in ICU in the context of daily sedation interruption
Feeding the critically ill patient
Feeding the critically ill patient. Critical Care Medicine, Dec. 2014, Vol. 42(12), p.2600-2610.
McClave, S.A., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/12000/Feeding_the_Critically_Ill_Patient.16.aspx
Critically ill patients are usually unable to maintain adequate volitional intake to meet their metabolic demands. As such, provision of nutrition is part of the medical care of these patients. This review provides detail and interpretation of current data on specialized nutrition therapy in critically ill patients, with focus on recently published studies.
McClave, S.A., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/12000/Feeding_the_Critically_Ill_Patient.16.aspx
Critically ill patients are usually unable to maintain adequate volitional intake to meet their metabolic demands. As such, provision of nutrition is part of the medical care of these patients. This review provides detail and interpretation of current data on specialized nutrition therapy in critically ill patients, with focus on recently published studies.
Effectiveness of implementing a wake-up and breathe program on sedation and delirium in the ICU
Effectiveness of implementing a wake-up and breathe program on sedation and delirium in the ICU. Critical Care Medicine, Dec. 2014, Vol. 42(2), p.e791-3795.
Khan, B.A., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/12000/Effectiveness_of_Implementing_a_Wake_Up_and.38.aspx
Mechanically ventilated critically ill patients receive significant amounts of sedatives and analgesics that increase their risk of developing coma and delirium. We evaluated the impact of a “Wake-up and Breathe Protocol” at our local ICU on sedation and delirium.
Khan, B.A., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/12000/Effectiveness_of_Implementing_a_Wake_Up_and.38.aspx
Mechanically ventilated critically ill patients receive significant amounts of sedatives and analgesics that increase their risk of developing coma and delirium. We evaluated the impact of a “Wake-up and Breathe Protocol” at our local ICU on sedation and delirium.
Protein in nutrition support: the newborn hero for the critically ill?
Protein in nutrition support: the newborn hero for the critically ill? Critical Care 2014, 18: 592
Oshima, T., et al.
http://ccforum.com/content/18/6/592
Oshima, T., et al.
http://ccforum.com/content/18/6/592
In their current review, Weijs and colleagues highlight the importance of protein and amino acid provision for improving clinical outcome in critically ill patients. The interdependence between energy and protein is highlighted. They call for urgent research to develop new methods to evaluate protein and amino acid requirements, accurately and conveniently, in order to optimize nutrition support for critically ill patients. Appropriate nutrition delivery for critically ill patients remains a highly debated issue. Energy, a critical factor for life, was until now the superstar of nutrition support. It now faces a rival or, more correctly, a partner in function, namely protein. This is a chance to take a close look at protein, the new hero in the field of critical care nutrition, and the struggles it encounters in becoming the true superstar.
Prehospital treatment of sepsis
Prehospital treatment of sepsis: What really makes the "golden hour" golden? Critical Care 2014, 18: 697
Sterling, S.A., et al.
http://ccforum.com/content/18/6/697
The early recognition of severe sepsis is important; however, early identification of severe sepsis can be challenging, especially in the prehospital setting. As previous research has shown, advanced notification of time-sensitive disease states by prehospital personnel can improve outcomes and time to initiation of treatments. Prehospital personnel can potentially impact outcomes in sepsis through early identification and treatment implementations, improving processes of care and transition of care. Further research is needed for a full evaluation of prehospital treatment effects of identification of sepsis and treatment by prehospital personnel and the impact on outcomes.
Sterling, S.A., et al.
http://ccforum.com/content/18/6/697
The early recognition of severe sepsis is important; however, early identification of severe sepsis can be challenging, especially in the prehospital setting. As previous research has shown, advanced notification of time-sensitive disease states by prehospital personnel can improve outcomes and time to initiation of treatments. Prehospital personnel can potentially impact outcomes in sepsis through early identification and treatment implementations, improving processes of care and transition of care. Further research is needed for a full evaluation of prehospital treatment effects of identification of sepsis and treatment by prehospital personnel and the impact on outcomes.
Timing of norepinephrine in septic patients
Timing of norepinephrine in septic patients: Not too little too late. Critical Care 2014, 18: 691
Rachoin, JS and Dellinger, R.P.
http://ccforum.com/content/18/6/691
After years and years of consensus expert opinion as to mean arterial pressure (MAP) target and vasopressor choice in septic shock management, literature is now emerging that supports the MAP target of 65 mm Hg and norepinephrine as the vasopressor choice. However, the literature remains sparse as to the timing of vasopressors relative to fluid resuscitation and how MAP support is balanced between the choices of vasopressor versus fluid resuscitation. Bai and colleagues report data that reveal an association between earlier vasopressor initiation in septic shock and better outcome. Whether this is a linkage to better care, is related to improved early tissue perfusion, or relates to sparing of fluids to reach the MAP target is not yet known.
Rachoin, JS and Dellinger, R.P.
http://ccforum.com/content/18/6/691
After years and years of consensus expert opinion as to mean arterial pressure (MAP) target and vasopressor choice in septic shock management, literature is now emerging that supports the MAP target of 65 mm Hg and norepinephrine as the vasopressor choice. However, the literature remains sparse as to the timing of vasopressors relative to fluid resuscitation and how MAP support is balanced between the choices of vasopressor versus fluid resuscitation. Bai and colleagues report data that reveal an association between earlier vasopressor initiation in septic shock and better outcome. Whether this is a linkage to better care, is related to improved early tissue perfusion, or relates to sparing of fluids to reach the MAP target is not yet known.
Effect of a fever control protocol-based strategy on ventilator-associated pneumonia in severely brain-injured patients
Effect of a fever control protocol-based strategy on ventilator-associated severely brain-injured patients. Critical Care 2014, 18: 689
Launey, Y., et al.
http://ccforum.com/content/pdf/s13054-014-0689-4.pdf
Fever is associated with a poor outcome in severely brain-injured patients, and its control is
one of the therapies used in this condition. But, fever suppression may promote infection, and
severely brain-injured patients are frequently exposed to infectious diseases, particularly
ventilator-associated pneumonia (VAP). Therefore, we designed a study to explore the role of
a fever control protocol in VAP development during neuro-intensive care.
Launey, Y., et al.
http://ccforum.com/content/pdf/s13054-014-0689-4.pdf
Fever is associated with a poor outcome in severely brain-injured patients, and its control is
one of the therapies used in this condition. But, fever suppression may promote infection, and
severely brain-injured patients are frequently exposed to infectious diseases, particularly
ventilator-associated pneumonia (VAP). Therefore, we designed a study to explore the role of
a fever control protocol in VAP development during neuro-intensive care.
Incidence, risk factors and outcomes of new-onset atrial fibrillation in patients with sepsis
Incidence, risk factors and outcomes of new-onset atrial fibrillation in patients with sepsis: a systematic review. Critical Care 2014, 18: 688
Kuipers, S., et al.
http://ccforum.com/content/pdf/s13054-014-0688-5.pdf
Critically ill patients with sepsis are prone to develop cardiac dysrhythmias, most commonly
atrial fibrillation (AF). Systemic inflammation, circulating stress hormones, autonomic
dysfunction, and volume shifts are all possible triggers for AF in this setting. We conducted a
systematic review to describe the incidence, risk factors and outcomes of new-onset AF in
patients with sepsis.
Kuipers, S., et al.
http://ccforum.com/content/pdf/s13054-014-0688-5.pdf
Critically ill patients with sepsis are prone to develop cardiac dysrhythmias, most commonly
atrial fibrillation (AF). Systemic inflammation, circulating stress hormones, autonomic
dysfunction, and volume shifts are all possible triggers for AF in this setting. We conducted a
systematic review to describe the incidence, risk factors and outcomes of new-onset AF in
patients with sepsis.
Association between vitamin D deficiency and mortality in critically ill adult patients
Association between vitamin D deficiency and mortality in critically ill adult patients: a meta-analysis of cohort studies. Critical Care 2014, 18: 684
Sun, TW, et al.
http://ccforum.com/content/pdf/s13054-014-0684-9.pdf
Vitamin D deficiency is common in critically ill patients, and was reported to be associated with adverse outcomes. However, the effect of vitamin D deficiency on mortality in critically ill patients remains unclear.
Sun, TW, et al.
http://ccforum.com/content/pdf/s13054-014-0684-9.pdf
Vitamin D deficiency is common in critically ill patients, and was reported to be associated with adverse outcomes. However, the effect of vitamin D deficiency on mortality in critically ill patients remains unclear.
A practical approach to goal-directed echocardiography in the critical care setting
A practical approach to goal-directed echocardiography in the critical care setting. Critical Care 2014, 18: 681
Walley, P.E., et al.
http://ccforum.com/content/18/6/681
Urgent cardiac ultrasound examination in the critical care setting is clinically useful. Application of goal-directed echocardiography in this setting is quite distinct from typical exploratory diagnostic comprehensive echocardiography, because the urgent critical care setting mandates a goal-directed approach. Goal-directed echocardiography most frequently aims to rapidly identify and differentiate the cause(s) of hemodynamic instability and/or the cause(s) of acute respiratory failure. Accordingly, this paper highlights 1) indications, 2) an easily memorized differential diagnostic framework for goal-directed echocardiography, 3) clinical questions that must be asked and answered, 4) practical issues to allow optimal image capture, 5) primary echocardiographic views, 6) key issues addressed in each view, and 7) interpretation of findings within the differential diagnostic framework.
Walley, P.E., et al.
http://ccforum.com/content/18/6/681
Urgent cardiac ultrasound examination in the critical care setting is clinically useful. Application of goal-directed echocardiography in this setting is quite distinct from typical exploratory diagnostic comprehensive echocardiography, because the urgent critical care setting mandates a goal-directed approach. Goal-directed echocardiography most frequently aims to rapidly identify and differentiate the cause(s) of hemodynamic instability and/or the cause(s) of acute respiratory failure. Accordingly, this paper highlights 1) indications, 2) an easily memorized differential diagnostic framework for goal-directed echocardiography, 3) clinical questions that must be asked and answered, 4) practical issues to allow optimal image capture, 5) primary echocardiographic views, 6) key issues addressed in each view, and 7) interpretation of findings within the differential diagnostic framework.
The early antibiotic therapy in septic patients
The early antibiotic therapy in septic patients - milestone or sticking point? Critical Care 2014, 18: 671
Bernhard, M., et al.
http://ccforum.com/content/18/6/671
Sepsis is one of the oldest and most elusive syndromes in medicine. Every effort should be made to treat these patients with the best available evidence. As a milestone, empiric antimicrobial therapy is essential in order to reduce morbidity and mortality of septic patients. As a sticking point, the use of broad-spectrum antimicrobial agents may be associated with induction of resistance among common pathogens.
Bernhard, M., et al.
http://ccforum.com/content/18/6/671
Sepsis is one of the oldest and most elusive syndromes in medicine. Every effort should be made to treat these patients with the best available evidence. As a milestone, empiric antimicrobial therapy is essential in order to reduce morbidity and mortality of septic patients. As a sticking point, the use of broad-spectrum antimicrobial agents may be associated with induction of resistance among common pathogens.
Sleep continuity
Sleep continuity: a new metric to quantify disrupted hypnograms in non-sedated intensive care unit patients. Critical Care 2014, 18: 628
Drouot, X., et al.
http://ccforum.com/content/pdf/s13054-014-0628-4.pdf
Sleep in intensive care unit (ICU) patients is severely altered. In a large proportion of critically ill patients, conventional sleep electroencephalogram (EEG) patterns are replaced by atypical sleep. On the other hand, some non-sedated patients can display usual sleep EEG patterns. In the latter, sleep is highly fragmented and disrupted and conventional rules may not be optimal. We sought to determine whether sleep continuity could be a useful metric to quantify the amount of sleep with recuperative function in critically ill patients with usual sleep EEG features.
Drouot, X., et al.
http://ccforum.com/content/pdf/s13054-014-0628-4.pdf
Sleep in intensive care unit (ICU) patients is severely altered. In a large proportion of critically ill patients, conventional sleep electroencephalogram (EEG) patterns are replaced by atypical sleep. On the other hand, some non-sedated patients can display usual sleep EEG patterns. In the latter, sleep is highly fragmented and disrupted and conventional rules may not be optimal. We sought to determine whether sleep continuity could be a useful metric to quantify the amount of sleep with recuperative function in critically ill patients with usual sleep EEG features.
Intravenous immunoglobulin for severe sepsis and septic shock
Intravenous immunoglobulin for severe sepsis and septic shock: clinical effectiveness, cost effectiveness and value of a further randomised controlled trial. Critical Care 2014, 18: 649
Soares, M.O., et al.
http://ccforum.com/content/pdf/s13054-014-0649-z.pdf
Prior to investing in a large, multicentre randomised controlled trial (RCT), the National Institute for Health Research in the UK called for an evaluation of the feasibility and value for money of undertaking a trial on intravenous immunoglobulin (IVIG) as an adjuvant therapy for severe sepsis/septic shock.MethodsIn response to this call, this paper assessed the clinical and cost-effectiveness of IVIG (using a decision model), and evaluated the value of conducting an RCT (using expected value of information (EVI) analysis).
Soares, M.O., et al.
http://ccforum.com/content/pdf/s13054-014-0649-z.pdf
Prior to investing in a large, multicentre randomised controlled trial (RCT), the National Institute for Health Research in the UK called for an evaluation of the feasibility and value for money of undertaking a trial on intravenous immunoglobulin (IVIG) as an adjuvant therapy for severe sepsis/septic shock.MethodsIn response to this call, this paper assessed the clinical and cost-effectiveness of IVIG (using a decision model), and evaluated the value of conducting an RCT (using expected value of information (EVI) analysis).
Sedation assessment in a mobile intensive care unit
Sedation assessment in a mobile intensive care unit: a prospective pilot-study on the relation of clinical sedation scales and the bispectral index. Critical Care 2014, 18: 615
Prottengeier, J., et al.
http://ccforum.com/content/18/6/615
The critically-ill undergoing inter-hospital transfers commonly receive sedatives in continuation of their therapeutic regime or to facilitate a safe transfer shielded from external stressors. While sedation assessment is well established in critical care in general, there is only little data available relating to the special conditions during patient transport and their effect on patient sedation levels. The aim of this prospective study was to investigate the feasibility and relationship of clinical sedation assessment (Richmond Agitation-Sedation Scale (RASS)) and objective physiological monitoring (bispectral index (BIS)) during patient transfers in our Mobile-ICU.
Prottengeier, J., et al.
http://ccforum.com/content/18/6/615
The critically-ill undergoing inter-hospital transfers commonly receive sedatives in continuation of their therapeutic regime or to facilitate a safe transfer shielded from external stressors. While sedation assessment is well established in critical care in general, there is only little data available relating to the special conditions during patient transport and their effect on patient sedation levels. The aim of this prospective study was to investigate the feasibility and relationship of clinical sedation assessment (Richmond Agitation-Sedation Scale (RASS)) and objective physiological monitoring (bispectral index (BIS)) during patient transfers in our Mobile-ICU.
Thursday, 13 November 2014
Early sedation use in critically ill mechanically ventilated patients
Early sedation use in critically ill mechanically ventilated patients: when less is more. Critical Care, Nov 2014, 18:600
Lee, C.M. and Mehta, S.
http://ccforum.com/content/18/6/600
Over the last 10 years, there has been an explosion of literature surrounding sedation management for critically ill patients. The clinical target has moved away from an unconscious and immobile patient toward a goal of light or no sedation and early mobility. The move away from terms such as ‘sedation’ toward more patient-centered and symptom-based control of pain, anxiety, and agitation makes the management of critically ill patients more individualized and dynamic. Over-sedation has been associated with negative ICU outcomes, including longer durations of mechanical ventilation and lengths of stay, but few studies have been able to associate deep sedation with increased mortality.
Lee, C.M. and Mehta, S.
http://ccforum.com/content/18/6/600
Over the last 10 years, there has been an explosion of literature surrounding sedation management for critically ill patients. The clinical target has moved away from an unconscious and immobile patient toward a goal of light or no sedation and early mobility. The move away from terms such as ‘sedation’ toward more patient-centered and symptom-based control of pain, anxiety, and agitation makes the management of critically ill patients more individualized and dynamic. Over-sedation has been associated with negative ICU outcomes, including longer durations of mechanical ventilation and lengths of stay, but few studies have been able to associate deep sedation with increased mortality.
The clinical utility window for acute kidney injury biomarkers in the critically ill
The clinical utility window for acute kidney injury biomarkers in the critically ill. Critical Care, Nov 2014, 18:601
Ralib, A.M., et al.
http://ccforum.com/content/pdf/s13054-014-0601-2.pdf
Acute Kidney Injury (AKI) biomarker utility depends on sample timing after the onset of renal injury. We compared biomarker performance on arrival in the emergency department (ED) with subsequent performance in the intensive care unit (ICU). Urinary and plasma Neutrophil Gelatinase-Associated Lipocalin (NGAL), and urinary Cystatin C (CysC), alkaline phosphatase, Glutamyl Transpeptidase (GGT), and-Glutamyl S-Transferase (GST), and albumin were measured on ED presentation, and at 0, 4, 8, and 16 hours, and days 2, 4 and 7 in the ICU in patients after cardiac arrest, sustained or profound hypotension or ruptured abdominal aortic aneurysm. AKI was defined as plasma creatinine increase 26.5??mol/l within 48?hours or ?50% within 7 days. Results: In total, 45 of 77 patients developed AKI. Most AKI patients had elevated urinary NGAL, and plasma NGAL and CysC in the period 6 to 24?hours post presentation. Biomarker performance in the ICU was similar or better than when measured earlier in the ED. Conclusion: Early measurement in the ED has utility, but not better AKI diagnostic performance than later ICU measurement. Plasma NGAL diagnosed AKI at all time points. Urinary NGAL best predicted mortality or dialysis compared to other biomarkers.
Ralib, A.M., et al.
http://ccforum.com/content/pdf/s13054-014-0601-2.pdf
Acute Kidney Injury (AKI) biomarker utility depends on sample timing after the onset of renal injury. We compared biomarker performance on arrival in the emergency department (ED) with subsequent performance in the intensive care unit (ICU). Urinary and plasma Neutrophil Gelatinase-Associated Lipocalin (NGAL), and urinary Cystatin C (CysC), alkaline phosphatase, Glutamyl Transpeptidase (GGT), and-Glutamyl S-Transferase (GST), and albumin were measured on ED presentation, and at 0, 4, 8, and 16 hours, and days 2, 4 and 7 in the ICU in patients after cardiac arrest, sustained or profound hypotension or ruptured abdominal aortic aneurysm. AKI was defined as plasma creatinine increase 26.5??mol/l within 48?hours or ?50% within 7 days. Results: In total, 45 of 77 patients developed AKI. Most AKI patients had elevated urinary NGAL, and plasma NGAL and CysC in the period 6 to 24?hours post presentation. Biomarker performance in the ICU was similar or better than when measured earlier in the ED. Conclusion: Early measurement in the ED has utility, but not better AKI diagnostic performance than later ICU measurement. Plasma NGAL diagnosed AKI at all time points. Urinary NGAL best predicted mortality or dialysis compared to other biomarkers.
Cerebral tissue saturation
Cerebral tissue saturation, the next step in cardiopulmonary resuscitation management? Critical Care, Nov 2014, 18:583
Genbrugge, C., et al.
http://ccforum.com/content/18/5/583
The goal of cardiopulmonary resuscitation (CPR) is to preserve the pre-arrest neurological state by maintaining sufficient cerebral blood flow and oxygenation, but the predictors thereof remain largely unknown. Despite recent attempts to improve the quality of basic and advanced life support, no monitored link to the neurological and physiological response of these CPR efforts has been established.
Genbrugge, C., et al.
http://ccforum.com/content/18/5/583
The goal of cardiopulmonary resuscitation (CPR) is to preserve the pre-arrest neurological state by maintaining sufficient cerebral blood flow and oxygenation, but the predictors thereof remain largely unknown. Despite recent attempts to improve the quality of basic and advanced life support, no monitored link to the neurological and physiological response of these CPR efforts has been established.
Minimizing antibiotic exposure in the ICU
Minimizing antibiotic exposure in the ICU: in search of the optimal strategy. Critical Care, Oct 2014, 18:613
Brun-Buisson, C.
http://ccforum.com/content/18/5/613
The current paradigm for antibiotic management in critically ill patients is to initiate broad-spectrum therapy followed by de-escalation based on microbiological results. Routine screening cultures may allow better targeting and reduce unnecessary exposure to antibiotics.
Brun-Buisson, C.
http://ccforum.com/content/18/5/613
The current paradigm for antibiotic management in critically ill patients is to initiate broad-spectrum therapy followed by de-escalation based on microbiological results. Routine screening cultures may allow better targeting and reduce unnecessary exposure to antibiotics.
A randomized clinical trial for the timing of tracheotomy in critically ill patients
A randomized clinical trial for the timing of tracheotomy in critically ill patients: factors precluding inclusion in a single center study. Critical Care, Oct 2014, 18:585
Diaz-Prieto, A., et al.
http://ccforum.com/content/pdf/s13054-014-0585-y.pdf
We investigated the potential benefits of early tracheotomy performed before day eight of mechanical ventilation (MV) compared with late tracheotomy (from day 14 if it still indicated) in reducing mortality, days of MV, days of sedation and ICU length of stay (LOS). Randomized controlled trial (RCT) including all-consecutive ICU admitted patients requiring seven or more days of MV. Between days five to seven of MV, before randomization, the attending physician (AP) was consulted about the expected duration of MV and acceptance of tracheotomy according to randomization. Results: A total of 489 patients were included in the RCT. Of 245 patients randomized to the early group, the procedure was performed for 167 patients (68.2%) whereas in the 244 patients randomized to the late group was performed for 135 patients (55.3%) (P <0 .004="" nbsp="" span="">Conclusions: This study shows that early tracheotomy reduces the days of sedation in patients undergoing MV, but was underpowered to prove any other benefit. In those patients selected by their attending physicians as potential candidates for a tracheotomy, an early procedure can lessen the days of MV, the days of sedation and LOS. However, the imprecision of physicians to select patients who will require prolonged MV challenges the potential benefits of early tracheotomy.
Diaz-Prieto, A., et al.
http://ccforum.com/content/pdf/s13054-014-0585-y.pdf
We investigated the potential benefits of early tracheotomy performed before day eight of mechanical ventilation (MV) compared with late tracheotomy (from day 14 if it still indicated) in reducing mortality, days of MV, days of sedation and ICU length of stay (LOS). Randomized controlled trial (RCT) including all-consecutive ICU admitted patients requiring seven or more days of MV. Between days five to seven of MV, before randomization, the attending physician (AP) was consulted about the expected duration of MV and acceptance of tracheotomy according to randomization. Results: A total of 489 patients were included in the RCT. Of 245 patients randomized to the early group, the procedure was performed for 167 patients (68.2%) whereas in the 244 patients randomized to the late group was performed for 135 patients (55.3%) (P <0 .004="" nbsp="" span="">Conclusions: This study shows that early tracheotomy reduces the days of sedation in patients undergoing MV, but was underpowered to prove any other benefit. In those patients selected by their attending physicians as potential candidates for a tracheotomy, an early procedure can lessen the days of MV, the days of sedation and LOS. However, the imprecision of physicians to select patients who will require prolonged MV challenges the potential benefits of early tracheotomy.
Rapid induction of COOLing in stroke patients
Rapid induction of COOLing in stroke patients: A randomised pilot study comparing cold infusions with nasopharyngeal cooling. Critical Care, Oct. 2014, 18:582
Poli, S., et al.
http://ccforum.com/content/pdf/s13054-014-0582-1.pdf
Induction methods for therapeutic cooling are under investigated. We compared the effectiveness and safety of cold infusions (CI) and nasopharyngeal cooling (NPC) used for cooling induction in stroke patients. A prospective, open-label, randomised (1:1), single-centre pilot trial with partially blinded safety endpoint assessment was conducted at the neurointensive care unit of Heidelberg University. Intubated stroke patients with an indication for therapeutic cooling and an intracranial pressure (ICP)/temperature brain probe were randomly assigned to CI (4?C, 2L at 4L/h) or NPC (60L/min for 1?h). Results: Of 221 patients screened, 20 were randomized within 5 months. Conclusions: In intubated stroke patients, brain cooling is faster during CI than during NPC. Importantly, contrary to previous expectations, brain cooling stopped soon after CI cessation. Oesophageal but neither bladder nor rectal temperature is suited as surrogate for brain temperature during CI and NPC. Several severe adverse events in CI and in NPC demand further studying of safety.
Poli, S., et al.
http://ccforum.com/content/pdf/s13054-014-0582-1.pdf
Induction methods for therapeutic cooling are under investigated. We compared the effectiveness and safety of cold infusions (CI) and nasopharyngeal cooling (NPC) used for cooling induction in stroke patients. A prospective, open-label, randomised (1:1), single-centre pilot trial with partially blinded safety endpoint assessment was conducted at the neurointensive care unit of Heidelberg University. Intubated stroke patients with an indication for therapeutic cooling and an intracranial pressure (ICP)/temperature brain probe were randomly assigned to CI (4?C, 2L at 4L/h) or NPC (60L/min for 1?h). Results: Of 221 patients screened, 20 were randomized within 5 months. Conclusions: In intubated stroke patients, brain cooling is faster during CI than during NPC. Importantly, contrary to previous expectations, brain cooling stopped soon after CI cessation. Oesophageal but neither bladder nor rectal temperature is suited as surrogate for brain temperature during CI and NPC. Several severe adverse events in CI and in NPC demand further studying of safety.
Short and long-term outcome in elderly patients after out-of-hospital cardiac arrest
Short and long-term outcome in elderly patients after out-of-hospital cardiac arrest: A cohort study. Critical Care Medicine, Nov 2014, Vol.42 (11), p.2350-57.
Grimaldi, D., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/11000/Short__and_Long_Term_Outcome_in_Elderly_Patients.5.aspx
Determinants of outcome and long-term survival are unknown in elderly patients successfully resuscitated after out-of-hospital cardiac arrest. Our aim was to identify factors associated with short- and long-term neurologic outcome in such patients.
Grimaldi, D., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/11000/Short__and_Long_Term_Outcome_in_Elderly_Patients.5.aspx
Determinants of outcome and long-term survival are unknown in elderly patients successfully resuscitated after out-of-hospital cardiac arrest. Our aim was to identify factors associated with short- and long-term neurologic outcome in such patients.
Argatroban v Lepirudin in critically ill patients
Argatroban versus Lepirudin in critically ill patients: A randomized controlled trial. Critical Care, Oct. 2014, 18:588
Treschan, T.A., et al.
http://ccforum.com/content/pdf/s13054-014-0588-8.pdf
Critically ill patients often require renal replacement therapy accompanied by thrombocytopenia. Thrombocytopenia during heparin anticoagulation may be due to heparin-induced thrombocytopenia with need for alternative anticoagulation. Therefore, we compared argatroban and lepirudin in critically ill surgical patients. Following institutional review board approval and written informed consent, critically ill surgical patients more than or equal to 18 years with suspected heparin-induced thrombocytopenia, were randomly assigned to receive double-blind argatroban or lepirudin anticoagulation targeting an activated Partial Thromboplastin Time (aPTT) of 1.5 to 2 times baseline. In patients requiring continuous renal replacement therapy we compared the life-time of hemodialysis filters. We evaluated in all patients the incidence of bleeding and thrombembolic events. Conclusions: This first randomized controlled double-blind trial comparing two direct thrombin inhibitors showed comparable effectiveness for renal replacement therapy, but suggests fewer bleeds in surgical patients with argatroban anticoagulation.
Treschan, T.A., et al.
http://ccforum.com/content/pdf/s13054-014-0588-8.pdf
Critically ill patients often require renal replacement therapy accompanied by thrombocytopenia. Thrombocytopenia during heparin anticoagulation may be due to heparin-induced thrombocytopenia with need for alternative anticoagulation. Therefore, we compared argatroban and lepirudin in critically ill surgical patients. Following institutional review board approval and written informed consent, critically ill surgical patients more than or equal to 18 years with suspected heparin-induced thrombocytopenia, were randomly assigned to receive double-blind argatroban or lepirudin anticoagulation targeting an activated Partial Thromboplastin Time (aPTT) of 1.5 to 2 times baseline. In patients requiring continuous renal replacement therapy we compared the life-time of hemodialysis filters. We evaluated in all patients the incidence of bleeding and thrombembolic events. Conclusions: This first randomized controlled double-blind trial comparing two direct thrombin inhibitors showed comparable effectiveness for renal replacement therapy, but suggests fewer bleeds in surgical patients with argatroban anticoagulation.
Nutritional support in critically ill adults
Nutritional support in critically ill adults. NEJM, Oct. 2014 [podcast]
http://podcast.nejm.org/summaries/nejm_2014.371.issue-18.summary.mp3
http://podcast.nejm.org/summaries/nejm_2014.371.issue-18.summary.mp3
Monday, 20 October 2014
The route of early nutrition in critical illness
The route of early nutrition in critical illness. NEJM, October 2014 [online]
Cook, D. and Arabi, Y.
http://www.nejm.org/doi/full/10.1056/NEJMe1411474?af=R&rss=currentIssue
Randomized trials may be broadly categorized as explanatory or pragmatic. Explanatory trials address the question, “Can this intervention work under ideal conditions?” Pragmatic trials ask, “Does this intervention work under usual conditions?” Usual conditions, of course, are context-dependent. In the United Kingdom, the CALORIES trial by Harvey et al.,1 reported in the Journal,addresses the clinical effectiveness of early enteral nutrition, as compared with early parenteral nutrition, in critically ill patients without contraindications to either route of delivery. This trial, commissioned and sponsored by the Health Technology Assessment Program of the National Institute for Health Research, was pragmatic in design and conduct.
Cook, D. and Arabi, Y.
http://www.nejm.org/doi/full/10.1056/NEJMe1411474?af=R&rss=currentIssue
Randomized trials may be broadly categorized as explanatory or pragmatic. Explanatory trials address the question, “Can this intervention work under ideal conditions?” Pragmatic trials ask, “Does this intervention work under usual conditions?” Usual conditions, of course, are context-dependent. In the United Kingdom, the CALORIES trial by Harvey et al.,1 reported in the Journal,addresses the clinical effectiveness of early enteral nutrition, as compared with early parenteral nutrition, in critically ill patients without contraindications to either route of delivery. This trial, commissioned and sponsored by the Health Technology Assessment Program of the National Institute for Health Research, was pragmatic in design and conduct.
Goal-directed resuscitation for patients with early septic shock
Goal-directed resuscitation for patients with early septic shock. NEJM, October 2014 [online]
The ARISE Investigators and the ANZICS Clinical Trials Group
http://www.nejm.org/doi/full/10.1056/NEJMoa1404380?af=R&rss=currentIssue
The ARISE Investigators and the ANZICS Clinical Trials Group
http://www.nejm.org/doi/full/10.1056/NEJMoa1404380?af=R&rss=currentIssue
Early goal-directed therapy has been endorsed in the guidelines of the Surviving Sepsis Campaign as a key strategy to decrease mortality among patients presenting to the emergency department with septic shock. However, its effectiveness is uncertain.
Lower versus higher hemoglobin threshold for transfusion in septic shock
Lower versus higher hemoglobin threshold for transfusion in septic shock. NEJM, October 2014 [online]
Holst, L.B., et al.
http://www.nejm.org/doi/full/10.1056/NEJMoa1406617?af=R&rss=currentIssue
Blood transfusions are frequently given to patients with septic shock. However, the benefits and harms of different hemoglobin thresholds for transfusion have not been established. In this multicenter, parallel-group trial, we randomly assigned patients in the intensive care unit (ICU) who had septic shock and a hemoglobin concentration of 9 g per deciliter or less to receive 1 unit of leukoreduced red cells when the hemoglobin level was 7 g per deciliter or less (lower threshold) or when the level was 9 g per deciliter or less (higher threshold) during the ICU stay. The primary outcome measure was death by 90 days after randomization.
Holst, L.B., et al.
http://www.nejm.org/doi/full/10.1056/NEJMoa1406617?af=R&rss=currentIssue
Blood transfusions are frequently given to patients with septic shock. However, the benefits and harms of different hemoglobin thresholds for transfusion have not been established. In this multicenter, parallel-group trial, we randomly assigned patients in the intensive care unit (ICU) who had septic shock and a hemoglobin concentration of 9 g per deciliter or less to receive 1 unit of leukoreduced red cells when the hemoglobin level was 7 g per deciliter or less (lower threshold) or when the level was 9 g per deciliter or less (higher threshold) during the ICU stay. The primary outcome measure was death by 90 days after randomization.
Trial of the route of early nutritional support in critically ill adults
Trial of the route of early nutritional support in critically ill adults. NEJM, October 2014 [online]
Harvey, S.E., et al.
http://www.nejm.org/doi/full/10.1056/NEJMoa1409860?af=R&rss=currentIssue#t=articleTop
Nutritional support is standard for critically ill patients and requires a complex calculus of timing, route of delivery, and the amount and type of nutrients that are administered — all of which may affect patient outcomes. The interpretation of published meta-analyses of trials comparing nutritional support through the parenteral route versus the enteral route in critically ill patients is complicated by small sample sizes, variable quality, selection bias, lack of standardized definitions, and interventions that combine multiple elements of nutritional support (e.g., timing and route). Currently, the enteral route is the mainstay, largely on the grounds of physiological rationale and modest evidence suggesting an association with fewer infections, yet it can also be associated with gastrointestinal intolerance and underfeeding. The parenteral route, though more invasive, more often secures delivery of the intended nutrition but has been associated with greater risks and rates of complications. However, these studies have not considered improvements in delivery, formulation, and monitoring of parenteral nutrition.
Harvey, S.E., et al.
http://www.nejm.org/doi/full/10.1056/NEJMoa1409860?af=R&rss=currentIssue#t=articleTop
Nutritional support is standard for critically ill patients and requires a complex calculus of timing, route of delivery, and the amount and type of nutrients that are administered — all of which may affect patient outcomes. The interpretation of published meta-analyses of trials comparing nutritional support through the parenteral route versus the enteral route in critically ill patients is complicated by small sample sizes, variable quality, selection bias, lack of standardized definitions, and interventions that combine multiple elements of nutritional support (e.g., timing and route). Currently, the enteral route is the mainstay, largely on the grounds of physiological rationale and modest evidence suggesting an association with fewer infections, yet it can also be associated with gastrointestinal intolerance and underfeeding. The parenteral route, though more invasive, more often secures delivery of the intended nutrition but has been associated with greater risks and rates of complications. However, these studies have not considered improvements in delivery, formulation, and monitoring of parenteral nutrition.
The effect of goal-directed therapy on mortality in patients with sepsis
The effect of goal-directed therapy on mortality in patients with sepsis - earlier is better: a meta-analysis of randomized controlled trials. Critical Care 2014, 18:570
Gu, W-J., et al.
http://ccforum.com/content/pdf/s13054-014-0570-5.pdf
The Surviving Sepsis Campaign guidelines recommend goal-directed therapy (GDT) for the early resuscitation of patients with sepsis. However, the findings of the ProCESS (Protocolized Care for Early Septic Shock) trial show no benefit from GDT for reducing mortality rates in early septic shock. We performed a meta-analysis to integrate these findings with existing literature on this topic and evaluate the effect of GDT on mortality from sepsis. We searched the PubMed, EMBASE, CENTRAL, and reference lists of articles. Randomized controlled trials comparing GDT with standard therapy or usual care in patients with sepsis were included. The prespecified primary outcome was overall mortality.
Gu, W-J., et al.
http://ccforum.com/content/pdf/s13054-014-0570-5.pdf
The Surviving Sepsis Campaign guidelines recommend goal-directed therapy (GDT) for the early resuscitation of patients with sepsis. However, the findings of the ProCESS (Protocolized Care for Early Septic Shock) trial show no benefit from GDT for reducing mortality rates in early septic shock. We performed a meta-analysis to integrate these findings with existing literature on this topic and evaluate the effect of GDT on mortality from sepsis. We searched the PubMed, EMBASE, CENTRAL, and reference lists of articles. Randomized controlled trials comparing GDT with standard therapy or usual care in patients with sepsis were included. The prespecified primary outcome was overall mortality.
Critical care telemedicine
Critical care telemedicine: evolution and state of the art. Critical Care Medicine, Nov 2014, Vol. 42(11), p.2429-36
Lilly, C., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/11000/Critical_Care_Telemedicine___Evolution_and_State.14.aspx
To review the growth and current penetration of ICU telemedicine programs, association with outcomes, studies of their impact on medical education, associations with medicolegal risks, identify program revenue sources and costs, regulatory aspects, and the ICU telemedicine research agenda.
Lilly, C., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/11000/Critical_Care_Telemedicine___Evolution_and_State.14.aspx
To review the growth and current penetration of ICU telemedicine programs, association with outcomes, studies of their impact on medical education, associations with medicolegal risks, identify program revenue sources and costs, regulatory aspects, and the ICU telemedicine research agenda.
Beyond the evidence: treating pulmonary hypertension in the intensive care unit
Beyond the evidence: treating pulmonary hypertension in the intensive care unit. Critical Care, 2014, 18: 542
Bauer, S.R. and Tonelli, A.R.
http://ccforum.com/content/18/5/524
Most patients with pulmonary arterial hypertension succumb to their disease in the ICU; however, limited evidence-based information exists to guide treatment in those that present with advanced right ventricular failure. Critical care physicians should be aware of the complexities of the treatment of patients with pulmonary arterial hypertension and should develop a strategy for their care. Current management is based on the pathophysiology of the disease and involves a multidisciplinary team supported by institutional polices directed at optimizing patient safety.
Bauer, S.R. and Tonelli, A.R.
http://ccforum.com/content/18/5/524
Most patients with pulmonary arterial hypertension succumb to their disease in the ICU; however, limited evidence-based information exists to guide treatment in those that present with advanced right ventricular failure. Critical care physicians should be aware of the complexities of the treatment of patients with pulmonary arterial hypertension and should develop a strategy for their care. Current management is based on the pathophysiology of the disease and involves a multidisciplinary team supported by institutional polices directed at optimizing patient safety.
Measuring pain in non-verbal critically ill patients
Measuring pain in non-verbal critically ill patients: which pain instrument? Critical Care, Oct 2014, 18: 554
Payen, J-F and Gelinas, C.
http://ccforum.com/content/18/5/554
Pain is experienced by many critically ill patients. Although the patient’s self-report represents the gold-standard measure for pain, many patients are unable to communicate in the ICU. In this commentary, we discuss the study findings comparing three objective scales for the assessment of pain in non-verbal patients and the importance of the tool selection process.
Payen, J-F and Gelinas, C.
http://ccforum.com/content/18/5/554
Pain is experienced by many critically ill patients. Although the patient’s self-report represents the gold-standard measure for pain, many patients are unable to communicate in the ICU. In this commentary, we discuss the study findings comparing three objective scales for the assessment of pain in non-verbal patients and the importance of the tool selection process.
Three-year risk of cardiovascular disease among intensive care patients with acute kidney injury
Three-year risk of cardiovascular disease among intensive care patients with acute kidney injury: a population based cohort study. Critical Care, Oct 2014, 18: 492
Gammelager, H., et al.
http://ccforum.com/content/18/5/492
Acute kidney injury (AKI) is common among intensive care unit (ICU) patients, but follow-up data on subsequent risk of cardiovascular disease remain sparse. We examined the impact of AKI on three-year risk of first-time heart failure, myocardial infarction (MI), and stroke among ICU patients surviving to hospital discharge, and whether this risk is modified by renal recovery before hospital discharge.
Gammelager, H., et al.
http://ccforum.com/content/18/5/492
Acute kidney injury (AKI) is common among intensive care unit (ICU) patients, but follow-up data on subsequent risk of cardiovascular disease remain sparse. We examined the impact of AKI on three-year risk of first-time heart failure, myocardial infarction (MI), and stroke among ICU patients surviving to hospital discharge, and whether this risk is modified by renal recovery before hospital discharge.
Detecting acute distress and risk of future psychological morbidity in critically ill patients
Detecting acute distress and risk of future psychological morbidity in critically ill patients: validation of the intensive care psychological assessment tool. Critical Care, Sept 2014, 18: 519
Wade, D., et al.
http://ccforum.com/content/pdf/s13054-014-0519-8.pdf
The psychological impact of critical illness on a patient can be severe, and frequently results in acute distress as well as psychological morbidity after leaving hospital. A UK guideline states that patients should be assessed in critical care units, both for acute distress and risk of future psychological morbidity; but no suitable method for carrying out this assessment exists. The Intensive care psychological assessment tool (IPAT) was developed as a simple, quick screening tool to be used routinely to detect acute distress, and the risk of future psychological morbidity, in critical care units.
Wade, D., et al.
http://ccforum.com/content/pdf/s13054-014-0519-8.pdf
The psychological impact of critical illness on a patient can be severe, and frequently results in acute distress as well as psychological morbidity after leaving hospital. A UK guideline states that patients should be assessed in critical care units, both for acute distress and risk of future psychological morbidity; but no suitable method for carrying out this assessment exists. The Intensive care psychological assessment tool (IPAT) was developed as a simple, quick screening tool to be used routinely to detect acute distress, and the risk of future psychological morbidity, in critical care units.
The changing role of palliative care in the ICU
The changing role of palliative care in the ICU. Critical Care Medicine, Nov 2014, Vol. 42(11), p.2418-28.
Aslakson, R.A., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/11000/The_Changing_Role_of_Palliative_Care_in_the_ICU.13.aspx
Palliative care is an interprofessional specialty as well as an approach to care by all clinicians caring for patients with serious and complex illness. Unlike hospice, palliative care is based not on prognosis but on need and is an essential component of comprehensive care for critically ill patients from the time of ICU admission. In this clinically focused article, we review evidence of opportunities to improve palliative care for critically ill adults, summarize strategies for ICU palliative care improvement, and identify resources to support implementation.
Aslakson, R.A., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/11000/The_Changing_Role_of_Palliative_Care_in_the_ICU.13.aspx
Palliative care is an interprofessional specialty as well as an approach to care by all clinicians caring for patients with serious and complex illness. Unlike hospice, palliative care is based not on prognosis but on need and is an essential component of comprehensive care for critically ill patients from the time of ICU admission. In this clinically focused article, we review evidence of opportunities to improve palliative care for critically ill adults, summarize strategies for ICU palliative care improvement, and identify resources to support implementation.
Tuesday, 2 September 2014
The opportunity cost of futile treatment in the ICU
The opportunity cost of futile treatment in the ICU. Critical Care Medicine, Sept 2014, Vol. 42(9), p.1977-82.
Huynh, T.N. et al.
http://journals.lww.com/ccmjournal/Abstract/2014/09000/The_Opportunity_Cost_of_Futile_Treatment_in_the.2.aspx
When used to prolong life without achieving a benefit meaningful to the patient, critical care is often considered “futile.” Although futile treatment is acknowledged as a misuse of resources by many, no study has evaluated its opportunity cost, that is, how it affects care for others. Our objective was to evaluate delays in care when futile treatment is provided.
Huynh, T.N. et al.
http://journals.lww.com/ccmjournal/Abstract/2014/09000/The_Opportunity_Cost_of_Futile_Treatment_in_the.2.aspx
When used to prolong life without achieving a benefit meaningful to the patient, critical care is often considered “futile.” Although futile treatment is acknowledged as a misuse of resources by many, no study has evaluated its opportunity cost, that is, how it affects care for others. Our objective was to evaluate delays in care when futile treatment is provided.
Is high-frequency oscillatory ventilation more effective and safer than conventional protective ventilation in adult acute respiratory distress syndrome patients?
Is high-frequency oscillatory ventilation more effective and safer than conventional protective ventilation in adult acute respiratory distress syndrome patients? A meta-analysis of randomized controlled trials. Critical Care 2014, 18: R111
Gu, X. et al.
http://ccforum.com/content/pdf/cc13900.pdf
Comprehensively evaluating the efficacy and safety of high-frequency oscillatory ventilation (HFOV) is
important to allow clinicians who are using or considering this intervention to make appropriate decisions.
Although HFOV seems not to increase the risk of barotrauma or hypotension, and reduces the risk of oxygenation failure, it does not improve survival in adult acute respiratory distress syndrome patients.
Gu, X. et al.
http://ccforum.com/content/pdf/cc13900.pdf
Comprehensively evaluating the efficacy and safety of high-frequency oscillatory ventilation (HFOV) is
important to allow clinicians who are using or considering this intervention to make appropriate decisions.
Although HFOV seems not to increase the risk of barotrauma or hypotension, and reduces the risk of oxygenation failure, it does not improve survival in adult acute respiratory distress syndrome patients.
High-frequency oscillatory ventilation in adults
High-frequency oscillatory ventilation in adults: handle with care. Critical Care 2014, 18: 464
Ferguson, N.D.
http://ccforum.com/content/pdf/s13054-014-0464-6.pdf
In the previous issue of Critical Care, Gu and colleagues reported the results of a systematic review
and meta-analysis of randomized trials comparing high-frequency oscillatory ventilation (HFOV) with
conventional ventilation in adults with acute respiratory distress syndrome (ARDS). In contrast to findings of prior meta-analyses, their main finding was that, despite reducing risks of oxygenation failure, HFOV does not improve survival in adults with ARDS.
Ferguson, N.D.
http://ccforum.com/content/pdf/s13054-014-0464-6.pdf
In the previous issue of Critical Care, Gu and colleagues reported the results of a systematic review
and meta-analysis of randomized trials comparing high-frequency oscillatory ventilation (HFOV) with
conventional ventilation in adults with acute respiratory distress syndrome (ARDS). In contrast to findings of prior meta-analyses, their main finding was that, despite reducing risks of oxygenation failure, HFOV does not improve survival in adults with ARDS.
Conservative fluid therapy in septic shock
Conservative fluid therapy in septic shock: an example of targeted therapeutic minimization. Critical Care 2014, 18: 481
Chen, C. and Kollef, M.H.
http://ccforum.com/content/pdf/s13054-014-0481-5.pdf
Intravenous fluids (IVFs) represent a basic therapeutic intervention utilized in septic shock. Unfortunately, the
optimal method for administering IVFs to maximize patient outcomes is unknown. A meta-analysis of
four randomized trials of goal-directed therapy did not demonstrate a significant reduction in mortality
(odds ratio 0.609; 95% confidence interval 0.363 to 1.020; P = 0.059), whereas 18 trials with historical
controls showed a significant increase in survival (odds ratio 0.580; 95% confidence interval 0.501 to
0.672; P < 0.0001). Based on these data, clinicians should be aware of the potential for harm due to
the excessive administration of IVFs to patients with septic shock.
Chen, C. and Kollef, M.H.
http://ccforum.com/content/pdf/s13054-014-0481-5.pdf
Intravenous fluids (IVFs) represent a basic therapeutic intervention utilized in septic shock. Unfortunately, the
optimal method for administering IVFs to maximize patient outcomes is unknown. A meta-analysis of
four randomized trials of goal-directed therapy did not demonstrate a significant reduction in mortality
(odds ratio 0.609; 95% confidence interval 0.363 to 1.020; P = 0.059), whereas 18 trials with historical
controls showed a significant increase in survival (odds ratio 0.580; 95% confidence interval 0.501 to
0.672; P < 0.0001). Based on these data, clinicians should be aware of the potential for harm due to
the excessive administration of IVFs to patients with septic shock.
Septic acute kidney injury
Septic acute kidney injury: molecular mechanisms and the importance of stratification and targeting therapy. Critical Care 2014, 18: 501.
Morrell, E.D., et al.
http://ccforum.com/content/pdf/s13054-014-0501-5.pdf
The most common cause of acute kidney injury (AKI) in hospitalized patients is sepsis. However, the molecular pathways and mechanisms that mediate septic AKI are not well defined. Experiments performed over the past 20 years suggest that there are profound differences in the pathogenesis between septic and ischemic AKI. Septic AKI often occurs independently of hypoperfusion, and is mediated by a concomitant pro- and anti-inflammatory state that is activated in response to various pathogen-associated molecular patterns, such as endotoxin, as well as damage-associated molecular patterns. These molecular patterns are recognized by Toll-like receptors (TLRs) found in the kidney, and effectuate downstream inflammatory pathways. Additionally, apoptosis has been proposed to play a role in the pathogenesis of septic AKI. However, targeted therapies designed to mitigate the above aspects of the inflammatory state, TLR-related pathways, and apoptosis have failed to show significant clinical benefit. This failure is likely due to the protean nature of septic AKI, whereby different patients present at different points along
the immunologic spectrum. While one patient may benefit from targeted therapy at one end of the spectrum,
another patient at the other end may be harmed by the same therapy. We propose that a next important step in septic AKI research will be to identify where patients lie on the immunologic spectrum in order to appropriately target therapies at the inflammatory cascade, TLRs, and possibly apoptosis.
Morrell, E.D., et al.
http://ccforum.com/content/pdf/s13054-014-0501-5.pdf
The most common cause of acute kidney injury (AKI) in hospitalized patients is sepsis. However, the molecular pathways and mechanisms that mediate septic AKI are not well defined. Experiments performed over the past 20 years suggest that there are profound differences in the pathogenesis between septic and ischemic AKI. Septic AKI often occurs independently of hypoperfusion, and is mediated by a concomitant pro- and anti-inflammatory state that is activated in response to various pathogen-associated molecular patterns, such as endotoxin, as well as damage-associated molecular patterns. These molecular patterns are recognized by Toll-like receptors (TLRs) found in the kidney, and effectuate downstream inflammatory pathways. Additionally, apoptosis has been proposed to play a role in the pathogenesis of septic AKI. However, targeted therapies designed to mitigate the above aspects of the inflammatory state, TLR-related pathways, and apoptosis have failed to show significant clinical benefit. This failure is likely due to the protean nature of septic AKI, whereby different patients present at different points along
the immunologic spectrum. While one patient may benefit from targeted therapy at one end of the spectrum,
another patient at the other end may be harmed by the same therapy. We propose that a next important step in septic AKI research will be to identify where patients lie on the immunologic spectrum in order to appropriately target therapies at the inflammatory cascade, TLRs, and possibly apoptosis.
Thursday, 7 August 2014
High versus low blood pressure target in patients with septic shock
High versus low blood pressure target in patients with septic shock. New Eng J Med 2014; 370:1583-93.
Asfar, P., et al.
http://www.nejm.org/doi/full/10.1056/NEJMoa1312173
The Surviving Sepsis Campaign recommends targeting a mean arterial pressure of at least 65 mm Hg during initial resuscitation of patients with septic shock. However, whether this blood-pressure target is more or less effective than a higher target is unknown.
Asfar, P., et al.
http://www.nejm.org/doi/full/10.1056/NEJMoa1312173
The Surviving Sepsis Campaign recommends targeting a mean arterial pressure of at least 65 mm Hg during initial resuscitation of patients with septic shock. However, whether this blood-pressure target is more or less effective than a higher target is unknown.
Early prediction of new-onset physical disability after intensive care unit stay
Early prediction of new-onset physical disability after intensive care unit stay: preliminary instrument. Critical Care 2014, 18: 455.
Schandl, A., et al.
http://ccforum.com/content/pdf/s13054-014-0455-7.pdf
Many intensive care unit (ICU) survivors suffer from physical disability for months after ICU
stay. There is no structured method to identify patients at risk for such problems. The purpose
of the study was to develop a method for early in-ICU prediction of the patient’s individual
risk for new-onset physical disability two months after ICU stay.
Schandl, A., et al.
http://ccforum.com/content/pdf/s13054-014-0455-7.pdf
Many intensive care unit (ICU) survivors suffer from physical disability for months after ICU
stay. There is no structured method to identify patients at risk for such problems. The purpose
of the study was to develop a method for early in-ICU prediction of the patient’s individual
risk for new-onset physical disability two months after ICU stay.
Early sedation and clinical outcomes of mechanically ventilated patients
Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study. Critical Care 2014, 18: R156.
Tanaka, L.M.S, et al.
http://ccforum.com/content/pdf/cc13995.pdf
Sedation overuse is frequent and possibly associated with poor outcomes in the intensive care
unit (ICU) patients. However, the association of early over-sedation with clinical outcomes
has not been thoroughly evaluated. The aim of this study was to assess the association of
early sedation strategies with outcomes of critically ill adult patients under mechanical
ventilation.
Tanaka, L.M.S, et al.
http://ccforum.com/content/pdf/cc13995.pdf
Sedation overuse is frequent and possibly associated with poor outcomes in the intensive care
unit (ICU) patients. However, the association of early over-sedation with clinical outcomes
has not been thoroughly evaluated. The aim of this study was to assess the association of
early sedation strategies with outcomes of critically ill adult patients under mechanical
ventilation.
One year mortality in patients requiring prolonged mechanical ventilation
One year mortality in patients requiring prolonged mechanical ventilation: multicenter evaluation of the ProVent score. Critical Care 2014, 18:R155.
Leroy, G., et al.
http://ccforum.com/content/18/4/R155
Current severity-of-illness indexes are unable to assess the long-term prognosis of patients requiring prolonged mechanical ventilation. A prognostic scoring system (Prognosis for Prolonged Ventilation score - ProVent - score) seems able to evaluate one-year mortality of such patients. However, testing of the model outside the developers' centers has not been reported. So, it is unclear how the ProVent score performs in non-US and non-tertiary ICUs. The goal of our study was to evaluate its performances in a French multicenter, community hospital-based setting.
Leroy, G., et al.
http://ccforum.com/content/18/4/R155
Current severity-of-illness indexes are unable to assess the long-term prognosis of patients requiring prolonged mechanical ventilation. A prognostic scoring system (Prognosis for Prolonged Ventilation score - ProVent - score) seems able to evaluate one-year mortality of such patients. However, testing of the model outside the developers' centers has not been reported. So, it is unclear how the ProVent score performs in non-US and non-tertiary ICUs. The goal of our study was to evaluate its performances in a French multicenter, community hospital-based setting.
Experimental and clinical evidences for glucose control in intensive care
Experimental and clinical evidences for glucose control in intensive care: is infused glucose the key point for study interpretation? Critical Care 2014, 18: 232.
Mazeraud, A., et al.
http://ccforum.com/content/18/4/232
Stress-induced hyperglycemia has been considered an adaptive mechanism to stress up to the first intensive insulin therapy trial, which showed a 34% reduction in relative risk of in-hospital mortality when normalizing blood glucose levels. Further trials had conflicting results and, at present, stress-induced hyperglycemia management remains non-consensual. These findings could be explained by discrepancies in trials, notably regarding the approach to treat hyperglycemia: high versus restrictive caloric intake. Stress-induced hyperglycemia is a frequent complication during intensive care unit stay and is associated with a higher mortality. It results from an imbalance between insulin and counter-regulatory hormones, increased neoglucogenesis, and the cytokine-induced insulin-resistant state of tissues. In this review, we summarize detrimental effects of hyperglycemia on organs in the critically ill (peripheric and central nervous, liver, immune system, kidney, and cardiovascular system). Finally, we show clinical and experimental evidence of potential benefits from glucose and insulin administration, notably on metabolism, immunity, and the cardiovascular system.
Mazeraud, A., et al.
http://ccforum.com/content/18/4/232
Stress-induced hyperglycemia has been considered an adaptive mechanism to stress up to the first intensive insulin therapy trial, which showed a 34% reduction in relative risk of in-hospital mortality when normalizing blood glucose levels. Further trials had conflicting results and, at present, stress-induced hyperglycemia management remains non-consensual. These findings could be explained by discrepancies in trials, notably regarding the approach to treat hyperglycemia: high versus restrictive caloric intake. Stress-induced hyperglycemia is a frequent complication during intensive care unit stay and is associated with a higher mortality. It results from an imbalance between insulin and counter-regulatory hormones, increased neoglucogenesis, and the cytokine-induced insulin-resistant state of tissues. In this review, we summarize detrimental effects of hyperglycemia on organs in the critically ill (peripheric and central nervous, liver, immune system, kidney, and cardiovascular system). Finally, we show clinical and experimental evidence of potential benefits from glucose and insulin administration, notably on metabolism, immunity, and the cardiovascular system.
Psychometric comparison of three behavioural scales for the assessment of pain in critically ill patients unable to self-report
Psychometric comparison of three behavioural scales for the assessment of pain in patients unable to self-report. Critical Care 2014, 18:R160.
Chanques, G., et al.
http://ccforum.com/content/pdf/cc14000.pdf
Pain assessment is associated with important outcomes in ICU patients but remains
challenging, particularly in non-communicative patients. Use of a reliable tool is paramount
to allow any implementation of sedation/analgesia protocols in a multidisciplinary team. This
study compared psychometric properties (inter-rater agreement primarily; validity, responsiveness and feasibility secondarily) of three pain scales: Behavioural Pain Scale (BPS/BPS-NI, that is BPS for Non-Intubated patients), Critical Care Pain Observation Tool (CPOT) and Non-Verbal Pain Scale (NVPS), the pain tool routinely used in this 16-bed medical ICU.
Chanques, G., et al.
http://ccforum.com/content/pdf/cc14000.pdf
Pain assessment is associated with important outcomes in ICU patients but remains
challenging, particularly in non-communicative patients. Use of a reliable tool is paramount
to allow any implementation of sedation/analgesia protocols in a multidisciplinary team. This
study compared psychometric properties (inter-rater agreement primarily; validity, responsiveness and feasibility secondarily) of three pain scales: Behavioural Pain Scale (BPS/BPS-NI, that is BPS for Non-Intubated patients), Critical Care Pain Observation Tool (CPOT) and Non-Verbal Pain Scale (NVPS), the pain tool routinely used in this 16-bed medical ICU.
A comparison of different diagnostic criteria of acute kidney injury in critically ill patients
A comparison of different diagnostic criteria of acute kidney injury in critically ill patients. Critical Care 2014, 18: R144.
Luo, X., et al.
http://ccforum.com/content/18/4/R144
Recently, the Kidney Disease: Improving Global Outcomes (KDIGO) proposed a new definition and classification of acute kidney injury (AKI) on the basis of the RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage renal failure) and AKIN (Acute Kidney Injury Network) criteria, but comparisons of the three criteria in critically ill patients are rare.
Luo, X., et al.
http://ccforum.com/content/18/4/R144
Recently, the Kidney Disease: Improving Global Outcomes (KDIGO) proposed a new definition and classification of acute kidney injury (AKI) on the basis of the RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage renal failure) and AKIN (Acute Kidney Injury Network) criteria, but comparisons of the three criteria in critically ill patients are rare.
ICU-acquired weakness and recovery from critical illness
ICU-acquired weakness and recovery from critical illness. N Engl J of Med, 2014, 371:287-288
Kress, JP and Hall, JB.
http://www.nejm.org/doi/pdf/10.1056/NEJMra1209390
Kress, JP and Hall, JB.
http://www.nejm.org/doi/pdf/10.1056/NEJMra1209390
Feasibility of a multiple-choice mini mental state examination for chronically critically ill patients
Feasibility of a multiple-choice mini mental state examination for chronically critically ill patients. Critical Care Medicine, Aug 2014, Vol.42(8), p.1874-81.
Miguélez, M., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/08000/Feasibility_of_a_Multiple_Choice_Mini_Mental_State.15.aspx
Following treatment in an ICU, up to 70% of chronically critically ill patients present neurocognitive impairment that can have negative effects on their quality of life, daily activities, and return to work. The Mini Mental State Examination is a simple, widely used tool for neurocognitive assessment. Although of interest when evaluating ICU patients, the current version is restricted to patients who are able to speak. This study aimed to evaluate the feasibility of a visual, multiple-choice Mini Mental State Examination for ICU patients who are unable to speak.
Miguélez, M., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/08000/Feasibility_of_a_Multiple_Choice_Mini_Mental_State.15.aspx
Following treatment in an ICU, up to 70% of chronically critically ill patients present neurocognitive impairment that can have negative effects on their quality of life, daily activities, and return to work. The Mini Mental State Examination is a simple, widely used tool for neurocognitive assessment. Although of interest when evaluating ICU patients, the current version is restricted to patients who are able to speak. This study aimed to evaluate the feasibility of a visual, multiple-choice Mini Mental State Examination for ICU patients who are unable to speak.
Use of a daily goals checklist for morning ICU rounds
Use of a daily goals checklist for morning ICU rounds: a mixed-methods study. Critical Care Medicine, Aug 2014, Vol. 42(8), p.1797-1803.
Centofanti, J.E., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/08000/Use_of_a_Daily_Goals_Checklist_for_Morning_ICU.6.aspx
Centofanti, J.E., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/08000/Use_of_a_Daily_Goals_Checklist_for_Morning_ICU.6.aspx
Objective: To understand the perspectives and attitudes of ICU clinicians about use of a daily goals checklist on rounds. Design: Our three data collection methods were as follows: 1) Field observations: two investigators conducted field observations to understand how and by whom the daily goals checklist was used for 80 ICU patient rounds over 6 days. 2) Document analysis: The 72 completed daily goals checklists from observed rounds were analyzed using mixed methods. 3) Interviews: With 56 clinicians, we conducted semistructured individual and focus-group interviews, analyzing transcripts using a qualitative descriptive approach and content analysis. Triangulation was achieved by a multidisciplinary investigative team using two research methods and three data sources.
Statins and delirium during critical illness
Statins and delirium during critical illness: A multicenter, prospective cohort study. Critical Care Medicine Aug. 2014, Vol. 42(8), p.1899-1909.
Morandi, A., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/08000/Statins_and_Delirium_During_Critical_Illness___A.18.aspx
Since statins have pleiotropic effects on inflammation and coagulation that may interrupt delirium pathogenesis, we tested the hypotheses that statin exposure is associated with reduced delirium during critical illness, whereas discontinuation of statin therapy is associated with increased delirium.
Morandi, A., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/08000/Statins_and_Delirium_During_Critical_Illness___A.18.aspx
Since statins have pleiotropic effects on inflammation and coagulation that may interrupt delirium pathogenesis, we tested the hypotheses that statin exposure is associated with reduced delirium during critical illness, whereas discontinuation of statin therapy is associated with increased delirium.
A randomized trial of protocol-based care for early septic shock
A randomized trial of protocol-based care for early septic shock. N E Jnl Med 2014; 370:1683-93.
The ProCESS Investigators
http://www.nejm.org/doi/full/10.1056/NEJMoa1401602
In a single-center study published more than a decade ago involving patients presenting to the emergency department with severe sepsis and septic shock, mortality was markedly lower among those who were treated according to a 6-hour protocol of early goal-directed therapy (EGDT), in which intravenous fluids, vasopressors, inotropes, and blood transfusions were adjusted to reach central hemodynamic targets, than among those receiving usual care. We conducted a trial to determine whether these findings were generalizable and whether all aspects of the protocol were necessary.
The ProCESS Investigators
http://www.nejm.org/doi/full/10.1056/NEJMoa1401602
In a single-center study published more than a decade ago involving patients presenting to the emergency department with severe sepsis and septic shock, mortality was markedly lower among those who were treated according to a 6-hour protocol of early goal-directed therapy (EGDT), in which intravenous fluids, vasopressors, inotropes, and blood transfusions were adjusted to reach central hemodynamic targets, than among those receiving usual care. We conducted a trial to determine whether these findings were generalizable and whether all aspects of the protocol were necessary.
Monday, 30 June 2014
Revisiting therapeutic hypothermia for severe traumatic brain injury...again
Revisiting therapeutic hypothermia for severe traumatic brain injury...again. Critical Care 2014, 18: 160
Marion, D.W. and Regasa, L.E.
http://ccforum.com/content/18/3/160
Improved understanding of the molecular mechanisms of secondary brain injury has informed the optimum depth and duration of cooling and led to increased clinical interest in the therapeutic moderate hypothermia for severe traumatic brain injury over the past two decades. Although several large multi-center clinical trials have not found a treatment effect, multiple single-center trials have, and a recent meta-analysis by Crossley and colleagues now finds that the cumulative findings of those single-center trials dilute the multi-center trial results and show an overall reduction in mortality and poor outcomes associated with cooling. The need for consistent support of key physiologic parameters during cooling is emphasized by this finding.
Marion, D.W. and Regasa, L.E.
http://ccforum.com/content/18/3/160
Improved understanding of the molecular mechanisms of secondary brain injury has informed the optimum depth and duration of cooling and led to increased clinical interest in the therapeutic moderate hypothermia for severe traumatic brain injury over the past two decades. Although several large multi-center clinical trials have not found a treatment effect, multiple single-center trials have, and a recent meta-analysis by Crossley and colleagues now finds that the cumulative findings of those single-center trials dilute the multi-center trial results and show an overall reduction in mortality and poor outcomes associated with cooling. The need for consistent support of key physiologic parameters during cooling is emphasized by this finding.
It's not just the antibiotics, it's the treatment
It's not just the antibiotics, it's the treatment. Critical Care 2014, 18: 147
Guidry, C.A. and Sawyer, R.G.
http://ccforum.com/content/18/3/147
The recent study by Bloos and colleagues demonstrates that early initiation of antimicrobial therapy is not associated with improved survival in sepsis. We contend that these findings should not be surprising. This study is yet another part of the growing case against early and aggressive antimicrobial therapy and highlights the important roles resuscitation and source control play in the management of the septic patient. We suggest that, whenever possible, antimicrobial therapy should we withheld until objective evidence of infection has been obtained.
Guidry, C.A. and Sawyer, R.G.
http://ccforum.com/content/18/3/147
The recent study by Bloos and colleagues demonstrates that early initiation of antimicrobial therapy is not associated with improved survival in sepsis. We contend that these findings should not be surprising. This study is yet another part of the growing case against early and aggressive antimicrobial therapy and highlights the important roles resuscitation and source control play in the management of the septic patient. We suggest that, whenever possible, antimicrobial therapy should we withheld until objective evidence of infection has been obtained.
Intensive care unit admission in chronic obstructive pulmonary disease
Intensive care unit admission in chronic obstructive pulmonary disease: patient information and the physician's decision-making process. Critical Care 2014, 18: R115
Schmidt, M., et al.
http://ccforum.com/content/pdf/cc13906.pdf
ICU admission is required in more than 25% of patients with chronic obstructive pulmonary disease (COPD) at some time during the course of the disease. However, only limited information is available on how physicians communicate with COPD patients about ICU admission. COPD patients and relatives from 19 French ICUs were interviewed at ICU discharge about their knowledge of COPD. French pulmonologists self-reported their practices for informing and discussing intensive care treatment preferences with COPD patients. Finally, pulmonologists and ICU physicians reported barriers and facilitators for transfer of COPD
patients to the ICU and to propose invasive mechanical ventilation.
Schmidt, M., et al.
http://ccforum.com/content/pdf/cc13906.pdf
ICU admission is required in more than 25% of patients with chronic obstructive pulmonary disease (COPD) at some time during the course of the disease. However, only limited information is available on how physicians communicate with COPD patients about ICU admission. COPD patients and relatives from 19 French ICUs were interviewed at ICU discharge about their knowledge of COPD. French pulmonologists self-reported their practices for informing and discussing intensive care treatment preferences with COPD patients. Finally, pulmonologists and ICU physicians reported barriers and facilitators for transfer of COPD
patients to the ICU and to propose invasive mechanical ventilation.
Continuous glucose control in the ICU
Continuous glucose control in the ICU: report of a 2013 round table meeting. Critical Care 2014, 18: 226
Wernerman, J., et al.
http://ccforum.com/content/18/3/226
Achieving adequate glucose control in critically ill patients is a complex but important part of optimal patient management. Until relatively recently, intermittent measurements of blood glucose have been the only means of monitoring blood glucose levels. With growing interest in the possible beneficial effects of continuous over intermittent monitoring and the development of several continuous glucose monitoring (CGM) systems, a round table conference was convened to discuss and, where possible, reach consensus on the various aspects related to glucose monitoring and management using these systems. In this report, we discuss the advantages and limitations of the different types of devices available, the potential advantages of continuous over intermittent testing, the relative importance of trend and point accuracy, the standards necessary for reporting results in clinical trials and for recognition by official bodies, and the changes that may be needed in current glucose management protocols as a result of a move towards increased use of CGM. We close with a list of the research priorities in this field, which will be necessary if CGM is to become a routine part of daily practice in the management of critically ill patients.
Wernerman, J., et al.
http://ccforum.com/content/18/3/226
Achieving adequate glucose control in critically ill patients is a complex but important part of optimal patient management. Until relatively recently, intermittent measurements of blood glucose have been the only means of monitoring blood glucose levels. With growing interest in the possible beneficial effects of continuous over intermittent monitoring and the development of several continuous glucose monitoring (CGM) systems, a round table conference was convened to discuss and, where possible, reach consensus on the various aspects related to glucose monitoring and management using these systems. In this report, we discuss the advantages and limitations of the different types of devices available, the potential advantages of continuous over intermittent testing, the relative importance of trend and point accuracy, the standards necessary for reporting results in clinical trials and for recognition by official bodies, and the changes that may be needed in current glucose management protocols as a result of a move towards increased use of CGM. We close with a list of the research priorities in this field, which will be necessary if CGM is to become a routine part of daily practice in the management of critically ill patients.
Midazolam and propofol used alone or sequentially for long-term sedation in critically ill, mechanically ventilated patients
Midazolam and propofol used alone or sequentially for long-term sedated, critically ill patients: a prospective, randomized study. Critical Care 2014, 18: R122
Zhou, Y., et al.
http://ccforum.com/content/pdf/cc13922.pdf
Midazolam and propofol used alone for long-term sedation are associated with adverse effects. Sequential use may reduce the adverse effects, and lead to faster recovery, earlier extubation and lower costs. This study evaluates the effects, safety, and cost of midazolam, propofol, and their sequential use for long-term sedation in critically ill mechanically ventilated patients.
Zhou, Y., et al.
http://ccforum.com/content/pdf/cc13922.pdf
Midazolam and propofol used alone for long-term sedation are associated with adverse effects. Sequential use may reduce the adverse effects, and lead to faster recovery, earlier extubation and lower costs. This study evaluates the effects, safety, and cost of midazolam, propofol, and their sequential use for long-term sedation in critically ill mechanically ventilated patients.
Long-term outcome of delirium during intensive care unit stay in survivors of critical illness
Long-term outcome of delirium during intensive care unit stay in survivors of critical illness: a prospective cohort study. Critical Care 2014, 18: R125
Wolters, A.E., et al.
http://ccforum.com/content/pdf/cc13929.pdf
Delirium is associated with impaired outcome, but it is unclear whether this relationship is limited to in-hospital outcomes and whether this relationship is independent of the severity of underlying conditions. The aim of this study was to investigate the association between delirium in the intensive care unit (ICU) and long-term mortality, self-reported health-related quality of life (HRQoL), and self-reported problems with cognitive functioning in survivors of critical illness, taken severity of illness at baseline and throughout ICU stay into account.
Wolters, A.E., et al.
http://ccforum.com/content/pdf/cc13929.pdf
Delirium is associated with impaired outcome, but it is unclear whether this relationship is limited to in-hospital outcomes and whether this relationship is independent of the severity of underlying conditions. The aim of this study was to investigate the association between delirium in the intensive care unit (ICU) and long-term mortality, self-reported health-related quality of life (HRQoL), and self-reported problems with cognitive functioning in survivors of critical illness, taken severity of illness at baseline and throughout ICU stay into account.
Inflammation biomarkers and delirium in critically ill patients
Inflammation biomarkers and delirium in critically ill patients: new insights? Critical Care 2014, 18:153
Sobbi, S.C. and van den Boogaard, M.
http://ccforum.com/content/18/3/153
The pathophysiological mechanism of the serious and frequently occurring disorder delirium is poorly understood. Inflammation and sepsis are known risk factors for ICU delirium and therefore these patients are highly susceptible to delirium. Several studies have been performed to determine which cytokines are most associated with delirium but the results are inconclusive. Also, new biomarkers associated with brain dysfunction and cognitive impairment are still recognized and need to be studied to determine their relation with delirium. In this commentary we address some limitations concerning an interesting new study that warrants directions for future studies.
Sobbi, S.C. and van den Boogaard, M.
http://ccforum.com/content/18/3/153
The pathophysiological mechanism of the serious and frequently occurring disorder delirium is poorly understood. Inflammation and sepsis are known risk factors for ICU delirium and therefore these patients are highly susceptible to delirium. Several studies have been performed to determine which cytokines are most associated with delirium but the results are inconclusive. Also, new biomarkers associated with brain dysfunction and cognitive impairment are still recognized and need to be studied to determine their relation with delirium. In this commentary we address some limitations concerning an interesting new study that warrants directions for future studies.
Tight glycemic control in the ICU
Tight glycemic control in the ICU - is the earth flat? Critical Care 2014, 18: 159
Steil, G.M. and Agus, M.S.D.
http://ccforum.com/content/18/3/159
Tight glycemic control in the ICU has been shown to reduce mortality in some but not all prospective randomized control trials. Confounding the interpretation of these studies are differences in how the control was achieved and underlying incidence of hypoglycemia, which can be expected to be affected by the introduction of continuous glucose monitoring (CGM). In this issue of Critical Care, a consensus panel provides a list of the research priorities they believe are needed for CGM to become routine practice in the ICU. We reflect on these recommendations and consider the implications for using CGM today.
Steil, G.M. and Agus, M.S.D.
http://ccforum.com/content/18/3/159
Tight glycemic control in the ICU has been shown to reduce mortality in some but not all prospective randomized control trials. Confounding the interpretation of these studies are differences in how the control was achieved and underlying incidence of hypoglycemia, which can be expected to be affected by the introduction of continuous glucose monitoring (CGM). In this issue of Critical Care, a consensus panel provides a list of the research priorities they believe are needed for CGM to become routine practice in the ICU. We reflect on these recommendations and consider the implications for using CGM today.
Persistent inflammation and T cell exhaustion in severe sepsis in the elderly
Persistent inflammation and T cell exhaustion in severe sepsis in the elderly. Critical Care 2014, 18: R130
Inoue, S., et al.
http://ccforum.com/content/pdf/cc13941.pdf
Sepsis is known as a complex immunological response with hyperinflammation in the acute
phase followed by immunosuppression. Although aging is crucial in sepsis, the impact of
aging on inflammation and immunosuppression is still unclear. The purpose of this study was
to investigate the relationship between inflammation and immunosuppression in aged patients
and mice after sepsis.
Inoue, S., et al.
http://ccforum.com/content/pdf/cc13941.pdf
Sepsis is known as a complex immunological response with hyperinflammation in the acute
phase followed by immunosuppression. Although aging is crucial in sepsis, the impact of
aging on inflammation and immunosuppression is still unclear. The purpose of this study was
to investigate the relationship between inflammation and immunosuppression in aged patients
and mice after sepsis.
Monday, 28 April 2014
Continuous endotracheal tube cuff pressure control system protects against ventilator-associated pneumonia
Continuous endotracheal tube cuff pressure control system protects against ventilator-associated pneumonia. Critical Care, 2014, 18:R77
Lorente, L., et al.
http://ccforum.com/content/pdf/cc13837.pdf
The use of a system for continuous control of endotracheal tube cuff pressure reduced the
incidence of ventilator-associated pneumonia (VAP) in one randomized controlled trial
(RCT) with 112 patients but not in another RCT with 142 patients. In several guidelines on
the prevention of VAP, the use of a system for continuous or intermittent control of
endotracheal cuff pressure is not reviewed. The objective of this study was to compare the incidence of VAP in a large sample of patients (n=284) treated with either continuous or intermittent control of endotracheal tube cuff pressure.
Lorente, L., et al.
http://ccforum.com/content/pdf/cc13837.pdf
The use of a system for continuous control of endotracheal tube cuff pressure reduced the
incidence of ventilator-associated pneumonia (VAP) in one randomized controlled trial
(RCT) with 112 patients but not in another RCT with 142 patients. In several guidelines on
the prevention of VAP, the use of a system for continuous or intermittent control of
endotracheal cuff pressure is not reviewed. The objective of this study was to compare the incidence of VAP in a large sample of patients (n=284) treated with either continuous or intermittent control of endotracheal tube cuff pressure.
Parenteral glutamine supplementation in critical illness: a systematic review
Parenteral glutamine supplementation in critical illness: a systematic review. Critical Care, 2014, 18:R76.
Wischmeyer, P.E. et al.
http://ccforum.com/content/pdf/cc13836.pdf
The potential benefit of parenteral glutamine (GLN) supplementation has been one of the most commonly studied nutritional interventions in the critical care setting. The aim of this systematic review was to incorporate recent trials of traditional parenteral GLN supplementation in critical illness with previously existing data.
Wischmeyer, P.E. et al.
http://ccforum.com/content/pdf/cc13836.pdf
The potential benefit of parenteral glutamine (GLN) supplementation has been one of the most commonly studied nutritional interventions in the critical care setting. The aim of this systematic review was to incorporate recent trials of traditional parenteral GLN supplementation in critical illness with previously existing data.
Do heart rate and respiratory rate variability improve prediction of extubation outcomes in critically ill patients?
Do heart rate and respiratory rate variability improve prediction of extubation outcomes in critically ill patients? Critical Care, 2014, 18:R65
Seely, AJE, et al.
http://ccforum.com/content/pdf/cc13822.pdf
Prolonged ventilation and failed extubation are associated with increased harm and cost. The
added value of heart and respiratory rate variability (HRV and RRV) during spontaneous
breathing trials (SBTs) to predict extubation failure remains unknown.
Seely, AJE, et al.
http://ccforum.com/content/pdf/cc13822.pdf
Prolonged ventilation and failed extubation are associated with increased harm and cost. The
added value of heart and respiratory rate variability (HRV and RRV) during spontaneous
breathing trials (SBTs) to predict extubation failure remains unknown.
Ventriculo-arterial decoupling in human septic shock
Ventriculo-arterial decoupling in human septic shock. Critical Care 2014, 18:R80
Guarracino, F., et al.
http://ccforum.com/content/pdf/cc13842.pdf
Septic shock is the most severe manifestation of sepsis. It is characterized as a hypotensive
cardiovascular state associated with multiorgan dysfunction and metabolic disturbances.
Management of septic shock is targeted to preserve an adequate organ perfusion pressure
without precipitating pulmonary edema or massive volume overload. Cardiac dysfunction
often occurs in septic shock patients and can significantly affect outcome; one physiologic
approach to disclose the interaction between the heart and the circulation when both are
affected is to examine ventriculo-arterial coupling defined by the ratio of arterial elastance
(Ea) and left ventricular elastance (Ees). We aimed to analyze ventriculo-arterial coupling in
a cohort of patients admitted to ICUs presenting or not with septic shock.
Guarracino, F., et al.
http://ccforum.com/content/pdf/cc13842.pdf
Septic shock is the most severe manifestation of sepsis. It is characterized as a hypotensive
cardiovascular state associated with multiorgan dysfunction and metabolic disturbances.
Management of septic shock is targeted to preserve an adequate organ perfusion pressure
without precipitating pulmonary edema or massive volume overload. Cardiac dysfunction
often occurs in septic shock patients and can significantly affect outcome; one physiologic
approach to disclose the interaction between the heart and the circulation when both are
affected is to examine ventriculo-arterial coupling defined by the ratio of arterial elastance
(Ea) and left ventricular elastance (Ees). We aimed to analyze ventriculo-arterial coupling in
a cohort of patients admitted to ICUs presenting or not with septic shock.
A systematic review of therapeutic hypothermia for adult patients following traumatic brain injury
A systematic review of therapeutic hypothermia for adult patients following traumatic brain injury. Critical Care 2014, 18:R75
Crossley, S., et al.
http://ccforum.com/content/pdf/cc13835.pdf
Research into therapeutic hypothermia following traumatic brain injury has been
characterised by small trials of poor methodological quality, producing variable results. The
Cochrane review, published in 2009, now requires updating. The aim of this systematic
review is to assess the effectiveness of the application of therapeutic hypothermia to reduce
death and disability when administered to adult patients who have been admitted to hospital
following traumatic brain injury.
Crossley, S., et al.
http://ccforum.com/content/pdf/cc13835.pdf
Research into therapeutic hypothermia following traumatic brain injury has been
characterised by small trials of poor methodological quality, producing variable results. The
Cochrane review, published in 2009, now requires updating. The aim of this systematic
review is to assess the effectiveness of the application of therapeutic hypothermia to reduce
death and disability when administered to adult patients who have been admitted to hospital
following traumatic brain injury.
Effect of statin therapy on mortality from infection and sepsis
Effect of statin therapy on mortality from infection and sepsis: a meta-analysis of randomized and observational studies. Critical Care 2014, 18:R71
You-Dong Wan, et al.
http://ccforum.com/content/pdf/cc13828.pdf
Observational data have suggested that statin therapy may reduce mortality in patients with
infection and sepsis; however, results from randomized studies are contradictory and do not
support the use of statins in this context. Here, we performed a meta-analysis to investigate
the effects of statin therapy on mortality from infection and sepsis.
You-Dong Wan, et al.
http://ccforum.com/content/pdf/cc13828.pdf
Observational data have suggested that statin therapy may reduce mortality in patients with
infection and sepsis; however, results from randomized studies are contradictory and do not
support the use of statins in this context. Here, we performed a meta-analysis to investigate
the effects of statin therapy on mortality from infection and sepsis.
Intensive care unit depth of sleep
Intensive care unit depth of sleep: proof of concept of a simple electroencephalography index in the non-sedated. Critical Care 2014, 18:R66
Reinke, L., et al.
http://ccforum.com/content/pdf/cc13823.pdf
Intensive care unit (ICU) patients are known to experience severely disturbed sleep, with
possible detrimental effects on short- and long- term outcomes. Investigation into the exact
causes and effects of disturbed sleep has been hampered by cumbersome and time consuming
methods of measuring and staging sleep. We introduce a novel method for ICU depth of sleep
analysis, the ICU depth of sleep index (IDOS index), using single channel
electroencephalography (EEG) and apply it to outpatient recordings. A proof of concept is
Reinke, L., et al.
http://ccforum.com/content/pdf/cc13823.pdf
Intensive care unit (ICU) patients are known to experience severely disturbed sleep, with
possible detrimental effects on short- and long- term outcomes. Investigation into the exact
causes and effects of disturbed sleep has been hampered by cumbersome and time consuming
methods of measuring and staging sleep. We introduce a novel method for ICU depth of sleep
analysis, the ICU depth of sleep index (IDOS index), using single channel
electroencephalography (EEG) and apply it to outpatient recordings. A proof of concept is
shown in non-sedated ICU patients.
Impact of critical care nursing on 30-day mortality of mechanically ventilated older adults
Impact of critical care nursing on 30-day mortality of mechanically ventilated older adults. Critical Care Medicine, May 2014, Vol. 42(5), p.1089-95.
Kelly, D.M., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/05000/Impact_of_Critical_Care_Nursing_on_30_Day.9.aspx
The mortality rate for mechanically ventilated older adults in ICUs is high. A robust research literature shows a significant association between nurse staffing, nurses’ education, and the quality of nurse work environments and mortality following common surgical procedures. A distinguishing feature of ICUs is greater investment in nursing care. The objective of this study is to determine the extent to which variation in ICU nursing characteristics—staffing, work environment, education, and experience—is associated with mortality, thus potentially illuminating strategies for improving patient outcomes.
Kelly, D.M., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/05000/Impact_of_Critical_Care_Nursing_on_30_Day.9.aspx
The mortality rate for mechanically ventilated older adults in ICUs is high. A robust research literature shows a significant association between nurse staffing, nurses’ education, and the quality of nurse work environments and mortality following common surgical procedures. A distinguishing feature of ICUs is greater investment in nursing care. The objective of this study is to determine the extent to which variation in ICU nursing characteristics—staffing, work environment, education, and experience—is associated with mortality, thus potentially illuminating strategies for improving patient outcomes.
The highs and lows of blood pressure
The highs and lows of blood pressure: toward meaningful clinical targets in patients with shock. Critical Care Medicine, May 2014, Vol. 42(5), p.1241-51.
Magder, S.A.
http://journals.lww.com/ccmjournal/Abstract/2014/05000/The_Highs_and_Lows_of_Blood_Pressure__Toward.26.aspx
Measurement of blood pressure is fundamental for the management of patients in shock, yet the physiological basis and meaning of blood pressure measurements are complex and often not well understood. This article is in two parts: part 1 deals with the mechanical and physiological aspects of blood pressure and its measurement and part 2 deals with the role of changes in regional resistances in the determination of tissue perfusion and bedside approaches to management of shock.
Magder, S.A.
http://journals.lww.com/ccmjournal/Abstract/2014/05000/The_Highs_and_Lows_of_Blood_Pressure__Toward.26.aspx
Measurement of blood pressure is fundamental for the management of patients in shock, yet the physiological basis and meaning of blood pressure measurements are complex and often not well understood. This article is in two parts: part 1 deals with the mechanical and physiological aspects of blood pressure and its measurement and part 2 deals with the role of changes in regional resistances in the determination of tissue perfusion and bedside approaches to management of shock.
Rehabilitation interventions for postintensive care syndrome
Rehabilitation interventions for postintensive care syndrome: A systematic review. Critical Care Medicine, May 2014, Vol. 42(5), p.1263-71.
Mehlhorn, J., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/05000/Rehabilitation_Interventions_for_Postintensive.28.aspx
An increasing number of ICU patients survive and develop mental, cognitive, or physical impairments. Various interventions support recovery from this postintensive care syndrome. Physicians in charge of post-ICU patients need to know which interventions are effective.
Mehlhorn, J., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/05000/Rehabilitation_Interventions_for_Postintensive.28.aspx
An increasing number of ICU patients survive and develop mental, cognitive, or physical impairments. Various interventions support recovery from this postintensive care syndrome. Physicians in charge of post-ICU patients need to know which interventions are effective.
Family presence during brain death evaluation
Family presence during brain death evaluation: A randomized controlled trial. Critical Care Medicine, April 2014, Vol. 42(4), p.934-42.
Tawil, I., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/04000/Family_Presence_During_Brain_Death_Evaluation__A.21.aspx
To evaluate if a family presence educational intervention during brain death evaluation improves understanding of brain death without affecting psychological distress.
Tawil, I., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/04000/Family_Presence_During_Brain_Death_Evaluation__A.21.aspx
To evaluate if a family presence educational intervention during brain death evaluation improves understanding of brain death without affecting psychological distress.
Psychological wellbeing, health related quality of life and memories of intensive care
Psychological wellbeing, health related quality of life and memories of intensive care and a specialised weaning centre reported by survivors of prolonged mechanical ventilation. Intensive and Critical Care Nursing, June 2014, Vol. 30(3), p.145-51.
Rose, L., et al.
http://www.intensivecriticalcarenursing.com/article/S0964-3397(13)00116-X/abstract?rss=yes
To compare memories and recall of intensive care unit and specialised weaning centre admission, characterise health-related quality of life and psychological morbidity, and examine the relationship between delusional memories and psychological outcomes.
Rose, L., et al.
http://www.intensivecriticalcarenursing.com/article/S0964-3397(13)00116-X/abstract?rss=yes
To compare memories and recall of intensive care unit and specialised weaning centre admission, characterise health-related quality of life and psychological morbidity, and examine the relationship between delusional memories and psychological outcomes.
Monday, 10 March 2014
Sedation and delirium in the intensive care unit
Sedation and delirium in the intensive care unit. Anaesthesia and intensive care medicine, 2013, 14:1
Porter, R. and McClure, J.
http://www.alfredicu.org.au/assets/Documents/Reserach-Docs/Full-Publications/2013-Publications/2013-PorterSedationAIC.PDF
Porter, R. and McClure, J.
http://www.alfredicu.org.au/assets/Documents/Reserach-Docs/Full-Publications/2013-Publications/2013-PorterSedationAIC.PDF
Two decades of mortality trends among patients with severe sepsis
Two decades of mortality trends among patients with severe sepsis. Critical care medicine, March 2014, Vol. 42(3), p.625-31.
Stevenson, E.K., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/03000/Two_Decades_of_Mortality_Trends_Among_Patients.16.aspx
We searched MEDLINE for multicenter randomized trials that enrolled patients with severe sepsis from 1991 to 2009. We calculated standardized mortality ratios for each trial from observed 28-day mortality of usual care participants and predicted mortality from severity-of-illness scores. To compare mortality trends from clinical trials to administrative data, we identified adult severe sepsis hospitalizations in the Nationwide Inpatient Sample, 1993–2009, using two previously validated algorithms.
Stevenson, E.K., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/03000/Two_Decades_of_Mortality_Trends_Among_Patients.16.aspx
We searched MEDLINE for multicenter randomized trials that enrolled patients with severe sepsis from 1991 to 2009. We calculated standardized mortality ratios for each trial from observed 28-day mortality of usual care participants and predicted mortality from severity-of-illness scores. To compare mortality trends from clinical trials to administrative data, we identified adult severe sepsis hospitalizations in the Nationwide Inpatient Sample, 1993–2009, using two previously validated algorithms.
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