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.
Thursday, 13 November 2014
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
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