Rate of Perihematomal Edema Expansion Predicts Outcome After Intracerebral Hemorrhage

Rate of Perihematomal Edema Expansion Predicts Outcome After Intracerebral Hemorrhage

Critical Care Medicine: April 2016 - Volume 44 - Issue 4 - p 790–797
Urday, S et al

Objectives: Intracerebral hemorrhage is a devastating disorder with no current treatment. Whether perihematomal edema is an independent predictor of neurologic outcome is controversial. We sought to determine whether perihematomal edema expansion rate predicts outcome after intracerebral hemorrhage. Design: Retrospective cohort study. Setting: Tertiary medical center. Patients: One hundred thirty-nine consecutive supratentorial spontaneous intracerebral hemorrhage patients 18 years or older admitted between 2000 and 2013. Interventions: None. Measurements and Main Results: Intracerebral hemorrhage, intraventricular hemorrhage, and perihematomal edema volumes were measured from CT scans obtained at presentation, 24-hours, and 72-hours postintracerebral hemorrhage. Perihematomal edema expansion rate was the difference between initial and follow-up perihematomal edema volumes divided by the time interval. Logistic regression was performed to evaluate the relationship between 1) perihematomal edema expansion rate at 24 hours and 90-day mortality and 2) perihematomal edema expansion rate at 24 hours and 90-day modified Rankin Scale score. Perihematomal edema expansion rate between admission and 24-hours postintracerebral hemorrhage was a significant predictor of 90-day mortality (odds ratio, 2.97; 95% CI, 1.48–5.99; p = 0.002). This association persisted after adjusting for all components of the intracerebral hemorrhage score (odds ratio, 2.21; 95% CI, 1.05–4.64; p = 0.04). Similarly, higher 24-hour perihematomal edema expansion rate was associated with poorer modified Rankin Scale score in an ordinal shift analysis (odds ratio, 2.40; 95% CI, 1.37–4.21; p = 0.002). The association persisted after adjustment for all intracerebral hemorrhage score components (odds ratio, 2.07; 95% CI, 1.12–3.83; p = 0.02). Conclusions: Faster perihematomal edema expansion rate 24-hours postintracerebral hemorrhage is associated with worse outcome. Perihematomal edema may represent an attractive translational target for secondary injury after intracerebral hemorrhage.

Subglottic Secretion Drainage and Objective Outcomes: A Systematic Review and Meta-Analysis

Critical Care Medicine: April 2016 - Volume 44 - Issue 4 - p 830–840
Caroff, D

Objective: Current guidelines recommend endotracheal tubes with subglottic secretion drainage to prevent ventilator-associated pneumonia. Subglottic secretion drainage is associated with fewer ventilator-associated pneumonia diagnoses, but it is unclear to what extent this reflects fewer invasive pneumonias versus fewer false-positive diagnoses due to less secretions and/or less microbial colonization of the oropharynx. We, therefore, undertook a systematic review and meta-analysis of the impact of subglottic secretion drainage on duration of mechanical ventilation, ICU and hospital length of stay, ventilator-associated events, mortality, antibiotic utilization, stridor, and reintubations to better understand the net benefits and limitations of this intervention. Data Sources: We searched Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica Database, and PubMed from inception through February 22, 2015, without language restrictions. Study Selection: Randomized controlled trials comparing subglottic secretion drainage versus no subglottic secretion drainage in adult patients on mechanical ventilation. Data Extraction: Eligible trials were abstracted and assessed for risk of bias by two reviewers. Data Synthesis: We identified 17 eligible trials with a total of 3,369 patients. Subglottic secretion drainage was associated with lower ventilator-associated pneumonia rates (risk ratio, 0.58; 95% CI, 0.51–0.67; I2 = 0%), but there were no significant differences between groups in duration of mechanical ventilation (weighted mean difference, −0.16 d; 95% CI, −0.64 to 0.33; I2 = 0%), ICU length of stay (weighted mean difference, +0.17 d; 95% CI, −0.62 to 0.95; I2 = 0%), hospital length of stay (weighted mean difference, −0.57 d; 95% CI, −2.44 to 1.30; I2 = 0%), ventilator-associated events (risk ratio, 0.97; 95% CI, 0.65–1.43), or mortality (risk ratio, 0.93; 95% CI, 0.84–1.03; I2 = 0%). Two studies observed significantly less antibiotic use with subglottic secretion drainage whereas a third did not. There were no significant differences between groups in stridor or reintubations. Conclusions: Subglottic secretion drainage is associated with lower ventilator-associated pneumonia rates but does not clearly decrease duration of mechanical ventilation, length of stay, ventilator-associated events, mortality, or antibiotic usage. Further data are required to demonstrate the benefits of subglottic secretion drainage.

Impact of Initial Central Venous Pressure on Outcomes of Conservative Versus Liberal Fluid Management in Acute Respiratory Distress Syndrome

Critical Care Medicine: April 2016 - Volume 44 - Issue 4 - p 782–789

Semler, M et al

Objectives: In acute respiratory distress syndrome, conservative fluid management increases ventilator-free days without affecting mortality. Response to fluid management may differ based on patients’ initial central venous pressure. We hypothesized that initial central venous pressure would modify the effect of fluid management on outcomes. Design: Retrospective analysis of the Fluid and Catheter Treatment Trial, a multicenter randomized trial comparing conservative with liberal fluid management in acute respiratory distress syndrome. We examined the relationship between initial central venous pressure, fluid strategy, and 60-day mortality in univariate and multivariable analysis. Setting: Twenty acute care hospitals. Patients: Nine hundred thirty-four ventilated acute respiratory distress syndrome patients with a central venous pressure available at enrollment, 609 without baseline shock (for whom fluid balance was managed by the study protocol). Interventions: None. Measurements and Main Results: Among patients without baseline shock, those with initial central venous pressure greater than 8 mm Hg experienced similar mortality with conservative and liberal fluid management (18% vs 18%; p = 0.928), whereas those with central venous pressure of 8 mm Hg or less experienced lower mortality with a conservative strategy (17% vs 36%; p = 0.005). Multivariable analysis demonstrated an interaction between initial central venous pressure and the effect of fluid strategy on mortality (p = 0.031). At higher initial central venous pressures, the difference in treatment between arms was predominantly furosemide administration, which was not associated with mortality (p = 0.122). At lower initial central venous pressures, the difference between arms was predominantly fluid administration, with additional fluid associated with increased mortality (p = 0.013). Conclusions: Conservative fluid management decreases mortality for acute respiratory distress syndrome patients with a low initial central venous pressure. In this population, the administration of IV fluids seems to increase mortality.

Relationship between ICU Length of Stay and Long-Term Mortality for Elderly ICU Survivors

Relationship between ICU Length of Stay and Long-Term Mortality for Elderly ICU Survivors

Critical Care Medicine: April 2016 - Volume 44 - Issue 4 - p 655–662

Moitra, V et al

Objectives: To evaluate the association between length of ICU stay and 1-year mortality for elderly patients who survived to hospital discharge in the United States. Design: Retrospective cohort study of a random sample of Medicare beneficiaries who survived to hospital discharge, with 1- and 3-year follow-up, stratified by the number of days of intensive care and with additional stratification based on receipt of mechanical ventilation. Interventions: None. Patients: The cohort included 34,696 Medicare beneficiaries older than 65 years who received intensive care and survived to hospital discharge in 2005. Measurements and Main Results: Among 34,696 patients who survived to hospital discharge, the mean ICU length of stay was 3.4 days (± 4.5 d). Patients (88.9%) were in the ICU for 1–6 days, representing 58.6% of ICU bed-days. Patients (1.3%) were in the ICU for 21 or more days, but these patients used 11.6% of bed-days. The percentage of mechanically ventilated patients increased with increasing length of stay (6.3% for 1–6 d in the ICU and 71.3% for ≥ 21 d). One-year mortality was 26.6%, ranging from 19.4% for patients in the ICU for 1 day, up to 57.8% for patients in the ICU for 21 or more days. For each day beyond 7 days in the ICU, there was an increased odds of death by 1 year of 1.04 (95% CI, 1.03–1.05) irrespective of the need for mechanical ventilation. Conclusions: Increasing ICU length of stay is associated with higher 1-year mortality for both mechanically ventilated and non–mechanically ventilated patients. No specific cut off was associated with a clear plateau or sharp increase in long-term risk.

Mechanical circulatory support in the new era: an overview

Critical Care 2016 20:66

Shekar K, Gregory S, Fraser J

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency medicine 2016. Other selected articles can be found online in the annual update at www.biomedcentral.com and by following the link here

Noise in the ICU patient room – Staff knowledge and clinical improvements

Noise in the ICU patient room – Staff knowledge and clinical improvements

Intensive and Critical Care Nursing Article in Press
Johansson L, Knutson S, Bergbom I, Lindahl B.

The acoustic environment in the intensive care unit patient room, with high sound levels and unpredictable sounds, is known to be poor and stressful. Therefore, the present study had two aims: to investigate staff knowledge concerning noise in the intensive care unit and: to identify staff suggestions for improving the sound environment in the intensive care unit patient room.

Remote Ischemic Preconditioning and Protection of the Kidney—A NovelTherapeutic Option

Remote Ischemic Preconditioning and Protection of the Kidney—A Novel Therapeutic Option

Critical Care Medicine: March 2016 - Volume 44 - Issue 3 - p 607–616

Zarbock A,  Kellum J


Objective: Acute kidney injury is a common complication in critically ill patients and is associated with increased morbidity and mortality. Sepsis, major surgery, and nephrotoxic drugs are the most common causes of acute kidney injury. There is currently no effective strategy available to prevent or treat acute kidney injury. Therefore, novel treatment regimens are required to decrease acute kidney injury prevalence and to improve clinical outcomes. Remote ischemic preconditioning, triggered by brief episodes of ischemia and reperfusion applied in distant tissues or organs before the injury of the target organ, attempts to invoke adaptive responses that protect against acute kidney injury. We sought to evaluate the clinical evidence for remote ischemic preconditioning as a potential strategy to protect the kidney and to review the underlying mechanisms in light of recent studies. Data Sources: We searched PubMed for studies reporting the effect of remote ischemic preconditioning on kidney function in surgical patients (search terms: “remote ischemic preconditioning,” “kidney function,” and “surgery”). We also reviewed bibliographies of relevant articles to identify additional citations. Study Selection: Published studies, consisting of randomized controlled trials, are reviewed. Data Extraction: The authors used consensus to summarize the evidence behind the use of remote ischemic preconditioning. Data Synthesis: In addition, the authors suggest patient populations and clinical scenarios in which remote ischemic preconditioning might be best applied. Conclusions: Several experimental and clinical studies have shown tissue-protective effects of remote ischemic preconditioning in various target organs, including the kidneys. Remote ischemic preconditioning may offer a novel, noninvasive, and inexpensive treatment strategy for decreasing acute kidney injury prevalence in high-risk patients. Although many new studies have further advanced our knowledge in this area, the appropriate intensity of remote ischemic preconditioning, its mechanisms of action, and the role of biomarkers for patient selection and monitoring are still unknown.

Association Between Index Hospitalization and Hospital Readmission in Sepsis Survivors

Association between Index Hospitalization and Hospital Readmission in Sepsis Survivors

Critical Care Medicine March 2016 - Volume 44 - Issue 3 - p 478–487

Sun A et al
Objectives: Hospital readmission is common after sepsis, yet the relationship between the index admission and readmission remains poorly understood. We sought to examine the relationship between infection during the index acute care hospitalization and readmission and to identify potentially modifiable factors during the index sepsis hospitalization associated with readmission. Design: In a retrospective cohort study, we evaluated 444 sepsis survivors at risk of an unplanned hospital readmission in 2012. The primary outcome was 30-day unplanned hospital readmission. Setting: Three hospitals within an academic healthcare system. Subjects: Four hundred forty-four sepsis survivors. Measurements and Main Results: Of 444 sepsis survivors, 23.4% (95% CI, 19.6–27.6%) experienced an unplanned 30-day readmission compared with 10.1% (95% CI, 9.6–10.7%) among 11,364 nonsepsis survivors over the same time period. The most common cause for readmission after sepsis was infection (69.2%, 72 of 104). Among infection-related readmissions, 51.4% were categorized as recurrent/unresolved. Patients with sepsis present on their index admission who also developed a hospital-acquired infection (“second hit”) were nearly twice as likely to have an unplanned 30-day readmission compared with those who presented with sepsis at admission and did not develop a hospital-acquired infection or those who presented without infection and then developed hospital-acquired sepsis (38.6% vs 22.2% vs 20.0%, p = 0.04). Infection-related hospital readmissions, specifically, were more likely in patients with a “second hit” and patients receiving a longer duration of antibiotics. The use of total parenteral nutrition (p = 0.03), longer duration of antibiotics (p = 0.047), prior hospitalizations, and lower discharge hemoglobin (p = 0.04) were independently associated with hospital readmission. Conclusions: We confirmed that the majority of unplanned hospital readmissions after sepsis are due to an infection. We found that patients with sepsis at admission who developed a hospital-acquired infection, and those who received a longer duration of antibiotics, appear to be high-risk groups for unplanned, all-cause 30-day readmissions and infection-related 30-day readmissions.