Impact of ICU-acquired weakness on post-ICU physical functioning: a follow-up study. Critical Care 2015, 19: 196
Wieske, L., et al.
http://ccforum.com/content/pdf/s13054-015-0937-2.pdf
Intensive Care Unit – acquired weakness (ICU-AW) is thought to mediate physical impairments in survivors of critical illness but few studies have investigated this thoroughly. The purpose was to investigate differences in post-ICU mortality and physical functioning between patients with and without ICU-AW at 6 months after ICU discharge. Method ICU patients, mechanically ventilated ≥2 days, were included in a single center prospective observational cohort study. ICU-AW was diagnosed when the average Medical Research Council (MRC) score was <4 in awake and attentive patients. Post-ICU mortality was recorded until 6 months after ICU discharge; in surviving patients physical functioning was assessed using the Short-Form Health Survey (SF-36) physical functioning (PF) domain. The independent effect of ICU-AW on post-ICU mortality was analyzed using a multivariable Cox proportional hazards model. The independent effect of ICU-AW on the PF domain score was analyzed using a multivariable linear regression model. Results: 156 patients were included, of whom 80 with ICU-AW. Twenty-three patients died in the ICU (20 with ICU-AW); during the 6 months follow-up after ICU discharge another 25 patients died (17 with ICU-AW). PF scores were available for 96 survivors (39 patients with ICU-AW). ICU-AW was independently associated with an increase in post-ICU mortality (HR 3.6 (95% CI: 1.3 to 9.8); p:0.01) and with a decrease in physical functioning (β: -16.7 points (95% CI: -30.2 to -3.1); p:0.02). Conclusion: ICU-AW is independently associated with higher post-ICU mortality and with clinically relevant lower physical functioning in survivors at 6 months after ICU discharge.
Tuesday, 28 April 2015
Early deep sedation is associated with decreased in-hospital and two-years follow-up survival
Early deep sedation is associated with decreased in-hospital and two-years follow-up survival. Critical Care 2015, 19: 197
Balzer, F., et al.
http://ccforum.com/content/pdf/s13054-015-0929-2.pdf
There is increasing evidence that deep sedation is detrimental to critically ill patients. The aim of this study was to examine effects of deep sedation during the early period after ICU admission on short- and long-term survival. Methods: In this observational, matched-pair analysis, patients with mechanical ventilation that were admitted to ICUs of a tertiary university hospital in six consecutive years were grouped as either lightly or deeply sedated within the first 48 hours after ICU admission. The Richmond-Agitation and Sedation Score (RASS) was used to assess sedation depth (light sedation: −2 to 0; deep: −3 or below). Multivariate Cox regression was conducted to investigate the impact of early deep sedation within the first 48 hours of admission on in-hospital and two-years follow-up survival. Results: In total, 1,884 patients met inclusion criteria out of which 27.2% (n = 513) were deeply sedated. Deeply sedated patients had longer ventilation times, increased length of stay and higher rates of mortality. Early deep sedation was associated with a hazard ratio of 1.661 (95% CI: 1.074-2.567; p = 0.022) for in-hospital survival and 1.866 (95% CI: 1.351-2.576; p < 0.001) for two-years follow-up survival. Conclusions: Early deep sedation during the first 48 hours of intensive care treatment was associated with decreased in-hospital and two-years follow-up survival. Since early deep sedation is a modifiable risk factor, this data shows an urgent need for prospective clinical trials focusing on light sedation in the early phase of ICU treatment.
Balzer, F., et al.
http://ccforum.com/content/pdf/s13054-015-0929-2.pdf
There is increasing evidence that deep sedation is detrimental to critically ill patients. The aim of this study was to examine effects of deep sedation during the early period after ICU admission on short- and long-term survival. Methods: In this observational, matched-pair analysis, patients with mechanical ventilation that were admitted to ICUs of a tertiary university hospital in six consecutive years were grouped as either lightly or deeply sedated within the first 48 hours after ICU admission. The Richmond-Agitation and Sedation Score (RASS) was used to assess sedation depth (light sedation: −2 to 0; deep: −3 or below). Multivariate Cox regression was conducted to investigate the impact of early deep sedation within the first 48 hours of admission on in-hospital and two-years follow-up survival. Results: In total, 1,884 patients met inclusion criteria out of which 27.2% (n = 513) were deeply sedated. Deeply sedated patients had longer ventilation times, increased length of stay and higher rates of mortality. Early deep sedation was associated with a hazard ratio of 1.661 (95% CI: 1.074-2.567; p = 0.022) for in-hospital survival and 1.866 (95% CI: 1.351-2.576; p < 0.001) for two-years follow-up survival. Conclusions: Early deep sedation during the first 48 hours of intensive care treatment was associated with decreased in-hospital and two-years follow-up survival. Since early deep sedation is a modifiable risk factor, this data shows an urgent need for prospective clinical trials focusing on light sedation in the early phase of ICU treatment.
Clinical impact of stress dose steroids in patients with septic shock
Clinical impact of stress dose steroids in patients with septic shock: Insights from the PROWESS-Shock trial. Critical Care, 2015, 19: 193
Povoa, P., et al.
http://ccforum.com/content/pdf/s13054-015-0921-x.pdf
The aim of our study was to evaluate the clinical impact of the administration of intravenous steroids, alone or in conjunction with drotrecogin-alfa (activated) (DrotAA), on the outcomes in septic shock patients. Methods: We performed a sub-study of the PROWESS-Shock trial (septic shock patients who received fluids and vasopressors above a predefined threshold for at least 4 hours were randomized to receive either DrotAA or placebo for 96 hours). A propensity score for the administration of intravenous steroids for septic shock at baseline was constructed using multivariable logistic regression. Cox proportional hazards model using inverse probability of treatment weighting of the propensity score was used to estimate the effect of intravenous steroids, alone or in conjunction with DrotAA, on 28-day and 90-day all-cause mortality. Results: A total of 1695 patients were enrolled of which 49.5% received intravenous steroids for treatment of septic shock at baseline (DrotAA + steroids N = 436; DrotAA + no steroids N = 414; placebo + steroids N = 403; placebo + no steroids N = 442). The propensity weighted risk of 28-day as well as 90-day mortality in those treated vs. those not treated with steroids did not differ among those randomized to DrotAA vs. placebo (interaction p-value = 0.38 and p = 0.27, respectively) nor was a difference detected within each randomized treatment. Similarly, the course of vasopressor use and cardiovascular SOFA did not appear to be influenced by steroid therapy. In patients with lung infection (N = 744), abdominal infection (N = 510), Gram-positive sepsis (N = 420) and Gram-negative sepsis (N = 461), the propensity weighted risk of 28-day as well as 90-day mortality in those treated vs. those not treated with steroids did not differ among those randomized to DrotAA vs. placebo (interaction 28-day, p = 0.65, p = 0.58, p = 0.49, p = 0.12; 90-day, p = 0.75, p = 0.56, p = 0.18, p = 0.12, respectively) nor was a difference detected within each randomized treatment. Conclusions: In the present study of septic shock patients, after adjustment for treatment selection bias, we were unable to find noticeable positive impact from intravenous steroids for treatment of septic shock at baseline either in patients randomized for DrotAA or placebo.
Povoa, P., et al.
http://ccforum.com/content/pdf/s13054-015-0921-x.pdf
The aim of our study was to evaluate the clinical impact of the administration of intravenous steroids, alone or in conjunction with drotrecogin-alfa (activated) (DrotAA), on the outcomes in septic shock patients. Methods: We performed a sub-study of the PROWESS-Shock trial (septic shock patients who received fluids and vasopressors above a predefined threshold for at least 4 hours were randomized to receive either DrotAA or placebo for 96 hours). A propensity score for the administration of intravenous steroids for septic shock at baseline was constructed using multivariable logistic regression. Cox proportional hazards model using inverse probability of treatment weighting of the propensity score was used to estimate the effect of intravenous steroids, alone or in conjunction with DrotAA, on 28-day and 90-day all-cause mortality. Results: A total of 1695 patients were enrolled of which 49.5% received intravenous steroids for treatment of septic shock at baseline (DrotAA + steroids N = 436; DrotAA + no steroids N = 414; placebo + steroids N = 403; placebo + no steroids N = 442). The propensity weighted risk of 28-day as well as 90-day mortality in those treated vs. those not treated with steroids did not differ among those randomized to DrotAA vs. placebo (interaction p-value = 0.38 and p = 0.27, respectively) nor was a difference detected within each randomized treatment. Similarly, the course of vasopressor use and cardiovascular SOFA did not appear to be influenced by steroid therapy. In patients with lung infection (N = 744), abdominal infection (N = 510), Gram-positive sepsis (N = 420) and Gram-negative sepsis (N = 461), the propensity weighted risk of 28-day as well as 90-day mortality in those treated vs. those not treated with steroids did not differ among those randomized to DrotAA vs. placebo (interaction 28-day, p = 0.65, p = 0.58, p = 0.49, p = 0.12; 90-day, p = 0.75, p = 0.56, p = 0.18, p = 0.12, respectively) nor was a difference detected within each randomized treatment. Conclusions: In the present study of septic shock patients, after adjustment for treatment selection bias, we were unable to find noticeable positive impact from intravenous steroids for treatment of septic shock at baseline either in patients randomized for DrotAA or placebo.
Thursday, 26 March 2015
Systematic inflammatory response criteria in defining severe sepsis
Systematic inflammatory response criteria in defining severe sepsis. NEJM, March 2015.
Kaukonen, K.M., et al.
http://www.nejm.org/doi/full/10.1056/NEJMoa1415236#t=article
The consensus definition of severe sepsis requires suspected or proven infection, organ failure, and signs that meet two or more criteria for the systemic inflammatory response syndrome (SIRS). We aimed to test the sensitivity, face validity, and construct validity of this approach.
Kaukonen, K.M., et al.
http://www.nejm.org/doi/full/10.1056/NEJMoa1415236#t=article
The consensus definition of severe sepsis requires suspected or proven infection, organ failure, and signs that meet two or more criteria for the systemic inflammatory response syndrome (SIRS). We aimed to test the sensitivity, face validity, and construct validity of this approach.
Age of transfused blood in critically ill adults
Age of transfused blood in critically ill adults. NEJM, March 2015
Lacroix, J., et al.
http://www.nejm.org/doi/full/10.1056/NEJMoa1500704#t=article
Blood transfusions are administered frequently and may have unintended consequences in critically ill patients. Current regulations permit the storage of red cells for up to 42 days, but prolonged storage has been associated with changes that may render red cells ineffective as oxygen carriers and that lead to the accumulation of substances that have untoward biologic effects.
Lacroix, J., et al.
http://www.nejm.org/doi/full/10.1056/NEJMoa1500704#t=article
Blood transfusions are administered frequently and may have unintended consequences in critically ill patients. Current regulations permit the storage of red cells for up to 42 days, but prolonged storage has been associated with changes that may render red cells ineffective as oxygen carriers and that lead to the accumulation of substances that have untoward biologic effects.
Trial of early, goal-directed resuscitation for septic shock
Trial of early, goal-directed resuscitation for septic shock. NEJM, March 2015
Mouncey, P.R., et al.
http://www.nejm.org/doi/full/10.1056/NEJMoa1500896#t=article
The incidence of severe sepsis and septic shock in adults is estimated to range from 56 to 91 per 100,000 population per year. Affected patients have high rates of death, complications, and resource utilization.
Mouncey, P.R., et al.
http://www.nejm.org/doi/full/10.1056/NEJMoa1500896#t=article
The incidence of severe sepsis and septic shock in adults is estimated to range from 56 to 91 per 100,000 population per year. Affected patients have high rates of death, complications, and resource utilization.
Strain echocardiography in septic shock
Strain echocardiography in septic shock - a comparison with systolic and diastolic function parameters cardiac biomarkers and outcome. Critical Care, 2015, 19: 122
De Geer, L., et al.
http://ccforum.com/content/19/1/122
Myocardial dysfunction is a well-known complication in septic shock but its characteristics and frequency remains elusive. Here, we evaluate global longitudinal peak strain (GLPS) of the left ventricle as a diagnostic and prognostic tool in septic shock.
De Geer, L., et al.
http://ccforum.com/content/19/1/122
Myocardial dysfunction is a well-known complication in septic shock but its characteristics and frequency remains elusive. Here, we evaluate global longitudinal peak strain (GLPS) of the left ventricle as a diagnostic and prognostic tool in septic shock.
Characteristics and outcomes of patients admitted to ICU following activation of the Medical Emergency Team
Characteristics and outcomes of patients admitted to ICU following activation of the Medical Emergency Team: Impact of introducing a two-tier response system. Critical Care Medicine, April 2015, Vol. 43(4), p.765-73.
Aneman, A., et al.
http://journals.lww.com/ccmjournal/Abstract/2015/04000/Characteristics_and_Outcomes_of_Patients_Admitted.6.aspx
To determine the impact of introducing a two-tier system for responding to deteriorating ward patients on ICU admissions after medical emergency team review.
Aneman, A., et al.
http://journals.lww.com/ccmjournal/Abstract/2015/04000/Characteristics_and_Outcomes_of_Patients_Admitted.6.aspx
To determine the impact of introducing a two-tier system for responding to deteriorating ward patients on ICU admissions after medical emergency team review.
A qualitative study exploring moral distress in the ICU team
A qualitative study exploring moral distress in the ICU team: The importance of Unit functionality and intrateam dynamics. Critical Care Medicine, April 2015, Vol. 43(4), p.823-31.
Bruce, C.R., et al.
http://journals.lww.com/ccmjournal/Abstract/2015/04000/A_Qualitative_Study_Exploring_Moral_Distress_in.13.aspx
Our study objectives were to determine the key sources of moral distress in diverse critical care professionals and how they manage it in the context of team-based models.
Bruce, C.R., et al.
http://journals.lww.com/ccmjournal/Abstract/2015/04000/A_Qualitative_Study_Exploring_Moral_Distress_in.13.aspx
Our study objectives were to determine the key sources of moral distress in diverse critical care professionals and how they manage it in the context of team-based models.
Frequency, cost and risk factors of readmissions among severe sepsis survivors
Frequency, cost and risk factors of readmissions among severe sepsis survivors. Critical Care Medicine, April 2015, Vol. 43(4), p.738-46
Goodwin, A.J., et al.
http://journals.lww.com/ccmjournal/Fulltext/2015/04000/Frequency,_Cost,_and_Risk_Factors_of_Readmissions.3.aspx
To determine the frequency, mortality, cost, and risk factors associated with readmission after index hospitalization with severe sepsis.
Goodwin, A.J., et al.
http://journals.lww.com/ccmjournal/Fulltext/2015/04000/Frequency,_Cost,_and_Risk_Factors_of_Readmissions.3.aspx
To determine the frequency, mortality, cost, and risk factors associated with readmission after index hospitalization with severe sepsis.
Extracorporeal gas exchange for acute respiratory failure in adult patients
Extracorporeal gas exchange for acute respiratory failure in adult patients: A systematic review. Critical Care 2015, 19: 99
Schmidt, M., et al.
http://ccforum.com/content/19/1/99
Mechanical ventilation remains the cornerstone of respiratory support for patients with acute respiratory failure. However, high pressure and volume associated with tidal ventilation are known to aggravate lung injury in this setting. Furthermore, profound gas-exchange abnormalities threatening patients’ lives can occur in the most severe forms of the disease despite recourse to conventional salvage therapies. Extracorporeal gas exchange devices, i.e., venovenous extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal (ECCO2R), were developed more than 40 years ago to rescue these dying patients.
Schmidt, M., et al.
http://ccforum.com/content/19/1/99
Mechanical ventilation remains the cornerstone of respiratory support for patients with acute respiratory failure. However, high pressure and volume associated with tidal ventilation are known to aggravate lung injury in this setting. Furthermore, profound gas-exchange abnormalities threatening patients’ lives can occur in the most severe forms of the disease despite recourse to conventional salvage therapies. Extracorporeal gas exchange devices, i.e., venovenous extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal (ECCO2R), were developed more than 40 years ago to rescue these dying patients.
Noninvasive ventilation and survival in acute care settings
Noninvasive ventilation and survival in acute care settings: A comprehensive systematic review and metanalysis of randomized controlled trials. Critical Care Medicine, April 2015, Vol. 43(4), p.880-88.
Cabrini, L., et al.
http://journals.lww.com/ccmjournal/Abstract/2015/04000/Noninvasive_Ventilation_and_Survival_in_Acute_Care.20.aspx
Noninvasive ventilation is increasingly applied to prevent or treat acute respiratory failure, but its benefit on survival is still controversial for many indications. We performed a metaanalysis of randomized controlled trials focused on the effect of noninvasive ventilation on mortality.
Cabrini, L., et al.
http://journals.lww.com/ccmjournal/Abstract/2015/04000/Noninvasive_Ventilation_and_Survival_in_Acute_Care.20.aspx
Noninvasive ventilation is increasingly applied to prevent or treat acute respiratory failure, but its benefit on survival is still controversial for many indications. We performed a metaanalysis of randomized controlled trials focused on the effect of noninvasive ventilation on mortality.
After critical care: Patient support after critical care
After critical care: Patient support after critical care. A mixed-method longitudinal study using email interviews and questionnaires. Intensive and Critical Care Nursing, March 2015 [in press]
Pattison, N., et al.
http://www.intensivecriticalcarenursing.com/article/S0964-3397(14)00126-8/abstract
To explore experiences and needs over time, of patients discharged from ICU using the Intensive Care Experience (ICE-q) questionnaire, Hospital Anxiety and Depression Scale (HADS) and EuroQoL (EQ-5D), associated clinical predictors (APACHE II, TISS, Length of stay, RIKER scores) and in-depth email interviewing.
Pattison, N., et al.
http://www.intensivecriticalcarenursing.com/article/S0964-3397(14)00126-8/abstract
To explore experiences and needs over time, of patients discharged from ICU using the Intensive Care Experience (ICE-q) questionnaire, Hospital Anxiety and Depression Scale (HADS) and EuroQoL (EQ-5D), associated clinical predictors (APACHE II, TISS, Length of stay, RIKER scores) and in-depth email interviewing.
Nurses' experiences of caring for critically ill, non-sedated, mechanically ventilated patients in the Intensive Care Unit
Nurses' experiences of caring for critically ill, non-sedated, mechanically ventilated patients in the Intensive Care Unit: A qualitative study. Intensive and Critical Care Nursing, March 2015 [in press]
Laerkner, E., et al.
http://www.intensivecriticalcarenursing.com/article/S0964-3397(15)00007-5/abstract?rss=yes
The objective was to explore nurses’ experiences of caring for non-sedated, critically ill patients requiring mechanical ventilation.
Laerkner, E., et al.
http://www.intensivecriticalcarenursing.com/article/S0964-3397(15)00007-5/abstract?rss=yes
The objective was to explore nurses’ experiences of caring for non-sedated, critically ill patients requiring mechanical ventilation.
Does intermediate care improve patient outcomes or reduce costs?
Does intermediate care improve patient outcomes or reduce costs? Critical Care 2015, 19: 89
Vincent, J-L and Rubenfeld, G.D.
http://ccforum.com/content/19/1/89
ICUs are an essential but expensive part of all modern hospitals. With increasingly limited healthcare funding, methods to reduce expenditure without negatively influencing patient outcomes are, therefore, of interest. One possible solution has been the development of ‘intermediate care units’, which provide more intensive monitoring and patient management with higher nurse:patient ratios than the general ward but less than is offered in the ICU. However, although such units have been introduced in many hospitals, there is relatively little published, especially prospective, evidence to support the benefits of this approach on costs or patient outcomes. We review the available data and suggest that, where possible, a larger unit with combined intermediate care and intensive care beds in one location may be preferable in terms of greater flexibility and efficiency.
Vincent, J-L and Rubenfeld, G.D.
http://ccforum.com/content/19/1/89
ICUs are an essential but expensive part of all modern hospitals. With increasingly limited healthcare funding, methods to reduce expenditure without negatively influencing patient outcomes are, therefore, of interest. One possible solution has been the development of ‘intermediate care units’, which provide more intensive monitoring and patient management with higher nurse:patient ratios than the general ward but less than is offered in the ICU. However, although such units have been introduced in many hospitals, there is relatively little published, especially prospective, evidence to support the benefits of this approach on costs or patient outcomes. We review the available data and suggest that, where possible, a larger unit with combined intermediate care and intensive care beds in one location may be preferable in terms of greater flexibility and efficiency.
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