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.

Long-Term Outcome Following Tracheostomy in Critical Care: A Systematic Review

Long-Term Outcome Following Tracheostomy in Critical Care: A Systematic Review

Critical Care Medicine: March 2016 - Volume 44 - Issue 3 - p 617–628

Dempsey, G

Objectives: The prevalence and impact of longer-term outcomes following percutaneous tracheostomy, particularly tracheal stenosis, are unclear. Previous meta-analyses addressing this problem have been confounded by the low prevalence of tracheal stenosis and a limited number of studies. Design: Embase, PubMed-Medline, and the Cochrane Central Register of Clinical Trials were searched to identify all prospective studies of tracheostomy insertion in the critically ill. To reflect contemporary practice, the search was limited to studies published from 2000 onward. We scrutinized the bibliographies of returned studies for additional articles. Meta-analyses were undertaken to estimate the pooled risk difference of tracheal stenosis, bleeding, and wound infection comparing different techniques. Measurements and Main Results: We identified a total of 463 studies, 29 (5,473 patients) of which met the inclusion criteria. Nine were randomized controlled trials, six were nonrandomized comparative studies, and 14 were single-arm cohort studies. Risk of wound infection was greater for the surgical tracheostomy than for the Ciaglia multiple dilator technique, pooled risk difference 0.12 (95% CI, 0.02–0.23). We did not identify significant risk differences in other meta-analyses. Pooling across all studies according to the random-effects proportion meta-analysis suggests a higher prevalence of tracheal stenosis, wound infection, and major bleeding for surgical tracheostomies. Conclusions: Considering comparative data, there was no significant difference in the prevalence of tracheal stenosis or major bleeding between percutaneous and surgical tracheostomy. In relation to wound infection, we have found a reduction associated with the original Ciaglia technique when compared with that with the surgical tracheostomy. Considering all published data reporting long-term outcomes pooled proportion meta-analysis indicates a trend toward a higher rate of tracheal stenosis and an increased risk of major bleeding and wound infection for surgical tracheostomies. This finding may be biased as a result of targeted patient selection, and f

Application of a Framework to Assess the Usefulness of Alternative Sepsis Criteria

Application of a Framework to Assess the Usefulness of Alternative Sepsis Criteria

Critical Care Medicine: March 2016 - Volume 44 - Issue 3 - p e122–e130

Seymour, C

The current definition of sepsis is life-threatening, acute organ dysfunction secondary to a dysregulated host response to infection. Criteria to operationalize this definition can be judged by six domains of usefulness (reliability, content, construct and criterion validity, measurement burden, and timeliness). The relative importance of these six domains depends on the intended purpose for the criteria (clinical care, basic and clinical research, surveillance, or quality improvement [QI] and audit). For example, criteria for clinical care should have high content and construct validity, timeliness, and low measurement burden to facilitate prompt care. Criteria for surveillance or QI/audit place greater emphasis on reliability across individuals and sites and lower emphasis on timeliness. Criteria for clinical trials require timeliness to ensure prompt enrollment and reasonable reliability but can tolerate high measurement burden. Basic research also tolerates high measurement burden and may not need stability over time. In an illustrative case study, we compared examples of criteria designed for clinical care, surveillance and QI/audit among 396,241 patients admitted to 12 academic and community hospitals in an integrated health system. Case rates differed four-fold and mortality three-fold. Predictably, clinical care criteria, which emphasized timeliness and low burden and therefore used vital signs and routine laboratory tests, had the greater case identification with lowest mortality. QI/audit criteria, which emphasized reliability and criterion validity, used discharge information and had the lowest case identification with highest mortality. Using this framework to identify the purpose and apply domains of usefulness can help with the evaluation of existing sepsis diagnostic criteria and provide a roadmap for future work.

Evaluation Following Staggered Implementation of the “Rethinking Critical Care” ICU Care Bundle in a Multicenter Community Setting

Evaluation Following Staggered Implementation of the “Rethinking Critical Care” ICU Care Bundle in a Multicenter Community Setting

Critical Care Medicine: March 2016 - Volume 44 - Issue 3 - p 460–467

Liu, V et al

Objectives: To evaluate process metrics and outcomes after implementation of the “Rethinking Critical Care” ICU care bundle in a community setting. Design: Retrospective interrupted time-series analysis. Setting: Three hospitals in the Kaiser Permanente Northern California integrated healthcare delivery system. Patients: ICU patients admitted between January 1, 2009, and August 30, 2013. Interventions: Implementation of the Rethinking Critical Care ICU care bundle which is designed to reduce potentially preventable complications by focusing on the management of delirium, sedation, mechanical ventilation, mobility, ambulation, and coordinated care. Rethinking Critical Care implementation occurred in a staggered fashion between October 2011 and November 2012. Measurements and Main Results: We measured implementation metrics based on electronic medical record data and evaluated the impact of implementation on mortality with multivariable regression models for 24,886 first ICU episodes in 19,872 patients. After implementation, some process metrics (e.g., ventilation start and stop times) were achieved at high rates, whereas others (e.g., ambulation distance), available late in the study period, showed steep increases in compliance. Unadjusted mortality decreased from 12.3% to 10.9% (p < 0.01) before and after implementation, respectively. The adjusted odds ratio for hospital mortality after implementation was 0.85 (95% CI, 0.73–0.99) and for 30-day mortality was 0.88 (95% CI, 0.80–0.97) compared with before implementation. However, the mortality rate trends were not significantly different before and after Rethinking Critical Care implementation. The mean duration of mechanical ventilation and hospital stay also did not demonstrate incrementally greater declines after implementation. Conclusions: Rethinking Critical Care implementation was associated with changes in practice and a 12–15% reduction in the odds of short-term mortality. However, these findings may represent an evaluation of changes in practices and outcomes still in the mid implementation phase and cannot be directly attributed to the elements of bundle implementation.

Quiet time for mechanically ventilated patients in the medical intensive care unit

Quiet time for mechanically ventilated patients in the medical intensive care unit

Intensive and Critical Care Nursing [Article in press]

McAndrew NS

Sleep disruption occurs frequently in critically ill patients. The primary aim of this study was to examine the effect of quiet time (QT) on patient sedation frequency, sedation and delirium scores; and to determine if consecutive QTs influenced physiologic measures (heart rate, mean arterial blood pressure and respiratory rate).

Vigilant attentiveness in families observing deterioration in the dying intensive care patient: A secondary analysis study

Vigilant attentiveness in families observing deterioration in the dying intensive care patient: A secondary analysis study

Intensive and Critical Care Nursing April 2016 Volume 33, Pages 65–71


Coombs M et al

Family support in intensive care is often focussed on what information is communicated to families. This is particularly important during treatment withdrawal and end of life care. However, this positions families as passive receivers of information. Less is known about what bereaved family members actually observe at end of life and how this is interpreted.

Outcomes of patients admitted to intensive care units for acute manifestation of small-vessel vasculitis: a multicenter, retrospective study

Outcomes of patients admitted to intensive care units for acute manifestation of small-vessel vasculitis: a multicenter, retrospective study
Critical Care 2016 20:27 DOI: 10.1186/s13054-016-1189-5
Kimmoun A et al


Background: The outcomes of patients admitted to the intensive care unit (ICU) for acute manifestation of small-vessel vasculitis are poorly reported. The aim of the present study was to determine the mortality rate and prognostic factors of patients admitted to the ICU for acute small-vessel vasculitis. Methods: This retrospective, multicenter study was conducted from January 2001 to December 2014 in 20 ICUs in France. Patients were identified from computerized registers of each hospital using the International Classification of Diseases, Ninth Revision (ICD-9). Inclusion criteria were (1) known or highly suspected granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, microscopic polyangiitis (respectively, ICD-9 codes M31.3, M30.1, and M31.7), or anti–glomerular basement membrane antibody disease (ICD-9 codes N08.5X-005 or M31.0+); (2) admission to the ICU for the management of an acute manifestation of vasculitis; and (3) administration of a cyclophosphamide pulse in the ICU or within 48 h before admission to the ICU. The primary endpoint was assessment of mortality rate 90 days after admission to the ICU. Results: Eighty-two patients at 20 centers were included, 94 % of whom had a recent ...................see full article

Economic Evaluation of Telemedicine for Patients in ICUs

Economic Evaluation of Telemedicine for Patients in ICUs
Critical Care Medicine: February 2016 - Volume 44 - Issue 2 - p 265–274
Byung-Kwang Y et al


Objective: Despite telemedicine’s potential to improve patients’ health outcomes and reduce costs in the ICU, hospitals have been slow to introduce telemedicine in the ICU due to high up-front costs and mixed evidence on effectiveness. This study’s first aim was to conduct a cost-effectiveness analysis to estimate the incremental cost-effectiveness ratio of telemedicine in the ICU, compared with ICU without telemedicine, from the healthcare system perspective. The second aim was to examine potential cost saving of telemedicine in the ICU through probabilistic analyses and break-even analyses. Design: Simulation analyses performed by standard decision models. Setting: Hypothetical ICU defined by the U.S. literature. Patients: Hypothetical adult patients in ICU defined by the U.S. literature. Interventions: The intervention was the introduction of telemedicine in the ICU, which was assumed to affect per-patient per-hospital-stay ICU cost and hospital mortality. Telemedicine in the ICU operation costs included the telemedicine equipment-installation (start-up) costs with 5-year depreciation, maintenance costs, and clinician staffing costs. Telemedicine in the ICU effectiveness was measured by cumulative quality-adjusted life years for 5 years after ICU discharge. Measurements and Main Results: The base case cost-effectiveness analysis estimated telemedicine in the ICU to extend 0.011 quality-adjusted life years with an incremental cost of $516 per patient compared with ICU without telemedicine, resulting in an incremental cost-effectiveness ratio of $45,320 per additional quality-adjusted life year (= $516/0.011). The probabilistic cost-effectiveness analysis estimated an incremental cost-effectiveness ratio of $50,265 with a wide 95% CI from a negative value (suggesting cost savings) to $375,870. These probabilistic analyses projected that cost saving is achieved 37% of 1,000 iterations. Cost saving is also feasible if the per-patient per-hospital-stay operational cost and physician cost were less than $422 and less than $155, respectively, based on break-even analyses. Conclusions: Our analyses suggest that telemedicine in the ICU is cost-effective in most cases and cost saving in some cases. The thresholds of cost and effectiveness, estimated by break-even analyses, help hospitals determine the impact of telemedicine in the ICU and potential cost saving.