Antimicrobial resistance and antibiotic stewardship programs in the ICU: insistence and persistence in the fight against resistance. A position statement from ESICM/ESCMID/WAAAR round table on multi-drug resistance.

Antimicrobial resistance and antibiotic stewardship programs in the ICU: insistence and persistence in the fight against resistance. A position statement from ESICM/ESCMID/WAAAR round table on multi-drug resistance.

Author(s) De Waele, Jan J; Akova, Murat; Antonelli, Massimo; Canton, Rafael; Carlet, Jean et al.

Source Intensive care medicine; Feb 2018; vol. 44 (no. 2); p. 189-196

Publication Date Feb 2018

DOI 10.1007/s00134-017-5036-1

ISSN 1432-1238

Database Medline

Antimicrobial resistance (AMR) is a clear and present danger to patients in any intensive care unit (ICU) around the world. Whereas AMR may affect any patient in the hospital, patients in the ICU are particularly at risk of acquiring AMR infections due to the intensity of the treatment, use of invasive devices, increased risk of transmission and exposure to antibiotics. AMR is present in every ICU, although prevalence is geographically different and AMR pathogens encountered are variable. Intensive care and infectious disease specialists from the European Society of Intensive Care Medicine, European Society of Microbiology and Infectious Diseases and World Alliance Against Antimicrobial Resistance, united in the ANTARCTICA (Antimicrobial Resistance in Critical Care) coalition, call for increased awareness and action among health care professionals to reduce AMR development in critically ill patients, to improve treatment of AMR infections and to coordinate scientific research in this high-risk patient population. Close collaboration with other specialties, and combining these and other interventions in antibiotic stewardship programmes should be a priority in every ICU. Considerate antibiotic use and adopting strict infection control practices to halt AMR remains a responsibility shared by all healthcare workers, from physicians to maintenance personnel, from nurses to physiotherapists, from consultants to medical students. Together, we can reduce AMR in our ICUs and continue to treat our patients effectively.

Predictors of pressure ulcer risk in adult intensive care patients: A retrospective case-control study.

Predictors of pressure ulcer risk in adult intensive care patients: A retrospective case-control study.

Author(s) de Almeida Medeiros, Ana Beatriz; da Conceição Dias Fernandes, Maria Isabel; de Sá Tinôco, Jéssica Dantas; Cossi, Marcelly Santos; de Oliveira Lopes, Marcos Venicios; de Carvalho Lira, Ana Luisa Brandão

Source Intensive & critical care nursing; Apr 2018; vol. 45 ; p. 6-10

Publication Date Apr 2018

Place of Publication Netherlands

DOI 10.1016/j.iccn.2017.09.007

Accession Number 29223413

ISSN 1532-4036

PubMed ID 29223413

Publication Type(s) Journal Article

Database Medline

Abstract

OBJECTIVESTo evaluate the predictive power of risk factors for pressure ulcers in adult intensive care patients.METHODA retrospective case-control study was performed utilising a heterogeneous sample group allocated into a case group with pressure ulcers (n=90) and a control group without pressure ulcers (n=90). The analysis explored the predictive power of risk factors for pressure ulcers using a hierarchical logistic regression model.RESULTSThe risk factors that predicted pressure ulcers were friction (OR=5.97), previous history of pressure ulcers (OR=5.43), prolonged intensive care unit stay (OR=3.92), dehydration (OR=3.18), elevated skin temperature by 1-2°C (OR=3.12) and treatment of other comorbidities (OR=2.79).CONCLUSIONAdult intensive care patients have an increased risk of developing a pressure ulcer. These risk factors are regarded as strong predictors for pressure ulceration. This study advances nursing knowledge in that it investigates additional risk factors for the development of pressure ulcers and it identifies a set of factors that best predict their occurrence, which may contribute to the nurses' diagnostic reasoning in the intensive care unit.

Person-centred care during prolonged weaning from mechanical ventilation, nurses’ views: an interview study

Person-centred care during prolonged weaning from mechanical ventilation, nurses’ views: an interview study

1 Intensive and Critical Care Nursing by Carl-Johan Cederwall, Sepideh Olausson, Louise Rose, Silvana Naredi, Mona Ringdal 

Abstract

Objective

To determine: 1) if the three elements of person-centred care (initiating, working and safeguarding the partnership) were present, and 2) to identify evidence of barriers to person-centred care during prolonged weaning from mechanical ventilation.

Research methodology

Secondary analysis of semi structured interviews with 19 critical care nurses using theoretical thematic analysis.

Setting

This study was conducted in three Swedish intensive care units, one in a regional hospital and two in a university hospital.

Findings

Three themes and nine subthemes related to person-centred care were identified. The three themes included: 1) ‘finding a person behind the patient’ related to the ‘initiating the partnership’ phase, 2) ‘striving to restore patient́s sense of control’ related to ‘working the partnership’ phase and 3) ‘impact of patient involvement’ related to ‘safeguarding the partnership’ phase of person-centred care’. Additionally a further theme ‘barriers to person-centred care’ was identified.

Conclusion

We found evidence of all three person-centred care routines. Barriers to person-centred care comprised of lack team collaboration and resources. Facilitating patients to actively participate in decision-making during the weaning process may optimise weaning outcomes and warrants further research.

Delay Within the 3-Hour Surviving Sepsis Campaign Guideline on Mortality for Patients With Severe Sepsis and Septic Shock*

Pruinelli, Lisiane PhD, RN1; Westra, Bonnie L. PhD, RN, FAAN, FACMI1,2; Yadav, Pranjul PhD3; Hoff, Alexander3; Steinbach, Michael PhD3; Kumar, Vipin PhD3; Delaney, Connie W. PhD, RN, FAAN, FACMI1,2; Simon, Gyorgy PhD2,4

Critical Care Medicine: April 2018 - Volume 46 - Issue 4 - p 500–505

doi: 10.1097/CCM.0000000000002949

Objectives: To specify when delays of specific 3-hour bundle Surviving Sepsis Campaign guidelinerecommendations applied to severe sepsis or septic shock become harmful and impact mortality.

Design: Retrospective cohort study.

Setting: One health system composed of six hospitals and 45 clinics in a Midwest state from January 01, 2011, to July 31, 2015.

Patients: All adult patients hospitalized with billing diagnosis of severe sepsis or septic shock.

Interventions: Four 3-hour Surviving Sepsis Campaign guideline recommendations: 1) obtain blood culture before antibiotics, 2) obtain lactate level, 3) administer broad-spectrum antibiotics, and 4) administer 30 mL/kg of crystalloid fluid for hypotension (defined as “mean arterial pressure” < 65) or lactate (> 4).

Measurements and Main Results: To determine the effect of t minutes of delay in carrying out each intervention, propensity score matching of “baseline” characteristics compensated for differences in health status. The average treatment effect in the treated computed as the average difference in outcomes between those treated after shorter versus longer delay. To estimate the uncertainty associated with the average treatment effect in the treated metric and to construct 95% CIs, bootstrap estimation with 1,000 replications was performed. From 5,072 patients with severe sepsis or septic shock, 1,412 (27.8%) had in-hospital mortality. The majority of patients had the four 3-hour bundle recommendations initiated within 3 hours. The statistically significant time in minutes after which a delay increased the risk of death for each recommendation was as follows: lactate, 20.0 minutes; blood culture, 50.0 minutes; crystalloids, 100.0 minutes; and antibiotic therapy, 125.0 minutes.

Conclusions: The guideline recommendations showed that shorter delays indicates better outcomes. There was no evidence that 3 hours is safe; even very short delays adversely impact outcomes. Findings demonstrated a new approach to incorporate time t when analyzing the impact on outcomes and provide new evidence for clinical practice and research.

Practice Patterns and Outcomes Associated With Early SedationDepth in Mechanically Ventilated Patients: A Systematic Review and Meta-Analysis*

Stephens, Robert J. BS1; Dettmer, Matthew R. MD2; Roberts, Brian W. MD3; Ablordeppey, Enyo MD, MPH4,5; Fowler, Susan A. MLIS6; Kollef, Marin H. MD7; Fuller, Brian M. MD, MSCI4,5

Critical Care Medicine: March 2018 - Volume 46 - Issue 3 - p 471–479

doi: 10.1097/CCM.0000000000002885

Objectives: Emerging data suggest that early deep sedation may negatively impact clinical outcomes. This systematic review and meta-analysis defines and quantifies the impact of deep sedation within 48 hours of initiation of mechanical ventilation, as described in the world’s literature. The primary outcome was mortality. Secondary outcomes included hospital and ICU lengths of stay, mechanical ventilation duration, and delirium and tracheostomy frequency.

Data Sources: The following data sources were searched: MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews and Effects, Cochrane Database of Systematic Reviews databases, ClinicalTrials.gov, conference proceedings, and reference lists.

Study Selection: Randomized controlled trials and nonrandomized studies were included.

Data Extraction: Two reviewers independently screened abstracts of identified studies for eligibility.

Data Synthesis: Nine studies (n = 4,521 patients) published between 2012 and 2017 were included. A random effects meta-analytic model revealed that early light sedation was associated with lower mortality (9.2%) versus deep sedation (27.6%) (odds ratio, 0.34 [0.21–0.54]). Light sedation was associated with fewer mechanical ventilation (mean difference, –2.1; 95% CI, –3.6 to –0.5) and ICU days (mean difference, –3.0 (95% CI, –5.4 to –0.6). Delirium frequency was 28.7% in the light sedation group and 48.5% in the deep sedation group, odds ratio, 0.50 (0.22–1.16).

Conclusions: Deep sedation in mechanically ventilated patients, as evaluated in a small number of qualifying heterogeneous randomized controlled trials and observational studies, was associated with increased mortality and lengths of stay. Interventions targeting early sedation depth assessment, starting in the emergency department and subsequent ICU admission, deserve further investigation and could improve outcome.

The Association of ICU Acuity With Outcomes of Patients at Low Risk of Dying

Vranas, Kelly C. MD1,2; Jopling, Jeffrey K. MD, MSHS1,3; Scott, Jennifer Y. MS1; Badawi, Omar PharmD, MPH4,5,6; Harhay, Michael O. PhD7,8; Slatore, Christopher G. MD, MS2,9; Ramsey, Meghan C. MD1,10; Breslow, Michael J. MD4; Milstein, Arnold S. MD, MPH1; Kerlin, Meeta Prasad MD, MSCE11

Objective: Many ICU patients do not require critical care interventions. Whether aggressive care environments increase risks to low-acuity patients is unknown. We evaluated whether ICU acuity was associated with outcomes of low mortality-risk patients. We hypothesized that admission to high-acuity ICUs would be associated with worse outcomes. This hypothesis was based on two possibilities: 1) high-acuity ICUs may have a culture of aggressive therapy that could lead to potentially avoidable complications and 2) high-acuity ICUs may focus attention toward the many sicker patients and away from the fewer low-risk patients.

Design: Retrospective cohort study.

Setting: Three hundred twenty-two ICUs in 199 hospitals in the Philips eICU database between 2010 and 2015.

Patients: Adult ICU patients at low risk of dying, defined as an Acute Physiology and Chronic Health Evaluation-IVa–predicted mortality of 3% or less.

Exposure: ICU acuity, defined as the mean Acute Physiology and Chronic Health Evaluation IVa score of all admitted patients in a calendar year, stratified into quartiles.

Measurements and Main Results: We used generalized estimating equations to test whether ICU acuity is independently associated with a primary outcome of ICU length of stay and secondary outcomes of hospital length of stay, hospital mortality, and discharge destination. The study included 381,997 low-risk patients. Mean ICU and hospital length of stay were 1.8 ± 2.1 and 5.2 ± 5.0 days, respectively. Mean Acute Physiology and Chronic Health Evaluation IVa–predicted hospital mortality was 1.6% ± 0.8%; actual hospital mortality was 0.7%. In adjusted analyses, admission to low-acuity ICUs was associated with worse outcomes compared with higher-acuity ICUs. Specifically, compared with the highest-acuity quartile, ICU length of stay in low-acuity ICUs was increased by 0.24 days; in medium-acuity ICUs by 0.16 days; and in high-acuity ICUs by 0.09 days (all p < 0.001). Similar patterns existed for hospital length of stay. Patients in lower-acuity ICUs had significantly higher hospital mortality (odds ratio, 1.28 [95% CI, 1.10–1.49] for low-; 1.24 [95% CI, 1.07–1.42] for medium-, and 1.14 [95% CI, 0.99–1.31] for high-acuity ICUs) and lower likelihood of discharge home (odds ratio, 0.86 [95% CI, 0.82–0.90] for low-, 0.88 [95% CI, 0.85–0.92] for medium-, and 0.95 [95% CI, 0.92–0.99] for high-acuity ICUs).

Conclusions: Admission to high-acuity ICUs is associated with better outcomes among low mortality-risk patients. Future research should aim to understand factors that confer benefit to patients with different risk profiles.

Evaluation of ICU Risk Models Adapted for Use as Continuous Markers of Severity of Illness Throughout the ICU Stay*

Badawi, Omar PharmD, MPH, FCCM1,2,3; Liu, Xinggang MD, PhD1; Hassan, Erkan PharmD, FCCM1; Amelung, Pamela J. MD, FCCP1; Swami, Sunil PhD, MPH, MBBS1

Critical Care Medicine: March 2018 - Volume 46 - Issue 3 - p 361–367

doi: 10.1097/CCM.0000000000002904

Objectives: Evaluate the accuracy of different ICU risk models repurposed as continuous markers of severity of illness.

Design: Nonintervention cohort study.

Setting: eICU Research Institute ICUs using tele-ICU software calculating continuous ICU Discharge Readiness Scores between January 2013 and March 2016.

Patients: Five hundred sixty-one thousand four hundred seventy-eight adult ICU patients with an ICU length of stay between 4 hours and 30 days.

Interventions: Not available.

Measurements and Main Results: Hourly Acute Physiology and Chronic Health Evaluation IV, Sequential Organ Failure Assessment, and Discharge Readiness Scores were calculated beginning hour 4 of the ICU stay. Primary outcome was the area under the receiver operating characteristic curve for the mean score with ICU mortality. Secondary outcomes included area under the receiver operating characteristic curves for ICU mortality with admission, median, maximum and last scores, and for death within 24 hours. The trajectories of each score were visualized by plotting the hourly averages against time in the ICU, stratified by mortality and length of stay. The area under the receiver operating characteristic curves for mean Acute Physiology and Chronic Health Evaluation, Sequential Organ Failure Assessment, and Discharge Readiness Scores were 0.90 (0.89–0.90), 0.86 (0.86–0.86), and 0.94 (0.94–0.94), respectively. The area under the receiver operating characteristic curves for hourly Acute Physiology and Chronic Health Evaluation, Sequential Organ Failure Assessment, and Discharge Readiness Scores predicting 24-hour mortality were 0.81 (0.81–0.81), 0.76 (0.76–0.76), and 0.86 (0.86–0.86). Discharge Readiness Scores had a higher area under the receiver operating characteristic curve than both Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment for each metric. Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment scores increased throughout the first 24 hours in both survivors and nonsurvivors; Discharge Readiness Scores continuously decreased in survivors and temporarily decreased before increasing by hour 36 in nonsurvivors with longer length of stays.

Conclusions: Acute Physiology and Chronic Health Evaluation, Sequential Organ Failure Assessment, and Discharge Readiness Scores all have relatively high discrimination for ICU mortality when used continuously; Discharge Readiness Scores tended to have slightly higher area under the receiver operating characteristic curves for each endpoint. These findings validate the use of these models on a population level for continuous risk adjustment in the ICU, although Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment appear slower to respond to improvements in patient status than Discharge Readiness Scores, and Discharge Readiness Scores may reflect physiologic improvement from interventions, potentially underestimating risk.

Temporal Trends in Incidence, Sepsis-Related Mortality, and Hospital-Based Acute Care After Sepsis

Meyer, Nathaniel MD1; Harhay, Michael O. PhD2; Small, Dylan S. PhD3,4; Prescott, Hallie C. MD, MSc5; Bowles, Kathryn H. PhD, RN6,7; Gaieski, David F. MD8; Mikkelsen, Mark E. MD, MSCE2,4,9

Critical Care Medicine: March 2018 - Volume 46 - Issue 3 - p 354–360doi: 10.1097/CCM.0000000000002872 Late Breaker Articles

Objectives: A growing number of patients survive sepsis hospitalizations each year and are at high risk for readmission. However, little is known about temporal trends in hospital-based acute care (emergency department treat-and-release visits and hospital readmission) after sepsis. Our primary objective was to measure temporal trends in sepsis survivorship and hospital-based acute care use in sepsis survivors. In addition, because readmissions after pneumonia are subject to penalty under the national readmission reduction program, we examined whether readmission rates declined after sepsis hospitalizations related to pneumonia.

Design and Setting: Retrospective, observational cohort study conducted within an academic healthcare system from 2010 to 2015.

Patients: We used three validated, claims-based approaches to identify 17,256 sepsis or severe sepsis hospitalizations to examine trends in hospital-based acute care after sepsis.

Interventions: None.

Measurements and Main Results: From 2010 to 2015, sepsis as a proportion of medical and surgical admissions increased from 3.9% to 9.4%, whereas in-hospital mortality rate for sepsis hospitalizations declined from 24.1% to 14.8%. As a result, the proportion of medical and surgical discharges at-risk for hospital readmission after sepsis increased from 2.7% to 7.8%. Over 6 years, 30-day hospital readmission rates declined modestly, from 26.4% in 2010 to 23.1% in 2015, driven largely by a decline in readmission rates among survivors of nonsevere sepsis, and nonpneumonia sepsis specifically, as the readmission rate of severe sepsis survivors was stable. The modest decline in 30-day readmission rates was offset by an increase in emergency department treat-and-release visits, from 2.8% in 2010 to a peak of 5.4% in 2014.

Conclusions: Owing to increasing incidence and declining mortality, the number of sepsis survivors at risk for hospital readmission rose significantly between 2010 and 2015. The 30-day hospital readmission rates for sepsis declined modestly but were offset by a rise in emergency department treat-and-release visits.

Dilemmas in infection control in the intensive care unit

Dilemmas in infection control in the intensive care unit

Zahar J-R,  Blot S
Intensive and Critical Care Nursing, Article in press

Intensive care unit (ICU) patients are at a particular risk for infection with multidrug resistant micro-organisms because they experience high severity of acute illness, present with predisposing underlying conditions, are exposed to a plethora of invasive procedures and are at the extremes of age, either neonatal or very old (Depuydt et al., 2006; Blot, 2008; Blot et al., 2014b; Verstraete et al., 2015; Afonso and Blot, 2017). Healthcare-associated infection and multidrug resistance are a major concern in ICUs as it is associated with considerable morbidity and possibly mortality (Blot et al., 2002, 2003; Verstraete et al., 2016) As a consequence substantial efforts in infection prevention and control are required to reduce the burden of infectious complications (Rello et al., 2013; Blot et al., 2014a ;  Sousa et al., 2018). While infection prevention targets the avoidance of specific infections at an individual patient level, infection control is more focused on containing the problem and preventing further spread of epidemiologically important pathogens throughout the unit or the hospital.

Infection control is a key element in the management of multidrug resistant organism (MDRO) carriers/infected patients in ICU....

Editorial

The Effect of ICU Out-of-Hours Admission on Mortality: A Systematic Review and Meta-Analysis

The Effect of ICU Out-of-Hours Admission on Mortality: A Systematic Review and Meta-Analysis

Galloway, M et al

Critical Care Medicine: February 2018 - Volume 46 - Issue 2 - p 290–299

Objectives: Organizational factors are associated with outcome of critically ill patients and may vary by time of day and day of week. We aimed to identify the association between out-of-hours admission to critical care and mortality. 
Data Sources: MEDLINE (via Ovid) and EMBASE (via Ovid). Study Selection: We performed a systematic search of the literature for studies on out-of-hours adult general ICU admission on patient mortality. 
Data Extraction: Meta-analyses were performed and Forest plots drawn using RevMan software. Data are presented as odds ratios ([95% CIs], p values). 
Data Synthesis: A total of 16 studies with 902,551 patients were included in the analysis with a crude mortality of 18.2%. Fourteen studies with 717,331 patients reported mortality rates by time of admission and 11 studies with 835,032 patients by day of admission. Admission to ICU at night was not associated with an increased odds of mortality compared with admissions during the day (odds ratio, 1.04 [0.98–1.11]; p = 0.18). However, admissions during the weekend were associated with an increased odds of death compared with ICU admissions during weekdays (1.05 [1.01–1.09]; p = 0.006). Increased mortality associated with weekend ICU admissions compared with weekday ICU admissions was limited to North American countries (1.08 [1.03–1.12]; p = 0.0004). The absence of a routine overnight on-site intensivist was associated with increased mortality among weekend ICU admissions compared with weekday ICU admissions (1.11 [1.00–1.22]; p = 0.04) and nighttime admissions compared with daytime ICU admissions (1.11 [1.00–1.23]; p = 0.05). 
Conclusions: Adjusted risk of death for ICU admission was greater over the weekends compared with weekdays. The absence of a dedicated intensivist on-site overnight may be associated with increased mortality for acute admissions. These results need to be interpreted in context of the organization of local healthcare resources before changes to healthcare policy are implemented.

Predictors of Intubation in Patients With Acute Hypoxemic Respiratory Failure Treated With a Noninvasive Oxygenation Strategy

Predictors of Intubation in Patients With Acute Hypoxemic Respiratory Failure Treated With a Noninvasive Oxygenation Strategy

Frat, J-P et al

Critical Care Medicine: February 2018 - Volume 46 - Issue 2 - p 208–215

Objectives: In patients with acute hypoxemic respiratory failure, noninvasive ventilation and high-flow nasal cannula oxygen are alternative strategies to conventional oxygen therapy. Endotracheal intubation is frequently needed in these patients with a risk of delay, and early predictors of failure may help clinicians to decide early. We aimed to identify factors associated with intubation in patients with acute hypoxemic respiratory failure treated with different noninvasive oxygenation techniques. 

Design: Post hoc analysis of a randomized clinical trial. Setting: Twenty-three ICUs. Patients: Patients with a respiratory rate greater than 25 breaths/min and a PaO2/FIO2 ratio less than or equal to 300 mm Hg. Intervention: Patients were treated with standard oxygen, high-flow nasal cannula oxygen, or noninvasive ventilation. 

Measurement and Main Results: Respiratory variables one hour after treatment initiation. Under standard oxygen, patients with a respiratory rate greater than or equal to 30 breaths/min were more likely to need intubation (odds ratio, 2.76; 95% CI, 1.13–6.75; p = 0.03). One hour after high-flow nasal cannula oxygen initiation, increased heart rate was the only factor associated with intubation. One hour after noninvasive ventilation initiation, a PaO2/FIO2 ratio less than or equal to 200 mm Hg and a tidal volume greater than 9 mL/kg of predicted body weight were independent predictors of intubation (adjusted odds ratio, 4.26; 95% CI, 1.62–11.16; p = 0.003 and adjusted odds ratio, 3.14; 95% CI, 1.22–8.06; p = 0.02, respectively). A tidal volume above 9 mL/kg during noninvasive ventilation remained independently associated with 90-day mortality. Conclusions: In patients with acute hypoxemic respiratory failure breathing spontaneously, the respiratory rate was a predictor of intubation under standard oxygen, but not under high-flow nasal cannula oxygen or noninvasive ventilation. A PaO2/FIO2 below 200 mm Hg and a high tidal volume greater than 9 mL/kg were the two strong predictors of intubation under noninvasive ventilation.

Prevention of Ventilator-Associated Pneumonia: The Multimodal Approach of the Spanish ICU “Pneumonia Zero” Program

Prevention of Ventilator-Associated Pneumonia: The Multimodal Approach of the Spanish ICU “Pneumonia Zero” Program

Alvarez-Lerma, F et al

Critical Care Medicine: February 2018 - Volume 46 - Issue 2 - p 181–188

Objectives: The “Pneumonia Zero” project is a nationwide multimodal intervention based on the simultaneous implementation of a comprehensive evidence-based bundle measures to prevent ventilator-associated pneumonia in critically ill patients admitted to the ICU. Design: Prospective, interventional, and multicenter study. Setting: A total of 181 ICUs throughout Spain. Patients: All patients admitted for more than 24 hours to the participating ICUs between April 1, 2011, and December 31, 2012. 
Intervention: Ten ventilator-associated pneumonia prevention measures were implemented (seven were mandatory and three highly recommended). The database of the National ICU-Acquired Infections Surveillance Study (Estudio Nacional de Vigilancia de Infecciones Nosocomiales [ENVIN]) was used for data collection. Ventilator-associated pneumonia rate was expressed as incidence density per 1,000 ventilator days. Ventilator-associated pneumonia rates from the incorporation of the ICUs to the project, every 3 months, were compared with data of the ENVIN registry (April–June 2010) as the baseline period. Ventilator-associated pneumonia rates were adjusted by characteristics of the hospital, including size, type (public or private), and teaching (postgraduate) or university-affiliated (undergraduate) status. 
Measurements and Main Results: The 181 participating ICUs accounted for 75% of all ICUs in Spain. In a total of 171,237 ICU admissions, an artificial airway was present on 505,802 days (50.0% of days of stay in the ICU). A total of 3,474 ventilator-associated pneumonia episodes were diagnosed in 3,186 patients. The adjusted ventilator-associated pneumonia incidence density rate decreased from 9.83 (95% CI, 8.42–11.48) per 1,000 ventilator days in the baseline period to 4.34 (95% CI, 3.22–5.84) after 19–21 months of participation. 
Conclusions: Implementation of the bundle measures included in the “Pneumonia Zero” project resulted in a significant reduction of more than 50% of the incidence of ventilator-associated pneumonia in Spanish ICUs. This reduction was sustained 21 months after implementation.

Should Transfusion Trigger Thresholds Differ for Critical Care Versus Perioperative Patients? A Meta-Analysis of Randomized Trials

Should Transfusion Trigger Thresholds Differ for Critical Care Versus Perioperative Patients? A Meta-Analysis of Randomized Trials

Chong, M et al

Critical Care Medicine: February 2018 - Volume 46 - Issue 2 - p 252–263

Objective: To address the significant uncertainty as to whether transfusion thresholds for critical care versus surgical patients should differ. Design: Meta-analysis of randomized controlled trials. Setting: Medline, EMBASE, and Cochrane Library searches were performed up to 15 June 2016. Patients: Trials had to enroll adult surgical or critically ill patients for inclusion. Interventions: Studies had to compare a liberal versus restrictive threshold for the transfusion of allogeneic packed RBCs. 
Measurements and Main Results: The primary outcome was 30-day all-cause mortality, sub-grouped by surgical and critical care patients. Secondary outcomes included myocardial infarction, stroke, renal failure, allogeneic blood exposure, and length of stay. Odds ratios and weighted mean differences were calculated using random effects meta-analysis. To assess whether subgroups were significantly different, tests for subgroup interaction were used. Subgroup analysis by trials enrolling critically ill versus surgical patients was performed. Twenty-seven randomized controlled trials (10,797 patients) were included. In critical care patients, restrictive transfusion resulted in significantly reduced 30-day mortality compared with liberal transfusion (odds ratio, 0.82; 95% CI, 0.70–0.97). In surgical patients, a restrictive transfusion strategy led to the opposite direction of effect for mortality (odds ratio, 1.31; 95% CI, 0.94–1.82). The subgroup interaction test was significant (p = 0.04), suggesting that the effect of restrictive transfusion on mortality is statistically different for critical care (decreased risk) versus surgical patients (potentially increased risk or no difference). Regarding secondary outcomes, for critically ill patients, a restrictive strategy resulted in reduced risk of stroke/transient ischemic attack, packed RBC exposure, transfusion reactions, and hospital length of stay. In surgical patients, restrictive transfusion resulted in reduced packed RBC exposure. 
Conclusions: The safety of restrictive transfusion strategies likely differs for critically ill patients versus perioperative patients. Further trials investigating transfusion strategies in the perioperative setting are necessary.

Predictors, Prevalence, and Outcomes of Early Crystalloid Responsiveness Among Initially Hypotensive Patients With Sepsis and Septic Shock

Predictors, Prevalence, and Outcomes of Early Crystalloid Responsiveness Among Initially Hypotensive Patients With Sepsis and Septic Shock

Leisman, D et al

Critical Care Medicine: February 2018 - Volume 46 - Issue 2 - p 189–198

Objectives: The prevalence of responsiveness to initial fluid challenge among hypotensive sepsis patients is unclear. To avoid fluid overload, and unnecessary treatment, it is important to differentiate these phenotypes. We aimed to 1) determine the proportion of hypotensive sepsis patients sustaining favorable hemodynamic response after initial fluid challenge, 2) determine demographic and clinical risk factors that predicted refractory hypotension, and 3) assess the association between timeliness of fluid resuscitation and refractoriness. 
Design: Secondary analysis of a prospective, multisite, observational, consecutive-sample cohort. Setting: Nine tertiary and community hospitals over 1.5 years. Patients: Inclusion criteria 1) suspected or confirmed infection, 2) greater than or equal to two systemic inflammatory response syndrome criteria, 3) systolic blood pressure less than 90 mm Hg, greater than 40% decrease from baseline, or mean arterial pressure less than 65 mm Hg. 
Measurements and Main Results: Sex, age, heart failure, renal failure, immunocompromise, source of infection, initial lactate, coagulopathy, temperature, altered mentation, altered gas exchange, and acute kidney injury were used to generate a risk score. The primary outcome was sustained normotension after fluid challenge without vasopressor titration. Among 3,686 patients, 2,350 (64%) were fluid responsive. Six candidate risk factors significantly predicted refractoriness in multivariable analysis: heart failure (odds ratio, 1.43; CI, 1.20–1.72), hypothermia (odds ratio, 1.37; 1.10–1.69), altered gas exchange (odds ratio, 1.33; 1.12–1.57), initial lactate greater than or equal to 4.0 mmol/L (odds ratio, 1.28; 1.08–1.52), immunocompromise (odds ratio, 1.23; 1.03–1.47), and coagulopathy (odds ratio, 1.23; 1.03–1.48). High-risk patients (≥ three risk factors) had 70% higher (CI, 48–96%) refractory risk (19% higher absolute risk; CI, 14–25%) versus low-risk (zero risk factors) patients. Initiating fluids in greater than 2 hours also predicted refractoriness (odds ratio, 1.96; CI, 1.49–2.58). Mortality was 15% higher (CI, 10-18%) for refractory patients. 
Conclusions: Two in three hypotensive sepsis patients were responsive to initial fluid resuscitation. Heart failure, hypothermia, immunocompromise, hyperlactemia, and coagulopathy were associated with the refractory phenotype. Fluid resuscitation initiated after the initial 2 hours more strongly predicted refractoriness than any patient factor tested.

Acute Physiologic Stress and Subsequent Anxiety Among Family Members of ICU Patients

Acute Physiologic Stress and Subsequent Anxiety Among Family Members of ICU Patients

Beesley, S et al

Critical Care Medicine: February 2018 - Volume 46 - Issue 2 - p 229–235

Objectives: The ICU is a complex and stressful environment and is associated with significant psychologic morbidity for patients and their families. We sought to determine whether salivary cortisol, a physiologic measure of acute stress, was associated with subsequent psychologic distress among family members of ICU patients. Design: This is a prospective, observational study of family members of adult ICU patients. Setting: Adult medical and surgical ICU in a tertiary care center. Subjects: Family members of ICU patients. Interventions: Participants provided five salivary cortisol samples over 24 hours at the time of the patient ICU admission. The primary measure of cortisol was the area under the curve from ground; the secondary measure was the cortisol awakening response. Outcomes were obtained during a 3-month follow-up telephone call. The primary outcome was anxiety, measured by the Hospital Anxiety and Depression Scale-Anxiety. Secondary outcomes included depression and posttraumatic stress disorder. Measurements and Main Results: Among 100 participants, 92 completed follow-up. Twenty-nine participants (32%) reported symptoms of anxiety at 3 months, 15 participants (16%) reported depression symptoms, and 14 participants (15%) reported posttraumatic stress symptoms. In our primary analysis, cortisol level as measured by area under the curve from ground was not significantly associated with anxiety (odds ratio, 0.94; p = 0.70). In our secondary analysis, however, cortisol awakening response was significantly associated with anxiety (odds ratio, 1.08; p = 0.02). Conclusions: Roughly one third of family members experience anxiety after an ICU admission for their loved one, and many family members also experience depression and posttraumatic stress. Cortisol awakening response is associated with anxiety in family members of ICU patients 3 months following the ICU admission. Physiologic measurements of stress among ICU family members may help identify individuals at particular risk of adverse psychologic outcomes.