Morbidity and mortality from sepsis remains unacceptably high. Large variability in clinical practice, plus the increasing awareness that certain processes of care associated with improved critical...

/pdf/severe-sepsis-and-septic-shock-4qc6kawnx8.pdf

Severe sepsis and septic shock

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(09)60658-9.pdf

Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial.

Background There have been few detailed, in-person interviews and examinations to obtain follow-up data on 5-year outcomes among survivors of the acute respiratory distress syndrome (ARDS). Methods We evaluated 109 survivors of ARDS at 3, 6, and 12 months and at 2, 3, 4, and 5 years after discharge from the intensive care unit. At each visit, patients were interviewed and examined; underwent pulmonary-function tests, the 6-minute walk test, resting and exercise oximetry, chest imaging, and a quality-of-life evaluation; and reported their use of health care services. Results At 5 years, the median 6-minute walk distance was 436 m (76% of predicted distance) and the Physical Component Score on the Medical Outcomes Study 36-Item Short-Form Health Survey was 41 (mean norm score matched for age and sex, 50). With respect to this score, younger patients had a greater rate of recovery than older patients, but neither group returned to normal predicted levels of physical function at 5 years. Pulmonary function wa...

Functional disability 5 years after acute respiratory distress syndrome.

Background In patients undergoing mechanical ventilation for the acute respiratory distress syndrome (ARDS), neuromuscular blocking agents may improve oxygenation and decrease ventilator-induced lung injury but may also cause muscle weakness. We evaluated clinical outcomes after 2 days of therapy with neuromuscular blocking agents in patients with early, severe ARDS. Methods In this multicenter, double-blind trial, 340 patients presenting to the intensive care unit (ICU) with an onset of severe ARDS within the previous 48 hours were randomly assigned to receive, for 48 hours, either cisatracurium besylate (178 patients) or placebo (162 patients). Severe ARDS was defined as a ratio of the partial pressure of arterial oxygen (PaO 2 ) to the fraction of inspired oxygen (FiO 2 ) of less than 150, with a positive end-expiratory pressure of 5 cm or more of water and a tidal volume of 6 to 8 ml per kilogram of predicted body weight. The primary outcome was the proportion of patients who died either before hospital discharge or within 90 days after study enrollment (i.e., the 90-day in-hospital mortality rate), adjusted for predefined covariates and baseline differences between groups with the use of a Cox model. Results The hazard ratio for death at 90 days in the cisatracurium group, as compared with the placebo group, was 0.68 (95% confidence interval [CI], 0.48 to 0.98; P = 0.04), after adjustment for both the baseline PaO 2 :FIO 2 and plateau pressure and the Simplified Acute Physiology II score. The crude 90-day mortality was 31.6% (95% CI, 25.2 to 38.8) in the cisatracurium group and 40.7% (95% CI, 33.5 to 48.4) in the placebo group (P = 0.08). Mortality at 28 days was 23.7% (95% CI, 18.1 to 30.5) with cisatracurium and 33.3% (95% CI, 26.5 to 40.9) with placebo (P = 0.05). The rate of ICU-acquired paresis did not differ significantly between the two groups. Conclusions In patients with severe ARDS, early administration of a neuromuscular blocking agent improved the adjusted 90-day survival and increased the time off the ventilator without increasing muscle weakness. (Funded by Assistance Publique–Hopitaux de Marseille and the Programme Hospitalier de Recherche Clinique Regional 2004-26 of the French Ministry of Health; ClinicalTrials.gov number, NCT00299650.)

https://www.nejm.org/doi/pdf/10.1056/NEJMoa1005372

Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome

Background Hydrocortisone is widely used in patients with septic shock even though a survival benefit has been reported only in patients who remained hypotensive after fluid and vasopressor resuscitation and whose plasma cortisol levels did not rise appropriately after the administration of corticotropin. Methods In this multicenter, randomized, double-blind, placebo-controlled trial, we assigned 251 patients to receive 50 mg of intravenous hydrocortisone and 248 patients to receive placebo every 6 hours for 5 days; the dose was then tapered during a 6-day period. At 28 days, the primary outcome was death among patients who did not have a response to a corticotropin test. Results Of the 499 patients in the study, 233 (46.7%) did not have a response to corticotropin (125 in the hydrocortisone group and 108 in the placebo group). At 28 days, there was no significant difference in mortality between patients in the two study groups who did not have a response to corticotropin (39.2% in the hydrocortisone group and 36.1% in the placebo group, P = 0.69) or between those who had a response to corticotropin (28.8% in the hydrocortisone group and 28.7% in the placebo group, P = 1.00). At 28 days, 86 of 251 patients in the hydrocortisone group (34.3%) and 78 of 248 patients in the placebo group (31.5%) had died (P = 0.51). In the hydrocortisone group, shock was reversed more quickly than in the placebo group. However, there were more episodes of superinfection, including new sepsis and septic shock. Conclusions Hydrocortisone did not improve survival or reversal of shock in patients with septic shock, either overall or in patients who did not have a response to corticotropin, although hydrocortisone hastened reversal of shock in patients in whom shock was reversed. (ClinicalTrials.gov number, NCT00147004.)

/pdf/hydrocortisone-therapy-for-patients-with-septic-shock-g190lf2ymr.pdf

Hydrocortisone Therapy for Patients with Septic Shock

ContextAlthough electrophysiologic and histologic neuromuscular abnormalities
are common in intensive care unit (ICU) patients, the clinical incidence of
ICU-acquired neuromuscular disorders in patients recovering from severe illness
remains unknown.ObjectivesTo assess the clinical incidence, risk factors, and outcomes of ICU-acquired
paresis (ICUAP) during recovery from critical illness in the ICU and to determine
the electrophysiologic and histologic patterns in patients with ICUAP.DesignProspective cohort study conducted from March 1999 to June 2000.SettingThree medical and 2 surgical ICUs in 4 hospitals in France.ParticipantsAll consecutive ICU patients without preexisting neuromuscular disease
who underwent mechanical ventilation for 7 or more days were screened daily
for awakening. The first day a patient was considered awake was day 1. Patients
with severe muscle weakness on day 7 were considered to have ICUAP.Main Outcome MeasuresIncidence and duration of ICUAP, risk factors for ICUAP, and comparative
duration of mechanical ventilation between ICUAP and control patients.ResultsAmong the 95 patients who achieved satisfactory awakening, the incidence
of ICUAP was 25.3% (95% confidence interval [CI], 16.9%-35.2%). All ICUAP
patients had a sensorimotor axonopathy, and all patients who underwent a muscle
biopsy had specific muscle involvement not related to nerve involvement. The
median duration of ICUAP after day 1 was 21 days. Mean (SD) duration of mechanical
ventilation after day 1 was significantly longer in patients with ICUAP compared
with those without (18.2 [36.3] vs 7.6 [19.2] days; P =
.03). Independent predictors of ICUAP were female sex (odds ratio [OR], 4.66;
95% CI, 1.19-18.30), the number of days with dysfunction of 2 or more organs
(OR, 1.28; 95% CI, 1.11-1.49), duration of mechanical ventilation (OR, 1.10;
95% CI, 1.00-1.22), and administration of corticosteroids (OR, 14.90; 95%
CI, 3.20-69.80) before day 1.ConclusionsIdentified using simple bedside clinical criteria, ICUAP was frequent
during recovery from critical illness and was associated with a prolonged
duration of mechanical ventilation. Our findings suggest an important role
of corticosteroids in the development of ICUAP.

/pdf/paresis-acquired-in-the-intensive-care-unit-a-prospective-1qsiegb2rf.pdf

Estelle Renaud

Papers

Paresis acquired in the intensive care unit: a prospective multicenter study.

Paresis Acquired in the Intensive Care Unit

Drivers of predation by pet cats: environment overcomes predator’s intrinsic characteristics