Showing papers in "Critical Care Medicine in 2004"
TL;DR: Evidence-based recommendations can be made regarding many aspects of the acute management of sepsis and septic shock that will hopefully translate into improved outcomes for the critically ill patient.
Abstract: To develop management guidelines for severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis. The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. The modified Delphi methodology used for grading recommendations built upon a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along 5 levels to create recommendation grades from A–E, with A being the highest grade. Pediatric considerations were provided to contrast adult and pediatric management. Participants included 44 critical care and infectious disease experts representing 11 international organizations. A total of 46 recommendations plus pediatric management considerations. Evidence-based recommendations can be made regarding many aspects of the acute management of sepsis and septic shock that will hopefully translate into improved outcomes for the critically ill patient. The impact of these guidelines will be formally tested and guidelines updated annually, and even more rapidly when some important new knowledge becomes available.
3,703 citations
Journal Article•
1,839 citations
TL;DR: The number of RBC transfusions a patient received during the study was independently associated with longer ICU and hospital lengths of stay and an increase in mortality and a nadir hemoglobin level of <9 g/dL was a predictor of increased mortality and length of stay.
Abstract: ObjectiveTo quantify the incidence of anemia and red blood cell (RBC) transfusion practice in critically ill patients and to examine the relationship of anemia and RBC transfusion to clinical outcomes.DesignProspective, multiple center, observational cohort study of intensive care unit (ICU) patient
1,256 citations
TL;DR: The LRINEC score, based on laboratory tests routinely performed for the evaluation of severe soft tissue infections, is a robust score capable of detecting even clinically early cases of necrotizing fasciitis.
Abstract: was used to select significant predictors. Total white cell count, hemoglobin, sodium, glucose, serum creatinine, and C-reactive protein were selected. The LRINEC score was constructed by converting into integer the regression coefficients of independently predictive factors in the multiple logistic regression model for diagnosing necrotizing fasciitis. The cutoff value for the LRINEC score was 6 points with a positive predictive value of 92.0% and negative predictive value of 96.0%. Model performance was very good (Hosmer-Lemeshow statistic, p .910); area under the receiver operating characteristic curve was 0.980 and 0.976 in the developmental and validation cohorts, respectively. Conclusions: The LRINEC score is a robust score capable of detecting even clinically early cases of necrotizing fasciitis. The variables used are routinely measured to assess severe soft tissue infections. Patients with a LRINEC score of >6 should be carefully evaluated for the presence of necrotizing fasciitis. (Crit Care Med 2004; 32:1535‐1541)
1,133 citations
TL;DR: One in five Americans die using ICU services and the doubling of persons over the age of 65 yrs by 2030 will require a system-wide expansion in ICU care for dying patients unless the healthcare system pursues rationing, more effective advanced care planning, and augmented capacity to care for Dying patients in other settings.
Abstract: ObjectiveDespite concern over the appropriateness and quality of care provided in an intensive care unit (ICU) at the end of life, the number of Americans who receive ICU care at the end of life is unknown. We sought to describe the use of ICU care at the end of life in the United States using hospi
1,088 citations
TL;DR: Microcirculatory alterations improve rapidly in septic shock survivors but not in patients dying with multiple organ failure, regardless of whether shock has resolved.
Abstract: Objective:To characterize the time course of microcirculatory alterations and their relation to outcome in patients with septic shock.Design:Prospective, observational study.Setting:Thirty-one-bed, medico-surgical intensive care unit in a university hospital.Patients:Forty-nine patients with septic
1,076 citations
TL;DR: Lactate clearance early in the hospital course may indicate a resolution of global tissue hypoxia and is associated with decreased mortality rate, and patients with higher lactate clearance after 6 hrs of emergency department intervention have improved outcome compared with those with lower lactate cleared.
Abstract: Objective: Serial lactate concentrations can be used to examine disease severity in the intensive care unit. This study examines the clinical utility of the lactate clearance before intensive care unit admission (during the most proximal period of disease presentation) as an indicator of outcome in severe sepsis and septic shock. We hypothesize that a high lactate clearance in 6 hrs is associated with decreased mortality rate. Design: Prospective observational study. Setting: An urban emergency department and intensive care unit over a 1-yr period. Patients: A convenience cohort of patients with severe sepsis or septic shock. Interventions: Therapy was initiated in the emergency department and continued in the intensive care unit, including central venous and arterial catheterization, antibiotics, fluid resuscitation, mechanical ventilation, vasopressors, and inotropes when appropriate. Measurements and Main Results: Vital signs, laboratory values, and Acute Physiology and Chronic Health Evaluation (APACHE) II score were obtained at hour 0 (emergency department presentation), hour 6, and over the first 72 hrs of hospitalization. Therapy given in the emergency department and intensive care unit was recorded. Lactate clearance was defined as the percent decrease in lactate from emergency department presentation to hour 6. Logistic regression analysis was performed to determine independent variables associated with mortality. One hundred and eleven patients were enrolled with mean age 64.9 16.7 yrs, emergency department length of stay 6.3 3.2 hrs, and overall in-hospital mortality rate 42.3%. Baseline APACHE II score was 20.2 6.8 and lactate 6.9 4.6 mmol/L. Survivors compared with nonsurvivors had a lactate clearance of 38.1 34.6 vs. 12.0 51.6%, respectively (p .005). Multivariate logistic regression analysis of statistically significant univariate variables showed lactate clearance to have a significant inverse relationship with mortality (p .04). There was an approximately 11% decrease likelihood of mortality for each 10% increase in lactate clearance. Patients with a lactate clearance >10%, relative to patients with a lactate clearance <10%, had a greater decrease in APACHE II score over the 72-hr study period and a lower 60-day mortality rate (p .007). Conclusions: Lactate clearance early in the hospital course may indicate a resolution of global tissue hypoxia and is associated with decreased mortality rate. Patients with higher lactate clearance after 6 hrs of emergency department intervention have improved outcome compared with those with lower lactate clearance. (Crit Care Med 2004; 32:1637‐1642)
999 citations
TL;DR: Multifaceted interventions that helped to ensure adherence with evidence-based infection control guidelines nearly eliminated CR-BSIs in the authors' surgical ICU.
Abstract: Objective To determine whether a multifaceted systems intervention would eliminate catheter-related bloodstream infections (CR-BSIs). Design Prospective cohort study in a surgical intensive care unit (ICU) with a concurrent control ICU. Setting The Johns Hopkins Hospital. Patients All patients with a central venous catheter in the ICU. Intervention To eliminate CR-BSIs, a quality improvement team implemented five interventions: educating the staff; creating a catheter insertion cart; asking providers daily whether catheters could be removed; implementing a checklist to ensure adherence to evidence-based guidelines for preventing CR-BSIs; and empowering nurses to stop the catheter insertion procedure if a violation of the guidelines was observed. Measurement The primary outcome variable was the rate of CR-BSIs per 1,000 catheter days from January 1, 1998, through December 31, 2002. Secondary outcome variables included adherence to evidence-based infection control guidelines during catheter insertion. Main results Before the intervention, we found that physicians followed infection control guidelines during 62% of the procedures. During the intervention time period, the CR-BSI rate in the study ICU decreased from 11.3/1,000 catheter days in the first quarter of 1998 to 0/1,000 catheter days in the fourth quarter of 2002. The CR-BSI rate in the control ICU was 5.7/1,000 catheter days in the first quarter of 1998 and 1.6/1,000 catheter days in the fourth quarter of 2002 (p = .56). We estimate that these interventions may have prevented 43 CR-BSIs, eight deaths, and 1,945,922 dollars in additional costs per year in the study ICU. Conclusions Multifaceted interventions that helped to ensure adherence with evidence-based infection control guidelines nearly eliminated CR-BSIs in our surgical ICU.
901 citations
TL;DR: The causes of death in the study were consistent with those expected in patients with septic shock, although there was a higher proportion of cardiovascular deaths and a lower incidence of deaths caused by multiple organ failure in the 546C88 group.
Abstract: Objective: To assess the safety and efficacy of the nitric oxide synthase inhibitor 546C88 in patients with septic shock. The predefined primary efficacy objective was survival at day 28. Design: Multiple-center, randomized, two-stage, double-blind, placebo-controlled, safety and efficacy study. Setting: A total of 124 intensive care units in Europe, North America, South America, South Africa, and Australasia. Patients: A total of 797 patients with septic shock diagnosed for <24 hrs. Interventions: Patients with septic shock were allocated to receive 546C88 or placebo (5% dextrose) for up to 7 days (stage 1) or 14 days (stage 2) in addition to conventional therapy. Study drug was initiated at 0.05 mL·kg 1 ·hr 1 (2.5 mg·kg 1 ·hr 1 546C88) and titrated up to a maximum rate of 0.4 mL·kg 1 ·hr 1 to maintain mean arterial pressure between 70 and 90 mm Hg while attempting to withdraw concurrent vasopressors. Measurements and Main Results: Hemodynamic variables, organ function data, microbiological data, concomitant therapy, and adverse event data were recorded at baseline, throughout treatment, and at follow-up. The primary end point was day-28 survival. The trial was stopped early after review by the independent data safety monitoring board. Day-28 mortality was 59% (259/439) in the 546C88 group and 49% (174/358) in the placebo group (p < .001). The overall incidence of adverse events was similar in both groups, although a higher proportion of the events was considered possibly attributable to study drug in the 546C88 group. Most of the events accounting for the disparity between the groups were associated with the cardiovascular system (e.g., decreased cardiac output, pulmonary hypertension, systemic arterial hypertension, heart failure). The causes of death in the study were consistent with those expected in patients with septic shock, although there was a higher proportion of cardiovascular deaths and a lower incidence of deaths caused by multiple organ failure in the 546C88 group. Conclusions: In this study, the nonselective nitric oxide synthase inhibitor 546C88 increased mortality in patients with septic shock. (Crit Care Med 2004; 32:21‐30)
876 citations
TL;DR: Delirium is a common clinical event in mechanically ventilated medicalintensive care unit patients and is associated with significantly higher intensive care unit and hospital costs, which have the potential to improve patient outcomes and reduce costs of care.
Abstract: ObjectiveTo determine the costs associated with delirium in mechanically ventilated medical intensive care unit patients.DesignProspective cohort study.SettingA tertiary care academic hospital.PatientsPatients were 275 consecutive mechanically ventilated medical intensive care unit patients.Interven
746 citations
TL;DR: Normal healthy volunteers demonstrate a lack of correlation between initial central venous pressure/pulmonary artery occlusion pressure and both end-diastolic ventricular volume indexes and stroke volume index, suggesting a more universal phenomenon that includes normal subjects.
Abstract: of normal saline loading correlated well with initial stroke volume index and changes in stroke volume index, respectively. The relationship between left ventricular end-diastolic volume index and stroke volume index was confirmed in group 2 subjects using mathematically independent techniques to measure these variables. In addition, initial central venous pressure, right ventricular end-diastolic volume index, pulmonary artery occlusion pressure, and left ventricular end-diastolic volume index failed to correlate significantly with changes in cardiac performance in response to saline infusion in group 1 subjects. Conclusions: Normal healthy volunteers demonstrate a lack of correlation between initial central venous pressure/pulmonary artery occlusion pressure and both end-diastolic ventricular volume indexes and stroke volume index. Similar results are found with respect to changes in these variables following volume infusion. In contrast, initial enddiastolic ventricular volume indexes and changes in end-diastolic ventricular volume indexes in response to saline loading correlate strongly with initial and postsaline loading changes in cardiac performance as measured by stroke volume index. These data suggest that the lack of correlation of these variables in specific patient groups described in other studies represents a more universal phenomenon that includes normal subjects. Neither central venous pressure nor pulmonary artery occlusion pressure appears to be a useful predictor of ventricular preload with respect to optimizing cardiac performance. (Crit Care Med 2004; 32:691‐699)
TL;DR: The association between the initial tidal volume and the development of acute lung injury suggests that ventilator-associated lung injury may be an important cause of this syndrome.
Abstract: Objective:Although ventilation with small tidal volumes is recommended in patients with established acute lung injury, most others receive highly variable tidal volume aimed in part at normalizing arterial blood gas values. We tested the hypothesis that acute lung injury, which develops after the in
TL;DR: This study demonstrates that the benefits of early tracheotomy outweigh the risks of prolonged translaryngeal intubation, and gives credence to the practice of subjecting this group of critically ill medical patients to early trachotomy rather than delayed tracheotom.
Abstract: Objective: The timing of tracheotomy in patients requiring mechanical ventilation is unknown. The effects of early percutaneous dilational tracheotomy compared with delayed tracheotomy in critically ill medical patients needing prolonged mechanical ventilation were assessed. Design: Prospective, randomized study. Setting: Medical intensive care units. Patients: One hundred and twenty patients projected to need ventilation >14 days. Interventions: None. Measurements and Main Results: Patients were prospectively randomized to either early percutaneous tracheotomy within 48 hrs or delayed tracheotomy at days 14 –16. Time in the intensive care unit and on mechanical ventilation and the cumulative frequency of pneumonia, mortality, and accidental extubation were documented. The airway was assessed for oral, labial, laryngeal, and tracheal damage. Early group showed significantly less mortality (31.7% vs. 61.7%), pneumonia (5% vs. 25%), and accidental extubations compared with the prolonged translaryngeal group (0 vs. 6). The early tracheotomy group spent less time in the intensive care unit (4.8 1.4 vs. 16.2 3.8 days) and on mechanical ventilation (7.6 2.0 vs. 17.4 5.3 days). There was also significantly more damage to mouth and larynx in the prolonged translaryngeal intubation group. Conclusions: This study demonstrates that the benefits of early tracheotomy outweigh the risks of prolonged translaryngeal intubation. It gives credence to the practice of subjecting this group of critically ill medical patients to early tracheotomy rather than delayed tracheotomy. (Crit Care Med 2004; 32:1689 –1694)
TL;DR: Although both intra- and interhospital transport must comply with regulations, it is believed that patient safety is enhanced during transport by establishing an organized, efficient process supported by appropriate equipment and personnel.
Abstract: Objective: The development of practice guidelines for the conduct of intra- and interhospital transport of the critically ill patient. Data Source: Expert opinion and a search of Index Medicus from January 1986 through October 2001 provided the basis for these guidelines. A task force of experts in the field of patient transport provided personal experience and expert opinion. Study Selection and Data Extraction: Several prospective and clinical outcome studies were found. However, much of the published data comes from retrospective reviews and anecdotal reports. Experience and consensus opinion form the basis of much of these guidelines. Results of Data Synthesis: Each hospital should have a formalized plan for intra- and interhospital transport that addresses a) pretransport coordination and communication; b) transport personnel; c) transport equipment; d) monitoring during transport; and e) documentation. The transport plan should be developed by a multidisciplinary team and should be evaluated and refined regularly using a standard quality improvement process. Conclusion: The transport of critically ill patients carries inherent risks. These guidelines promote measures to ensure safe patient transport. Although both intra- and interhospital transport must comply with regulations, we believe that patient safety is enhanced during transport by establishing an organized, efficient process supported by appropriate equipment and personnel. (Crit Care Med 2004; 32:256 ‐262)
TL;DR: The introduction of an intensive care unit-based medical emergency team in a teaching hospital was associated with a reduced incidence of postoperative adverse outcomes, postoperative mortality rate, and mean duration of hospital stay.
Abstract: ObjectiveTo determine whether the introduction of an intensive care unit-based medical emergency team, responding to hospital-wide preset criteria of physiologic instability, would decrease the rate of predefined adverse outcomes in patients having major surgery.DesignProspective, controlled before-
TL;DR: An organized approach to the hemodynamic support of sepsis was formulated, and specific recommendations for fluid resuscitation, vasopressor therapy, and inotropic therapy of septic in adult patients were promulgated.
Abstract: bated, and the task force chairman modified the document until <10% of the experts disagreed with the recommendations. Conclusions: An organized approach to the hemodynamic support of sepsis was formulated. The fundamental principle is that clinicians using hemodynamic therapies should define specific goals and end points, titrate therapies to those end points, and evaluate the results of their interventions on an ongoing basis by monitoring a combination of variables of global and regional perfusion. Using this approach, specific recommendations for fluid resuscitation, vasopressor therapy, and inotropic therapy of septic in adult patients were promulgated. (Crit Care Med 2004; 32:1928 ‐1948)
TL;DR: An inversely proportional relationship between mean intratracheal pressure and coronary perfusion pressure during CPR is demonstrated, demonstrating that professional rescuers consistently hyperventilated patients during out-of-hospital CPR.
Abstract: Context:This translational research initiative focused on the physiology of cardiopulmonary resuscitation (CPR) initiated by a clinical observation of consistent hyperventilation by professional rescuers in out-of-hospital cardiac arrest. This observation generated scientific hypotheses that could o
TL;DR: Survival in critically ill children receiving CVVH in this large series was higher than in previous reports, andCVVH survival may be associated with less percent fluid overload in patients with ≥3-organ MODS.
Abstract: Objective:Continuous venovenous hemofiltration (CVVH) is used for renal replacement and fluid management in critically ill children. A previous small study suggested that survival was associated with less percent fluid overload (%FO) in the intensive care unit (ICU) before hemofiltration. We reviewe
TL;DR: It is suggested that allowing family members more opportunity to speak during conferences may improve family satisfaction, and increased proportion of family speech during ICU family conferences was significantly associated with increased family satisfaction with physician communication.
Abstract: Objective:Family members of critically ill patients report dissatisfaction with family-clinician communication about withdrawing life support, yet limited data exist to guide clinicians in this communication. The hypothesis of this analysis was that increased proportion of family speech during ICU f
TL;DR: CCM is increasingly used and prominent in a shrinking U.S. hospital system and is using proportionally less of national health expenses and the gross domestic product than previously estimated.
Abstract: Objective:To establish a database that permits description and analysis of the evolving role, patterns of use, and costs of critical care medicine (CCM) in the United States from 1985 to 2000.Design:Retrospective study combining data from federal (Hospital Cost Report Information System, Center for
TL;DR: This study confirms previous work showing that delirium is an independent predictor for increased mortality among mechanically ventilated patients.
Abstract: Objectives:To revalidate a means of assessing delirium in intensive care unit patients and to investigate the independent effect of delirium on the mortality of mechanically ventilated patientsDesign:A prospective cohort studySetting:A 37-bed medical intensive care unit of a tertiary care hospital
TL;DR: The apparent success of this on-going multiple-site program, implemented with commercially available equipment, suggests that telemedicine may provide a means for hospitals to achieve quality improvements associated with intensivist care using fewer intensivists.
Abstract: ObjectiveTo examine whether a supplemental remote intensive care unit (ICU) care program, implemented by an integrated delivery network using a commercial telemedicine and information technology system, can improve clinical and economic performance across multiple ICUs.DesignBefore-and-after trial t
TL;DR: Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation reduces intensive care unit length of stay and, in turn, decreases the incidence of complications of critical illness associated with prolonged intubation and mechanical ventilation.
Abstract: Objective:In critically ill patients receiving mechanical ventilation, daily interruption of sedative infusions decreases duration of mechanical ventilation and intensive care unit length of stay. Whether this sedation strategy reduces the incidence of complications commonly associated with critical
TL;DR: In this paper, the authors proposed a scoring system for disseminated intravascular coagulation (DIC) based on activated partial thromboplastin time (aPTT) waveform analysis.
Abstract: Objectives A diagnosis of disseminated intravascular coagulation (DIC) is hampered by the lack of an accurate diagnostic test. Based on the retrospective analysis of studies in patients with DIC, a scoring system (0-8 points) using simple and readily available routine laboratory tests has been proposed. The aim of this study was to prospectively validate this scoring system and assess its feasibility, sensitivity, and specificity in a consecutive series of intensive care patients. Design Prospective cohort of intensive care patients. Setting Adult intensive care unit in a tertiary academic center. Patients Consecutive patients with a clinical suspicion of disseminated intravascular coagulation. Interventions Patients were followed during their admission to the intensive care unit, and the DIC score was calculated every 48 hrs and compared with a "gold standard" based on expert opinion. In addition, an activated partial thromboplastin time (aPTT) waveform analysis, which has been reported to be a good predictor for the absence or presence of DIC, was performed. Measurements and main results We analyzed 660 samples from 217 consecutive patients. The prevalence of DIC was 34%. There was a strong correlation between an increasing DIC score and 28-day mortality (for each 1-point increment in the DIC score, the odds ratio for mortality was 1.25). The sensitivity of the DIC score was 91% and the specificity 97%. An abnormal aPTT waveform was seen in 32% of patients and correlated well with the presence of DIC (sensitivity 88%, specificity 97%). In 19% of patients, the aPTT waveform-based diagnosis of DIC preceded the diagnosis based on the scoring system. Conclusions A diagnosis of DIC based on a simple scoring system, using widely available routine coagulation tests, is sufficiently accurate to make or reject a diagnosis of DIC in intensive care patients with a clinical suspicion of this condition. An aPTT waveform analysis is an interesting and promising tool to assist in the diagnostic management of DIC.
TL;DR: In this setting, brain natriuretic peptide seems useful to detect myocardial dysfunction, and high plasma levels appear to be associated with poor outcome of sepsis, but further studies are needed.
Abstract: ObjectiveTo investigate the value of brain natriuretic peptide plasma levels as a marker of systolic myocardial dysfunction during severe sepsis and septic shock.DesignProspective observational study.SettingIntensive care unit.PatientsA total of 34 consecutive patients with severe sepsis (nine patie
TL;DR: Clinicians caring for patients at risk for HAP/VAP should promote the development and application of local programs encompassing these interventions based on local resource availability, occurrence rates of HAP and VAP, and the prevalence of infection due to antibiotic-resistant bacteria.
Abstract: Objective:To synthesize the available clinical data for the prevention of hospital-associated pneumonia (HAP) and ventilator-associated pneumonia (VAP) into a practical guideline for clinicians.Data Source:A Medline database and references from identified articles were used to perform a literature s
TL;DR: Strong recommendations for research to improve end-of-life care in the ICU via answers to previously identified questions relating to variability in practice, inadequate predictive models for death, elusive knowledge of patient preferences, poor communication between staff and surrogates, insufficient or absent training of healthcare providers, the use of imprecise and insensitive terminology and incomplete documentation in the medical record are made.
Abstract: Objective The purpose of the conference was to provide clinical practice guidance in end-of-life care in the ICU via answers to previously identified questions relating to variability in practice, inadequate predictive models for death, elusive knowledge of patient preferences, poor communication between staff and surrogates, insufficient or absent training of healthcare providers, the use of imprecise and insensitive terminology and incomplete documentation in the medical record. Participants Presenters and jury were selected by the sponsoring organizations (American Thoracic Society, European Respiratory Society, European Society of Intensive Care Medicine, Society of Critical Care Medicine, Societe de Reanimation de Langue Francaise). Presenters were experts on the question they addressed. Jury members were general intensivists without special expertise in the areas considered. Experts presented in an open session to jurors and other healthcare professionals. Evidence Experts prepared review papers on their specific topics in advance of the conference for the jury's reference in developing the consensus statement. Consensus process Jurors heard experts' presentations over 2 days and asked questions of the experts during the open sessions. Jury deliberation with access to the review papers occurred for 2 days following the conference. A writing committee drafted the consensus statement for review by the entire jury. The 5 sponsoring organizations reviewed the document and suggested revisions to be incorporated into the final statement. Conclusions Strong recommendations for research to improve end-of-life care were made. The jury advocates a shared approach to end-of-life decision-making involving the caregiver team and patient surrogates. Respect for patient autonomy and the intention to honor decisions to decline unwanted treatments should be conveyed to the family. The process is one of negotiation, and the outcome will be determined by the personalities and beliefs of the participants. Ultimately, it is the attending physician's responsibility, as leader of the team, to decide on the reasonableness of the planned action. If a conflict cannot be resolved, an ethics consultation may be helpful. The patient must be assured of a pain-free death. The jury subscribes to the moral and legal principles that prohibit administering treatments specifically designed to hasten death. The patient must be given sufficient analgesia to alleviate pain and distress; if such analgesia hastens death, this "double-effect" should not detract from the primary aim to ensure comfort.
TL;DR: In the context of reducing risk of nosocomial bloodstream infections, failing to provide ≥25% of the recommended calories may be harmful and higher caloric goals may be necessary to achieve other clinically important outcomes.
Abstract: Objective: To determine whether caloric intake is associated with risk of nosocomial bloodstream infection in critically ill medical patients. Design: Prospective cohort study. Setting: Urban, academic medical intensive care unit. Patients: Patients were 138 adult patients who did not take food by mouth for >96 hrs after medical intensive care unit admission. Measurements: Daily caloric intake was recorded for each patient. Participants subsequently were grouped into one of four categories of caloric intake: 75% of average daily recommended calories based on the American College of Chest Physicians guidelines. Simplified Acute Physiology Score II and serum albumin were measured on medical intensive care unit admission. Serum glucose (average value and maximum value each day) and route of feeding (enteral, parenteral, or both) were collected daily. Nosocomial bloodstream infections were identified by infection control surveillance methods. Main Results: The overall mean (SD) daily caloric intake for all study participants was 49.4 29.3% of American College of Chest Physicians guidelines. Nosocomial bloodstream infection occurred in 31 (22.4%) participants. Bivariate Cox analysis revealed that receiving >25% of recommended calories compared with 25% of recommended calories was associated with a significantly lower risk of bloodstream infection (relative hazard, 0.27; 95% confidence interval, 0.11– 0.68). Conclusions: In the context of reducing risk of nosocomial bloodstream infections, failing to provide >25% of the recommended calories may be harmful. Higher caloric goals may be necessary to achieve other clinically important outcomes. (Crit Care Med 2004; 32:350 –357)
TL;DR: Afelimomab resulted in a significant reduction in tumor necrosis factor and interleukin-6 levels and a more rapid improvement in organ failure scores compared with placebo, and is safe, biologically active, and well tolerated in patients with severe sepsis.
Abstract: Objective: To evaluate whether administration of afelimomab, an anti-tumor necrosis factor F(ab')2 monoclonal antibody fragment, would reduce 28-day all-cause mortality in patients with severe sepsis and elevated serum levels of IL-6. Design: Prospective, randomized, double-blind, placebo-controlled, multiple-center, phase III clinical trial. Setting: One hundred fifty-seven intensive care units in the United States and Canada. Patients: Subjects were 2,634 patients with severe sepsis secondary to documented infection, of whom 998 had elevated interleukin-6 levels. Interventions: Patients were stratified into two groups by means of a rapid qualitative interleukin-6 test kit designed to identify patients with serum interleukin-6 levels above (test positive) or below (test negative) approximately 1000 pg/mL. Of the 2,634 patients, 998 were stratified into the test-positive group, 1,636 into the test-negative group. They were then randomly assigned 1:1 to receive afelimomab 1 mg/kg or placebo for 3 days and were followed for 28 days. The a priori population for efficacy analysis was the group of patients with elevated baseline interleukin-6 levels as defined by a positive rapid interleukin-6 test result. Measurements and Main Results: In the group of patients with elevated interleukin-6 levels, the mortality rate was 243 of 510 (47.6%) in the placebo group and 213 of 488 (43.6%) in the afelimomab group. Using a logistic regression analysis, treatment with afelimomab was associated with an adjusted reduction in the risk of death of 5.8% (p .041) and a corresponding reduction of relative risk of death of 11.9%. Mortality rates for the placebo and afelimomab groups in the interleukin-6 test negative population were 234 of 819 (28.6%) and 208 of 817 (25.5%), respectively. In the overall population of interleukin-6 test positive and negative patients, the placebo and afelimomab mortality rates were 477 of 1,329 (35.9%)and 421 of 1,305 (32.2%), respectively. Afelimomab resulted in a significant reduction in tumor necrosis factor and interleukin-6 levels and a more rapid improvement in organ failure scores compared with placebo. The safety profile of afelimomab was similar to that of placebo. Conclusions: Afelimomab is safe, biologically active, and well tolerated in patients with severe sepsis, reduces 28-day all-cause mortality, and attenuates the severity of organ dysfunction in patients with elevated interleukin-6 levels. (Crit Care Med 2004; 32:2173‐2182)
TL;DR: Most healthcare professionals consider delirium in the intensive care unit a common and serious problem, although few actually monitor for this condition and most admit that it is underdiagnosed.
Abstract: Objective: Recently published clinical practice guidelines of the Society of Critical Care Medicine recommend monitoring for the presence of delirium in all mechanically ventilated patients because of the potential for adverse outcomes associated with this comorbidity, yet little is known about healthcare professionals’ opinions regarding intensive care unit delirium or how they manage this organ dysfunction. The aim of this survey was to assess the medical community’s beliefs and practices regarding delirium in the intensive care unit. Design: Survey administration was conducted both without a delirium definition (phase 1) and then with a definition of delirium (phase 2). Setting: Critical care meetings and continuing medical education/ board review courses from October 2001 to July 2002 Participants: A convenience sample of physicians (n 753), nurses (n 113), pharmacists (n 13), physician assistants (n 12), respiratory care practitioners (n 8), and others (n 13). Interventions: Survey. Measurements and Main Results: Participants completed 912 of the surveys. The majority (68%) of respondents thought that >25% of adult mechanically ventilated patients experience delirium. Delirium was considered a significant or very serious problem in the intensive care unit by 92% of healthcare professionals, yet underdiagnosis was acknowledged by 78%. Only 40% reported routinely screening for delirium, and only 16% indicated using a specific tool for delirium assessment. Delirium was considered important in the outcome of elderly and young patients by 89% and 60% of the respondents, respectively (p 50 mg/day of either medication. Conclusions: Most healthcare professionals consider delirium in the intensive care unit a common and serious problem, although few actually monitor for this condition and most admit that it is underdiagnosed. Data from this survey point to a disconnect between the perceived significance of delirium in the intensive care unit and current practices of monitoring and treatment. (Crit Care Med 2004; 32:106 –112)