Showing papers in "Critical Care Medicine in 2005"
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3,023 citations
TL;DR: Ventilator-associated pneumonia occurs in a considerable proportion of patients undergoing mechanical ventilation and is associated with substantial morbidity, a two-fold mortality rate, and excess cost, and strategies that effectively prevent VAP are urgently needed.
Abstract: Background:Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in critically ill patients. The clinical and economic consequences of VAP are unclear, with a broad range of values reported in the literatureObjective:To perform a systematic review to determine the incidence o
994 citations
TL;DR: Adverse events and serious errors involving critically ill patients were common and often potentially life-threatening, and failure to carry out intended treatment correctly was the leading category.
Abstract: Objective: Critically ill patients require high-intensity care and may be at especially high risk of iatrogenic injury because they are severely ill. We sought to study the incidence and nature of adverse events and serious errors in the critical care setting. Design: We conducted a prospective 1-year observational study. Incidents were collected with use of a multifaceted approach including direct continuous observation. Two physicians independently assessed incident type, severity, and preventability as well as systems-related and individual performance failures. Setting: Academic, tertiary-care urban hospital. Patients Medical intensive care unit and coronary care unit patients. Interventions: None. Measurements and Main Results: The primary outcomes of interest were the incidence and rates of adverse events and serious errors per 1000 patient-days. A total of 391 patients with 420 unit admissions were studied during 1490 patient-days. We found 120 adverse events in 79 patients (20.2%), including 66 (55%) nonpreventable and 54 (45%) preventable adverse events as well as 223 serious errors. The rates per 1000 patient-days for all adverse events, preventable adverse events, and serious errors were 80.5, 36.2, and 149.7, respectively. Among adverse events, 13% (16/120) were life-threatening or fatal; and among serious errors, 11% (24/223) were potentially life-threatening. Most serious medical errors occurred during the ordering or execution of treatments, especially medications (61%; 170/277). Performance level failures were most commonly slips and lapses (53%; 148/ 277), rather than rule-based or knowledge-based mistakes. Conclusions: Adverse events and serious errors involving critically ill patients were common and often potentially life-threatening. Although many types of errors were identified, failure to carry out intended treatment correctly was the leading category. Copyright © 2005 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.
886 citations
TL;DR: Consensus definitions of infection were developed for the six most frequent causes of infections in septic patients: pneumonia, bloodstream infections (including infective endocarditis), intravascular catheter-related sepsis, intra-abdominal infections, urosepsi, and surgical wound infections.
Abstract: refined and improved during discussion. Modifications were circulated electronically and subsequently agreed upon as part of an iterative process until consensus was reached. Result: Consensus definitions of infection were developed for the six most frequent causes of infections in septic patients: pneumonia, bloodstream infections (including infective endocarditis), intravascular catheter-related sepsis, intra-abdominal infections, urosepsis, and surgical wound infections. Conclusions: We have described standardized definitions of the common sites of infection associated with sepsis in critically ill patients. Use of these definitions in clinical trials should help improve the quality of clinical research in this field. (Crit Care Med 2005; 33:1538‐1548)
782 citations
TL;DR: Intensive care unit costs are highest during the first 2 days of admission, stabilizing at a lower level thereafter, and the mean incremental cost of mechanical ventilation in intensive care unit patients was $1,522 per day (p < .001).
Abstract: Objective:To quantify the mean daily cost of intensive care, identify key factors associated with increased cost, and determine the incremental cost of mechanical ventilation during a day in the intensive care unit.Design:Retrospective cohort analysis using data from NDCHealth’s Hospital Patient Lev
768 citations
TL;DR: Clinicians can diagnose and report TRALI cases to the blood bank and researchers can use this definition to determine incidence, pathophysiology, and strategies to prevent this leading cause of transfusion-associated mortality.
Abstract: Background:Transfusion-related acute lung injury (TRALI) is now the leading cause of transfusion-associated mortality, even though it is probably still underdiagnosed and underreported.National Heart, Lung, and Blood Institute Action:The National Heart, Lung, and Blood Institute convened a working g
668 citations
TL;DR: In patients with acute lung injury, plasma interleukin-6 and interleucin-8 levels are associated with morbidity and mortality, suggesting that clinical risk factor should be considered when both developing and testing therapeutic interventions.
Abstract: Objectives:To evaluate the association between interleukin-6, interleukin-8, and interleukin-10 and clinical outcomes including mortality in patients with acute lung injury and to determine whether lower tidal volume ventilation was associated with a decrease in plasma cytokines in patients with acu
664 citations
TL;DR: The mean intraabdominal pressure on admission was not an independent risk factor for mortality; however, the occurrence of intraabDominal hypertension during the intensive care unit stay was an independent outcome predictor.
Abstract: Objective: Intraabdominal hypertension is associated with significant morbidity and mortality in surgical and trauma patients. The aim of this study was to assess, in a mixed population of critically ill patients, whether intraabdominal pressure at admission was an independent predictor for mortality and to evaluate the effects of intraabdominal hypertension on organ functions. Design: Multiple-center, prospective epidemiologic study. Setting: Fourteen intensive care units in six countries. Patients: A total of 265 consecutive patients admitted for >24 hrs during the 4-wk study period. Interventions: None. Measurements and Main Results: Intraabdominal pressure was measured twice daily via the bladder. Data recorded on admission were the patient demographics with Simplified Acute Physiology Score II, Acute Physiology and Chronic Health Evaluation II score, and type of admission; during intensive care stay, Sepsis-Related Organ Failure Assessment score and intraabdominal pressure were measured daily together with fluid balance. Nonsurvivors had a significantly higher mean intraabdominal pressure on admission than survivors: 11.4 4.8 vs. 9.5 4.8 mm Hg. Independent predictors for mortality were age (odds ratio, 1.04; 95% confidence interval, 1.01‐1.06; p .003), Acute Physiology and Chronic Health Evaluation II score (odds ratio, 1.1; 95% confidence interval, 1.05‐1.15; p < .0001), type of intensive care unit admission (odds ratio, 2.5 medical vs. surgical; 95% confidence interval, 1.24‐5.16; p .01), and the presence of liver dysfunction (odds ratio, 2.5; 95% confidence interval, 1.06‐5.8; p .04). The occurrence of intraabdominal hypertension during the intensive care unit stay was also an independent predictor of mortality (relative risk, 1.85; 95% confidence interval, 1.12‐3.06; p .01). Patients with intraabdominal hypertension at admission had significantly higher Sepsis-Related Organ Failure Assessment scores during the intensive care unit stay than patients without intraabdominal hypertension. Conclusions: Intraabdominal hypertension on admission was associated with severe organ dysfunction during the intensive care unit stay. The mean intraabdominal pressure on admission was not an independent risk factor for mortality; however, the occurrence of intraabdominal hypertension during the intensive care unit stay was an independent outcome predictor. (Crit Care Med 2005; 33:315‐322)
632 citations
TL;DR: For the diagnosis of occult pneumothorax, ultrasound can decrease the need for computed tomography, and this study concluded that lung ultrasound could be of any help in this situation.
Abstract: Objectives:Pneumothorax can be missed by bedside radiography, and computed tomography is the current alternative. We asked whether lung ultrasound could be of any help in this situation.Design:Retrospective study.Setting:The medical intensive care unit of a university-affiliated teaching hospital.Pa
556 citations
TL;DR: Hypoxia-inducible factor-1 (HIF-1) is a transcription factor that acts as a master regulator of gene expression induced by low oxygen conditions (hypoxia) and broadly include those involved in oxygen homeostasis and glucose-energy metabolism.
Abstract: Hypoxia-inducible factor-1 (HIF-1) is a transcription factor that acts as a master regulator of gene expression induced by low oxygen conditions (hypoxia) (1). Genes regulated by HIF-1 broadly include those involved in oxygen homeostasis and glucose-energy metabolism. Some genes regulated by HIF help to augment tissue oxygen supply, while others confer increased tolerance to severe oxygen deprivation (2). The protective effects induced by HIF are not immediate, since the response to HIF activation requires de novo transcription and translation of new proteins. Hence, HIF activation is an anticipatory response that begins with even mild hypoxia. HIF-1 is a heterodimer consisting of and subunits. Both proteins are constitutively expressed, but the subunit protein is rapidly degraded by the 28S proteasomal system under normoxic conditions (3). Under hypoxic conditions, degradation of HIF-1 is inhibited, allowing the protein to accumulate in the cell, heterodimerize, relocate to the nucleus, and activate transcription.
503 citations
TL;DR: Mild therapeutic hypothermia improves short-term neurologic recovery and survival in patients resuscitated from cardiac arrest of presumed cardiac origin and its long-term effectiveness and feasibility at an organizational level need further research.
Abstract: Objective: Only a few patients survive cardiac arrest with favorable neurologic recovery. Our objective was to assess whether induced hypothermia improves neurologic recovery in survivors of primary cardiac arrest. Data Source: Studies were identified by a computerized search of MEDLINE, EMBASE, CINAHL, PASCAL, the Cochrane Controlled Trial Register, and BIOSIS. Study Selection: We included randomized and quasi-randomized, controlled trials of adults who were successfully resuscitated, where therapeutic hypothermia was applied within 6 hrs after arrival at the emergency department and where the neurologic outcome was compared. We excluded studies without a control group and studies with historical controls. Data Extraction: All authors of the identified trials supplied individual patient data with a predefined set of variables. Data Synthesis: We identified three randomized trials. The analyses were conducted according to the intention-to-treat principle. Summary odds ratios were calculated using a random effects model and translated into risk ratios. More patients in the hypothermia group were discharged with favorable neurologic recovery (risk ratio, 1.68; 95% confidence interval, 1.29‐2.07). The 95% confidence interval of the number-needed-to-treat to allow one additional patient to leave the hospital with favorable neurologic recovery was 4‐13. One study followed patients to 6 months or death. Being alive at 6 months with favorable functional neurologic recovery was more likely in the hypothermia group (risk ratio, 1.44; 95% confidence interval, 1.11‐1.76). Conclusions: Mild therapeutic hypothermia improves shortterm neurologic recovery and survival in patients resuscitated from cardiac arrest of presumed cardiac origin. Its long-term effectiveness and feasibility at an organizational level need further research. (Crit Care Med 2005; 33:414‐418)
TL;DR: NIV was more effective than SMT in preventing postextubation respiratory failure in a population considered at risk of developing this complication and resulted in a reduction of risk of intensive care unit mortality.
Abstract: Objective:Compared with standard medical therapy (SMT), noninvasive ventilation (NIV) does not reduce the need for reintubation in unselected patients who develop respiratory failure after extubation. The goal of this study was to assess whether early application of NIV, immediately after extubation
TL;DR: Packed red blood cell transfusion was associated with an increased development of and increased mortality in ARDS and was described here the clinical predictors of ARDS risk and mortality including the role of red cell transfusions.
Abstract: Objective: Clinical predictors for acute respiratory distress syndrome (ARDS) have been studied in few prospective studies. Although transfusions are common in the intensive care unit, the role of submassive transfusion in non-trauma-related ARDS has not been studied. We describe here the clinical predictors of ARDS risk and mortality including the role of red cell transfusion. Design: Observational prospective cohort. Selling: Intensive care unit of Massachusetts General Hospital. Patients: We studied 688 patients with sepsis, trauma, aspiration, and hypertransfusion. Interventions: None. Measurements and Main Results: Two hundred twenty-one (32%) subjects developed ARDS with a 60-day mortality rate of 46%. Significant predictors for ARDS on multivariate analyses included trauma (adjusted odds ratio [OR adj ] 0.22, 95% confidence interval [Cl] 0.09-0.53), diabetes (OR adj 0.58, 95% Cl 0.36-0.92), direct pulmonary injury (OR adj 3.78, 95% Cl 2.45-5.81), hematologic failure (OR adj 1.84, 95% Cl 1.05-3.21), transfer from another hospital (OR adj 2.08, 95% Cl 1.33-3.25), respiratory rate >33 breaths/min (OR adj 2.39, 95% Cl 1.51-3.78), hematocrit >37.5% (OR adj 1.77,95% Cl 1.14-2.77), arterial pH <7.33 (OR adj 2.00,95% Cl 1.31-3.05), and albumin ≤2.3 g/dL (OR adj 1.80, 95% Cl 1.18-2.73). Packed red blood cell transfusion was associated with ARDS (OR adj 1.52, 95% Cl 1.00-2.31, p =.05). Significant predictors for mortality in ARDS included age (OR adj 1.96, 95% Cl 1.50-2.53), Acute Physiology and Chronic Health Evaluation III score (OR adj 1.78, 95% Cl 1.16-2.73), trauma (OR adj 0.075, 95% Cl 0.006-0.96), corticosteroids before ARDS (OR adj 4.65, 95% Cl 1.47-14.7), and arterial pH <7.22 (OR adj 2.32, 95% Cl 1.02-5.25). Packed red blood cell transfusions were associated with increased mortality in ARDS (OR adj 1.10 per unit transfused; 95% Cl 1.04-1.17) with a significant dose-dependent response (p =.02). Conclusions: Important predictors for the development of and mortality in ARDS were identified. Packed red blood cell transfusion was associated with an increased development of and increased mortality in ARDS.
TL;DR: This study found no predictable correlation between serum levels of HMGB1 and severity of infection, and levels remained high in the majority of patients up to 1 wk after admittance, indicating that the cytokine indeed is a downstream and late mediator of inflammation.
Abstract: Objective: To study the systemic release and kinetics of high mobility group box-1 protein (HMGB1) in relation to clinical features in a population of patients with severe sepsis or septic shock and to compare these with the kinetics of the cytokines interleukin-6, interleukin-8, interleukin-10, and tumor necrosis factor-. Design: Prospective study of two cohorts of patients. Setting: Intensive care unit and infectious disease clinic at Karolinska University Hospital Huddinge. Patients: Twenty-six patients with severe sepsis, 33 patients with septic shock, and a reference group of five patients with sepsis. Interventions: None. Measurements and Main Results: Sixty-four patients were included, ten of whom died within 28 days. Cytokine levels were measured at five time points during the first week after admission and were correlated to Acute Physiology and Chronic Health Evaluation II and Sepsis-related Organ Failure Assessment scores. Two HMGB1 assays were used. Both demonstrated delayed kinetics for HMGB1 with high levels on inclusion that remained high throughout the study period. Serum concentration at 144 hrs, the last sampling point, was 300 times higher, 34,000 76,000 pg/mL (mean SD), than any of the other cytokines. This study, however, found no predictable correlation between serum levels of HMGB1 and severity of infection. We did quite unexpectedly find significantly lower levels of HMGB1 in nonsurvivors compared with survivors as measured by our main assay, but the other showed no difference between the two groups. Levels of interleukin-6, interleukin-8, interleukin-10, and tumor necrosis factor- correlated significantly with severity of disease, and all were significantly higher in patients with septic shock compared with those with severe sepsis. Neither of these comparisons showed significant correlations for HMGB1. Conclusions: This is the first prospective study assessing the release over time of HMGB1 in a population of patients with sepsis, severe sepsis, or septic shock. Levels remained high in the majority of patients up to 1 wk after admittance, indicating that the cytokine indeed is a downstream and late mediator of inflammation. Further studies are required to fully define the relationship of HMGB1 to severity of disease. (Crit Care Med 2005; 33:564‐573)
TL;DR: Acute, short-term hyperglycemia affects all major components of innate immunity and impairs the ability of the host to combat infection, even though certain distinctive proinflammatory alterations of the immune response can be observed under these conditions.
Abstract: Objective:To extract from the biomedical literature the reported effects of acute hyperglycemia on the major components of the innate immune system and to describe the clinical benefits of strict blood glucose control in certain patients.Data Source and Selection:A Medline/PubMed search (1966 to Jul
TL;DR: The magnitude of the differences in the glucose values offered by the four different methods of glucose measurement led to frequent clinical disagreements regarding insulin dose titration in the context of an insulin infusion protocol for aggressive glucose control.
Abstract: Background: Glycemic control is increasingly being recognized as a priority in the treatment of critically ill patients. Titration and monitoring of insulin infusions involve frequent blood glucose measurement to achieve target glucose ranges and prevent adverse events related to hypoglycemia. Therefore, it is imperative that bedside glucose testing methods be safe and accurate. Objective: To determine the accuracy and clinical impact of three common methods of bedside point-of-care testing for glucose measurements in critically ill patients receiving insulin infusions. Design: Prospective observational study. Setting: A 21-bed mixed medical/surgical intensive care unit of a tertiary care teaching hospital. Patients: Thirty consecutive critically ill patients who were vasopressor-dependent (n = 10), had significant peripheral edema (n = 10), or were admitted following major surgery (n = 10). Measurements: Findings from three different methods of glucose measurement were compared with central laboratory measurements: (1) glucose meter analysis of capillary blood (finger-stick); (2) glucose meter analysis of arterial blood; and (3) blood gas/chemistry analysis of arterial blood. Patients were enrolled for a maximum of 3 days and had a maximum of nine sets of measurements determined during this time. Results: Clinical agreement with the central laboratory was significantly better with arterial blood analysis (69.9% and 76.5% for glucose meter and blood gas/chemistry analysis, respectively) than with capillary blood analysis (56.8%; p = .039 and .001, respectively). During hypoglycemia, clinical agreement was only 26.3% with capillary blood analysis and 55.6% and 64.9% for glucose meter and blood gas/chemistry analysis of arterial blood (p = .010 and <.001, respectively). Glucose meter analysis of both arterial and capillary blood tended to provide higher glucose values, whereas blood gas/chemistry analysis of arterial blood tended to yield lower glucose values. Conclusions: The magnitude of the differences in the glucose values offered by the four different methods of glucose measurement led to frequent clinical disagreements regarding insulin dose titration in the context of an insulin infusion protocol for aggressive glucose control.
TL;DR: The pathogenic role of Mif in inflammatory disease is discussed and the novel structural, functional, and mechanistic properties of MIF are highlighted.
Abstract: Macrophage migration inhibitory factor (MIF) has been proposed to be the physiologic counter-regulator of glucocorticoid action within the immune system. In this role, MIF's position within the cytokine cascade is to act in concert with glucocorticoids to control both the "set point" and the magnitude of the inflammatory response. As well as overriding the immunosuppressive effects of glucocorticoids, it is now well established that MIF has a direct proinflammatory role in inflammatory diseases, such as sepsis, rheumatoid arthritis, and glomerulonephritis. The functions of MIF within the immune system are both unique and diverse, and although a unified molecular mechanism of action remains to be elucidated, there have been significant advances in our understanding of how MIF affects cellular processes. This review discusses the pathogenic role of MIF in inflammatory disease and highlights the novel structural, functional, and mechanistic properties of MIF.
TL;DR: Despite universal thromboprophylaxis, medical-surgical critically ill patients remain at risk for lower extremity deep venousThrombosis, and further research is needed to evaluate the risks and benefits of more intense venous thromboembolism prophylaxis.
Abstract: Objective: Critically ill patients may be at high risk of venous thromboembolism. The objective was to determine the prevalence, incidence, and risk factors for proximal lower extremity deep venous thrombosis among critically ill medical-surgical patients. Design: Prospective cohort. Setting: Closed university-affiliated intensive care unit. Patients: We enrolled consecutive patients >18 yrs of age expected to be in intensive care unit for >72 hrs. Exclusion criteria were an admitting diagnosis of trauma, orthopedic surgery, pregnancy, and life support withdrawal. Interventions: Interventions included bilateral lower extremity compression ultrasound within 48 hrs of intensive care unit admission, twice weekly, and if venous thromboembolism was clinically suspected. Thromboprophylaxis was protocol directed and universal. We recorded deep venous thrombosis risk factors at baseline and daily, using multivariate regression analysis to determine independent predictors. Patients were followed to hospital discharge. Results: Among 261 patients with a mean Acute Physiology and Chronic Health Evaluation II score of 25.5 (8.4), the prevalence of deep venous thrombosis was 2.7% (95% confidence interval 1.1‐5.5) on intensive care unit admission, and the incidence was 9.6% (95% confidence interval 6.3‐13.8) over the intensive care unit stay. We identified four independent risk factors for intensive care unit-acquired deep venous thrombosis: personal or family history of venous thromboembolism (hazard ratio 4.0, 95% confidence interval 1.5‐ 10.3), end-stage renal failure (hazard ratio 3.7, 95% confidence interval 1.2‐11.1), platelet transfusion (hazard ratio 3.2, 95% confidence interval 1.2‐8.4), and vasopressor use (hazard ratio 2.8, 95% confidence interval 1.1‐7.2). Patients with deep venous thrombosis had a longer duration of mechanical ventilation (p .03), intensive care unit stay (p .005), and hospitalization (p < .001) than patients without deep venous thrombosis. Conclusions: Despite universal thromboprophylaxis, medicalsurgical critically ill patients remain at risk for lower extremity deep venous thrombosis. Further research is needed to evaluate the risks and benefits of more intense venous thromboembolism prophylaxis. (Crit Care Med 2005; 33:1565‐1571)
TL;DR: A review of the literature regarding ovarian hyperstimulation syndrome (OHSS) can be found in this article, which is a rare Iatrogenic complication of ovarian stimulation usually occurring during the luteal phase or during the early part of pregnancy.
Abstract: Objective: Ovarian hyperstimulation syndrome (OHSS) is a rare iatrogenic complication of ovarian stimulation usually occurring during the luteal phase or during the early part of pregnancy. OHSS is a potential complication of ovarian induction by almost every agent used for ovarian stimulation. Today, due to aggressive treatment protocols including the development of in vitro fertilization and cryopreservation with the goal of obtaining sufficient numbers of oocytes and embryos, an increased risk of developing OHSS is present. OHSS is now becoming increasingly more recognized due to the higher number of women undergoing assisted reproductive techniques. Design: Review of the literature regarding ovarian hyperstimulation syndrome. Methods: A review of the epidemiology, pathophysiology, risk factors, classification, clinical features, and treatment and prevention of OHSS. Conclusion: OHSS can be thought of as the loss of control over the hyperstimulation of the ovaries. Although the prevalence of the severe form of OHSS is small, it is important to remember that OHSS is usually an iatrogenic complication of a nonvital treatment that has the potential for a fatal outcome. Therefore, critical care physicians play an integral part in the care of these patients and therefore should be familiar with and recognize the various clinical manifestations and potential outcomes of this entity.
TL;DR: Results suggest that outcomes for patients with severe sepsis are closely related to early (baseline to day 1 here) improvement, or lack thereof, in organ function, and clinical improvement on subsequent days may have little additional impact on the likelihood of survival.
Abstract: Objective:Early identification and treatment of severe sepsis can significantly reduce mortality rate. We hypothesized that a risk prediction model based on early (baseline to day 1 of study) response to standard care should be significantly related to 28-day survival.Design:Analysis of organ dysfun
TL;DR: Although early EN significantly reduced complication rates, this needs to be interpreted in the light of missing data and heterogeneity, and the enthusiasm that early EN, as compared with early PN, would reduce mortality appears misplaced.
Abstract: Objective Nutritional support as enteral or parenteral nutrition (PN) is used in hospitalized patients to reduce catabolism. This study compares outcomes of early enteral nutrition (EN) with early PN in hospitalized patients. Design The authors conducted a metaanalysis of randomized, controlled trials (RCT) comparing early EN with PN. Studies on immunonutrition were excluded. Studies were categorized as medical, surgical, or trauma. Patients RCTs of early EN/PN were identified by search of 1) MEDLINE (1966-2002), 2) published abstracts from scientific meetings, and 3) bibliographies of relevant articles. Measurements and main results Thirty RCTs (ten medical, 11 surgical, and nine trauma) compared early EN with PN. The effect of nutrition type on hospital mortality and complication rates was reported as risk difference (RD%) and hospital length of stay (LOS) as mean weighted difference (MWD days). Missing data, by outcomes, varied from 20% to 63%. As a result of heterogeneity of treatment effects, the DerSimonian-Laird random-effects estimator was reported. There was no differential treatment effect of nutrition type on hospital mortality for all patients (0.6%, p = .4) and subgroups. PN was associated with increases in infective complications (7.9%, p = .001), catheter-related blood stream infections (3.5%, p = .003), noninfective complications (4.9%, p = .04), and hospital LOS (1.2 days, p = .004). There was no effect of nutrition type on technical complications (4.1%, p = .2). EN was associated with a significant increase in diarrheal episodes (8.7%, p = .001). Publication bias was not demonstrated. Metaanalytic regression analysis did not demonstrate any effect of age, time to initiate treatment, and average albumin on mortality estimates. Cumulative metaanalysis showed no change in the mortality estimates with time. Conclusion There was no mortality effect with the type of nutritional supplementation. Although early EN significantly reduced complication rates, this needs to be interpreted in the light of missing data and heterogeneity. The enthusiasm that early EN, as compared with early PN, would reduce mortality appears misplaced.
TL;DR: Over a wide range of RV, increasing from 0 mL to >400 mL, the frequency of regurgitation and aspiration did not change appreciably, and bowel function scores did not correlate with the incidence of aspiration or Regurgitation.
Abstract: Background and Aims:Elevated residual volumes (RV), considered a marker for the risk of aspiration, are used to regulate the delivery of enteral tube feeding. We designed this prospective study to validate such use.Methods:Critically ill patients undergoing mechanical ventilation in the medical, cor
TL;DR: ENHANCE provides supportive evidence for the favorable benefit/risk ratio observed in PROWESS and suggests that more effective use of drotrecogin alfa (activated) might be obtained by initiating therapy earlier.
Abstract: Objective:To provide further evidence for the efficacy and safety of drotrecogin alfa (activated) treatment in severe sepsis.Design:Single-arm, open-label, trial of drotrecogin alfa (activated) treatment in severe sepsis patients. Enrollment began in March 2001 and day-28 follow-up completed in Janu
TL;DR: Hemodynamic improvement seemed to be related to endogenous cortisol levels, whereas immune effects appeared to be independent of adrenal reserve, suggesting both hemodynamic and immunomodulatory effects of steroid treatment.
Abstract: Objectives:To investigate the effect of low-dose hydrocortisone on time to shock reversal, the cytokine profile, and its relation to adrenal function in patients with early septic shock.Design:Prospective, randomized, double-blind, single-center study.Setting:Medical intensive care unit of a univers
TL;DR: Recombinant factor VIIa appears to be relatively safe with a 1–2% incidence of thrombotic complications based on published trials, and off-label use of recombinantfactor VIIa may be considered in patients with life-threatening bleeding.
Abstract: Background:Recombinant activated factor VII (factor VIIa) is a prohemostatic agent that can be used for patients with complicated coagulation disorders. Recombinant factor VIIa is, however, increasingly used for several other indications, including patients with a preexistent normal coagulation syst
TL;DR: In critically ill septic patients, critical illness polyneuropathy significantly increases the duration of mechanical ventilation and prolongs the lengths of intensive care unit and hospital stays.
Abstract: Objectives:No previous study has demonstrated whether critical illness polyneuropathy itself lengthens mechanical ventilation or whether this prolonged duration of ventilatory support is explained by concomitant risk factors for weaning failure. Our objectives were to evaluate the impact of critical
TL;DR: Increasing mean arterial pressure from 65 to 85 mm Hg with norepinephrine neither affects metabolic variables nor improves renal function.
Abstract: Objective:To measure the effects of increasing mean arterial pressure on oxygen variables and renal function in septic shock.Design:Prospective, open-label, randomized, controlled study.Setting:Medical-surgical intensive care unit of a tertiary care teaching hospital.Patients:Twenty-eight patients w
TL;DR: Intravenous medication errors and adverse drug events were frequent and could be detected using smart pumps, but there was no measurable impact on the serious medication error rate.
Abstract: Verpleegkundigen gebruikten de bypassmodule te vaak om de geneesmiddelenbibliotheek niet te hoeven gebruiken en negeerden het alarm bij overschrijding van de door de computer geindiceerde limieten. De onderzoeksresultaten zijn waarschijnlijk beinvloed door de volgende factoren. Complexe, computergestuurde pompsystemen vereisten een intensievere training van verpleegkundigen. Door te weinig ervaring werd te vaak de bibliotheekfunctie omzeild en ook omdat alarmeringen van limietoverschrijdingen veel te vaak voorkwamen, werd deze functie niet meer serieus genomen.
TL;DR: Airway pressure release ventilation may offer potential clinical advantages for ventilator management of acute lung injury/acute respiratory distress syndrome and may be considered as an alternative “open lung approach” to mechanical ventilation.
Abstract: Objective:To review the use of airway pressure release ventilation (APRV) in the treatment of acute lung injury/acute respiratory distress syndrome.Data Source:Published animal studies, human studies, and review articles of APRV.Data Summary:APRV has been successfully used in neonatal, pediatric, an
TL;DR: The addition of albumin to furosemide therapy in hypoproteinemic patients with acute lung injury/acute respiratory distress syndrome significantly improves oxygenation, with greater net negative fluid balance and better maintenance of hemodynamic stability.
Abstract: Objective Hypoproteinemia is a common condition in critically ill patients, associated with the development of acute lung injury and acute respiratory distress syndrome and subsequent worse clinical outcomes. Albumin with furosemide benefits lung physiology in hypoproteinemic patients with acute lung injury/acute respiratory distress syndrome, but the independent pharmacologic effects of these drugs are unknown. Design Randomized, double-blinded, placebo-controlled multicentered trial. Setting Eleven medical, surgical, and trauma intensive care units including 190 beds within two university hospital systems. Patients Forty mechanically ventilated patients with acute lung injury/acute respiratory distress syndrome, whose serum total protein concentrations were Interventions Subjects were equally randomly allocated to receive furosemide with albumin or furosemide with placebo for 72 hrs, titrated to fluid loss and normalization of serum total protein concentration. Measurements and main results The primary outcome was change in oxygenation from baseline to day 1, with secondary physiologic and clinical outcomes. There were no differences in baseline characteristics of the subjects in relation to group assignment. Albumin-treated patients had greater increases in oxygenation (mean change in Pao2/Fio2: +43 vs. -24 mm Hg at 24 hrs and +49 vs. -13 mm Hg at day 3), serum total protein (1.5 vs. 0.5 g/dL at day 3), and net fluid loss (-5480 vs. -1490 mL at day 3) throughout the study period (all p Conclusions The addition of albumin to furosemide therapy in hypoproteinemic patients with acute lung injury/acute respiratory distress syndrome significantly improves oxygenation, with greater net negative fluid balance and better maintenance of hemodynamic stability. Additional randomized clinical trials are necessary to examine mechanisms and determine the effect on important clinical outcomes, such as the duration of mechanical ventilation.