Showing papers in "Critical Care Medicine in 2008"

Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2008

Abstract: Objective:To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” published in 2004.Design:Modified Delphi method with a consensus conference of 55 international experts, s

Early intensive care unit mobility therapy in the treatment of acute respiratory failure

Abstract: Objective:Immobilization and subsequent weakness are consequences of critical illness. Despite the theoretical advantages of physical therapy to address this problem, it has not been shown that physical therapy initiated in the intensive care unit offers benefit.Design and Setting:Prospective cohort

Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College of Critical Care Medicine

Abstract: Background: These recommendations have been developed to improve the care of intensive care unit (ICU) patients during the dying process. The recommendations build on those published in 2003 and highlight recent developments in the field from a U.S. perspective. They do not use an evidence grading system because most of the recommendations are based on ethical and legal principles that are not derived from empirically based evidence. Principal Findings: Family-centered care, which emphasizes the importance of the social structure within which patients are embedded, has emerged as a comprehensive ideal for managing end-of-life care in the ICU. ICU clinicians should be competent in all aspects of this care, including the practical and ethical aspects of withdrawing different modalities of life-sustaining treatment and the use of sedatives, analgesics, and nonpharmacologic approaches to easing the suffering of the dying process. Several key ethical concepts play a foundational role in guiding end-oflife care, including the distinctions between withholding and withdrawing treatments, between actions of killing and allowing to die, and between consequences that are intended vs. those that are merely foreseen (the doctrine of double effect). Improved communication with the family has been shown to improve patient care and family outcomes. Other knowledge unique to endof-life care includes principles for notifying families of a patient’s death and compassionate approaches to discussing options for organ donation. End-of-life care continues even after the death of the patient, and ICUs should consider developing comprehensive bereavement programs to support both families and the needs of the clinical staff. Finally, a comprehensive agenda for improving end-of-life care in the ICU has been developed to guide research, quality improvement efforts, and educational curricula. Conclusions: End-of-life care is emerging as a comprehensive area of expertise in the ICU and demands the same high level of knowledge and competence as all other areas of ICU practice. (Crit Care Med 2008; 36:953‐963)

Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature.

Abstract: Background Red blood cell (RBC) transfusions are common in intensive care unit, trauma, and surgical patients. However, the hematocrit that should be maintained in any particular patient because the risks of further transfusion of RBC outweigh the benefits remains unclear. Objective A systematic review of the literature to determine the association between red blood cell transfusion, and morbidity and mortality in high-risk hospitalized patients. Data sources MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles. Study selection Cohort studies that assessed the independent effect of RBC transfusion on patient outcomes. From 571 articles screened, 45 met inclusion criteria and were included for data extraction. Data extraction Forty-five studies including 272,596 were identified (the outcomes from one study were reported in four separate publications). The outcome measures were mortality, infections, multiorgan dysfunction syndrome, and acute respiratory distress syndrome. The overall risks vs. benefits of RBC transfusion on patient outcome in each study was classified as (i) risks outweigh benefits, (ii) neutral risk, and (iii) benefits outweigh risks. The odds ratio and 95% confidence interval for each outcome measure was recorded if available. The pooled odds ratios were determined using meta-analytic techniques. Data synthesis Forty-five observational studies with a median of 687 patients/study (range, 63-78,974) were analyzed. In 42 of the 45 studies the risks of RBC transfusion outweighed the benefits; the risk was neutral in two studies with the benefits outweighing the risks in a subgroup of a single study (elderly patients with an acute myocardial infarction and a hematocrit Conclusions Despite the inherent limitations in the analysis of cohort studies, our analysis suggests that in adult, intensive care unit, trauma, and surgical patients, RBC transfusions are associated with increased morbidity and mortality and therefore, current transfusion practices may require reevaluation. The risks and benefits of RBC transfusion should be assessed in every patient before transfusion.

Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: consensus statements from an international task force by the American College of Critical Care Medicine.

Abstract: Objective:To develop consensus statements for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients.Participants:A multidisciplinary, multispecialty task force of experts in critical care medicine was convened from the membership of the Society of Critical Car

Glycemic variability: a strong independent predictor of mortality in critically ill patients.

Abstract: Objectives:To determine the effect of glycemic variability, assessed by the standard deviation of each patient’s mean glucose level, on mortality in a population of critically ill adult patients.Design:Retrospective review of a large cohort of prospectively evaluated patients.Setting:Fourteen-bed me

Variation in critical care services across North America and Western Europe.

Abstract: Objective:Critical care represents a large percentage of healthcare spending in developed countries. Yet, little is known regarding international variation in critical care services. We sought to understand differences in critical care delivery by comparing data on the distribution of services in ei

Outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock*

Abstract: Objective:To assess the outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation (ECMO) for refractory cardiogenic shock.Design, Setting, and Patients:Refractory cardiogenic shock is almost always lethal without emergency circulatory support, e.g., ECMO. EC

Procalcitonin assay in systemic inflammation, infection, and sepsis: clinical utility and limitations.

Abstract: Objective:The use of procalcitonin (ProCT) as a marker of several clinical conditions, in particular, systemic inflammation, infection, and sepsis, will be clarified, and its current limitations will be delineated. In particular, the need for a more sensitive assay will be emphasized. For these purp

Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America.

Abstract: Objective: To update the practice parameters for the evaluation of adult patients who develop a new fever in the intensive care unit, for the purpose of guiding clinical practice. Participants: A task force of 11 experts in the disciplines related to critical care medicine and infectious diseases was convened from the membership of the Society of Critical Care Medicine and the Infectious Diseases Society of America. Specialties represented included critical care medicine, surgery, internal medicine, infectious diseases, neurology, and laboratory medicine/microbiology. Evidence: The task force members provided personal experience and determined the published literature (MEDLINE articles, textbooks, etc.) from which consensus was obtained. Published literature was reviewed and classified into one of four categories, according to study design and scientific value. Consensus Process: The task force met twice in person, several times by teleconference, and held multiple e-mail discussions during a 2-yr period to identify the pertinent literature and arrive at consensus recommendations. Consideration was given to the relationship between the weight of scientific evidence and the strength of the recommendation. Draft documents were composed and debated by the task force until consensus was reached by nominal group process. Conclusions: The panel concluded that, because fever can have many infectious and noninfectious etiologies, a new fever in a patient in the intensive care unit should trigger a careful clinical assessment rather than automatic orders for laboratory and radiologic tests. A cost-conscious approach to obtaining cultures and imaging studies should be undertaken if indicated after a clinical evaluation. The goal of such an approach is to determine, in a directed manner, whether infection is present so that additional testing can be avoided and therapeutic decisions can be made. (Crit Care Med 2008; 36:1330‐1349)

Effect of obesity on intensive care morbidity and mortality: a meta-analysis.

Abstract: not associated with an increased risk of intensive care unit mortality (relative risk, 1.00; 95% confidence interval, 0.86‐1.16; p .97). However, duration of mechanical ventilation and intensive care unit length of stay were significantly longer in the obese group by 1.48 days (95% confidence interval, 0.07‐2.89; p .04) and 1.08 days (95% confidence interval, 0.27‐1.88; p .009), respectively, compared with the nonobese group. In a subgroup analysis, an improved survival was observed in obese patients with body mass index ranging between 30 and 39.9 kg/m 2 compared with nonobese patients (relative risk, 0.86; 95% confidence interval, 0.81‐0.91; p < .001). Conclusion: Obesity in critically ill patients is not associated with excess mortality but is significantly related to prolonged duration of mechanical ventilation and intensive care unit length of stay. Future studies should target this population for intervention studies to reduce their greater resource utilization. (Crit Care Med 2008; 36:151‐158)

Intensive versus conventional insulin therapy: a randomized controlled trial in medical and surgical critically ill patients.

Abstract: Objective:The role of intensive insulin therapy in medical surgical intensive care patients remains unclear. The objective of this study was to examine the effect of intensive insulin therapy on mortality in medical surgical intensive care unit patients.Design:Randomized controlled trial.Settings:Te

Epidemiology of acute kidney injury: how big is the problem?

Abstract: Objective:Acute kidney injury (AKI) is a complication that occurs frequently in hospitalized patients. In this article, we provide an overview of the literature on the epidemiology of AKI in hospitalized patients.Patients and Setting:The overview is restricted to hospitalized patients, and most emph

Actual incidence of global left ventricular hypokinesia in adult septic shock.

Abstract: Rationale and Objective:To evaluate the actual incidence of global left ventricular hypokinesia in septic shock.Method:All mechanically ventilated patients treated for an episode of septic shock in our unit were studied by transesophageal echocardiography, at least once a day, during the first 3 day

Glucose variability and mortality in patients with sepsis.

Abstract: Objective:Treatment and prevention of hyperglycemia has been advocated for subjects with sepsis. Glucose variability, rather than the glucose level, has also been shown to be an important factor associated with in-hospital mortality, in general, critically ill patients. Our objective was to determin

Serum neutrophil gelatinase-associated lipocalin (NGAL) as a marker of acute kidney injury in critically ill children with septic shock.

Abstract: Objective To validate serum neutrophil gelatinase-associated lipocalin (NGAL) as an early biomarker for acute kidney injury (AKI) in critically ill children with septic shock.

Impact of tight glycemic control on cerebral glucose metabolism after severe brain injury : A microdialysis study

Abstract: Objectives:To analyze the effect of tight glycemic control with the use of intensive insulin therapy on cerebral glucose metabolism in patients with severe brain injury.Design:Retrospective analysis of a prospective observational cohort.Setting:University hospital neurologic intensive care unit.Pati

Blood glucose concentration and outcome of critical illness: The impact of diabetes*

Abstract: Objective:To study the impact of diabetes mellitus on the relationship between glycemia and mortality in critically ill patients.Design:Retrospective observational study.Setting:Intensive care units of two university hospitals.Patients:Cohort of 4946 critically ill patients including 728 patients wi

Pathophysiology of septic acute kidney injury: what do we really know?

Abstract: Septic acute kidney injury accounts for close to 50% of all cases of acute kidney injury in the intensive care unit and, in its various forms, affects between 15% and 20% of intensive care unit patients. However, there is little we really know about its pathophysiology. Although hemodynamic factors might play a role in the loss of glomerular filtration rate, they may not act through the induction of renal ischemia. Septic acute renal failure may, at least in patients with a hyperdynamic circulation, represent a unique form of acute renal failure: hyperemic acute renal failure. Measurements of renal blood flow in septic humans are now needed to resolve this pivotal pathophysiological question. Whatever may happen to renal blood flow during septic acute kidney injury in humans, the evidence available suggests that urinalysis fails to provide useful diagnostic or prognostic information in this setting. In addition, nonhemodynamic mechanisms of cell injury are likely to be at work. These mechanisms are likely due to a combination of immunologic, toxic, and inflammatory factors that may affect the microvasculature and the tubular cells. Among these mechanisms, apoptosis may turn out to be important. It is possible that, as evidence accumulates, the paradigms currently used to explain acute renal failure in sepsis will shift from ischemia and vasoconstriction to hyperemia and vasodilation and from acute tubular necrosis to acute tubular apoptosis or simply tubular cell dysfunction or exfoliation. If this were to happen, our therapeutic approaches would also be profoundly altered.

Continuous versus intermittent renal replacement therapy for critically ill patients with acute kidney injury: a meta-analysis

Abstract: Objective:To appraise the literature on the effect of initial renal replacement therapy (RRT) modality on clinical outcomesDesign:Systematic review and meta-analysisSetting:Academic medical centerPatients and Participants:Adult critically ill patients with acute kidney injuryInterventions:Contin

Impact of minimal increases in serum creatinine on outcome in patients after cardiothoracic surgery: do we have to revise current definitions of acute renal failure?

Abstract: OBJECTIVE: Traditional cutoff values of serum creatinine considered to define postoperative acute renal failure have been challenged recently. In a previous investigation we demonstrated that minimal changes in serum creatinine concentration were associated with a substantial decrease in survival after cardiac surgery. In this investigation, we assessed the impact of minimal absolute increases in serum creatinine in a second institution, and we analyzed whether relative changes, as in the RIFLE classification and, partially, in Acute Kidney Injury Network (AKIN) classification, confer a different prognostic potential. DESIGN: Prospective analysis. SETTING: University hospital. PATIENTS: All consecutive patients undergoing cardiac surgery in the University Hospital of Zurich (Center USZ) over a 46-month period. INTERVENTIONS: Patients were prospectively documented. We analyzed maximal changes in serum creatinine in the first 48 hrs postoperatively (DeltaCrea) regarding death within 30 days. Results were compared with those of the University Hospital Vienna (Center AKH). Moreover, the prognostic potential of DeltaCrea within 48 hrs vs. serum creatinine elements according to RIFLE and AKIN classifications was assessed. MEASUREMENTS AND MAIN RESULTS: A total of 3,123 patients were evaluated from USZ. The majority of patients had decreased postoperative serum creatinine values (negative DeltaCrea) and the lowest mortality (1.8%). Minimal increases, [0, 0.5) mg x dL(-1), were associated with a more than doubled mortality in both centers (5%/6%). Mortality, according to RIFLE and AKIN classifications for both populations combined, was as follows: 7,023 (3.6%), 160 (29%), 43 (19%), and 15 (33%) for RIFLE Normal, Risk, Injury, and Failure; 6,644 (2.8), 463 (16.4), 3 (66.7), and 131 (1.8) for AKIN stage 0, 1, 2, and 3. CONCLUSIONS: Measuring repeat serum creatinine concentrations within 48 hrs and determining DeltaCrea were the most effective discrimination method to find patients at risk for adverse postoperative outcome after cardiac surgery, better than application of this sole criterion to the RIFLE (least discriminatory) or the AKIN classification.

Acute kidney injury.

Abstract: Diagnosis and classification of acute pathology in the kidney are major clinical problems. Azotemia and oliguria represent not only disease but normal responses of the kidney to extracellular volume depletion or decreased renal blood flow. Changes in urine output and glomerular filtration rate are therefore neither necessary nor sufficient for the diagnosis of renal pathology. However, no simple alternative for the diagnosis currently exists. By examining both glomerular and tubular function, clinicians routinely make inferences not only on the presence of renal dysfunction but also on its cause. However, pure prerenal physiology is unusual in hospitalized patients, and its effects are not necessary benign. Sepsis, the most common condition associated with acute renal failure in the intensive care unit, may alter renal function without any characteristic changes in urine indices, and classification of these abnormalities as prerenal will undoubtedly lead to incorrect management decisions. The clinical syndrome known as acute tubular necrosis does not actually manifest the morphologic changes that the name implies. A precise biochemical definition of acute renal failure has never been proposed, and until recently, there has been no consensus on the diagnostic criteria or clinical definition. Depending on the definition used, acute renal failure has been reported to affect from 1% to 25% of intensive care unit patients and has led to mortality rates ranging from 15% to 60%. From this chaos, two principles emerged: first, the need for a standard definition and, second, the need to classify the severity of the syndrome rather than only consider its most severe form. The RIFLE criteria were developed to achieve these goals, and the term acute kidney injury has been proposed to encompass the entire spectrum of the syndrome, from minor changes in renal function to requirement for renal replacement therapy. Thus, acute kidney injury is not acute tubular necrosis, nor is it renal failure. Small changes in kidney function in hospitalized patients are important and are associated with significant changes in short-term and possibly long-term outcomes. The RIFLE criteria provide a uniform definition of acute kidney injury and have now been validated in numerous studies.

Antibiotic resistance : What's dosing got to do with it?

Abstract: Objective: This review seeks to identify original research articles that link antibiotic dosing and the development of antibiotic resistance for different antibiotic classes. Using this data, we seek to apply pharmacodynamic principles to assist clinical practice for suppressing the emergence of resistance. Concepts such as mutant selection window and mutant prevention concentration will be discussed. Data Sources: PubMed, EMBASE, and the Cochrane Controlled Trial Register. Study Selection: All articles that related antibiotic doses and exposure to the formation of antibiotic resistance were reviewed. Data Synthesis: The escalation of antibiotic resistance continues worldwide, most prominently in patients in intensive care units. Data are emerging from in vitro and in vivo studies that suggest that inappropriately low antibiotic dosing may be contributing to the increasing rate of antibiotic resistance. Fluoroquinolones have widely been researched and publications on other antibiotic classes are emerging. Developing dosing regimens that adhere to pharmacodynamic principles and maximize antibiotic exposure is essential to reduce the increasing rate of antibiotic resistance. Conclusions: Antibiotic dosing must aim to address not only the bacteria isolated, but also the most resistant subpopulation in the colony, to prevent the advent of further resistant infections because of the inadvertent selection pressure of current dosing regimens. This may be achieved by maximizing antibiotic exposure by administering the highest recommended dose to the patient.

An overview of drug-induced acute kidney injury.

Abstract: The complex nature of critical illness often necessitates the use of multiple therapeutic agents, many of which may individually or in combination have the potential to cause renal injury. The use of nephrotoxic drugs has been implicated as a causative factor in up to 25% of all cases of severe acute renal failure in critically ill patients. Acute tubular necrosis is the most common form of renal injury from nephrotoxin exposure, although other types of renal failure may be seen. Given that this is a preventable cause of a potentially devastating complication, a comprehensive strategy should be used to avoid nephrotoxicity in critically ill patients including: accurate estimation of pre-existing renal function using serum creatinine-based glomerular filtration rates, avoidance of nephrotoxins if possible, ongoing monitoring of renal function, and immediate discontinuation of suspected nephrotoxins in the event of renal dysfunction.

Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority.

Abstract: Objective:Ambulation of patients with acute respiratory failure may be unnecessarily limited in the acute intensive care setting. We hypothesized that ambulation of patients with acute respiratory failure would increase with transfer to an intensive care unit where activity is a key component of pat

New biomarkers of acute kidney injury.

Abstract: Acute kidney injury (AKI) represents a major clinical problem, with rising incidence and high mortality rate. The lack of early biomarkers has resulted in a delay in initiating therapies. Fortunately, the tools of modern science have revealed promising novel biomarkers for AKI, with potentially high sensitivity and specificity. These include a plasma panel (neutrophil gelatinase-associated lipocalin and cystatin C) and a urine panel (neutrophil gelatinase-associated lipocalin, interleukin 18, and kidney injury molecule-1). Because they represent sequential biomarkers, it is likely that the AKI panels will be useful for timing the initial insult and assessing the duration of AKI (analogous to the cardiac panel for evaluating chest pain) and for predicting overall prognosis with respect to dialysis requirement and mortality. It is also likely that the AKI panels will help distinguish between the various types and pathogeneses of AKI. It will be important in future studies to validate the sensitivity and specificity of these biomarker panels in clinical samples from large cohorts and from multiple clinical situations. Such studies will be markedly facilitated by multidisciplinary participation of various specialties (intensivists, cardiologists, surgeons) in AKI clinical studies and by the availability of commercial tools for the reliable and reproducible measurement of biomarkers across different laboratories.

Incidence and clinical effects of intra-abdominal hypertension in critically ill patients.

Abstract: Objective The objective of this study was to determine the epidemiology and outcomes of intra-abdominal hypertension in a heterogeneous intensive care unit population. Design This was a prospective cohort study. Setting This study was conducted at a medical-surgical intensive care unit in a university hospital. Patients Study patients included all those consecutively admitted during 9 months, staying > 24 hrs, and requiring bladder catheterization. Measurements and main results On admission, epidemiologic data and risk factors for intra-abdominal hypertension were studied; then, daily maximal and mean intra-abdominal pressures (IAP(max) and IAP(mean)), abdominal perfusion pressure, fluid balances, filtration gradient, and sequential organ failure assessment score, were registered. IAPs were recorded through a bladder catheter every 6 hrs until death, discharge, or along 7 days. Intra-abdominal hypertension was defined as IAP > or = 12 mm Hg. Abdominal compartment syndrome was defined as IAP > or = 20 mm Hg plus > or = 1 new organ failure. Main outcome measure was hospital mortality. Of 83 patients, considering IAP(max), 31% had intra-abdominal hypertension on admission and another 33% developed it after (23% and 31% with IAP(mean)). Main risk factors were mechanical ventilation, acute respiratory distress syndrome, and fluid resuscitation (relative risk, 5.26, 3.19, and 2.50, respectively). Patients with intra-abdominal hypertension were sicker, had higher mortality (53% vs. 27%, p = .02), and consistently showed higher total and renal sequential organ failure assessment score, daily and cumulative fluid balances, and lower filtration gradient. Nonsurvivors had higher IAP(max), IAP(mean), and fluid balances and lower abdominal perfusion pressure. Abdominal compartment syndrome developed in 12%; 20% survived. Logistic regression identified IAP(max) as an independent predictor of mortality (odds ratio, 1.17; 95% confidence interval, 1.05-1.30; p = .003) after adjusting with Acute Physiology and Chronic Health Evaluation II and comorbidities (odds ratio, 1.15; 95% confidence interval, 1.06-1.25; p = .001; and odds ratio, 2.68; 95% confidence interval, 1.27-5.67; p = .013, respectively). Models with IAP(mean) and abdominal perfusion pressure also performed well. Areas under receiver operating characteristic curves were .81 and .83. Conclusions Intra-abdominal hypertension, diagnosed either with IAP(max) or IAP(mean), was frequent and showed an independent association with mortality. Intra-abdominal hypertension was significantly associated with more severe organ failures, particularly renal and respiratory, and a prolonged intensive care unit stay.

Psychiatric illness in the next of kin of patients who die in the intensive care unit.

Abstract: Objectives:To determine the rates of psychiatric illness in next of kin following the death of a relative in a medical intensive care unit.Design:Cross-sectional survey.Setting:A university teaching hospital, New Haven, CT.Patients:Forty-one next of kin who had served as primary surrogate decision m

Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review.

Abstract: Background:Advanced practitioners including nurse practitioners and physician assistants are contributing to care for critically ill patients in the intensive care unit through their participation on the multidisciplinary team and in collaborative physician practice roles. However, the impact of nur

Practical recommendations for prehospital and early in-hospital management of patients presenting with acute heart failure syndromes.

Abstract: Guideline recommendations for the prehospital and early in-hospital (first 6-12 hrs after presentation) management of acute heart failure syndromes are lacking. The American College of Cardiology/American Heart Association and European Society of Cardiology guidelines direct the management of these acute heart failure patients, but specific consensus on early management has not been published, primarily because few early management trials have been conducted. This article summarizes practical recommendations for the prehospital and early management of patients with acute heart failure syndromes; the recommendations were developed from a meeting of experts in cardiology, emergency medicine, and intensive care medicine from Europe and the United States. The recommendations are based on a unique clinical classification system considering the initial systolic blood pressure and other symptoms: 1) dyspnea and/or congestion with systolic blood pressure >140 mm Hg; 2) dyspnea and/or congestion with systolic blood pressure 100-140 mm Hg; 3) dyspnea and/or congestion with systolic blood pressure <100 mm Hg; 4) dyspnea and/or congestion with signs of acute coronary syndrome; and 5) isolated right ventricular failure. These practical recommendations are not intended to replace existing guidelines. Rather, they are meant to serve as a tool to facilitate guideline implementation where data are available and to provide suggested treatment approaches where formal guidelines and definitive evidence are lacking.