Showing papers in "Critical Care Medicine in 2012"

Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference.

Abstract: Background:Millions of patients are discharged from intensive care units annually. These intensive care survivors and their families frequently report a wide range of impairments in their health status which may last for months and years after hospital discharge.Objectives:To report on a 2-day Socie

Family response to critical illness: postintensive care syndrome-family.

Abstract: Background:The family response to critical illness includes development of adverse psychological outcomes such as anxiety, acute stress disorder, posttraumatic stress, depression, and complicated grief. This cluster of complications from exposure to critical care is now entitled postintensive care s

Hospitalizations, costs, and outcomes of severe sepsis in the United States 2003 to 2007.

Abstract: Objectives:To assess trends in number of hospitalizations, outcomes, and costs of severe sepsis in the United States.Design:Temporal trends study using the Nationwide Inpatient Sample.Patients:Adult patients with severe sepsis (defined as a diagnosis of sepsis and organ dysfunction) diagnosed betwee

Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients

Abstract: Objective: To evaluate the literature and identify important aspects of insulin therapy that facilitate safe and effective infusion therapy for a defined glycemic end point. Methods: Where available, the literature was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to assess the impact of insulin infusions on outcome for general intensive care unit patients and those in specific subsets of neurologic injury, traumatic injury, and cardiovascular surgery. Elements that contribute to safe and effective insulin infusion therapy were determined through literature review and expert opinion. The majority of the literature supporting the use of insulin infusion therapy for critically ill patients lacks adequate strength to support more than weak recommendations, termed suggestions, such that the difference between desirable and undesirable effect of a given intervention is not always clear. Recommendations: The article is focused on a suggested glycemic control end point such that a blood glucose ≥150 mg/dL triggers interventions to maintain blood glucose below that level and absolutely <180 mg/dL. There is a slight reduction in mortality with this treatment end point for general intensive care unit patients and reductions in morbidity for perioperative patients, postoperative cardiac surgery patients, post-traumatic injury patients, and neurologic injury patients. We suggest that the insulin regimen and monitoring system be designed to avoid and detect hypoglycemia (blood glucose ≤70 mg/dL) and to minimize glycemic variability. Important processes of care for insulin therapy include use of a reliable insulin infusion protocol, frequent blood glucose monitoring, and avoidance of finger-stick glucose testing through the use of arterial or venous glucose samples. The essential components of an insulin infusion system include use of a validated insulin titration program, availability of appropriate staffing resources, accurate mon itoring technology, and standardized approaches to infusion preparation, provision of consistent carbohydrate calories and nutritional support, and dextrose replacement for hypoglycemia prevention and treatment. Quality improvement of glycemic management programs should include analysis of hypoglycemia rates, run charts of glucose values <150 and 180 mg/dL. The literature is inadequate to support recommendations regarding glycemic control in pediatric patients. Conclusions: While the benefits of tight glycemic control have not been definitive, there are patients who will receive insulin infu sion therapy, and the suggestions in this article provide the structure for safe and effective use of this therapy. (Crit Care Med 2012; 40:3251–3276)

Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury.

Abstract: Objectives: We have sought to develop an automated methodology for the continuous updating of optimal cerebral perfusion pressure (CPPopt) for patients after severe traumatic head injury, using continuous monitoring of cerebrovascular pressure reactivity. We then validated the CPPopt algorithm by determining the association between outcome and the deviation of actual CPP from CPPopt. Design: Retrospective analysis of prospectively collected data. Setting: Neurosciences critical care unit of a university hospital. Patients: A total of 327 traumatic head-injury patients admitted between 2003 and 2009 with continuous monitoring of arterial blood pressure and intracranial pressure. Measurements and Main Results: Arterial blood pressure, intracranial pressure, and CPP were continuously recorded, and pressure reactivity index was calculated online. Outcome was assessed at 6 months. An automated curve fitting method was applied to determine CPP at the minimum value for pressure reactivity index (CPPopt). A time trend of CPPopt was created using a moving 4-hr window, updated every minute. Identification of CPPopt was, on average, feasible during 55% of the whole recording period. Patient outcome correlated with the continuously updated difference between median CPP and CPPopt (chi-square = 45, p CPPopt), and favorable outcome was associated with smaller deviations of CPP from the individualized CPPopt. While deviations from global target CPP values of 60 mm Hg and 70 mm Hg were also related to outcome, these relationships were less robust. Conclusions: Real-time CPPopt could be identified during the recording time of majority of the patients. Patients with a median CPP close to CPPopt were more likely to have a favorable outcome than those in whom median CPP was widely different from CPPopt. Deviations from individualized CPPopt were more predictive of outcome than deviations from a common target CPP. CPP management to optimize cerebrovascular pressure reactivity should be the subject of future clinical trial in severe traumatic head-injury patients. (Crit Care Med 2012; 40:2456-2463)

What is the Role of Chest Compression Depth during Out-of-Hospital Cardiac Arrest Resuscitation?

Abstract: Background The 2010 international guidelines for CPR recently recommended an increase in the minimum compression depth from 38 to 50 mm, although there are limited human data to support this. We sought to study patterns of CPR compression depth and their associations with patient outcomes in out-of-hospital cardiac arrest (OOHCA) cases treated by the 2005 guideline standards.

Ultrasound assessment of lung aeration loss during a successful weaning trial predicts postextubation distress

Abstract: Lung ultrasound determination of aeration changes during a successful spontaneous breathing trial may accurately predict postextubation distress.

Nutritional practices and their relationship to clinical outcomes in critically ill children—An international multicenter cohort study

Abstract: Objectives: To examine factors influencing the adequacy of en ergy and protein intake in the pediatric intensive care unit and to describe their relationship to clinical outcomes in mechanically ventilated children. Design, Setting, Patients: We conducted an international prospective cohort study of consecutive children (ages 1 month to 18 yrs) requiring mechanical ventilation longer than 48 hrs in the pediatric intensive care unit. Nutritional practices were recorded during the pediatric intensive care unit stay for a maximum of 10 days, and patients were followed up for 60 days or until hospital discharge. Multivariate analysis, accounting for pediatric intensive care unit clustering and important confounding variables, was used to examine the impact of nutritional variables and pediatric intensive care unit characteristics on 60-day mortality and the prevalence of acquired infections. Main Results: 31 pediatric intensive care units in academic hospitals in eight countries participated in this study. Five hundred patients with mean (sd) age 4.5 (5.1) yrs were enrolled and included in the analysis. Mortality at 60 days was 8.4%, and 107 of 500 (22%) patients acquired at least one infection during their pediatric intensive care unit stay. Over 30% of patients had severe malnutrition on admission, with body mass index z- score 2 (13.2%) or ,22 (17.1%) on admission. Mean prescribed goals for daily energy and protein intake were 64 kcals/kg and 1.7 g/kg respectively. Enteral nutrition was used in 67% of the patients and was initiated within 48 hrs of admission in the majority of patients. Enteral nutrition was subsequently interrupted on average for at least 2 days in 357 of 500 (71%) patients. Mean (sd) percentage daily nutritional intake (enteral nutrition) compared to prescribed goals was 38% (34) for energy and 43% (44) for protein. A higher percentage of goal energy intake via enteral nutrition route was significantly associ ated with lower 60-day mortality (Odds ratio for increasing energy intake from 33.3% to 66.6% is 0.27 [0.11, 0.67], p  .002). Mortality was higher in patients who received parenteral nutrition (odds ratio 2.61 [1.3, 5.3], p  .008). Patients admitted to units that utilized a feeding protocol had a lower prevalence of acquired infections (odds ratio 0.18 [0.05, 0.64], p  .008), and this association was independent of the amount of energy or protein intake. Conclusions: Nutrition delivery is generally inadequate in mechanically ventilated children across the world. Intake of a higher percentage of prescribed dietary energy goal via enteral route was associated with improved 60-day survival; conversely, parenteral nutrition use was associated with higher mortality. Pediatric intensive care units that utilized protocols for the initiation and advancement of enteral nutrient intake had a lower prevalence of acquired infections. Optimizing nutrition therapy is a potential avenue for improving clinical outcomes in critically ill children. (Crit Care Med 2012; 40: 2204–2211)

Critical illness from 2009 pandemic influenza A virus and bacterial coinfection in the United States.

Abstract: Objectives:The contribution of bacterial coinfection to critical illness associated with 2009 influenza A virus infection remains uncertain. The objective of this study was to determine whether bacterial coinfection increased the morbidity and mortality of 2009 influenza A.Design:Retrospective and p

Dopamine versus norepinephrine in the treatment of septic shock: a meta-analysis*.

Abstract: eptic shock is a life-threaten-ing condition associated withmortality rates close to 50% (1,2). Despite generous fluid ad-ministration, vasopressor agents are of-ten required to correct hypotension.Among the available vasopressors, dopa-mine and norepinephrine are used mostfrequently (3). These adrenergic agentshave different pharmacologic properties.Both agents stimulate -adrenergic re-ceptors, resulting in vasopressor effects,but this effect is weaker for dopaminethan for norepinephrine. However, dopa-mine stimulates -adrenergic receptorsmore than norepinephrine, and this mayresult in a greater increase in cardiacoutput. However, this -adrenergic stim-ulation can also promote tachycardia andarrhythmic events, increase cellular me-tabolism, and may be immunosuppres-sive (4). Finally, dopamine also stimu-lates dopaminergic receptors, which mayresult in increased splanchnic and renalperfusion, although this effect does notappear to prevent organ failure in criti-cally ill patients (5). Dopaminergic stim-ulation can also alter hypothalamo-pituitary function, resulting in a markeddecrease in prolactin and growth hor-mone levels (6).Current guidelines recommend theuseofeitherdopamineornorepinephrineas the first choice vasopressor in patientswith septic shock (7–10). Several obser-vational studies have suggested that do-pamine administration may be associatedwith higher mortality rates than norepi-nephrine administration (3, 11, 12), al-though one study reported the reverse(13). In 2004, a meta-analysis conductedby the Cochrane group (14) identifiedonly three randomized studies, including62 patients in total, that compared theeffects of dopamine and norepinephrinein patients with septic shock and pro-vided information on outcome. They con-cluded that these trials were underpow-ered and that the evidence available atthat time was insufficient to determinewhether one agent was superior to theother. Since then, the number of trialscomparingdopamineandnorepinephrinehas markedly increased. In particular,two randomized trials have specificallyevaluated the impact of dopamine on out-come. A large-scale, multicenter, ran-domized trial that included 1679 patientswith shock, of whom 1044 had septicshock, found no significant differences inoutcome in patients treated with norepi-

Delirium in critically ill patients: impact on long-term health-related quality of life and cognitive functioning.

Abstract: Objective: to examine the impact of delirium during intensive care unit stay on long-term health-related quality of life and cognitive function in intensive care unit survivors. Design: prospective 18-month follow-up study. Setting: four intensive care units of a university hospital. Patients: a median of 18 months after intensive care discharge, questionnaires were sent to 1,292 intensive care survivors with (n = 272) and without (n = 1020) delirium during their intensive care stay. Measurements and Main Results: the Short Form-36v1, checklist individual strength-fatigue, and cognitive failure questionnaire were used. Covariance analysis was performed to adjust for relevant covariates. Of the 915 responders, 171 patients were delirious during their intensive care stay (median age 65 [interquartile range 58–85], Acute Physiology and Chronic Health Evaluation II score 17 [interquartile range 14–20]), and 745 patients were not (median age 65 [interquartile range 57–72], Acute Physiology and Chronic Health Evaluation II score 13 [interquartile range 10–16]). After adjusting for covariates, no differences were found between delirium and nondelirium survivors on the Short Form-36 and checklist individual strength-fatigue. However, survivors who had suffered from delirium reported that they made significantly more social blunders, and their total cognitive failure questionnaire score was significantly higher, compared to survivors who had not been delirious. Survivors of a hypoactive delirium subtype performed significantly better on the domain mental health than mixed and hyperactive delirium patients. Duration of delirium was significantly correlated to problems with memory and names. Conclusions: intensive care survivors with delirium during their intensive care unit stay had a similar adjusted health-related quality of life evaluation, but significantly more cognitive problems than those who did not suffer from delirium, even after adjusting for relevant covariates. In addition, the duration of delirium was related to long-term cognitive problems

Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery: a randomized controlled trial*.

Abstract: Objectives:To evaluate the efficacy and safety of short-term low-dose intravenous haloperidol for delirium prevention in critically ill elderly patients after noncardiac surgery.Design:Prospective, randomized, double-blind, and placebo-controlled trial in two centers.Setting:Intensive care units of

Continuous electroencephalography monitoring for early prediction of neurological outcome in postanoxic patients after cardiac arrest: a prospective cohort study

Abstract: Objective: To evaluate the value of continuous electroencephalography in early prognostication in patients treated with hypothermia after cardiac arrest. Design: Prospective cohort study. Setting: Medical intensive care unit. Patients: Sixty patients admitted to the intensive care unit for therapeutic hypothermia after cardiac arrest. Intervention: None. Measurements and Main Results: In all patients, continuous electroencephalogram and daily somatosensory evoked potentials were recorded during the first 5 days of admission or until intensive care unit discharge. Neurological outcomes were based on each patient’s best achieved Cerebral Performance Category score within 6 months. Twenty-seven of 56 patients (48%) achieved good neurological outcome (Cerebral Performance Category score 1–2). At 12 hrs after resuscitation, 43% of the patients with good neurological outcome showed continuous, diffuse slow electroencephalogram rhythms, whereas this was never observed in patients with poor outcome. The sensitivity for predicting poor neurological outcome of lowvoltage and isoelectric electroencephalogram patterns 24 hrs after resuscitation was 40% (95% confidence interval 19%–64%) with a 100% specificity (confidence interval 86%–100%), whereas the sensitivity and specificity of absent somatosensory evoked potential responses during the first 24 hrs were 24% (confidence interval 10%–44%) and 100% (confidence interval: 87%–100%), respectively. The negative predictive value for poor outcome of low-voltage and isoelectric electroencephalogram patterns was 68% (confidence interval 50%–81%) compared to 55% (confidence interval 40%–60%) for bilateral somatosensory evoked potential absence, both with a positive predictive value of 100% (confidence inter val 63%–100% and 59%–100% respectively). Burst-suppression patterns after 24 hrs were also associated with poor neurological outcome, but not inevitably so. Conclusions: In patients treated with hypothermia, electroencephalogram monitoring during the first 24 hrs after resuscitation can contribute to the prediction of both good and poor neurological outcome. Continuous patterns within 12 hrs predicted good outcome. Isoelectric or low-voltage electroencephalograms after 24 hrs predicted poor outcome with a sensitivity almost two times larger than bilateral absent somatosensory evoked potential responses. (Crit Care Med 2012; 40:2867–2875)

Efficacy and safety of first-line rituximab in severe, acquired thrombotic thrombocytopenic purpura with a suboptimal response to plasma exchange. Experience of the French Thrombotic Microangiopathies Reference Center

Abstract: Objective:To assess the efficacy and safety of rituximab in adults responding poorly to standard treatment for severe autoimmune thrombotic thrombocytopenic purpura.Design:Open-label prospective study. Outcomes in the survivors were compared to those of 53 historical survivors who were given therape

Impact of an intensive care unit diary on psychological distress in patients and relatives

Abstract: Objective:To assess the impact of an intensive care unit diary on the psychological well-being of patients and relatives 3 and 12 months after intensive care unit discharge.Design:Prospective single-center study with an intervention period between two control periods.Setting:Medical-surgical intensi

Quantitative assessment of the microcirculation in healthy volunteers and in patients with septic shock.

Abstract: OBJECTIVE: The microcirculation of septic patients has been characterized only semiquantitatively. Our goal was to characterize the sublingual microcirculation in healthy volunteers and patients with septic shock quantitatively. Our hypotheses were that 1) hyperdynamic blood flow is absent in septic shock; 2) nonsurvivors show more severe alterations than survivors; and 3) quantitative and semiquantitative microcirculatory parameters have a similar performance. DESIGN: Prospective, observational study. SETTING: Teaching intensive care unit in a university-affiliated hospital. SUBJECTS: Twenty-five normal volunteers and 25 patients with septic shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The sublingual microcirculation was evaluated by means of sidestream dark field imaging. Semiquantitative and quantitative microcirculatory parameters were determined through the use of applied software. Septic patients showed decreased perfused capillary density (13.2±4.4 mm/mm² vs. 16.6±1.6 mm/mm²), proportion of perfused capillaries (0.78±0.23 vs. 1.00±0.01), microvascular flow index (2.15±0.61 vs. 2.97±0.03), and red blood cell velocity (830±183 µm/sec vs. 1332±187 µm/sec) along with increased heterogeneity flow index (1.64±1.14 vs. 0.25±0.19) compared with controls. No differences were found in total capillary density (16.9±2.2 vs. 16.7±1.6). Only 4% of capillaries analyzed showed red blood cell velocities>75th percentile of the velocities of the normal volunteers. The nonsurvivors exhibited decreased perfused capillary density, proportion of perfused capillaries, and microvascular flow index along with increased heterogeneity flow index compared with the survivors. The correlations between microvascular flow index and proportion of perfused capillaries, total capillary density and number of grid-crossing capillaries, and red blood cell velocities and microvascular flow index gave high R values (0.92, 0.65, and 0.52, respectively; p<.0001 for all). CONCLUSIONS: The main characteristics of sublingual microcirculation in patients with septic shock are hypoperfusion and increased flow heterogeneity. Hyperdynamic microvascular blood flow was not found. Nonsurvivors showed more severe alterations than survivors. Quantitative and semiquantitative microcirculatory variables displayed similar behaviors.

Cognitive and physical rehabilitation of intensive care unit survivors: results of the RETURN randomized controlled pilot investigation.

Abstract: Background Millions of patients who survive medical and surgical general ICU care every year suffer from newly acquired long-term cognitive impairment and profound physical and functional disabilities. To overcome the current reality in which patients receive inadequate rehabilitation, we devised a multi-faceted, in-home tele-rehabilitation program implemented using social workers and psychology technicians with the goal of improving cognitive and functional outcomes.

An observational study fluid balance and patient outcomes in the Randomized Evaluation of Normal vs. Augmented Level of Replacement Therapy trial.

Abstract: Objective: To examine associations between mean daily fluid balance during intensive care unit study enrollment and clinical outcomes in patients enrolled in the Randomized Evaluation of Normal vs. Augmented Level (RENAL) replacement therapy study. Design: Statistical analysis of data from multicenter, randomized, controlled trials. Setting: Thirty-five intensive care units in Australia and New Zealand. Patients: Cohort of 1453 patients enrolled in the RENAL study. Interventions: We analyzed the association between daily fluid balance on clinical outcomes using multivariable logistic regression, Cox proportional hazards, time-dependent analysis, and repeated measure analysis models. Measurements and main results: During intensive care unit stay, mean daily fluid balance among survivors was -234 mL/day compared with +560 mL/day among nonsurvivors (p < .0001). Mean cumulative fluid balance over the same period was -1941 vs. +1755 mL (p = .0003). A negative mean daily fluid balance during study treatment was independently associated with a decreased risk of death at 90 days (odds ratio 0.318; 95% confidence interval 0.24-0.43; p < .000.1) and with increased survival time (p < .0001). In addition, a negative mean daily fluid balance was associated with significantly increased renal replacement-free days (p = .0017), intensive care unit-free days (p < .0001), and hospital-free days (p = .01). These findings were unaltered after the application of different statistical models. Conclusions: In the RENAL study, a negative mean daily fluid balance was consistently associated with improved clinical outcomes. Fluid balance may be a target for specific manipulation in future interventional trials of critically ill patients receiving renal replacement therapy.

The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis.

Abstract: Background: Catheter-related bloodstream infections are an important cause of morbidity and mortality in hospitalized patients. Current guidelines recommend that femoral venous access should be avoided to reduce this complication (1A recommendation). However, the risk of catheter-related bloodstream infections from femoral as compared to subclavian and internal jugular venous catheterization has not been systematically reviewed. Objective: A systematic review of the literature to determine the risk of catheter-related bloodstream infections related to nontunneled central venous catheters inserted at the femoral site as compared to subclavian and internal jugular placement. Data Sources: MEDLINE, Embase, Cochrane Register of Controlled Trials, citation review of relevant primary and review articles, and an Internet search (Google). Study Selection: Randomized controlled trials and cohort studies that reported the frequency of catheter-related bloodstream infections (infections per 1,000 catheter days) in patients with nontunneled central venous catheters placed in the femoral site as compared to subclavian or internal jugular placement. Data Extraction: Data were abstracted on study design, study size, study setting, patient population, number of catheters at each insertion site, number of catheter-related bloodstream infections, and the prevalence of deep venous thrombosis. Studies were subgrouped according to study design (cohort and randomized controlled trials). Meta-analytic techniques were used to summarize the data. Data Synthesis: Two randomized controlled trials (1006 catheters) and 8 cohort (16,370 catheters) studies met the inclusion criteria for this systematic review. Three thousand two hundred thirty catheters were placed in the subclavian vein, 10,958 in the internal jugular and 3,188 in the femoral vein for a total of 113,652 catheter days. The average catheter-related bloodstream infections density was 2.5 per 1,000 catheter days (range 0.6–7.2). There was no significant difference in the risk of catheter-related bloodstream infections between the femoral and subclavian/internal jugular sites in the two randomized controlled trials (i.e., no level 1A evidence). There was no significant difference in the risk of catheterrelated bloodstream infections between the femoral and subclavian sites. The internal jugular site was associated with a significantly lower risk of catheter-related bloodstream infections compared to the femoral site (risk ratio 1.90; 95% confidence interval 1.21–2.97, p = .005, I 2 = 35%). This difference was explained by two of the studies that were statistical outliers. When these two studies were removed from the analysis there was no significant difference in the risk of catheter-related bloodstream infections between the femoral and internal jugular sites (risk ratio 1.35; 95% confidence interval 0.84–2.19, p = 0.2, I 2 = 0%). Meta-regression demonstrated a signifi cant interaction between the risk of infection and the year of publication (p = .01), with the femoral site demonstrating a higher risk of infection in the earlier studies. There was no significant difference in the risk of catheter-related bloodstream infection between the subclavian and internal jugular sites. The risk of deep venous thrombosis was assessed in the two randomized controlled trials. A metaanalysis of this data demonstrates that there was no difference in the risk of deep venous thrombosis when the femoral site was compared to the subclavian and internal jugular sites combined. There was, however, significant heterogeneity between studies. Conclusions: Although earlier studies showed a lower risk of catheter-related bloodstream infections when the internal jugular was compared to the femoral site, recent studies show no difference in the rate of catheter-related bloodstream infections between the three sites. (Crit Care Med 2012; 40: 2479–2485)

Guidelines for intensive care unit design.

Abstract: Objective:To develop a guideline to help guide healthcare professionals participate effectively in the design, construction, and occupancy of a new or renovated intensive care unit.Participants:A group of multidisciplinary professionals, designers, and architects with expertise in critical care, und

Chronic conditions among children admitted to U.S. pediatric intensive care units: their prevalence and impact on risk for mortality and prolonged length of stay*.

Abstract: Objective:To estimate the prevalence of chronic conditions among children admitted to U.S. pediatric intensive care units and to assess whether patients with complex chronic conditions experience pediatric intensive care unit mortality and prolonged length of stay risk beyond that predicted by commo

Spontaneous breathing during lung-protective ventilation in an experimental acute lung injury model: high transpulmonary pressure associated with strong spontaneous breathing effort may worsen lung injury.

Abstract: Objective:We investigated whether potentially injurious transpulmonary pressure could be generated by strong spontaneous breathing and exacerbate lung injury even when plateau pressure is limited to <30 cm H2O.Design:Prospective, randomized, animal study.Setting:University animal research laboratory

Prediction of outcome after moderate and severe traumatic brain injury: External validation of the International Mission on Prognosis and Analysis of Clinical Trials (IMPACT) and Corticoid Randomisation after Significant Head injury (CRASH) prognostic models

Abstract: Objective: The International Mission on Prognosis and Analysis of Clinical Trials and Corticoid Randomisation After Significant Head injury prognostic models predict outcome after traumatic brain injury but have not been compared in large datasets. The objective of this is study is to validate externally and compare the International Mission on Prognosis and Analysis of Clinical Trials and Corticoid Randomisation after Significant Head injury prognostic models for prediction of outcome after moderate or severe traumatic brain injury. Design: External validation study. Patients: We considered five new datasets with a total of 9,036 patients, comprising three randomized trials and two observational series, containing prospectively collected individual traumatic brain injury patient data. Measurements and Main Results: Outcomes were mortality and unfavorable outcome, based on the Glasgow Outcome Score at 6 months after injury. To assess performance, we studied the discrimination of the models (by area under the receiver operating characteristic curves), and calibration (by comparison of the mean observed to predicted outcomes and calibration slopes). The highest discrimination was found in the Trauma Audit and Research Network trauma registry (area under the receiver operating characteristic curves between 0.83 and 0.87), and the lowest discrimination in the Pharmos trial (area under the receiver operating characteristic curves between 0.65 and 0.71). Although differences in predictor effects between development and validation populations were found (calibration slopes varying between 0.58 and 1.53), the differences in discrimination were largely explained by differences in case mix in the validation studies. Calibration was good, the fraction of observed outcomes generally agreed well with the mean predicted outcome. No meaningful differences were noted in performance between the International Mission on Prognosis and Analysis of Clinical Trials and Corticoid Randomisation After Significant Head injury models. More complex models discriminated slightly better than simpler variants. Conclusions: Since both the International Mission on Prognosis and Analysis of Clinical Trials and the Corticoid Randomisation After Significant Head injury prognostic models show good generalizability to more recent data, they are valid instruments to quantify prognosis in traumatic brain injury.

The association between brain volumes, delirium duration, and cognitive outcomes in intensive care unit survivors: the VISIONS cohort magnetic resonance imaging study*.

Abstract: Objective Delirium duration is predictive of long-term cognitive impairment (LTCI) in Intensive Care Unit (ICU) survivors. Hypothesizing that a neuroanatomical basis may exist for the relationship between delirium and LTCI, we conducted this exploratory investigation of the associations between delirium duration, brain volumes and LTCI.

Transfer of multidrug-resistant bacteria to healthcare workers’ gloves and gowns after patient contact increases with environmental contamination

Abstract: Hospital-associated infections are estimated to contribute to the death of approximately 100,000 people per year in the United States (1). Multidrug-resistant (MDR) bacteria cause a significant proportion of hospital-associated infections (2–4). MDR bacteria are a significant problem worldwide with a high frequency of MDR bacteria in intensive care units (ICUs) from South America, Africa, Asia, and Europe (5–7). MDR Acinetobacter baumannii has emerged as epidemic in many countries (8). MDR bacteria are generally transmitted from patient-to-patient in the healthcare system by transiently contaminated healthcare workers, equipment, and the environment (9). In multiple smaller studies, looking at one or two organisms, different activities have been associated with a greater likelihood of healthcare worker (HCW) clothing contamination including contact with wound dressing, artificial airways, side rails, linens, infusion pumps, catheters or drain, and direct patient contact including performing a physical examination or spending a longer duration in a room (4, 10, 11). Studies have not assessed common risk factors for contamination with the most common MDR bacteria and have been limited by clustering of patients or repeated measurements of the same HCW. A. baumannii may be more likely than other MDR bacteria to contaminate HCW clothing or the environment, although it has not been directly compared to methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococci (4). Understanding factors that lead to contamination of HCW clothing, and thus increase potential for transmission, may help lead to interventions to prevent transmission of MDR bacteria. To our knowledge, no study has assessed the importance of environmental contamination leading to contamination of HCW clothing and thus the potential causal role of the environment inpatient-to-patient transmission of MDR bacteria. To evaluate the differential rate of contamination by MDR A. baumannii compared with other MDR bacteria as well as investigating the importance of environmental contamination in the transfer of MDR bacteria to HCW clothing, we studied a cohort of ICU-based HCWs performing routine patient care.

Impact of real-time electronic alerting of acute kidney injury on therapeutic intervention and progression of RIFLE class.

Abstract: OBJECTIVE: To evaluate whether a real-time electronic alert system or "AKI sniffer," which is based on the classification criteria (Risk, Injury and Failure), would have an impact on therapeutic interventions and acute kidney injury progression. DESIGN: Prospective intervention study. SETTING: Surgical and medical intensive care unit in a tertiary care hospital. PATIENTS: A total of 951 patients having in total 1079 admission episodes were admitted during the study period (prealert control group: 227, alert group: 616, and postalert control group: 236). INTERVENTIONS: Three study phases were compared: a 1.5-month prealert control phase in which physicians were blinded for the acute kidney injury sniffer and a 3-month intervention phase with real-time alerting of worsening class through the Digital Enhanced Cordless Technology telephone system followed by a second 1.5-month postalert control phase. MEASUREMENTS AND MAIN RESULTS: A total of 2593 acute kidney injury alerts were recorded with a balanced distribution over all study phases. Most acute kidney injury alerts were class risk (59.8%) followed by class injury (34.1%) and failure (6.1%). A higher percentage of patients in the alert group received therapeutic intervention within 60 mins after the acute kidney injury alert (28.7% in alert group vs. 7.9% and 10.4% in the pre- and postalert control groups, respectively, p < .001). In the alert group, more patients received fluid therapy (23.0% vs. 4.9% and 9.2%, p < .01), diuretics (4.2% vs. 2.6% and 0.8%, p < .001), or vasopressors (3.9% vs. 1.1% and 0.8%, p < .001). Furthermore, these patients had a shorter time to intervention (p < .001). A higher proportion of patients in the alert group showed return to a baseline kidney function within 8 hrs after an acute kidney injury alert "from normal to risk" compared with patients in the control group (p = .048). CONCLUSIONS: The real-time alerting of every worsening class by the acute kidney injury sniffer increased the number and timeliness of early therapeutic interventions. The borderline significant improvement of short-term renal outcome in the class risk patients needs to be confirmed in a large multicenter trial.

Survival in neutropenic patients with severe sepsis or septic shock.

Abstract: Objective:To determine whether the survival gains achieved in critically ill cancer patients in recent years exist in the subset with neutropenia and severe sepsis or septic shock.Design:Retrospective 11-yr study (1998–2008).Setting:Medical intensive care unit in a teaching hospital.Patients:Four hu

A controlled trial of electronic automated advisory vital signs monitoring in general hospital wards.

Abstract: OBJECTIVES: Deteriorating ward patients are at increased risk. Electronic automated advisory vital signs monitors may help identify such patients and improve their outcomes. SETTING: A total of 349 beds, in 12 general wards in ten hospitals in the United States, Europe, and Australia. PATIENTS: Cohort of 18,305 patients. DESIGN: Before-and-after controlled trial. INTERVENTION: We deployed electronic automated advisory vital signs monitors to assist in the acquisition of vital signs and calculation of early warning scores. We assessed their effect on frequency, type, and treatment of rapid response team calls; survival to hospital discharge or to 90 days for rapid response team call patients; overall type and number of serious adverse events and length of hospital stay. MEASUREMENTS AND MAIN RESULTS: We studied 9,617 patients before (control) and 8,688 after (intervention) deployment of electronic automated advisory vital signs monitors. Among rapid response team call patients, intervention was associated with an increased proportion of calls secondary to abnormal respiratory vital signs (from 21% to 31%; difference [95% confidence interval] 9.9 [0.1-18.5]; p = .029). Survival immediately after rapid response team treatment and survival to hospital discharge or 90 days increased from 86% to 92% (difference [95% confidence interval] 6.3 [0.0-12.6]; p = .04). Intervention was also associated with a decrease in median length of hospital stay in all patients (unadjusted p < .0001; adjusted p = .09) and more so in U.S. patients (from 3.4 to 3.0 days; unadjusted p < .0001; adjusted ratio [95% confidence interval] 1.03 [1.00-1.06]; p = .026). The time required to complete and record a set of vital signs decreased from 4.1 ± 1.3 mins to 2.5 ± 0.5 mins (difference [95% confidence interval] 1.6 [1.4-1.8]; p < .0001). CONCLUSIONS: Deployment of electronic automated advisory vital signs monitors was associated with an improvement in the proportion of rapid response team-calls triggered by respiratory criteria, increased survival of patients receiving rapid response team calls, and decreased time required for vital signs measurement and recording (NCT01197326).

Plasma angiopoietin-2 in clinical acute lung injury: prognostic and pathogenetic significance.

Abstract: Background:Angiopoietin-2 is a proinflammatory mediator of endothelial injury in animal models, and increased plasma angiopoietin-2 levels are associated with poor outcomes in patients with sepsis-associated acute lung injury. Whether angiopoietin-2 levels are modified by treatment strategies in pat

Effects of levosimendan on mortality and hospitalization. A meta-analysis of randomized controlled studies*

Abstract: Objective:Catecholaminergic inotropes have a place in the management of low output syndrome and decompensated heart failure but their effect on mortality is debated. Levosimendan is a calcium sensitizer that enhances myocardial contractility without increasing myocardial oxygen use. A meta-analysis