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Showing papers in "Critical Care Medicine in 2013"


Journal ArticleDOI
TL;DR: An update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008 is provided.
Abstract: Objective:To provide an update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008.Design:A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at ke

9,137 citations


Journal ArticleDOI
TL;DR: These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.
Abstract: Objective:To revise the “Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult” published in Critical Care Medicine in 2002.Methods:The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task f

3,005 citations


Journal ArticleDOI
TL;DR: There is substantial variability in incidence and mortality of severe sepsis depending on the method of database abstraction used, and a uniform, consistent method is needed for use in national registries to facilitate accurate assessment of clinical interventions and outcome comparisons between hospitals and regions.
Abstract: Background:In 1992, the first consensus definition of severe sepsis was published. Subsequent epidemiologic estimates were collected using administrative data, but ongoing discrepancies in the definition of severe sepsis produced large differences in estimates.Objectives:We seek to describe the vari

1,141 citations


Journal ArticleDOI
TL;DR: There are no data to support the widespread practice of using central venous pressure to guide fluid therapy, and this approach to fluid resuscitation should be abandoned.
Abstract: Background: Despite a previous meta-analysis that concluded that central venous pressure should not be used to make clinical decisions regarding fluid management, central venous pressure continues to be recommended for this purpose. Aim: To perform an updated meta-analysis incorporating recent studies that investigated indices predictive of fluid responsiveness. A priori subgroup analysis was planned according to the location where the study was performed (ICU or operating room). Data Sources: MEDLINE, EMBASE, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles. Study Selection: Clinical trials that reported the correlation coefficient or area under the receiver operating characteristic curve (AUC) between the central venous pressure and change in cardiac performance following an intervention that altered cardiac preload. From 191 articles screened, 43 studies met our inclusion criteria and were included for data extraction. The studies included human adult subjects, and included healthy controls (n = 1) and ICU (n = 22) and operating room (n = 20) patients. Data Extraction: Data were abstracted on study characteristics, patient population, baseline central venous pressure, the correlation coefficient, and/or the AUC between central venous pressure and change in stroke volume index/cardiac index and the percentage of fluid responders. Meta-analytic techniques were used to summarize the data. Data Synthesis: Overall 57% ± 13% of patients were fluid responders. The summary AUC was 0.56 (95% CI, 0.54–0.58) with no heterogenicity between studies. The summary AUC was 0.56 (95% CI, 0.52–0.60) for those studies done in the ICU and 0.56 (95% CI, 0.54–0.58) for those done in the operating room. The summary correlation coefficient between the baseline central venous pressure and change in stroke volume index/cardiac index was 0.18 (95% CI, 0.1–0.25), being 0.28 (95% CI, 0.16–0.40) in the ICU patients, and 0.11 (95% CI, 0.02–0.21) in the operating room patients. Conclusions: There are no data to support the widespread practice of using central venous pressure to guide fluid therapy. This approach to fluid resuscitation should be abandoned. (Crit Care Med 2013; 41:1774–1781)

655 citations


Journal ArticleDOI
TL;DR: Microcirculatory alterations are stronger predictors of outcome than global hemodynamic variables in patients with severe sepsis.
Abstract: Objectives: Sepsis induces microvascular alterations that may play an important role in the development of organ dysfunction. However, the relationship of these alterations to systemic variables and outcome is still not well defined. We investigated which factors may influence microcirculatory alterations in patients with severe sepsis and whether these are independently associated with mortality. Design: Analysis of prospectively collected data from previously published studies by our group. Setting: A 36-bed, medicosurgical university hospital Department of Intensive Care. Patients: A total of 252 patients with severe sepsis in whom the sublingual microcirculation was visualized using orthogonal polarization spectral or sidestream darkfield imaging techniques. Measurements and Main Results: Microcirculatory measurements were obtained either early, within 24 h of the onset of severe sepsis (n = 204), or later, after 48 h (n = 48). When multiple measurements were obtained, only the first was considered. Although global hemodynamic variables were relatively preserved (mean arterial pressure 70 [65–77] mm Hg, cardiac index 3.3 [2.7–4.0] L/min.m 2 , and Svo 2 68.3 [62.8–74.7]%),

446 citations


Journal ArticleDOI
TL;DR: The PEdiatric Logistic Organ Dysfunction-2 score, which allows assessment of the severity of cases of multiple organ dysfunction syndrome in the PICU with a continuous scale, was developed and validated and can be freely used in clinical trials.
Abstract: Objective:Multiple organ dysfunction syndrome is the main cause of death in adult ICUs and in PICUs. The PEdiatric Logistic Organ Dysfunction score developed in 1999 was primarily designed to describe the severity of organ dysfunction. This study was undertaken to update and improve the PEdiatric Lo

403 citations


Journal ArticleDOI
TL;DR: Physical therapy in the ICU appears to confer significant benefit in improving quality of life, physical function, peripheral and respiratory muscle strength, increasing ventilator-free days, and decreasing hospital and ICU stay.
Abstract: bjective: The purpose of this systematic review was to review the evidence base for exercise in critically ill patients. Data Sources and Study Selection: Using keywords critical care and physical therapy and related synonyms, randomized controlled trials, meta-analyses, and systematic reviews were identified through electronic database searches and citation tracking. Clinical trials with outcomes of mortality, length of hospital and ICU stay, physical function and quality of life, muscle strength, and ventilator-free days were included. Data Extraction and Synthesis: Two reviewers abstracted data and assessed quality independently. Effect sizes and 95% confidence intervals were calculated. From 3,126 screened abstracts, 10 randomized controlled trials and five reviews were found. The mean Physiotherapy Evidence Database score was 5.4. Overall there was a significant positive effect favoring physical therapy for the critically ill to improve the quality of life (g = 0.40, 95% confidence interval 0.08, 0.71), physical function (g = 0.46, 95% confidence interval 0.13, 0.78), peripheral muscle strength (g = 0.27, 95% confidence interval 0.02, 0.52), and respiratory muscle strength (g = 0.51, 95% confidence interval 0.12, 0.89). Length of hospital (g = -0.34, 95% confidence interval -0.53, -0.15) and ICU stay (g = -0.34, 95% confidence interval -0.51, -0.18) significantly decreased and ventilator-free days increased (g = 0.38, 95% confidence interval 0.16, 0.59) following physical therapy in the ICU. There was no effect on mortality. Conclusion: Physical therapy in the ICU appears to confer significant benefit in improving quality of life, physical function, peripheral and respiratory muscle strength, increasing ventilator-free days, and decreasing hospital and ICU stay. However, further controlled trials of better quality and larger sample sizes are required to verify the strength of these tentative associations.

392 citations


Journal ArticleDOI
TL;DR: Extracorporeal cardiopulmonary resuscitation can improve neurologic outcome after out-of-hospital cardiac arrest of cardiac origin; furthermore, pupil diameter on hospital arrival may be a key predictor to identify extracorporecular resuscitation candidates.
Abstract: Objective:Encouraging results of extracorporeal cardiopulmonary resuscitation for patients with refractory cardiac arrest have been shown. However, the independent impact on the neurologic outcome remains unknown in the out-of-hospital population. Our objective was to compare the neurologic outcome

304 citations


Journal ArticleDOI
TL;DR: An ICU-wide quality improvement intervention to improve sleep anddelirium is feasible and associated with significant improvements in perceived nighttime noise, incidence of delirium/coma, and daily delirio-coma-free status.
Abstract: Objectives:To determine if a quality improvement intervention improves sleep and delirium/cognition.Design:Observational, pre–post design.Setting:A tertiary academic hospital in the United States.Patients:300 medical ICU patients.Interventions:This medical ICU-wide project involved a “usual care” ba

268 citations


Journal ArticleDOI
TL;DR: ART-123 is a safe intervention in critically ill patients with sepsis and suspected disseminated intravascular coagulation and evidence suggestive of efficacy supporting further development of this drug in sepsi-associated coagulopathy is provided.
Abstract: Objectives:To determine the safety and efficacy of recombinant thrombomodulin (ART-123) in patients with suspected sepsis-associated disseminated intravascular coagulation.Design:Phase 2b, international, multicenter, double-blind, randomized, placebo-controlled, parallel group, screening trial.Setti

255 citations


Journal ArticleDOI
TL;DR: High-intensity staffing is associated with reduced ICU and hospital mortality and 24-hour in-hospital intensivist coverage did not reduce hospital, or ICU, mortality.
Abstract: Objective:To determine the effect of different intensivist staffing models on clinical outcomes for critically ill patients.Data Sources:A sensitive search of electronic databases and hand-search of major critical care journals and conference proceedings was completed in October 2012.Study Selection

Journal ArticleDOI
TL;DR: Current controlled data suggest that use of a dexmedetomidine- or propofol-based sedation regimen rather than a benzodiazepine- based sedative regimen in critically ill adults may reduce ICU length of stay and duration of mechanical ventilation.
Abstract: Background:Use of dexmedetomidine or propofol rather than a benzodiazepine sedation strategy may improve ICU outcomes. We reviewed randomized trials comparing a benzodiazepine and nonbenzodiazepine regimen in mechanically ventilated adult ICU patients to determine if differences exist between these

Journal ArticleDOI
TL;DR: Venoarterial extracorporeal membrane oxygenation rescued more than 70% of the patients who developed refractory cardiovascular dysfunction during severe bacterial septic shock and reported good health-related quality of life at long-term follow-up.
Abstract: Objectives:Profound myocardial depression can occur during severe septic shock. Although good outcomes of venoarterial extracorporeal membrane oxygenation–treated children with refractory septic shock have been reported, little is known about adults’ outcomes. This study was designed to assess the o

Journal ArticleDOI
TL;DR: In critically ill patients, proton pump inhibitors seem to be more effective than histamine 2 receptor antagonists in preventing clinically important and overt upper gastrointestinal bleeding.
Abstract: Background:Critically ill patients may develop bleeding caused by stress ulceration. Acid suppression is commonly prescribed for patients at risk of stress ulcer bleeding. Whether proton pump inhibitors are more effective than histamine 2 receptor antagonists is unclear.Objectives:To determine the e

Journal ArticleDOI
TL;DR: Lung edema forms (possibly as an all-or-none response) depending not only on global strain but also on its components, but not because the former merely counteracts fluid extravasation.
Abstract: Objective:Tidal volume (VT) and volume of gas caused by positive end-expiratory pressure (VPEEP) generate dynamic and static lung strains, respectively. Our aim was to clarify whether different combinations of dynamic and static strains, resulting in the same large global strain, constantly produce

Journal ArticleDOI
TL;DR: Extravascular lung water index and pulmonary vascular permeability index measured by transpulmonary thermodilution are independent risk factors of day-28 mortality in patients with acute respiratory distress syndrome.
Abstract: Objective:Acute respiratory distress syndrome might be associated with an increase in extravascular lung water index and pulmonary vascular permeability index, which can be measured by transpulmonary thermodilution. We tested whether extravascular lung water index and pulmonary vascular permeability

Journal ArticleDOI
TL;DR: In volume-responders, unlike markers of anaerobic metabolism, central venous oxygen saturation did not allow the prediction of whether a fluid-induced increase in oxygen delivery would result in an increase inoxy consumption, which suggests that along with indicators of volume-responsiveness, the indicators of an aerobic metabolism should be considered instead of central venOUS oxygen saturation for starting hemodynamic resuscitation.
Abstract: Objectives:During circulatory failure, the ultimate goal of treatments that increase cardiac output is to reduce tissue hypoxia. This can only occur if oxygen consumption depends on oxygen delivery. We compared the ability of central venous oxygen saturation and markers of anaerobic metabolism to pr

Journal ArticleDOI
TL;DR: In this article, the prevalence and risk factors for delirium among patients in a mixed cardiology and cardiac surgery intensive care unit (CVICU) were investigated. But, the authors did not identify any specific risk factors.
Abstract: Objective Delirium, an acute organ dysfunction, is common among critically ill patients leading to significant morbidity and mortality; its epidemiology in a mixed cardiology and cardiac surgery intensive care unit (CVICU) is not well established. We sought to determine the prevalence and risk factors for delirium among CVICU patients.

Journal ArticleDOI
TL;DR: Occupancy of U.S. ICUs was stable over time, but there is uneven distribution across different types and sizes of units, suggesting substantial surge capacity throughout the system to care for acutely critically ill patients.
Abstract: Objectives Detailed data on occupancy and use of mechanical ventilators in United States intensive care units (ICU) over time and across unit types, are lacking. We sought to describe the hourly bed occupancy and use of ventilators in US ICUs to improve future planning of both the routine and disaster provision of intensive care.

Journal ArticleDOI
TL;DR: A reduced severity of illness score had discrimination and calibration equivalent to more complex existing models and was accomplished in large part using machine-learning algorithms, which can effectively account for the nonlinear associations between physiologic parameters and outcome.
Abstract: Objectives:Severity of illness scores have gained considerable interest for their use in predicting outcomes such as mortality and length of stay. The most sophisticated scoring systems require the collection of numerous physiologic measurements, making their use in real-time difficult. A severity o

Journal ArticleDOI
TL;DR: In animals with mild lung injury, spontaneous breathing was beneficial to lung recruitment; however, in animals with severe lung injury the effects of spontaneous breathing could worsen lung Injury, and muscle paralysis might be more protective for injured lungs by preventing injuriously high transpulmonary pressure and high driving pressure.
Abstract: Objectives:The benefits of spontaneous breathing over muscle paralysis have been proven mainly in mild lung injury; no one has yet evaluated the effects of spontaneous breathing in severe lung injury. We investigated the effects of spontaneous breathing in two different severities of lung injury com

Journal ArticleDOI
TL;DR: The Cerebral Performance Category at hospital discharge is a useful surrogate measure of long-term survival and can be an informative tool for programmatic evaluation and research of resuscitation.
Abstract: Objective:Although measures of functional status are often advocated when assessing short-term survival following cardiac arrest, little is known about how these measures predict long-term prognosis. We sought to determine whether the Cerebral Performance Category (CPC) was associated with long-term

Journal ArticleDOI
TL;DR: There is no direct evidence to support the immediate implementation of permissive hypoxemia and a comprehensive evaluation of its value in critically ill patients should be a high research priority, but precise control of arterial oxygenation and permissive Hypoxemia are proposed as candidate management strategies.
Abstract: Objective: the management of hypoxemia in critically ill patients is challenging. Whilst the harms of tissue hypoxia are well recognized, the possibility of harm from excess oxygen administration, or other interventions targeted at mitigating hypoxemia, may be inadequately appreciated. The benefits of attempting to fully reverse arterial hypoxemia may be outweighed by the harms associated with high concentrations of supplemental oxygen and invasive mechanical ventilation strategies. We propose two novel related strategies for the management of hypoxemia in critically ill patients. First, we describe precise control of arterial oxygenation involving the specific targeting of arterial partial pressure of oxygen or arterial hemoglobin oxygen saturation to individualized target values, with the avoidance of significant variation from these levels. The aim of precise control of arterial oxygenation is to avoid the harms associated with inadvertent hyperoxia or hypoxia through careful and precise control of arterial oxygen levels. Secondly, we describe permissive hypoxemia: the acceptance of levels of arterial oxygenation lower than is conventionally tolerated in patients. The aim of permissive hypoxemia is to minimize the possible harms caused by restoration of normoxemia while avoiding tissue hypoxia. This review sets out to discuss the strengths and limitations of precise control of arterial oxygenation and permissive hypoxemia as candidate management strategies in hypoxemic critically ill patients. Design: we searched PubMed for references to "permissive hypoxemia/hypoxaemia" and "precise control of arterial oxygenation" as well as reference to "profound hypoxemia/hypoxaemia/hypoxia," "severe hypoxemia/hypoxaemia/hypoxia." We searched personal reference libraries in the areas of critical illness and high altitude physiology and medicine. We also identified large clinical studies in patients with critical illness characterized by hypoxemia such as acute respiratory distress syndrome. Subjects: studies were selected that explored the physiology of hypoxemia in healthy volunteers or critically ill patients. Setting: the data were subjectively assessed and combined to generate the narrative. Results: inadequate tissue oxygenation and excessive oxygen administration can be detrimental to outcome but safety thresholds lack definition in critically ill patients. Precise control of arterial oxygenation provides a rational approach to the management of arterial oxygenation that reflects recent clinical developments in other settings. Permissive hypoxemia is a concept that is untested clinically and requires robust investigation prior to consideration of implementation. Both strategies will require accurate monitoring of oxygen administration and arterial oxygenation. Effective, reliable measurement of tissue oxygenation along with the use of selected biomarkers to identify suitable candidates and monitor harm will aid the development of permissive hypoxemia as viable clinical strategy. Conclusions: implementation of precise control of arterial oxygenation may avoid the harms associated with excessive and inadequate oxygenation. However, at present there is no direct evidence to support the immediate implementation of permissive hypoxemia and a comprehensive evaluation of its value in critically ill patients should be a high research priority.

Journal ArticleDOI
TL;DR: Despite their “immaturity”, band forms are capable of mediating crucial innate immune functions during severe infections and sepsis, and their fate and capacity to mature in vivo remain to be determined.
Abstract: A hallmark of sepsis and severe systemic inflammatory response syndrome (SIRS) is the massive recruitment of immature neutrophils from the bone marrow into the circulation (left shift, band forms). Their capacity to participate in innate defense against bacteria is ill defined. We aimed at comparing various innate immune functions of mature vs. immature neutrophils circulating during sepsis and SIRS.

Journal ArticleDOI
TL;DR: Ventilator-associated events surveillance was implemented in January 2013 in the CDC’s National Healthcare Safety Network and can identify a broad range of conditions and complications occurring in mechanically ventilated adult patients, including but not limited to VAP.
Abstract: Objective:To develop and implement an objective, reliable approach to surveillance for ventilator-associated events in adult patients.Design:The Centers for Disease Control and Prevention (CDC) convened a Ventilator-Associated Pneumonia (VAP) Surveillance Definition Working Group in September 2011.

Journal ArticleDOI
TL;DR: Use of specific criteria to prompt proactive referral for palliative care consultation seems to help reduce utilization of ICU resources without changing mortality, while increasing involvement of palliatives care specialists for critically ill patients and families in need.
Abstract: Objective:To review the use of screening criteria (also known as “triggers”) as a mechanism for engaging palliative care consultants to assist with care of critically ill patients and their families in the ICU.Data Sources:We searched the MEDLINE database from inception to December 2012 for all Engl

Journal ArticleDOI
TL;DR: Clear factors were identified that both advanced and impeded adoption of this complex intervention that requires interprofessional education, coordination, and cooperation in a tertiary care setting.
Abstract: Objective The Awakening and Breathing Coordination, Delirium monitoring/management and Early exercise/mobility (ABCDE) bundle is an evidence-based, interprofessional, multicomponent strategy for minimizing sedative exposure, reducing duration of mechanical ventilation and managing intensive care unit (ICU) acquired delirium and weakness. The purpose of this study was to identify facilitators and barriers to ABCDE bundle adoption and to evaluate the extent to which bundle implementation was effective, sustainable, and conducive to dissemination.

Journal ArticleDOI
TL;DR: A financial model projects that investment in an ICU early rehabilitation program can generate net financial savings for U.S. hospitals, and even under the most conservative assumptions, the projected net cost of implementing such a program is modest relative to the substantial improvements in patient outcomes demonstrated by ICUEarly rehabilitation programs.
Abstract: Objective:To evaluate the potential annual net cost savings of implementing an ICU early rehabilitation program.Design:Using data from existing publications and actual experience with an early rehabilitation program in the Johns Hopkins Hospital Medical ICU, we developed a model of net financial sav

Journal ArticleDOI
TL;DR: Monitoring cerebral oximetry index may provide a novel method for precisely guiding mean arterial blood pressure targets during cardiopulmonary bypass, independently associated with for acute kidney injury.
Abstract: Objectives:To determine whether mean arterial blood pressure excursions below the lower limit of cerebral blood flow autoregulation during cardiopulmonary bypass are associated with acute kidney injury after surgerySetting:Tertiary care medical centerPatients:Four hundred ten patients undergoing c

Journal ArticleDOI
TL;DR: This narrative review, which summarizes the existing literature on the prevalence, mechanisms, risk factors, and prediction of cognitive impairment after surviving critical illness, suggests the potential role of exercise on cognitive recovery is an exciting area of exploration.
Abstract: In contrast to other clinical outcomes, long-term cognitive function in critical care survivors has not been deeply studied. In this narrative review, we summarize the existing literature on the prevalence, mechanisms, risk factors, and prediction of cognitive impairment after surviving critical illness. Depending on the exact clinical subgroup, up to 100% of critical care survivors may suffer some degree of long-term cognitive impairment at hospital discharge; in approximately 50%, decrements in cognitive function will persist years later. Although the mechanisms of acquiring this impairment are poorly understood, several risk factors have been identified. Unfortunately, no easy means of predicting long-term cognitive impairment exists. Despite this barrier, research is ongoing to test possible treatments for cognitive impairment. In particular, the potential role of exercise on cognitive recovery is an exciting area of exploration. Opportunities exist to incorporate physical and cognitive rehabilitation strategies across a spectrum of environments (in the ICU, on the hospital ward, and at home, posthospital discharge).