Showing papers in "Critical Care Medicine in 2014"
TL;DR: The results of the analysis of this large population of patients with severe sepsis and septic shock demonstrate that delay in first antibiotic administration was associated with increased in-hospital mortality, and there was a linear increase in the risk of mortality for each hour delay in antibiotic administration.
Abstract: Objectives:Compelling evidence has shown that aggressive resuscitation bundles, adequate source control, appropriate antibiotic therapy, and organ support are cornerstone for the success in the treatment of patients with sepsis. Delay in the initiation of appropriate antibiotic therapy has been reco
1,140 citations
TL;DR: The mortality trends identified in clinical trial participants appear similar to those identified using administrative data and support the use of administrative data to monitor mortality trends in patients with severe sepsis.
Abstract: Objectives:Trends in severe sepsis mortality derived from administrative data may be biased by changing International Classification of Diseases, 9th Revision, Clinical Modification, coding practices. We sought to determine temporal trends in severe sepsis mortality using clinical trial data that do
577 citations
TL;DR: Muscle weakness is common after acute lung injury, usually recovering within 12 months, and this weakness is associated with substantial impairments in physical function and health-related quality of life that continue beyond 24 months.
Abstract: Objective
Survivors of severe critical illness frequently develop substantial and persistent physical complications, including muscle weakness, impaired physical function, and decreased health-related quality of life (HRQOL). Our objective was to determine the longitudinal epidemiology of muscle weakness, physical function, and HRQOL, and their associations with critical illness and intensive care unit exposures.
476 citations
TL;DR: Critically ill patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle spent three more days breathing without assistance, experienced less delirium, and were more likely to be mobilized during their ICU stay than patients treated with usual care.
Abstract: Objective
The debilitating and persistent effects of intensive care unit (ICU)-acquired delirium and weakness warrant testing of prevention strategies. The purpose of this study was to evaluate the effectiveness and safety of implementing the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility (ABCDE) bundle into everyday practice.
415 citations
TL;DR: Delayed antimicrobial therapy was an independent risk factor for mortality and prolonged organ dysfunction in pediatric sepsis and persisted after adjustment for individual confounders and a propensity score analysis.
Abstract: The sepsis syndrome remains a major cause of morbidity and mortality in pediatrics. Over 75,000 children are hospitalized with severe sepsis in the United States each year at $4.8 billion in healthcare costs (1). For critically ill children with sepsis admitted to a PICU, mortality is 10–20% (2–6). Antibiotic therapy is a central component of treatment for sepsis. The Surviving Sepsis Campaign recommends administration of empiric antimicrobial therapy within 1 hour of recognition of severe sepsis or septic shock in adult and pediatric patients (7). This recommendation is based on data that delayed antimicrobial administration is associated with mortality in critically ill adults with sepsis (8–12).
The impact of time to antimicrobial administration on mortality for pediatric patients with severe sepsis or septic shock is not clear. Several studies evaluating sepsis bundle implementation in the pediatric emergency department (ED) have shown decreased time to antimicrobial administration, but improved mortality has not yet been established (13, 14). Given the many goals of initial resuscitation for patients with severe sepsis and septic shock, including IV access, collection of blood cultures and other laboratory tests, and fluid resuscitation, it is important to understand where to prioritize antimicrobial administration. Furthermore, despite unproven benefit in pediatric patients, early antimicrobial administration is increasingly being used as a quality metric (15–18). Data are therefore needed to justify, and potentially motivate, compliance with this recommendation in pediatric centers.
We sought to test the hypothesis that delayed administration of antimicrobial therapy is associated with increased mortality and prolonged organ dysfunction in patients treated for severe sepsis or septic shock in a PICU.
352 citations
TL;DR: The Cornell Assessment of Pediatric Delirium is a valid, rapid, observational nursing screen that is urgently needed for the detection of delirium in PICU settings.
Abstract: Objective:To determine validity and reliability of the Cornell Assessment of Pediatric Delirium, a rapid observational screening tool.Design:Double-blinded assessments were performed with the Cornell Assessment of Pediatric Delirium completed by nursing staff in the PICU. These ratings were compared
349 citations
TL;DR: Among critically ill adults with sepsis, resuscitation with balanced fluids was associated with a lower risk of in-hospital mortality, and if confirmed in randomized trials, this finding could have significant public health implications, as crystalloid resuscitation is nearly universal in sepsi.
Abstract: Objective:Isotonic saline is the most commonly used crystalloid in the ICU, but recent evidence suggests that balanced fluids like Lactated Ringer’s solution may be preferable We examined the association between choice of crystalloids and in-hospital mortality during the resuscitation of critically
335 citations
University of Technology, Sydney1, University of California, San Diego2, American Physical Therapy Association3, Primary Children's Hospital4, Brigham Young University5, University of Michigan6, University of Pennsylvania7, University of Minnesota8, Columbia University9, Johns Hopkins University10, Marianjoy Rehabilitation Hospital and Clinics11, Summa Health System12, University of Chicago13, NorthShore University HealthSystem14, University of Arkansas for Medical Sciences15, Houston Methodist Hospital16, St. Luke's Hospital17, University of Wisconsin-Madison18, Northwestern University19, University of Maryland, Baltimore20, Memorial Hospital of South Bend21, Rush University Medical Center22
TL;DR: Raising awareness of post–intensive care syndrome for the public and both critical care and non–critical care clinicians will inform a more coordinated approach to treatment and support during recovery after critical illness.
Abstract: Background Increasing numbers of survivors of critical illness are at risk for physical, cognitive, and/or mental health impairments that may persist for months or years after hospital discharge. The post-intensive care syndrome framework encompassing these multidimensional morbidities was developed at the 2010 Society of Critical Care Medicine conference on improving long-term outcomes after critical illness for survivors and their families. Objectives To report on engagement with non-critical care providers and survivors during the 2012 Society of Critical Care Medicine post-intensive care syndrome stakeholder conference. Task groups developed strategies and resources required for raising awareness and education, understanding and addressing barriers to clinical practice, and identifying research gaps and resources, aimed at improving patient and family outcomes. Participants Representatives from 21 professional associations or health systems involved in the provision of both critical care and rehabilitation of ICU survivors in the United States and ICU survivors and family members. Design Stakeholder consensus meeting. Researchers presented summaries on morbidities for survivors and their families, whereas survivors presented their own experiences. Meeting outcomes Future steps were planned regarding 1) recognizing, preventing, and treating post-intensive care syndrome, 2) building strategies for institutional capacity to support and partner with survivors and families, and 3) understanding and addressing barriers to practice. There was recognition of the need for systematic and frequent assessment for post-intensive care syndrome across the continuum of care, including explicit "functional reconciliation" (assessing gaps between a patient's pre-ICU and current functional ability at all intra- and interinstitutional transitions of care). Future post-intensive care syndrome research topic areas were identified across the continuum of recovery: characterization of at-risk patients (including recognizing risk factors, mechanisms of injury, and optimal screening instruments), prevention and treatment interventions, and outcomes research for patients and families. Conclusions Raising awareness of post-intensive care syndrome for the public and both critical care and non-critical care clinicians will inform a more coordinated approach to treatment and support during recovery after critical illness. Continued conceptual development and engagement with additional stakeholders is required.
318 citations
TL;DR: Palliative care is increasingly accepted as an essential component of comprehensive care for critically ill patients, regardless of diagnosis or prognosis, and resources including technical assistance and tools are available to support improvement efforts.
Abstract: Objectives
Palliative care is an interprofessional specialty as well as an approach to care by all clinicians caring for patients with serious and complex illness. Unlike hospice, palliative care is based not on prognosis but on need and is an essential component of comprehensive care for critically ill patients from the time of ICU admission. In this clinically focused article, we review evidence of opportunities to improve palliative care for critically ill adults, summarize strategies for ICU palliative care improvement, and identify resources to support implementation.
262 citations
TL;DR: In this 1-day point-prevalence study conducted across Germany, only 24% of all mechanically ventilated patients and only 8% of patients with an endotracheal tube were mobilized out of bed as part of routine care.
Abstract: Objectives:There is growing evidence to support early mobilization of adult mechanically ventilated patients in ICUs. However, there is little knowledge regarding early mobilization in routine ICU practice. Hence, the interdisciplinary German ICU Network for Early Mobilization undertook a 1-day poin
261 citations
TL;DR: Implementation of an interdisciplinary, postevent quantitative debriefing program was significantly associated with improved cardiopulmonary resuscitation quality and survival with favorable neurologic outcome.
Abstract: Cardiac arrest is a major public health problem with 200,000 in-hospital cardiac arrest resuscitations each year in the United States (1, 2). Importantly, quality of cardiopulmonary resuscitation (CPR) performed during resuscitations frequently does not meet recommended guidelines (3–5). In addition, wide variability in duration of resuscitations and survival outcomes further suggest opportunities for improvement (6). Because CPR quality is associated with survival (4, 7–10), interventions to improve quality of CPR are a promising method to improve cardiac arrest outcomes.
Approaches to improve CPR quality include standard resuscitation courses, automated real-time corrective feedback devices, and structured postresuscitation debriefing. Although standard courses are the mainstay of ongoing life support training and maintenance of certification, evidence that courses improve outcomes is modest (11–13). Automated real-time corrective feedback devices incorporated into monitor-defibrillator systems have been moderately effective to improve psychomotor aspects of basic life support (i.e., chest compressions [CCs] and ventilation delivery) (14, 15), yet data demonstrating improved long-term outcomes are limited (16). Structured postresuscitation debriefing is a comprehensive review of resuscitation efforts, including quantitative review of CPR variables. Interestingly, structured postresuscitation debriefing for physicians who were involved in resuscitations has been effective at improving CPR quality and short-term survival; however, its implementation has not been associated with higher rates of survival to hospital discharge or survival with favorable neurologic outcome (17).
To improve resuscitation performance by the entire resuscitation team, we developed a novel interdisciplinary, care-environment–targeted, postevent quantitative cardiac arrest debriefing program (18). Because over 90% of pediatric in-hospital cardiac arrests occur in ICUs (19), we focused our efforts on the interdisciplinary ICU team including physicians, nurses, and respiratory therapists. In a prospective quality improvement intervention, we compared quantitative resuscitation quality and patient outcomes before and after implementation of this novel postarrest quantitative debriefing program. We hypothesized that our intervention, by improving the resuscitative care provided by the entire interdisciplinary team, would improve cardiac arrest survival outcome.
TL;DR: Augmented renal clearance appears to be a common finding in this patient group, with sustained elevation of creatinine clearance throughout the first week in ICU, and the implications for accurate dosing of renally eliminated pharmaceuticals in patients with augmented renal clearance should be focused on.
Abstract: Objective: To describe the prevalence and natural history of augmented renal clearance in a cohort of recently admitted critically ill patients with normal plasma creatinine concentrations. Design: Multicenter, prospective, observational study. Setting: Four, tertiary-level, university-affiliated, ICUs in Australia, Singapore, Hong Kong, and Portugal. Patients: Study participants had to have an expected ICU length of stay more than 24 hours, no evidence of absolute renal impairment (admission plasma creatinine < 120 µmol/L), and no history of prior renal replacement therapy or chronic kidney disease. Convenience sampling was used at each participating site. Interventions: Eight-hour urinary creatinine clearances were collected daily, as the primary method of measuring renal function. Augmented renal clearance was defined by a creatinine clearance more than or equal to 130 mL/min/1.73 m2. Additional demographic, physiological, therapeutic, and outcome data were recorded prospectively. Measurements and Main Results: Nine hundred thirty-two patients were admitted to the participating ICUs over the study period, and 281 of which were recruited into the study, contributing 1,660 individual creatinine clearance measures. The mean age (95% CI) was 54.4 years (52.5–56.4 yr), Acute Physiology and Chronic Health Evaluation II score was 16 (15.2–16.7), and ICU mortality was 8.5%. Overall, 65.1% manifested augmented renal clearance on at least one occasion during the first seven study days; the majority (74%) of whom did so on more than or equal to 50% of their creatinine clearance measures. Using a mixed-effects model, the presence of augmented renal clearance on study day 1 strongly predicted (p = 0.019) sustained elevation of creatinine clearance in these patients over the first week in ICU. Conclusions: Augmented renal clearance appears to be a common finding in this patient group, with sustained elevation of creatinine clearance throughout the first week in ICU. Future studies should focus on the implications for accurate dosing of renally eliminated pharmaceuticals in patients with augmented renal clearance, in addition to the potential impact on individual clinical outcomes.
TL;DR: In the setting of critical illness, longer delirium duration is independently associated with increased odds of disability in activities of daily living and worse motor-sensory function in the following year.
Abstract: Objective:Survivors of critical illness are frequently left with long-lasting disability. The association between delirium and disability in critically ill patients has not been described. We hypothesized that the duration of delirium in the ICU would be associated with subsequent disability and wor
TL;DR: Combination of clinical examination, electroencephalography reactivity, and serum neuron-specific enolase offers the best outcome predictive performance for prognostication of early postanoxic coma, whereas somatosensory-evoked potentials do not add any complementary information.
Abstract: Objectives:Therapeutic hypothermia and pharmacological sedation may influence outcome prediction after cardiac arrest. The use of a multimodal approach, including clinical examination, electroencephalography, somatosensory-evoked potentials, and serum neuron-specific enolase, is recommended; however
TL;DR: Interventions which have substantial effects in post-ICU patients are rare and positive effects were seen for ICU-diary interventions for posttraumatic stress disorder.
Abstract: OBJECTIVE: An increasing number of ICU patients survive and develop mental, cognitive, or physical impairments. Various interventions support recovery from this postintensive care syndrome. Physicians in charge of post-ICU patients need to know which interventions are effective. DATA SOURCES: Systematic literature search in databases (MEDLINE, EMBASE, Cochrane CENTRAL, PsycInfo, CINAHL; 1991-2012), reference lists, and hand search. STUDY SELECTION: We included comparative studies of rehabilitation interventions in adult post-ICU patients if they considered health-related quality of life, frequency/severity of postintensive care syndrome symptoms, functional recovery, need for care, autonomy in activities of daily living, mortality, or hospital readmissions. DATA EXTRACTION: Two reviewers extracted data and assessed risk of bias independently. DATA SYNTHESIS: From 4,761 publications, 18 studies with 2,510 patients were included. Studies addressed 20 outcomes, using 45 measures, covering inpatient (n = 4 trials), outpatient (n = 9), and mixed (n = 5) healthcare settings. Eight controlled trials with moderate to high quality were considered for evaluation of effectiveness. They investigated inpatient geriatric rehabilitation, ICU follow-up clinic, outpatient rehabilitation, disease management, and ICU diaries. Five of these trials assessed posttraumatic stress disorder, with four trials showing positive effects: first, ICU diaries reduced new-onset posttraumatic stress disorder (5% vs 13%, p = 0.02) after 3 months and second showed a lower mean Impact of Event Scale-Revised score (21.0 vs 32.1, p = 0.03) after 12 months. Third, aftercare by ICU follow-up clinic reduced Impact of Event Scale for women (20 vs 31; p < 0.01). Fourth, a self-help manual led to fewer patients scoring high in the Impact of Event Scale after 8 weeks (p = 0.026) but not after 6 months. For none of the other outcomes did more than one study report positive impacts. CONCLUSION: Interventions which have substantial effects in post-ICU patients are rare. Positive effects were seen for ICU-diary interventions for posttraumatic stress disorder. More interventions for the growing number of ICU survivors are needed.
TL;DR: In ventilated stroke patients admitted to the ICU, arterial hyperoxia was independently associated with in-hospital death as compared with either normoxia or hypoxia, and the need for studies of controlled reoxygenation in ventilated critically ill stroke populations is underscore.
Abstract: Objective:To test the hypothesis that hyperoxia was associated with higher in-hospital mortality in ventilated stroke patients admitted to the ICU.Design:Retrospective multicenter cohort study.Setting:Primary admissions of ventilated stroke patients with acute ischemic stroke, subarachnoid hemorrhag
TL;DR: The mode of death in the PICU is proportionally similar to that reported over the past two decades, while the mortality rate has nearly halved.
Abstract: Objective:To determine the epidemiology of death in PICUs at 5 geographically diverse teaching hospitals across the United States.Design:Prospective case series.Setting:Five U.S. teaching hospitals.Subjects:We concurrently identified 192 consecutive patients who died prior to discharge from the PICU
TL;DR: This study demonstrates that lactate clearance is predictive of lower mortality rate in critically ill patients, and its diagnostic performance is optimal for clinical utility.
Abstract: Objectives:Lactate clearance has been widely investigated for its prognostic value in critically ill patients. However, the results are conflicting. The present study aimed to explore the diagnostic accuracy of lactate clearance in predicting mortality in critically or acutely ill patients.Data Sour
TL;DR: Left ventricular diastolic dysfunction and right ventricular dilatation are the echocardiographic variables correlating best with concomitant high-sensitivity troponin-T concentrations, and seem to explain the association of trop onin with mortality in severe sepsis and septic shock.
Abstract: Objective:Serum troponin concentrations predict mortality in almost every clinical setting they have been examined, including sepsis. However, the causes for troponin elevations in sepsis are poorly understood. We hypothesized that detailed investigation of myocardial dysfunction by echocardiography
TL;DR: The results highlight the heterogeneity in sedation practices among intensivists who care for critically ill children as well as a paucity of sleep promotion and delirium screening in PICUs worldwide.
Abstract: Objectives:To examine pediatric intensivist sedation management, sleep promotion, and delirium screening practices for intubated and mechanically ventilated children.Design:An international, online survey of questions regarding sedative and analgesic medication choices and availability, sedation pro
TL;DR: Compared with intermittent hemodialysis, initiation of continuous renal replacement therapy in critically ill adults with acute kidney injury is associated with a lower likelihood of chronic dialysis.
Abstract: Objective:Among critically ill patients with acute kidney injury, the impact of renal replacement therapy modality on long-term kidney function is unknown. Compared with conventional intermittent hemodialysis, continuous renal replacement therapy may promote kidney recovery by conferring greater hem
TL;DR: It is needed to improve the ability to define appropriate molecular targets for preclinical development and develop better methods to determine the clinical value of novel sepsis agents.
Abstract: Objective The developmental pipeline for novel therapeutics to treat sepsis has diminished to a trickle compared to previous years of sepsis research. While enormous strides have been made in understanding the basic molecular mechanisms that underlie the pathophysiology of sepsis, a long list of novel agents have now been tested in clinical trials without a single immunomodulating therapy showing consistent benefit. The only antisepsis agent to successfully complete a phase III clinical trial was human recumbent activated protein C. This drug was taken off the market after a follow-up placebo-controlled trial (human recombinant activated Protein C Worldwide Evaluation of Severe Sepsis and septic Shock [PROWESS SHOCK]) failed to replicate the favorable results of the initial registration trial performed ten years earlier. We must critically reevaluate our basic approach to the preclinical and clinical evaluation of new sepsis therapies. Data sources We selected the major clinical studies that investigated interventional trials with novel therapies to treat sepsis over the last 30 years. Study selection Phase II and phase III trials investigating new treatments for sepsis and editorials and critiques of these studies. Data extraction Selected manuscripts and clinical study reports were analyzed from sepsis trials. Specific shortcomings and potential pit falls in preclinical evaluation and clinical study design and analysis were reviewed and synthesized. Data synthesis After review and discussion, a series of 12 recommendations were generated with suggestions to guide future studies with new treatments for sepsis. Conclusions We need to improve our ability to define appropriate molecular targets for preclinical development and develop better methods to determine the clinical value of novel sepsis agents. Clinical trials must have realistic sample sizes and meaningful endpoints. Biomarker-driven studies should be considered to categorize specific "at risk" populations most likely to benefit from a new treatment. Innovations in clinical trial design such as parallel crossover design, alternative endpoints, or adaptive trials should be pursued to improve the outlook for future interventional trials in sepsis.
TL;DR: Simulation-based airway management curriculum is superior to no intervention and nonsimulation intervention for important education outcomes and further research is required to fine-tune optimal curricular design.
Abstract: Objective:To perform a systematic review and meta-analysis of the literature on teaching airway management using technology-enhanced simulation.Data Sources:We searched MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, Web of Science, and Scopus for eligible articles through May 11, 2011.Study Selection:Obse
TL;DR: The findings suggest that ventilator-associated pneumonia remains a common ICU infection and that P. aeruginosa is one of the most common causative pathogens.
Abstract: Objective:To estimate the prevalence of ventilator-associated pneumonia caused by Pseudomonas aeruginosa in patients at risk for ventilator-associated pneumonia and to describe risk factors for P. aeruginosa ventilator-associated pneumonia.Design:Prospective, observational study.Setting:ICUs at 56 s
TL;DR: Restoring pulsatility and decreasing left ventricular afterload with intra-aortic balloon pump was associated with smallerleft ventricular dimensions and lower pulmonary artery pressures but did not affect microcirculation variables in cardiogenic shock patients with little/no residual left vent cardiac ejection while on peripheral venoarterial extracorporeal membrane oxygenation.
Abstract: Objectives:This study was designed to assess the effects on macrocirculation and microcirculation of adding an intra-aortic balloon pump to peripheral venoarterial extracorporeal membrane oxygenation in patients with severe cardiogenic shock and little/no residual left ventricular ejection.Design:A
TL;DR: Nitric oxide does not reduce mortality in adults or children with acute respiratory distress syndrome, regardless of the degree of hypoxemia, and the lack of related ongoing or recently completed randomized trials means new data addressing the effectiveness of nitric oxide in patients with acute lungs distress syndrome and severe Hypoxemia will not be available for the foreseeable future.
Abstract: Objective:Treatment with inhaled nitric oxide improves oxygenation but not survival in mechanically ventilated patients with acute respiratory distress syndrome, but the effect may depend on the severity of hypoxemia. Our objective was to determine whether nitric oxide reduces hospital mortality in
TL;DR: Study of fluid-based interventions should utilize inclusion criteria to accurately capture patients with hypovolemia and tissue hypoperfusion who are most likely to benefit from fluids, and exclusion of patients with severe respiratory distress should be considered when ventilatory support is not readily available.
Abstract: In the United States, 750,000 people die each year from sepsis.(1) Although available data are limited, the number of sepsis-related deaths is likely much higher in sub-Saharan Africa, where more than half of all deaths are attributed to infections.(2) Cohort studies from the region have found sepsis to be the third leading cause of death among HIV-infected adults, after tuberculosis and cryptococcal meningitis,(3) and an unpublished audit at the University Teaching Hospital in Zambia showed sepsis to be the leading cause of death among hospitalized medical patients. However, optimal management strategies for septic patients in Africa remain controversial.(4-7)
Protocol-based management of sepsis has had wide uptake in North America and Europe.(8,9) Studies of early goal directed therapy have demonstrated that aggressive intravenous (IV) fluid administration, hemodynamic support, and blood transfusion can significantly reduce mortality due to sepsis. Central venous pressure or serum-lactate-guided approaches have generally resulted in patients receiving between 4 and 5 liters of fluid in the first 6 hours of admission.(10,11) In sub-Saharan Africa, however, uptake has been generally non-existent due to resource limitations.(12) Central venous catheters and lactic acid tests are not widely available, and the use of IV fluids for volume resuscitation has been much more conservative than guidelines recommend.(13,14) There are also questions regarding the generalizability of existing evidence to the sub-Saharan African setting, considering the under-representation of resource-limited study sites and HIV/AIDS patients in most sepsis trials.(15) Furthermore, the limited existing evidence from the region is conflicting regarding the potential benefits and harms of aggressive fluid resuscitation.(4,6)
We hypothesized that a novel simplified treatment protocol, based on existing early goal directed therapy protocols, would reduce mortality compared with usual care in African patients with severe sepsis. The simplified severe sepsis protocol (SSSP) intervention consisted of early goal-directed fluid administration, plus dopamine and/or blood transfusion when indicated. Patients in both arms received close nurse monitoring with early blood cultures and antibiotics.
TL;DR: This meta-analysis provides a unique ranking of plasma biomarkers according to their strength of association with acute respiratory distress syndrome diagnosis or acute respiratory distressed syndrome mortality.
Abstract: Objective:Numerous studies have focused on biomarkers for acute lung injury and acute respiratory distress syndrome. Although several biomarkers have been identified, their relative performance is unclear. We aim to provide a quantitative overview of plasma-derived biomarkers associated with acute r
TL;DR: Alterations of microcirculation in traumatic hemorrhagic shock patients result from the interplay among hemorrhage-induced tissue hypoperfusion, trauma injuries, inflammatory response, and subsequent resuscitation interventions.
Abstract: Objectives:Microcirculatory dysfunction has been well reported in clinical studies in septic shock. However, no clinical studies have investigated microcirculatory blood flow behavior in hemorrhagic shock. The main objective of this study was to assess the time course of sublingual microcirculation
TL;DR: In this multicenter cohort study, ventilator-associated pneumonia did not occur more frequently among elderly patients, but the associated mortality in these patients was higher and the importance of older age in the risk of death was confirmed.
Abstract: We investigated the epidemiology of ventilator-associated pneumonia in elderly ICU patients. More precisely, we assessed prevalence, risk factors, signs and symptoms, causative bacterial pathogens, and associated outcomes. Secondary analysis of a multicenter prospective cohort (EU-VAP project). Twenty-seven European ICUs. Patients who were mechanically ventilated for greater than or equal to 48 hours. We compared middle-aged (45-64 yr; n = 670), old (65-74 yr; n = 549), and very old patients (≥ 75 yr; n= 516). Ventilator-associated pneumonia occurred in 103 middle-aged (14.6%), 104 old (17.0%), and 73 very old patients (12.8%). The prevalence (n ventilator-associated pneumonia/1,000 ventilation days) was 13.7 in middle-aged patients, 16.6 in old patients, and 13.0 in very old patients. Logistic regression analysis could not demonstrate older age as a risk factor for ventilator-associated pneumonia. Ventilator-associated pneumonia in elderly patients was more frequently caused by Enterobacteriaceae (24% in middle-aged, 32% in old, and 43% in very old patients; p = 0.042). Regarding clinical signs and symptoms at ventilator-associated pneumonia onset, new temperature rise was less frequent among very old patients (59% vs 76% and 74% for middle-aged and old patients, respectively; p = 0.035). Mortality among patients with ventilator-associated pneumonia was higher among elderly patients: 35% in middle-aged patients versus 51% in old and very old patients (p = 0.036). Logistic regression analysis confirmed the importance of older age in the risk of death (adjusted odds ratio for old age, 2.1; 95% CI, 1.2-3.9 and adjusted odds ratio for very old age, 2.3; 95% CI, 1.2-4.4). Other risk factors for mortality in ventilator-associated pneumonia were diabetes mellitus, septic shock, and a high-risk pathogen as causative agent. In this multicenter cohort study, ventilator-associated pneumonia did not occur more frequently among elderly, but the associated mortality in these patients was higher. New temperature rise was less common in elderly patients with ventilator-associated pneumonia, whereas more episodes among elderly patients were caused by Enterobacteriaceae.