Showing papers in "Critical Care Medicine in 2016"
TL;DR: In this subgroup analysis, interleukin-1 receptor blockade was associated with significant improvement in survival of patients with sepsis and concurrent hepatobiliary dysfunction/disseminated intravascular coagulation.
Abstract: Objective:To determine the efficacy of anakinra (recombinant interleukin-1 receptor antagonist) in improving 28-day survival in sepsis patients with features of macrophage activation syndrome. Despite equivocal results in sepsis trials, anakinra is effective in treating macrophage activation syndrom
582 citations
TL;DR: A Task Force comprising 17 members of the Society of Critical Medicine with particular expertise in the use of neuromuscular-blocking agents met via teleconference and three face-to-face meetings and communicated via e-mail to examine the evidence and develop these practice guidelines.
Abstract: The decision to treat a patient in the intensive care unit (ICU) with neuromuscular blocking agents (NMBAs) (for reasons other than the placement of an endotracheal tube) is a difficult one that is guided more commonly by individual practitioner preference than by standards based on evidence-based medicine. Commonly cited reasons for the use of NMBAs in the ICU are to facilitate mechanical ventilation or different modes of mechanical ventilation and to manage patients with head trauma or tetanus. Independent of the reasons for using NMBAs, we emphasize that all other modalities to improve the clinical situation must be tried, using NMBAs only as a last resort. In 1995, the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM) published guidelines for the use of NMBAs in the ICU. The present document is the result of an attempt to reevaluate the literature that has appeared since the last guidelines were published and, based on that review, to update the recommendations for the use of NMBAs in the ICU. Appendix A summarizes our recommendations. Using methods previously described to evaluate the literature and grade the evidence (1), the task force reviewed the physiology of the neuromuscular receptor, the pharmacology of the NMBAs currently used in the ICU, the means to monitor the degree of blockade, the complications associated with NMBAs, and the economic factors to consider when choosing a drug.
441 citations
TL;DR: These recommendations provide a comprehensive framework to guide practitioners in making informed decisions during the admission, discharge, and triage process as well as in resolving issues of nonbeneficial treatment and rationing.
Abstract: Objectives:To update the Society of Critical Care Medicine’s guidelines for ICU admission, discharge, and triage, providing a framework for clinical practice, the development of institutional policies, and further research.Design:An appointed Task Force followed a standard, systematic, and evidence-
419 citations
TL;DR: It is found that several machine learning methods more accurately predicted clinical deterioration than logistic regression and use of detection algorithms derived from these techniques may result in improved identification of critically ill patients on the wards.
Abstract: Objective:Machine learning methods are flexible prediction algorithms that may be more accurate than conventional regression. We compared the accuracy of different techniques for detecting clinical deterioration on the wards in a large, multicenter database.Design:Observational cohort study.Setting:
407 citations
TL;DR: Clinicians should engage in a shared decision making process to define overall goals of care and when making major treatment decisions that may be affected by personal values, goals, and preferences, and research is needed to evaluate decision-making strategies.
Abstract: Objectives:Shared decision making is endorsed by critical care organizations; however, there remains confusion about what shared decision making is, when it should be used, and approaches to promote partnerships in treatment decisions. The purpose of this statement is to define shared decision makin
357 citations
TL;DR: A low expired tidal volume is almost impossible to achieve in the majority of patients receiving noninvasive ventilation for de novo acute hypoxemic respiratory failure, and a high expired tidalVolume is independently associated with non invasive ventilation failure.
Abstract: Objectives:A low or moderate expired tidal volume can be difficult to achieve during noninvasive ventilation for de novo acute hypoxemic respiratory failure (i.e., not due to exacerbation of chronic lung disease or cardiac failure). We assessed expired tidal volume and its association with noninvasi
347 citations
TL;DR: Clinically important depressive symptoms occurred in approximately one-third of ICU survivors and were persistent through 12-month follow-up, and greater research into treatment is needed for this common and persistent post-ICU morbidity.
Abstract: Objectives:To synthesize data on prevalence, natural history, risk factors, and post-ICU interventions for depressive symptoms in ICU survivorsData Sources:PubMed, EMBASE, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, and Cochrane Controlled Trials Registry (1970–2015)Study S
267 citations
TL;DR: Administration of thiamine did not improve lactate levels or other outcomes in the overall group of patients with septic shock and elevated lactate and a statistically significant decrease in mortality over time was not found.
Abstract: Objective:To determine if intravenous thiamine would reduce lactate in patients with septic shock.Design:Randomized, double-blind, placebo-controlled trial.Setting:Two US hospitals.Patients:Adult patients with septic shock and elevated (> 3 mmol/L) lactate between 2010 and 2014.Interventions:Thiamin
220 citations
TL;DR: In this paper, epidemiology, complication profiles, hospital outcome, and predisposing factors of CNS complications occurring during venoarterial extracorporeal membrane oxygenation in adults were elucidated.
Abstract: Objectives:To elucidate the epidemiology, complication profiles, hospital outcome, and predisposing factors of CNS complications occurring during venoarterial extracorporeal membrane oxygenation in adults.Design:Retrospective analysis of the Extracorporeal Life Support Organization registry.Setting:
199 citations
TL;DR: In patients with established acute respiratory distress syndrome, open lung approach improved oxygenation and driving pressure, without detrimental effects on mortality, ventilator-free days, or barotrauma.
Abstract: Objective:The open lung approach is a mechanical ventilation strategy involving lung recruitment and a decremental positive end-expiratory pressure trial. We compared the Acute Respiratory Distress Syndrome network protocol using low levels of positive end-expiratory pressure with open lung approach
196 citations
TL;DR: One third of individuals enrolled in a clinical trial who lived independently prior to severe sepsis had died and of those who survived, a further one third had not returned to independent living by 6 months, and both mortality and quality of life should be considered when designing new interventions and considering endpoints forsepsis trials.
Abstract: Objective: To describe quality of life (QoL) among sepsis survivors. Design: Secondary analyses of 2 international, randomized clinical trials (ACCESS [derivation cohort] and PROWESS-SHOCK [validation cohort]). Patients: Adults with severe sepsis admitted to the intensive care unit. We analyzed only patients who were functional and living at home without help before sepsis hospitalization (n=1,143 and 987 from ACCESS and PROWESS-SHOCK). Measurements and Main Results: In ACCESS and PROWESS-SHOCK, the average age of patients living at home independently was 63 and 61 years; 400 (34.9%) and 298 (30.2%) died by 6 months. In ACCESS, 580 patients had a QoL measured using EQ-5D at 6 months. Of these, 41.6% could not live independently (22.7% were home but required help, 5.1% were in nursing home or rehabilitation facilities, and 5.3% were in acute care hospitals). Poor QoL at 6 months, as evidenced by problems in mobility, usual activities, and self-care domains were reported in 37.4%, 43.7%, and 20.5%, respectively, and the high incidence of poor QoL was also seen in patients in PROWESS-SHOCK. Over 45%of patients with mobility and self-care problems at 6 months in ACCESS died or reported persistent problems at 1 year. Conclusions: Among individuals enrolled in a clinical trial who lived independently prior to severe sepsis, one third had died and of those who survived, a further one third had not returned to independent living by 6 months. Both mortality and QoL should be considered when designing new interventions and considering endpoints for sepsis trials.
TL;DR: In critical care trials reporting statistically significant effects on mortality, the findings often depend on a small number of events, so critical care clinicians should be wary of basing decisions on trials with a low fragility index.
Abstract: Recent literature has drawn attention to the potential inadequacy of frequentist analysis and threshold p values as tools for reporting outcomes in clinical trials. The fragility index, which is a measure of how many events the statistical significance of a result depends on, has been suggested as a means to aid the interpretation of trial results. This study aimed to calculate the fragility index of clinical trials in critical care medicine reporting a statistically significant effect on mortality (increasing or decreasing mortality).
Literature search (PubMed/MEDLINE) to identify all multicenter randomized controlled trials in critical care medicine.
We identified 862 trials; of which 56 fulfilled eligibility criteria and were included in our analysis.
Calculation of fragility index for trials reporting a statistically significant effect on mortality, and analysis of the relationship between trial characteristics and fragility index.
The median fragility index was 2 (interquartile range, 1-3.5), and greater than 40% of trials had a fragility index of less than or equal to 1. 12.5% of trials reported loss to follow-up greater than their fragility index. Trial sample size was positively correlated, and reported p value was negatively correlated, with fragility index.
In critical care trials reporting statistically significant effects on mortality, the findings often depend on a small number of events. Critical care clinicians should be wary of basing decisions on trials with a low fragility index. We advocate the reporting of fragility index for future trials in critical care to aid interpretation and decision making by clinicians.
TL;DR: Since critical care began over 50 years ago, there have been tremendous advances in the science and practice that allow more severely ill and injured patients to survive.
Abstract: Since critical care began over 50 years ago, there have been tremendous advances in the science and practice that allow more severely ill and injured patients to survive. Each year, millions of people are discharged back to the community. The recognition of long-term consequences for ICU survivors a
TL;DR: This statement provides added guidance to clinicians in the ICU environment and indicates the Society of Critical Care Medicine supports the seven-step process presented in the multiorganization statement.
Abstract: Objectives:The Society of Critical Care Medicine and four other major critical care organizations have endorsed a seven-step process to resolve disagreements about potentially inappropriate treatments. The multiorganization statement (entitled: An official ATS/AACN/ACCP/ESICM/SCCM Policy Statement:
TL;DR: A systematic meta-analysis determining the diagnostic performance of passive leg raising in different clinical settings with exploration of patient characteristics, measurement techniques, and outcome variables retained a high diagnostic performance in various clinical settings and patient groups.
Abstract: Objective:Passive leg raising creates a reversible increase in venous return allowing for the prediction of fluid responsiveness. However, the amount of venous return may vary in various clinical settings potentially affecting the diagnostic performance of passive leg raising. Therefore we performed
TL;DR: The PreSchool Confusion Assessment Method for the ICU is a highly valid and reliable delirium instrument for critically ill infants and preschool-aged children, in whom delirity is extremely prevalent.
Abstract: Objectives:Delirium assessments in critically ill infants and young children pose unique challenges due to evolution of cognitive and language skills. The objectives of this study were to determine the validity and reliability of a fundamentally objective and developmentally appropriate delirium ass
TL;DR: Evaluated study designs and measurement instruments used to assess physical, cognitive, mental health, and quality of life outcomes of survivors of critical illness over more than 40 years old showed evidence of consolidation in the instruments used, but the ability to compare results across studies remains impaired by the 250 different instruments used.
Abstract: Objectives:To evaluate the study designs and measurement instruments used to assess physical, cognitive, mental health, and quality of life outcomes of survivors of critical illness over more than 40 years old as a first step toward developing a core outcome set of measures for future trials to impr
TL;DR: Criteria defining the acute respiratory distress syndrome prior to need for positive pressure ventilation are required so that these patients can be enrolled in clinical studies and to facilitate early recognition and treatment of acute ventilation distress syndrome.
Abstract: OBJECTIVE The prevalence, clinical characteristics, and outcomes of critically ill, nonintubated patients with evidence of the acute respiratory distress syndrome remain inadequately characterized. DESIGN Secondary analysis of a prospective observational cohort study. SETTING Vanderbilt University Medical Center. PATIENTS Among adult patients enrolled in a large, multi-ICU prospective cohort study between the years of 2006 and 2011, we studied intubated and nonintubated patients with acute respiratory distress syndrome as defined by acute hypoxemia (PaO2/FIO2 ≤ 300 or SpO2/FIO2 ≤ 315) and bilateral radiographic opacities not explained by cardiac failure. We excluded patients not committed to full respiratory support. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 457 patients with acute respiratory distress syndrome, 106 (23%) were not intubated at the time of meeting all other acute respiratory distress syndrome criteria. Nonintubated patients had lower morbidity and severity of illness than intubated patients; however, mortality at 60 days was the same (36%) in both groups (p = 0.91). Of the 106 nonintubated patients, 36 (34%) required intubation within the subsequent 3 days of follow-up; this late-intubation subgroup had significantly higher 60-day mortality (56%) when compared with the both early intubation group (36%, P<0.03) and patients never requiring intubation (26%; p = 0.002). Increased mortality in the late intubation group persisted at 2-year follow-up. Adjustment for baseline clinical and demographic differences did not change the results. CONCLUSIONS A substantial proportion of critically ill adults with acute respiratory distress syndrome were not intubated in their initial days of intensive care, and many were never intubated. Late intubation was associated with increased mortality. Criteria defining the acute respiratory distress syndrome prior to need for positive pressure ventilation are required so that these patients can be enrolled in clinical studies and to facilitate early recognition and treatment of acute respiratory distress syndrome.
TL;DR: The increasing use of critical care medicine by the premature/neonatal and Medicaid populations should be considered by healthcare policy makers, state agencies, and hospitals as they wrestle with critical care bed growth and the associated costs.
Abstract: Objectives:To analyze patterns of critical care medicine beds, use, and costs in acute care hospitals in the United States and relate critical care medicine beds and use to population shifts, age groups, and Medicare and Medicaid beneficiaries from 2000 to 2010.Design:Retrospective study of data fro
Monash University1, Alfred Hospital2, University of Melbourne3, Royal Prince Alfred Hospital4, Curtin University5, St. Vincent's Health System6, Auckland City Hospital7, Fremantle Hospital8, Royal Brisbane and Women's Hospital9, The George Institute for Global Health10, Wellington Hospital11, Royal Perth Hospital12
TL;DR: Delivery of early goal-directed mobilization within a randomized controlled trial was feasible, safe and resulted in increased duration and level of active exercises.
Abstract: Objectives:To determine if the early goal-directed mobilization intervention could be delivered to patients receiving mechanical ventilation with increased maximal levels of activity compared with standard care.Design:A pilot randomized controlled trial.Setting:Five ICUs in Australia and New Zealand
TL;DR: Optimize positive end-expiratory pressure (set after lung recruitment) may reverse the harmful effects of spontaneous breathing by reducing inspiratory effort, pendelluft, and tidal recruitment.
Abstract: Objectives:We recently described how spontaneous effort during mechanical ventilation can cause “pendelluft,” that is, displacement of gas from nondependent (more recruited) lung to dependent (less recruited) lung during early inspiration. Such transfer depends on the coexistence of more recruited (
TL;DR: Burnout syndrome (BOS) is associated with many deleterious consequences, including increased rates of job turnover, reduced patient satisfaction, and decreased quality of care as mentioned in this paper, which is especially common in individuals who care for critically ill patients.
Abstract: Burnout syndrome (BOS) occurs in all types of healthcare professionals and is especially common in individuals who care for critically ill patients. The development of BOS is related to an imbalance of personal characteristics of the employee and work-related issues or other organizational factors. BOS is associated with many deleterious consequences, including increased rates of job turnover, reduced patient satisfaction, and decreased quality of care. BOS also directly affects the mental health and physical well-being of the many critical care physicians, nurses, and other healthcare professionals who practice worldwide. Until recently, BOS and other psychological disorders in critical care healthcare professionals remained relatively unrecognized. To raise awareness of BOS, the Critical Care Societies Collaborative (CCSC) developed this call to action. The present article reviews the diagnostic criteria, prevalence, causative factors, and consequences of BOS. It also discusses potential interventions that may be used to prevent and treat BOS. Finally, we urge multiple stakeholders to help mitigate the development of BOS in critical care healthcare professionals and diminish the harmful consequences of BOS, both for critical care healthcare professionals and for patients.
TL;DR: In a national inpatient database, intraaortic balloon pumping combined with venoarterial extracorporeal membrane oxygenation was associated with improved mortality and successful weaning from venoartership extracorporation of cardiogenic shock patients.
Abstract: Objectives:The role of intraaortic balloon pumping combined with venoarterial extracorporeal membrane oxygenation in cardiogenic shock patients remains unknown. This study investigated the effect of intraaortic balloon pumping combined with venoarterial extracorporeal membrane oxygenation on reducin
TL;DR: It is proposed that the development and evaluation of any definition or diagnostic criteria should follow four steps: define the epistemologic underpinning, agree on all relevant terms used to frame the exercise, state the intended purpose for any proposed set of criteria, and adopt a scientific approach to inform on their usefulness with regard to the intended Purpose.
Abstract: Although sepsis was described more than 2,000 years ago, and clinicians still struggle to define it, there is no "gold standard," and multiple competing approaches and terms exist. Challenges include the ever-changing knowledge base that informs our understanding of sepsis, competing views on which aspects of any potential definition are most important, and the tendency of most potential criteria to be distributed in at-risk populations in such a way as to hinder separation into discrete sets of patients. We propose that the development and evaluation of any definition or diagnostic criteria should follow four steps: 1) define the epistemologic underpinning, 2) agree on all relevant terms used to frame the exercise, 3) state the intended purpose for any proposed set of criteria, and 4) adopt a scientific approach to inform on their usefulness with regard to the intended purpose. Usefulness can be measured across six domains: 1) reliability (stability of criteria during retesting, between raters, over time, and across settings), 2) content validity (similar to face validity), 3) construct validity (whether criteria measure what they purport to measure), 4) criterion validity (how new criteria fare compared to standards), 5) measurement burden (cost, safety, and complexity), and 6) timeliness (whether criteria are available concurrent with care decisions). The relative importance of these domains of usefulness depends on the intended purpose, of which there are four broad categories: 1) clinical care, 2) research, 3) surveillance, and 4) quality improvement and audit. This proposed methodologic framework is intended to aid understanding of the strengths and weaknesses of different approaches, provide a mechanism for explaining differences in epidemiologic estimates generated by different approaches, and guide the development of future definitions and diagnostic criteria.
TL;DR: High-dose corticosteroid therapy significantly increased both 30-day and 60-day mortality and longer viral shedding in patients with influenza A (H7N9) viral pneumonia, whereas no significant impact was observed for low-to-moderate doses of Corticosteroids.
Abstract: Objective To determine the impact of adjuvant corticosteroids administered to patients hospitalized with influenza A (H7N9) viral pneumonia. Design The effects of adjuvant corticosteroids on mortality were assessed using multivariate Cox regression and a propensity score-matched case-control study. Nosocomial infections and viral shedding were also compared. Setting Hospitals with influenza A (H7N9) viral pneumonia patient admission in 84 cities and 16 provinces of Mainland China. Patients Adolescent and Adult patients aged >14 yr with severe laboratory-confirmed influenza A (H7N9) virus infections were screened from April 2013 to March 2015. Interventions None. Measurements and main results The study population comprised 288 cases who were hospitalized with influenza A (H7N9) viral pneumonia. The median age of the study population was 58 years, 69.8% of the cohort comprised male patients, and 51.4% had at least one type of underlying diseases. The in-hospital mortality was 31.9%. Two hundred and four patients (70.8%) received adjuvant corticosteroids; among them, 193 had hypoxemia and lung infiltrates, 11 had chronic obstructive pulmonary disease, and 11 had pneumonia only. Corticosteroids were initiated within 7 days (interquartile range, 5.0-9.4 d) of the onset of illness and the maximum dose administered was equivalent to 80-mg methylprednisolone (interquartile range, 40-120 mg). The patients were treated with corticosteroids for a median duration of 7 days (interquartile range, 4.0-11.3 d). Cox regression analysis showed that compared with the patients who did not receive corticosteroid, those who received corticosteroid had a significantly higher 60-day mortality (adjusted hazards ratio, 1.98; 95% CI, 1.03-3.79; p = 0.04). Subgroup analysis showed that high-dose corticosteroid therapy (> 150 mg/d methylprednisolone or equivalent) significantly increased both 30-day and 60-day mortality, whereas no significant impact was observed for low-to-moderate doses of corticosteroids (25-150 mg/d methylprednisolone or equivalent). The propensity score-matched case-control analysis showed that the median viral shedding time was much longer in the group that received high-dose corticosteroids (15 d), compared with patients who did not receive corticosteroids (13 d; p = 0.039). Conclusions High-dose corticosteroids were associated with increased mortality and longer viral shedding in patients with influenza A (H7N9) viral pneumonia.
TL;DR: Placement of earplugs in patients admitted to the ICU, either in isolation or as part of a bundle of sleep hygiene improvement, is associated with a significant reduction in risk of delirium.
Abstract: Objective:A systematic review and meta-analysis to assess the efficacy of earplugs as an ICU strategy for reducing delirium.Data Sources:MEDLINE, EMBASE, and the Cochrane Central Register of controlled trials were searched using the terms “intensive care,” “critical care,” “earplugs,” “sleep,” “slee
TL;DR: Malnutrition is prevalent in mechanically ventilated children on admission to PICUs worldwide and classification as underweight or obese was associated with higher risk of hospital-acquired infections and lower likelihood of hospital discharge.
Abstract: Objective:To determine the influence of admission anthropometry on clinical outcomes in mechanically ventilated children in the PICU.Design:Data from two multicenter cohort studies were compiled to examine the unique contribution of nutritional status, defined by body mass index z score, to 60-day m
TL;DR: Sociodemographic characteristics and in-ICU opioid administration, rather than traditional measures of critical illness severity, should be considered in identifying the patients at highest risk for psychiatric symptoms during recovery.
Abstract: Objective:To evaluate prevalence, severity, and co-occurrence of and risk factors for depression, anxiety, and posttraumatic stress disorder symptoms over the first year after acute respiratory distress syndrome.Design:Prospective longitudinal cohort study.Settings:Forty-one Acute Respiratory Distre
TL;DR: Pediatric delirium is associated with a major increase in PICU costs and further research directed at prevention and treatment of Pediatrics is essential to improve outcomes in this population and could lead to substantial healthcare savings.
Abstract: Objective:To determine the costs associated with delirium in critically ill children.Design:Prospective observational study.Setting:An urban, academic, tertiary-care PICU in New York city.Patients:Four-hundred and sixty-four consecutive PICU admissions between September 2, 2014, and December 12, 201
TL;DR: Delays in rapid response team activation occur frequently and are independently associated with worse patient mortality and morbidity outcomes.
Abstract: Objective:To identify whether delays in rapid response team activation contributed to worse patient outcomes (mortality and morbidity).Design:Retrospective observational cohort study including all rapid response team activations in 2012.Setting:Tertiary academic medical center.Patients:All those 18