Showing papers in "Intensive Care Medicine in 2004"
TL;DR: Two-thirds of the patients dying after out-of-hospital cardiac arrest died due to neurological injury and this proportion was approximately the same for ventricular fibrillation/ventricular tachycardia and pulseless electrical activity/asystole.
Abstract: To determine the mode of death in patients admitted to an intensive care unit (ICU) after cardiac arrest who died before hospital discharge. Prospectively defined retrospective review of a database and individual patient medical records and ICU charts. Eleven-bed multidisciplinary intensive care unit in a general hospital in the United Kingdom. All patients admitted to ICU between February 1998 and July 2003 after a cardiac arrest in the previous 24 h. The outcome at hospital discharge and mode of death in non-survivors were recorded. Based on the mode of death, non-survivors were placed in one of three groups: multiple organ failure death, neurological death or cardiovascular death. Two hundred and five patients were admitted to ICU after a cardiac arrest; 113 (55.1%) after out-of-hospital cardiac arrest and 92 (44.9%) after in-hospital cardiac arrest. One hundred and twenty-six (61.5%) patients died before hospital discharge and of these 58 (46.0%) died due to neurological injury. After cardiac arrest, 22.9% of the in-hospital patients and 67.7% of the out-of-hospital patients died due to neurological injury, irrespective of the primary cardiac arrest arrhythmia. Two-thirds of the patients dying after out-of-hospital cardiac arrest died due to neurological injury and this proportion was approximately the same for ventricular fibrillation/ventricular tachycardia and pulseless electrical activity/asystole. Approximately a quarter of the patients dying after in-hospital cardiac arrest died due to neurological injury.
825 citations
TL;DR: Analysis of ΔDIVC is a simple and non-invasive method to detect fluid responsiveness in mechanically ventilated patients with septic shock and identified responders with positive and negative predictive values of 93% and 92%, respectively.
Abstract: To investigate whether the respiratory variation in inferior vena cava diameter (ΔDIVC) could be related to fluid responsiveness in mechanically ventilated patients. Prospective clinical study. Medical ICU of a non-university hospital. Mechanically ventilated patients with septic shock (n=39). Volume loading with 8 mL/kg of 6% hydroxyethylstarch over 20 min. Cardiac output and ΔDIVC were assessed by echography before and immediately after the standardized volume load. Volume loading induced an increase in cardiac output from 5.7±2.0 to 6.4±1.9 L/min (P<0.001) and a decrease in ΔDIVC from 13.8±13.6 vs 5.2±5.8% (P<0.001). Sixteen patients responded to volume loading by an increase in cardiac output ≥15% (responders). Before volume loading, the ΔDIVC was greater in responders than in non-responders (25±15 vs 6±4%, P<0.001), closely correlated with the increase in cardiac output (r=0.82, P<0.001), and a 12% ΔDIVC cut-off value allowed identification of responders with positive and negative predictive values of 93% and 92%, respectively. Analysis of ΔDIVC is a simple and non-invasive method to detect fluid responsiveness in mechanically ventilated patients with septic shock.
762 citations
TL;DR: This study suggests that respiratory change in IVC diameter is an accurate predictor of fluid responsiveness in septic patients and suggests that central venous pressure did not accurately predict fluid responsiveness.
Abstract: To evaluate the extent to which respiratory changes in inferior vena cava (IVC) diameter can be used to predict fluid responsiveness. Prospective clinical study. Hospital intensive care unit. Twenty-three patients with acute circulatory failure related to sepsis and mechanically ventilated because of an acute lung injury. Inferior vena cava diameter (D) at end-expiration (Dmin) and at end-inspiration (Dmax) was measured by echocardiography using a subcostal approach. The distensibility index of the IVC (dIVC) was calculated as the ratio of Dmax − Dmin / Dmin, and expressed as a percentage. The Doppler technique was applied in the pulmonary artery trunk to determine cardiac index (CI). Measurements were performed at baseline and after a 7 ml/kg volume expansion using a plasma expander. Patients were separated into responders (increase in CI ≥15%) and non-responders (increase in CI <15%). Using a threshold dIVC of 18%, responders and non-responders were discriminated with 90% sensitivity and 90% specificity. A strong relation (r=0.9) was observed between dIVC at baseline and the CI increase following blood volume expansion. Baseline central venous pressure did not accurately predict fluid responsiveness. Our study suggests that respiratory change in IVC diameter is an accurate predictor of fluid responsiveness in septic patients.
760 citations
TL;DR: One third of patients presented with mild ALI, but more than half rapidly evolved to acute respiratory distress syndrome (ARDS), confirming the grading of severity between the two forms of the syndrome.
Abstract: Objectives
To re-examine the epidemiology of acute lung injury (ALI) in European intensive care units (ICUs).
618 citations
TL;DR: Although the attack rate of severe sepsis in French ICUs appears to have increased over the past decade, its associated mortality has decreased, suggesting improved management of patients.
Abstract: Objective Ten years ago 8.4% of patients in French intensive care units (ICUs) were found to have severe sepsis or shock and 56% died in the hospital. As novel therapies for severe sepsis are emerging, updated epidemiological information is required. Design and setting An inception cohort study conducted in 206 ICUs of randomly selected hospitals over a 2-week period in 2001, including all patients meeting criteria for clinically or microbiologically documented severe sepsis (with > or =1 organ dysfunction). Measurements and results Among 3738 admissions, 546 (14.6%) patients experienced severe sepsis or shock, of which 30% were ICU-acquired. The median age of patients was 65 years, and 54.1% had at least one chronic organ system dysfunction. The median (range) Simplified Acute Physiology Score (SAPS II) and Sequential Organ Failure Assessment (SOFA) at onset of severe sepsis were 48 (2-129) and 9 (1-24), respectively. Mortality was 35% at 30 days; at 2 months the mortality rate was 41.9%, and 11.4% of patients remained hospitalized. The median (range) hospital stay was 25 (0-112) days in survivors and 7 (0-90) days in non-survivors. Chronic liver and heart failure, acute renal failure and shock, SAPS II at onset of severe sepsis and 24-h total SOFA scores were the independent risk factors most strongly associated with death. Conclusions Although the attack rate of severe sepsis in French ICUs appears to have increased over the past decade, its associated mortality has decreased, suggesting improved management of patients. Severe sepsis incurs considerable resources use, and implementation of effective management strategies and continued research efforts are needed.
597 citations
TL;DR: A low BMI was independently associated with higher mortality and a high BMI with lower mortality in this large cohort of critically ill patients, which is absent from currently available scoring systems.
Abstract: Objective: To examine the association between body mass index (BMI) and mortality in adult intensive care unit (ICU) patients. Design: A prospective multi-center study. Interventions: None. Methods: A cohort study (yielding the OUTCOMEREA database) was conducted over 2 years in 6 medical-surgical ICUs. In each participating ICU, the following were collected daily: demographic information, admission height and weight, comorbidities, severity scores (SAPS II, LOD, and SOFA), ICU and hospital lengths of stay, and ICU and hospital mortality rates. Results: A total of 1,698 patients were examined and divided into 4 groups based on BMI: 30 kg/m 2 . These groups differed significantly for age, gender, admission category (medical, scheduled surgery, unscheduled surgery), ICU and hospital lengths of stay, and comorbidities. Severity at admission and within the first 2 days was similar in the 4 groups, except for the SOFA score. Overall hospital mortality was 31.3% (532 out of 1,698 patients). By multivariate analysis, a BMI below 18.5 kg/m 2 was independently associated with increased mortality (odds ratio 1.63; 95% confidence intervals 1.11-2.39). None of the other BMI categories were associated with higher mortality and even a BMI>30 kg/m 2 was protective of mortality (odds ratio 0.60, 95% confidence intervals 0.40-0.88). Conclusions: A low BMI was independently associated with higher mortality and a high BMI with lower mortality in this large cohort of critically ill patients. Since BMI is absent from currently available scoring systems, further studies are needed to determine whether adding BMI would improve the effectiveness of scores in predicting mortality.
577 citations
TL;DR: Although a quite high prevalence of intra-abdominal hypertension was found, no risk factors were reliably associated with IAH; consequently, to get valid information about IAH, IAP needs to be measured.
Abstract: Although intra-abdominal hypertension (IAH) can cause dysfunction of several organs and raise mortality, little information is available on the incidence and risk factors for IAH in critically ill patients This study assessed the prevalence of IAH and its risk factors in a mixed population of intensive care patients A multicentre, prospective 1-day point-prevalence epidemiological study conducted in 13 ICUs of six countries None Ninety-seven patients admitted for more than 24 h to one of the ICUs during the 1-day study period Intra-abdominal pressure (IAP) was measured four times (every 6 h) by the bladder pressure method Data included the demographics, medical or surgical type of admission, SOFA score, etiological factors such as abdominal surgery, haemoperitoneum, abdominal infection, massive fluid resuscitation, and ileus and predisposing conditions such as hypothermia, acidosis, polytransfusion, coagulopathy, sepsis, liver dysfunction, pneumonia and bacteraemia We enrolled 97 patients, mean age 64±15 years, 57 (59%) medical and 40 (41%) surgical admission, SOFA score of 65±40 Mean IAP was 98±47 mmHg The prevalence of IAH (defined as IAP 12 mmHg or more) was 505 and 82% had abdominal compartment syndrome (defined as IAP 20 mmHg or more) The only risk factor significantly associated with IAH was the body mass index, while massive fluid resuscitation, renal and coagulation impairment were at limit of significance Although we found a quite high prevalence of IAH, no risk factors were reliably associated with IAH; consequently, to get valid information about IAH, IAP needs to be measured
526 citations
TL;DR: The jurors identified numerous problems with end of life in the ICU including variability in practice, inadequate predictive models for death, elusive knowledge of patient preferences, poor communication between staff and surrogates, insufficient or absent training of health-care providers, the use of imprecise and insensitive terminology, and incomplete documentation in the medical records.
Abstract: The jurors identified numerous problems with end of life in the ICU including variability in practice, inadequate predictive models for death, elusive knowledge of patient preferences, poor communication between staff and surrogates, insufficient or absent training of health-care providers, the use of imprecise and insensitive terminology, and incomplete documentation in the medical records. The jury strongly recommends that research be conducted to improve end-of-life care. The jury advocates a “shared” approach to end-of-life decision-making involving the caregiver team and patient surrogates. Respect for patient autonomy and the intention to honour decisions to decline unwanted treatments should be conveyed to the family. The process is one of negotiation, and the outcome will be determined by the personalities and beliefs of the participants. Ultimately, it is the attending physician’s responsibility, as leader of the health-care team, to decide on the reasonableness of the planned action. In the event of conflict, the ICU team may agree to continue support for a predetermined time. Most conflicts can be resolved. If the conflict persists, however, an ethics consultation may be helpful. Nurses must be involved in the process. The patient must be assured of a pain-free death. The jury of the Consensus Conference subscribes to the moral and legal principles that prohibit administering treatments specifically designed to hasten death. The patient must be given sufficient analgesia to alleviate pain and distress; if such analgesia hastens death, this “double effect” should not detract from the primary aim to ensure comfort.
505 citations
TL;DR: This review will focus on the previously described indirect IAP measurement techniques and suggest new revised methods of IVP measurement less prone to error, as well as cost-effective manometry screening techniques and some options for the future with microchip transducers.
Abstract: The diagnosis of intra-ab- dominal hypertension (IAH) or ab- dominal compartment syndrome (ACS) is heavily dependant on the reproducibility of the intra-abdominal pressure (IAP) measurement tech- nique. Recent studies have shown that a clinical estimation of IAP by abdominal girth or by examiner's feel of the tenseness of the abdomen is far from accurate, with a sensitivity of around 40%. Consequently, the IAP needs to be measured with a more accurate, reproducible and reliable tool. The role of the intra-vesical pressure (IVP) as the gold standard for IAP has become a matter of debate. This review will focus on the previously described indirect IAP measurement techniques and will suggest new revised methods of IVP measurement less prone to error. Cost-effective manometry screening techniques will be discussed, as well as some options for the future with microchip transducers.
459 citations
TL;DR: Although induced hypothermia appears to be a highly promising treatment, it should be emphasized that it is associated with a number of potentially serious side effects, which may negate some or all of its potential benefits.
Abstract: Objective
Hypothermia has been used for medicinal purposes since ancient times. This paper reviews the current potential clinical applications for mild hypothermia (32–35°C).
455 citations
TL;DR: Superior vena cava measurement should be systematically performed during routine echocardiography in septic shock as it gives an accurate index of fluid responsiveness.
Abstract: In mechanically ventilated patients inspiratory increase in pleural pressure during lung inflation may produce complete or partial collapse of the superior vena cava. Occurrence of this collapse suggests that at this time external pressure exerted by the thoracic cavity on the superior vena cava is greater than the venous pressure required to maintain the vessel fully open. We tested the hypothesis that measurement of superior vena caval collapsibility would reveal the need for volume expansion in a given septic patient. Prospective data collection for 66 successive patients in septic shock admitted in a medical intensive care unit and mechanically ventilated for an associated acute lung injury. We simultaneously measured superior vena caval collapsibility by echocardiography and cardiac index by the Doppler technique at baseline and after a 10 ml/kg volume expansion by 6% hydroxyethyl starch in 30 min. The threshold superior vena caval collapsibility of 36%, calculated as (maximum diameter on expiration−minimum diameter on inspiration)/maximum diameter on expiration, allowed discrimination between responders (defined by an increase in cardiac index of at least 11% induced by volume expansion) and nonresponders, with a sensitivity of 90% and a specificity of 100%. Superior vena cava measurement should be systematically performed during routine echocardiography in septic shock as it gives an accurate index of fluid responsiveness.
TL;DR: The population incidence and outcome of severe sepsis occurring in adult patients treated in Australian and New Zealand intensive care units (ICUs), and compare with recent retrospective estimates from the USA and UK are determined.
Abstract: To determine the population incidence and outcome of severe sepsis occurring in adult patients treated in Australian and New Zealand intensive care units (ICUs), and compare with recent retrospective estimates from the USA and UK. Inception cohort study. Twenty-three closed multi-disciplinary ICUs of 21 hospitals (16 tertiary and 5 university affiliated) in Australia and New Zealand. A total of 5878 consecutive ICU admission episodes. Main outcome measures were population-based incidence of severe sepsis, mortality at ICU discharge, mortality at 28 days after onset of severe sepsis, and mortality at hospital discharge. A total of 691 patients, 11.8 (95% confidence intervals 10.9–12.6) per 100 ICU admissions, were diagnosed with 752 episodes of severe sepsis. Site of infection was pulmonary in 50.3% of episodes and abdominal in 19.3% of episodes. The calculated incidence of severe sepsis in adults treated in Australian and New Zealand ICUs is 0.77 (0.76–0.79) per 1000 of population. 26.5% of patients with severe sepsis died in ICU, 32.4% died within 28 days of the diagnosis of severe sepsis and 37.5% died in hospital. In this prospective study, 11.8 patients per 100 ICU admissions were diagnosed with severe sepsis and the calculated annual incidence of severe sepsis in adult patients treated in Australian and New Zealand ICUs is 0.77 per 1000 of population. This figure for the population incidence falls in the lower range of recent estimates from retrospective studies in the U.S. and the U.K.
TL;DR: Ultrasound provides a reliable non-invasive, bedside method for accurate detection and location of alveolar consolidation in critically ill patients and shows anterior involvement in all 3 cases of whole lung consolidation.
Abstract: Objective
Alveolar consolidation is a basic concern in critically ill patients. Radiography is not a precise tool, and referral to CT raises problems (transport, irradiation). The aim of this study was to assess the utility of ultrasound in the diagnosis of alveolar consolidation.
TL;DR: Olanzapine is a safe alternative to haloperidol in delirious critical care patients, and may be of particular interest in patients in whom hal operidol is contraindicated.
Abstract: Objective: To compare the safety and estimate the response profile of olanzapine, a second-gen- eration antipsychotic, to haloperidol in the treatment of delirium in the critical care setting. Design: Prospective randomized trial Setting: Tertiary care university affiliated critical care unit. Patients: All ad- missions to a medical and surgical intensive care unit with a diagnosis of delirium. Interventions: Patients were randomized to receive either enteral olanzapine or haloperidol. Measure- ments: Patient's delirium severity and benzodiazepine use were monitored over 5 days after the diagnosis of delirium. Main results: Delirium In- dex decreased over time in both groups, as did the administered dose of benzodiazepines. Clinical im- provement was similar in both treat- ment arms. No side effects were noted in the olanzapine group, whereas the use of haloperidol was associated with extrapyramidal side effects. Conclusions: Olanzapine is a safe alternative to haloperidol in delirious critical care patients, and may be of particular interest in patients in whom haloperidol is con- traindicated.
TL;DR: Intra-hospital transport poses an important risk to ICU patients and the adequate provision of highly qualified staff, specially designed and well maintained equipment, as well as continuous monitoring are essential to avoid/mitigate these incidents.
Abstract: Objective
Transportation of critically ill patients within the hospital poses important risks. We sought to identify causes, outcomes and contributing factors associated with intra-hospital transport.
TL;DR: Realizing hypothermia’s full therapeutic potential will require meticulous attention to the prevention and/or early treatment of side effects, as well as a basic knowledge and understanding of the underlying physiological and pathophysiological mechanisms.
Abstract: Induced hypothermia can be used to protect the brain from post-ischemic and traumatic neurological injury. Potential clinical applications and the available evidence are discussed in a separate paper. This review focuses on the practical aspects of cooling and physiological changes induced by hypothermia, as well as the potential side effects that may develop. These side effects can be serious and, if not properly dealt with, may negate some or all of hypothermia's potential benefits. However, many of these side effects can be prevented or modified by high-quality intensive care treatment, which should include careful monitoring of fluid balance, tight control of metabolic aspects such as glucose and electrolyte levels, prevention of infectious complications and various other interventions. The speed and duration of cooling and rate of re-warming are key factors in determining whether hypothermia will be effective; however, the risk of side effects also increases with longer duration. Realizing hypothermia's full therapeutic potential will therefore require meticulous attention to the prevention and/or early treatment of side effects, as well as a basic knowledge and understanding of the underlying physiological and pathophysiological mechanisms. These and other, related issues are dealt with in this review.
TL;DR: Continuous fiberoptic measurement of central vein O2 saturation has potential to be a reliable and convenient tool which could rapidly warn of acute change in the oxygen supply/demand ratio of critically ill patients.
Abstract: To compare the course of continuously measured mixed and central venous O2 saturations in high-risk patients and to evaluate the impact of various factors that might interfere with reflection spectrophotometry. Prospective, descriptive study in the interdisciplinary ICU of a university hospital. 32 critically ill patients with triple-lumen central vein catheters, including 29 patients requiring pulmonary artery catheterization. The accuracy of fiberoptic measurements was assessed by comparison to reference co-oximeter results at regular intervals. We examined the effect on measurement accuracy of physiological variables including hematocrit, hemoglobin, pH, temperature, and the administration of various solutions via central venous catheter. Continuous parallel measurements of SvO2 and ScvO2 were performed in patients with each type of catheters over a total observation time of 1097 h. ScvO2 values were more accurate and stable than in vitro oximeter measurements (r=0.96 from 150 samples, mean difference 0.15%, average drift 0.10%/day) and was not significantly affected by synchronous infusion therapy or by changes in hematocrit, hemoglobin, pH, or temperature. ScvO2 values closely paralleled SvO2, whether measured in vitro (r=0.88 from 150 samples) or in vivo (r=0.81 from 395,128 samples) but averaged about 7±4 saturation percentage higher. ScvO2 changed in parallel in 90% of the 1,498 instances in which SvO2 changed more than 5% (over an average of 43 min). Continuous fiberoptic measurement of central vein O2 saturation has potential to be a reliable and convenient tool which could rapidly warn of acute change in the oxygen supply/demand ratio of critically ill patients.
TL;DR: The pathophysiology of stress hyperglycemia in the critically ill septic patient is reviewed and a treatment strategy for the management of this disorder is outlined.
Abstract: Stress-hyperglycemia and insulin resistance are exceedingly common in critically ill patients, particularly those with sepsis. Multiple pathogenetic mechanisms are responsible for this metabolic syndrome; however, increased release of pro-inflammatory mediators and counter-regulatory hormones may play a pivotal role. Recent data suggests that hyperglycemia may potentiate the pro-inflammatory response while insulin has the opposite effect. Furthermore, emerging evidence suggests that tight glycemic control will improve the outcome of critically ill patients. This paper reviews the pathophysiology of stress hyperglycemia in the critically ill septic patient and outlines a treatment strategy for the management of this disorder.
TL;DR: The study suggests outreach reduces mortality in general hospital wards and may also increase length of stay, but the findings on this are equivocal.
Abstract: The purpose of the study was to investigate the effects of introducing a critical care outreach service on in-hospital mortality and length of stay in a general acute hospital. A pragmatic ward-randomised trial design was used, with intervention introduced to all wards in sequence. No blinding was possible. Sixteen adult wards in an 800-bed general hospital in the north of England. All admissions to the 16 surgical, medical and elderly care wards during 32-week study period were included (7450 patients in total, of whom 2903 were eligible for the primary comparison). Essential elements of the Critical Care Outreach service introduced during the study were a nurse-led team of nurses and doctors experienced in critical care, a 24-h service, emphasis on education, support and practical help for ward staff. The main outcome measures were in-hospital mortality and length of stay. Outreach intervention reduced in-hospital mortality compared with control (two-level odds ratio: 0.52 (95% CI 0.32–0.85). A possible increased length of stay associated with outreach was not fully supported by confirmatory and sensitivity analyses. The study suggests outreach reduces mortality in general hospital wards. It may also increase length of stay, but our findings on this are equivocal.
TL;DR: This physiological note focuses on how the understanding of renal physiology can be used to guide the definition of ARF.
Abstract: Definitions are never “right” or “wrong”. They are simply more or less “useful” for a given purpose. The same is true of the clinical syndrome of acute renal failure (ARF), which is common in the ICU [1, 2]. In many ways, its nature and epidemiology resemble those of other loosely defined ICU syndromes, such as sepsis or ARDS. In this physiological note, however, we wish to focus on how our understanding of renal physiology can be used to guide the definition of ARF.
TL;DR: A better comprehension of the multifactorial mechanisms of activation of coagulation, inflammation, and fibrinolytic pathways during CPB may enable a more effective use of the technical and pharmaceutical options which are currently available.
Abstract: Background
Postoperative bleeding is one of the most common complications of cardiac surgery.
TL;DR: In this paper, a prospective cohort of 95 patients who were enrolled in an incidence and risk factor study of ICU-acquired paresis (ICUAP) was determined whether ICUAP is an independent risk factor of prolonged weaning.
Abstract: To determine whether ICU-acquired paresis (ICUAP) is an independent risk factor of prolonged weaning. Second study of a prospective cohort of 95 patients who were enrolled in an incidence and risk factor study of ICUAP. Three medical and two surgical ICUs in four hospitals. Ninety-five patients without pre-existing neuromuscular disease recovering from the acute phase of critical illness after ≥7 days of mechanical ventilation. None. Duration of weaning from mechanical ventilation was defined as the duration of mechanical ventilation between awakening (day 1) and successful weaning. Muscle strength was evaluated at day 7 after awakening using the Medical Research Council (MRC) score. Patients with an MRC <48 were considered to have ICUAP. Among the 95 patients (mean age 62.0±15.3 years, SAPS 2 on admission 48.7±17.4) who regained satisfactory awakening after 7 or more days of mechanical ventilation, 67 (70.5%) were hospitalized in a medical ICU and 28 (29.5%) in a surgical ICU. Median duration (25th–75th percentiles) of weaning was longer in patients with ICUAP than in those without ICUAP: 6 days (1–22 days) vs 3 days (1–7 days); p=0.01; log-rank analysis. In multivariate analysis, the two independent predictors of prolonged weaning were ICUAP [hazard ratio (HR): 2.4; 95% confidence interval (CI): 1.4–4.2] and chronic obstructive pulmonary disease (HR: 2.7; 95% CI: 1.6–4.5) ICU-acquired paresis is an independent predictor of prolonged weaning. Prevention of ICU-acquired neuromuscular abnormalities in patients recovering from severe acute illness should result in shorter weaning duration.
TL;DR: Most catheter-related BSIs with short-term percutaneously inserted, noncuffed CVCs were extraluminally acquired and derived from the cutaneous microflora.
Abstract: Short-term, noncuffed, percutaneously inserted central venous catheters (CVCs) are widely used and cause more than 250,000 bloodstream infections (BSIs) in hospitals each year in the United States. We report a prospective study undertaken to determine the pathogenesis of CVC-related BSI. Prospective cohort study in a university hospital 24-bed medical-surgical intensive care unit. Patients participating in two randomized trials during 1998–2000—one studying the efficacy of a 1% chlorhexidine–75% alcohol solution for cutaneous antisepsis and the other a novel chlorhexidine-impregnated sponge dressing—formed the study population; CVC-related BSIs were considered to be extraluminally acquired if concordance was identified solely between isolates from catheter segments, skin, and blood cultures and intraluminally acquired if concordance was demonstrated only between hub or infusate and blood culture isolates, as confirmed by DNA subtyping of isolates from blood and catheter sites or infusate. Of 1,263 catheters (6075 CVC days) prospectively studied, 35 (2.7%) caused BSI (5.9 per 1000 CVC days); 27 were caused by coagulase-negative staphylococci. Overall, 45% of infections were extraluminally acquired, 26% were intraluminally derived, and the mechanism of infection was indeterminate in 29%. In the pooled control groups of the two trials, 25 CVC-related BSIs occurred (7.0 per 1000 CVC days), of which 60% of infections were extraluminally acquired, 12% were intraluminally derived and 28% were indeterminate. In contrast, CVC-related BSIs in the treatment groups were most often intraluminally derived (60%, p=0.006). Most catheter-related BSIs with short-term percutaneously inserted, noncuffed CVCs were extraluminally acquired and derived from the cutaneous microflora. Strategies achieving successful suppression of cutaneous colonization can substantially reduce the risk of catheter-related BSI with short-term CVCs.
TL;DR: Regional citrate anticoagulation seems superior to heparin for the filter lifetime and transfusion requirements in ICU patients treated by continuous renal replacement therapy.
Abstract: To compare the efficacy and safety of adjusted-dose unfractionated heparin with that of regional citrate anticoagulation in intensive care patients treated by continuous venovenous hemofiltration (CVVH). Prospective, randomized, clinical trial in a 32-bed medical and surgical ICU in a university teaching hospital. ICU patients with acute renal failure requiring continuous renal replacement therapy, without cirrhosis, severe coagulopathy, or known sensitivity to heparin. Before the first CVVH run patients were randomized to receive anticoagulation with heparin or trisodium citrate. Patients eligible for another CVVH run received the other study medication in a cross-over fashion until the fourth circuit. Forty-nine circuits (hemofilters) were analyzed: 23 with heparin and 26 with citrate. The median lifetime of hemofilters was 70 h (interquartile range 44–140) with citrate anticoagulation and 40 h (17–48) with heparin (p=0.0007). One major bleeding occurred during heparin anticoagulation and one metabolic alkalosis (pH=7.60) was noted with citrate after a protocol violation. Transfusion rates (units of red cells per day of CVVH) were, respectively, 0.2 (0.0–0.4) with citrate and 1.0 (0.0–2.0) with heparin (p=0.0008). Regional citrate anticoagulation seems superior to heparin for the filter lifetime and transfusion requirements in ICU patients treated by continuous renal replacement therapy.
TL;DR: Critically ill patients exhibit more frequent arousals and awakenings than is normal, and decreases in rapid eye movement and slow wave sleep, and measures to improve the quantity and quality of sleep in critically ill patients include careful attention to mode of mechanical ventilation, decreasing noise, and sedative agents (although the latter are double-edged swords).
Abstract: Abnormalities of sleep are extremely common in critically ill patients, but the mechanisms are poorly understood. About half of total sleep time occurs during the daytime, and circadian rhythm is markedly diminished or lost. Judgments based on inspection consistently overestimate sleep time and do not detect sleep disruption. Accordingly, reliable polygraphic recordings are needed to measure sleep quantity and quality in critically ill patients. Critically ill patients exhibit more frequent arousals and awakenings than is normal, and decreases in rapid eye movement and slow wave sleep. The degree of sleep fragmentation is at least equivalent to that seen in patients with obstructive sleep apnea. About 20% of arousals and awakenings are related to noise, 10% are related to patient care activities, and the cause for the remainder is not known; severity of underlying disease is likely an important factor. Mechanical ventilation can cause sleep disruption, but the precise mechanism has not been defined. Sleep disruption can induce sympathetic activation and elevation of blood pressure, which may contribute to patient morbidity. In healthy subjects, sleep deprivation can decrease immune function and promote negative nitrogen balance. Measures to improve the quantity and quality of sleep in critically ill patients include careful attention to mode of mechanical ventilation, decreasing noise, and sedative agents (although the latter are double-edged swords).
TL;DR: Initial linezolid therapy was associated with significantly better clinical cure and survival rates than was initial vancomycin therapy in patients with MRSA VAP.
Abstract: To assess the effect of baseline variables, including treatment, on clinical cure and survival rates in patients with Gram-positive, ventilator-associated pneumonia (VAP). Retrospective analysis of two randomized, double-blind studies. Multinational study with 134 sites. 544 patients with suspected Gram-positive VAP, including 264 with documented Gram-positive VAP and 91 with methicillin-resistant S. aureus (MRSA) VAP. Linezolid 600 mg or vancomycin 1 g every 12 h for 7–21 days, each with aztreonam. Clinical cure rates assessed 12–28 days after the end of therapy and excluding indeterminate or missing outcomes significantly favored linezolid in the Gram-positive and MRSA subsets. Logistic regression showed that linezolid was an independent predictor of clinical cure with odds ratios of 1.8 for all patients, 2.4 for Gram-positive VAP, and 20.0 for MRSA VAP. Kaplan-Meier survival rates favored linezolid in the MRSA subset. Logistic regression showed that linezolid was an independent predictor of survival with odds ratios of 1.6 for all patients, 2.6 for Gram-positive VAP, and 4.6 for MRSA VAP. Initial linezolid therapy was associated with significantly better clinical cure and survival rates than was initial vancomycin therapy in patients with MRSA VAP.
TL;DR: High levels of psychological distress in patients were found to be correlated with high levels in relatives, and written information concerning recovery from ICU provided to the patient and their close family did not reduce this.
Abstract: To evaluate the effectiveness of the provision of information in the form of a rehabilitation program following critical illness in reducing psychological distress in the patients’ close family. Randomised controlled trial, blind at follow-up with final assessment at 6 months. Two district general hospitals and one teaching hospital. The closest family member of 104 recovering intensive care unit (ICU) patients. Ward visits, ICU clinic appointments at 2 and 6 months. Relatives and patients received the rehabilitation program at 1 week after ICU discharge. The program comprised a 6-week self-help manual containing information about recovery from ICU, psychological information and practical advice. Psychological recovery of relatives was assessed by examining the rate of depression, anxiety, and post-traumatic stress disorder (PTSD)-related symptoms by 6 months after ICU. The proportion of relatives scoring in the range >19 on the Impact of Events Scale (cause for concern) was high in both groups at 49% at 6 months. No difference was shown in the rate of depression, anxiety, or PTSD-related symptoms between the study groups. A high incidence of psychological distress was evident in relatives. Written information concerning recovery from ICU provided to the patient and their close family did not reduce this. High levels of psychological distress in patients were found to be correlated with high levels in relatives.
TL;DR: These simple, reproducible methods may provide a clinically useful approach to guiding the extubation of patients who have passed a SBT, and there was synergistic interaction between these risk factors.
Abstract: Objective
To determine the degree to which neurologic function, cough peak flows and quantity of endotracheal secretions affected the extubation outcomes of patients who had passed a trial of spontaneous breathing (SBT).
TL;DR: A high incidence of symptoms consistent with PTSD 3 months after ICU discharge in this general ICU cohort was found, associated with younger patients and those who visited their GP or a mental health professional complaining of psychological symptoms.
Abstract: Objective
To determine the incidence and severity of symptoms related to the diagnosis of post-traumatic stress disorder (PTSD) in a cohort of general ICU patients.
TL;DR: The methodology for grading in this situation could be debated and making two separate recommendations, one for use of SUP and one for choice of agent, may be more practical as it would allow different grading for each.
Abstract: and van der Voort that the recommendation should be a grade A that SUP should not be used, our methodology for grading in this situation could be debated. One could take the position that the placebo-controlled clinical trials used to support the value of SUP are not large enough to engender an A grade and that a grade C would be more appropriate. Also making two separate recommendations, one for use of SUP and one for choice of agent, may be more practical as it would allow different grading for each. These options will be considered in the next revision of the guidelines.