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Showing papers in "Intensive Care Medicine in 2007"


Journal ArticleDOI
TL;DR: Delirium is associated with a history of hypertension and alcoholism, higher APACHE II score, and with clinical effects of sedative and analgesic drugs.
Abstract: Delirium in the critically ill is reported in 11–80% of patients. We estimated the incidence of delirium using a validated scale in a large cohort of ICU patients and determined the associated risk factors and outcomes. Prospective study in a 16-bed medical-surgical intensive care unit (ICU). 820 consecutive patients admitted to ICU for more than 24 h. Tools used were: the Intensive Care Delirium Screening Checklist for delirium, Richmond Agitation and Sedation Scale for sedation, and Numerical Rating Scale for pain. Risk factors were evaluated with univariate and multivariate analysis, and factors influencing mortality were determined using Cox regression. Delirium occurred in 31.8% of 764 patients. Risk of delirium was independently associated with a history of hypertension (OR 1.88, 95% CI 1.3–2.6), alcoholism (2.03, 1.2–3.2), and severity of illness (1.25, 1.03–1.07 per 5-point increment in APACHE II score) but not with age or corticosteroid use. Sedatives and analgesics increased the risk of delirium when used to induce coma (OR 3.2, 95% CI 1.5–6.8), and not otherwise. Delirium was linked to longer ICU stay (11.5 ± 11.5 vs. 4.4 ± 3.9 days), longer hospital stay (18.2 ± 15.7 vs. 13.2 ± 19.4 days), higher ICU mortality (19.7% vs. 10.3%), and higher hospital mortality (26.7% vs. 21.4%). Delirium is associated with a history of hypertension and alcoholism, higher APACHE II score, and with clinical effects of sedative and analgesic drugs.

908 citations


Journal ArticleDOI
TL;DR: Interventions likely to improve survival include: early recognition and stabilisation of patients at risk of IHCA to enable prevention, faster and better in-hospital resuscitation and early defibrillation.
Abstract: Design: Review. Objec- tive: Medical literature on in-hospital cardiac arrest (IHCA) was reviewed to summarise: (a) the incidence of and survival after IHCA, (b) major prognostic factors, (c) possible inter- ventions to improve survival. Results and conclusions: The incidence of IHCA is rarely reported in the literature. Values range between 1 and 5 events per 1,000 hospital admissions, or 0.175 events/bed annually. Reported survival to hos- pital discharge varies from 0% to 42%, the most common range being between 15% and 20%. Pre-arrest prognostic factors: the prognostic value of age is controversial. Among comorbidities, sepsis, cancer, renal failure and homebound lifestyle are significantly associated with poor survival. However, pre-arrest morbidity scores have not yet been prospectively validated as instruments to predict failure to survive after IHCA. Intra-arrest factors: ventricular fibrillation/ventricular tachycardia (VF/VT) as the first recorded rhythm and a shorter interval between IHCA and cardiopulmonary resuscitation or defibrillation are associated with higher survival. However, VF/VT is present in only 25-35% of IHCAs. Short-term survival is also higher in patients resuscitated with chest compression rates above 80/min. Interventions likely to improve sur- vival include: early recognition and stabilisation of patients at risk of IHCA to enable prevention, faster and better in-hospital resuscitation and early defibrillation. Mild ther- apeutic hypothermia is effective as post-arrest treatment of out-of- hospital cardiac arrest due to VF/VT, but its benefit after IHCA and af- ter cardiac arrest with non-VF/VT rhythms has not been clearly demon- strated.

608 citations


Journal ArticleDOI
TL;DR: The expected number of newly diagnosed cases with severe sepsis in Germany amounts to 76–110 per 100,000 adult inhabitants and future epidemiological studies should use standardized study methodologies with respect to sepsi definitions, hospital size, and daily and monthly variability.
Abstract: To determine the prevalence and mortality of ICU patients with severe sepsis in Germany, with consideration of hospital size. Prospective, observational, cross-sectional 1-day point-prevalence study. 454 ICUs from a representative nationwide sample of 310 hospitals stratified by size. Data were collected via 1-day on-site audits by trained external study physicians. Visits were randomly distributed over 1 year (2003). Inflammatory response of all ICU patients was assessed using the ACCP/SCCM consensus conference criteria. Patients with severe sepsis were followed up after 3 months for hospital mortality and length of ICU stay. Main outcome measures were prevalence and mortality. A total of 3,877 patients were screened. Prevalence was 12.4% (95% CI, 10.9–13.8%) for sepsis and 11.0% (95% CI, 9.7–12.2%) for severe sepsis including septic shock. The ICU and hospital mortality of patients with severe sepsis was 48.4 and 55.2%, respectively, without significant differences between hospital size. Prevalence and mean length of ICU stay of patients with severe sepsis were significantly higher in larger hospitals and universities (≤ 200 beds: 6% and 11.5 days, universities: 19% and 19.2 days, respectively). The expected number of newly diagnosed cases with severe sepsis in Germany amounts to 76–110 per 100,000 adult inhabitants. To allow better comparison between countries, future epidemiological studies should use standardized study methodologies with respect to sepsis definitions, hospital size, and daily and monthly variability.

589 citations


Journal ArticleDOI
TL;DR: The risk of CINMA is nearly 50% in ICU patients with sepsis, multi-organ failure, or protracted mechanical ventilation, and available data indicate glycemic control as a potential strategy to decrease CinMA risk.
Abstract: To determine the prevalence, risk factors, and outcomes of critical illness neuromuscular abnormalities (CINMA). Systematic review. MEDLINE, EMBASE, CINAHL, and the Cochrane Library were searched for reports on adult ICU patients who were evaluated for CINMA clinically and electrophysiologically. Studies were included if they contained sufficient data to quantify the association between CINMA and relevant exposures and/or outcome variables. CINMA was diagnosed in 655 of 1421 [46% (95% confidence interval 43–49%)] adult ICU patients enrolled in 24 studies, all with inclusion criteria of sepsis, multi-organ failure, or prolonged mechanical ventilation. Diagnostic criteria for CINMA were not uniform, and few reports unequivocally differentiated between polyneuropathy, myopathy, and mixed types of CINMA. The risk of CINMA was associated with hyperglycemia (and inversely associated with tight glycemic control), the systemic inflammatory response syndrome, sepsis, multiple organ dysfunction, renal replacement therapy, and catecholamine administration. Across studies, there was no consistent relationship between CINMA and patient age, gender, severity of illness, or use of glucocorticoids, neuromuscular blockers, aminoglycosides, or midazolam. Unadjusted mortality was not increased in the majority of patients with CINMA, but mechanical ventilation and ICU and hospital stay were prolonged. The risk of CINMA is nearly 50% in ICU patients with sepsis, multi-organ failure, or protracted mechanical ventilation. The association of CINMA with frequently cited CINMA risk factors (glucocorticoids, neuromuscular blockers) and with short-term survival is uncertain. Available data indicate glycemic control as a potential strategy to decrease CINMA risk.

519 citations


Journal ArticleDOI
TL;DR: This study supports the notion that, worldwide, CRRT practice is quite variable and not aligned with best evidence.
Abstract: Objective Little information is available regarding current practice in continuous renal replacement therapy (CRRT) for the treatment of acute renal failure (ARF) and the possible clinical effect of practice variation.

460 citations


Journal ArticleDOI
TL;DR: One of the most important recommendations was that hypotension is not required to define shock, and as a result, importance is assigned to the presence of inadequate tissue perfusion on physical examination.
Abstract: Objective Shock is a severe syndrome resulting in multiple organ dysfunction and a high mortality rate. The goal of this consensus statement is to provide recommendations regarding the monitoring and management of the critically ill patient with shock.

455 citations


Journal ArticleDOI
TL;DR: A wide variety of TTs were in use, with little evidence of reliability, validity and utility, and Sensitivity was poor, which might be due in part to the nature of the physiology monitored or to the choice of trigger threshold.
Abstract: Physiological track and trigger warning systems (TTs) are used to identify patients outside critical care areas at risk of deterioration and to alert a senior clinician, Critical Care Outreach Service, or equivalent. The aims of this work were: to describe published TTs and the extent to which each has been developed according to established procedures; to review the published evidence and available data on the reliability, validity and utility of existing systems; and to identify the best TT for timely recognition of critically ill patients. Systematic review of studies identified from electronic, citation and hand searching, and expert informants. Cohort study of data from 31 acute hospitals in England and Wales. Thirty-six papers were identified describing 25 distinct TTs. Thirty-one papers described the use of a TT, and five were studies examining the development or testing of TTs. None of the studies met all methodological quality standards. For the cohort study, outcome was measured by a composite of death, admission to critical care, ‘do not attempt resuscitation’ or cardiopulmonary resuscitation. Fifteen datasets met pre-defined quality criteria. Sensitivities and positive predictive values were low, with median (quartiles) of 43.3 (25.4–69.2) and 36.7 (29.3–43.8), respectively. A wide variety of TTs were in use, with little evidence of reliability, validity and utility. Sensitivity was poor, which might be due in part to the nature of the physiology monitored or to the choice of trigger threshold. Available data were insufficient to identify the best TT.

436 citations


Journal ArticleDOI
TL;DR: In the early posttraumatic period, ocular ultrasound scans may be useful for detecting high ICP after severe TBI in patients with severe traumatic brain injury.
Abstract: Objective To assess at admission to the ICU the relationship between optic nerve sheath diameter (ONSD) and intracranial pressure (ICP) and to investigate whether increased ONSD at patient admission is associated with raised ICP in the first 48 h after trauma.

384 citations


Journal ArticleDOI
TL;DR: Recent findings concerning the application of the RIFLE criteria to the assessment of the epidemiology and the prediction of the outcome of ARF are summarized and interpreted.
Abstract: Until recently, more than 30 different definitions of acute renal failure (ARF) had been used in the literature. This lack of a common reference point created confusion and made comparisons difficult. It also led to strong advocacy of a consensus definition. In response to the need for a common definition and classification of ARF, the Acute Dialysis Quality Initiative (ADQI) group of experts developed and published a consensus definition of ARF. This definition goes under the acronym of RIFLE to indicate that it classifies patients with renal dysfunction according to the degree of impairment into patients at risk (R), with injury (I), with failure (F), with sustained loss (L) and with end-stage (E) status in relation to their renal function. This editorial aims to summarize and interpret recent findings concerning the application of the RIFLE criteria to the assessment of the epidemiology and the prediction of the outcome of ARF.

368 citations


Journal ArticleDOI
TL;DR: The hypothesis that the impact of care within the ICU has an impact on subsequent psychological morbidity and therefore must be assessed in future studies looking at the way patients are sedated in theICU and how physical restraint is used is raised.
Abstract: Objective This prospective observational study was designed to explore the relationships between post-traumatic stress disorder (PTSD), patients' memories of the intensive care unit (ICU) and sedation practices.

354 citations


Journal ArticleDOI
TL;DR: In patients admitted with clinically suspected infection, the venous lactate level predicts 28-day in-hospital mortality independent of blood pressure and adds significant prognostic information to that provided by other clinical predictors.
Abstract: Objective To determine, in the early stages of suspected clinically significant infection, the independent relationship of the presenting venous lactate level to 28-day in-hospital mortality.

Journal ArticleDOI
TL;DR: When broadly implemented in routine practice, measurement of lactate in patients with infection and possible sepsis can affect assessment of mortality risk and substantially increases the probability of acute-phase death.
Abstract: To determine the utility of an initial serum lactate measurement for identifying high risk of death in patients with infection. Post-hoc analysis of a prospectively compiled registry in an urban academic hospital. Patients with (a) a primary or secondary diagnosis of infection and (b) lactate measurement who were admitted over the 18 months following hospital-wide implementation of the Surviving Sepsis Campaign guideline for lactate measurement in patients with infection and possible severe sepsis. There were 1,177 unique patients, with an in-hospital mortality of 19%. Outcome measures included acute-phase (≤ 3 days) death and in-hospital death. We defined lactate ranges a priori (low, 0.0–2.0; intermediate, 2.1–3.9; high, 4.0 mmol/l or above)—and tested for linear associations with mortality by one-way analysis of variance. We determined sensitivity/specificity, odds ratios, and likelihood ratios for a lactate ≥ 4.0 mmol/l and performed a Bayesian analysis to determine its impact on a full range (0.01–0.99) of hypothetical pretest probability estimates for death. In-hospital mortality was 15%, 25%, and 38% in low, intermediate, and high lactate groups, respectively. Acute-phase deaths and in-hospital deaths increased linearly with lactate. An initial lactate ≥ 4.0 mmol/l was associated with sixfold higher odds of acute-phase death; however, a lactate level less than 4 mmol/l had little impact on probability of death. When broadly implemented in routine practice, measurement of lactate in patients with infection and possible sepsis can affect assessment of mortality risk. Specifically, an initial lactate ≥ 4.0 mmol/l substantiallyincreases the probability of acute-phase death.

Journal ArticleDOI
TL;DR: Altered recovery in StO2 after an ischemic challenge is frequent in septic patients and more pronounced in the presence of shock, and the presence and persistence of these alterations in the first 24 h of sepsis are associated with worse outcome.
Abstract: To quantify sepsis-induced alterations in changes in muscle tissue oxygenation (StO2) after an ischemic challenge using near-infrared spectroscopy (NIRS), and to test the hypothesis that these alterations are related to outcome Prospective study Thirty-one-bed, university hospital Department of Intensive Care Seventy-two patients with severe sepsis or septic shock, 18 hemodynamically stable, acutely ill patients without infection, and 18 healthy volunteers Three-minute occlusion of the brachial artery using a cuff inflated 50 mmHg above systolic arterial pressure Thenar eminence StO2 was measured continuously by NIRS before (StO2baseline), during, and after the 3-min occlusion Changes in StO2 were assessed by the slope of increase in StO2 during the first 14 s following the ischemic period and by the difference between the maximum StO2 and StO2baseline (Δ) The slope was lower in septic patients than in controls and volunteers [23 (13–36), 48 (35–60), and 47 (32–63) %/s, p < 0001] Δ was also significantly lower in septic patients than in the other groups Slopes were lower in septic patients with than without shock [20 (12–29) vs 32 (18–45) %/s, p < 005] In 52 septic patients, in whom the slope was obtained every 24 h for 48 h, slopes were higher in survivors than in non-survivors and tended to increase in survivors but not in non-survivors Altered recovery in StO2 after an ischemic challenge is frequent in septic patients and more pronounced in the presence of shock The presence and persistence of these alterations in the first 24 h of sepsis are associated with worse outcome

Journal ArticleDOI
TL;DR: In critically ill patients with spontaneous breathing activity the response of echocardiographic stroke volume to passive leg raising was a good predictor of volume responsiveness and the common echOCardiographic markers of cardiac filling status were not valuable for this purpose.
Abstract: In hemodynamically unstable patients with spontaneous breathing activity, predicting volume responsiveness is a difficult challenge since the respiratory variation in arterial pressure cannot be used. Our objective was to test whether volume responsiveness can be predicted by the response of stroke volume measured with transthoracic echocardiography to passive leg raising in patients with spontaneous breathing activity. We also examined whether common echocardiographic indices of cardiac filling status are valuable to predict volume responsiveness in this category of patients. Prospective study in the medical intensive care unit of a university hospital. 24 patients with spontaneously breathing activity considered for volume expansion. We measured the response of the echocardiographic stroke volume to passive leg raising and to saline infusion (500 ml over 15 min). The left ventricular end-diastolic area and the ratio of mitral inflow E wave velocity to early diastolic mitral annulus velocity (E/Ea) were also measured before and after saline infusion. A passive leg raising induced increase in stroke volume of 12.5% or more predicted an increase in stroke volume of 15% or more after volume expansion with a sensitivity of 77% and a specificity of 100%. Neither left ventricular end-diastolic area nor E/Ea predicted volume responsiveness. In our critically ill patients with spontaneous breathing activity the response of echocardiographic stroke volume to passive leg raising was a good predictor of volume responsiveness. On the other hand, the common echocardiographic markers of cardiac filling status were not valuable for this purpose.

Journal ArticleDOI
TL;DR: Cardiac output measured by NICOM had most often acceptable accuracy, precision, and responsiveness in a wide range of circulatory situations.
Abstract: To evaluate the clinical utility of a new device for continuous noninvasive cardiac output monitoring (NICOM) based on chest bio-reactance compared with cardiac output measured semi-continuously by thermodilution using a pulmonary artery catheter (PAC-CCO). Prospective, single-center study. Intensive care unit. Consecutive adult patients immediately after cardiac surgery. Cardiac output measurements obtained from NICOM and thermodilution were simultaneously recorded minute by minute and compared in 110 patients. We evaluated the accuracy, precision, responsiveness, and reliability of NICOM for detecting cardiac output changes. Tolerance for each of these parameters was specified prospectively. A total of 65,888 pairs of cardiac output measurements were collected. Mean reference values for cardiac output ranged from 2.79 to 9.27 l/min. During periods of stable PAC-CCO (slope < ± 10%, 2SD/mean < 20%), the correlation between NICOM and thermodilution was R = 0.82; bias was +0.16 ± 0.52 l/min (+4.0 ± 11.3%), and relative error was 9.1% ± 7.8%. In 85% of patients the relative error was < 20%. During periods of increasing output, slopes were similar with the two methods in 96% of patients and intra-class correlation was positive in 96%. Corresponding values during periods of decreasing output were 90% and 84%, respectively. Precision was always better with NICOM than with thermodilution. During hemodynamic challenges, changes were 3.1 ± 3.8 min faster with NICOM (p < 0.01) and amplitude of changes did not differ significantly. Finally, sensitivity of the NICOM for detecting significant directional changes was 93% and specificity was 93%. Cardiac output measured by NICOM had most often acceptable accuracy, precision, and responsiveness in a wide range of circulatory situations.

Journal ArticleDOI
TL;DR: Patients with no delirium were more likely to be discharged home and less likely to need convalescence or long-term care than those with subsyndromalDelirium or clinical deliria, and ICDSC score increments higher than 4/8 were not associated with a change in mortality or LOS.
Abstract: Objective ICU delirium is common and adverse. The Intensive Care Delirium Screening Checklist (ICDSC) score ranges from 0 to 8, with a score of 4 or higher indicating clinical delirium. We investigated whether lower (subsyndromal) values affect outcome.

Journal ArticleDOI
TL;DR: This prospective study found the incidence of ICU-treated severe sepsis in Finland to be 0.38 per 1,000 of the population, lower than earlier reported in United States or Australia.
Abstract: To determine the incidence and outcome of severe sepsis in the adult Finnish population and to evaluate how treatment guidelines in severe sepsis are applied in clinical practice. A prospective study in 24 closed multidisciplinary ICUs in 21 hospitals (4 university and 17 tertiary hospitals) in Finland. All 4,500 consecutive ICU admission episodes were screened for severe sepsis during a 4-month period (1 November 2004 – 28 February 2005). The referral population was 3,743,225. The severe sepsis criteria were fulfilled in 470 patients, who had472 septic episodes. The incidence of severe sepsis in the ICUs in Finland was 0.38/1000 in the adult population (95% confidence interval 0.34–0.41). The mean ICU length of stay was 8.2 ± 8.1 days. ICU, hospital, and 1-year mortality rates were 15.5%, 28.3%, and 40.9%, respectively. Respiratory failure requiring ventilation support was the most common organ failure (86.2%); septic shock was present in 77% and acute renal failure in 20.6% of cases. Activated protein C was given to only 15 of the 55 patients with indication (27%) and low-dose corticosteroids to 150 of 366 (41%) patients with septic shock. This prospective study found the incidence of ICU-treated severe sepsis in Finland to be 0.38 per 1,000 of the population. The ICU and hospital mortalities were also lower than earlier reported in United States or Australia. Evidence-based sepsis therapies were not used as often as recommended.

Journal ArticleDOI
TL;DR: Limited training of noncardiologist ICU residents without previous knowledge in ultrasound appears feasible and efficient to address simple clinical questions using point-of-care echography.
Abstract: We sought to evaluate the efficacy of a limited training dedicated to residents without knowledge in ultrasound for performing goal-oriented echocardiography in ICU patients. Prospective pilot observational study. Medical-surgical ICU of a teaching hospital. 61 consecutive adult ICU patients (SAPS II score: 38 ± 17; 46 ventilated patients) requiring a transthoracic echocardiography were studied. After a curriculum including a 3-h training course and 5 h of hands-on training, one of four noncardiologist residents and an intensivist experienced in ultrasound subsequently performed hand-held echocardiography (HHE), independently and in random order. Assessable “rule in, rule out” clinical questions were purposely limited to easily identifiable conditions by the sole use of two-dimensional imaging. When compared with residents, the experienced intensivist performed shorter examinations (4 ± 1 vs. 11 ± 4 min: p < 0.0001) and had significantly less unsolved clinical questions [3 (0.8%) vs. 27 (7.4%) of 366 clinical questions: p < 0.0001]. When addressed, clinical questions were adequately appraised by residents: left ventricular systolic dysfunction [Kappa: 0.76 ± 0.09 (95% CI: 0.59–0.93)], left ventricular dilatation [Kappa: 0.66 ± 0.12 (95% CI: 0.43–0.90)], right ventricular dilatation [Kappa: 0.71 ± 0.12 (95% CI: 0.46–0.95)], pericardial effusion [Kappa: 0.68 ± 0.18 (95 CI: 0.33–1.03)], and pleural effusion [Kappa: 0.71 ± 0.09 (95% CI: 0.53–0.88)]. The only case of tamponade was accurately diagnosed by the resident. Limited training of noncardiologist ICU residents without previous knowledge in ultrasound appears feasible and efficient to address simple clinical questions using point-of-care echography. Influence of the learning curve on diagnostic accuracy and potential therapeutic impact remain to be determined.

Journal ArticleDOI
TL;DR: Bedside measurement of cardiac output or stroke volume by Doppler techniques during passive leg raising was predictive of a positive hemodynamic effect of fluid expansion in spontaneously breathing patients with suspected central hypovolemia.
Abstract: Objective Suspected central hypovolemia is a frequent clinical situation in hospitalized patients, and no simple bedside diagnostic test in spontaneously breathing patients is available. We tested the value of passive leg raising to predict hemodynamic improvement after fluid expansion in patients with suspected central hypovolemia.

Journal ArticleDOI
TL;DR: The prevalence of the hypoactive or “quiet” subtype of delirium in surgical and trauma ICU patients appears similar to that of previously published data in medical ICu patients.
Abstract: Acute brain dysfunction or delirium occurs in the majority of mechanically ventilated (MV) medical intensive care unit (ICU) patients and is associated with increased mortality. Unfortunately delirium often goes undiagnosed as health care providers fail to recognize in particular the hypoactive form that is characterized by depressed consciousness without the positive symptoms such as agitation. Recently, clinical tools have been developed that help to diagnose delirium and determine the subtypes. Their use, however, has not been reported in surgical and trauma patients. The objective of this study was to identify the prevalence of the motoric subtypes of delirium in surgical and trauma ICU patients. Adult surgical and trauma ICU patients requiring MV longer than 24 h were prospectively evaluated for arousal and delirium using well validated instruments. Sedation and delirium were assessed using the Richmond Agitation Sedation Scale (RASS) and the Confusion Assessment Method in the ICU (CAM-ICU), respectively. Patients were monitored for delirium for a maximum of 10 days or until ICU discharge. A total of 100 ICU patients (46 surgical and 54 trauma) were enrolled in this study. Three patients were excluded from the final analysis because they stayed persistently comatose prior to their death. Prevalence of delirium was 70% for the entire study population with 73% surgical and 67% trauma ICU patients having delirium. Evaluation of the subtypes of delirium revealed that in surgical and trauma patients, hypoactive delirium (64% and 60%, respectively) was significantly more prevalent than the mixed (9% and 6%) and the pure hyperactive delirium (0% and 1%). The prevalence of the hypoactive or “quiet” subtype of delirium in surgical and trauma ICU patients appears similar to that of previously published data in medical ICU patients. In the absence of active monitoring with a validated clinical instrument (CAM-ICU), however, this subtype of delirium goes undiagnosed and the prevalence of delirium in surgical and trauma ICU patients remains greatly underestimated.

Journal ArticleDOI
TL;DR: Significant differences associated with religious affiliation and culture were observed for the type of end-of-life decision, the times to therapy limitation and death, and discussion of decisions with patient families.
Abstract: To determine the influence of religious affiliation and culture on end-of-life decisions in European intensive care units (ICUs). A prospective, observational study of European ICUs was performed on consecutive patients with any limitation of therapy. Prospectively defined end-of-life practices in 37 ICUs in 17 European countries studied from 1 January 1999 to 30 June 2000 were compared for frequencies, patterns, timing, and communication by religious affiliation of physicians and patients and regions. Of the 31,417 patients 3,086 had limitations. Withholding occurred more often than withdrawing if the physician was Jewish (81%), Greek Orthodox (78%), or Moslem (63%). Withdrawing occurred more often for physicians who were Catholic (53%), Protestant (49%), or had no religious affiliation (47%). End-of-life decisions differed for physicians between regions and who had any religious affiliation vs. no religious affiliation in all three geographical regions. Median time from ICU admission to first limitation of therapy was 3.2 days but varied by religious affiliation; from 1.6 days for Protestant to 7.6 days for Greek Orthodox physicians. Median times from limitations to death also varied by physician's religious affiliation. Decisions were discussed with the families more often if the physician was Protestant (80%), Catholic (70%), had no religious affiliation (66%) or was Jewish (63%). Significant differences associated with religious affiliation and culture were observed for the type of end of life decision, the times to therapy limitation and death, and discussion of decisions with patient families.

Journal ArticleDOI
TL;DR: The diagnosis of sepsis-associated delirium relies mainly on clinical and electrophysiological criteria, and its treatment is entirely based on general management ofsepsis.
Abstract: Sepsis-associated delirium is a common and poorly understood neurological complication of sepsis. This review provides an update of the diagnostic criteria and treatment strategies and the current knowledge about the mechanisms involved in sepsis associated brain dysfunction. Articles published between 1981 and 2006 were identified through a Medline search for “encephalopathy” and “sepsis” and by hand searching of articles cited in the identified publications. The immune response to sepsis results in multiorgan failure including brain dysfunction. The potential mechanisms for sepsis-associated delirium include vascular damage, endothelial activation, breakdown of the blood-brain barrier, metabolic disorders, brain inflammation and apoptosis. On the other hand, there is evidence for distinct neuroprotective factors, such as anti-inflammatory mediators and glial cell activity. The diagnosis of sepsis-associated delirium relies mainly on clinical and electrophysiological criteria, and its treatment is entirely based on general management of sepsis.

Journal ArticleDOI
TL;DR: Guiding therapy by an algorithm based on GEDVI leads to a shortened and reduced need for vasopressors, catecholamines, mechanical ventilation, and ICU therapy in patients undergoing cardiac surgery.
Abstract: We examined whether guiding therapy by an algorithm based on optimizing the global end-diastolic volume index (GEDVI) reduces the need for vasopressor and inotropic support and helps to shorten ICU stay in cardiac surgery patients. Single-center clinical study with a historical control group at an university hospital. Forty cardiac bypass surgery patients were included prospectively and compared with a control group. In the goal-directed therapy (GDT) group hemodynamic management was guided by an algorithm based on GEDVI. Hemodynamic goals were: GEDVI above 640 ml/m2, cardiac index above 2.5 l/min/m2, and mean arterial pressure above 70 mmHg. The control group was treated at the discretion of the attending physician based on central venous pressure, mean arterial pressure, and clinical evaluation. In the GDT group duration of catecholamine and vasopressor dependence was shorter (187 ± 70 vs. 1458 ± 197 min), and fewer vasopressors (0.73 ± 0.32 vs. 6.67 ± 1.21 mg) and catecholamines (0.01 ± 0.01 vs. 0.83 ± 0.27 mg) were administered. They received more colloids (6918 ± 242 vs. 5514 ± 171 ml). Duration of mechanical ventilation (12.6 ± 3.6 vs. 15.4 ± 4.3 h) and time until achieving status of fit for ICU discharge (25 ± 13 vs. 33 ± 17 h) was shorter in the GDT group. Guiding therapy by an algorithm based on GEDVI leads to a shortened and reduced need for vasopressors, catecholamines, mechanical ventilation, and ICU therapy in patients undergoing cardiac surgery.

Journal ArticleDOI
TL;DR: It is found that there is no additional survival benefit from strict glucose control compared with moderate glucose control with a target between 6 and 8 mmol/l in OHCA patients.
Abstract: Objective Elevated blood glucose is associated with poor outcome in patients resuscitated from out-of-hospital cardiac arrest (OHCA). Our aim was to determine whether strict glucose control with intensive insulin treatment improves outcome of OHCA patients.

Journal ArticleDOI
TL;DR: The true prevalence of PTSD and the optimum timing and method of PTSD assessment have not yet been determined in intensive care unit survivors, and rigorous longitudinal studies are needed.
Abstract: To determine the prevalence of post traumatic stress disorder in survivors of intensive care treatment. Systematic literature review including Medline, Embase, CINAHL, PsycINFO and references from identified papers. Studies determining the prevalence of PTSD in adult patients who had at least 24 h treatment on an intensive care unit. Independent duplicate data extraction. Study quality was evaluated in terms of study design and method and timing of PTSD assessment. Of the 1472 citations identified, 30 studies meeting the selection criteria were reviewed. PTSD was diagnosed by standardised clinical interview alone in 2 studies. A self-report measure alone was used in 19 studies to measure PTSD symptomatology. The remaining 9 studies applied both standardised clinical interview and a self-report measure. The reported prevalence of PTSD was 0–64% when diagnosed by standardised clinical interview and 5–64% by self-report measure. PTSD assessments occurred 7 days to 8 years after intensive care discharge. The true prevalence of PTSD and the optimum timing and method of PTSD assessment have not yet been determined in intensive care unit survivors. Deficiencies in design, methodology and reporting make interpretation and comparison of quoted prevalence rates difficult, and rigorous longitudinal studies are needed.

Journal ArticleDOI
TL;DR: This preliminary study showed that sepsis-induced brain lesions can be documented by magnetic resonance imaging, suggesting increasedblood–brain barrier permeability, and were associated with poor outcome.
Abstract: Understanding of sepsis-induced brain dysfunction remains poor, and relies mainly on data from animals or post-mortem studies in patients. The current study provided findings from magnetic resonance imaging of the brain in septic shock. Nine patients with septic shock and brain dysfunction [7 women, median age 63 years (interquartile range 61–79 years), SAPS II: 48 (44–56), SOFA: 8 (6–10)] underwent brain magnetic resonance imaging including gradient echo T1-weighted, fluid-attenuated inversion recovery (FLAIR), T2-weighted and diffusion isotropic images, and mapping of apparent diffusion coefficient. Brain imaging was normal in two patients, showed multiple ischaemic strokes in two patients, and in the remaining patients showed white matter lesions at the level of the centrum semiovale, predominating around Virchow–Robin spaces, ranging from small multiple areas to diffuse lesions, and characterised by hyperintensity on FLAIR images. The main lesions were also characterised by reduced signal on diffusion isotropic images and increased apparent diffusion coefficient. The lesions of the white matter worsened with increasing duration of shock and were correlated with Glasgow Outcome Score. This preliminary study showed that sepsis-induced brain lesions can be documented by magnetic resonance imaging. These lesions predominated in the white matter, suggesting increasedblood–brain barrier permeability, and were associated with poor outcome.

Journal ArticleDOI
TL;DR: Results suggest that indexes of pulmonary permeability provided by transpulmonary thermodilution may be useful for determining the mechanism of pulmonary edema in the critically ill.
Abstract: To test whether assessing pulmonary permeability by transpulmonary thermodilution enables to differentiate increased permeability pulmonary edema (ALI/ARDS) from hydrostatic pulmonary edema. Retrospective review of cases. A 24-bed medical intensive care unit of a university hospital. Forty-eight critically ill patients ventilated for acute respiratory failure with bilateral infiltrates on chest radiograph, a PaO2/FiO2 ratio < 300 mmHg and extravascular lung water indexed for body weight ≥ 12 ml/kg. We assessed pulmonary permeability by two indexes obtained from transpulmonary thermodilution: extravascular lung water/pulmonary blood volume (PVPI) and the ratio of extravascular lung water index over global end-diastolic volume index. The cause of pulmonary edema was determined a posteriori by three experts, taking into account medical history, clinical features, echocardiographic left ventricular function, chest radiography findings, B-type natriuretic peptide serum concentration and the time-course of these findings with therapy. Experts were blind for pulmonary permeability indexes and for global end-diastolic volume. ALI/ARDS was diagnosed in 36 cases. The PVPI was 4.7 ± 1.8 and 2.1 ± 0.5 in patients with ALI/ARDS and hydrostatic pulmonary edema, respectively (p < 0.05). The extravascular lung water index/global end-diastolic volume index ratio was 3.0 × 10−2 ± 1.2 × 10−2 and 1.4 × 10−2 ± 0.4 × 10−2 in patients with ALI/ARDS and with hydrostatic pulmonary edema, respectively (p < 0.05). A PVPI ≥ 3 and an extravascular lung water index/global end-diastolic index ratio ≥ 1.8 × 10−2 allowed the diagnosis of ALI/ARDS with a sensitivity of 85% and specificity of 100%. These results suggest that indexes of pulmonary permeability provided by transpulmonary thermodilution may be useful for determining the mechanism of pulmonary edema in the critically ill.

Journal ArticleDOI
TL;DR: The use of CRRT is associated with better renal recovery than IHD, but mortality does not differ between the groups, according to a nationwide retrospective cohort study between the years 1995 and 2004.
Abstract: Objective Acute renal failure can be treated with continuous renal replacement therapy (CRRT) or intermittent haemodialysis (IHD). Whether this choice affects renal recovery has been debated, since it has implications on quality of life and costs. Our objective was to determine the impact of CRRT and IHD on renal recovery.

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TL;DR: Comparing available instruments for assessing delirium in critically ill adults that have undergone validity testing and providing clinicians with strategies to incorporate these instruments into clinical practice to improve patient care is compared.
Abstract: To compare available instruments for assessing delirium in critically ill adults that have undergone validity testing and provide clinicians with strategies to incorporate these instruments into clinical practice. Medline (1966–September 2006) was searched using the key words: delirium, cognitive dysfunction, assessment, intensive care unit, and critical illness to identify assessment tools that have been used to evaluate delirium in critically ill adults. A special emphasis was placed on delirium assessment tools that have been properly validated. Data on how these tools have been adopted into clinical practice as well as strategies for clinicians to improve delirium assessment in the ICU are highlighted. Six delirium assessment instruments including the Cognitive Test for Delirium (CTD), abbreviated CTD, Confusion Assessment Method–ICU, Intensive Care Delirium Screening Checklist, NEECHAM scale, and the Delirium Detection Score were identified. While each of these scales have undergone validation in critically ill adults, substantial differences exist among the scales in terms of the quality and extent of the validation effort, the specific components of the delirium syndrome each address, their ability to identify hypoactive delirium, their use in patients with a compromised level of consciousness, and their ease of use. Incorporation of delirium assessment into clinical practice in the intensive care unit using a validated tool may improve patient care. Clinicians can adopt a number of different strategies to overcome the many barriers associated with routine delirium assessment in the ICU.

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TL;DR: According to this review, it is impossible to define evidence-based recommendations for ICU admission of the elderly, and further studies that encompass several aspects, such as the initial triage process and the long-term prognosis (mortality, autonomy and quality of life).
Abstract: As the general population ages, an increasing number of patients over 80 years are being admitted to the intensive care unit (ICU) Selection of older patients for ICU admission results in lower rates of co-morbidities and underlying fatal diseases After adjustment for disease severity, ICU and post-ICU mortality rates are higher in elderly patients than in younger populations Age itself explains only a small part of the increased hospital mortality, suggesting that specific information such as functional, cognitive, and nutritional status, as well as co-morbidities, should be collected to predict mortality in elderly ICU patients The long-term prognosis depends chiefly on functional status, whereas initial disease severity no longer influences mortality According to our review, it is impossible to define evidence-based recommendations for ICU admission of the elderly This justifies further studies that encompass several aspects, such as the initial triage process and the long-term prognosis (mortality, autonomy and quality of life)