Showing papers in "Intensive Care Medicine in 2011"

The ALIEN study: incidence and outcome of acute respiratory distress syndrome in the era of lung protective ventilation

Abstract: While our understanding of the pathogenesis and management of acute respiratory distress syndrome (ARDS) has improved over the past decade, estimates of its incidence have been controversial. The goal of this study was to examine ARDS incidence and outcome under current lung protective ventilatory support practices before and after the diagnosis of ARDS. This was a 1-year prospective, multicenter, observational study in 13 geographical areas of Spain (serving a population of 3.55 million at least 18 years of age) between November 2008 and October 2009. Subjects comprised all consecutive patients meeting American-European Consensus Criteria for ARDS. Data on ventilatory management, gas exchange, hemodynamics, and organ dysfunction were collected. A total of 255 mechanically ventilated patients fulfilled the ARDS definition, representing an incidence of 7.2/100,000 population/year. Pneumonia and sepsis were the most common causes of ARDS. At the time of meeting ARDS criteria, mean PaO2/FiO2 was 114 ± 40 mmHg, mean tidal volume was 7.2 ± 1.1 ml/kg predicted body weight, mean plateau pressure was 26 ± 5 cmH2O, and mean positive end-expiratory pressure (PEEP) was 9.3 ± 2.4 cmH2O. Overall ARDS intensive care unit (ICU) and hospital mortality was 42.7% (95%CI 37.7–47.8) and 47.8% (95%CI 42.8–53.0), respectively. This is the first study to prospectively estimate the ARDS incidence during the routine application of lung protective ventilation. Our findings support previous estimates in Europe and are an order of magnitude lower than those reported in the USA and Australia. Despite use of lung protective ventilation, overall ICU and hospital mortality of ARDS patients is still higher than 40%.

The tight calorie control study (TICACOS): a prospective, randomized, controlled pilot study of nutritional support in critically ill patients

Abstract: To determine whether nutritional support guided by repeated measurements of resting energy requirements improves the outcome of critically ill patients. This was a prospective, randomized, single-center, pilot clinical trial conducted in an adult general intensive care (ICU) unit. The study population comprised mechanically ventilated patients (n = 130) expected to stay in ICU more than 3 days. Patients were randomized to receive enteral nutrition (EN) with an energy target determined either (1) by repeated indirect calorimetry measurements (study group, n = 56), or (2) according to 25 kcal/kg/day (control group, n = 56). EN was supplemented with parenteral nutrition when required. The primary outcome was hospital mortality. Measured pre-study resting energy expenditure (REE) was similar in both groups (1,976 ± 468 vs. 1,838 ± 468 kcal, p = 0.6). Patients in the study group had a higher mean energy (2,086 ± 460 vs. 1,480 ± 356 kcal/day, p = 0.01) and protein intake (76 ± 16 vs. 53 ± 16 g/day, p = 0.01). There was a trend towards an improved hospital mortality in the intention to treat group (21/65 patients, 32.3% vs. 31/65 patients, 47.7%, p = 0.058) whereas length of ventilation (16.1 ± 14.7 vs. 10.5 ± 8.3 days, p = 0.03) and ICU stay (17.2 ± 14.6 vs. 11.7 ± 8.4, p = 0.04) were increased. In this single-center pilot study a bundle comprising actively supervised nutritional intervention and providing near target energy requirements based on repeated energy measurements was achievable in a general ICU and may be associated with lower hospital mortality.

Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: a systematic review and meta-analysis

Abstract: To evaluate the diagnostic accuracy of ultrasonography of optic nerve sheath diameter (ONSD) for assessment of intracranial hypertension. Systematic review without language restriction based on electronic databases, with manual review of literature and conference proceedings until July 2010. Studies were eligible if they compared ultrasonography of ONSD with intracranial pressure (ICP) monitoring. Data were extracted independently by three authors. Random-effects meta-analysis and meta-regression were performed. Six studies including 231 patients were reviewed. No significant heterogeneity was detected for sensitivity, specificity, positive and negative likelihood ratios or diagnostic odds ratio. For detection of raised intracranial pressure, pooled sensitivity was 0.90 [95% confidence interval (CI) 0.80–0.95; p for heterogeneity, p het = 0.09], pooled specificity was 0.85 (95% CI 0.73–0.93, p het = 0.13), and the pooled diagnostic odds ratio was 51 (95% CI 22–121). The area under the summary receiver-operating characteristic (SROC) curve was 0.94 (95% CI 0.91–0.96). Ultrasonography of ONSD shows a good level of diagnostic accuracy for detecting intracranial hypertension. In clinical decision-making, this technique may help physicians decide to transfer patients to specialized centers or to place an invasive device when specific recommendations for this placement do not exist.

Beneficial effects of humidified high flow nasal oxygen in critical care patients: a prospective pilot study

Abstract: Purpose To evaluate the efficiency, safety and outcome of high flow nasal cannula oxygen (HFNC) in ICU patients with acute respiratory failure.

Lung ultrasound in critically ill patients: comparison with bedside chest radiography.

Abstract: Purpose To compare the diagnostic performance of lung ultrasound and bedside chest radiography (CXR) for the detection of various pathologic abnormalities in unselected critically ill patients, using thoracic computed tomography (CT) as a gold standard.

The Italian ECMO network experience during the 2009 influenza A(H1N1) pandemic: preparation for severe respiratory emergency outbreaks.

Abstract: Purpose In view of the expected 2009 influenza A(H1N1) pandemic, the Italian Health Authorities set up a national referral network of selected intensive care units (ICU) able to provide advanced respiratory care up to extracorporeal membrane oxygenation (ECMO) for patients with acute respiratory distress syndrome (ARDS). We describe the organization and results of the network, known as ECMOnet.

Impact of albumin compared to saline on organ function and mortality of patients with severe sepsis.

Abstract: To determine the effect of random assignment to fluid resuscitation with albumin or saline on organ function and mortality in patients with severe sepsis.

International expert statement on training standards for critical care ultrasonography

Abstract: Training in ultrasound techniques for intensive care medicine physicians should aim at achieving competencies in three main areas: (1) general critical care ultrasound (GCCUS), (2) "basic" critical care echocardiography (CCE), and (3) advanced CCE. A group of 29 experts representing the European Society of Intensive Care Medicine (ESICM) and 11 other critical care societies worldwide worked on a potential framework for organizing training adapted to each area of competence. This framework is mainly aimed at defining minimal requirements but is by no means rigid or restrictive: each training organization can be adapted according to resources available. There was 100% agreement among the participants that general critical care ultrasound and "basic" critical care echocardiography should be mandatory in the curriculum of intensive care unit (ICU) physicians. It is the role of each critical care society to support the implementation of training in GCCUS and basic CCE in its own country.

Recommendations on basic requirements for intensive care units: structural and organizational aspects

Abstract: Objective: To provide guidance and recommendations for the planning or renovation of inten- sive care units (ICUs) with respect to the specific characteristics relevant to organizational and structural aspects of intensive care medicine. Methodology: The Working Group on Quality Improvement (WGQI) of the European Society of Intensive Care Medicine (ESICM) identified the basic requirements for ICUs by a comprehensive literature search and an iterative process with several rounds of consensus finding with the participation of 47 intensive care physicians from 23 countries. The starting point of this process was an ESICM recommendation published in 1997 with the need for an updated version. Results: The document consists of operational guidelines and design recommendations for ICUs. In the first part it covers the definition and objectives of an ICU, functional criteria, activity criteria, and the management of equipment. The sec- ond part deals with recommendations with respect to the planning process, floorplan and connections, accom- modation, fire safety, central services, and the necessary communication systems. Conclusion: This docu- ment provides a detailed framework for the planning or renovation of ICUs based on a multinational con- sensus within the ESICM.

Immunoparalysis and nosocomial infection in children with multiple organ dysfunction syndrome.

Abstract: Immunoparalysis defined by prolonged monocyte human leukocyte antigen DR depression is associated with adverse outcomes in adult severe sepsis and can be reversed with granulocyte macrophage colony-stimulating factor (GM-CSF). We hypothesized that immunoparalysis defined by whole-blood ex vivo lipopolysaccharide-induced tumor necrosis factor-alpha (TNFα) response 200 pg/mL by 7 days (p < 0.05) and prevented nosocomial infection (no infections in seven patients versus eight infections in seven patients) (p < 0.05). Similar to in adults, immunoparalysis is a potentially reversible risk factor for development of nosocomial infection in pediatric MODS. Whole-blood ex vivo TNFα response is a promising biomarker for monitoring this condition.

Predictors of successful extracorporeal membrane oxygenation (ECMO) weaning after assistance for refractory cardiogenic shock.

Abstract: Purpose Detailed extracorporeal membrane oxygenation (ECMO) weaning strategies and specific predictors of ECMO weaning success are lacking. This study evaluated a weaning strategy following support for refractory cardiogenic shock to identify clinical, hemodynamic, and Doppler echocardiography parameters associated with successful ECMO removal.

Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery

Abstract: To describe the change in ventilatory practice in a tertiary paediatric intensive care unit (PICU) in the 5-year period after the introduction of high-flow nasal prong (HFNP) therapy in infants <24 months of age. Additionally, to identify the patient subgroups on HFNP requiring escalation of therapy to either other non-invasive or invasive ventilation, and to identify any adverse events associated with HFNP therapy. The study was a retrospective chart review of infants <24 months of age admitted to our PICU for HFNP therapy. Data was also extracted from both the local database and the Australian New Zealand paediatric intensive care (ANZPIC) registry for all infants admitted with bronchiolitis. Between January 2005 and December 2009, a total of 298 infants <24 months of age received HFNP therapy. Overall, 36 infants (12%) required escalation to invasive ventilation. In the subgroup with a primary diagnosis of viral bronchiolitis (n = 167, 56%), only 6 (4%) required escalation to invasive ventilation. The rate of intubation in infants with viral bronchiolitis reduced from 37% to 7% over the observation period corresponding with an increase in the use of HFNP therapy. No adverse events were identified with the use of HFNP therapy. HFNP therapy has dramatically changed ventilatory practice in infants <24 months of age in our institution, and appears to reduce the need for intubation in infants with viral bronchiolitis.

Sonographic diagnosis of pneumothorax

Abstract: Over the last decade, the use of ultrasound as a technique to look for pneumothorax has rapidly evolved. This review aims to analyze and synthesize current knowledge on lung ultrasound targeted at the diagnosis of pneumothorax. The technique and its usefulness in different scenarios are explained, and its merits over conventional radiology are highlighted. A systematic literature search (1995–2010) was performed, involving PubMed, to describe the more recent scientific evidence on the topic. Moreover, this review is also a synopsis of experts’ opinion and personal clinical experience. Ultrasound diagnosis of pneumothorax relies on the recognition of four sonographic artifact signs: the lung sliding, the B lines, the lung point, and the lung pulse. Combining these few signs, it is possible to accurately rule in or rule out pneumothorax at the bedside in several different clinical scenarios. Sensitivity of a lung ultrasound in the detection of pneumothorax is higher than that of conventional anterior–posterior chest radiography, and similar to that of computerized tomography. A major benefit of a lung ultrasound is that it can be used quickly to diagnose pneumothorax at the bedside in any critical situation, like cardiac arrest and hemodynamically unstable patients. Moreover, it can be used to detect radio-occult pneumothorax and to quantify the extension of the air layer. Advantages in terms of reduced complexity, feasibility at the bedside, and absence of exposure to ionizing radiation make lung ultrasound the method of choice in several common clinical situations.

Sepsis as a cause and consequence of acute kidney injury: Program to Improve Care in Acute Renal Disease

Abstract: Purpose Sepsis commonly contributes to acute kidney injury (AKI); however, the frequency with which sepsis develops as a complication of AKI and the clinical consequences of this sepsis are unknown This study examined the incidence of, and outcomes associated with, sepsis developing after AKI

Mottling score predicts survival in septic shock

Abstract: Experimental and clinical studies have identified a crucial role of microcirculation impairment in severe infections. We hypothesized that mottling, a sign of microcirculation alterations, was correlated to survival during septic shock. We conducted a prospective observational study in a tertiary teaching hospital. All consecutive patients with septic shock were included during a 7-month period. After initial resuscitation, we recorded hemodynamic parameters and analyzed their predictive value on mortality. The mottling score (from 0 to 5), based on mottling area extension from the knees to the periphery, was very reproducible, with an excellent agreement between independent observers [kappa = 0.87, 95% CI (0.72–0.97)]. Sixty patients were included. The SOFA score was 11.5 (8.5–14.5), SAPS II was 59 (45–71) and the 14-day mortality rate 45% [95% CI (33–58)]. Six hours after inclusion, oliguria [OR 10.8 95% CI (2.9, 52.8), p = 0.001], arterial lactate level [ 3 OR 9.6 (2.1–70.6), p = 0.01] and mottling score [score 0–1 OR 1; score 2–3 OR 16, 95% CI (4–81); score 4–5 OR 74, 95% CI (11–1,568), p < 0.0001] were strongly associated with 14-day mortality, whereas the mean arterial pressure, central venous pressure and cardiac index were not. The higher the mottling score was, the earlier death occurred (p < 0.0001). Patients whose mottling score decreased during the resuscitation period had a better prognosis (14-day mortality 77 vs. 12%, p = 0.0005). The mottling score is reproducible and easy to evaluate at the bedside. The mottling score as well as its variation during resuscitation is a strong predictor of 14-day survival in patients with septic shock.

Clinical presentation, management and outcomes in the Acute Heart Failure Global Survey of Standard Treatment (ALARM-HF)

Abstract: We performed a survey on acute heart failure (AHF) in nine countries in four continents. We aimed to describe characteristics and management of AHF among various countries, to compare patients with de novo AHF versus patients with a pre-existing episode of AHF, and to describe subpopulations hospitalized in intensive care unit (ICU) versus cardiac care unit (CCU) versus ward. Data from 4,953 patients with AHF were collected via questionnaire from 666 hospitals. Clinical presentation included decompensated congestive HF (38.6%), pulmonary oedema (36.7%) and cardiogenic shock (11.7%). Patients with de novo episode of AHF (36.2%) were younger, had less comorbidities and lower blood pressure despite greater left ventricular ejection fraction (LVEF) and were more often admitted to ICU. Overall, intravenous (IV) diuretics were given in 89.7%, vasodilators in 41.1%, and inotropic agents (dobutamine, dopamine, adrenaline, noradrenaline and levosimendan) in 39% of cases. Overall hospital death rate was 12%, the majority due to cardiogenic shock (43%). More patients with de novo AHF (14.2%) than patients with a pre-existing episode of AHF (10.8%) (p = 0.0007) died. There was graded mortality in ICU, CCU and ward patients with mortality in ICU patients being the highest (17.8%) (p < 0.0001). Our data demonstrated the existence of different subgroups based on de novo or pre-existing episode(s) of AHF and the site of hospitalization. Recognition of these subgroups might improve management and outcome by defining specific therapeutic requirements.

Neurally adjusted ventilatory assist improves patient–ventilator interaction

Abstract: To determine if, compared with pressure support (PS), neurally adjusted ventilatory assist (NAVA) reduces trigger delay, inspiratory time in excess, and the number of patient–ventilator asynchronies in intubated patients. Prospective interventional study in spontaneously breathing patients intubated for acute respiratory failure. Three consecutive periods of ventilation were applied: (1) PS1, (2) NAVA, (3) PS2. Airway pressure, flow, and transesophageal diaphragmatic electromyography were continuously recorded. All results are reported as median (interquartile range, IQR). Twenty-two patients were included, 36.4% (8/22) having obstructive pulmonary disease. NAVA reduced trigger delay (ms): NAVA, 69 (57–85); PS1, 178 (139–245); PS2, 199 (135–256). NAVA improved expiratory synchrony: inspiratory time in excess (ms): NAVA, 126 (111–136); PS1, 204 (117–345); PS2, 220 (127–366). Total asynchrony events were reduced with NAVA (events/min): NAVA, 1.21 (0.54–3.36); PS1, 3.15 (1.18–6.40); PS2, 3.04 (1.22–5.31). The number of patients with asynchrony index (AI) >10% was reduced by 50% with NAVA. In contrast to PS, no ineffective effort or late cycling was observed with NAVA. There was less premature cycling with NAVA (events/min): NAVA, 0.00 (0.00–0.00); PS1, 0.14 (0.00–0.41); PS2, 0.00 (0.00–0.48). More double triggering was seen with NAVA, 0.78 (0.46–2.42); PS1, 0.00 (0.00–0.04); PS2, 0.00 (0.00–0.00). Compared with standard PS, NAVA can improve patient–ventilator synchrony in intubated spontaneously breathing intensive care patients. Further studies should aim to determine the clinical impact of this improved synchrony.

Non-invasive ventilation in postoperative patients: a systematic review

Abstract: Postoperative pulmonary complications, generally defined as any pulmonary abnormality occurring in the postoperative period, are still a significant issue in clinical practice increasing hospital length of stay, morbidity and mortality. Non-invasive ventilation (NIV), primarily applied in cardiogenic pulmonary edema, decompensated COPD and hypoxemic pulmonary failure, is nowadays also used in perioperative settings. Investigate the application and results of preventive and therapeutic NIV in postsurgical patients. A systematic review. Medical literature databases were searched for articles about “clinical trials,” “randomized controlled trials” and “meta-analyses.” The keywords “cardiac surgery,” “thoracic surgery,” “lung surgery,” “abdominal surgery,” “solid organ transplantation,” “thoraco-abdominal surgery” and “bariatric surgery” were combined with any of these: “non-invasive positive pressure ventilation,” “continuous positive airway pressure,” “bilevel ventilation,” “postoperative complications,” “postoperative care,” “respiratory care,” “acute respiratory failure,” “acute lung injury” and “acute respiratory distress syndrome.” Twenty-nine articles (N = 2,279 patients) met the inclusion criteria. Nine studies evaluated NIV in post-abdominal surgery, three in thoracic surgery, eight in cardiac surgery, three in thoraco-abdominal surgery, four in bariatric surgery and two in post solid organ transplantation used both for prophylactic and therapeutic purposes. NIV improved arterial blood gases in 15 of the 22 prophylactic and in 4 of the 7 therapeutic studies, respectively. NIV reduced the intubation rate in 11 of the 29 studies and improved outcome in only 1. Despite these limited data and the necessity of new randomized trials, NIV could be considered as a prophylactic and therapeutic tool to improve gas exchange in postoperative patients.

Short-term survival by treatment among patients hospitalized with acute heart failure: the global ALARM-HF registry using propensity scoring methods

Abstract: To date, treatment with intravenous (IV) agents such as vasodilators, diuretics, and inotropes has shown marginal or mixed benefits in acute heart failure (AHF) trials. The aim of this study was to identify the risks and benefits of IV drugs in patients hospitalized with acute decompensated heart failure. The AHF global survey of standard treatment (ALARM-HF) reviewed in-hospital treatments in eight countries. The present study was a post hoc analysis of ALARM-HF data in which propensity scoring was used to identify groups of patients who differed by treatment but had the same multivariate distribution of covariates. Such propensity matching allowed estimations of the effect of specific treatments on the outcome of in-hospital mortality. Unadjusted analysis showed a lower in-hospital mortality rate in AHF patients receiving “diuretics + vasodilators” (n = 1,805) compared to those receiving “diuretics alone” (n = 2,362) (7.6 vs. 14.2%, p 2.5-fold increase for norepinephrine or epinephrine use. In terms of in-hospital survival, a vasodilator in combination with a diuretic fared better than treatment with only a diuretic. Catecholamine inotropes should be used cautiously as it has been seen that they actually increase the risk for in-hospital mortality.

Use of early corticosteroid therapy on ICU admission in patients affected by severe pandemic (H1N1)v influenza A infection

Abstract: Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza A infection, although relatively common, remains controversial. Prospective, observational, multicenter study from 23 June 2009 through 11 February 2010, reported in the European Society of Intensive Care Medicine (ESICM) H1N1 registry. Two hundred twenty patients admitted to an intensive care unit (ICU) with completed outcome data were analyzed. Invasive mechanical ventilation was used in 155 (70.5%). Sixty-seven (30.5%) of the patients died in ICU and 75 (34.1%) whilst in hospital. One hundred twenty-six (57.3%) patients received corticosteroid therapy on admission to ICU. Patients who received corticosteroids were significantly older and were more likely to have coexisting asthma, chronic obstructive pulmonary disease (COPD), and chronic steroid use. These patients receiving corticosteroids had increased likelihood of developing hospital-acquired pneumonia (HAP) [26.2% versus 13.8%, p < 0.05; odds ratio (OR) 2.2, confidence interval (CI) 1.1–4.5]. Patients who received corticosteroids had significantly higher ICU mortality than patients who did not (46.0% versus 18.1%, p < 0.01; OR 3.8, CI 2.1–7.2). Cox regression analysis adjusted for severity and potential confounding factors identified that early use of corticosteroids was not significantly associated with mortality [hazard ratio (HR) 1.3, 95% CI 0.7–2.4, p = 0.4] but was still associated with an increased rate of HAP (OR 2.2, 95% CI 1.0–4.8, p < 0.05). When only patients developing acute respiratory distress syndrome (ARDS) were analyzed, similar results were observed. Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza A infection did not result in better outcomes and was associated with increased risk of superinfections.

Serum procalcitonin as a diagnostic marker for neonatal sepsis: a systematic review and meta-analysis.

Abstract: To assess the value of serum procalcitonin (PCT) for the differentiation between patients with and without neonatal sepsis. We systematically searched PubMed, Scopus, and the Cochrane Library for studies evaluating PCT in neonatal sepsis. PCT had to be measured in neonatal blood samples, at the initial presentation of patients with suspected sepsis, before the administration of antibiotics. We performed a bivariate meta-analysis of sensitivity and specificity, and constructed a hierarchical summary receiver-operating characteristic (HSROC) curve. Overall, 29 studies eligible for inclusion were identified. We analyzed the 16 studies (involving 1,959 neonates) that evaluated PCT in neonates with culture-proven or clinically diagnosed sepsis in comparison with ill neonates with other conditions. The pooled (95% confidence interval) sensitivity and specificity were 81% (74–87%) and 79% (69–87%), respectively. The area under the HSROC curve (AUC) was 0.87. The diagnostic accuracy of PCT seemed higher for neonates with late-onset sepsis (>72 h of life) than for those with early onset sepsis; the AUC for these analyses was 0.95 and 0.78, respectively. However, fewer data were available for late-onset sepsis. High statistical heterogeneity was observed for all analyses. Our findings suggest that serum PCT at presentation has very good diagnostic accuracy (AUC = 0.87) for the diagnosis of neonatal sepsis. However, in view of the marked observed statistical heterogeneity, along with the lack of a uniform definition for neonatal sepsis, the interpretation of these findings should be done with appropriate caution.

Diagnostic accuracy of Doppler renal resistive index for reversibility of acute kidney injury in critically ill patients.

Abstract: Diagnosing persistent acute kidney injury (AKI) as opposed to transient AKI in critically ill patients may help physicians in making treatment decisions. This diagnosis relies chiefly on urinary indices, which may be of limited value or difficult to obtain. We assessed the performance of the Doppler renal resistive index (RI) in diagnosing persistent AKI. Prospective observational study. Twenty-four-bed medical intensive care unit in a university hospital. Consecutive patients requiring mechanical ventilation, without severe chronic renal dysfunction or receiving diuretic therapy. Persistent AKI was defined as AKI lasting longer than 3 days. AKI resolving within 3 days in a patient with a cause of renal hypoperfusion was considered to be transient AKI. Results are reported as median values with interquartile range (IQR). Of the 51 patients enrolled in the study, 16 had no AKI, 13 had transient AKI, and 22 had persistent AKI. The RI was 0.71 (0.66–0.77) in the no-AKI group, 0.71 (0.62–0.77) in the transient AKI group, and 0.82 (0.80–0.89) in the persistent AKI group (P 0.795 had a 92% sensitivity and 85% specificity for persistent AKI. Logistic regression analysis revealed that an RI > 0.795 [odds ratio (OR) 28.2; 95% CI 4.0–198] and a higher logistic organ dysfunction score (OR 1.85/point; 95% CI 1.20–2.85) predicted persistent AKI. These preliminary results suggest that Doppler renal RI may be a promising tool for predicting the reversibility of AKI in critically ill patients.

Weight-based determination of fluid overload status and mortality in pediatric intensive care unit patients requiring continuous renal replacement therapy

Abstract: Purpose In pediatric intensive care unit (PICU) patients, fluid overload (FO) at initiation of continuous renal replacement therapy (CRRT) has been reported to be an independent risk factor for mortality. Previous studies have calculated FO based on daily fluid balance during ICU admission, which is labor intensive and error prone. We hypothesized that a weight-based definition of FO at CRRT initiation would correlate with the fluid balance method and prove predictive of outcome.

Long-term sedation in intensive care unit: a randomized comparison between inhaled sevoflurane and intravenous propofol or midazolam

Abstract: Purpose To evaluate efficacy and adverse events related to inhaled sevoflurane for long-term sedation compared with standard intravenous (IV) sedation with propofol or midazolam.

Circulating high sensitivity troponin T in severe sepsis and septic shock: distribution, associated factors, and relation to outcome.

Abstract: Purpose To assess the clinical utility of a recently developed highly sensitive cardiac troponin T (hs-cTnT) assay for providing prognostic information on patients with sepsis.

The effect of etomidate on adrenal function in critical illness: a systematic review.

Abstract: Purpose Although etomidate is a preferred anesthetic agent for rapid sequence intubation (RSI) in critical illness, as an inhibitor of cortisol synthesis (11β-hydroxylase), it may be associated with adrenal dysfunction. The objectives are to review the effects of etomidate versus comparator anesthetics in critical illness for: primary outcome of mortality and secondary outcome of adrenal insufficiency (AI).

The obesity paradox in surgical intensive care unit patients

Abstract: Purpose To investigate the possible impact of obesity, as assessed by body mass index (BMI), on outcome in surgical intensive care unit (ICU) patients.

Clinicians' response to hyperoxia in ventilated patients in a Dutch ICU depends on the level of FiO2.

Abstract: Purpose Hyperoxia may induce pulmonary injury and may increase oxidative stress. In this retrospective database study we aimed to evaluate the response to hyperoxia by intensivists in a Dutch academic intensive care unit.

Severity assessment tools to guide ICU admission in community-acquired pneumonia: systematic review and meta-analysis.

Abstract: The aim of this meta-analysis was to determine if severity assessment tools can be used to guide decisions regarding intensive care unit (ICU) admission of patients with community-acquired pneumonia. A search of PUBMED and EMBASE (1980–2009) was conducted to identify studies reporting pneumonia severity scores and prediction of ICU admission. Two reviewers independently collected data and assessed study quality. Performance characteristics were pooled using a random-effects model. Sufficient data were collected to perform a meta-analysis on five current scoring systems: the Pneumonia Severity Index (PSI), the CURB65 score, the CRB65 score, the American Thoracic Society (ATS) 2001 criteria and the Infectious Disease Society of America/ATS (IDSA/ATS) 2007 criteria. The analysis was limited due to large variations in the ICU admission criteria, ICU admission rates and patient characteristics between different studies and different healthcare systems. In the pooled analysis, PSI, CURB65 and CRB65 performed similarly in terms of sensitivity and specificity across a range of cut-offs. Patients in CURB65 group 0 were at lowest risk of ICU admission (negative likelihood ratio 0.14; 95% confidence interval 0.06–0.34) while the ATS 2001 criteria had the highest positive likelihood ratio (7.05; 95% confidence interval 4.39–11.3). Large variations exist in the use of ICU resources between different studies and different healthcare systems. Scoring systems designed to predict 30-day mortality perform less well when ICU admission is taken into account. Further studies of dedicated ICU admission scores are required.

Glucose variability measures and their effect on mortality: a systematic review

Abstract: Objective To systematically review the medical literature on the association between glucose variability measures and mortality in critically ill patients.