Journal of Critical Care

2011—year in review

Philip D. Lumb — 2012-02-01

The year 2011 marked the first year the Journal of Critical Care published on a bimonthly schedule. This, coupled with an increased page allocation and accelerated submission rate, has created a robust and increasingly visible publication that depends upon its volunteer reviewers to succeed. Therefore, it is not only appropriate and fitting but also a pleasure and responsibility to thank the Journal's nine hundred fifty-eight completed reviews (out of 2024 invitations) 2011 reviewers for their expert commentaries, unstinting commitment to excellence, and selfless dedication to the concept that peer review is one of the highest forms of academic commitment and a bastion of journalistic integrity. This year has seen a number of challenges to the reputation of the process, but despite several high profile examples of malfeasance, the overall regard for journalistic provenance remains high, and its viability is assured. Please review the names of this year's reviewers and, with all of us at Elsevier, thank them for their commitment to academic excellence and publishing integrity.

Health-care system distrust in the intensive care unit

Yael Schenker, Douglas B. White, David A. Asch, Jeremy M. Kahn — 2011-06-29

Abstract: Purpose: To examine the performance and properties of the Revised Health Care System Distrust Scale among surrogates in the intensive care unit (ICU).Materials and Methods: Pilot, prospective cohort study of 50 surrogates of adult, mechanically ventilated patients surveyed on days 1, 3, and 7 of ICU admission.Results: Responses on the Health Care System Distrust Scale on day 1 ranged from 9 to 34 (possible range 9-45, with higher scores indicating more distrust), with a mean and SD of 20.3 ± 6.9. Factor analysis demonstrated a 2-factor structure, corresponding to the domains of values and competence. Cronbach α for the overall scale was .83, for the competence subscale, .76, and for the values subscale, .74. Health-care system distrust was inversely correlated with trust in ICU physicians (Pearson coefficient −.63). When evaluated over the course of each patient's ICU stay, health-care system distrust ratings decreased by 0.31 per patient-day (95% CI 0.55-0.06, P = .015). Correlation between health-care system distrust and trust in ICU physicians decreased slightly over time.Conclusions: Among surrogates in the ICU, the Health Care System Distrust Scale has high internal consistency and convergent validity. There was substantial variability in surrogates' trust in the health-care system.

Organizational and safety culture in Canadian intensive care units: Relationship to size of intensive care unit and physician management model

2011-09-29

Abstract: Purpose: The objectives of this study are to describe organizational and safety culture in Canadian intensive care units (ICUs), to correlate culture with the number of beds and physician management model in each ICU, and to correlate organizational culture and safety culture.Materials and Methods: In this cross-sectional study, surveys of organizational and safety culture were administered to 2374 clinical staff in 23 Canadian tertiary care and community ICUs. For the 1285 completed surveys, scores were calculated for each of 34 domains. Average domain scores for each ICU were correlated with number of ICU beds and with intensivist vs nonintensivist management model. Domain scores for organizational culture were correlated with domain scores for safety culture.Results: Culture domain scores were generally favorable in all ICUs. There were moderately strong positive correlations between number of ICU beds and perceived effectiveness at recruiting/retaining physicians (r = 0.58; P < .01), relative technical quality of care (r = 0.66; P < .01), and medical director budgeting authority (r = 0.46; P = .03), and moderately strong negative correlations with frequency of events reported (r = −0.46; P = .03), and teamwork across hospital units (r = −0.51; P = .01). There were similar patterns for relationships with intensivist management. For most pairs of domains, there were weak correlations between organizational and safety culture.Conclusion: Differences in perceptions between staff in larger and smaller ICUs highlight the importance of teamwork across units in larger ICUs.

Ventilator-associated pneumonia is an important risk factor for mortality after major cardiac surgery

2011-05-19

Abstract: Purpose: Ventilator-associated pneumonia (VAP) is the main infectious complication in cardiac surgery patients and is associated with an important increase in morbidity and mortality. The aim of our study was to analyze the impact of VAP on mortality excluding other comorbidities and to study its etiology and the risk factors for its development.Materials and Methods: This prospective cohort study included 1610 postoperative cardiac surgery patients' status post cardiopulmonary bypass (CPB) between July 2004 and January 2008. The primary outcome measures were the development of VAP and in-hospital mortality.Results: Ventilator-associated pneumonia was observed in 124 patients (7.7%). Patients with VAP had a longer length of hospitalization (40.7 ± 35.1 vs 16.1 ± 30.1 days, P < .0001) and greater in-hospital mortality (49.2% [61/124] vs 2.0% [30/1486], P = .0001) in comparison with patients without VAP. After performing the Cox multivariant analysis adjustment, VAP was identified as the most important independent mortality risk factor (adjusted hazard ratio [HR], 8.53; 95% confidence interval, 4.21-17.30; P = .0001). Other independent risk factors of in-hospital mortality were chronic renal failure (HR, 2.56), diabetes mellitus (HR, 1.90), CPB time (HR, 1.51), respiratory failure (HR, 2.13), acute renal failure (HR, 2.39), and mediastinal bleeding of at least 1000 mL (HR, 1.81).Conclusions: The development of VAP after CPB is the most important independent risk factor for in-hospital mortality. Identification of effective strategies for the prevention of VAP is needed.

Comparison of ventilator-associated pneumonia (VAP) rates between different ICUs: Implications of a zero VAP rate

Krishna M. Sundar, David Nielsen, Paul Sperry — 2011-07-07

Abstract: Objective: Ventilator-associated pneumonia (VAP) is associated with significant morbidity and mortality. Measures to reduce the incidence of VAP have resulted in institutions reporting a zero or near-zero VAP rates. The implications of zero VAP rates are unclear. This study was done to compare outcomes between two intensive care units (ICU) with one of them reporting a zero VAP rate.Design, Setting and Patients: This study retrospectively compared VAP rates between two ICUs: Utah Valley Regional Medical Center (UVRMC) with 25 ICU beds and American Fork Hospital (AFH) with 9 ICU beds. Both facilities are under the same management and attended by a single group of intensivists. Both ICUs have similar nursing and respiratory staffing patterns. Both ICUs use the same intensive care program for reduction of VAP rates. ICU outcomes between AFH (reporting zero VAP rate) and UVRMC (VAP rate of 2.41/1000 ventilator days) were compared for the years 2007-2008.Measurements and Main Results: UVRMC VAP rates during 2007 and 2008 were 2.31/1000 ventilator days and 2.5/1000 ventilator days respectively compared to a zero VAP rate at AFH. The total days of ventilation, mean days of ventilation per patient and mean duration of ICU stay per patient was higher in the UVRMC group as compared to AFH ICU group. There was no significant difference in mean age and APACHE II score between ICU patients at UVRMC and AFH. There was no statistical difference in rates of VAP and mortality between UVRMC and AFH.Conclusions: During comparisons of VAP rate between institutions, a zero VAP rate needs to be considered in the context of overall ventilator days, mean durations of ventilator stay and ICU mortality.

Hemodynamic effects of positive end-expiratory pressure during abdominal hyperpression: A preliminary study in healthy volunteers

2011-04-22

Abstract: Purpose: An increase in abdominal pressure induces an increase in left ventricular afterload under clinical conditions. We tested the hypothesis that positive end-expiratory pressure (PEEP) could reverse the hemodynamic consequences of abdominal hyperpression by opposing the increase in left ventricular afterload.Materials and methods: Eight healthy volunteers were investigated during 3 experimental conditions: (1) baseline, (2) increase in abdominal pressure by means of medical antishock trousers (MAST) inflation, and (3) addition of PEEP +10 cm H2O. Heart loading conditions and left ventricular systolic and diastolic function were assessed by transthoracic echocardiography.Results: The application of PEEP significantly reduced the prior increase in end-systolic wall stress: 45 ± 11 vs 55 ± 14 kdyn/cm2, P < .05. Medical antishock trousers inflation significantly altered the deceleration time of mitral E wave: 199 ± 23 vs 156 ± 38 milliseconds, P < .05. Left ventricular preload and global systolic performance were unaffected by MAST and PEEP applications.Conclusions: The increase in left ventricular afterload induced by MAST inflation can be efficiently reduced by the use of a moderate PEEP. Potential clinical applications in the abdominal compartment syndrome or in the setting of laparoscopic surgery should be developed.

Manual compression of the abdomen to assess expiratory flow limitation during mechanical ventilation

Malcolm Lemyze, Raphael Favory, Isabelle Alves, Thierry Perez, Daniel Mathieu — 2011-07-28

Abstract: Purpose: The aim of this study was to evaluate the manual compression of the abdomen (MCA) during expiration as a simple bedside method to detect expiratory flow limitation (EFL) during daily clinical practice of mechanical ventilation (MV).Methods: We studied 44 semirecumbent intubated and sedated critically ill patients. Flow-volume loops obtained during MCA were superimposed upon the preceding breaths and recorded with the ventilator. Expiratory flow limitation was expressed as percentage of expiratory tidal volume without any increase in flow during MCA (MCA [%VT]). In the first 13 patients, MCA was validated by comparison with the negative expiratory pressure (NEP) technique. Esophageal pressure changes during MCA and intrinsic positive end-expiratory pressure were also recorded in all the patients.Results: Manual compression of the abdomen and NEP agreed in all cases in detecting EFL with a bias of −0.16%. Percentage of expiratory tidal volume without any increase in flow during MCA is highly correlated with percentage of expiratory tidal volume without any increase in flow during NEP (n = 13, P < .0001, r2 = 0.99) and intrinsic positive end-expiratory pressure (n = 44, P < .001, r2 = 0.78), with a good repeatability (n = 44; within-subject SD, 5.7%) and reproducibility (n = 13; within-subject SD, 2.41%). Two third of the patients were flow limited, among whom one third had no previously known respiratory disease.Conclusions: Manual compression of the abdomen provides a simple, rapid, and safe bedside reliable maneuver to detect and quantify EFL during mechanical ventilation.

Effect of an antibiotic algorithm on the adequacy of empiric antibiotic therapy given by a medical emergency team

2011-07-28

Abstract: Introduction: Delayed administration of effective antimicrobial therapy increases mortality in patients with septic shock. Empiric antibiotic selection in this setting can be inaccurate. The objective of this study was to determine whether an antibiotic algorithm (AA) tailored to institutional resistance patterns improves the adequacy of antimicrobial therapy.Methods: A retrospective review of our rapid response system database was performed. Patients with possible sepsis with positive microbiological culture results were enrolled. Pathogens identified by culture were used to determine adequacy of antibiotic selection before and after implementation of an AA.Results: A total of 234 patients with septic shock were reviewed (before AA, n = 36; after AA, n = 198). Seventy-two patients had positive cultures and were enrolled (before AA, n = 13; after AA, n = 59). Significantly more patients received adequate coverage after AA implementation (54% vs 86%, P = .02). Before AA, inadequate Gram-negative coverage was the most common reason for failure. Reasons for failure in the after-AA group were nonadherence to the algorithm (n = 5) and multidrug-resistant pathogens (n = 3). The algorithm failed in patients with vancomycin-resistant enterococci (n = 3), multidrug-resistant Klebsiella pneumoniae (n = 1), and Candida albicans (n = 1).Conclusions: The use of an AA significantly improves the adequacy of empiric antimicrobial therapy.

Outcomes for critically ill patients with HIV and severe sepsis in the era of highly active antiretroviral therapy

Jared A. Greenberg, Jeffrey L. Lennox, Greg S. Martin — 2011-10-28

Abstract: Rationale: With the advent of highly active antiretroviral therapy (HAART), sepsis has become a more frequent ICU diagnosis for patients with HIV infections. Yet, little is known about the etiologies of acute infections in critically ill patients with HIV and the factors that affect in-hospital mortality.Methods: Cases of patients with HIV requiring intensive care specifically for severe sepsis were identified over 27 months. Demographic information, variables related to acute illness severity, variables related to HIV infection, and all acute infections contributing to ICU stay were recorded.Results: Of 990 patients admitted to the ICU with severe sepsis, 136 (13.7%) were HIV-infected. There were 194 acute infections among the 125 patients with full data available; 112 of the infections were nosocomial/health care–associated, 55 were AIDS-related, and 27 were community-acquired. Patients with nosocomial/health care–associated and AIDS-related infections had lower CD4 counts and were less likely to be on HAART (P < .05). The inpatient mortality was 42%. In a multivariable logistic regression model, only the APACHE II score (odds ratio, 1.12; 95% confidence interval, 1.02-1.23) was significantly associated with hospital mortality, although any HAART use (odds ratio, 0.53; 95% confidence interval, 0.22-1.33, P = .18) approached statistical significance.Conclusions: In this large cohort study, nosocomial/health care–associated infections were common in ICU patients with HIV and severe sepsis. Hospital mortality was associated with acute illness severity, but not clearly associated with variables related to HIV infection. Interventions that aim to prevent or more effectively treat nosocomial infections in critically ill patients with HIV may favorably impact clinical outcomes.

Time spent in the emergency department and mortality rates in severely injured patients admitted to the intensive care unit: An observational study

2011-09-29

Abstract: Purpose: The aim of this study was to identify the determinants of a shorter emergency department time (EDt) in patients with severe trauma (STPs) admitted to the intensive care unit and determine whether EDt influences mortality.Patients and Methods: A prospective observational study of STPs (2005-2007) was conducted. With the variables available from the ED, 2 multiple logistic regression models (MLRM) were created: one for the factors associated with EDt less than or equal to median and the other with mortality.Results: A total of 243 patients were included. The mean age was 43 years; 76% were male. The overall mortality rate was 20%. The median EDt was 120 minutes. The independent factors that were associated with the MLRM for an EDt of 120 minutes or less included age less than 60 years, mechanical ventilation, severe traumatic brain injury, and a trauma and injury severity score of 20 or higher. The MLRM for mortality was age greater than 60 years, mechanical ventilation, traumatic brain injury and shock. An EDt of 120 minutes or less was associated with an increased risk of death in the univariate analysis but not in the MLRM.Conclusions: Patients in the ED with indicators of high trauma severity have a reduced EDt but a higher mortality rate. Advanced age increases both mortality and EDt. With the factors included in the model, EDt was not an independent factor for mortality in STPs.

Peak postoperative troponin levels outperform preoperative cardiac risk indices as predictors of long-term mortality after vascular surgery: Troponins and postoperative outcomes

2011-07-28

Abstract: Background: The utility of postoperative troponins as an independent predictor of long-term mortality after vascular surgery is unknown.Methods: One hundred sixty-four consecutive patients underwent vascular surgery and postoperative mortality was determined at 2.5 years. Troponins were drawn within 48 hours postsurgery and the peak levels, defined by the upper reference limit (URL), were categorized as negative (

Short-term prognosis of critically ill surgical patients: The impact of duration of invasive organ support therapies

2011-07-07

Abstract: Purpose: We wanted to identify the importance of the duration of invasive ventilation and of renal replacement therapy for short-term prognosis of surgical patients treated in an intensive care unit (ICU).Methods: We analyzed adult patients (n = 1462) who had an ICU length of stay of more than 4 days and who were followed up until the end of the short-term phase after ICU admission. Duration of different invasive therapies was evaluated by constructing specific vectors that tested effects of time-dependent variables on outcome after a lag time of 7 days.Measurements and Main Results: Eight hundred eight patients (56.6%) were still alive at the end of the short-term phase. During the short-term phase, 85.3% of the 1462 patients required invasive ventilation, and 16.1%, a continuous renal replacement therapy. Besides the underlying disease and disease severity at ICU admission, the need for invasive ventilation or renal replacement therapy was associated with poorer outcome. Duration of invasive ventilation shortened survival if treatment lasted for more than 11 days (nonlinear association). In contrast, duration of renal replacement therapy was unimportant for short-term prognosis.Conclusion: Prolonged duration of invasive ventilation but not of renal replacement therapy is inversely related to short-term survival.

Cerebral perfusion pressure, microdialysis biochemistry, and clinical outcome in patients with spontaneous intracerebral hematomas

2011-06-24

Abstract: Purpose: The aim of our study was to investigate the roles of cerebral perfusion pressure (CPP) and microdialysis marker values on the clinical outcome of patients with spontaneous intracerebral hematoma.Materials and Methods: Twenty-seven patients (18 men; mean ± SD age, 54.17 ± 10.05 years; 9 women, mean ± SD age, 65.00 ± 4.24 years) with a GCS of 8 or less upon admission were included in this study. After a 6-month follow-up period, a linear regression model was applied to evaluate the outcomes using the Glasgow Outcome Scale (GOS).Results: Of the 27 patients, 16 died within the first 6 months after discharge from the hospital. Six patients had a favorable prognosis after 6 months. In the patients who had a favorable outcome (GOS = 4 or GOS = 5), the CPP was above 75.46 mm Hg, and intracranial pressure was below 14.21 mm Hg. No patient with a favorable prognosis had a lactate-pyruvate (L/P) ratio greater than 37.40. An inverse linear relationship was found among the L/P ratio, the CPP, and patient outcome.Conclusion: The L/P ratio and CPP were found to be related to patient outcome. In addition, a CPP greater than 75.46 mm Hg and an L/P ratio lower than 37.40 mm Hg were related to a favorable outcome.

Exercise testing in survivors of intensive care—is there a role for cardiopulmonary exercise testing?

Steve Benington, David McWilliams, Jane Eddleston, Dougal Atkinson — 2011-09-29

Abstract: Purpose: The aims of this study were to assess the feasibility of cardiopulmonary exercise testing (CPET) for the early assessment of cardiorespiratory fitness in general adult intensive care unit (ICU) survivors and to characterize the pathophysiology of exercise limitation in this population.Methods: Fifty general ICU survivors (ventilated for ≥5 days) performed a maximal cycle ergometer CPET within 6 weeks of hospital discharge. Health-related quality of life was measured by the Medical Outcome Study Short Form 36 version 2.0 questionnaire.Results: Fifty patients (median age, 57 years; median Acute Physiology And Chronic Health Evaluation II score, 16) completed a CPET 24 ± 14 days after hospital discharge with no adverse events. Significant exercise limitation was present with peak Vo2 56% ± 16% predicted and anaerobic threshold (AT) 41% ± 13% of peak predicted Vo2. Prospectively stratified subgroup comparison showed that patients ventilated for 14 days or more had a significantly lower AT and peak Vo2 than those ventilated for 5 to 14 days (AT: 9.6 vs 11.7 mL/kg per minute O2, P = .009; peak Vo2: 12.9 vs 15.3 mL/kg per minute O2, P = .022). At peak exercise, heart rate reserve was 25% ± 14%, breathing reserve was 47% ± 19%, and the respiratory exchange ratio was 0.96 ± 0.11. Ventilatory equivalents for CO2 (Eqco2) were 39 ± 9.Conclusions: Significant exercise limitation is evident in patients who have had critical illness. Etiology of exercise limitation appears multifactorial, with general deconditioning and muscle weakness as major contributory factors. Early CPET appears a practical method of assessing exercise capacity in ICU survivors. Cardiopulmonary exercise testing could be used to select patients who may benefit most from a targeted physical rehabilitation program, aid in exercise prescription, and help assess the response to intervention.

Palliative care in a neonatal intensive care unit

Jeffrey I. Gold, Lara P. Nelson — 2011-07-28

In this issue of Journal of Critical Care, Peng et al present the results of a retrospective chart review of infants who received end-of-life care in a neonatal intensive care unit (NICU) during their last week of life. This article highlights the increasing importance of palliative care throughout the spectrum of medical care offered to patients, regardless of age. The authors recognize and highlight that palliation in the NICU is an understudied area.

2011 Reviewers

2012-02-01

Zinc supplementation in intensive care: Results of a UK survey

Andrew Duncan, Pamela Dean, Malcolm Simm, Denis StJ. O'Reilly, John Kinsella — 2011-09-29

Abstract: Purpose: Our laboratory receives many routine requests for plasma zinc analysis from intensive care units (ICUs) throughout Scotland. However, such requests are inappropriate because plasma zinc concentrations fall independently of nutritional deficiency during the systemic inflammatory response and, therefore, in critically ill patients. This survey was performed to investigate how widespread this practice was and if low plasma zinc concentrations were interpreted as zinc deficiency so triggering inappropriate initiation of zinc supplementation.Materials and Methods: A questionnaire was sent to ICUs throughout the UK; nonresponders were contacted by telephone, and the questionnaire details were recorded. The questionnaire asked if plasma zinc was routinely requested, the frequency of requests, whether patients were supplemented with zinc, and if so, the grounds for supplementation and the dose given.Results: Plasma measurement of zinc was routinely performed in 18% of UK ICUs. Zinc supplementation was given in 10%, usually as a result of finding low plasma zinc concentrations. Dosages of supplementation varied widely between ICUs: from 0.4 to 135 mg zinc per day. Approximately 6% of ICUs gave very high supplements of zinc of 90 and 135 mg/d.Conclusions: The finding of a low plasma zinc concentration in Intensive Therapy Unit patients is often misinterpreted as indicating zinc deficiency and inappropriately prompts zinc supplementation. There is no evidence base to support high-dose zinc supplementation in ICU patients. This practice is justifiable only if future randomized trials demonstrate a benefit.

To explore the conditions of dying infants in NICU in Taiwan

Niang-Huei Peng, Chao-Huei Chen, Hsin-Li Liu, Ho-Yu Lee — 2011-05-19

Abstract: Purposes: Research purposes were to document the symptoms characteristic of neonates during their last week of life and to describe the activities undertaken in nursing care of dying neonates in neonatal intensive care unit (NICU).Methods: A retrospective chart review was used in this research. All charts of neonatal inpatients who died in the NICU between 2002 and 2008 and who met entry criteria were included the research review.Results: Sixty-one charts were evaluated in this research. The major underlying disease was the complications of prematurity (33%). Major physiological distress signs in the last week of life included respiratory distress (67.2%), cyanosis (54.1%), bradycardia (36.1%), oliguria (31.1%), and generalized edema (37.7%). All infants were intubated and received artificial ventilation in the last week of life. Physicians prescribed an analgesic medicine for 7 infants, and 7 infants received comfort interventions to manage their distress signs. Forty-one infants had preexisting do-not-resuscitate order at the time of death.Conclusions: Research findings suggest that the application of palliative care paradigm and more aggressive comfort care to manage signs in NICU might be beneficial to dying infants.

Earthquake-related injuries: Evaluation with multidetector computed tomography and digital radiography of 1491 patients

2011-04-22

Abstract: Purpose: The aim of this study was to evaluate the common features of earthquake-related injuries using radiography and computed tomography.Materials and Methods: We retrospectively reviewed the radiography and multidetector computed tomography features of 1491 patients injured in 2008 Sichuan earthquake. We categorized patients by age group (<35, 35-64, and ≥65 years) and time to imaging. Injuries were categorized by anatomical distribution.Results: We detected earthquake-related trauma in 1197 patients (80.28%), including head injuries, facial fractures, thoracic injuries, abdominal injuries, pelvic fractures, spinal injuries, and extremity fractures in 91, 41, 354, 30, 204, 299, and 732 (61.15%) patients, respectively (χ2 = 1844.747, P < .001). Injuries in 2 or more anatomical locations occurred in 384 cases. We discovered significant difference in the anatomical distribution of injuries among the 3 age groups (χ2 = 104.113, P < .001) and among the time-to-imaging categories (χ2 = 64.420, P < .001). Twenty-two patients (1.48%) eventually died. Abdominal injuries (B = 2.285, P = .004), head injuries (B = 2.194, P < .001), thoracic injuries (B = 1.989, P < .001), and age (B = 1.539, P < .001) were all associated with patient death.Conclusions: The Sichuan earthquake most commonly resulted in extremity fractures, but there was a high incidence of injuries to multiple body areas. Head, abdominal, and thoracic injuries and age older than 64 years all were significant risk factors for earthquake mortality.

Effect of attachment styles of individuals discharged from an intensive care unit on intensive care experience

Nurten Kaya — 2011-07-07

Abstract: Introduction: The present study was conducted as a cross-sectional type to examine the effect of attachment styles of individuals discharged from an intensive care unit (ICU) on intensive care experience and health status.Methods: The population of the study included patients discharged from the ICU in a university hospital. The sample included 108 patients who were selected via simple random sampling method. Data were collected using a Demographic Information Questionnaire, Intensive Care Experience Questionnaire, the Relationship Scales Questionnaire, and Acute Physiology and Chronic Health Evaluation II system. In the analysis of data, frequency, percentage, mean, standard deviation, minimum and maximum values, and Mann-Whitney U, Kruskal-Wallis, Bonferroni-adjusted Mann-Whitney, and Spearman ρ correlation tests were used.Results: A significant difference in the awareness of surroundings subscale for attachment styles was noted (χ2 = 10.820, P ≤ .01). Moreover, participants' attachment styles (fearful, preoccupied, and dismissing) and intensive care experience were significantly correlated. A significant correlation was found between participants' secure attachment style points and Acute Physiology and Chronic Health Evaluation II score during discharge from the ICU (r = 0.322, P = .001).Conclusion: Individuals' attachment styles should be taken into consideration when planning and implementing the nursing care and treatment of individuals hospitalized in an ICU.

Analysis of progression in risk, injury, failure, loss, and end-stage renal disease classification on outcome in patients with severe sepsis and septic shock

Won Young Kim, Jin Won Huh, Chae-Man Lim, Younsuck Koh, Sang-Bum Hong — 2011-06-29

Abstract: Introduction: A few studies have assessed risk, injury, failure, loss, and end-stage renal disease (RIFLE) criteria in patients with severe sepsis and septic shock, a setting in which acute kidney injury (AKI) is common and dramatically worsens outcome.Methods: Study subjects included all consecutive patients with severe sepsis and septic shock who had been admitted to the medical intensive care unit between January 2005 and December 2006.Results: Of 326 patients admitted during the study period, 291 were included. According to RIFLE criteria, 204 patients (70.1%) had AKI (risk, 26.1%; injury, 26.5%; failure, 17.5%) on admission. Overall, 28-day mortality rate was 48.5%. Mortality was not associated with admission RIFLE (risk, 44.7%; injury, 53.2%; failure, 51.0%; P = .58). However, maximum RIFLE was associated with increased 28-day mortality (P < .01). After adjustment for age, sex, Acute Physiology and Chronic Health Evaluation II score, and Sequential Organ Failure Assessment score, independent risk factors for 28-day mortality were newly developed AKI (odds ratio [OR], 11.4; P < .01), progression of RIFLE risk to higher RIFLE class (OR, 14.5; P < .01), maximum RIFLE injury (OR, 5.58; P < .01), and maximum RIFLE failure (OR, 7.64; P < .01).Conclusions: Progression of RIFLE class and newly developed AKI after hospital admission were better able to predict 28-day mortality than RIFLE criteria on the first day of admission in patients with severe sepsis and septic shock.

Critical care in Colombia: Differences between teaching and nonteaching intensive care units. A prospective cohort observational study

2011-06-24

Abstract: Objective: The aim of this study was to determine the differences in the efficacy and efficiency in providing critical care to hospitalized patients in teaching vs nonteaching intensive care units (ICUs) in Colombia.Methods: A prospective cohort observational study was conducted.Location: This study was conducted in 11 teaching and 8 nonteaching ICUs. From June 1 until December 31, 2005, data on 826 patients admitted consecutively to teaching ICUs and 825 patients admitted to nonteaching ICUs were analyzed.Measurements: Acute Physiology and Chronic Health Evaluation II, Simplified Therapeutic Intervention Scoring System, ICU discharge status (dead or alive) and ICU length of stay, and standardized mortality ratios were considered in this study. A logistic regression and robust linear regression were performed.Results: There were no differences in mortality (P = .25). Standardized mortality was less than 1 for both types of units. The teaching ICUs length of stay was 1 day longer (P < .01). Resource use is 25% higher in teaching units (P = .01). When the Simplified Therapeutic Intervention Scoring System score on the last day was from 21 to 35, a higher ratio of patients from the nonteaching ICUs was observed going floor or home when discharged from the ICU (P < .01).Conclusions: Nonteaching ICUs discharge patients earlier than do teaching ICUs, but the effect of it remains to be clarified with further studies addressing questions as what happens after ICU discharge.

Intensive care admissions and outcome at the University of Calabar Teaching Hospital, Nigeria

Iniabasi U. Ilori, Queeneth N. Kalu — 2012-02-01

Abstract: An intensive care unit (ICU) is for critically ill patients who are likely to benefit from the expertise care provided. The outcome is dependent on the available human and material resources. The University of Calabar Teaching Hospital is a 410-bed hospital. It has a 3-bed general ICU consisting of 2 adult and 1 pediatric beds. A retrospective analysis of all ICU admissions as well as the mortality rate during a 12-month period that spans April 2009 and March 2010 was done. The data were collected from the ICU admissions and nurses' report books. The data extracted were the patients ages, stratified to pediatric (0-18 years) and adult (>18 years); the source of admission, primary diagnosis, the duration of admission, and the patients who were ventilated were also noted. The outcome in terms of mortality was examined in relation to parameters stated above. Eighty-five patients were admitted during the 1-year period, with a bed occupancy rate of 23%. There were 11 (12.9%) pediatric patients and 74 (87.1%) adult patients. Sources of admissions were 64 (75.3%) patients from the operating room, 8 (9.4%) from the inpatient wards, and 13 (15.3%) from the accident and emergency department. Among the adult patients, there were 23 (31%) patients with trauma. There were 45 (61%) surgical patients and 6 (8%) medical patients. Sixteen (19%) patients were mechanically ventilated. The overall mortality was 28 (32.9%). Sixty-four percent of the mortality occurred during the first 24 hours of admission. A mortality rate of 83.3% was recorded among medical patients and 62.5% in those referred from the wards. In mechanically ventilated patients, the mortality rate was 62.5%. Ventilator malfunction, power failure, and oxygen exhaustion led to the unfavorable outcome in patients who were ventilated. In pediatric patients, the mortality rate was 45.5%. Early identification and referral of critically ill patients from the wards, availability of ventilator with battery backup, and maintenance of functioning equipment would reduce the high mortality rate recorded in the study.

Device-associated infection rates and extra length of stay in an intensive care unit of a university hospital in Wroclaw, Poland: International Nosocomial Infection Control Consortium's (INICC) findings

2011-07-07

Abstract: Purpose: The aim of this study was to determine device-associated health care–associated infections (DA-HAI) rates, microbiologic profile, bacterial resistance, and length of stay in one intensive care unit (ICU) of a hospital member of the International Nosocomial Infection Control Consortium (INICC) in Poland.Materials and Methods: A prospective DA-HAI surveillance study was conducted on an adult ICU from January 2007 to May 2010. Data were collected by implementing the methodology developed by INICC and applying the definitions of DA-HAI provided by the National Healthcare Safety Network at the US Centers for Disease Control and Prevention.Results: A total of 847 patients hospitalized for 9386 days acquired 206 DA-HAIs, an overall rate of 24.3% (95% confidence interval [CI], 21.5-27.4), and 21.9 (95% CI, 19.0-25.1) DA-HAIs per 1000 ICU-days. Central line–associated bloodstream infection rate was 4.01 (95% CI, 2.8-5.6) per 1000 catheter-days, ventilator-associated pneumonia rate was 18.2 (95% CI, 15.5-21.6) per 1000 ventilator-days, and catheter-associated urinary tract infection rate was 4.8 (95% CI, 3.5-6.5) per 1000 catheter-days. Length of stay was 6.9 days for those patients without DA-HAI, 10.0 days for those with central line–associated bloodstream infection, 15.5 days for those with ventilator-associated pneumonia, and 15.0 for those with catheter-associated urinary tract infection.Conclusions: Most DA-HAI rates are lower in Poland than in INICC, but higher than in the National Healthcare Safety Network, expressing the feasibility of lowering infection rates and increasing patient safety.

Cardiac manifestations in patients with pandemic (H1N1) 2009 virus infection needing intensive care

2011-07-07

Abstract: Purpose: To characterize the cardiac manifestations in severe pandemic (H1N1) 2009 virus [P(H1N1)2009v] infection.Materials and Methods: Adult patients admitted to the intensive care unit were recruited. Patients with an elevated troponin I (>1.5 ng/mL) and those requiring vasoactive agents had an echocardiogram. Myocardial injury was defined as elevated troponin I. Patients with reduced ejection fraction lower than 50% were diagnosed as having left ventricular systolic dysfunction. Myocarditis was presumed when myocardial injury was associated with global myocardial dysfunction. Myocardial injury and dysfunction were correlated with mortality and expressed as odds ratio (OR) with 95% confidence intervals (CI).Results: Thirty-seven patients presented at 6.4 (SD 3.2) days of illness. Four patients had valvular heart disease and 1 preexisting ischemic heart disease. Seventeen (46%) patients had evidence of myocardial injury. Twenty of 28 patients in whom an echocardiogram was clinically indicated had left ventricular systolic dysfunction. Of these, 14 patients were diagnosed as having myocarditis, and most of them (12 patients) developed it early. Myocarditis was associated with longer duration of vasoactive agents (OR 1.46, 95% CI 1.06-2.02) and mortality. Patients with elevated troponin I had an increased risk of death (OR 8.7, 95% CI 1.5-60). A higher mortality was observed in patients with left ventricular systolic dysfunction (OR 9.6, 95% CI 1.7-58) compared with those in whom an echocardiogram was normal or not indicated.Conclusion: In our cohort of severe P(H1N1)2009v infection, myocardial injury and dysfunction was frequent and associated with high mortality.

Efficacy and cardiovascular tolerability of continuous veno-venous hemodiafiltration in acute decompensated heart failure: A randomized comparative study

Sahar S.I. Badawy, Ahmed Fahmy — 2011-07-07

Abstract: Background and Objectives: Recently, continuous veno-venous hemodiafiltration (CVVHDF) has received increased attention in the treatment of congestive heart failure (CHF). The aim of this study is to assess the safety and efficacy of CVVHDF compared with intravenous furosemide in patients with CHF.Methods: Forty patients having CHF were included in this prospective, randomized, comparative trial. We randomized patients to treatment for 72 hours with CVVHDF or intravenous furosemide. Outcomes assessed were weight loss, total fluid output, length of stay (LOS) in the intensive care unit (ICU), 30-day mortality, and cardiovascular stability.Results: Demographic data were comparable in both groups. Weight loss (P ≤ .05) and total fluid output (P ≤ .01) were greater in the CVVHDF group. Length of stay in the ICU was significantly reduced in the CVVHDF group (P ≤ .05). The mortality rates were comparable in both groups. The cardiac output and the stroke volume significantly increased, whereas the pulmonary capillary wedge pressure significantly decreased (P ≤ .05) in both groups compared with the baseline. A transient attack of hypotension occurred in 1 patient in the CVVHDF group.Conclusion: In CHF, the use of CVVHDF effectively and safely produced greater weight and fluid loss and decreased LOS in the ICU more than the intravenous furosemide with no hemodynamic instability.

2012-02-01

Editorial Board

2012-02-01

Journal of Critical Care

2011—year in review

Health-care system distrust in the intensive care unit

Organizational and safety culture in Canadian intensive care units: Relationship to size of intensive care unit and physician management model

Ventilator-associated pneumonia is an important risk factor for mortality after major cardiac surgery

Comparison of ventilator-associated pneumonia (VAP) rates between different ICUs: Implications of a zero VAP rate

Hemodynamic effects of positive end-expiratory pressure during abdominal hyperpression: A preliminary study in healthy volunteers

Manual compression of the abdomen to assess expiratory flow limitation during mechanical ventilation

Effect of an antibiotic algorithm on the adequacy of empiric antibiotic therapy given by a medical emergency team

Outcomes for critically ill patients with HIV and severe sepsis in the era of highly active antiretroviral therapy

Time spent in the emergency department and mortality rates in severely injured patients admitted to the intensive care unit: An observational study

Peak postoperative troponin levels outperform preoperative cardiac risk indices as predictors of long-term mortality after vascular surgery: Troponins and postoperative outcomes

Short-term prognosis of critically ill surgical patients: The impact of duration of invasive organ support therapies

Cerebral perfusion pressure, microdialysis biochemistry, and clinical outcome in patients with spontaneous intracerebral hematomas

Exercise testing in survivors of intensive care—is there a role for cardiopulmonary exercise testing?

Palliative care in a neonatal intensive care unit

2011 Reviewers

Zinc supplementation in intensive care: Results of a UK survey

To explore the conditions of dying infants in NICU in Taiwan

Earthquake-related injuries: Evaluation with multidetector computed tomography and digital radiography of 1491 patients

Effect of attachment styles of individuals discharged from an intensive care unit on intensive care experience

Analysis of progression in risk, injury, failure, loss, and end-stage renal disease classification on outcome in patients with severe sepsis and septic shock

Critical care in Colombia: Differences between teaching and nonteaching intensive care units. A prospective cohort observational study

Intensive care admissions and outcome at the University of Calabar Teaching Hospital, Nigeria

Device-associated infection rates and extra length of stay in an intensive care unit of a university hospital in Wroclaw, Poland: International Nosocomial Infection Control Consortium's (INICC) findings

Cardiac manifestations in patients with pandemic (H1N1) 2009 virus infection needing intensive care

Efficacy and cardiovascular tolerability of continuous veno-venous hemodiafiltration in acute decompensated heart failure: A randomized comparative study

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Editorial Board