Journal of Critical Care RSS feed: Current Issue. The Journal of Critical Care , the official publication of the World Federation of Societies of Intensive and Critical Care Medicine (WFSICCM), is a leading international, peer-reviewed journal providing original research, review articles, tutorials, and invited articles for physicians and allied health professionals involved in treating the critically ill. The Journal aims to improve patient care by furthering understanding of health systems research and its integration into clinical practice. The Journal will include articles which discuss: All aspects of health services research in critical care System based practice in anesthesiology, perioperative and critical care medicine The interface between anesthesiology, critical care medicine and pain Integrating intraoperative management in preparation for postoperative critical care management and recovery Optimizing patient management, i.e., exploring the interface between evidence-based principles or clinical insight into management and care of complex patients The team approach in the OR and ICU System-based research Medical ethics Technology in medicine Seminars discussing current, state of the art, and sometimes controversial topics in anesthesiology, critical care medicine, and professional education Residency Education: Providing a series of clinically relevant tutorials from experienced practitioners focusing on the six core competencies: Medical Knowledge Professionalism Patient Care Interpersonal and communication skills Case based learning and improvement Systems based practice The editorial board represents an international cross section of individuals actively involved in the disciplines of Critical Care Medicine and Anesthesiology.http://www.jccjournal.org/?rss=yesElsevier Inc.en © 2010 Elsevier Inc. All rights reserved. Journal of Critical Care0883-9441251March 2010 © 2010 Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.jccjournal.org/article/PIIS0883944110000158/abstract?rss=yesThis issue of the Journal of Critical Care is dedicated to the memory of Dr Jose Besso, a passionately caring clinician, a daring physician leader, and a good friend to many. His professional accomplishments are recognized in the accompanying obituary; his personal qualities will remain as bright memories and continuing inspiration for those who knew him. His contributions to Critical Care Medicine are recognized by national and international societies, named lectures, and an indelible footprint as a true leader in the specialty he loved. However, commitment to his profession, his patients, his students, his colleagues, and above all, his family is his greater legacy. We shall miss him and recognize that our lives and profession were enhanced by the time he spent and shared with us all.Editor's introductionPhilip D. Lumb10.1016/j.jcrc.2010.02.001Journal of Critical Care 25, 1 (2010)2010-03-01Journal of Critical Care2010-03-01251S0883-9441(10)X0002-8Editorial11http://www.jccjournal.org/article/PIIS088394411000016X/abstract?rss=yes It was with great sadness that the World Federation learned of the passing of its Immediate Past President Dr José Besso following a long battle with an illness he faced with great courage and fortitude. Dr Besso died peacefully at his home in Caracas on Wednesday, December 9th 2009.José Besso MD 1948-200910.1016/j.jcrc.2010.02.002Journal of Critical Care 25, 1 (2010)2010-03-01Journal of Critical Care2010-03-01251S0883-9441(10)X0002-8Obituary22http://www.jccjournal.org/article/PIIS0883944109001166/abstract?rss=yesAbstract: Purpose: The aim of the study is to determine which factors are associated with the deterioration of Pao2/fraction of inspired oxygen (Fio2) ratio in patients with normal oxygenation at admission and ventilated according to a lung protective ventilation strategy.Materials and Methods: Retrospective cohort study of ventilated (≥3 days) intensive care unit patients with an admission Pao2/Fio2 ratio of 300 mm Hg or higher (n = 105). Patients who developed lung injury (Pao2/Fio2 ratio, <300 mm Hg) on day 7 (n = 37) were compared to those who did not (n = 68), with regard to ventilator settings, gas exchange variables, and lung injury risk factors.Results: Mean ± SD of administered tidal volume was 7.9 ± 1.3 mL/kg. Patients who developed lung injury were older (P = .019), had lower Pao2 (P = .009), higher Paco2 (P = .045), and lower Pao2/Fio2 ratio (P = .002) at admission. Postoperative state (Hazard risk [HR], 5.1) and controlled ventilation mode (HR, 4.3) were identified as independent risk factors. Lung injury-free time was shorter in patients with low initial Pao2/Fio2 ratio (odds ratio, 1.7; P = .039). This effect was not only caused by the baseline difference, as the decrease in Pao2/Fio2 ratio was more pronounced in patients who developed lung injury compared to those who did not (P = .008).Conclusions: Lung injury exacerbates during mechanical ventilation. In patients treated with a mean tidal volume of 7.9 mL/kg, controlled ventilation is a major risk factor.Risk factors for the deterioration of oxygenation ratio in ventilated intensive care unit patients: A retrospective cohort studyIlma W.F. Fick, Myrthe M. Tijdink, Feico J.J. Halbertsma, Johannes G. van der Hoeven, Peter Pickkers10.1016/j.jcrc.2009.04.007Journal of Critical Care 25, 1 (2010)2009-07-10Journal of Critical Care2009-07-10251S0883-9441(10)X0002-8Respiration/Mechanical Ventilation39http://www.jccjournal.org/article/PIIS0883944109000094/abstract?rss=yesAbstract: Introduction: Recruitment maneuvers (RMs) are advocated to prevent pulmonary collapse during low tidal volume ventilation and improve oxygenation. However, convincing clinical evidence for improved outcome is lacking. Recent experimental studies demonstrate that RMs translocate pulmonary inflammatory mediators into the circulation. To determine whether a single RM in ventilated children affects pulmonary and systemic cytokine levels, we performed a prospective intervention study.Methods: Cardiorespiratory stable ventilated patients (0.5-45 months, n = 7) with acute lung injury were subjected to an RM determining opening and closing pressures (peak inspiratory pressure ≤45 cmH2O, positive end expiratory pressure (PEEP) ≤30 cmH2O). Before and after RM, cardiorespiratory parameters and ventilator settings were recorded, blood gas analysis performed, and bronchoalveolar lavage fluid and plasma TNF-α, IL-1β, IL-6, IL-8, and IL-10 concentrations were determined.Results: Fifteen minutes after the RM, an increase was observed in plasma tumor necrosis factor-α (400% ± 390% of baseline, P = .04), IL-6 (120% ± 35%, P = .08), and IL-1β (520% ± 535%, P = .04), which decreased at T = 60 minutes, hence indicative of translocation. Recruitment maneuver did not change the plasma levels of the anti-inflammatory IL-10 (105% ± 12%, P = .5). Apart from a nonsignificant increase of IL-8 after 360 minutes (415% ± 590%,P = .1), bronchoalveolar cytokine levels were not influenced by the RM. No increase in oxygenation or improvement of lung kinetics was observed.Conclusions: A single RM can translocate pro-inflammatory cytokines from the alveolar space into the systemic circulation in ventilated critically ill children.A single recruitment maneuver in ventilated critically ill children can translocate pulmonary cytokines into the circulationFeico J. Halbertsma, Michiel Vaneker, Peter Pickkers, Chris Neeleman, Gert J. Scheffer, Johannes G. Hoeven van der10.1016/j.jcrc.2009.01.006Journal of Critical Care 25, 1 (2010)2009-03-31Journal of Critical Care2009-03-31251S0883-9441(10)X0002-8Respiration/Mechanical Ventilation1015http://www.jccjournal.org/article/PIIS0883944109000562/abstract?rss=yesAbstract: Purpose: The aim of this study is to evaluate the value of extravascular lung water (EVLW) to intrathoracic blood volume, global end-diastolic volume, or pulmonary blood volume ratios as a reflection of pulmonary permeability in nonseptic critically ill patients with or at risk for acute lung injury/acute respiratory distress syndrome (ALI/ARDS).Methods: Pulmonary permeability was measured by the pulmonary leak index (PLI) for 67gallium-labeled transferrin and EVLW and blood volumes by the transpulmonary indicator dilution technique in 20 mechanically ventilated patients, before and after fluid loading, guided by changes in central venous pressure.Results: Nine (45%) patients had ALI/ARDS according to current criteria. The PLI was high (≥30.0 × 10−3/min) in 25% before and 30% after fluid loading. The EVLW was high (≥10 mL/kg) in 10% before and in none after fluid loading and did not increase with fluid loading, whereas blood volumes increased. Before fluid loading, PLI related to EVLW/blood volume ratios (minimum r = 0.48, P = .032). After fluid loading, PLI related to EVLW to pulmonary blood volume or intrathoracic blood volume ratios (minimum r = 0.46, P = .041). The relations were unaffected by fluid loading and pressure forces.Conclusions: The EVLW/blood volume ratios are determined, at least in part, by moderately increased pulmonary permeability in nonseptic critically ill patients with or at risk for ALI/ARDS, independent of fluid status and pressure forces. Normal ratios may help to exclude high permeability.Extravascular lung water to blood volume ratios as measures of pulmonary capillary permeability in nonseptic critically ill patientsMelanie van der Heijden, A.B. Johan Groeneveld10.1016/j.jcrc.2009.02.009Journal of Critical Care 25, 1 (2010)2009-05-11Journal of Critical Care2009-05-11251S0883-9441(10)X0002-8Respiration/Mechanical Ventilation1622http://www.jccjournal.org/article/PIIS0883944108002372/abstract?rss=yesAbstract: Purpose: The response to inhaled nitric oxide (iNO) is inconsistent in patients with acute respiratory distress syndrome (ARDS). We sought to determine whether the response to iNO, defined as 20% Pao2/Fio2 increase from baseline, depends on the level of cardiac natriuretic peptides.Materials and methods: This is a prospective cohort study including 11 consecutive patients with ARDS who were eligible to receive iNO. Measurements of plasma concentrations of atrial natriuretic peptide (ANP), N-Terminal-Pro-B-Type Natriuretic Peptide (NT-pro-BNP) and 3′,5′-cyclic guanosine monophosphate were obtained before initiating iNO and 30 minutes later during iNO. Baseline cardiac peptides, oxygenation, and hemodynamic variables and their change during iNO were compared among responders and nonreponders to iNO.Results: Baseline ANP and NT-pro-BNP concentrations were higher in patients that responded to iNO and tended to decrease during iNO in responders only. 3′,5′-Cyclic guanosine monophosphate concentrations were not different among responders and nonresponders and were unchanged during iNO. Baseline ANP was strongly correlated with change in intrapulmonary shunt, and baseline NT-pro-BNP and its change were correlated with the change in cardiac output.Conclusions: High ANP and NT-pro-BNP concentrations are associated with the response to iNO. These data suggest that cardiac peptides have the potential to identify a subgroup of patients with ARDS who might derive clinical benefit from iNO.Atrial and brain natriuretic peptide concentrations and the response to inhaled nitric oxide in patients with acute respiratory distress syndromeMiriam M. Treggiari, Karim Bendjelid, N. David Yanez, Claudia-Paula Heidegger, Peter M. Suter, Jacques-André Romand10.1016/j.jcrc.2008.10.014Journal of Critical Care 25, 1 (2010)2009-02-17Journal of Critical Care2009-02-17251S0883-9441(10)X0002-8Respiration/Mechanical Ventilation2329http://www.jccjournal.org/article/PIIS0883944109001312/abstract?rss=yesAbstract: Purpose: The aim of this study was to assess the impact of the 3 types of initial respiratory support (noninvasive positive pressure ventilation vs invasive positive pressure ventilation vs supplemental oxygen only) in hematological patients with acute hypoxemic respiratory failure (ARF).Materials and Methods: This study is a retrospective analysis of a cohort of hematological patients admitted to the intensive care unit (ICU) of a tertiary care hospital between January 1, 2002, and June 30, 2006.Results: One hundred thirty-seven hematological patients were admitted at the ICU with ARF (defined as Pao2/Fio2 <200): within the first 24 hours, 24 and 67 patients received noninvasive positive pressure ventilation and invasive positive pressure ventilation, respectively, and 46 received supplemental oxygen only. Intensive care unit mortality in the 3 patient categories was 71%, 63%, and 32%, respectively (P = .001), and in-hospital mortality was 75%, 80%, and 47%, respectively (P = .001). In multivariate regression analysis, increasing cancer-specific severity-of-illness score upon admission and more organ failure after 24 hours of ICU admission, but not the type of initial respiratory support, were significantly associated with ICU or in-hospital mortality.Conclusions: Intensive care unit and in-hospital mortality in our population of hematological patients with hypoxemic ARF was determined by severity of illness and not by the type of initial respiratory support.The impact of the initial ventilatory strategy on survival in hematological patients with acute hypoxemic respiratory failurePieter O. Depuydt, Dominique D. Benoit, Carl D. Roosens, Fritz C. Offner, Lucien A. Noens, Johan M. Decruyenaere10.1016/j.jcrc.2009.02.016Journal of Critical Care 25, 1 (2010)2009-08-17Journal of Critical Care2009-08-17251S0883-9441(10)X0002-8Respiration/Mechanical Ventilation3036http://www.jccjournal.org/article/PIIS0883944109000823/abstract?rss=yesAcute respiratory failure (ARF) is a severe complication and a leading reason for admission to intensive care units (ICUs) of patients with malignancies . For decades, ARF developing in these patients was considered a consequence of refractory pulmonary diseases hence associated with very high mortality rates. For the last years, improved survival rates were reported in different specialized centers . In addition to oncological and hematologic advances and to intensive care improvements, investigators have attributed the increased survival to the use of noninvasive ventilation (NIV) . In 2001, a randomized control trial from Hilbert et al reported several benefits of NIV including improvements in oxygenation parameters and reduced need for endotracheal intubation and its related complications in immunosuppressed patients with ARF. Although only 30 patients with malignancies were included in that study, the improved survival rates placed NIV as the initial method of choice for ventilatory support for hypoxemic ARF in these patients. However, concerns were raised about patient's outcomes in the control group in whom intubation was associated with up to 94% mortality. Moreover, later studies demonstrated that NIV failure (as defined by subsequent need for intubation and mechanical ventilation [MV]) was reported to occur at least in half of the patients with ARF . It should be stressed that NIV failure in hypoxemic cancer patients is associated with remarkably high (73%-92%) mortality rates . Furthermore, a delay from the time of ICU admission to the start of NIV was associated with increased risk for failure, and NIV failure was described as an independent predictor for worse outcome . Azoulay et al reported a 100% mortality rate in patients who received NIV for longer than 72 hours. Studies in the field observed that acute respiratory distress syndrome, the need for vasopressors or renal replacement therapy, a nonrapidly reversible reason or the lack of a definite etiologic diagnosis of ARF, and the presence of airway involvement by the malignancy are other relevant indicators that NIV will very probably fail .Noninvasive ventilation in patients with malignancies and hypoxemic acute respiratory failure: A still pending questionMárcio Soares, Jorge I.F. Salluh, Élie Azoulay10.1016/j.jcrc.2009.04.001Journal of Critical Care 25, 1 (2010)2009-07-06Journal of Critical Care2009-07-06251S0883-9441(10)X0002-8Respiration/Mechanical Ventilation3738http://www.jccjournal.org/article/PIIS0883944109001142/abstract?rss=yesAbstract: Discontinuation of mechanical ventilation in critically ill patients is a challenging task and involves a careful weighting of the benefits of early extubation and the risks of premature spontaneous breathing trial. Recently, apart from studying different physiological variables by means of descriptive statistical tests, breathing pattern variability analysis has been performed for the assessment of weaning readiness. A limited number of clinical studies implementing different weaning protocols in heterogeneous groups of patients and using a variable set of signal processing techniques have appeared in the critical care literature, with varying results.The purpose of this review article is 3-fold: (1) to describe the different signal processing techniques being implemented for the assessment of weaning readiness, (2) to provide insight into the pathophysiological mechanisms that may govern breath-to-breath variability/complexity in health and disease, and (3) to present results from the critical care literature derived from the application of biosignal analysis tools for the identification of possible weaning indices.Biosignal analysis techniques for weaning outcome assessmentVasilios Papaioannou, Christos Dragoumanis, Ioannis Pneumatikos10.1016/j.jcrc.2009.04.006Journal of Critical Care 25, 1 (2010)2009-07-10Journal of Critical Care2009-07-10251S0883-9441(10)X0002-8Respiration/Mechanical Ventilation3946http://www.jccjournal.org/article/PIIS088394410900118X/abstract?rss=yesAbstract: Bronchopleural fistula is a potentially fatal condition that may result after a variety of clinical conditions, most commonly after pulmonary resection. Either surgical or bronchoscopic repair is required to definitively correct these lesions, though a small number may resolve spontaneously with optimal ventilatory care and other options available to an intensivist in the management of this complex condition. The successful management of a bronchopleural fistula depends on formulating a treatment strategy tailored to individual patient needs.Bronchopleural fistula: An update for intensivistsKiran Shekar, Carole Foot, John Fraser, Marc Ziegenfuss, Peter Hopkins, Morgan Windsor10.1016/j.jcrc.2009.05.007Journal of Critical Care 25, 1 (2010)2009-07-10Journal of Critical Care2009-07-10251S0883-9441(10)X0002-8Respiration/Mechanical Ventilation4755http://www.jccjournal.org/article/PIIS0883944109000756/abstract?rss=yesAbstract: Purpose: Ventilator-associated pneumonia (VAP) is associated with significant morbidity and mortality in pediatric intensive care unit (PICU). Our purpose was to evaluate the effects of ventilator circuit change on the rate of VAP in the PICU.Methods: A prospective randomized controlled trial was conducted at a university hospital PICU. Children (younger than 18 years) who received mechanical ventilation from December 2006 to November 2007 were randomly assigned to receive ventilator circuit changes every 3 or 7 days.Results: Of 176 patients, 88 were assigned to receive ventilator circuit every 3 days and 88 patients had a change weekly. The rate of VAP was 13.9/1000 ventilator days for the 3-day circuit change (n = 12) vs 11.5/1000 ventilator days (n = 10) for the 7-day circuit change (odds ratio, 0.8; confidence interval, 0.3-1.9; P = .6). There was a trend toward decreased PICU stay and mortality rate in 7-day change group compared to 3-day change group but did not reach statistical significance. Furthermore, switching from a 3-day to a 7-day change policy could save costs up to US $22,000/y.Conclusions: The 7-day ventilator circuit change did not contribute to increased rates of VAP in our PICU. Thus, it may be used as a guide to save workload and supply costs.Effect of frequency of ventilator circuit changes (3 vs 7 days) on the rate of ventilator-associated pneumonia in PICURujipat Samransamruajkit, Suree Jirapaiboonsuk, Sirirush Siritantiwat, Ornanong Tungsrijitdee, Jitladda Deerojanawong, Suchada Sritippayawan, Nuanchan Prapphal10.1016/j.jcrc.2009.03.005Journal of Critical Care 25, 1 (2010)2009-07-10Journal of Critical Care2009-07-10251S0883-9441(10)X0002-8Ventilator-Associated Pneumonia5661http://www.jccjournal.org/article/PIIS088394410900121X/abstract?rss=yesAbstract: Methods: We studied patients requiring mechanical ventilation for more than 48 hours who died in the intensive care unit and whose bodies were autopsied. We evaluated 3 clinical definitions of ventilator-associated pneumonia: loose definition, defined as chest radiograph infiltrates and 2 of 3 clinical criteria (leukocytosis, fever, purulent respiratory secretions); rigorous definition, defined as chest radiograph infiltrates and all of the clinical criteria; and a clinical pulmonary infection score higher than 6 points. Sensitivity, specificity, and likelihood ratios were calculated by using pathology pattern as criterion standard.Results: One hundred forty-two (56%) of the 253 patients included had histological criteria of pneumonia. Patients who met the clinical criteria of ventilator-associated pneumonia were 163 (64%) for the loose definition, 32 (13%) for the rigorous definition, and 109 (43%) for the clinical pulmonary infection score. The operative indexes (sensitivity and specificity) of each definition were as follows: loose definition, 64.8% and 36%; rigorous definition, 91% and 15.5%; and clinical pulmonary infection score higher than 6, 45.8% and 60.4%. The addition of microbiological data to the clinical definitions increased the specificity and decreased the sensitivity but not significantly.Conclusions: Accuracy of 3 commonly used clinical definitions of ventilator-associated pneumonia was poor taking the autopsy findings as reference standard.Accuracy of clinical definitions of ventilator-associated pneumonia: Comparison with autopsy findingsEva Tejerina, Andrés Esteban, Pilar Fernández-Segoviano, Fernando Frutos-Vivar, José Aramburu, Daniel Ballesteros, José María Rodríguez-Barbero10.1016/j.jcrc.2009.05.008Journal of Critical Care 25, 1 (2010)2009-07-10Journal of Critical Care2009-07-10251S0883-9441(10)X0002-8Ventilator-Associated Pneumonia6268http://www.jccjournal.org/article/PIIS0883944109000720/abstract?rss=yesAbstract: Background: Because of the high frequency of multidrug resistant bacteria in our intensive care units (ICUs), we implemented a ventilator-associated pneumonia (VAP) clinical pathway based on unit-specific minimum inhibitory concentration (MIC) distributions and pharmacodynamic modeling in 3 of our ICUs.Methods: This was a prospective, observational evaluation with a historical control group in adult patients (n = 168) who met clinical and radiologic criteria for VAP. Monte Carlo simulation was used to determine antibiotic regimens having the greatest likelihood of achieving bactericidal exposures against Pseudomonas aeruginosa. Antibiotic regimens were incorporated into an ICU-specific computerized clinical pathway as empiric agents of choice.Results: Pharmacodynamic modeling found 3-hour infusions of cefepime 2 g every 8 hours or meropenem 2 g every 8 hours plus tobramycin and vancomycin would provide the greatest probability of empirically treating VAP in these ICUs. Infection-related mortality was reduced by 69% (8.5% vs 21.6%; P = .029), infection-related length of stay was shorter (11.7 ± 8.1 vs 26.1 ± 18.5; P < .001), and fewer superinfections were observed in patients treated on the pathway. A number of patients with nonsusceptible P aeruginosa were successfully treated with high-dose, 3-hour infusion regimens.Conclusions: In our ICUs where multidrug resistant bacteria are common, an approach considering ICU-specific antibiotic MICs coupled with pharmacodynamic dosing strategies resulted in improved outcomes and shorter duration of treatments.Pharmacodynamic-based clinical pathway for empiric antibiotic choice in patients with ventilator-associated pneumoniaAnthony M. Nicasio, Kathryn J. Eagye, David P. Nicolau, Eric Shore, Marc Palter, Judith Pepe, Joseph L. Kuti10.1016/j.jcrc.2009.02.014Journal of Critical Care 25, 1 (2010)2009-05-08Journal of Critical Care2009-05-08251S0883-9441(10)X0002-8Ventilator-Associated Pneumonia6977http://www.jccjournal.org/article/PIIS0883944108002074/abstract?rss=yesAbstract: Purpose: The aim of this study is to compare blood sugar control and safety profile of nurse-titrated and medically ordered glucose-insulin regimens.Materials and Methods: We conducted a retrospective cohort study in a 9-bedded regional intensive care unit (ICU) in Queensland, Australia. Seventy critically ill patients requiring one-on-one nursing and intravenous insulin were included. In the nursing group, the ICU nurse decided initial and ongoing insulin infusion rates and glucose measurement frequency. The medical group had a traditional insulin sliding scale prescription.Results: Thirty-seven patients in the nursing group had 1949 glucose measurements. Thirty-three patients in the medical group had 2118 measurements. Mean blood sugar levels (±SD) were 8.33 ± 2.34 and 8.78 ± 2.74 in nursing and medical groups (P < .001). Eighteen percent of glucose readings were greater than 10 mmol/L in the nursing group compared with 27% in the medical group (P = .038). The incidence of hypoglycemia (<2.2 mmol/L) was similar in the 2 groups.Conclusions: In a regional ICU, nurse-titrated glycemic control is safe, effective, and results in high compliance with a glucose target range.Improving blood sugar control during critical illness: A cohort studyEnda O'Connor, David Tragen, Paul Fahey, Michael Robinson, Theresa Cremasco10.1016/j.jcrc.2008.10.008Journal of Critical Care 25, 1 (2010)2009-02-17Journal of Critical Care2009-02-17251S0883-9441(10)X0002-8Glucose Control7883http://www.jccjournal.org/article/PIIS0883944108002347/abstract?rss=yesAbstract: Purpose: The aim of this study is to compare the safety and efficacy of 2 different strategies for glycemic control in critically ill adult patients.Materials and Methods: A total of 337 patients were randomly assigned to a carbohydrate-restrictive strategy (group 1) through glucose-free venous hydration, hypoglycidic nutritional formula, and subcutaneous insulin if blood glucose level was higher than 180 mg/dL or to strict normalization of blood glucose levels (80-120 mg/dL) with the use of insulin infusion (group 2).Results: Patients in group 1 (n = 169) received 2 (0-6.5) units of regular insulin per day, whereas patients in group 2 (n = 168) received 52 (35-74.5) units per day (P < .001). The median blood glucose level was 144 mg/dL in group 1 and 133.6 mg/dL in group 2 (P = .003). Hypoglycemia occurred in 6 (3.5%) patients in group 1 and 27 (16%) in group 2 (P < .001) and was an independent risk factor for neurological dysfunction and mortality.Conclusions: A carbohydrate-restrictive strategy reduced significantly the incidence of hypoglycemia in critically ill patients compared to intensive insulin therapy. Mortality and morbidity were comparable between the 2 groups.A carbohydrate-restrictive strategy is safer and as efficient as intensive insulin therapy in critically ill patientsJosé Raimundo A. de Azevedo, Leonardo Oliveira de Araujo, Widlani Sousa da Silva, Renato Palácio de Azevedo10.1016/j.jcrc.2008.10.011Journal of Critical Care 25, 1 (2010)2009-02-17Journal of Critical Care2009-02-17251S0883-9441(10)X0002-8Glucose Control8489http://www.jccjournal.org/article/PIIS0883944109002202/abstract?rss=yesAbstract: Purpose: Preventing harmful hyperglycemia is important in critical illness. However, insulin therapy increases the risk of hypoglycemia. In patients with diabetes, isomaltulose-based enteral formula (IF) feeding has been shown to reduce glycemia. This randomized controlled crossover study was conducted to determine whether IF feeding improves glycemia in postoperative critically ill patients.Material and Methods: Eight patients who developed hyperglycemia (>150 mg/dL) after esophagectomy were included. Patients were randomized to either the IF or the standard feeding formula (SF) arm. After 16 hours of administration of randomized formula and 8 hours of washout, patients crossed over to the other formula for the next 16 hours. Continuous glucose measurement using STG-22 (Nikkiso, Tokyo, Japan) was performed during the trial.Results: Maximum blood glucose concentration was 181 mg/dL with IF, significantly lower than the 206 mg/dL with SF (P = .001). Mean glycemia during feeding periods was 162 mg/dL with IF, significantly lower than the 176 mg/dL with SF (P = .0001). Seven (87.5%) patients taking SF exceeded 180 mg/dL compared with 3 (37.5%) patients taking IF (P = .005). This effect was seen without any risk of hypoglycemia and complication.Conclusions: Isomaltulose-based enteral formula might be useful for safer glycemic control in postoperative critically ill patients. Further study to determine clinical benefit of IF feeding is justified.Safer glycemic control using isomaltulose-based enteral formula: A pilot randomized crossover trialMoritoki Egi, Yuichiro Toda, Hiroshi Katayama, Masataka Yokoyama, Kiyoshi Morita, Hidekazu Arai, Tomoki Yamatsuji, Michael Bailey, Yoshio Naomoto10.1016/j.jcrc.2009.07.006Journal of Critical Care 25, 1 (2010)2009-09-25Journal of Critical Care2009-09-25251S0883-9441(10)X0002-8Glucose Control9096http://www.jccjournal.org/article/PIIS0883944109002445/abstract?rss=yesAbstract: Purpose: “Glucosafe’ is a new model-based decision support system for glycemic control in critical care. Safety and achievement of glycemic goals using the system are tested prospectively.Methods: Four penalty functions were developed to balance regimens of nutrition and insulin therapy against model-predicted glycemic outcome. The system advises the regimen where the penalty sum is minimal. An interactive interface allows advice alterations. Ten hyperglycemic patients (median Acute Physiology and Chronic Health Evaluation II, 12.5; interquartile range, 7.5-16.3) from a neuro and trauma intensive care unit were included for pilot testing using Glucosafe for 12 to 14 hours. Glycemic outcomes were compared to the 24-hour intervals before and after intervention.Results: Hypoglycemia (blood glucose [BG] <3.5 mmol/L) was not observed. Mean log-normal BG ± standard deviation was reduced from 8.6 ± 2.4 mmol/L preintervention to 7.0 ± 1.1 mmol/L during the intervention. Nine patients reached the 4.4- to 6.1-mmol/L band after a mean 5 hours. At 5 hours intervention, mean log-normal BG was 6.7 mmol/L, 40% of measurements were in the 4.4- to 6.1-mmol/L band, and 84% were in the 4.4- to 7.75-mmol/L band.Conclusions: Safety was demonstrated with the developed penalty functions. The low BG variance achieved may permit minor adjustments of the penalty function values to reduce average BG if desired.The Glucosafe system for tight glycemic control in critical care: A pilot evaluation studyUlrike Pielmeier, Steen Andreassen, Brian Juliussen, J. Geoffrey Chase, Birgitte Steenfeldt Nielsen, Pernille Haure10.1016/j.jcrc.2009.10.003Journal of Critical Care 25, 1 (2010)2009-11-20Journal of Critical Care2009-11-20251S0883-9441(10)X0002-8Glucose Control97104http://www.jccjournal.org/article/PIIS0883944109000574/abstract?rss=yesAbstract: Purpose: The aim of this study was to analyze the predictive value of blood urea nitrogen (BUN) and other variables in acute necrotizing pancreatitis on hospital stay, intensive care unit (ICU) stay, and death.Materials and Methods: We retrospectively analyzed 118 consecutive case records of patients admitted with acute pancreatitis. Forty-four patients had a severe acute necrotizing pancreatitis and only those were analyzed. We compared variables on admission and in the course of the disease in association to hospital stay, ICU stay, and death.Results: Patients with elevated BUN on admission had a significantly prolonged ICU stay (≥14 days: 32 ± 25 mg/dL vs <14 days: 15 ± 8 mg/dL; univariate P = .007; multivariate P = .0390; odds ratio, 1.042; 95% confidence interval, 1.002-1.084). Positive and negative predictive values (PPV, NPV) were 89% and 62% with a cutoff at 33 mg/dL. The ICU stay was also significantly prolonged when BUN was elevated in the course of the disease (≥14 days: 60 ± 33 mg/dL vs <14 days: 20 ± 8 mg/dL; P < .0001; PPV 89% and NPV 77%). Mortality in patients with elevated BUN on admission was significantly increased (nonsurvivors: 39 ± 30 vs survivors: 17 ± 11 mg/dL; P = .028; PPV 67%, NPV 82%). Later in the course of the disease, elevated BUN was also associated with increased mortality (nonsurvivors: 69 ± 38 mg/dL vs survivors: 27 ± 16 mg/dL; P = .003; PPV 56% and NPV 92%).Conclusion: Although not as reliable as complex clinical scoring systems, BUN as a single marker is a useful routine, easy to perform, and a cheap marker to predict ICU stay and probable survival in acute necrotizing pancreatitis.Elevated blood urea nitrogen is an independent risk factor of prolonged intensive care unit stay due to acute necrotizing pancreatitisMaik Faisst, Ulrich F. Wellner, Stefan Utzolino, Ulrich T. Hopt, Tobias Keck10.1016/j.jcrc.2009.02.002Journal of Critical Care 25, 1 (2010)2009-05-11Journal of Critical Care2009-05-11251S0883-9441(10)X0002-8ICU105111http://www.jccjournal.org/article/PIIS0883944109000604/abstract?rss=yesAbstract: Purpose: The study aimed to evaluate the relative impact of clinical and demographic factors associated with the prevalence and incidence of anemia (hemoglobin [Hb] <12 g/dL) in critically ill patients with cancer.Materials and Methods: We performed an electronic chart review for demographic and clinical data of adult patients with cancer with or without anemia admitted to the intensive care unit (ICU). Prevalence of anemia was determined at admission, and incidence determined if anemia developed during ICU stay. Anemia was classified as mild, moderate, or severe. The additive impact of clinical and demographic factors was evaluated by using a hierarchical linear regression model.Results: A total of 4705 patients were included in the study. The prevalence and incidence of anemia were 68.0% and 46.6%, respectively. In prevalent cases, we found that the clinical covariates modified sequential organ failure assessment score, admission to the medical ICU, prior chemotherapy, diagnosis of hematologic cancer, and length of hospital stay before ICU admission explained 18.7% of the variance in the model, whereas the demographic covariates (age, sex, and race) explained only an additional 0.6%. The pattern was similar for incidence cases.Conclusions: Clinical factors are more influential than demographic factors in the observed rates of prevalence and incidence of anemia in the ICU; thus, protocols are needed to identify subgroups of patients with cancer who could benefit from novel management strategies.Factors associated with anemia in patients with cancer admitted to an intensive care unitMarylou Cardenas-Turanzas, Mark A. Cesta, Chris Wakefield, Susannah Kish Wallace, Rudolph Puana, Kristen J. Price, Joseph L. Nates10.1016/j.jcrc.2009.02.004Journal of Critical Care 25, 1 (2010)2009-07-06Journal of Critical Care2009-07-06251S0883-9441(10)X0002-8ICU112119http://www.jccjournal.org/article/PIIS0883944109000690/abstract?rss=yesAbstract: Background: Studies investigating the metabolic effects of citrate-based substitution fluids are lacking. This study aims to compare the effect of citrate- vs bicarbonate-based substitution fluid used during continuous venovenous hemofiltration (CVVH) for acute kidney injury on acid-base balance and electrolytes in critically ill patients.Methods: This was a prospective sequential cohort study in patients with a contraindication for systemic anticoagulation. The first cohort was treated by bicarbonate-based CVVH (n = 10) and the second cohort was treated by CVVH with citrate-based substitution fluid (n = 19). Flow of the latter was coupled to blood flow, and ionized calcium concentrations were monitored and kept constant by calcium-glubionate infusion.Results: No major differences between the 2 groups were found in baseline acid-base parameters. In both groups, arterial pH increased after initiation of treatment and normalized on the average within 18 hours in either group. No differences were found in bicarbonate concentrations. Electrolyte control was comparable for the groups.Conclusion: Citrate-based substitution fluid is comparable to bicarbonate-based substitution fluid during CVVH in critically ill patients with acute kidney injury, concerning acid-base balance and electrolyte control. This implies complete conversion of citrate to bicarbonate in the patients studied.Metabolic effects of citrate- vs bicarbonate-based substitution fluid in continuous venovenous hemofiltration: A prospective sequential cohort studyJurjan Aman, S. Azam Nurmohamed, Marc G. Vervloet, A.B. Johan Groeneveld10.1016/j.jcrc.2009.02.013Journal of Critical Care 25, 1 (2010)2009-05-11Journal of Critical Care2009-05-11251S0883-9441(10)X0002-8ICU120127http://www.jccjournal.org/article/PIIS0883944108001986/abstract?rss=yesAbstract: Introduction: Monitoring of physiologic parameters in critically ill patients is currently performed by threshold alarm systems with high sensitivity but low specificity. As a consequence, a multitude of alarms are generated, leading to an impaired clinical value of these alarms due to reduced alertness of the intensive care unit (ICU) staff. To evaluate a new alarm procedure, we currently generate a database of physiologic data and clinical alarm annotations.Methods: Data collection is taking place at a 12-bed medical ICU. Patients with monitoring of at least heart rate, invasive arterial blood pressure, and oxygen saturation are included in the study. Numerical physiologic data at 1-second intervals, monitor alarms, and alarm settings are extracted from the surveillance network. Bedside video recordings are performed with network surveillance cameras.Results: Based on the extracted data and the video recordings, alarms are clinically annotated by an experienced physician. The alarms are categorized according to their technical validity and clinical relevance by a taxonomy system that can be broadly applicable. Preliminary results showed that only 17% of the alarms were classified as relevant, and 44% were technically false.Discussion: The presented system for collecting real-time bedside monitoring data in conjunction with video-assisted annotations of clinically relevant events is the first allowing the assessment of 24-hour periods and reduces the bias usually created by bedside observers in comparable studies. It constitutes the basis for the development and evaluation of “smart” alarm algorithms, which may help to reduce the number of alarms at the ICU, thereby improving patient safety.Collection of annotated data in a clinical validation study for alarm algorithms in intensive care—a methodologic frameworkSylvia Siebig, Silvia Kuhls, Michael Imhoff, Julia Langgartner, Michael Reng, Jürgen Schölmerich, Ursula Gather, Christian E. Wrede10.1016/j.jcrc.2008.09.001Journal of Critical Care 25, 1 (2010)2009-01-19Journal of Critical Care2009-01-19251S0883-9441(10)X0002-8ICU128135http://www.jccjournal.org/article/PIIS088394410900207X/abstract?rss=yesAbstract: Background: Delirium is a rather common complication among patients admitted in intensive care units (ICUs), and rather than a single entity, it can be considered a spectrum of diseases where, besides overt cases, there are also many subsyndromal forms. Although there are many data about ICU delirium, there are few data concerning this complication in patients transferred from the ICU to a step-down unit (SDU) once clinically stable.Objectives: With the present study, we wanted to assess the incidence of and risk factors for delirium and subsyndromal forms and their impact on clinical outcome in a group of patients transferred from an ICU to an SDU.Methods: All patients transferred from an ICU to our SDU over a 2-year period were screened for delirium and subsyndromal delirious forms using the Intensive Care Delirium Screening Checklist, a simple tool already validated in the ICU. The following data were also recorded: demographic data, severity score (SAPS II), reason for admission to the SDU, length of stay, death rate, use of sedatives, impact of delirium on weaning from mechanical ventilation (MV).Results: Among the 234 patients, the incidence of delirium and subsyndromal forms was 7.6% and 20%, respectively. Subsyndromal forms diagnosed at admission represented a risk factor for the subsequent development of delirium (odds ratio [OR], P < .0001). A previous episode of brain failure during ICU stay and older age were risks factors for the development of subsyndromal forms, whereas not needing MV was a protective factor. Delirium significantly prolonged the stay in the SDU but did not influence survival and the process of weaning from MV. Overall, the percentage of patients with an abnormal Intensive Care Delirium Screening Checklist score at discharge (5%) was reduced compared with that recorded at admission (18%).Conclusions: Delirium may still occur after discharge from an ICU in patients who are transferred to an SDU. The strategy of care adopted in the SDU seems to positively affect the recovery from a delirious state. Patients with subsyndromal forms should be promptly recognized and treated because of the risk of developing delirium. Weaning from MV is not hindered by delirium.Delirium in patients admitted to a step-down unit: Analysis of incidence and risk factorsPiero Ceriana, Francesco Fanfulla, Fulvio Mazzacane, Carmen Santoro, Stefano Nava10.1016/j.jcrc.2009.07.004Journal of Critical Care 25, 1 (2010)2009-09-25Journal of Critical Care2009-09-25251S0883-9441(10)X0002-8Delirium136143http://www.jccjournal.org/article/PIIS0883944109002299/abstract?rss=yesAbstract: Purpose: Delirium occurs frequently in critical care but often remains undiagnosed because delirium monitoring is often dismissed as being too time-consuming. This study determined the validity and reliability of the “CAM-ICU Flowsheet,” a practical, time-sparing algorithm to assess the 4 delirium criteria in intubated patients.Materials and Methods: With permission from our institution's ethics committee, patients of a 31-bed surgical intensive care unit department were screened for delirium (1) by a psychiatrist as the reference rater using the 4 delirium criteria of the Diagnostic and Statistical Manual of Mental Diseases, Fourth Edition (DSM-IV), and (2) by 2 physician investigators using a German translation of the CAM-ICU Flowsheet.Results: Fifty-four surgical ICU patients underwent the complete protocol assessment with paired observations; 46% were diagnosed with delirium by the reference rater (n = 25), 9% had hyperactive delirium (n = 5), and 37% were hypoactive (n = 20). The CAM-ICU Flowsheet investigators had sensitivities of 88% (95% confidence interval, 69%-98%) and 92% (74%-99%), specificities of 100% (85%-100%), very high interrater reliability (κ, 0.96; 0.87-1.00), and needed 50 seconds (interquartile range, 40-120 seconds) in patients with delirium vs 45 seconds (interquartile range, 40–75 seconds) in those without delirium to complete assessments.Conclusions: The CAM-ICU Flowsheet has high sensitivity, high specificity, and very high interrater reliability. False-negative ratings can occur infrequently and mostly reflect the fluctuating course of delirium. The CAM-ICU Flowsheet is a valid, reliable, and quickly performed bedside delirium instrument.Validity and Reliability of the CAM-ICU Flowsheet to diagnose delirium in surgical ICU patientsUlf Guenther, Julius Popp, Lena Koecher, Thomas Muders, Hermann Wrigge, E. Wesley Ely, Christian Putensen10.1016/j.jcrc.2009.08.005Journal of Critical Care 25, 1 (2010)2009-10-14Journal of Critical Care2009-10-14251S0883-9441(10)X0002-8Delirium144151http://www.jccjournal.org/article/PIIS0883944109002251/abstract?rss=yesWe read with interest the meta-analysis by Alexiou et al on the impact of patient position on the incidence of ventilator-associated pneumonia (VAP). In particular, the analysis of semirecumbent position in 3 randomized controlled studies including 337 patients (168 test, 169 control) concluded that “patient positioned semirecumbently 45° have significantly lower incidence of clinically diagnosed VAP compared to patients positioned supinely.” We disagree with these conclusions because there are not supported by the results of the meta-analysis.Semirecumbent position to prevent ventilator-associated pneumonia is not evidence basedLuciano Silvestri, Dario Gregori, Hendrick K.F. van Saene, Roberto Belli, Miranda Blazic10.1016/j.jcrc.2009.08.002Journal of Critical Care 25, 1 (2010)2009-10-14Journal of Critical Care2009-10-14251S0883-9441(10)X0002-8Letters to the Editor152153http://www.jccjournal.org/article/PIIS088394410900224X/abstract?rss=yesWe would like to thank Dr Silvestri and colleagues for their interest in our work. First, it should be noted that all of the limitations, mentioned by the authors of this letter to the editor, have been acknowledged in the published manuscript and concerns regarding the statistical methods have been discussed.Re: Semirecumbent position to prevent ventilator-associated pneumonia is not evidence basedVangelis G. Alexiou, Vrettos Ierodiakonou, George Dimopoulos, Matthew E. Falagas10.1016/j.jcrc.2009.08.001Journal of Critical Care 25, 1 (2010)2009-10-14Journal of Critical Care2009-10-14251S0883-9441(10)X0002-8Letters to the Editor153154http://www.jccjournal.org/article/PIIS0883944110000146/abstract?rss=yesIn this issue of the Journal of Critical Care, we present our findings after implementation of an antibiotic dosing clinical pathway for the empiric treatment of ventilator-associated pneumonia (VAP) at our institution . The basis for our pathway was identification of the most common bacterial pathogens causing VAP in our intensive care units, susceptibility and minimum inhibitor concentration testing of these isolates, and design of an empiric antibiotic regimen that would achieve the greatest probability of achieving optimal pharmacodynamic exposure against the infecting organisms . These surveillance, microbiology, and pharmacodynamic studies led us to implement a computerized clinical pathway for antibiotic selection with high-dose, prolonged infusions of cefepime or meropenem, combined with empiric vancomycin and high-dose, extended-interval tobramycin. The detailed dosing regimens originally implemented can be found in a supplementary online document available at the journal's Web site.Optimal cefepime and meropenem dosing for ventilator-associated pneumonia patients with reduced renal function: An update to our clinical pathwayJoseph L. Kuti, David P. Nicolau10.1016/j.jcrc.2010.01.001Journal of Critical Care 25, 1 (2010)2010-03-01Journal of Critical Care2010-03-01251S0883-9441(10)X0002-8Letters to the Editor155156http://www.jccjournal.org/article/PIIS0883944108002657/abstract?rss=yesAbstract: Purpose: The study aimed to examine query strategies that would provide an exhaustive search method to retrieve the most referenced articles within specific categories of critical care.Material and Methods: A comprehensive list of the most cited critical care medicine articles was generated by searching the Science Citation Index Expanded data set using general critical care terms keywords such as “critical care,” critical care journal titles, and keywords for subsubjects of critical care.Results: The final database included 1187 articles published between 1905 and 2006. The most cited article was referenced 4909 times. The most productive search term was intensive care. However, this term only retrieved 25% of the top 100 articles. Furthermore, 662 of the top 1000 articles could not be found using any of the basic critical care search terms. Sepsis, acute lung injury, and mechanical ventilation were the most common areas of focus for the articles retrieved.Conclusion: Retrieving frequently cited, influential articles in critical care requires using multiple search terms and manuscript sources. Periodic compilations of most cited articles may be useful for critical care practitioners and researches to keep abreast of important information.The most influential articles in critical care medicineAndrew L. Rosenberg, Ravi S. Tripathi, James Blum10.1016/j.jcrc.2008.12.010Journal of Critical Care 25, 1 (2010)2009-03-31Journal of Critical Care2009-03-31251S0883-9441(10)X0002-8A View of the Literature157170http://www.jccjournal.org/article/PIIS0883944109002226/abstract?rss=yesAbstract: Purpose: When patients are unable to communicate their own wishes, surrogates are commonly used to aid in decision making. Although each jurisdiction has its own rules or legislation governing how surrogates are to make health care decisions, many rely on the notion of “best interests” when no prior expressed wishes are known.Methods: We purposively sampled written decisions of the Ontario Consent and Capacity Board that focused on the best interests of patients at the end of life. Interpretive content analysis was performed independently by 2 reviewers, and themes that were identified by consensus as describing best interests were construed, as well as the characteristics of an end-of-life dispute that may be most appropriately handled by an application to the Consent and Capacity Board.Results: We found that many substitute decision makers rely on an appeal to religion or God in their interpretation of best interests, whereas physicians focused narrowly on the clinical condition of the patient in their interpretations.Conclusions: Several lessons are drawn for the benefit of health care teams engaged in end-of-life conflicts with substitute decision makers over the best interests of patients.Best interests at end of life: A review of decisions made by the Consent and Capacity Board of OntarioRobert W. Sibbald, Paula Chidwick10.1016/j.jcrc.2009.07.008Journal of Critical Care 25, 1 (2010)2009-09-25Journal of Critical Care2009-09-25251S0883-9441(10)X0002-8Electronic Articles171.e1171.e7http://www.jccjournal.org/article/PIIS0883944109002858/abstract?rss=yesAbstract: Purpose: Nosocomial rhinosinusitis (NS) is diagnosed in 2% to 26% of intubated patients and is associated with ventilator-associated pneumonia, septicemia, and fever of unknown etiology. The purpose of this study was to review the underlying pathogenetic mechanisms and the treatment options that derive from them.Result: The pathogenesis of NS seems to be mainly a combination of the failure of the local defenses and self-clearance mechanisms and the development of topical factors, which favor the colonization of the nasal and antral cavities with pathogens. The systemic administration of antibiotics, which are the current treatment of NS, have a limited, if any, effect on any of the above pathophysiologic mechanisms. However, the review of the literature demonstrates that the research on functionally orientated treatment options has been limited to the effect of orotracheal vs nasotracheal intubation. There are no clinical trials investigating the effect, which combinations of pathophysiology-based measures may have on the prevalence and treatment of NS and ventilator-associated pneumonia.Conclusion: An update of the pathogenetic mechanisms demonstrates that the prevention and treatment of nosocomial rhinosinusitis may expand well beyond the systemic administration of antibiotics.Rhinosinusitis in the intensive care unit patients: A review of the possible underlying mechanisms and proposals for the investigation of their potential role in functional treatment interventionsMaria Riga, Vasilios Danielidis, Ioannis Pneumatikos10.1016/j.jcrc.2009.11.008Journal of Critical Care 25, 1 (2010)2010-01-15Journal of Critical Care2010-01-15251S0883-9441(10)X0002-8Electronic Articles171.e9171.e14http://www.jccjournal.org/article/PIIS0883944109001257/abstract?rss=yesAbstract: Purpose: The present study was performed to clarify the relationships between body mass index (BMI), interleukin-6 (IL-6) production, and respiratory muscle weakness in patients undergoing coronary artery bypass grafting (CABG).Materials and Methods: The correlations among BMI, changes in maximum inspiratory and expiratory pressure (ΔMIP, ΔMEP) on postoperative days (POD) 1 and 7, postoperative IL-6, and rapid turnover proteins (retinol-binding protein, prealbumin, and transferrin) on POD1 were assessed in 154 consecutive patients undergoing elective CABG. The patients were divided into quartiles of BMI, Q1 (BMI, <20.8 kg/m2) to Q4 (BMI, ≥25.25 kg/m2), and compared among groups.Results: There were significant correlations between ΔMIP and BMI (POD1, r = −0.369; POD7, r = −0.285) and IL-6 (POD1, r = 0.423; POD7, r = 0.431), and between ΔMEP and BMI (POD1, r = −0.252; POD7, r = −0.228) and IL-6 (POD1, r = 0.252; POD7, r = 0.384). Interleukin-6 showed a significant negative correlation with BMI (r = −0.374) and retinol-binding protein (r = −0.382). Interleukin-6 was highest in Q1 and lowest in Q4. Higher BMI indicated greater respiratory muscle strength than lower BMI.Conclusions: Preoperative BMI is correlated with respiratory muscle strength and cytokine production after CABG. The findings of this study suggest that BMI may be a valuable predictor for respiratory management in CABG patients.Body mass index is negatively correlated with respiratory muscle weakness and interleukin-6 production after coronary artery bypass graftingYuki Iida, Sumio Yamada, Osamu Nishida, Tomoyuki Nakamura10.1016/j.jcrc.2009.05.012Journal of Critical Care 25, 1 (2010)2009-08-17Journal of Critical Care2009-08-17251S0883-9441(10)X0002-8Electronic Articles172.e1172.e8http://www.jccjournal.org/article/PIIS0883944109001270/abstract?rss=yesAbstract: Purpose: Infusion filters, 0.2 μm, are commonly used in intensive care units as in-line filters to minimize particle and microbiological burden on patients. These filters usually contain either a positively charged or an uncharged membrane. The aim of the present study was to identify and to quantify an additive causing an unexpected maximum at 234.5 nm in the ultraviolet spectrum of a filtered drug solution using a filter.Materials and Methods: For identification and quantification of the substance, water for injection was used as eluent. Measurements were done by mass spectrometry and ultraviolet spectroscopy.Results: The unexpected additive in the filter was found to be N,N-dimethylacrylamide. The eluate of 2 filter batches had a mean N,N-dimethylacrylamide concentration of 3.9 and 2.5 μg/mL, respectively. Further investigations showed that after infusion breaks of different duration, the N,N-dimethylacrylamide concentration at the beginning of the next infusion cycle reaches a higher level than that at the end of the preceding infusion cycle.Conclusions: The type of filter examined in this study is primarily used in premature infants, newborns, and infants. These patients are vulnerable to neurotoxic substances having a long-term effect. Therefore, N,N-dimethylacrylamide should be completely removed from the final filter product.Contamination of 0.2-micrometer infusion filters by N,N-dimethylacrylamideJoanna Gasch, Reinhard Oertel, Claudia S. Leopold, Holger Knoth10.1016/j.jcrc.2009.05.013Journal of Critical Care 25, 1 (2010)2009-08-17Journal of Critical Care2009-08-17251S0883-9441(10)X0002-8Electronic Articles172.e9172.e14http://www.jccjournal.org/article/PIIS0883944109000719/abstract?rss=yesAbstract: Purpose: Microcirculatory disturbances are well known during shock; however, the accompanied histomorphological alterations are widely unknown. We used high resolution confocal-laser-scanning microscopy for the evaluation of microcirculation and histomorphology during Burn Shock treatment.Methods: Confocal-laser-scanning microscopy was performed in 10 burn shock patients (4 women, 6 men; aged 40.6 ± 11.4 years, burn extent >20% body surface area) initially and 24 hours after shock resuscitation. Ten matched hemodynamic stable burn intensive care unit patients served as controls. The following parameters were evaluated: quantitative blood cell flow, cell size of the granular layer, basal layer thickness, and epidermal thickness.Results: Quantitative blood cell flow in controls was 62.45 ± 3.39 cells per minute. Burn shock significantly reduced blood cell flow to 37.27 ± 3.64 cells per minute; fluid resuscitation effectively restored baseline blood flow (65.18 ± 3.76 cells per minute) after 24 hours. Granular cell size was 793.61 ± 41.58 μm2 in controls vs 644.27 ± 42.96 μm2 during burn shock. Post resuscitation granular cell size measured 932.74 ± 38.83 μm2. Basal layer thickness was 14.84 ± 0.59 μm in controls, 13.26 ± 0.54 μm in burn patients at admission and before resuscitation, and 17.50 ± 0.46 μm after resuscitation. Epidermal thickness in control patients was 49.60 ± 2.36 μm, 37.83 ± 2.47 μm in burn patients at admission and 69.50 ± 3.18 μm after resuscitation.Conclusions: Confocal-laser-scanning microscopy provides a noninvasive tool for simultaneous evaluation of microcirculation and tissue histomorphology. It may help to assess the adequacy of and response to resuscitation of burn patients early after trauma.Insight in microcirculation and histomorphology during burn shock treatment using in vivo confocal-laser-scanning microscopyMehmet Ali Altintas, Ahmet Ali Altintas, Merlin Guggenheim, Matthias C. Aust, Andreas David Niederbichler, Karsten Knobloch, Peter M. Vogt10.1016/j.jcrc.2009.03.003Journal of Critical Care 25, 1 (2010)2009-05-11Journal of Critical Care2009-05-11251S0883-9441(10)X0002-8Electronic Articles173.e1173.e7http://www.jccjournal.org/article/PIIS0883944109001117/abstract?rss=yesAbstract: Purpose: Traumatic hemodynamic instability is associated with high mortality if not expeditiously corrected. Hypotension despite adequate volume resuscitation is treated with vasopressors. Although catecholamines are typically the first agent used, arginine vasopressin (AVP) is increasingly been used as an adjuvant agent. Mortality with refractory hypotension and vasopressin use in trauma patients is unknown.Materials and Methods: A retrospective cohort analysis of trauma patients requiring vasopressors within 72 hours of admission was performed. Two groups were identified: patients who received AVP (AVP+) and those who did not (AVP−). Primary outcome was mortality.Results: Five hundred thirty nine patients met the criteria with 189 patients receiving AVP. Demographics, Injury Severity Score, minimum hemoglobin, and blood volume resuscitation (packed red blood cell, fresh frozen plasma, and platelets) were similar between groups. Trauma and Injury Severity Score suggested a higher probability of survival in AVP+ (0.88 vs 0.73, P < .001); however, the observed mortality was higher (55% vs 41%, P = .002). The age, Injury Severity Score, initial lactate, and severe head injury adjusted odds ratio of death for AVP+ patients was 1.6 (95% confidence interval, 1.1-2.4; P = .02).Conclusions: Arginine vasopressin is associated with increased mortality in trauma patients with refractory hypotension. Arginine vasopressin may be a marker of illness or possibly play a causal role in adverse outcomes. Clinicians should reconsider expanding the indications of AVP use.Vasopressin use is associated with death in acute trauma patients with shockBryan Collier, Lesly Dossett, Mindy Mann, Bryan Cotton, Oscar Guillamondegui, Jose Diaz, Sloan Fleming, Addison May, John Morris10.1016/j.jcrc.2009.05.003Journal of Critical Care 25, 1 (2010)2009-08-17Journal of Critical Care2009-08-17251S0883-9441(10)X0002-8Electronic Articles173.e9173.e14http://www.jccjournal.org/article/PIIS0883944109000860/abstract?rss=yesAbstract: Background: Setting goals for monitoring and initiating life-saving interventions such as prostaglandins (prostaglandin E1 [PGE1]) during transport stabilization are dependent on establishing an accurate clinical diagnosis.Objective: The aim of this study was to determine the accuracy of clinical diagnosis of suspected congenital heart disease (CHD) and the decision to initiate PGE1 in neonates presenting with hypoxemia.Methods: A retrospective cohort study (2002-2004) on hypoxemic neonates who were transported to an outborn neonatal intensive care unit (NICU) was conducted. Provisional diagnosis established by the transport team was categorized as suspected CHD (group 1), suspected persistent pulmonary hypertension of the newborn (group 2), and suspected CHD and/or persistent pulmonary hypertension of the newborn (group 3) based on history, physical examination, laboratory test, chest radiograph, and initial response to treatment. A definitive diagnosis was established on arrival to NICU by echocardiography.Results: A total of 115 neonates were included in the study. The mean gestational age at birth, median age at admission to NICU, and the mean stabilization time were 38.2 (2.4) weeks, 1 (1-26) days, and 217 (108) hours, respectively. The interventions provided during transport stabilization included mechanical ventilation (n = 86, 75%), PGE1 (n = 70, 61%), inotropes (n = 41, 36%), and fluid bolus (n = 50, 43%). The accuracy of a provisional diagnosis of CHD by transport team was 87.7% and the positive predictive value was 88.1%. Sixty neonates (88%) received PGE1 appropriately. Eight neonates (12%) with duct-dependent CHD (n = 68) did not receive PGE1 and were considered as missed opportunities. Ventilated neonates in groups 1 and 3 were identified as the groups that can potentially benefit from more liberal use of PGE1 and without any adverse effects.Conclusion: Although the accuracy of a diagnosis of CHD and the decision to initiate PGE1 was high, 12% of neonates with a duct-dependent CHD were transported without commencement of PGE1. Lower thresholds for PGE1 administration to hypoxemic neonates may potentially improve preoperative stabilization and minimize neonatal morbidity.Accuracy of clinical diagnosis and decision to commence intravenous prostaglandin E1 in neonates presenting with hypoxemia in a transport settingSandesh Shivananda, Joel Kirsh, Hilary E. Whyte, Koshy Muthalally, Patrick J. McNamara10.1016/j.jcrc.2009.04.005Journal of Critical Care 25, 1 (2010)2009-07-06Journal of Critical Care2009-07-06251S0883-9441(10)X0002-8Electronic Articles174.e1174.e9http://www.jccjournal.org/article/PIIS0883944109001427/abstract?rss=yesAbstract: “Bundles” strategies improve health care–associated infection (HCAI) rates in medical intensive care units (MICUs). However, few studies have analyzed HCAI rates adjusted for the device removal component of the bundles.An observational study of adult MICU patients while using bundles to prevent HCAIs associated with endovascular catheters, mechanical ventilation, and urinary tract catheters was conducted. The HCAI rates, unadjusted and adjusted for device use, were calculated using incidence rate ratios (unadjusted IRRs [uIRR] and adjusted IRRs [aIRR], respectively).Among 4550 study patients, HCAIs declined from 47 in 2004 to 10 in 2005, 8 in 2006, and 3 in 2007. Catheter-related blood stream infection (CRBSI) rates decreased from 10.77 to 1.67 per 1000 central line days (uIRR, 0.155; 95% confidence interval [CI], 0.13-0.18; P < .0001). Foley-related urinary tract infections (CA-UTI) decreased from 6.23 to 0.63 per 1000 device days (uIRR, 0.1; 95% CI, 0.08-0.19; P < .0001). Ventilator-associated pneumonia (VAP) per 1000 ventilator days diminished from 2.17 to 0.62 (uIRR, 0.29; 95% CI, 0.21-0.38; P < .0001). After adjustment for device use, aIRRs of CRBSI (0.14; 95% CI, 0.11-0.18), UTI (0.09; 95% CI, 0.06-0.12), and VAP (0.33; 95% CI, 0.22-0.47) declined significantly (P < .00001). Implementing comprehensive bundle strategies reduces HCAI beyond the impact of device removal.Study of device use adjusted rates in health care–associated infections after implementation of “bundles” in a closed-model medical intensive care unitSindhaghatta Venkatram, Sonal Rachmale, Balavenkatesh Kanna10.1016/j.jcrc.2009.06.016Journal of Critical Care 25, 1 (2010)2009-08-17Journal of Critical Care2009-08-17251S0883-9441(10)X0002-8Electronic Articles174.e11174.e18http://www.jccjournal.org/article/PIIS0883944109001269/abstract?rss=yesAbstract: Background: The deleterious effects of elevated intra-abdominal pressure (IAP) have been known for more than a century. The proposed objectives were to measure changes in IAP and analyze increase-related factors and complications and whether high IAP and its persistence are related to complications and mortality in a predominantly medical intensive care unit.Methods: Over a 1-year period, we conducted a prospective cohort study in which IAP was measured using the bladder method. Hospitalization time, demographic variables, diagnosis on admission, APACHE II score, and clinical complications were recorded.Results: A total of 130 patients were studied. Overall mean IAP was 12.3 mm Hg (standard deviation [SD], 3.79; 95% confidence interval [CI], 11.7-13), and on the first day, 12.68 mm Hg (SD, 5.32; 95% CI, 11.8-13.6); maximum IAP was 16.4 mm Hg (SD, 4.6; 95% CI, 15.6-17.2). A positive correlation was found between IAP, APACHE (Acute Physiology And Chronic Health Evaluation) II, and age. Higher IAP values were independently associated with higher age, prolonged activated partial thromboplastin time, need for dialysis, and intolerance to enteral feeding. The value showing the best sensitivity and specificity in predicting mortality was persistence of IAP 20 mm Hg or greater for 4 days or more. The number of days with IAP 20 mm Hg or greater was a factor associated with a higher risk of death (odds ratio, 2.3). Patients who died showed a tendency to increased IAP.Conclusion: In this study, a threshold IAP of 20 mm Hg and its permanence over time were the best predictive factors of complications and mortality. Among other relationships, we also observed that older patients had higher IAP. High IAP was a cause of intolerance to enteral nutrition.Usefulness of intra-abdominal pressure in a predominantly medical intensive care unitIsabel M. Murcia-Sáez, María L. Sobrino-Hernandez, Fernando García-Lopez, Virgilio Córcoles-González, José L. Cortés-Monedero, Antonio Tendero-Egea, Antonio Martínez-García, Antonio S. Salinas-Sánchez10.1016/j.jcrc.2009.05.017Journal of Critical Care 25, 1 (2010)2009-08-17Journal of Critical Care2009-08-17251S0883-9441(10)X0002-8Electronic Articles175.e1175.e6http://www.jccjournal.org/article/PIIS0883944109001439/abstract?rss=yesAbstract: Aim: The aim of this study was to review the patterns of severe childhood injuries and poisoning necessitating pediatric intensive care in a regional trauma center.Methods: We reviewed discharge data of all children who were hospitalized for severe injuries and poisoning at the pediatric intensive care unit of a teaching hospital between October 2002 and December 2008.Results: There were 86 patients (males/females, 2:1). Road traffic injuries (n = 19), falls (n = 17), and scalds (n = 13) were the 3 leading categories and accounted for 57% of these pediatric intensive care unit admissions. Injuries more commonly occurred indoor (63%), and victims of indoor accidents were younger (median age, 2.6 vs 8.4 years; P < .0001), with scalds, poisoning, and foreign body aspiration being predominant, whereas road traffic accidents predominated in outdoor accidents. As a risk factor, premorbid neurodevelopmental conditions such as mental retardation, convulsion disorder, or cerebral palsy were only present in indoor accidents. Children in outdoor injuries were generally healthy. Both groups were associated with significant morbidity (mechanical ventilation in 60%, inotrope use in 20%, anticonvulsants in 24%, and neurological/neurosurgical supports in 49%). Comparing the 3 most common categories of patients, there were significant differences in the median age, requirement of neurological/neurosurgical supports, and median hospital stay. Although not requiring neurological/neurosurgical supports, scalds injuries involved the youngest age group and required the longest hospital stay.Conclusions: The causes of severe childhood injuries are heterogeneous. Cardiopulmonary or neurological/neurosurgical supports are often required. These injuries more commonly occur indoor and involve toddlers with underlying neurodevelopmental conditions. These findings have important implications and serve to heighten public awareness especially on home safety measures in the prevention of childhood accidents.Severe childhood injuries and poisoning in a densely populated city: Where do they occur and what type?Kam-Lun Hon, Ting-Fan Leung, Kam-Lau Cheung, Siu-Ying Angel Nip, Judy Ng, Tai-Fai Fok, Pak-Cheung Ng10.1016/j.jcrc.2009.06.011Journal of Critical Care 25, 1 (2010)2009-08-17Journal of Critical Care2009-08-17251S0883-9441(10)X0002-8Electronic Articles175.e7175.e12http://www.jccjournal.org/article/PIIS0883944109001233/abstract?rss=yesAbstract: Purpose: The aim of the study was to assess the ability of plasma neutrophil gelatinase-associated lipocalin (pNGAL) to predict acute kidney injury (AKI) in adult intensive care unit (ICU) patients.Methods: All consecutives patients admitted to 3 ICUs were enrolled in this prospective-observational study. Plasma neutrophil gelatinase-associated lipocalin was analyzed at ICU admission. Risk, injury, failure, loss, and end-stage kidney (RIFLE) criteria were calculated at admission and for each day during the first week. Patients were classified according to whether they met the threshold for RIFLE criteria (RIFLE 0 or 1) at admission and during the first week. Four groups were identified: RIFLE (0-0), (1-1), (1-0), and (0-1).Results: During this 1-month period, 88 patients were included in the study. Thirty-six patients met the criteria for RIFLE 0-0 with a mean pNGAL of 98 ± 60 nmol/L, 22 for RIFLE 1-1 with a mean pNGAL of 516 ± 221 nmol/L, and 20 patients had no AKI at admission but develop AKI at 48 hours (24-96 hours) (RIFLE 0-1) with a pNGAL of 342 ± 183 nmol/L. Ten patients met the criteria for RIFLE 1-0 and had a mean pNGAL of 169 ± 100 nmol/L. Using a cutoff of 155 nmol/L, sensitivity and specificity to predict AKI were 82% and 97%, respectively (area under the curve [AUC] = 0.92 [0.852-0.972]; P = .001). Looking at the patients without AKI at admission (n = 56) and who developed (n = 20) or did not develop (n = 36) AKI, receiver operating characteristic curve analysis was as follows: AUC = 0.956 (0.864-0.992). Sensitivity was 85% and specificity was 97%. Of the 7 patients who required renal replacement therapy, all of them had pNGAL of more than 303 nmol/L (AUC = 0.788 [0.687-0.868]).Conclusion: Plasma neutrophil gelatinase-associated lipocalin at ICU admission is an early biomarker of AKI in adult ICU patients. Plasma neutrophil gelatinase-associated lipocalin increased 48 hours before RIFLE criteria.Plasma neutrophil gelatinase-associated lipocalin is an early marker of acute kidney injury in adult critically ill patients: A prospective studyJean-Michel Constantin, Emmanuel Futier, Sebastien Perbet, Laurence Roszyk, Alexandre Lautrette, Thierry Gillart, Renaud Guerin, Matthieu Jabaudon, Bertrand Souweine, Jean-Etienne Bazin, Vincent Sapin10.1016/j.jcrc.2009.05.010Journal of Critical Care 25, 1 (2010)2009-09-25Journal of Critical Care2009-09-25251S0883-9441(10)X0002-8Electronic Articles176.e1176.e6http://www.jccjournal.org/article/PIIS0883944109001130/abstract?rss=yesAbstract: Objectives: The aim of this study was to determine whether cytokine expression (interleukin [IL]-1β, IL-6, IL-8, IL-10, and tumor necrosis factor [TNF]-α), C-reactive protein, and endotoxins on the first day of intensive care unit (ICU) admission are associated with hospital mortality in severe community-acquired pneumonia (CAP).Design: This was a prospective study with bronchoalveolar lavage (BAL) and blood sampling.Setting: This study was carried out in a 44-bed medical ICU of a 1700-bed university hospital.Patients: Participants included 112 mechanically ventilated patients with severe CAP.Interventions: Serum and BAL fluid IL-1β, IL-6, IL-8, IL-10, TNF-α, C-reactive protein, and endotoxins on the first day of ICU admission were obtained.Measurements and Main Results: The concentrations of TNF-α in BALF and IL-6, IL-8, IL-10, and TNF-α in serum were higher in nonsurvivors than in survivor patients with CAP. Of these 112 patients with severe CAP (39%), 44 developed acute respiratory distress syndrome (ARDS); these patients seemed to have higher serum IL-6, IL-8, and IL-10 levels than did the non-ARDS group. Furthermore, in the ARDS population, we found that the endotoxin levels in the BAL fluid were higher in the survival than in the nonsurvival group and BAL fluid concentrations of IL-6, IL-8, and IL-1β and sera levels of IL-6 and IL-10 were lower in the survival than in the nonsurvival group, and they were associated with a high negative predictive value.Conclusions: Serum and BAL fluid levels of the studied cytokines on admission may provide valuable prognostic information for patients with severe CAP.Systemic and bronchoalveolar cytokines as predictors of in-hospital mortality in severe community-acquired pneumoniaYao-Ling Lee, Wei Chen, Ling-Yun Chen, Chia-Hung Chen, Yu-Chao Lin, Shinn-Jye Liang, Chuen-Ming Shih10.1016/j.jcrc.2009.05.002Journal of Critical Care 25, 1 (2010)2009-07-10Journal of Critical Care2009-07-10251S0883-9441(10)X0002-8Electronic Articles176.e7176.e13http://www.jccjournal.org/article/PIIS0883944110000286/abstract?rss=yesContents10.1016/S0883-9441(10)00028-6Journal of Critical Care 25, 1 (2010)2010-03-01Journal of Critical Care2010-03-01251S0883-9441(10)X0002-8FrontmatterA1A4http://www.jccjournal.org/article/PIIS0883944110000298/abstract?rss=yesEditorial Board10.1016/S0883-9441(10)00029-8Journal of Critical Care 25, 1 (2010)2010-03-01Journal of Critical Care2010-03-01251S0883-9441(10)X0002-8FrontmatterA5A5