Journal of Critical Care - Articles in Press

Revised Acute Physiology and Chronic Health Evaluation score as a predictor of neurosurgery intensive care unit readmission: A case-controlled study - Corrected Proof

Huan Fang Lee, Shu-Ching Lin, Chin-Li Lu, Chiao Fang Chen, Miaofen Yen — 2010-03-02

Abstract: Purpose: Patients with neurologic system problems are among the most common patients readmitted to the intensive care unit (ICU). Readmission predictors for neurologic ICU patients have not been established. Previous research suggests that the Revised Acute Physiology and Chronic Health Evaluation (APACHE II) score is one indication of the critical status of ICU-admitted patients; however, the ability of the discharge APACHE II to predict readmission to the ICU requires further study. The purpose of this study was to investigate the ability of the APACHE II scoring system to predict ICU readmission of neurosurgical and ICU patients.Materials and Methods: A retrospective case-controlled comparison study and a review of patient records for all patients admitted to 8 ICUs from January 2003 to June 2005 (N = 753) were conducted. Readmitted neurosurgery ICU patients were matched with 58 randomly selected nonreadmitted patients.Results: Nine variables were significantly different between the readmission and case-controlled group. The APACHE II discharge score was the only significant predictor and was able to predict 18.6% of neurologic ICU readmissions. The risk of ICU readmission increased when the APACHE II score at the time of discharge exceeded 8.5 points.Conclusions: The risk of ICU readmission of neurologic ICU patients can be predicted by determining APACHE II score upon ICU discharge.

Managing intensive care units: Make LOVE, not war! - Corrected Proof

2010-03-02

Abstract: Objective: Describe a program set up in a French intensive care unit (ICU) aimed at improving communication inside the team and communication information given to patients and their relatives; explain how those actions can improve communication inside the ICU and ultimately why it could improve patient's outcome.Design and Methods: Position paper.Intervention: Progressive implementation of multifaceted quality improvement program.Results: The program Leadership, Ownership, Values, and Evaluation (LOVE) was developed over 10 years. It was usually well accepted by the members of the team, patients, and relatives, in particular the 24-hour visiting program that was prospectively evaluated. Information and decisions were shared with the patients or more often with the relatives, who became for some of them really “part of the team.” Additional actions such as participation to some of the simplest cares by the families are under investigation. A prospective evaluation of such programs, although difficult to perform, remains probably necessary.Conclusion: Quality of life within the ICU is based on many factors including a strong and positive leadership, an absolute respect of individuals, and a rigorous evaluation of quality of care, which could influence heavily the quality of life in the ICU for patients, relatives, and health care professionals and facilitate team work. Whether this could really influence outcome remains to be demonstrated.

Triggers for emergency team activation: A multicenter assessment - Corrected Proof

2010-03-02

Abstract: Purpose: The purpose of the study was to examine triggers for emergency team activation in hospitals with or without a medical emergency team (MET) system.Materials and Methods: Within a cluster randomized controlled trial examining the effect of introducing a MET system, we recorded the triggers for emergency team activation. We compared the proportion and rate of such triggers in hospitals with or without a MET system and in relation to type of hospital, type of patient ward, and time of day.Results: In control hospitals, the most common trigger for emergency team activation was a decrease in Glasgow Coma Score by 2 or more points (45.6%), whereas in MET hospitals, it was the fact that staff members were “worried” or the call occurred despite the lack of a “specified reason” (39.3%). In particular, MET hospitals were 35 times more likely to make a call because of staff being “worried” about the patient (14.1% vs 0.4%, P < .001). Control hospitals were also significantly more likely to call an emergency team because of a deteriorating respiratory (P = .003) or pulse (P < .001) rate, more calls had at least 3 triggers for activation (20.8% vs 10.2%, P = .036), and the average number of triggers per call was significantly higher (P = .013). Nonmetropolitan hospitals were more likely to call an emergency team because of respiratory rate abnormalities (33.6% vs 23.2%, P = .015). Coronary care unit calls were more likely to be triggered by abnormalities in pulse rate and systolic blood pressure, and more calls occurred during the period from 6:00 am to noon.Conclusions: In MET hospitals, more emergency team calls are triggered because staff members are worried about the patient; and fewer calls have multiple triggers. Type of hospital, type of ward, and time of day also affect the nature and frequency of triggers for emergency team activation.

Intravenous paracetamol reduced the use of opioids, extubation time, and opioid-related adverse effects after major surgery in intensive care unit - Corrected Proof

Dilek Memis, Mehmet Turan Inal, Gulsum Kavalci, Atakan Sezer, Necdet Sut — 2010-03-02

Abstract: Background: This study assessed the analgesic efficacy, side effects, and time to extubation of intravenous paracetamol when administered as an adjuvant to intravenous meperidine after major surgery in intensive care unit (ICU).Material: Patients were randomized postoperatively into 2 groups in ICU. Patients received either 100 mL of serum saline intravenous (IV) every 6 hours and IV meperidine (n = 20 group M) or IV paracetamol 1 g every 6 hours and IV meperidine (n = 20, group MP) into a peripheral vein for 24 hours. Behavioral Pain Scale (BPS) is used until extubation, and visual analog score (VAS) is used after extubation. When BPS and VAS values were more than 4, meperidine, 1 mg/kg IV, was administered and noted in 2 groups. Pain scores, total meperidine consumption, time to extubation, sedation scores, and side effects are 24-hour postoperatively noted.Results: Behavioral Pain Scale and VAS scores are significantly lower in group paracetamol-meperidine at 24 hours (P < .05). In group MP, postoperative meperidine consumption (76.75 ± 18.2 mg vs. 198 ± 66.4 mg) and extubation time (64.3 ± 40.6 min vs. 204.5 ± 112.7 min) were lower than in group M (P < .01). In addition to, postoperative nausea-vomiting and sedation scores were significantly lower in group MP when compared with group M (P < .05).Conclusion: We have demonstrated important clinical benefits by the addition of 4 g/d of paracetamol to meperidine after major surgery. This benefit has been shown in a range of patients under routine clinical conditions and therefore has important practical consequences in ICU. These data suggest that intravenous paracetamol is a useful component of the multimodal analgesia model, especially after major surgery.

Polymorphisms of genes encoding tumor necrosis factor-alpha, interleukin-10, cluster of differentiation-14 and interleukin-1ra in critically ill patients - Corrected Proof

2010-02-17

Abstract: Purpose: The aim of the study was to determine whether distributions of tumor necrosis factor (TNF)-α308, interleukin (IL)-101082, CD14159, and IL-1ra gene intron 2 genotypes in critically ill patients are associated with outcome, underlying cause of sepsis, and type of microorganism.Materials and methods: Blood samples from 106 critically ill white patients were genotyped by method based on polymerase chain reaction for TNF-α308, IL-101082, CD14159, and IL-1ra gene intron 2.Results: All patients with TNF-α308AA genotype survived; relative risk (RR) of death in patients with AG was 3.250 and with GG, 1.923 (P < .01). In patients with Gram-positive sepsis, IL-101082AA and then AG genotypes were the most frequent ones (odds ratio [OR], 18.67 and 7.20, respectively; P < .01). When comparing IL-101082AA with AG, RR of pancreatitis was 1.80 and OR was 3.40. When AA and GG were compared, RR was 7.33 and OR was 20.00. In patients with GG, RR of peritonitis was 4.07 and OR was 5.88 (P < .01). In patients with Gram-positive sepsis, CD14159CT was the most frequent one with OR of 5.25. Distribution of 6 IL-1ra gene intron 2 genotypes showed no significant association.Conclusions: Distribution of TNF-α308 genotypes is associated with outcome, IL-101082 with type of microorganism and underlying cause of sepsis, and CD14159 with type of microorganism.

The S/Z ratio: A simple and reliable clinical method of evaluating laryngeal function in patients after intubation - Corrected Proof

Graeme Van der Meer, Yolandi Ferreira, James W. Loock — 2010-02-11

Abstract: Objectives: 1. To determine the consequences of prolonged intubation on laryngeal function.2. To evaluate simple clinical criteria or tests that could alert the clinician to potential laryngeal pathology requiring ear, nose, and throat/otolaryngology (ENT) referral.Design: A prospective case series.Setting: A surgical intensive care unit in a tertiary academic hospital in Cape Town, South Africa.Participants: Thirty-two patients who had undergone a period of translaryngeal intubation for a period greater than 12 hours.Main outcome measures: 1. Patient subjective voice change rating.2. Clinician assessment of laryngeal function.3. S/Z ratio.4. Presence of laryngeal pathology on endoscopic assessment of the larynx.Results: Upon initial evaluation within 6 hours of extubation, 26 (81%) of patients exhibited symptomatic laryngeal dysfunction. At this stage, 13 (40%) had S/Z ratios greater than 1.4. The degree of dysfunction as described by subjective scoring and the S/Z ratio was proportional to the duration of intubation. After 24 hours, 23 (72%) patients' voices had improved subjectively; and the S/Z ratio exceeded 1.4 in just 6 patients (19%). Of these 6 patients, 4 exhibited laryngeal pathology on flexible nasoendoscopy. These 4 patients were followed up over 1 year, and 1 patient was ultimately offered a vocal cord medialization procedure. The S/Z ratio is 100% sensitive and 93% specific, with an accuracy of 93.75%, in diagnosing laryngeal pathology requiring ENT referral.Conclusions: 1. A period of laryngeal intubation carries signification risk of laryngeal dysfunction. Most, but not all, dysfunction resolves within 24 hours.2. Residual laryngeal pathology can be reliably and simply screened for by the use of the S/Z ratio. We recommend that patients with an S/Z ratio greater than 1.4 more than 24 hours after extubation require ENT referral for laryngoscopy.

Troponin-I as a prognosticator of mortality in severe sepsis patients - Corrected Proof

2010-02-11

Abstract: Purpose: The purpose of this retrospective study was to evaluate cardiac troponin-I (cTnI) as a 28-day mortality prognosticator and predictor for a drotrecogin alfa (activated) (DrotAA) survival benefit in recombinant human activated Protein C Worldwide Evaluation in Severe Sepsis patients.Methods: Cardiac troponin-I was measured using the Access AccuTnI Troponin I assay (Beckman Coulter, Fullerton, CA). There were 598 patients (305 DrotAA, 293 placebo) with baseline cTnI data (cTnI negative [<0.06 ng/mL], n = 147; cTnI positive [≥0.06 ng/mL], n = 451).Results: Cardiac troponin-I–positive patients were older (mean age, 61 vs 56 years; P = .002), were sicker (mean Acute Physiology and Chronic Health Evaluation II, 26.1 vs 22.3; P < .001), had lower baseline protein C levels (mean level, 49% vs 56%; P = .017), and had higher 28-day mortality (32% vs 14%, P < .0001) than cTnI-negative patients. Elevated cTnI was an independent prognosticator of mortality (odds ratio, 2.020; 95% confidence interval, 1.153-3.541) after adjusting for other significant variables. Breslow-Day interaction test between cTnI levels and treatment was not significant (P = .65).Conclusion: This is the largest severe sepsis study reporting an association between elevated cTnI and higher mortality. Cardiac troponin-I elevation was not predictive of a survival benefit with DrotAA treatment.

Practical experiences and in vitro and in vivo validation studies with a new gastric tonometric probe in human adult patients - Corrected Proof

Péter Palágyi, László Vimláti, Krisztina Boda, Gyula Tálosi, Domokos Boda — 2010-02-11

Abstract: Purpose: This study provides practical experiences with a new, simple, balloon-free gastric tonometric probe (probe) and reports the results of simultaneous in vitro and in vivo measurements with a conventional, ballooned gastric air tonometer (catheter) and the new device.Materials and Methods: Ten healthy volunteers and 50 anesthetized surgical patients with different American Society of Anesthesiologists (ASA) scores, scheduled for neurologic, orthopedic, trauma, and cardiac operations, were enrolled in the study. The values of 60 in vitro and, in 12 surgical patients, 101 in vivo paired Pco2 measurements—performed simultaneously with the new tonometric probe and the catheter that was connected to a Tonocap monitor—were compared. The tolerability of the measurement with the new probe was examined, and the results of gastric tonometry and, in surgical cases, the gastric tonometric, end-expiratory, and arterial Pco2 values were registered. The results were evaluated by analysis of variance test. The data of the in vivo paired measurements were evaluated by Bland-Altman analysis.Results: The use of the probe proved to be well tolerated and easily applicable in the studied cases. The results of 20 measurements obtained in healthy volunteers and those of 520 measurements in the surgical cases correspond to the data obtained with the classical methods published in the medical literature. During in vitro paired measurements, there was a good agreement between the data obtained with the 2 methods; however, in the in vivo studies, the results of measurements performed with the probe were mostly higher.Conclusions: The differences between the results obtained with the 2 methods might have been caused by the quicker equilibration property of the probe and by the fundamental differences between the 2 methods. The new probe seems to be applicable for routine human measurements.

Prognostic factors of mortality in patients with community-acquired bloodstream infection with severe sepsis and septic shock - Corrected Proof

2010-02-11

Abstract: Purpose: The purpose of the study was to determine the independent risk factors on mortality in patients with community-acquired severe sepsis and septic shock.Methods: A single-site prospective cohort study was carried out in a medical-surgical intensive care unit in an academic tertiary care center. One hundred twelve patients with community-acquired bloodstream infection with severe sepsis and septic shock were identified. Clinical, microbiologic, and laboratory parameters were compared between hospital survivors and hospital deaths.Results: One-hundred twelve patients were included. The global mortality rate was 41.9%, 44.5% in septic shock and 34.4% in severe sepsis. One or more comorbidities were present in 66% of patients. The most commonly identified bloodstream pathogens were Escherichia coli (25%) and Staphylococcus aureus (21.4%). The proportion of patients receiving inadequate antimicrobial treatment was 8.9%. By univariate analysis, age, Acute Physiology and Chronic Health Evaluation II score, at least 3 organ dysfunctions, and albumin, but neither microbiologic characteristics nor site of infection, differed significantly between survivors and nonsurvivors. Acute Physiology and Chronic Health Evaluation II (odds ratio, 1.13; 95% confidence interval, 1.06-1.21) and albumin (odds ratio, 0.34; 95% confidence interval, 0.15-0.76) were independent risk factors associated with global mortality in logistic regression analysis.Conclusion: In addition to the severity of illness, hypoalbuminemia was identified as the most important prognostic factor in community-acquired bloodstream infection with severe sepsis and septic shock.

Effect of head rotation on overlap and relative position of internal jugular vein to carotid artery in infants and children: A study of the anatomy using ultrasonography - Corrected Proof

Jeong-Yeon Hong, Bon Nyeo Koo, Won Ok Kim, Eunkyeong Choi, Hae Keum Kil — 2010-02-11

Abstract: Purpose: The aim of this study was to evaluate the influence of head rotation on the relative anatomy of internal jugular vein (IJV) and carotid artery (CA) in infants and children.Materials and Methods: Two hundred pediatric patients (26.5 ± 23.3 months old) who were undergoing elective surgery were eligible for this consecutive and prospective study. Using 2-dimensional ultrasound, the amount of overlap and the relative position of the 2 vessels were compared between heads in the neutral position and in 90° of rotation.Results: The mean percentage overlap of CA by IJV in the neutral position increased significantly as the head was rotated to the right (23.3% vs 39.2%) and left (35.3% vs 52.8%). The incidence of lateral positioning of IJV to CA decreased significantly when the head was rotated (40% vs 21% in right, 26.5% vs 10.5% in left). The right IJV is associated with less overlap of the CA than the left, regardless of head position.Conclusions: The head should be kept in as near a neutral position as possible because the overlap increased by head rotation in both sides. In addition, the right IJV should be preferred because of less CA overlap and more lateral positioning than the left.

The 4Ts scoring system for heparin-induced thrombocytopenia in medical-surgical intensive care unit patients - Corrected Proof

2010-02-11

Abstract: Background: Heparin-induced thrombocytopenia (HIT) is commonly considered but rarely confirmed in critically ill patients. The 4Ts score (Thrombocytopenia, Timing of thrombocytopenia, Thrombosis, and oTher reason) might identify individual patients at risk of having this disorder.Objective: The aim of the study was to evaluate the value of the 4Ts HIT score in comparison with the serotonin-release assay (SRA) in critically ill patients.Methods: This study describes the combined results of 3 prospective studies enrolling critically ill patients who were investigated for HIT if platelets fell to less than 50 × 109/L or if platelet counts decreased to less than 50% of the value upon intensive care unit admission. We confirmed HIT by a positive platelet SRA. We assigned a 4Ts score blinded to SRA results to all 50 patients investigated for HIT; those with positive SRA results were scored in duplicate.Results: Of 528 patients, 50 (9.5%) were investigated for HIT; 39 (78%) of 50 (64%-88%) of these patients were scored as “low probability” by 4Ts score and none had a positive SRA. Of 49 patients who underwent SRA testing because of thrombocytopenia, only 2 (4.1%; 0.5-14.0) had a positive SRA (1 with a moderate 4Ts score and 1 with a high 4Ts score). Therefore, the overall incidence of HIT confirmed by SRA was 2 (0.4%) of 528 (0.04%-1.4%).Conclusions: Significant thrombocytopenia during heparin administration occurred in 9.5% of critically ill patients, but HIT was confirmed in only 4.1% of those undergoing testing, for an overall incidence of 0.4%. A low 4Ts score occurred in 78% of patients investigated for HIT; none of these patients had a positive SRA. We conclude that HIT is uncommon in critically ill patients and that the 4Ts score is worthy of further evaluation in this patient population.

Ginger extract reduces delayed gastric emptying and nosocomial pneumonia in adult respiratory distress syndrome patients hospitalized in an intensive care unit - Corrected Proof

2010-02-11

Abstract: Purpose: The purpose of this study was to evaluate the effect of ginger extract on delayed gastric emptying, developing ventilator-associated pneumonia, and clinical outcomes in adult respiratory distress syndrome (ARDS).Materials and Methods: Thirty-two ARDS patients who were dependent on mechanical ventilation and fed via nasogastric tube were studied. After enrolment, patients were randomized to 2 groups. The control group received 1 g of coconut oil as placebo, and the study group received 120 mg of ginger extract. The amount of feeding tolerated at the first 48 hours of feeding, amount of feeding tolerated during the entire study period, nosocomial pneumonia, number of intensive care unit (ICU)–free days, number of ventilator-free days, and mortality were evaluated during 21 days of intervention.Results: There was a significant difference between the ginger group and the control group in the amount of feeding tolerated at the first 48 hours of enteral feeding (51% vs 57%, P < .005). There was a trend toward a decrease in pneumonia in the ginger group (P = .07). The overall in-ICU mortality was 15.6%, with no significant difference in the 2 groups. The number of ventilator-free days and that of ICU-free days were lower in the control group compared with the ginger group (P = .04 and P = .02).Conclusion: This study showed that gastric feed supplementation with ginger extract might reduce delayed gastric emptying and help reduce the incidence of ventilator-associated pneumonia in ARDS.

Scoring systems in acute pancreatitis: Which one to use in intensive care units? - Corrected Proof

Deven Juneja, Palepu B. Gopal, Murthy Ravula — 2010-02-11

Abstract: Purpose: The aim of the study was to assess and compare the efficacy of various scoring systems in predicting the severity and outcome of patients with acute pancreatitis (AP) admitted in intensive care unit (ICU).Methods: Prospective, single institution review of 55 consecutive AP patients admitted in ICU during a 2-year period. Disease severity scores and mortality predictions were calculated using the collected data in the first 48 hours of ICU admission for Ranson and Glasgow scores and in the first 24 hours for other scores.Results: Forty-two patients (76.4%) developed severe pancreatitis. Intensive care unit and 30-day mortality was 18.2% and 27.3%, respectively. Use of mechanical ventilation (MV) was an independent predictor of outcome on multivariate analysis with lack of MV being protective (adjusted odds ratio, 0.003; 95% confidence interval [CI], 0.00001-0.67; P = .04). All scoring systems had comparable accuracy in predicting severity and 30-day mortality, but sequential organ failure assessment (SOFA) score had greater efficacy with its area under curve for predicting severity and 30-day mortality being 0.81 (95% CI, 0.69-0.92) and 0.93 (95% CI, 0.85-0.99), respectively. Sensitivity and specificity (SOFA score, >4) was 76.2% and 69.2%, respectively, for predicting severity, and sensitivity and specificity (SOFA score, >8) was 86.7% and 90%, respectively, for predicting 30-day mortality.Conclusions: Use of MV is an independent predictor of outcome in AP patients admitted to ICU. Although all scoring systems had reliable accuracy in predicting severity and outcome, SOFA score performed better with additional advantages of easy applicability and timely assessment.

Prospective evaluation of a decision support system for setting inspired oxygen in intensive care patients - Corrected Proof

2010-02-11

Abstract: Purpose: The aim of the study was to prospectively evaluate a decision support system for its ability to provide appropriate suggestions of inspired oxygen fraction in intensive care patients comparing with levels used by clinicians in attendance.Materials and methods: Thirteen mechanically ventilated patients were studied in an intensive care unit where up to 4 experiments were performed during 2 consecutive days. Inspired oxygen fraction was selected in each experiment by both the decision support system and attending clinicians, and each selection was evaluated by measuring arterial oxygen saturation.Results: Median (interquartile range [range]) changes in inspired oxygen fraction from baseline level by attending clinicians and the decision support system were 0.00 (−0.05 to 0.00 [−0.10 to 0.05]) and −0.03 (−0.07 to 0.01 [−0.16 to 0.12]), respectively. Clinician ranges of inspired oxygen fraction and arterial oxygen saturation were 0.25 to 0.70 and 0.92 to 0.99, respectively. Decision support system ranges of inspired oxygen fraction and arterial oxygen saturation were 0.26 to 0.54 and 0.94 to 0.99, respectively.Conclusions: The decision support system selects appropriate levels of inspired oxygen fraction in intensive care patients and could be used for automatic frequent assessment of patients, freeing the focus of clinicians to concentrate on more challenging therapy.

Mechanical ventilation mode (volume × pressure) does not change the variables obtained by indirect calorimetry in critically ill patients - Corrected Proof

2010-01-18

Abstract: Purpose: The aim of the study was to analyze the difference between the results obtained by indirect calorimetry (IC) using volume-controlled and pressure-controlled mechanical ventilation in 2 different ventilators and to characterize the variables achieved by IC after well-defined changes in minute volume (Vm).Materials and Methods: Prospective study of 20 critically ill patients under volume-controlled (n = 15) or pressure-controlled (n = 5) mechanical ventilation. Three IC measurements of 45 minutes each were taken; values of oxygen consumption (Vo2), carbon dioxide production (Vco2), Vm, resting energy expenditure (REE), and respiratory quotient (RQ) were obtained. For the last measurement, Vm was set at 20% above the baseline.Results: There were no differences between the results obtained by IC during volume-controlled and pressure-controlled mechanical ventilation. The most relevant changes in the variables obtained by IC before and after intervention in Vm were a significant increase in Vco2 (from 165 to 177 mL·min−1; P < .01), a decrease in Paco2 (from 38.49 to 28.46 mm Hg; P < .01), and a rise in pH (from 7.41 to 7.49; P < .01). There were no alterations in Vo2, REE, or RQ.Conclusions: Ventilators and ventilation modes do not influence the IC measurements. The observed changes have no clinical effects and are reversible, provided that increased Vm is maintained for no longer than 45 minutes.

The association between deprivation and hospital mortality for admissions to critical care units in England - Corrected Proof

Catherine A. Welch, David A. Harrison, Andrew Hutchings, Kathryn Rowan — 2010-01-15

Abstract: Introduction: Few studies have investigated the association between level of social deprivation and acute hospital outcome for admissions to adult general critical care units. It is important to be aware if an association exists because risk prediction models do not adjust for deprivation.Materials and Methods: Deprivation was measured using the Index of Multiple Deprivation (IMD) 2004, developed using 2001 census data in England. Eighty-four thousand four hundred twenty-three admissions to 138 adult general critical care units in England were selected from the Case Mix Programme Database from 1 year before to 1 year after the census date and linked to the IMD using postcodes. Logistic regression analysis was used to investigate a possible association between quintile of IMD and acute hospital mortality.Results: As deprivation increased, acute hospital mortality also increased (P < .001). This association remained after adjusting for age, sex, acute severity, medial history, source of admission, and reason for admission to critical care (adjusted odds ratio for most vs least deprived quintile, 1.19; 95% confidence interval, 1.10-1.28).Conclusions: There is an association between increasing deprivation and increasing risk of mortality for admissions to adult general critical care unit units in England. Further research is required to identify other unmeasured potential confounders (eg, smoking, alcohol consumption) as possible explanations for this association.

Combination of high frequency oscillatory ventilation and interventional lung assist in severe acute respiratory distress syndrome - Corrected Proof

2010-01-15

Abstract: Background: The combination of high-frequency oscillatory ventilation (HFOV) and extracorporeal carbon dioxide removal with the interventional lung assist (iLA) in severe acute respiratory distress syndrome (ARDS) represents a novel treatment option.Methods: The study used a retrospective single-center analysis of 21 consecutive adult patients with severe ARDS, ventilated with HFOV/iLA. Efficiency, side effects, and outcome of combined treatment are presented as median (interquartile range).Measurements and main results: The following were used to determine patient characteristics: sequential organ failure assessment score, 14; simplified acute physiology score II, 41; and Murray score, 4. The duration of combined treatment was 6 days. The blood flow through the iLA was 1.9 L/min.The Pao2/inspired fraction of oxygen ratio increased from 61 (47-86) to 98 (67-116) within 2 hours and to 106 (70-135) mm Hg at 24 hours. Paco2 decreased from 58 (50-76) to 37 (29-47) mm Hg at 2 hours with normalization of pH 7.28 (7.16-7.36) to 7.43 (7.33-7.49) after 2 hours associated with hemodynamic stabilization. In 6 patients, complications due to iLA treatment were observed, and in 3 patients, complications associated with HFOV were seen. Weaning from HFOV/iLA was successful in 10 patients. The 30-day mortality rate was 43%, and hospital mortality rate was 57%.Conclusion: The combination of HFOV/iLA is an option in severe pulmonary failure if conventional ventilation fails and pumpdriven extracorporeal membrane oxygenation therapy is not available.

Impact of endotracheal tube size on preextubation respiratory variables - Corrected Proof

2010-01-15

Abstract: Purpose: Many parameters have been evaluated to predict successful extubation. These are all affected by extrapulmonary variables. The purpose of this study was to evaluate the effect of endotracheal tube (ETT) size on preextubation predictors of successful extubation.Materials and Methods: Twenty-two intubated and mechanically ventilated subjects were recruited when ready for extubation. Subjects were ventilated with T-piece, continuous positive airway pressure (CPAP) of 5 cm H2O, and pressure support ventilation (PSV) of 5 cm H2O in randomized order for 15 minutes each. Pulmonary mechanics—including respiratory frequency (f), tidal volume (VT), f/VT ratio, negative change in esophageal pressure, pressure time product (PTP), work of breathing, and the airway occlusion pressure 100 milliseconds after the onset of inspiratory flow—were measured using a microprocessor-based monitor at the end of each interval. After extubation, measurement of pulmonary mechanics was repeated at 15 and 60 minutes.Results: In patients with 7.0- or 7.5-mm ETT compared with patients with 8.0-mm ETT, (1) f was significantly higher during all ventilatory modes and 15 minutes after extubation; (2) VT during PSV and CPAP was significantly lower; (3) mean f/VT was significantly higher (122 ± 57 vs 69 ± 35, P = .026); and (4) PTP was significantly higher during CPAP, PSV, and 15 minutes after extubation. There was a nonsignificant trend toward increased negative change in esophageal pressure, work of breathing, and airway occlusion pressure 100 milliseconds after the onset of inspiratory flow in the smaller-ETT group.Conclusions: The ETT size has a significant impact on f, VT, f/VT ratio, and PTP.

De-escalation after empirical meropenem treatment in the intensive care unit: Fiction or reality? - Corrected Proof

2010-01-15

Abstract: Introduction: De-escalation of antimicrobial therapy is often advocated to reduce the use of broad-spectrum antibiotics in critically ill patients. However, little data are available on the application of this strategy in daily clinical practice.Methods: This is a retrospective analysis of all meropenem prescriptions in a surgical intensive care unit (ICU) during 1 year. Age, Acute Physiology and Chronic Health Evaluation II score on admission to the ICU, site of infection, causative organism, duration of meropenem administration, other antibiotic prescription for the same infectious episode for which meropenem was administered, and ICU mortality were recorded. De-escalation was defined as the administration of an antibiotic with a narrower spectrum within 3 days of the start of meropenem.Results: Data from 113 meropenem prescriptions were available for analysis. Pulmonary (46%) and complicated intraabdominal (31%) infections were the most frequent infections. In 37 patients, meropenem was used after identification of a multiresistant gram-negative organism (MRGN), whereas in 76 patients, empirical treatment with meropenem was started. Empirical prescription of meropenem was de-escalated in 42% of the patients. In the majority of the patients in whom de-escalation was not done, no conclusive cultures were available to guide treatment; also, colonization with MRGN at other sites was frequently associated with non–de-escalation. Patients in whom antibiotics were de-escalated had a trend toward a lower mortality rate (7% vs 21%, P = .12).Conclusions: De-escalation after empirical treatment with meropenem was performed in less than half of the patients. Reasons for not de-escalating included the absence of conclusive microbiology and colonization with MRGN.

Practice of sedation and the perception of discomfort during mechanical ventilation in Chinese intensive care units - Corrected Proof

2010-01-11

Abstract: Purpose: The purpose of this study was to investigate sedation practices and the perception of discomfort during mechanical ventilation in Chinese intensive care units (ICUs).Material and Method: A prospective, observational, cohort study was conducted in 31 Chinese ICUs in academic hospitals from June 15 to August 15, 2006. Conscious patients who were discharged from the ICU after mechanical ventilation were consecutively included. Using a standardized questionnaire, a personal interview was conducted with each patient within 2 days after discharge from the ICU. Patients were asked about recollections of emotional and physical discomfort. Sedation and analgesia administration data were collected from patient records.Results: As prospectively defined, 83 (50.9%) of 163 patients met criteria for complex-mixed discomfort (ie, at least 1 emotional and 2 physical disturbances). Similarly, 79.1% of patients remembered seriously uncomfortable experiences associated with 1 of the 3 predefined sources. Both protocolized sedation and continuous sedation without a defined protocol, but not intermittent sedation, significantly reduced the relative risk of complex-mixed discomfort occurrences (P < .001). Notably, only 14.7% of patients received protocolized sedation, and 61 (37.4%) of 163 were not given any sedatives.Conclusion: Mechanically ventilated ICU patients in Chinese academic hospitals were inadequately treated for discomfort. Protocolized sedation can effectively improve patient comfort.

Rehabilitation therapy and outcomes in acute respiratory failure: An observational pilot project - Corrected Proof

2009-11-30

Abstract: Purpose: The aim of this study was to describe the frequency, physiologic effects, safety, and patient outcomes associated with traditional rehabilitation therapy in patients who require mechanical ventilation.Materials and Methods: Prospective observational report of consecutive patients ventilated 4 or more days and eligible for rehabilitation in a single medical intensive care unit (ICU) during a 13-week period was conducted.Results: Of the 32 patients who met the inclusion criteria, only 21 (66%) received physician orders for evaluation by rehabilitation services (physical and/or occupational therapy). Fifty rehabilitation treatments were provided to 19 patients on a median of 12% of medical ICU days per patient, with deep sedation and unavailability of rehabilitation staff representing major barriers to treatment. Physiologic changes during rehabilitation therapy were minimal. Joint contractures were frequent in the lower extremities and did not improve during hospitalization. In 53% and 79% of initial ICU assessments, muscle weakness was present in upper and lower extremities, respectively, with a decreased prevalence of 19% and 43% at hospital discharge, respectively. New impairments in physical function were common at hospital discharge.Conclusions: This pilot project illustrated important barriers to providing rehabilitation to mechanically ventilated patients in an ICU and impairments in strength, range of motion, and functional outcomes at hospital discharge.

Is positive end-expiratory pressure suitable for liver recipients with a rescue organ offer? - Corrected Proof

2009-11-30

Abstract: Purpose: Rescue organ offers may help to overcome the organ shortage. However, because of initial poor liver function, the recipient may develop a severe lung injury with the requirement for higher positive end-expiratory pressure (PEEP) levels to achieve adequate oxygenation. Positive end-expiratory pressure has been associated with perfusion impairment in the hepatosplanchnic area. We assessed the effects of increased PEEP levels on systemic hemodynamic and liver perfusion in liver transplantation (LT) patients with a rescue organ.Methods: Twenty-four LT recipients of a rescue organ offer were enrolled. All patients were postoperatively mechanically ventilated with biphasic positive airway pressure, and 3 different PEEP levels (0, 5, 10 mbar) were randomly set within 4 hours after admission at the intensive care unit. Systemic hemodynamic parameters were recorded using a pulmonary artery catheter; and flow velocities of the hepatic artery, portal vein, and right hepatic vein were measured using Doppler.Results: Positive end-expiratory pressure of 10 mbar did not impair the systemic hemodynamic. Flow velocities in the right hepatic vein, the portal vein, and the hepatic artery were not influenced by PEEP.Conclusion: Our study demonstrates that PEEP up to 10 mbar did not impair the liver outflow in recipients with a rescue organ offer.

Is there a difference between strong ion gap in healthy volunteers and intensive care unit patients? - Corrected Proof

Kyle J. Gunnerson, Nattachai Srisawat, John A. Kellum — 2009-11-27

Abstract: Purpose: Abnormalities of strong ion gap (SIG) are common in critically ill intensive care unit (ICU) patients in conjunction with a high incidence of acid-base abnormalities. However, it is unknown whether abnormalities in SIG are also seen in ICU patients without active acid-base abnormalities. Thus, we conducted this pilot study to examine differences in quantitative acid-base variables between healthy adult volunteers and stable ICU patients with no suspected acid-base abnormalities.Methods: The study used a prospective observational study of 2 cohorts, 15 healthy adult volunteers and 15 stable adult patients just before ICU discharge who were not receiving renal replacement therapy and had no known active acid-base derangements. We analyzed venous blood for acid-base variables (potential hydrogen in central venous blood [pHCV], partial tension of carbon dioxide in central venous blood [pCVco2], standard base excess [SBE], lactate, Na+, K+, Cl−, Mg2+, Ca2+, phosphate, and albumin). From these, we calculated strong ion difference (SID) and SIG for both cohorts.Results: Although mean values for pHCV, pCVCO2, and SBE were within the normal range in both cohorts, 10 (66.7%) of 15 of ICU patients were found to have occult acid-base disorders. The ICU patients also had reduced albumin and SID measurements and significantly greater mean SIG (5.1 ± 2.9 mEq/L) compared to healthy controls (1.4 ± 1.8 mEq/L) (P = .0002). None of the healthy controls had a SIG higher than 5.0 mEq/L, whereas 7 (46.7%) of 15 of ICU patients had a SIG higher than 5.0 mEq/L. Even among ICU patients with no abnormalities of pHCV, pCVCO2, and SBE, mean SIG was 6.4 (±3.3 mEq/L).Conclusions: Stable ICU patients have much higher levels of unexplained anions when comparing with healthy controls. Whether this finding represents occult acid-base disorders or simply metabolic differences among the critically ill is uncertain. Further study in larger populations is warranted to establish the significance of high SIG in otherwise stable ICU patients.

Discontinuation of vasopressin before norepinephrine increases the incidence of hypotension in patients recovering from septic shock: A retrospective cohort study - Corrected Proof

2009-11-20

Abstract: Purpose: There are little data regarding the discontinuation of vasoactive medications in patients recovering from septic shock. We designed this retrospective cohort study to evaluate the incidence of hypotension based on the order of removal of norepinephrine (NE) and vasopressin (AVP) in patients receiving concomitant NE and AVP infusions for the treatment of septic shock.Materials and Methods: Consecutive patients receiving concomitant NE and AVP infusions for septic shock admitted to the intensive care units of a tertiary care academic medical center were evaluated.Results: Of 50 included patients, the first vasoactive medication discontinued was NE in 32 patients and AVP in 18 patients. The groups had similar Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores at shock onset and at the time of discontinuation of the first agent. Five patients who had NE discontinued first (16%) versus 10 patients who had AVP discontinued first (56%) developed hypotension within 24 hours (unadjusted relative risk, 3.6; 95% confidence interval, 1.5-4.5; P = .008). In a multivariate analysis, only discontinuation of AVP first was independently associated with hypotension (adjusted relative risk, 5.9; 95% confidence interval, 1.7-21.0; P = .006).Conclusions: Discontinuation of AVP before NE may lead to a higher incidence of hypotension in patients recovering from septic shock receiving concomitant AVP and NE.

Does the time of onset of severe sepsis in a surgical intensive care unit influence mortality rates: a single-center retrospective analysis - Corrected Proof

2009-11-16

Abstract: Purpose: The purpose of this study was to investigate possible differences in characteristics and mortality rates between early- and late-onset severe sepsis in surgical intensive care unit (ICU) patients.Materials and Methods: Prospectively collected data from all adult patients (>18 years) admitted to our 50-bed surgical ICU between 1st March 2004 and 30th July 2006 were analyzed retrospectively.Results: Of 5925 patients admitted during the study period, 234 patients (3.9%) had severe sepsis: 74 (31.6%) early onset and 160 (68.4%) late onset. Respiratory infections (48.1 versus 27.0%, P = .002) and infections of unknown origin (21.9 versus 12.2%, P = .005) were recorded more frequently in patients with late-onset than in those with early-onset severe sepsis; abdominal infections were more frequent in early-onset than in late-onset severe sepsis (20.3% versus 7.5%, P = .005). Gram-positive infections were more frequent in late-onset than in early-onset severe sepsis (63.1 versus 51.4%, P = .036). The time of onset of severe sepsis was not independently associated with an increased risk of ICU (early versus late: odds ratio, 1.1; confidence interval, 0.78-0.59; P = .786) or in-hospital (early versus late: odds ratio, 0.68; 95% confidence interval, 0.36-1.29; P = .689) death.Conclusions: Patterns of infection are different in patients with early-onset and those with late-onset severe sepsis. The time of onset of severe sepsis in surgical ICU patients has no impact on mortality. These data may be important in risk stratification and may be useful in resource allocation in the ICU.

Vena caval thromboses - Corrected Proof

2009-11-16

Abstract: Background: Patients with vena caval (VC) thrombosis have been reported with a variety of clinical presentations, which may create a diagnostic challenge for physicians.Objective: The objective of the study was to evaluate the clinical characteristics of patients with VC thrombosis.Patients and methods: Files and all imaging methods of consecutive patients with superior or inferior VC thrombosis with or without pulmonary embolism (PE) between January 26, 2001, and May 12, 2006, were retrospectively studied in detail.Results: In our series, VC thromboses within the inferior and superior VC were detected in 28 patients, mostly by combined computed tomographic venography and spiral computed tomographic pulmonary angiography. Nine of these 28 patients (32.1%) had VC thromboses without PE (7 patients with isolated and 2 patients with nonisolated VC thrombosis). Key symptoms and findings in the 9 patients without PE were unexplained dyspnea and tachypnea, respectively.Conclusions: Many patients with VC thrombosis do not have peripheral vein thrombosis. Moreover, nearly one third of patients with VC thrombosis have negative pulmonary angiograms but do have dyspnea and tachypnea.

Unplanned discharges from a surgical intensive care unit: Readmissions and mortality - Corrected Proof

2009-11-16

Abstract: Purpose: There is great patient turnover every day on surgical intensive care units (SICUs). Surgical intensive care unit beds are provided for major elective surgery. Emergency admissions trigger unplanned discharges. Those patients are at risk for a worse outcome.Materials and Methods: We retrospectively analyzed 2558 patients discharged from a 20-bed SICU within 1 year. They were followed up whether discharged electively or not. Patients readmitted to the SICU were stratified according to reason for readmission.Results: Readmission rate to the SICU was 8.3% (139/1675) in elective discharges, and 25.1% (110/439) in unplanned discharges (P < .001); 50% (125/249) of all readmissions were for surgical complications. Hospital mortality was 2.28% (50/2,197) in patients not readmitted to the SICU and 13.3% (33/249) for those readmitted (P < .001). The mortality rate increased by 4% in readmissions for each year of age (P < .05, OR for death 1.04 for each year of age, 95% CI 1.010-1.071). Respiratory failure as a reason for readmission implied a 44% risk of death (P < .001, OR 11.85, 95% CI 5.11-27.45).Conclusions: Earlier-than-planned discharge from a SICU leads to a substantially higher readmission rate. Readmission correlates with an elevated risk of death. Most readmissions in a surgical clinic are due to surgical complications. Readmission for respiratory failure accounts for most of the mortality.

Quality of life after septic illness - Corrected Proof

Andrea Lazosky, G. Bryan Young, Sandra Zirul, Renee Phillips — 2009-11-16

Abstract: Purpose: The study was undertaken to evaluate the quality of life of survivors of septic illness.Materials and Methods: A questionnaire survey of survivors of septic illness (experimental group) and acute myocardial infarction (control group) was conducted using information from the Adult Neuropsychological History and the Sickness Impact Profile forms. Eight patients diagnosed with sepsis (using the Bone et al 1992 criteria [Bone RC, Sprung CL, Sibbald WJ. Crit Care Med 1992;20:724-726]) and 15 patients diagnosed with acute myocardial infarction participated in the study.Results: On the Sickness Impact Profile, greater difficulty with work was reported in the sepsis group than in the cardiac control group (P < .04). When retired individuals were excluded from the analysis, individuals in the sepsis group reported more symptoms on the sensory, physical, and behavior sections of the Adult Neuropsychological History form and greater difficulty with sleep and rest, emotional behavior, body care and movement, and physical and psychosocial functioning on the Sickness Impact Profile. As well, more individuals in the sepsis than the control group endorsed symptoms related to problem solving, concentration, memory, sensory, and physical ability.Conclusions: Individuals surviving sepsis may have problems with physical, sensory, emotional, and cognitive functioning that become most apparent when involved in more challenging activities, such as working.

Hyperglycemia in sepsis is a risk factor for development of type II diabetes - Corrected Proof

Ivan Gornik, Ana Vujaklija, Edita Lukić, Goran Madžarac, Vladimir Gašparović — 2009-11-16

Abstract: Background: Hyperglycemia is frequent in sepsis, even in patients without diabetes or impaired glucose metabolism. It is a consequence of inflammatory response and stress, so its occurrence is related to severity of illness. However, not all severely ill develop hyperglycemia and some do even in mild disease. We hypothesized the existence of latent disturbance of glucose metabolism that contributes to development of hyperglycemia and that those patients might have increased risk for diabetes.Methods: Patients admitted with sepsis and no history of impaired glucose metabolism were included and divided in the hyperglycemia group (glucose ≥7.8 mmol/L) and normoglycemia group. Severity of sepsis was assessed. Surviving patients without diabetes at discharge were followed-up for 5 years to investigate risk for development of diabetes.Results: Hyperglycemia was related to severity of sepsis. Follow-up was finished for 55 patients with hyperglycemia, of which 8 (15.7%) developed diabetes, and 118 patients with normoglycemia, of which 5 (4.2%) developed diabetes (P = .002). Relative risk for developing type 2 diabetes was 4.29 (95% CI, 1.35-13.64).Conclusion: Patients with hyperglycemia in sepsis who are not diagnosed with diabetes before or during the hospitalization should be considered a population at increased risk for developing diabetes.

Soluble triggering receptor expressed on myeloid cells 1 and the diagnosis of sepsis - Corrected Proof

2009-11-16

Abstract: Purpose: Early diagnosis and assessment of the systemic inflammatory response to infection are difficult with usual markers (fever, leukocytosis, C-reactive protein [CRP]). Triggering receptor expressed on myeloid cells-1 (TREM-1) expression on phagocytes is up-regulated by microbial products. We studied the ability of soluble TREM-1 (sTREM-1) to identify patients with sepsis.Materials and Methods: Plasma samples were obtained on intensive care unit admission from patients with systemic inflammatory response syndrome for sTREM-1 measurement.Results: Soluble TREM-1, CRP concentrations and erythrocyte sedimentation rate (ESR) were higher in the sepsis group (n = 52) than in the non-infectious systemic inflammatory response syndrome group (n = 43; P = .00, .02, and .001, respectively). Soluble TREM-1, CRP concentrations, white blood cell count and ESR were higher in the sepsis group than in the non SIRS group (n = 37; P = .04, .00, .01, and .00, respectively).In a receiver-operating characteristic curve analysis, ESR, CRP and sTREM-1 had an area under the curve larger than 0.65 (P = .00), in distinguishing between septic and non-infectious SIRS patients. CRP, ESR, sTREM-1 had a sensitivity of 60%, 70% and 70% and a specificity of 60%, 69% and, 60% respectively in diagnosing infection in SIRS.Conclusion: C-reactive protein and ESR performed better than sTREM-1 and white blood cell count in diagnosing infection.

Outcome of patients with injection drug use–associated endocarditis admitted to an intensive care unit - Corrected Proof

Ghulam Saydain, Jatinder Singh, Bhavinkumar Dalal, Wonsuk Yoo, Donald P. Levine — 2009-11-12

Abstract: Purpose: The purpose of this study was to study the outcome of patients with injection drug use–associated infective endocarditis (IDU-IE) admitted to an intensive care unit (ICU).Material and Methods: A retrospective review of medical records of 33 consecutive patients with IDU-IE admitted to ICU was conducted.Results: Main indications for admission to ICU were as follows: severe sepsis or septic shock (36%), respiratory failure (33%), and neurologic deterioration (18%). Staphylococcus aureus was found in 94% of patients, and 15% had polymicrobial infection. Fifteen (45%) patients had septic emboli to 1 or more organs, including 12 (36%) to lungs and 7 (21%) to central nervous system. In-hospital mortality was 27%, and in univariate analysis, previous history of endocarditis (odds ratio [OR], 11.2; P = .03), respiratory failure (OR, 7; P = .03), neurologic failure (OR, 6.25; P = .03), and high Acute Physiology and Chronic Health Evaluation II (OR, 1.21; P = .016) and Sequential Organ Failure Assessment scores (OR, 1.25; P = .01) increased risk of death. By multivariate logistic regression analysis, previous history of endocarditis and high Acute Physiology and Chronic Health Evaluation II score were independently associated with poor survival.Conclusions: Complicated IDU-IE necessitating admission to ICU is associated with high mortality. In addition to consequences of sepsis, septic embolization to central nervous system and lungs contributes to development of organ failure. Increased severity of illness and prior history of endocarditis are associated with poor outcome.

High concentrations of resistin in the peripheral blood of patients with acute basal ganglia hemorrhage are associated with poor outcome - Corrected Proof

Xiao-Qiao Dong, Yue-Yu Hu, Wen-Hua Yu, Zu-Yong Zhang — 2009-11-11

Abstract: Purpose: Resistin increases in peripheral blood of patients with intracerebral hemorrhage (ICH). We sought to evaluate its relation with disease outcome.Materials and methods: Thirty healthy controls and 86 patients with acute ICH were included. Plasma samples were obtained on admission. Its concentration was measured by enzyme-linked immunosorbent assay.Results: Thirty-two patients (37.2%) died from ICH in a week. The plasma resistin level (24.2 ± 9.7 ng/mL) in patients was significantly higher than that (8.8 ± 2.4 ng/mL) in healthy controls after adjustment by age, sex, hypertension, diabetes mellitus, hyperlipidemia, and body mass index using analysis of covariate (F = 9.507, P = .003).A univariate correlation analysis found Glasgow Coma Scale (GCS) score and ICH volume, but a multivariate linear regression only selected GCS score (t = −4.587, P < .001) to be related to plasma resistin level. On a multivariate logistic regression, plasma resistin level (odds ratio = 1.257, 95% confidence interval = 1.058-1.492, P = .009) was an independent variable predicting 1-week mortality. A receiver operating characteristic curve identified that a plasma resistin level greater than 26.3 ng/mL predicted 1-week mortality of patients with 81.2% sensitivity and 81.5% specificity (P < .001). Areas under curves of GCS score and ICH volume were not statistically significantly larger than that of plasma resistin level (P > .05).Conclusions: Increased resistin level is found after ICH, in association with a poor clinical outcome.

Corticosteroid therapy for acute lung injury, acute respiratory distress syndrome, and severe pneumonia: A meta-analysis of randomized controlled trials - Corrected Proof

2009-11-06

Abstract: Background: Randomized trials investigating the effect of corticosteroids in the treatment of acute lung injury, acute respiratory distress syndrome, and severe pneumonia have had mixed results. We sought to determine whether systemic corticosteroids reduce hospital mortality from these illnesses.Methods: We conducted a systematic review of published and unpublished randomized trials. We searched MEDLINE, EMBASE, CENTRAL, and CINAHL and reviewed proceedings from relevant society meetings. Two reviewers screened the literature and extracted data independently. For each outcome, we used Grading of Recommendations Assessments, Development and Evaluation (GRADE) criteria to evaluate the quality of the underlying evidence.Results: We included 12 trials enrolling 966 patients. Pooling across all trials, corticosteroids did not significantly reduce hospital mortality (relative risk, 0.84; 95% confidence interval, 0.66-1.06). In a subgroup analysis by dose of corticosteroid, trials using the equivalent of 2 mg kg−1 d−1 or less of methylprednisolone (9 trials) found lower hospital mortality with corticosteroid therapy (relative risk 0.68; 95% confidence interval, 0.49-0.96). The quality of the evidence underlying the pooled estimate of effect on hospital mortality was low, downgraded for inconsistency and imprecision.Conclusions: Low-dose corticosteroids administered within 14 days of disease onset may reduce all-cause mortality in patients with acute lung injury, acute respiratory distress syndrome, and severe pneumonia. However, the overall quality of the evidence precludes definitive conclusions regarding the use of corticosteroids in this population.

Pressure ulcer incidence and risk factors in ventilated intensive care patients - Corrected Proof

2009-11-02

Abstract: Purpose: The aim of this study was to determine the incidence of pressure ulcers (PUs) in ventilated patients in all intensive care units (ICUs) in Granada (Spain) and identify risk factors for their development.Materials and Methods: A prospective cohort study in 9 medical-surgical ICUs was conducted. Two hundred ninety-nine patients with more than 24 hours on mechanical ventilation (MV) were enrolled during 2 periods in a 5-month study. Pressure ulcers of patients were measured according to the European Pressure Ulcer Advisory Panel.Results: Of the 299 patients initially enrolled, 47 (16%) developed PUs of at least grade II severity. The incidence density of PUs was 13.4 cases per 1000 patient-days of ICU stay and 19.6 cases per 1000 patient-days on MV. Logistic regression identified first-day respiratory sequential organ failure assessment (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.026-2.360; P = .037), fourth-day cardiovascular sequential organ failure assessment (OR, 1.33; 95% CI, 1.066-1.664; P = .012), age (OR, 1.042; 95% CI, 1.013-1.072; P = .004), winter period (OR, 4.60; 95% CI, 1.99-10.59; P < .001), and length of MV before PUs (OR, 1.042; 95% CI, 1.005-1.080; P = .024) as significant independent predictors of PU development.Conclusions: Among other factors previously known in ventilated patients, duration of MV and winter period were identified as risk factors for PUs.

The “fever workup” and respiratory culture practice in critically ill trauma patients - Corrected Proof

2009-10-22

Abstract: Purpose: Fever and leukocytosis (FAL) in critically ill patients often triggers a “workup” that includes a respiratory secretion culture (RCx). We evaluated our respiratory culture practice associated with FAL. We hypothesized that FAL would be associated with a RCx, but would not be associated with a positive culture or treating a respiratory infection in critically injured patients during their first 14 intensive care unit (ICU) days.Materials and methods: An 18-month retrospective analysis was performed on consecutive ICU trauma patients admitted for 2 days or more to a level I trauma center. Data collected included demographics, injuries, RCxs (bronchoalveolar lavage or tracheal aspirate), maximum daily temperature, and a daily leukocyte count during the first 14 ICU days.Results: A total of 510 patients with a mean age of 49 and injury severity score of 19 were evaluated for a total of 3839 patient-days. Two hundred eleven patients had 489 RCxs obtained (2.4 RCxs/patient); 94 (19%) were obtained on consecutive days. Obtaining a RCx was associated with fever (relative risk, 4.8; 95% confidence interval, 4.1-5.8) and the combination of FAL (relative risk, 2.6; 95% confidence interval, 2.2-3.1), but not leukocytosis alone. Fever, leukocytosis, or FAL did not predict a positive RCx. One hundred twenty-eight patients were treated for a respiratory infection. Treatment of respiratory infections was contrary to the RCx results 24% of the time. The sensitivity and specificity of a positive RCx being associated with respiratory infection were 97% and 46%, respectively.Conclusions: Fever and leukocytosis were associated with the decision to obtain RCxs but were not associated with positive RCxs in our ICU practice. Respiratory secretion culture results had a low specificity and did not consistently impact treatment decisions. Factors other than fever and leukocytosis alone should influence the decision to obtain RCxs during the first 14 days in the ICU after trauma.

Extubation versus tracheostomy in withdrawal of treatment—ethical, clinical, and legal perspectives - Corrected Proof

2009-10-22

Abstract: The provision of life-sustaining ventilation, such as tracheostomy to critically ill patients, is commonly performed. However, the utilization of tracheostomy or extubation after a withdrawal of treatment decision is debated. There is a dearth of practical information available to aid clinical decision making because withdrawal of treatment is a challenging scenario for all concerned. This is further complicated by medicolegal and ethical considerations. Care of the “hopelessly ill” patient should be based on daily evaluation and comfort making it impossible to fit into general algorithms. Although respect for autonomy is important in healthcare, it is limited for patients in an unconscious state. Beneficence remains the basis for withdrawing treatment in futile cases and underpins the “doctrine of double effect.” This article presents a relevant clinical case of hypoxic brain injury where a question of withdrawal of treatment arose and examines the ethical, clinical, and medicolegal considerations inherent in such cases, including beneficence, nonmaleficence, and the “sanctity of life doctrine.” In addition, the considerations of prognosis for recovery, patient autonomy, patient quality of life, and patient family involvement, which are central to decision making, are addressed. The varying legal frameworks that exist internationally regarding treatment withdrawal are also described. Good ethics needs sound facts, and despite the lack of legal foundation in several countries, withdrawal of treatment remains practiced, and the principles described within this article aim to aid clinician decision making during such complex and multifaceted end-of-life decisions.

Depression among white and nonwhite caregivers of the chronically critically ill - Corrected Proof

Sara L. Douglas, Barabara J. Daly, Elizabeth O'Toole, Ronald L. Hickman — 2009-10-19

Abstract: Purpose: The study aimed to describe characteristics of caregivers of chronically critically ill (CCI) patients, describe key outcomes (depression, employment, physical health), and examine race as one of several predictors of post-hospital depressive symptoms.Materials and Methods: This was a prospective study of caregivers of hospital survivors of prolonged (>72 hours) mechanical ventilation. Caregivers were interviewed at admission to the intensive care unit (ICU) and 2 months post-discharge.Results: Patients discharged to an institution had a high risk of post-hospital mortality (odds ratio, 8.61; P = .01). Caregivers of patients residing in an institution 2 months post-discharge had greater odds of being depressed than caregivers of patients residing at home (odds ratio, 2.75; P = .001). Nonwhite caregivers of patients residing in an institution had the least improvement in depression over time. Predictors of depression 2 months post-discharge were depression during hospitalization (P = .001), sex (P = .019), health status (P = .009), and residence of the patient (P = .001), with no change based on race. Almost 50% of employed caregivers had a reduction in paid work. There was a significant reduction in physical health status over time (P = .001) with no difference based on race.Conclusions: Caregivers of CCI patients are at risk for depression post-hospital discharge. Nonwhite caregivers of patients residing in an institution 2 months post-discharge are at highest risk for depression.

The effect of comorbidity and age on hospital mortality and length of stay in patients with sepsis - Corrected Proof

Yong Yang, Kok Soong Yang, Yin Maw Hsann, Vincent Lim, Biauw Chi Ong — 2009-10-16

Abstract: Purpose: Sepsis is believed to be responsible for substantial health care burden, but there is limited information about its magnitude and the factors affecting health outcomes in Asian population. The aim of the study was to assess the disease burden of sepsis and to test the usefulness of Charlson Comorbidity Index (CCI) and age as risk-adjusted hospital mortality predictors in patients with sepsis using hospital administrative database.Methods: A retrospective cohort study of hospital discharge database from 2004 to 2007 to identify cases with sepsis, comorbidity, and organ failure using the International Statistical Classification of Diseases and Related Health Problems, 9th Revision, Australian Modification codes was conducted.Results: Of 305 637 hospitalized patients over 4 years, 6929 (2.27%) patients had sepsis, with 1216 (17.5%) patients associated with intensive care unit (ICU) admission. The mortality rates increased consistently in patients with CCI ranging from none to low, moderate and high grade for both patients with ICU admission (39.4%, 51.6%, 55.9%, and 54.3% respectively; P < .001) and patients without ICU admission (6.4%, 8.7%, 17.1%, and 25.3% respectively; P < .001). Logistic regression analysis showed that CCI (odds ratio, 11.8; high versus none) and age (odds ratio, 8.46; aged 85 years and older versus aged 18-54 years old) were significant and independent predictors of hospital mortality. Similar results were seen with hospital length of stay by zero-truncated negative binomial regression model analysis.Conclusion: The sepsis-related mortality and resource utilization are high in this population as well. Comorbidities and advanced age were some of the most important contributors to hospital mortality and resource utilization.

Systematized Nomenclature of Medicine–Clinical Terms direction and its implications on critical care - Corrected Proof

Reza Shahpori, Christopher Doig — 2009-10-16

Abstract: Purpose: The aim of this study was to describe the new advancements in Systematized Nomenclature of Medicine–Clinical Terms (SNOMED-CT) terminology and its applicability to critical care documentation.Materials and Methods: Narrative review of existing literature published in indexed medical and health informatics journals and of gray literature available on the Internet and personal communication with authors and researchers engaged in SNOMED-CT projects related to critical care are conducted.Results: Systematized Nomenclature of Medicine–Clinical Terms is a system of comprehensive health and clinical terminology that covers most of the needs of health care documentation. It will potentially become the terminology of clinical enterprise and administrative information systems. Despite a ground swell of international support from health information management experts, the terminology remains unknown to most clinicians. We discuss the reasons why clinical familiarity with SNOMED-CT is an important prerequisite to proceeding with local or national electronic health records or clinical information systems.Conclusions: We propose that SNOMED-CT is suitable for use in critical care; however, work is urgently required to validate the completeness of terminology and to determine clinicians' perceptions on the utility of such a standardized terminology for use in critical care clinical information systems.

Ultrasound-guided peripheral intravenous access in the intensive care unit - Corrected Proof

2009-10-16

Abstract: Purpose: Central venous catheters continue to be a popular means of maintaining vascular access in surgical intensive care units despite well-described complications. With edema, obesity, and difficult to visualize veins potentially affecting the surgically ill, inability to obtain peripheral intravenous (PIV) access may hinder the clinician's ability to avoid the use of central lines. With ultrasound gaining increased popularity for obtaining vascular access, we evaluated its utility in ultrasonagraphically placing PIV catheters for the purposes of either avoiding central venous access or removing central venous catheters.Materials and Methods: We performed a retrospective cohort review of our requests for ultrasound-guided PIV access in the intensive care unit between September 2007 and February 2008.Results: Over a 6-month period, 77 requests for ultrasound-guided PIV access were made for 59 surgical, trauma, and cardiothoracic intensive care unit patients. Reasons for inability to obtain PIVs through standard means included edema (95%), obesity (42%), IV drug abuse history (8%), and emergency access (4%). Of the 148 PIV lines that were requested, 147 PIV catheters were successfully placed (99%). Of these, 105 PIV catheters were placed on the first attempt (71%). Complications of PIVs included IV infiltration (3.4%), inadvertent removal (2.7%), and phlebitis/cellulitis (0.7%). As a result of placing these PIV catheters, 40 central lines were discontinued and 34 central lines were avoided. The average number of line days at the time of central venous catheter removal was 11 ± 11 days.Conclusion(s): In intensive care unit patients who do not require central venous lines, ultrasound-guided PIV access can have a high placement success rate and can result in fewer central line days and/or less reliance on central venous catheters for access-only purposes.

Severe hypocholesterolemia in surgical patients, sepsis, and critical illness - Corrected Proof

2009-10-14

Abstract: After surgery, in sepsis and various critical illnesses, factors such as severity of the acute phase response, liver dysfunction, and hemodilution from blood loss have cumulative impacts in decreasing cholesterol; therefore, degree of hypocholesterolemia often reflects severity of illness. The direct correlation between cholesterol and several plasma proteins is mediated by the parallel impact of commonly shared determinants. Cholestasis is associated with a moderation of the degree of hypocholesterolemia. In human sepsis, the poor implications of hypocholesterolemia seem to be aggravated by the simultaneous development of hypertriglyceridemia. Cholesterol and triglyceride levels reflect altered lipoprotein patterns, and the issue is too complex and too poorly understood to be reduced to simple concepts; nevertheless, these simple measurements often represent helpful adjunctive clinical tools.

Hospitalist bed management effecting throughput from the emergency department to the intensive care unit - Corrected Proof

Eric Howell, Edward Bessman, Robert Marshall, Scott Wright — 2009-10-14

Abstract: Rationale: Emergency department (ED) patients in need of an intensive care unit (ICU) admission are very sick. Reducing the length of time to get these patients into ICU beds is associated with improved outcomes.Objective: To reduce the ED length of stay for patients requiring admission to the medical ICU or coronary care unit through the implementation of the “active bed management” (ABM) intervention.Methods: A pre-post study design compared data from November 2006 to February 2007 with those from those same months in the prior year at Johns Hopkins Bayview Medical Center in Baltimore. The ABM intervention was carried out by hospitalist physicians and involved: (i) making triage decisions for patients to be admitted and facilitating their transfer from ED to the appropriate care setting and (ii) having proactive management of Department of Medicine resources, which included twice-daily ICU bed management rounds and regular visits to the ED to assess flow.Measurement: Throughput time for patients presenting to the ED requiring ICU admission was analyzed.Main Results: The ED census was higher during the intervention period as compared with the control period, 17 573 versus 16 148 patients. Throughput from ED to coronary care unit and medical ICU beds was reduced by 99 (±14) minutes (from 353 minutes in the control period to 254 minutes in the 4 months after the initiation of ABM, P < .0001). Staffing, length of stay, case mix index, ICU transfer rates, and ICU death rates were stable across the 2 periods, all P = not significant.Conclusion: Conscientious management of hospital beds, in this case by hospitalist physicians providing ABM, can have a positive and substantial impact on the ED throughput of critically ill patients admitted to ICU beds. This efficiency is likely to positively have impacted on patient satisfaction and safety.

Passive limb movements for patients in an intensive care unit: A survey of physiotherapy practice in Australia - Corrected Proof

Louise Wiles, Kathy Stiller — 2009-10-12

Abstract: Purpose: This study aimed to investigate physiotherapists' clinical practice regarding passive limb movements for adult patients in Australian intensive care units (ICUs).Materials and Methods: A prospective survey using a purpose-designed questionnaire was mailed to the senior physiotherapist working in each Australian level 3 (tertiary) adult ICU.Results: Of 65 questionnaires sent, 51 (78%) were returned. A minority of respondents (35%) undertook routine assessment of passive limb range of movement (ROM) for all ICU patients. Instead, most based the need for assessment on criteria such as length of stay, reason for admission, and medical history. A minority (14%) provided passive limb ROM exercises on a routine basis for all patients, instead most intervened only for high-risk patients or those with loss of ROM. The most frequently used interventions were manually applied passive limb ROM exercises, positioning, and mobilization, and the actual exercise prescription varied markedly. Respondents thought contracture was uncommon in ICU patients, was multifactorial in origin, and caused moderate problems. Personal experience and colleagues' advice were the factors most influencing clinical practice.Conclusions: Although selective passive limb ROM assessment and intervention formed a part of most physiotherapists' clinical ICU practice, considerable variability was found in its application between respondents.

Reduced expression of systemic proinflammatory and myocardial biomarkers after off-pump versus on-pump coronary artery bypass surgery: A prospective randomized study - Corrected Proof

2009-09-25

Abstract: Background: The effects of off-pump (OffPCABG) and on-pump (OnPCABG) coronary artery bypass grafting (CABG) on myocardium and inflammation are unclear.Objective: Compare the inflammatory response and myocardial injury from patients (pts) submitted to OffPCABG with those that undergo OnPCABG.Methods: Patients with normal left ventricular function were assigned to OffPCABG (n = 40) and OnPCABG (n = 41). Blood samples were collected before and 24 hours after surgery for determination of creatine kinase (CK)–MB (CK-MB), troponin I (cTnI), interleukin (IL)–6, IL-8, P-selectin, intercellular adhesion molecule (ICAM)-1 and C-reactive protein (CRP). Mortalities were registered at 12 months.Results: Preoperative CK-MB and cTnI levels were 3.1 ± 0.6 IU and 1.2 ± 0.5 ng/mL for OffPCABG and 3.0 ± 0.5 IU and 1.0 ± 0.2 ng/mL for OnPCABG pts. Postoperative CK-MB and cTnI levels were 13.9 ± 6.5 IU and 19.0 ± 9.0 ng/mL for OffPCABG vs 29.5 ± 11.0 IU and 31.5 ± 10.1 ng/mL for OnPCABG (P < .01). OffPCABG and OnPCABG pts had similar preoperative IL-6 (10 ± 7 and 9 ± 13 pg/mL), IL-8 (19 ± 7 and 17 ± 7 pg/mL), soluble P-selectin (70 ± 21 and 76 ± 23 pg/mL), soluble ICAM–1 (117 ± 50 and 127 ± 52 ng/mL), and CRP (0.09 ± 0.05 and 0.11 ± 0.07 mg/L). At 24 hours, for OffPCABG and OnPCABG: IL-6 was 37 ± 38* and 42 ± 41*,† g/mL; IL-8, 33 ± 31* and 60 ± 15*,† pg/mL; soluble P-selectin, 99 ± 26 and 172 ± 30*,† pg/mL; soluble ICAM-1, 227 ± 47 and 236 ± 87*,† ng/mL; and CRP, 10 ± 11* and 14 ± 13*,† mg/L (*P < .01 vs preoperation; †P < .01 vs OffPCABG). Increased 24-hour postoperative CRP levels was the only marker to have significant positive correlations with events and occurred just for the OnPCABG pts. In-hospital and 1-year mortalities for the OnPCABG and OffPCABG pts were 2.0% and 2.2% (P = .1) and 2.7% and 4.7% (P = .06), respectively.Conclusions: Thus, the absence of CPB during CABG preserves better the myocardium and attenuates inflammation—however, without improving survival.

Hemodynamic effects of recombinant human activated protein C in patients with septic shock - Corrected Proof

2009-09-25

Abstract: Purpose: The aim of this study is to examine the effects of recombinant human activated protein C (rhAPC) on hemodynamic parameters in patients with septic shock.Methods: This is a retrospective study of 2 university-hospital critical care units. Patients with septic shock with pulmonary artery catheterization or transthoracic thermodilution monitoring were studied. We matched patients with septic shock with at least 2 organ failures (18 treated with rhAPC and 18 controls) on sex, age, sequential organ failure assessment (SOFA), Acute Physiology and Chronic Health Evaluation (APACHE) II, and sepsis etiology. We recorded norepinephrine dose and hemodynamic parameters at baseline and 24, 36, and 48 hours after the real or theoretical start of rhAPC treatment.Results: Mean arterial pressure remained stable in both groups. In rhAPC patients, norepinephrine requirements, initially higher than in controls, were significantly lower at 48 hours, and stroke volume at 24 and 48 hours improved (P < .05).Conclusion: Recombinant human activated protein C use correlated with improved hemodynamic parameters and decreased norepinephrine requirements. The retrospective nature of the study limits the strength of these findings.

Real-time monitoring of heart rate variability in critically ill patients - Corrected Proof

2009-09-25

Abstract: Purpose: Heart rate variability (HRV) is widely used to evaluate autonomic nervous function; however, real-time monitoring of HRV has rarely been attempted in the intensive care unit (ICU). We report our experience in performing real-time monitoring of HRV in our ICU.Methods: We investigated 10 critically ill patients on total ventilatory support. Heart rate variability analysis was performed using the MemCalc system, which is a noninvasive, real-time analysis system. The low-frequency (LF) component of HRV reflects sympathetic and parasympathetic modulation, whereas the high-frequency (HF) component mainly reflects parasympathetic modulation. The LF/HF ratio represents a measure of sympathetic/parasympathetic balance.Results: The HRV parameters for patients breathing spontaneously after extubation were significantly higher than those for patients on total ventilatory support. These findings suggest that mechanical ventilation under sedation may reduce autonomic nervous function in critically ill patients. In a representative case with septic shock, systolic blood pressure and LF/HF ratio showed a significant increase after intravenous infusion of epinephrine and then the HF component showed a significant increase due to vagal reflex.Conclusions: The MemCalc system is practicable for real-time monitoring of HRV in the ICU. Heart rate variability parameters may offer useful information in the management of critically ill patients.

High-flow nasal oxygen vs high-flow face mask: A randomized crossover trial in extubated patients - Corrected Proof

Ravindranath Tiruvoipati, David Lewis, Kavi Haji, John Botha — 2009-09-25

Abstract: Purpose: Oxygen delivery after extubation is critical to maintain adequate oxygenation and to avoid reintubation. The delivery of oxygen in such situations is usually by high-flow face mask (HFFM). Yet, this may be uncomfortable for some patients. A recent advance in oxygen delivery technology is high-flow nasal prongs (HFNP). There are no randomized trials comparing these 2 modes.Methods: Patients were randomized to either protocol A (n = 25; HFFM followed by HFNP) or protocol B (n = 25; HFNP followed by HFFM) after a stabilization period of 30 minutes after extubation. The primary objective was to compare the efficacy of HFNP to HFFM in maintaining gas exchange as measured by arterial blood gas. Secondary objective was to compare the relative effects on heart rate, blood pressure, respiratory rate, comfort, and tolerance.Results: Patients in both protocols were comparable in terms of age, demographic, and physiologic variables including arterial blood gas, blood pressure, heart rate, respiratory rate, Glasgow Coma Score, sedation, and Acute Physiology and Chronic Health Evaluation (APACHE) III scores. There was no significant difference in gas exchange, respiratory rate, or hemodynamics. There was a significant difference (P = .01) in tolerance, with nasal prongs being well tolerated. There was a trend (P = .09) toward better patient comfort with HFNP.Conclusions: High-flow nasal prongs are as effective as HFFM in delivering oxygen to extubated patients who require high-flow oxygen. The tolerance of HFNP was significantly better than in HFFM.

Electroencephalogram for prognosis after cardiac arrest - Corrected Proof

2009-09-25

Abstract: Background: In assessing neurologic prognosis after cardiac arrest (CA), electroencephalogram (EEG) reactivity has not been specifically included with EEG classifications. Most studies have divided recordings into benign and malignant; however, some patterns within these groups may have greater prognostic significance than such broad classifications. We sought to explore reactivity, with broad classifications and subclassifications for their prognostic significance.Methods: All consecutive adults in coma who had an EEG recording performed at least 1 day after CA or during normothermia after a 24-hour mild hypothermia protocol. Outcomes were dichotomous: recovery of awareness or no recovery of awareness during hospitalization.Results: Twenty-nine patients met the inclusion criteria. Of the 18 patients with no reactivity, only 1 recovered awareness; of the 11 patients who demonstrated reactivity, 10 recovered awareness (sensitivity of 90% [95% confidence interval, or CI, 0.57-1] and specificity of 94% [95% CI, 0.7-1]). Of those with benign patterns, 7 recovered awareness and 1 did not; however, those patients demonstrating malignant patterns, 4 recovered and 17 did not (sensitivity of 94% [95% CI, 0.7-1] and a specificity of 63% [95% CI, 0.32-0.88]). None of the 15 patients with suppression or generalized spikes recovered consciousness, and none of these patients demonstrated reactivity.Conclusions: Electroencephalogram reactivity after CA is a relatively favorable EEG feature; generalized suppression or generalized epileptiform activity, without reactivity, is associated with lack of recovery of awareness.

Relevant risk factors affecting time of ventilation during early postoperative period after orthotopic liver transplantation - Corrected Proof

Qiang Li, Gaiqi Yao, Qinggang Ge, Min Yi, Jing Gao, Xi Zhu — 2009-09-25

Abstract: Purpose: The aim of this study is to examine the relevant factors affecting the duration of mechanical ventilation after orthotopic liver transplantation.Materials and Methods: The 96 patients who underwent liver transplantation were divided into 2 groups according to whether or not the duration of mechanical ventilation after operation was longer than 24 hours. Nineteen variables, including clinical and experimental variables, were analyzed by t test for continuous variables and χ2 test for discrete variables. The variables with significance (P < .05) were then analyzed with stepwise logistic regression.Results: Nine continuous preoperative clinical and experimental variables, including preoperative Child-Pugh stage, time of operation, volume of intraoperative liquid transfusion, volume of intraoperative blood loss, volume of intraoperative blood transfusion, volume of intraoperative urine, time of intraoperative hypotension, postoperative renal failure, and postoperative pulmonary edema revealed significant differences between the 2 groups. Stepwise logistic regression analysis for 9 variables indicated that volume of intraoperative blood loss, volume of intraoperative urine, and postoperative renal failure are relevant independent risk factors.Conclusion: The relevant risks affecting the time of ventilation in patients after orthotopic liver transplantation are multiple. The volume of intraoperative blood loss, volume of intraoperative urine, and postoperative renal failure are independent risk factors.

Whole-body ultrasound in the intensive care unit: A new role for an aged technique - Corrected Proof

Andreas Karabinis, Mariantina Fragou, Dimitrios Karakitsos — 2009-09-25

Abstract: Management of critically ill patients requires rapid and safe diagnostic techniques. Ultrasonography has become an indispensable tool that supplements physical examination in the intensive care unit. It enables early recognition of neurological emergencies, assists the diagnosis of abdominal and lung pathologies, and provides real-time information on the cardiac performance of critically ill patients. Furthermore, it detects possible infectious sites and renders therapeutic invasive procedures more convenient and less complicated. Whole-body ultrasound in the hands of adequately trained intensivists has the ability to reinvigorate the physical examination, without subjecting the patient to excessive irradiation and the risks of transport.