Journal of Critical Care - Articles in Press

Failure to reduce C-reactive protein levels more than 25% in the last 24 hours before intensive care unit discharge predicts higher in-hospital mortality: A cohort study - Corrected Proof

2012-01-09

Abstract: Purpose: To discharge a patient from the intensive care unit (ICU) is a complex decision-making process because in-hospital mortality after critical illness may be as high as up to 27%. Static C-reactive protein (CRP) values have been previously evaluated as a predictor of post-ICU mortality with conflicting results. Therefore, we evaluated the CRP ratio in the last 24 hours before ICU discharge as a predictor of in-hospital outcomes.Methods: A retrospective cohort study was performed in 409 patients from a 6-bed ICU of a university hospital. Data were prospectively collected during a 4-year period. Only patients discharged alive from the ICU with at least 72 hours of ICU length of stay were evaluated.Results: In-hospital mortality was 18.3% (75/409). Patients with reduction less than 25% in CRP concentrations at 24 hours as compared with 48 hours before ICU discharge had a worse prognosis, with increased mortality (23% vs 11%, P = .002) and post-ICU length of stay (26 [7-43] vs 11 [5-27] days, P = .036). Moreover, among hospital survivors (n = 334), patients with CRP reduction less than 25% were discharged later (hazard ratio, 0.750; 95% confidence interval, 0.602-0.935; P = .011).Conclusions: In this large cohort of critically ill patients, failure to reduce CRP values more than 25% in the last 24 hours of ICU stay is a strong predictor of worse in-hospital outcomes.

Survival and functional outcomes after cardiopulmonary resuscitation in the intensive care unit - Corrected Proof

Hayley B. Gershengorn, Guohua Li, Andrew Kramer, Hannah Wunsch — 2012-01-09

Abstract: Purpose: Comparatively less is known about the outcomes of cardiopulmonary resuscitation (CPR) in patients in the intensive care unit (ICU) compared with those not in an ICU. In this study, we evaluated survival rates, functional status, and predictors of good outcomes after in-ICU CPR.Methods: We used the Project IMPACT (Cerner Corporation, Kansas City, Mo) database to conduct a retrospective cohort study of adults who underwent in-ICU CPR in the United States from 2001 to 2008. We characterized survival rates and functional outcomes and identified predictors of better prognosis using multivariate logistic regression analyses.Results: Of 362 074 ICU admissions, 6518 (1.8%) received in-ICU CPR with 15.7% (n = 1025) surviving to hospital discharge. Survival decreased with age, more comorbidities, and for certain admitting diagnoses, such as sepsis. Patients who survived incurred significant functional morbidity. Of survivors, only 33.6% were discharged home, and only 20.1% were functionally independent on hospital discharge. A total of 63.4% had a decrease in functional status compared with admission. Only 3.3% of all patients (21.7% of survivors) were both functionally independent and discharged home (“optimal” functional outcome). Among survivors, the risk-adjusted odds of having an optimal functional outcome decreased with age (P ≤ .022) and with failure of 3 or more organs during ICU stay (P = .006).Conclusions: Only 1 of 6 adults receiving in-ICU CPR survives to hospital discharge, and less than 5% are discharged home with independent function. Among survivors, most show large decreases in functional status compared with hospital admission.

Cerebral vasoreactivity to acetazolamide is not impaired in patients with severe sepsis - Corrected Proof

2012-01-09

Abstract: Introduction: The pathophysiology of sepsis-associated encephalopathy (SAE) is not entirely clear, but one of the possible underlying mechanisms is the alteration of the cerebral microvascular function. The aim of the present work was to test whether cerebral vasomotor reactivity is impaired in patients with severe sepsis.Methods: Patients fulfilling the criteria of clinical sepsis and showing at least 2 organ dysfunctions were included (n = 16). Nonseptic healthy persons without previous diseases affecting cerebral vasoreactivity served as controls (n = 16). Transcranial Doppler blood flow velocities were measured at rest and at 5, 10, 15, and 20 minutes after intravenous administration of 15 mg/kg acetazolamide. The time course of the acetazolamide effect on cerebral blood flow velocity (cerebrovascular reactivity [CVR]) and the maximal vasodilatory effect of acetazolemide (cerebrovascular reserve capacity [CRC]) were compared among the groups.Results: Absolute blood flow velocities after administration of the vasodilator drug did not differ between control and septic patients. Assessment of the time course of the vasomotor reaction showed that patients with sepsis reacted in a similar fashion to the vasodilatory stimulus than control persons. When assessing the maximal vasodilatory ability of the cerebral arterioles to acetazolamide during vasomotor testing, we found that there was no difference in vasodilatory ability between septic and healthy subjects (CRC controls, 54.8% ± 11.1%; CRC sepsis-associated encephalopathy, 61.1% ± 34.4%; P = .49).Conclusions: We conclude that cerebrovascular reactivity is not impaired in patients with severe sepsis. It is conceivable that cerebral vasoreactivity may be differently involved at different severity stages of the septic process.

Disagreement between ion selective electrode direct and indirect sodium measurements: Estimation of the problem in a tertiary referral hospital - Corrected Proof

Goce Dimeski, Thomas J. Morgan, Jeffrey J. Presneill, Balasubramanian Venkatesh — 2012-01-09

Abstract: Purpose: We estimated the proportion of indirect ion selective electrode (ISE) plasma sodium analyses in intensive care unit (ICU) and hospital wide, exhibiting important disagreement with direct ISE results in relation to abnormal plasma protein concentrations.Materials and Methods: Direct and indirect ISE plasma sodium measurements were performed on 346 clinical specimens selected to reflect low, normal, or high total protein concentrations. Important intermethod disagreement was defined as |4| mmol/L or higher. Results were extrapolated to a 3-month laboratory series of 48 033 indirect ISE assays, including 2877 samples from intensive care.Results: Intermethod sodium disagreement at |4| mmol/L or higher was predicted for 25% of ICU samples. Almost all (97%) occurred in hypoproteinemic samples where indirect tended to exceed direct ISE estimates. Hospital wide, such disagreement was projected to occur in 8% of samples, of which the majority (70%) were also hypoproteinemic.Conclusions: Important disagreement between indirect and direct ISE sodium measurements may exist in up to 1 in 4 ICU specimens and 1 in 12 hospital-wide samples. The main problem is indirect ISE overestimation associated with hypoproteinemia, potentially leading to misclassifications of pseudohypernatremia and pseudonormonatremia. We recommend that hospital laboratories consider standardization using direct ISE sodium measurement.

Blood glucose amplitude variability as predictor for mortality in surgical and medical intensive care unit patients: a multicenter cohort study - Corrected Proof

2012-01-09

Abstract: Purpose: The aim of this study was to test the hypothesis that blood glucose amplitude variability (BGAV) is associated with mortality in critically ill patients.Method: A prospectively collected multicenter data set including all glucose measurements during intensive care unit (ICU) treatment and outcome was analyzed. We used logistic regression to assess the association between hospital mortality and standard deviation (SD), mean amplitude of glycemic excursions (MAGE), mean absolute glucose change per hour (MAG), and glycemic lability index (GLI). The analysis was adjusted for ICU, Acute Physiology And Chronic Health Evaluation IV–expected mortality, the presence of severe hypoglycemia, mean glucose, mean glucose measurement interval, and interaction between the latter 2.Results: There were 855 032 glucose measurements included of 20 375 patients admitted to 37 Dutch ICUs in 2008 and 2009. Median Acute Physiology And Chronic Health Evaluation IV–predicted mortality was 14%, and median glucose was 7.3 mmol/L. In all patients combined, adjusted hospital mortality was associated with SD and MAGE, but not with MAG and GLI. In surgical patients, adjusted hospital mortality was associated with SD, MAGE, and MAG, but not GLI. In medical patients, adjusted mortality was associated with SD but not with other BGAV measures.Conclusion: Not all BGAV measures were associated with mortality. Blood glucose amplitude variability as quantified by SD was consistently independently associated with hospital mortality.

Early bacterial genome detection in body fluids from patients with severe sepsis: A pilot study - Corrected Proof

2012-01-09

Abstract: Purpose: The purpose of this study is to evaluate the feasibility and interest of real-time polymerase chain reaction (RT-PCR) testing for bacterial genomes in body fluids other than blood in patients with acute severe sepsis.Methods: Twenty-six consecutive patients admitted for severe sepsis or septic shock were prospectively studied. Body fluids were sampled as clinically indicated and tested using standard microbiological methods and modified RT-PCR methods (universal PCR and specific PCRs). Results of standard microbiological tests were compared with those of PCR tests.Results: Direct RT-PCR testing was successfully performed on all nonblood body fluids. Of 29 body fluids collected, 23 were positive for at least 1 microorganism with conventional tests. Of 18 microbiological tests positive for a single microorganism, 15 fully agreed with RT-PCR assays, and the remaining 3 samples were infected with bacteria not screened by PCR testing. Among the 5 polymicrobial results obtained with conventional tests, RT-PCR agreed in 4 patients. The RT-PCR tests allowed additional clinically relevant bacterial identification in 3 of 6 samples with negative microbiological culture.Conclusions: Our results indicate that direct PCR testing may improve the detection of bacteria in body fluids other than blood in patients with acute severe sepsis.

Implementation challenges in the intensive care unit: The why, who, and how of daily interruption of sedation - Corrected Proof

Melissa A. Miller, Emily A. Bosk, Theodore J. Iwashyna, Sarah L. Krein — 2012-01-09

Abstract: Purpose: Despite strong medical evidence and policy initiatives supporting the use of daily interruption of sedation in mechanically ventilated patients, compliance remains suboptimal. We sought to identify new barriers to daily interruption of sedation.Materials and Methods: We conducted 5 focus groups of intensive care unit physicians, nurses, and respiratory therapists during a 2-month period to identify attitudes, barriers, and motivations to perform a daily interruption of sedation. Each focus group was audiotaped, and the transcripts were analyzed using qualitative methods to identify recurrent themes.Results: There was wide consensus on the importance of daily interruptions of sedation; however, practitioners usually performed sedation interruption for 1 of 5 distinct reasons: minimizing the dose of sedation, performing a neurologic examination, facilitating ventilator weaning, reducing intensive care unit length of stay, and assessing patient pain. Participants rarely espoused more than 1 main reason, and there was no shared understanding of why one might do a daily interruption of sedation. This lack of shared understanding led to different patients being selected and diverse approaches to carrying out the DIS.Conclusions: Despite apparent consensus, lack of shared understanding of the rationale for an intervention may lead to divergent practice patterns and failure to implement standardized, evidence-based practice.

A weaning protocol administered by critical care nurses for the weaning of patients from mechanical ventilation - Corrected Proof

2012-01-09

Abstract: Purpose: The primary objective of this clinical trial of patients on mechanical ventilation was to determine if a weaning protocol implemented solely by nurses could reduce the weaning time relative to usual care (UC).Materials and Methods: This study is a prospective, randomized, controlled trial conducted from January 2007 to January 2009 that compared protocol-based weaning (PBW) with UC. A total of 122 patients who received invasive ventilation in the medical ICU of the Asan Medical Center were examined. Nurses operated the mechanical ventilators according to a predesigned ventilator-weaning protocol for the PBW group (n = 61), and intensive care unit (ICU) physicians managed weaning in the UC group (n = 61).Results: There were no significant differences in the 2 groups at baseline. The number of patients who successfully discontinued mechanical ventilation was similar in the 2 groups (PBW, 46 patients, 75.4%; UC, 47 patients, 77.0%; P = .832). The weaning time was 47 hours (interquartile range, 24-168 hours) in the UC group and 25 hours (interquartile range, 5.75-134 hours) in the PBW group (P = .010).Conclusions: The weaning protocol administered by the nurses was safe and reduced the weaning time from mechanical ventilation in patients who were recovering from respiratory failure.

Reliability of the validated clinical diagnosis of pneumonia on validated outcomes after intracranial hemorrhage - Corrected Proof

2012-01-09

Abstract: Purpose: Reducing the incidence of hospital-acquired pneumonia (PNU) is important but depends on accurate assessment. We sought to determine the interrater reliability of diagnosis of PNU and its impact on resource utilization and functional outcomes in a high-risk population.Materials and Methods: Patients admitted in 2007 with intracranial hemorrhage were prospectively identified. Pneumonia was prospectively diagnosed by Centers for Disease Control criteria by a neurointensivist and infection control. An independent retrospective determination was made by a fellow, an infectious disease attending physician, and a pulmonologist after review of the electronic medical records and radiographs. Interrater reliability was analyzed with κ statistics. One and 3-month outcomes were measured with the modified Rankin scale.Results: Of 103 patients, the incidence of PNU ranged from 5% to 25%. Interrater reliability was poor (median κ = 0.30 [0.19-0.42]; P < .001). Any ascertainment of PNU was associated with longer intensive care unit length of stay, more fever and ventilator dependence, and worse functional outcomes.Conclusions: Pneumonia had poor interrater reliability despite highly trained reviewers and validated criteria. Although the clinical assessment of PNU is difficult, it was associated with greater resource use and worse outcomes. Diagnosis of clinical PNU may be suboptimal for measuring quality of intensive care.

Factors associated with acute lung injury in combat casualties receiving massive blood transfusions: A retrospective analysis - Corrected Proof

Chee M. Chan, Andrew F. Shorr, Jeremy G. Perkins — 2012-01-09

Abstract: Purpose: We sought to determine if use of warm fresh whole blood (WFWB), rather than blood component therapy, alters rates of acute lung injury (ALI) in patients with trauma.Materials and Methods: We retrospectively analyzed rates of ALI in patients undergoing massive blood transfusions while at a combat support hospital. Patients with ALI were compared with those not developing ALI with respect to demographics, trauma type, severity of illness, crystalloid volume given, and exposure to WFWB. Logistic regression was used to identify variables associated with ALI.Results: The cohort included 591 subjects (mean age, 28 ± 8.1 years; male, 96.7%). Acute lung injury occurred in 11.2%, and 34.4% received WFWB. After adjusting for the type of trauma, severity of illness, and volume of crystalloid administered, WFWB remained independently associated with ALI (adjusted odds ratio [AOR], 1.06; 95% confidence interval [CI], 1.00-1.13). Nearly two thirds of persons with ALI never received WFWB; factors associated with the use of WFWB were also examined. Severity of illness (AOR, 1.18; 95% CI, 1.02-1.35), crystalloid volume (AOR, 1.12; 95% CI, 1.06-1.18), recombinant factor VIIa use (AOR, 1.94; 95% CI, 1.06-3.57), and US citizenship (AOR, 3.06; 95% CI, 1.74-5.37) correlated with WFWB use.Conclusions: Warm fresh whole blood may be associated with an increased risk of ALI, but this is confounded by increased injury and crystalloid use in patients receiving WFWB.

Respiratory syncytial virus morbidity, premorbid factors, seasonality, and implications for prophylaxis - Corrected Proof

2012-01-09

Abstract: Objectives: We investigated factors associated with morbidity and pediatric intensive care unit (PICU) admission in children with respiratory syncytial virus (RSV) infection and explored seasonality and implication of prophylaxis.Methods: A retrospective study between 2006 and 2008 of every child with a laboratory-confirmed RSV infection was included.Results: Six hundred seventy RSV admissions were identified. Ten (1.5%) required PICU admissions. Children admitted to PICU were younger than non-PICU admissions (median [interquartile range] age, 0.3 [0.11-0.48] vs 1.18 [0.46-2.49] years; P = .001). Odds associated with PICU admissions included history of chronic lung disease (odds ratio [95% confidence interval], 18.08 [2.29-114.95]; P = .010), history of acyanotic heart disease (7.61 [1.04-42.59], P = .043), and neurodevelopmental conditions (mental retardation, cerebral palsy, or neuromuscular disease; 8.41 [1.63-38.57], P = .012). Odds of bacterial coinfections was 13.50 (1.77-81.29), P = .017. There appeared no significant PICU predilection in terms of sex, history of prematurity, cyanotic heart disease, seizure disorders, chromosomal disorders, or malignancy. Admissions associated with proven RSV infections accounted for 2.4% of PICU annual admissions. The duration of PICU stay was generally brief (median, 3 days). However, median length of hospital stay was significantly longer in the PICU category (8.5 vs 3 days, P < .001). There was no death in the study period. Only 5 (0.75%) of 665 patients were readmitted to the pediatric infectious disease isolation ward in consecutive years, and none required PICU support. Twenty (3%) of admissions involved neonates younger than 30 days. There was no definite seasonality, but incidence was lowest between October and January.Conclusions: Most infants have mild disease and do not require PICU support. Young infants with history of chronic lung disease, congenital heart disease, and neurodevelopmental conditions appear to be at significantly increased risk for PICU support. There is no winter seasonality for RSV disease in Hong Kong. Therefore, any prophylaxis for at-risk population should provide adequate coverage for the warmer months in subtropical regions.

Model for End-Stage Liver Disease score for predicting outcome in critically ill medical patients with liver cirrhosis - Corrected Proof

2012-01-09

Abstract: Purpose: We hypothesized that the Model for End-Stage Liver Disease (MELD) score at admission to the intensive care unit (ICU) can predict in-hospital mortality for patients with liver cirrhosis. We also tested the MELD-natremia (Na) score and compared the predictive value of the 2 models.Materials and Methods: This is a retrospective cohort study. A total of 441 consecutive patients with liver cirrhosis admitted to the ICU were included. The MELD and MELD-Na scores and other variables were obtained upon patients' admission to the ICU.Results: The area under the receiver operating characteristic curve to predict in-hospital mortality was 0.77 (95% confidence interval, 0.73-0.82) for the MELD score and 0.77 (95% confidence interval, 0.73-0.81) for the MELD-Na score.Conclusion: The MELD scoring system provides useful prognostic information for critically ill patients with liver cirrhosis admitted to an ICU. The MELD and MELD-Na scores had similar predictive value.

Predictors of prolonged vasopressin infusion for the treatment of septic shock - Corrected Proof

Heather A. Personett, Joanna L. Stollings, Stephen S. Cha, Lance J. Oyen — 2012-01-09

Abstract: Purpose: Prolonged catecholamine use has been linked with poor clinical outcomes, including higher mortality. The objective was to identify characteristics that may be predictive of prolonged arginine vasopressin (AVP) use for 7 days or more in patients with septic shock.Materials and Methods: This was a retrospective nested cohort analysis of adult patients receiving AVP as initial hemodynamic support for septic shock, either alone or in combination with norepinephrine, between 2008 and 2010.Results: Univariate factors predictive of patients requiring extended AVP support were peripheral vascular disease (PVD) (48% vs 18%, P = .001), congestive heart failure (30% vs 12%, P = .024), and acute kidney injury (AKI) (83% vs 49%, P = .003). Patients requiring extended AVP support more frequently experienced a new intensive care unit (ICU) arrhythmia, typically atrial fibrillation (39% vs 7%, P < .001), and had higher 28-day mortality (74% vs 20%, P < .001). Multivariate analysis revealed that the strongest independent predictors of prolonged AVP dependence were new ICU arrhythmia (odds ratio [OR], 5.3; 95% confidence interval [CI], 1.6-17.8), PVD (OR, 4.3; 95% CI, 1.4-13.1), and AKI (OR, 3.9; 95% CI, 1.1-14.5).Conclusions: Patients with preexisting PVD and AKI and those experiencing a new ICU arrhythmia on AVP may be more likely to remain on AVP for 7 or more days.

Fever in non-neurological critically ill patients: A systematic review of observational studies - Corrected Proof

Moritoki Egi, Kiyoshi Morita — 2012-01-09

Abstract: Purpose: There is no recommendation on how increased body temperature should be treated in non-neurological critically ill patients. To understand the epidemiology of fever and its association with mortality, we conducted a systematic review of the literature to search for data related to the association between fever and mortality.Materials and Methods: We searched MEDLINE and PUBMED related articles and reference lists from January 1978 to July 2011 to select observational studies for assessment of the association of fever with mortality in non-neurological critically ill patients.Results: We reviewed 1464 articles and found 9 relevant articles. We found that (1) there is no uniform definition of fever, (2) fever (37.5°C to >39.0°C) was not significantly associated with mortality (odds ratio, 1.22; P = .52), and (3) high fever (39.3°C to 39.5°C) was significantly associated with mortality (odds ratio, 2.95; P = .03). We also found that there has been no multicenter prospective observational study including important confounding factors, such as the use of antipyretic treatments, steroids, and extracorporeal circuits.Conclusions: The limited evidence available suggests that the recommended definition of fever (38.3°C) might be too low to predict increased mortality. Because fever is common in the intensive care unit, there is an urgent need for more studies in this field.

Serum neutrophil gelatinase–associated lipocalin in ballistic injuries: A comparison between blast injuries and gunshot wounds - Corrected Proof

Adrian J. Mellor, David Woods — 2012-01-06

Abstract: Neutrophil gelatinase–associated lipocalin (NGAL) is part of a functionally diverse family of proteins that generally bind small, hydrophobic ligands. Neutrophil gelatinase–associated lipocalin is expressed in a number of human tissues including gastrointestinal, respiratory, and urinary tracts and tends to rise in response to inflammation. For this reason, we hypothesized that levels of NGAL might be expressed at higher levels after blast injury compared with other ballistic injury.Purpose: The purpose of this study is to test the hypothesis that NGAL may be a marker of injury severity in blast injury.Materials: Twenty-three combat casualties (13 blast, 10 gunshot wounds) admitted to the multinational role 3 facility in Helmand province were studied. Serum NGAL was measured using a Biosite Triage point-of-care monitor at 5 time points after injury.Results: Neutrophil gelatinase–associated lipocalin rose in both groups of casualties and was significantly predictive of death or renal failure at intensive care unit admission, 12 and 24 hours after injury.Conclusions: Neutrophil gelatinase–associated lipocalin is not a specific marker of blast injury but is predictive of both renal failure and poor outcome.

Subcutaneous heparin does not increase postoperative complications in neurosurgical patients: An institutional experience - Corrected Proof

2012-01-06

Abstract: Introduction: Prophylaxis for venous thromboembolic disease continues to pose a challenging management problem in postoperative neurosurgical patients, particularly those in the intensive care unit (ICU). This study evaluates neurosurgical patients admitted to the surgical ICU (SICU) at a tertiary hospital and compared those who had received subcutaneous unfractionated heparin (SQUFH) to those who did not. This study was conducted to better evaluate if the administration of SQUFH to neurosurgical patients is safe and whether the administration of SQUFH is an independent risk factor for bleeding in this patient population.Methods: Retrospective analysis was performed on prospectively collected data on all postoperative neurosurgical patients admitted over the course of 11 years to the SICU at Long Island Jewish Medical Center. This study included neurosurgical patients who received SQUFH and those who did not. Data acquired included demographic information, hemodynamic monitoring, pharmacologic interventions, laboratory results, and survival outcomes as well as occurrences of heparin-induced thrombocytopenia and pulmonary embolism. Subcutaneous unfractionated heparin for venous thromboembolic prophylaxis were dosed according to previously established literature based hospital protocols. Data were analyzed by χ2, Fisher exact test, Mann-Whitney U test, or the product limit method, where appropriate.Results: Five hundred twenty-two neurosurgical patients were included in the study. Two hundred thirteen patients (40.8%) with mean age of 58 years received SQUFH (133 patients received SQUFH within 24 hours of surgery and 80 patients received SQUFH 24 hours postoperatively). Once SQUFH was initiated, it was continued until discharge from the hospital. Three hundred nine patients (59.2%) with mean age 57.8 years received no anticoagulation. In the SQUFH patient population, 72 patients (33.8%) had a diagnosis of subarachnoid hemorrhage compared with 125 patients (40.5%) from the group who had not received anticoagulation. There was no significant difference in ICU length of stay between the groups, 5.8 ± 5.4 (no deep vein thrombosis prophylaxis), and those receiving SQUFH, 6.7 ± 6.1 (over 24 hours) and 5.9 ± 4.8 (over 24 hours). No postoperative hemorrhages were observed (confirmed by computed tomography of the brain) in any of the neurosurgical patients with subarachnoid hemorrhage, intracerebral hemorrhage, or subdural or epidural hemorrhage. No instances of heparin-induced thrombocytopenia (HIT) or pulmonary embolism (PE) were observed.Conclusions: Administration of SQUFH dosed according to the risk for thromboembolism does not appear to contribute to postoperative hemorrhage in neurosurgical patients. This study supports the concept that the administration of SQUFH is safe in postoperative neurosurgical population.

Prehospital amiodarone may increase the incidence of acute respiratory distress syndrome among patients at risk - Corrected Proof

2012-01-06

Abstract: Purpose: Amiodarone has been implicated as a risk factor for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) when used in the hospital. This study aims to estimate whether prehospital amiodarone also increases the risk of ALI/ARDS.Materials: Adult patients admitted to 22 centers with at least 1 risk factor for developing ALI were recruited. In a secondary analysis of this cohort, the prehospital use of amiodarone was documented on admission, and the patients followed for the primary outcome of ALI and secondary outcomes of ARDS, the need for invasive ventilation, and mortality. Dose/duration of amiodarone therapy was not available. Propensity matching was performed to account for imbalances in being assigned to amiodarone. The adjusted risk for ALI/ARDS was then estimated from a conditional logistic regression model of this propensity-matched set.Results: Forty of 5584 patients were on amiodarone at the time of hospitalization; of those, 6 developed ALI, with 5 progressing to ARDS. In comparison, 371 patients not on amiodarone developed ALI, with 224 having ARDS. After propensity score matching, the prehospital use of amiodarone was not statistically associated with an increased risk for all ALI (odds ratio [OR], 1.8; 95% confidence interval [CI], 0.7-5.0; P = .25), invasive ventilation (OR, 1.9; 95% CI, 1.0-3.6; P = .059), or in-hospital mortality (OR, 1.2; 95% CI, 0.5-2.9; P = .75); but its use appeared to significantly increase the risk for ARDS (OR 3.8; 95% CI, 1.1-13.1; P = .036).Conclusions: Prehospital use of amiodarone may independently increase the risk for ARDS in patients who have at least 1 predisposing condition for ALI.

Epidemiology and management of atrial fibrillation in medical and noncardiac surgical adult intensive care unit patients - Corrected Proof

2012-01-06

Abstract: Purpose: The aim of the study was to describe the epidemiology and management of atrial fibrillation (AF) in noncardiac surgery critically ill patients in a retrospective, observational study at 3 mixed medical-surgical, university-affiliated intensive care units (ICUs).Methods: Consecutive patients admitted during a 1-year period with any documentation of AF during ICU stay were identified. Demographic data, risk factors, interventions, and outcomes were collected from the medical record.Results: A total of 3081 patients were admitted during the 1-year study period in which 348 consecutive patients (10.5%) had documented AF. Atrial fibrillation was of new onset in 139 patients (4.5%) and preexisting in 186 patients (6.0%). Hemodynamic instability developed in 37% and 10% of patients with new-onset AF and patients with preexisting AF, respectively. Most (73%) patients with new-onset AF had at least 1 modifiable risk factor. Pharmacologic rhythm conversion was attempted in 76% and 26% of patients with new-onset AF and patients with preexisting AF, respectively. Although initially successful in 87% of new-onset cases, 42% reverted back to AF. Electrical conversion was successful in 7 (27%) of 26 and 0 (0%) of 5 of patients with new-onset AF and patients with preexisting AF, respectively. In total, 18% and 62% of patients with new-onset AF and patients with preexisting AF, respectively, who survived to ICU discharge left the ICU in AF.Conclusions: Atrial fibrillation is common but transient in most ICU patients. Electrical cardioversion is often unsuccessful, and pharmacologic rhythm conversion is often only transiently effective. Modifiable risk factors are common among these patients. Future studies are needed to address the management of AF in the ICU.

The flow-time waveform predicts respiratory system resistance and compliance - Corrected Proof

Boulos S. Nassar, Nicole D. Collett, Gregory A. Schmidt — 2012-01-06

Abstract: Purpose: Knowledge of patients' lung compliance and resistance aids clinical management. We investigated whether these values, readily measured during volume assist-control ventilation (VACV), could also be estimated during pressure assist-control ventilation (PACV).Methods: Data were collected in 12 mechanically ventilated human subjects. During VACV, peak pressure, plateau pressure, end-expiratory pressure, tidal volume, and inspiratory flow rate were measured. During PACV, inspiratory pressure, end-expiratory pressure, and tidal volume were recorded. The linear component of the pressure-time waveform was extrapolated to time and flow axes. Using the equation of motion for the respiratory system, assuming a nonlinear resistance, we calculated inspiratory resistance and compliance. During VACV, compliance and inspiratory resistance were calculated in the conventional manner.Results: In ventilated subjects, mean compliance during PACV was 37.06 ± 15.65 mL/cm H2O, and during VACV, 36.93 ± 12.18 mL/cm H2O. Mean inspiratory resistance during PACV was 15.17 ± 5.14 cm H2O/L per second, whereas during VACV, it was 12.50 ± 2.99 cm H2O/L per second. A strong correlation is evident between compliance and inspiratory resistance calculated during PACV vs VACV (r2 of 0.73 and 0.51, respectively).Conclusions: During PACV, the inspiratory flow waveform is linear, and its slope contains information regarding inspiratory resistance and compliance. Calculated values correlate with those during VACV.

Predictors of short-term mortality in patients undergoing percutaneous dilatational tracheostomy - Corrected Proof

2011-12-16

Abstract: Purpose: The purpose of the study was to identify the predictors of short-term mortality in patients undergoing percutaneous dilatational tracheostomy (PDT).Materials and Methods: Retrospective analysis of data pertaining to adult patients who underwent PDT between July 2005 and June 2008 in an urban, academic, tertiary care medical center was done. Clinical and demographic data were analyzed for 483 patients undergoing PDT via multivariate logistic regression.Results: Mortality data were examined at in-hospital, 14, 30, and 180 days postprocedure. Overall mortality rates were 11% at 14 days, 19% at 30 days, and 40% at 180 days. In-hospital mortality was 30%.Conclusions: Patients undergoing PDT have significant short-term mortality with 11% dying within 14 days and an in-hospital mortality rate of 30%. We identified an index diagnosis of ventilator-associated pneumonia and trauma to be associated with a higher survival rate, whereas older age, oncological diagnosis, cardiogenic shock, and ventricular-assist devices were associated with higher mortality. There is significant heterogeneity in both underlying diagnosis and patient outcomes, and these factors should be considered when deciding to perform this procedure and discussed with patients/family members to provide a realistic expectation of potential prognosis.

Diagnostic value of positron emission tomography combined with computed tomography for evaluating patients with septic shock of unknown origin - Corrected Proof

2011-12-16

Abstract: Purpose: 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) combined with computed tomography (CT) is a promising new tool for the identification of infectious foci. The aim of our work was to evaluate the diagnostic value of FDG-PET/CT in critically ill patients with septic shock of unknown origin.Methods: We performed a single-center, 6-year retrospective evaluation of the value of FDG-PET/CT in critically ill patients with severe sepsis or septic shock of unknown origin.Results: Eighteen patients underwent FDG-PET/CT. Microbiological tests (blood culture, urine, and respiratory secretions), chest x-rays, CT scans, and transesophageal echocardiography were performed on all patients before FDG-PET/CT scanning. Pathologic FDG accumulation could be demonstrated in 14 of 18 FDG-PET/CT scans. On a per-patient basis, 11 were “true positive,” 3 were “false positive,” 4 were true negative, and there were no false negatives. In 6 cases, the results of the PET/CT scan had direct therapeutic consequences (surgery, 2; pacemaker removal, 2; initiation of antibiotic therapy, 1; and prolonged antibiotic therapy, 1); 12 (66%) of the 18 patients survived to hospital discharge.Conclusions: The FDG-PET/CT is a valuable tool for the localization of infectious foci in critically ill patients with severe sepsis/septic shock in whom conventional diagnostic methods fail to detect these foci. Prospective studies with more patients are warranted to further evaluate the diagnostic accuracy and feasibility of this diagnostic tool in critically ill patients with severe sepsis.

Plasma C-reactive protein levels are associated with mortality in elderly with acute lung injury - Corrected Proof

2011-12-16

Abstract: Purpose: The plasma C-reactive protein (CRP) level is considered to be a predictor of severity in both hospital- and community-acquired pneumonias, whereas recent reports have shown that higher CRP levels lead to better outcomes in patients with acute lung injury (ALI). To explain this discrepancy, we evaluated the relationship among plasma CRP levels, etiology, affectors of CRP production, and mortality in patients with ALI.Materials and Methods: This was a case-control study of 76 consecutive patients with ALI. The plasma CRP levels had been measured in all of the patients within 1 hour of visiting an emergency department. The associations between the plasma CRP levels and 60-day mortality were analyzed after adjusting for the causes of ALI, disease severity, the patients' age, use of corticosteroids, and presence of hepatic failure.Results: The CRP levels and patients' ages were strongly related to the mortality (adjusted hazard ratio, 1.005 [P = .007] and 1.059 [P = .011], respectively), whereas the etiology of ALI did not affect the mortality (adjusted hazard ratio, 0.789 [P = .530]) in the Cox proportional hazard models.Conclusions: The plasma CRP level may be a predictor of mortality in elderly patients with ALI.

Fluid Resuscitation with 5% albumin versus Normal Saline in Early Septic Shock: A pilot randomized, controlled trial - Corrected Proof

2011-12-16

Abstract: Purpose: Randomized, controlled trials of fluid resuscitation in early septic shock face many logistic challenges. We describe the Fluid Resuscitation with 5% albumin versus Normal Saline in Early Septic Shock (PRECISE) pilot trial study design and report feasibility of patient recruitment.Materials and Methods: Six Canadian academic centers enrolled adult patients with early suspected septic shock from the emergency department and intensive care unit department. Consent was deferred. Using concealed allocation, participants were randomized to either 5% albumin or 0.9% sodium chloride. Blinded fluid resuscitation started immediately and continued for 7 days in the intensive care unit. Target recruitment was established a priori at 2 patients per site per month.Results: Fifty-one patients were enrolled; 50 patients received study fluid. We recruited a median of 2.5 patients (interquartile range [IQR], 1.5-3.0) per site per month into the trial. Median age and Acute Physiology and Chronic Health Evaluation II scores were 64.5 (IQR, 55.0-78.0) and 25.0 (IQR, 20.0-29.0), respectively. Most patients (n = 37 [74.0%]) were enrolled from the emergency department for a median of 1.6 hours (IQR, 0.8-3.5 hours) from their first hypotensive event and received a median of 2.4 L (IQR, 1.5-3.0 L) of resuscitation fluid before inclusion. Consent was deferred for 44 patients (89.8%).Conclusions: Patient recruitment into the PRECISE pilot trial met our prespecified feasibility targets, and the PRECISE team is planning the larger trial.

Effect of osmotic agents on regional cerebral blood flow in traumatic brain injury - Corrected Proof

2011-12-16

Abstract: Purpose: Cerebral blood flow (CBF) is reduced after severe traumatic brain injury (TBI) with considerable regional variation. Osmotic agents are used to reduce elevated intracranial pressure (ICP), improve cerebral perfusion pressure, and presumably improve CBF. Yet, osmotic agents have other physiologic effects that can influence CBF. We sought to determine the regional effect of osmotic agents on CBF when administered to treat intracranial hypertension.Materials and Methods: In 8 patients with acute TBI, we measured regional CBF with positron emission tomography before and 1 hour after administration of equi-osmolar 20% mannitol (1 g/kg) or 23.4% hypertonic saline (0.686 mL/kg) in regions with focal injury and baseline hypoperfusion (CBF <25 mL per 100 g/min).Results: The ICP fell (22.4 ± 5.1 to 15.7 ± 7.2 mm Hg, P = .007), and cerebral perfusion pressure rose (75.7 ± 5.9 to 81.9 ± 10.3 mm Hg, P = .03). Global CBF tended to rise (30.9 ± 3.7 to 33.1 ± 4.2 mL per 100 g/min, P = .07). In regions with focal injury, baseline flow was 25.7 ± 9.1 mL per 100 g/min and was unchanged; in hypoperfused regions (15% of regions), flow rose from 18.6 ± 5.0 to 22.4 ± 6.4 mL per 100 g/min (P < .001). Osmotic therapy reduced the number of hypoperfused brain regions by 40% (P < .001).Conclusion: Osmotic agents, in addition to lowering ICP, improve CBF to hypoperfused brain regions in patients with intracranial hypertension after TBI.

Absolute eosinophils count as a marker of mortality in patients with severe sepsis and septic shock in an intensive care unit - Corrected Proof

2011-12-16

Abstract: Introduction: Eosinophils in the circulating blood undergo apoptosis during sepsis syndromes induced by the action of certain cytokines.Objective: The aim of the study was to evaluate the absolute eosinophils count (EC) as a marker of mortality in severe sepsis and septic shock.Patients and Method: A prospective cohort study of patients with a diagnosis of sepsis or septic shock admitted to the intensive care unit (ICU) of the Dr Gustavo Fricke Hospital between January 2008 and December 2009 was conducted. Daily EC in all patients was analyzed. Receiver operating characteristic curve analysis was used to assess the performance of the diagnostic test.Results: We studied a total of 240 patients. The median age was 62 years (interquartile range [IQR], 48-72 years), and 67 (27.9%) died. The median EC in patients who died was 43 (IQR, 14-121), whereas in surviving patients, it was 168 (IQR, 98-292) (P < .001). When the EC on the fifth day of hospital stay was assessed, an area under the curve (AUC) of 0.64 (95% confidence interval, 0.55-0.73) was observed. Eosinophils count at intensive care unit discharge showed an area under the curve of 0.81 (95% confidence interval, 0.76-0.87).Discussion: Eosinophils counts were lower in patients who died of sepsis than in those who survived, but its clinical usefulness seems limited. Their role as an indicator of clinical stability seems to be important.

Adverse events and clinical outcome associated with drotrecogin alfa-activated: A single-center experience of 498 patients over 8 years - Corrected Proof

Alison Boyle, Cathrine McKenzie, Sarah Yassin, Angela McLuckie, Duncan Wyncoll — 2011-12-15

Abstract: Purpose: Licensed in 2002 for severe sepsis, drotrecogin alfa-activated (DAA) remains a much debated therapy particularly with respect to outcomes and a potentially increased risk of serious bleeding events (SBEs). Recent publications have suggested a significantly increased incidence of SBEs and death in those with baseline bleeding risks (BBRs). Our center is one of the highest prescribers of DAA worldwide; we describe our experience of SBEs and other clinical outcomes.Methods: Prospectively collected data using a clinical guideline audit tool and database to track outcome and adverse events of DAA-treated severe sepsis patients were analyzed.Results: Four hundred ninety-eight patients received DAA over an 8-year period. Hospital, critical care, and 28-day mortalities were 46.2%, 39.6%, and 35.1%, respectively. Contraindications were identified for 40 (8.0%) patients, of whom 24 (4.8%) had BBRs. Hospital mortality was 47.5% (19/40) for patients with any contraindication and 45.8% (11/24) for those with a BBR. Seventy-six (15.3%) bleeding events were reported; 22 (4.4%) were considered serious. Hospital mortality was 60.5% for patients with any bleeding event and 77.3% for those with SBEs.Conclusions: This large single-center case series demonstrates that DAA has an incidence of SBEs similar to initial clinical trials. As expected, SBEs were associated with a poor outcome.

Evaluation of consulting and critiquing decision support systems: Effect on adherence to a lower tidal volume mechanical ventilation strategy - Corrected Proof

2011-12-15

Abstract: Purpose: Our hypothesis was that both styles are effective to decrease tidal volume (VT) but that critiquing comprises the most effective strategy. The purpose of this study is to test this hypothesis by measuring the effect of an active computerized decision support system, in 2 communication styles, consulting and critiquing, on adherence to VT recommendations.Materials and Methods: We developed and implemented an active computerized decision support system (CDSS) working in a consulting style that always shows the preferred VT and in a critiquing style that shows the preferred VT only if VT is above the desired threshold. A prospective, off-on-off-on study evaluated the system's performance in a mixed medical-surgical intensive care unit of a university hospital.Results: Four thousand seven hundred sixty-four patient-day mechanical ventilation from 757 patients were analyzed. The percentage of ventilation time in excess of 6 and 8 mL/kg predicted body weight decreased significantly after intervening with the consulting style (12% reduction and P < .001; 22% reduction and P < .001) and again increased after stopping the CDSS (11% increase and P < .001; 29% increase and P < .001). With the critiquing CDSS, the percentage of ventilation time in excess of 6 and 8 mL/kg predicted body weight again decreased significantly (6% reduction and P < .001; 15% reduction and P < .001).Conclusions: The use of a CDSS in both communication styles improved the use of lower VTs for ventilated patients. When decision support was not sustained, adherence to low VT fell back to its original value. Interestingly, the consulting style had a slightly larger effect. This may stem from the high frequency of showing reminders in this style and the relatively simple underlying guideline where its display implies the associated action of lowering VT. The consulting style, however, was more interruptive for clinicians, calling upon the need to strike a balance between effect and intrusiveness.

Incidence and risk factors for sepsis in surgical patients: A cohort study - Corrected Proof

2011-12-15

Abstract: Purpose: The aim of the study was to evaluate risk factors for infection and sepsis in surgical patients admitted to the intensive care unit (ICU).Materials and Methods: Data were prospectively collected from a cohort of surgical patients from January 2005 to December 2007. We analyzed the incidence of infection and sepsis and certain other variables from the pre-, intra-, and postoperative periods as risk factors for infection and sepsis.Results: We studied 625 surgical patients. The mortality rate was 18.2%, and the mean age of the subjects was 53.1 ± 18.8 years. The incidences of severe sepsis and septic shock were 5% and 11.5%, respectively. A multivariate analysis showed that the following variables were associated with sepsis in the postoperative period: urgent surgery (odds ratio, 2.63; 95% confidence interval [CI], 1.50-4.63), fluid resuscitation (odds ratio, 1.90; 95% CI, 1.18-3.05), vasoactive drugs (odds ratio, 2.58; 95% CI, 1.61-4.14), and mechanical ventilation (odds ratio, 5.51; 95% CI, 3.07-9.89). A Sequential Organ Failure Assessment was associated with infection or sepsis upon ICU admission (area under the curve, 0.737 ± 0.019; 95% CI, 0.748-0.825).Conclusions: This study showed that sepsis has high incidence and mortality in surgical patients admitted to the ICU. Urgent surgeries, mechanical ventilation, fluid resuscitation, and vasoactive drugs in the postoperative period and Sequential Organ Failure Assessment at ICU admission were risk factors for sepsis.

Endothelial dysfunction assessed by brachial artery ultrasound in severe sepsis and septic shock - Corrected Proof

2011-12-15

Abstract: Purpose: Noninvasive evaluation of endothelial function may be accomplished by ultrasound assessment of flow-mediated vasodilation (FMD) of the brachial artery. This study aims to investigate the role of FMD analysis on intrahospital prognosis of patients with sepsis.Methods: Adult patients admitted to the intensive care unit with severe sepsis or septic shock were consecutively included. Brachial artery FMD was measured upon admission, after 24 and 72 hours. A group of apparently healthy subjects paired for sex and age was used as controls. Patients were followed up to discharge or death.Results: We studied 42 patients (mean age, 51 ± 19 years) with sepsis predominantly of abdominal or respiratory etiology (75%). Acute Physiology And Chronic Health Evaluation II risk score was 23 ± 7, and intrahospital mortality rate was 33%. Flow-mediated vasodilation in septic patients was significantly lower than in healthy controls (1.5 ± 7% vs 6 ± 4%, P < .001). Most of the nonsurvivors (86%) showed a decline in sequential FMD analyses, whereas only 43% of survivors showed a reduction of FMD (P = .01). In nonsurvivors, FMD was significantly lower 72 hours after sepsis onset (−3.3% ± 10% vs 5.2% ± 4%; P < .05; time-group interaction P value = .03).Conclusions: Brachial FMD is altered in septic patients with hemodynamic instability, and its deterioration may be an early marker of unfavorable prognosis.

A model to predict short-term death or readmission after intensive care unit discharge - Corrected Proof

2011-12-15

Abstract: Objective: Early unplanned readmission to the intensive care unit (ICU) carries a poor prognosis, and post-ICU mortality may be related, in part, to premature ICU discharge. Our objectives were to identify independent risk factors for early post-ICU readmission or death and to construct a prediction model.Design: Retrospective analysis of a prospective database was done.Setting: Four ICUs of the French Outcomerea network participated.Patients: Patients were consecutive adults with ICU stay longer than 24 hours who were discharged alive to same-hospital wards without treatment-limitation decisions.Main results: Of 5014 admitted patients, 3462 met our inclusion criteria. Age was 60.6 ± 17.6 years, and admission Simplified Acute Physiology Score II (SAPS II) was 35.1 ± 15.1. The rate of death or ICU readmission within 7 days after ICU discharge was 3.0%. Independent risk factors for this outcome were age, SAPS II at ICU admission, use of a central venous catheter in the ICU, Sepsis-related Organ Failure Assessment and Systemic Inflammatory Response Syndrome scores before ICU discharge, and discharge at night. The predictive model based on these variables showed good calibration. Compared with SAPS II at admission or Stability and Workload Index for Transfer at discharge, discrimination was better with our model (area under receiver operating characteristics curve, 0.74; 95% confidence interval, 0.68-0.79).Conclusion: Among patients without treatment-limitation decisions and discharged alive from the ICU, 3.0% died or were readmitted within 7 days. Independent risk factors were indicators of patients' severity and discharge at night. Our prediction model should be evaluated in other ICU populations.

Feasibility of continuous multiorgan variability analysis in the intensive care unit - Corrected Proof

Beverly Bradley, Geoffrey C. Green, Izmail Batkin, Andrew J.E. Seely — 2011-12-15

Abstract: Purpose: The aim of the study was to evaluate the feasibility of continuous heart and respiratory rate variability (HRV and RRV, respectively) monitoring in critically ill patients derived from electrocardiogram (ECG) and end-tidal capnography (etCO2) waveforms.Methods: Thirty-four patients (age, 56.5 ± 15.9 years; Acute Physiology and Chronic Health Evaluation II score, 22.8 ± 6.7) underwent continuous recording of ECG and etCO2 waveforms from intensive care unit admission and intubation to discharge or maximum of 14 days. Overlapping 5-minute windows were analyzed with a wide range of variability measures (time, frequency, entropy, and scale-invariant and nonlinear domains). Waveform data quality, presence of disconnections and arrhythmias, quality of beat and breath detection, and subsequent variability computations were evaluated.Results: Patients were enrolled for 11.0 ± 3.6 days. The proportion of missing waveform data among all patients was (median [interquartile range, maximum]) 2.9% (1.3%-9.7%, 36.4%) for ECG and 3.1% (1.1%-11.4%, 84.5%) for etCO2. Heart rate variability data loss (ie, proportion of windows removed) was 1.3% (1.0%-2.1%, 5.9%) due to disconnection, 0.6% (0.1%-3.9%, 39.5%) due to atrial fibrillation, and 6.6% (1.4%-17.9%, 89.0%) due to data cleaning. Respiratory rate variability data loss was 7.3% (2.9%-11.6%, 47.7%) due to disconnection (or apnea) and 5.5% (2.9%-8.4%, 56.4%) due to cleaning. Continuous individualized multiorgan variability analysis processing resulted in HRV and RRV computations for 81.2% ± 25.0% and 87.5% ± 11.9% of available ECG and etCO2 waveform data, respectively.Conclusions: The quality of continuously recorded ECG and etCO2 waveforms in critically ill patients is adequate for subsequent continuous variability monitoring in this pilot study. The clinical utility of continuous variability analysis merits further investigation.

Effect of 24-hour mandatory vs on-demand critical care specialist presence on long-term survival and quality of life of critically ill patients in the intensive care unit of a teaching hospital - Corrected Proof

Martin Reriani, Michelle Biehl, Jeff A. Sloan, Michael Malinchoc, Ognjen Gajic — 2011-12-15

Abstract: Background: Mandatory compared with on-demand intensivist presence improves processes of care and decreases intensive care unit (ICU) complication rate and hospital length of stay. The effect of continuous mandatory intensivist coverage on long-term patient mortality and quality of life (QOL) is not known.Methods: We compared the long-term survival before (year 2005) and after (year 2006) the intervention when the staffing model changed from on-demand presence to mandatory 24-hour staff-critical care specialist presence in the medical ICU. Baseline and 6-month QOL surveys (SF-36 [short form 36 health survey]) were compared in subgroups of patients admitted before and after the staffing change. Cox proportional hazard and paired statistical analyses were used for survival and QOL comparisons.Results: The baseline characteristics did not differ significantly between the 2 groups except for race and Acute Physiology and Chronic Health Evaluation III score (median, 30 vs 37; P < .001 before and after the staffing model change). Long-term survival was not significantly different before and after the staffing change—adjusted hazard ratio, 1.05; 95% confidence interval, 0.95 to 1.16; P = .3. In a subset of ICU survivors, SF-36 physical component score improved significantly at 6 months compared with baseline after the staffing model change—Δ mean (SD) 8 (14) vs 2 (11), P = .03. However, there was no difference in the Δ mean mental component score of the SF-36 between the 2 groups (P = .77).Conclusions: Introduction of an additional night shift to provide mandatory as opposed to on-demand 24-hour staff critical care specialist coverage did not affect long-term survival of medical ICU patients.

Near-infrared spectroscopy cerebral and somatic (renal) oxygen saturation correlation to continuous venous oxygen saturation via intravenous oximetry catheter - Corrected Proof

Gilma A. Marimón, W. Keith Dockery, Michael J. Sheridan, Swati Agarwal — 2011-12-15

Abstract: Purpose: Near-infrared spectroscopy (NIRS) and continuous central venous oxygen saturation (ScvO2) via oximetry catheter are 2 modalities available to estimate adequacy of oxygen delivery in postoperative pediatric cardiac patients. Near-infrared spectroscopy measures regional tissue oxygenation and is routinely used in pediatric cardiac surgery patients. By not requiring an invasive catheter, NIRS has the advantage over mixed venous oxygen saturation (SvO2) monitoring. An alternative marker of global tissue oxygenation is central venous oxygen saturation (ScvO2). A recently developed pediatric-sized oximetric catheter (PediaSat; Edwards Lifesciences, Irvine, CA, USA) functions as a central venous catheter and provides a continuous ScvO2 reading, an accepted surrogate to SvO2. To date, the correlation between NIRS and ScvO2 has not been quantified. The aim of this study was to examine the strength of the bivariate correlation between NIRS and ScvO2 measurements.Design/methods: Twenty pediatric patients undergoing cardiac surgery had the PediaSat catheter placed with the tip in the superior vena cava and NIRS sensors (cerebral and renal) placed in the operating room per routine protocol. Hourly measurements of NIRS-cerebral (NIRS-C), NIRS-renal, and ScvO2 readings were recorded for each patient for up to 48 hours postoperatively.Results: A cumulative total of 630 hours of data were collected. Spearman correlation coefficients for NIRS-renal vs ScvO2 and NIRS-C vs ScvO2 measurements were r = 0.38 (P = .09) and r = 0.58 (P < .008), respectively.Conclusions: In this small cohort of pediatric patients undergoing heart surgery, there was a moderate but statistically significant correlation between the ScvO2-catheter and the NIRS-C values. Further studies are required to determine which oxymetric modality of monitoring cardiac output most aids in the postoperative management of these patients.

The adequacy of timely empiric antibiotic therapy for ventilator-associated pneumonia: An important determinant of outcome - Corrected Proof

2011-12-02

Abstract: Objective: The individual impact of timeliness vs adequacy of empiric antibiotic therapy for a clinical suspicion of ventilator-associated pneumonia (CSVAP) is unknown. Accordingly, in patients with CSVAP and timely initiation of empiric antibiotic therapy, we determined the impact of inadequate therapy (IT).Methods: Analysis of a randomized trial of CSVAP treated empirically with meropenem or meropenem plus ciprofloxacin was done. Adequate therapy (AT) was considered present if all pathogens in the index culture were sensitive to the empiric antibiotics; IT was defined as the presence of pathogens resistant to the empiric antibiotics. A priori, for Pseudomonas sp, 2 antibiotics with activity against the organisms were required for AT to be considered present.Results: Of 739 patients with CSVAP, 350 had positive cultures: 313 (89.4%) had AT, and 37 (10.6%), IT. The IT group had higher intensive care unit (35.1% vs 11.8%, P = .0001) and hospital mortalities (48.7% vs 19.5%, P < .0001), increased mechanical ventilation (15.8 vs 6.8 days, P = .0005), intensive care unit stay (13.5 vs 8.4 days, P = .02), and hospital stay (42.2 vs 27.9 days, P = .04). In multivariate analysis and a separate case control analysis, the odds ratio of hospital mortality with IT was 3.05 (95% confidence interval, 1.25-7.45; P = .01) and 3.00 (95% confidence interval, 1.24-7.24; P = .01), respectively.Conclusion: In the context of early administration of empiric broad spectrum antibiotics for CSVAP, IT is associated with higher morbidity and mortality.

Prognostic value of extravascular lung water index in critically ill patients: A systematic review of the literature - Corrected Proof

Zhongheng Zhang, Baolong Lu, Hongying Ni — 2011-12-02

Abstract: Background: The prognostic value of extravascular lung water (EVLW) has been widely investigated; however, a wide range of its predictive accuracy has been reported.Study Design: A meta-analysis of diagnostic test studies was conducted.Setting and Population: Various patient populations in the intensive care unit were included, such as burned patients and patients with acute lung injury/acute respiratory distress syndrome and sepsis.Selection Criteria: A computerized search of PubMed, Current Contents, CINAHL, and EMBASE from inception until March 1, 2011, was performed to identify potentially relevant articles. The inclusion criteria were studies investigating the prognostic value of EVLW in critically ill patients. There was no language restriction in the searching.Index Tests: The EVLW index (EVLWI) was used.Reference Tests: The outcome was mortality (including in-hospital mortality, intensive care unit mortality, and 28-day mortality).Results: We analyzed data from 11 studies and 9 countries involving 670 patients. Overall, the EVLWI was significantly higher in nonsurvivors than in survivors, with a mean difference of 5.06 mL/kg (95% confidence interval, −7.53 to −2.58). The heterogeneity was significant with I2 = 90%. The pooled statistics of diagnostic accuracy together with relevant 95% confidence interval were as follows: sensitivity, 0.81 (0.72-0.88); specificity, 0.66 (0.55-0.76); diagnostic odds ratio, 8.84 (3.83-20.4), positive likelihood ratio, 2.44 (1.69-3.52); negative likelihood ratio, 0.28 (0.16-0.46).Limitations: The sample sizes of included studies were small.Conclusion: The EVLWI appears to be a good predictor of mortality in critically ill patients.

The sensitivity and specificity of ultrasound estimation of central venous pressure using the internal jugular vein - Corrected Proof

Brian Siva, Austin Hunt, Neil Boudville — 2011-12-02

Abstract: Purpose: The fluid volume status of a patient is difficult to assess clinically. The aim of this study was to compare the ultrasound estimation of the height of the right internal jugular vein (CVPIJV) with direct estimation of central venous pressure (CVP) (CVPCVC).Materials and Methods: A portable ultrasound machine defined the “top” of the right internal jugular vein in 44 patients from a single tertiary hospital. The vertical height from this point to the sternal angle was used to estimate CVPIJV. A central venous catheter was then inserted and direct measurement of CVP was made with a pressure transducer. A normal CVP was defined as 3 to 6 mm Hg.Results: For overloaded patients, CVPIJV correlated well with CVPCVC, P = .004, sensitivity of 64.3%, specificity of 81.3%, and positive predictive value of 85.7%. The area under the curve for the receiver operating characteristic curve was 0.73 (95% confidence interval, 0.59-0.86). For undervolumed patients, the correlation remained statistically significant, P < .001, sensitivity of 88.9%, specificity of 77.1%, and negative predictive value of 96.4%. The area under the curve was 0.83 (95% confidence interval, 0.70-0.96).Conclusion: Ultrasound estimation of CVP using a portable ultrasound machine and the internal jugular vein is simple, noninvasive, and accurate.

Evolution of neutrophil apoptosis in septic shock survivors and nonsurvivors - Corrected Proof

2011-11-14

Abstract: Purpose: The aims were to analyze the temporal evolution of neutrophil apoptosis, to determine the differences in neutrophil apoptosis among 28-day survivors and nonsurvivors, and to evaluate the use of neutrophil apoptosis as a predictor of mortality in patients with septic shock.Materials and Methods: Prospective multicenter observational study carried out between July 2006 and June 2009. The staining solution study included 80 patients with septic shock and 25 healthy volunteers. Neutrophil apoptosis was assessed by fluorescein isothiocyanate (FITC)–conjugated annexin V and aminoactinomycin D staining.Results: The percentage of neutrophil apoptosis was significantly decreased at 24 hours, 5 days, and 12 days after the diagnosis of septic shock (14.8% ± 13.4%, 13.4% ± 8.4%, and 15.4% ± 12.8%, respectively; P < .0001) compared with the control group (37.6% ± 12.8%). The difference in apoptosis between 28-day surviving and nonsurviving patients was nonsignificant (P > .05). The mortality rate at 28 days was 53.7%. The crude hazard ratio for mortality in patients with septic shock did not differ according to the percentage of apoptosis (hazard ratio, 1.006; 95% confidence interval, 0.98-1.03; P = .60).Conclusions: During the first 12 days of septic shock development, the level of neutrophil apoptosis decreases and does not recover normal values. No differences were observed between surviving and nonsurviving patients.

Prevalence and significance of lactic acidosis in diabetic ketoacidosis - Corrected Proof

2011-10-28

Abstract: Purpose: The prevalence and clinical significance of lactic acidosis in diabetic ketoacidosis (DKA) are understudied. The objective of this study was to determine the prevalence of lactic acidosis in DKA and its association with intensive care unit (ICU) length of stay (LOS) and mortality.Methods: Retrospective, observational study of patients with DKA presenting to the emergency department of an urban tertiary care hospital between January 2004 and June 2008.Results: Sixty-eight patients with DKA who presented to the emergency department were included in the analysis. Of 68 patients, 46 (68%) had lactic acidosis (lactate, >2.5 mmol/L), and 27 (40%) of 68 had a high lactate (>4 mmol/L). The median lactate was 3.5 mmol/L (interquartile range, 3.32-4.12). There was no association between lactate and ICU LOS in a multivariable model controlling for Acute Physiology and Chronic Health Evaluation II, glucose, and creatinine. Lactate correlated negatively with blood pressure (r = −0.44; P < .001) and positively with glucose (r = 0.34; P = .004).Conclusions: Lactic acidosis is more common in DKA than traditionally appreciated and is not associated with increased ICU LOS or mortality. The positive correlation of lactate with glucose raises the possibility that lactic acidosis in DKA may be due not only to hypoperfusion but also to altered glucose metabolism.

Clinical implications of right ventricular dysfunction in patients with acute symptomatic pulmonary embolism: Short- and long-term clinical outcomes - Corrected Proof

Jung-Wan Yoo, Sang-Bum Hong, Chae-Man Lim, Younsuck Koh — 2011-10-28

Abstract: Purpose: Right ventricular dysfunction (RVD) has been found to have a negative impact on the short-term prognosis of patients with pulmonary embolism (PE). However, the long-term prognosis of such patients has not been well defined. We evaluated the effect of RVD on short- and long-term mortality in Korean patients with PE.Materials and Methods: We retrospectively assessed 180 patients with PE who underwent transthoracic echocardiography to evaluate RVD between January 2004 and December 2008. Patients were categorized as hemodynamically stable without RVD (stable without RVD, n = 70), hemodynamically stable with RVD (stable with RVD, n = 74), or hemodynamically unstable with RVD (unstable with RVD, n = 36). The clinical courses of all patients were followed up in-hospital and after discharge.Results: Nineteen patients (10.5%) died during hospitalization, with the unstable with RVD group showing the highest rate of in-hospital mortality (27.8%, P < .05) and PE-related deaths (16.7%, P < .05), but no difference in these parameters was noted between the other 2 groups. Multivariate analysis showed that older age and hemodynamic instability were independent risk factors for poor in-hospital outcomes. Eleven patients died after discharge. Multivariate analysis showed that older age, immobilization, and malignancy were independent predictors of long-term mortality.Conclusion: Right ventricular dysfunction without hemodynamic instability was not associated with short- or long-term mortality of patients with PE.

Incidence, morbidity, and mortality of contrast-induced acute kidney injury in a surgical intensive care unit: A prospective cohort study - Corrected Proof

2011-10-28

Abstract: Purpose: Data on contrast-induced acute kidney injury (CI-AKI) in intensive care unit (ICU) are scarce and controversial. The objectives of the study were to evaluate the incidence and characteristics of CI-AKI in a surgical ICU.Materials and Methods: We conducted a 13-month prospective observational study. Three definitions were compared to characterize CI-AKI: Barrett and Parfrey criteria; Risk of renal dysfunction, Injury to the kidney, Failure of kidney function, Loss of kidney function and End stage renal disease (RIFLE) classification; and Acute Kidney Injury Network (AKIN) criteria. Patients hospitalized in surgical ICU who had received an injection of contrast medium, who were not on renal replacement therapy, who had stable serum creatinine before injection, and no other etiology for new acute kidney injury were included.Results: One hundred one patients were included. The frequency of CI-AKI was 17%, 19%, and 19% according to Barrett and Parfrey criteria; RIFLE classification; and AKIN criteria, respectively. Diabetes mellitus, creatinine clearance less than 60 mL/min, and concomitant aminoglycoside administration were associated with CI-AKI. Statistically significant associations were found between CI-AKI and renal replacement therapy with all 3 definitions and between CI-AKI and mortality when AKIN criteria were used.Conclusions: These results show that CI-AKI is not inconsequential in critically ill patients. In the present study, AKIN criteria appear to be most relevant to define CI-AKI. Further studies are required to explore CI-AKI prevention in ICU.

Use of simulation-based education to improve resident learning and patient care in the medical intensive care unit: A randomized trial - Corrected Proof

2011-10-28

Abstract: Purpose: The purpose of this study is to determine the effect of simulation-based education on the knowledge and skills of internal medicine residents in the medical intensive care unit (MICU).Methods and Materials: From January 2009 to January 2010, 60 first-year residents at a tertiary care teaching hospital were randomized by month of rotation to an intervention group (simulator-trained, n = 26) and a control group (traditionally trained, n = 34). Simulator-trained residents completed 4 hours of simulation-based education before their medical intensive care unit (MICU) rotation. Topics included circulatory shock, respiratory failure, and mechanical ventilation. After their rotation, residents completed a standardized bedside skills assessment using a 14-item checklist regarding respiratory mechanics, ventilator settings, and circulatory parameters. Performance of simulator-trained and traditionally trained residents was compared using a 2-tailed independent-samples t test.Results: Simulator-trained residents scored significantly higher on the bedside skills assessment compared with traditionally trained residents (82.5% ± 10.6% vs 74.8% ± 14.1%, P = .027). Simulator-trained residents were highly satisfied with the simulation curriculum.Conclusions: Simulation-based education significantly improved resident knowledge and skill in the MICU. Knowledge acquired in the simulated environment was transferred to improved bedside skills caring for MICU patients. Simulation-based education is a valuable adjunct to standard clinical training for residents in the MICU.

High-frequency oscillatory ventilation with and without arteriovenous extracorporeal lung assist in patients with severe respiratory failure - Corrected Proof

2011-10-28

Abstract: Purpose: Elimination of carbon dioxide by an arteriovenous extracorporeal lung assist (av-ECLA) can facilitate the lung protective capabilities of high-frequency oscillatory ventilation (HFOV). This case series describes patients treated with HFOV because of severe respiratory failure with and without additional av-ECLA.Methods: A retrospective analysis of 31 patients regarding patient characteristics, gas exchange, respirator settings, hemodynamics, and outcome. In 18 patients, av-ECLA was started before, together with, or during HFOV.Results: The initial arterial carbon dioxide tension before HFOV and av-ECLA was higher in patients who received av-ECLA compared with patients without (P = .043): 65 (48-84) mm Hg and 50 (44-60) mmHg (median and interquartile range). The initial arterial oxygen tension (Pao2)/inspiratory oxygen fraction (Fio2) index in patients who received av-ECLA was 79 (63-133) mm Hg. The Pao2/Fio2 index immediately before HFOV was 84 (65-124) mm Hg (av-ECLA) and 121 (68-150) mmHg (no av-ECLA) and improved to 149 (89-231) mm Hg and 200 (117-233) mmHg during HFOV. Similarly, the oxygenation index improved. No statistically significant differences among groups were detected for Pao2/Fio2 index, oxygenation index, and arterial carbon dioxide tension immediately before and during HFOV. The hospital mortality was 39% (av-ECLA) and 69% (no av-ECLA).Conclusions: High-frequency oscillatory ventilation improved the oxygenation in patients with severe respiratory failure. Additional av-ECLA may facilitate using lung protective HFOV settings in more severe lung injury and hypercapnia.

Physiologic determinants of prolonged mechanical ventilation in patients after major surgery - Corrected Proof

2011-10-28

Abstract: Purpose: The aim of the study was to evaluate the physiologic determinants of ventilator dependency in patients who underwent major surgery.Materials and Methods: In this observational study, 43 stable tracheostomized patients undergoing prolonged ventilation (>14 days) were evaluated. Diaphragmatic muscle function was assessed invasively by the tension-time index of the diaphragm (TTdi), an indicator of diaphragm endurance time. The TTdi was calculated as transdiaphragmatic pressure/maximum transdiaphragmatic pressure × inspiratory time/total respiratory time and was recorded either when weaning from mechanical ventilation had finally been successful (n = 28 patients) or at the end of the fifth week in those patients in whom weaning failed (FW) (n = 15). Furthermore, the characteristics of survivors (n = 33) were compared with those of nonsurvivors (n = 10).Results: Successfully weaned patients had a lower breathing frequency/tidal volume or rapid shallow breathing index compared with FW patients (93.9 ± 45.5 vs 142.4 ± 60.3, respectively; P < .005). The TTdi was significantly higher in FW than in successfully weaned patients (0.107 ± 0.050 vs 0.148 ± 0.059; P < .023) and in nonsurvivors than in survivors (0.106 ± 0.046 vs 0.174 ± 0.058, P < .0001, respectively). A transdiaphragmatic pressure/maximum transdiaphragmatic pressure ratio of more than 40% was an independent predictor of mortality, whereas an increased frequency/tidal volume ratio and TTdi were independent predictors of weaning failure.Conclusions: Difficult-to-wean patients after major surgery have overall a limited diaphragm endurance time, in particular, FW breathe very close to the fatigue threshold, and they adopt a rapid shallow breathing respiratory pattern to avoid crossing this threshold.

The evaluation of the effect of body positioning on intra-abdominal pressure measurement and the effect of intra-abdominal pressure at different body positioning on organ function and prognosis in critically ill patients - Corrected Proof

Min Yi, Yuxin Leng, Yu Bai, Gaiqi Yao, Xi Zhu — 2011-10-28

Abstract: Purpose: Current literatures confirmed the widespread and frequent development of both intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) among the critically ill with a significant associated risk of organ failure and increased mortality. The 2004 International ACS Consensus Conference committee proposed that intra-abdominal pressure (IAP) be measured in complete supine position; however, the supine position of intensive care unit (ICU) patients (<30° of bed increase) presented a significant risk for ventilator-associated pneumonia. Therefore, the potential contribution of head of bed (HOB) position in elevating IAP should be considered. The purpose of this study was to evaluate the effect of body positioning on IAP measurement and the effect of IAP at different body positions on organ function and prognosis in critically ill patients.Materials and Methods: A prospective cohort study to investigate the effect of different patient positioning on IAP, organ function, and prognosis was conducted on 88 patients admitted to a medical-surgical ICU. On admission, patients' epidemiological data and risk factors for IAH were studied; daily mean IAPs, abdominal perfusion pressure, filtration gradient, Acute Physiology and Chronic Health Evaluation II score, sequential organ failure assessment score, and multiple organ dysfunction scores were registered; next, conventional hemodynamic variables, intrathoracic blood volume index, global end-diastolic volume index and extravascular lung water using the pulse contour cardiac output system were recorded. Intra-abdominal pressures were recorded through a bladder catheter every 4 hours on the first day. Intra-abdominal pressure was measured with the patient HOB increases from 0° to 45°. Mean arterial pressure was recorded simultaneously, whereas abdominal perfusion pressure and filtration gradient (FG) were also calculated simultaneously.Results: The main results of this study were the incidence of IAH (28.4%) and ACS (2.3%) in ICU patients; the significant and independent relationship between IAP and HOB increases. Considering the absolute numbers of IAP, the HOB of 10° and 20° showed slight differences, whereas that of 30° and 45° showed clinically significant differences; HOB elevation was associated with clinically significant decreases in abdominal perfusion pressure and FG; patients with IAH were prone to the development of shock and multiple organ dysfunction syndrome and exhibited significantly lower intrathoracic blood volume index and global end-diastolic volume index and higher extravascular lung water.Conclusions: There is a significant and independent relationship between IAP and HOB positioning in critically ill patients, with the HOB of 30° and 45° showing significant difference. Abdominal perfusion pressure and FG are significantly decreased when the patient's HOB is elevated. The potential contribution of body position in elevating IAP should be considered in critically ill patients with the risk of IAH and ACS.

The frequency and significance of postintubation hypotension during emergency airway management - Corrected Proof

Alan C. Heffner, Douglas Swords, Jeffrey A. Kline, Alan E. Jones — 2011-10-28

Abstract: Objective: Arterial hypotension is a recognized complication of emergency intubation, but the consequence of this event is poorly described. Our aim was to identify the incidence of postintubation hypotension (PIH) after emergency intubation and to determine its association with inhospital mortality.Methods: Retrospective cohort study of tracheal intubations performed in a large, urban emergency department over a 1-year period. Patients were included if they were older than 17 years and had no systolic blood pressure measurements less than 90 mm Hg for 30 consecutive minutes before intubation. Patients were analyzed in 2 groups, those with PIH, defined as any recorded systolic blood pressure less than 90 mm Hg within 60 minutes of intubation, and those with no PIH. The primary outcome was inhospital mortality.Results: Of 465 patients who underwent emergency intubation, 336 met inclusion criteria and were analyzed. Postintubation hypotension occurred in 79 (23%) of 336 patients. Patients with PIH had significantly higher inhospital mortality (33% vs 21%; 95% confidence interval for 12% difference, 1%-23%) and longer mean intensive care length of stay (LOS) (9.7 vs 5.9 days, P < .01) and hospital LOS (17.0 vs 11.4 days, P < .01). Postintubation hypotension remained a significant predictor of inhospital mortality after adjusting for confounding using multivariable logistic regression analysis (odds ratio, 1.9; 95% confidence interval, 1.1-3.5).Conclusion: Postintubation hypotension occurs in almost one quarter of normotensive patients undergoing emergency intubation. Postintubation hypotension is independently associated with higher inhospital mortality and longer intensive care unit and hospital LOS.

Glucose variability negatively impacts long-term functional outcome in patients with traumatic brain injury - Corrected Proof

2011-10-28

Abstract: Purpose: Significant glycemic excursions (so-called glucose variability) affect the outcome of generic critically ill patients but has not been well studied in patients with traumatic brain injury (TBI). The purpose of this study was to evaluate the impact of glucose variability on long-term functional outcome of patients with TBI.Material and Methods: A noncomputerized tight glucose control protocol was used in our intensivist model surgical intensive care unit. The relationship between the glucose variability and long-term (a median of 6 months after injury) functional outcome defined by extended Glasgow Outcome Scale (GOSE) was analyzed using ordinal logistic regression models. Glucose variability was defined by SD and percentage of excursion (POE) from the preset range glucose level.Results: A total of 109 patients with TBI under tight glucose control had long-term GOSE evaluated. In univariable analysis, there was a significant association between lower GOSE score and higher mean glucose, higher SD, POE more than 60, POE 80 to 150, and single episode of glucose less than 60 mg/dL but not POE 80 to 110. After adjusting for possible confounding variables in multivariable ordinal logistic regression models, higher SD, POE more than 60, POE 80 to 150, and single episode of glucose less than 60 mg/dL were significantly associated with lower GOSE score.Conclusions: Glucose variability was significantly associated with poorer long-term functional outcome in patients with TBI as measured by the GOSE score. Well-designed protocols to minimize glucose variability may be key in improving long-term functional outcome.

Comparison of Predisposition, Insult/Infection, Response, and Organ dysfunction, Acute Physiology And Chronic Health Evaluation II, and Mortality in Emergency Department Sepsis in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle - Corrected Proof

H. Bryant Nguyen, Chad Van Ginkel, Michael Batech, Jim Banta, Stephen W. Corbett — 2011-10-28

Abstract: Purpose: The aim of the study was to examine the performance of the Predisposition, Insult/Infection, Response, and Organ dysfunction (PIRO) model compared with the Acute Physiology and Chronic Health Evaluation (APACHE) II and Mortality in Emergency Department Sepsis (MEDS) scoring systems in predicting in-hospital mortality for patients presenting to the emergency department (ED) with severe sepsis or septic shock.Materials and Methods: This study was an analysis of a prospectively maintained registry including adult patients with severe sepsis or septic shock meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle over a 6-year period. The registry contains data on patient demographics, sepsis category, vital signs, laboratory values, ED length of stay, hospital length of stay, physiologic scores, and outcome status. The discrimination and calibration characteristics of PIRO, APACHE II, and MEDS were analyzed.Results: Five-hundred forty-one patients with age 63.5 ± 18.5 years were enrolled, 61.9% in septic shock, 46.9% blood-culture positive, and 31.8% in-hospital mortality. Median (25th and 75th percentile) PIRO, APACHE II, and MEDS scores were 6 (5 and 8), 28 (22 and 34), and 12 (9 and 15), with predicted mortalities of 48.5% (40.1 and 63.9), 66.0% (42.0 and 83.0), and 16.0% (9.0 and 39.0), respectively. The area under the receiver operating characteristic curves for PIRO was 0.71 (95% confidence interval, 0.66-0.75); APACHE II, 0.71 (0.66-0.76); and MEDS, 0.63 (0.60-0.70). The standardized mortality ratio was 0.70 (0.08-1.41), 0.70 (−0.46 to 1.80), and 4.00 (−8.53 to 16.62), respectively. Actual mortality significantly increased with increasing PIRO score in patients with APACHE II 25 or more (P < .01).Conclusions: The PIRO, APACHE II, and MEDS have variable abilities to early discriminate and estimate in-hospital mortality of patients presenting to the ED meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle. The PIRO may provide additional risk stratification in patients with APACHE II 25 or more. More studies are required to evaluate the clinical applicability of PIRO in high-risk patients with severe sepsis and septic shock.

Caution when using prognostic models: A prospective comparison of 3 recent prognostic models - Corrected Proof

2011-10-28

Abstract: Purpose: Prognostic models have been developed to estimate mortality and to compare outcomes in different intensive care units. However, these models need to be validated before their use in different populations. In this study, we assessed the performance of 3 recently developed general prognostic models (Acute Physiologic and Chronic Health Evaluation [APACHE] IV, Simplified Acute Physiology Score [SAPS] 3 and Mortality Probability Model III [MPM0-III]) in a population admitted at 3 medical-surgical Brazilian intensive care units.Materials and Methods: All patients admitted from July 2008 to December 2009 were evaluated for inclusion in the study. Standardized mortality ratios were calculated for all models. Calibration was assessed by the Hosmer-Lemeshow goodness-of-fit test. Discrimination was evaluated using the area under the receiver operator curve.Results: A total of 5780 patients were included. Inhospital mortality was 9.1%. Discrimination was very good for all models (area under the receiver operator curve for APACHE IV, SAPS 3 and MPM0-III was 0.883, 0.855 and 0.840, respectively). APACHE IV showed better discrimination than SAPS 3 and MPM0-III (P < .001 for both comparisons). All models calibrated poorly and overestimated hospital mortality (Hosmer–Lemeshow statistic was 53.7, 134.2, 226.6 for APACHE IV, MPM0-III, and SAPS 3, respectively; P < .001 for all).Conclusions: In this study, all models showed poor calibration, while discrimination was very good for all of them. As this has been a common finding in validation studies, caution is warranted when using prognostic models for benchmarking.

Liberation of neurosurgical patients from mechanical ventilation and tracheostomy in neurocritical care - Corrected Proof

Christos Lazaridis, Stacia M. DeSantis, Marc McLawhorn, Vibhor Krishna — 2011-10-28

Abstract: Neurosurgical patients commonly require mechanical ventilation and monitoring in a neurocritical care unit. There are only few studies that specifically address the process of liberation from mechanical ventilation in this population. Patients who remain ventilator or artificial airway dependent receive a tracheostomy. The appropriate timing for the procedure is not well defined and may be different among an inhomogeneous population of critically ill patients. In this article, we review the general principles of liberation and the current literature as it pertains to neurosurgical patients with primary brain injury. The criteria for “readiness of extubation” include a combination of neurologic assessment, hemodynamic, and respiratory parameters. Future studies are required to better assess indicators for extubation readiness, evaluate the predictors of extubation failure in brain-injured patients, and define the most appropriate timing for a tracheostomy.

Charlson's weighted index of comorbidities is useful in assessing the risk of death in septic patients - Corrected Proof

2011-10-28

Abstract: Purpose: We investigated the efficiency of the Charlson's weighted index of comorbidities (WIC) in predicting the risk of death in septic patients.Materials and Methods: A single-center, 3-year analysis of all septic patients was conducted; WIC and organ failure assessed using the Sepsis-related Organ Failure Assessment (SOFA) score were calculated retrospectively.Results: Of 250 septic patients, 60 patients (34%) had WIC above 2. Fifty-five patients (22%) died during the hospitalization. Increasing WIC was associated with increased mortality. Mean WIC differed significantly between survivors and nonsurvivors (P < .0001), and the univariate logistic regression revealed that risk of death depends significantly of WIC with odds ratio of 1.59 (95% confidence interval, 1.31-1.93; P < .001). The accuracy of prediction for the risk of death was 79.2%. Receiver operating characteristics curve indicated a WIC of 2 as a cutoff value, the association between WIC greater than 2, and the risk of death being described by an odds ratio of 1.87 (95% confidence interval, 1.017-3.457; P = .042); the area under the receiver operating characteristics curve in predicting mortality was 0.81 for the SOFA score and 0.68 for WIC; WIC correlated positively with SOFA (r = 0.27; P < .0001).Conclusion: In septic patients, WIC is predictive for hospital mortality, and the risk of death significantly depends on WIC.