SCCM Pediatric Critical Care MedicineCritical Care Explorations,
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Patient Outcomes and Cost-Effectiveness of a Sepsis Care Quality Improvement Program in a Health System
Afshar, Majid; Arain, Erum; Ye, Chen; More
Critical Care Medicine. ., Post Author Corrections: July 15, 2019
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Objectives:
Assess patient outcomes in patients with suspected infection and the cost-effectiveness of implementing a quality improvement program.
Design, Setting, and Participants:
We conducted an observational single-center study of 13,877 adults with suspected infection between March 1, 2014, and July 31, 2017. The 18-month period before and after the effective date for mandated reporting of the sepsis bundle was examined. The Sequential Organ Failure Assessment score and culture and antibiotic orders were used to identify patients meeting Sepsis-3 criteria from the electronic health record.
Interventions:
The following interventions were performed as follows: 1) multidisciplinary sepsis committee with sepsis coordinator and data abstractor; 2) education campaign; 3) electronic health record tools; and 4) a Modified Early Warning System.
Main Outcomes and Measures:
Primary health outcomes were in-hospital death and length of stay. The incremental cost-effectiveness ratio was calculated and the empirical 95% CI for the incremental cost-effectiveness ratio was estimated from 5,000 bootstrap samples.
Results:
In multivariable analysis, the odds ratio for in-hospital death in the post- versus pre-implementation periods was 0.70 (95% CI, 0.57–0.86) in those with suspected infection, and the hazard ratio for time to discharge was 1.25 (95% CI, 1.20–1.29). Similarly, a decrease in the odds for in-hospital death and an increase in the speed to discharge was observed for the subset that met Sepsis-3 criteria. The program was cost saving in patients with suspected infection (–$272,645.7; 95% CI, –$757,970.3 to –$79,667.7). Cost savings were also observed in the Sepsis-3 group.
Conclusions and Relevance:
Our health system’s program designed to adhere to the sepsis bundle metrics led to decreased mortality and length of stay in a cost-effective manner in a much larger catchment than just the cohort meeting the Centers for Medicare and Medicaid Services measures. Our single-center model of interventions may serve as a practice-based benchmark for hospitalized patients with suspected infection.
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Declining Mortality of Cirrhotic Variceal Bleeding Requiring Admission to Intensive Care A Binational Cohort Study
Majeed, Ammar; Majumdar, Avik; Bailey, Michael; More
Critical Care Medicine. ., Post Author Corrections: July 15, 2019
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Objectives:
We aimed to describe changes over time in admissions and outcomes, including length of stay, discharge destinations, and mortality of cirrhotic patients admitted to the ICU for variceal bleeding, and to compare it to the outcomes of those with other causes of ICU admissions.
Design:
Retrospective analysis of data captured prospectively in the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database.
Settings:
One hundred eighty-three ICUs in Australia and New Zealand.
Patients:
Consecutive admissions to these ICUs for upper gastrointestinal bleeding related to varices in patients with cirrhosis between January 1, 2005, and December 31, 2016.
Interventions:
None.
Measurements and Main Results:
ICU admissions for variceal bleeding in cirrhotic patients accounted for 4,003 (0.6%) of all 720,425 nonelective ICU admissions. The proportion of ICU admissions for variceal bleeding fell significantly from 0.8% (83/42,567) in 2005 to 0.4% (53/80,388) in 2016 ( p < 0.001). Hospital mortality rate was significantly higher within admissions for variceal bleeding compared with nonelective ICU admissions (20.0% vs 15.7%; p < 0.0001), but decreased significantly over time, from 24.6% in 2005 to 15.8% in 2016 (annual decline odds ratio, 0.93; 95% CI, 0.90–0.96). There was no difference in the reduction in mortality from variceal bleeding over time between liver transplant and nontransplant centers ( p = 0.26).
Conclusions:
Admission rate to ICU and mortality of cirrhotic patients with variceal bleeding has declined significantly over time compared with other causes of ICU admissions with the outcomes comparable between liver transplant and nontransplant centers.
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Implementation of a Bundled Consent Process in the ICU A Single-Center Experience
Anandaiah, Asha M.; Stevens, Jennifer P.; Sullivan,, Amy M.
Critical Care Medicine. ., Post Author Corrections: July 11, 2019
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Objectives:
A bundled consent process, where patients or surrogates provide consent for all commonly performed procedures on a single form at the time of ICU admission, has been advocated as a method for improving both rates of documented consent and patient/family satisfaction, but there has been little published literature about the use of bundled consent. We sought to determine how residents in an academic medical center with a required bundled consent process actually obtain consent and how they perceive the overall value, efficacy, and effects on families of this approach.
Design:
Single-center survey study.
Setting:
Medical ICUs in an urban academic medical center.
Subjects:
Internal medicine residents.
Interventions:
We administered an online survey about bundled consent use to all residents. Quantitative and qualitative data were analyzed.
Measurements and Main Results:
One-hundred two of 164 internal medicine residents (62%) completed the survey. A majority of residents (55%) reported grouping procedures and discussing general risks and benefits; 11% reported conducting a complete informed consent discussion for each procedure. Respondents were divided in their perception of the value of bundled consent, but most (78%) felt it scared or stressed families. A minority (26%) felt confident that they obtained valid informed consent for critical care procedures with the use of bundled consent. An additional theme that emerged from qualitative data was concern regarding the validity of anticipatory consent.
Conclusions:
Resident physicians experienced with the use of bundled consent in the ICU held variable perceptions of its value but raised concerns about the effect on families and the validity of consent obtained with this strategy. Further studies are necessary to further explore what constitutes best practice for informed consent in critical care.
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Agreement With Consensus Statements on End-of-Life Care A Description of Variability at the Level of the Provider, Hospital, and Country
Long, Ann C.; Brumback, Lyndia C.; Curtis, J. Randall; More
Critical Care Medicine. ., Post Author Corrections: July 11, 2019
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Objectives:
To develop an enhanced understanding of factors that influence providers’ views about end-of-life care, we examined the contributions of provider, hospital, and country to variability in agreement with consensus statements about end-of-life care.
Design and Setting:
Data were drawn from a survey of providers’ views on principles of end-of-life care obtained during the consensus process for the Worldwide End-of-Life Practice for Patients in ICUs study.
Subjects:
Participants in Worldwide End-of-Life Practice for Patients in ICUs included physicians, nurses, and other providers. Our sample included 1,068 providers from 178 hospitals and 31 countries.
Interventions:
None.
Measurements and Main Results:
We examined views on cardiopulmonary resuscitation and withholding/withdrawing life-sustaining treatments, using a three-level linear mixed model of responses from providers within hospitals within countries. Of 1,068 providers from 178 hospitals and 31 countries, 1% strongly disagreed, 7% disagreed, 11% were neutral, 44% agreed, and 36% strongly agreed with declining to offer cardiopulmonary resuscitation when not indicated. Of the total variability in those responses, 98%, 0%, and 2% were explained by differences among providers, hospitals, and countries, respectively. After accounting for provider characteristics and hospital size, the variance partition was similar. Results were similar for withholding/withdrawing life-sustaining treatments.
Conclusions:
Variability in agreement with consensus statements about end-of-life care is related primarily to differences among providers. Acknowledging the primary source of variability may facilitate efforts to achieve consensus and improve decision-making for critically ill patients and their family members at the end of life.
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Quantitative Electroencephalogram Trends Predict Recovery in Hypoxic-Ischemic Encephalopathy
Ghassemi, Mohammad M.; Amorim, Edilberto; Alhanai, Tuka; More
Critical Care Medicine. ., Post Author Corrections: June 21, 2019
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Objectives:
Electroencephalogram features predict neurologic recovery following cardiac arrest. Recent work has shown that prognostic implications of some key electroencephalogram features change over time. We explore whether time dependence exists for an expanded selection of quantitative electroencephalogram features and whether accounting for this time dependence enables better prognostic predictions.
Design:
Retrospective.
Setting:
ICUs at four academic medical centers in the United States.
Patients:
Comatose patients with acute hypoxic-ischemic encephalopathy.
Interventions:
None.
Measurements and Main Results:
We analyzed 12,397 hours of electroencephalogram from 438 subjects. From the electroencephalogram, we extracted 52 features that quantify signal complexity, category, and connectivity. We modeled associations between dichotomized neurologic outcome (good vs poor) and quantitative electroencephalogram features in 12-hour intervals using sequential logistic regression with Elastic Net regularization. We compared a predictive model using time-varying features to a model using time-invariant features and to models based on two prior published approaches. Models were evaluated for their ability to predict binary outcomes using area under the receiver operator curve, model calibration (how closely the predicted probability of good outcomes matches the observed proportion of good outcomes), and sensitivity at several common specificity thresholds of interest. A model using time-dependent features outperformed (area under the receiver operator curve, 0.83 ± 0.08) one trained with time-invariant features (0.79 ± 0.07; p < 0.05) and a random forest approach (0.74 ± 0.13; p < 0.05). The time-sensitive model was also the best-calibrated.
Conclusions:
The statistical association between quantitative electroencephalogram features and neurologic outcome changed over time, and accounting for these changes improved prognostication performance.
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Enablers and Barriers to Implementing ICU Follow-Up Clinics and Peer Support Groups Following Critical Illness The Thrive Collaboratives
Haines, Kimberley J.; McPeake, Joanne; Hibbert, Elizabeth; More
Critical Care Medicine. ., Post Author Corrections: June 21, 2019
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Objectives:
Data are lacking regarding implementation of novel strategies such as follow-up clinics and peer support groups, to reduce the burden of postintensive care syndrome. We sought to discover enablers that helped hospital-based clinicians establish post-ICU clinics and peer support programs, and identify barriers that challenged them.
Design:
Qualitative inquiry. The Consolidated Framework for Implementation Research was used to organize and analyze data.
Setting:
Two learning collaboratives (ICU follow-up clinics and peer support groups), representing 21 sites, across three continents.
Subjects:
Clinicians from 21 sites.
Measurement and Main Results:
Ten enablers and nine barriers to implementation of “ICU follow-up clinics” were described. A key enabler to generate support for clinics was providing insight into the human experience of survivorship, to obtain interest from hospital administrators. Significant barriers included patient and family lack of access to clinics and clinic funding. Nine enablers and five barriers to the implementation of “peer support groups” were identified. Key enablers included developing infrastructure to support successful operationalization of this complex intervention, flexibility about when peer support should be offered, belonging to the international learning collaborative. Significant barriers related to limited attendance by patients and families due to challenges in creating awareness, and uncertainty about who might be appropriate to attend and target in advertising.
Conclusions:
Several enablers and barriers to implementing ICU follow-up clinics and peer support groups should be taken into account and leveraged to improve ICU recovery. Among the most important enablers are motivated clinician leaders who persist to find a path forward despite obstacles.
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Outcome Prediction in Postanoxic Coma With Deep Learning
Tjepkema-Cloostermans, Marleen C.; da Silva Lourenço, Catarina; Ruijter, Barry J.; More
Critical Care Medicine. ., Post Author Corrections: June 03, 2019
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Objectives:
Visual assessment of the electroencephalogram by experienced clinical neurophysiologists allows reliable outcome prediction of approximately half of all comatose patients after cardiac arrest. Deep neural networks hold promise to achieve similar or even better performance, being more objective and consistent.
Design:
Prospective cohort study.
Setting:
Medical ICU of five teaching hospitals in the Netherlands.
Patients:
Eight-hundred ninety-five consecutive comatose patients after cardiac arrest.
Interventions:
None.
Measurements and Main Results:
Continuous electroencephalogram was recorded during the first 3 days after cardiac arrest. Functional outcome at 6 months was classified as good (Cerebral Performance Category 1–2) or poor (Cerebral Performance Category 3–5). We trained a convolutional neural network, with a VGG architecture (introduced by the Oxford Visual Geometry Group), to predict neurologic outcome at 12 and 24 hours after cardiac arrest using electroencephalogram epochs and outcome labels as inputs. Output of the network was the probability of good outcome. Data from two hospitals were used for training and internal validation ( n = 661). Eighty percent of these data was used for training and cross-validation, the remaining 20% for independent internal validation. Data from the other three hospitals were used for external validation ( n = 234). Prediction of poor outcome was most accurate at 12 hours, with a sensitivity in the external validation set of 58% (95% CI, 51–65%) at false positive rate of 0% (CI, 0–7%). Good outcome could be predicted at 12 hours with a sensitivity of 48% (CI, 45–51%) at a false positive rate of 5% (CI, 0–15%) in the external validation set.
Conclusions:
Deep learning of electroencephalogram signals outperforms any previously reported outcome predictor of coma after cardiac arrest, including visual electroencephalogram assessment by trained electroencephalogram experts. Our approach offers the potential for objective and real time, bedside insight in the neurologic prognosis of comatose patients after cardiac arrest.
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Impact of Telemonitoring of Critically Ill Emergency Department Patients Awaiting Intensive Care Unit Transfer
Kadar, Rachel B.; Amici, David R.; Hesse, Kathleen; More
Critical Care Medicine. ., Post Author Corrections: May 30, 2019
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Objectives:
Because of overcrowding and limited critical care resources, critically ill patients in the emergency department may spend hours to days awaiting transfer to the ICU. In these patients, often termed “ICU boarders,” delayed ICU transfer is associated with poor outcomes. We implemented an emergency department–based, electronic ICU monitoring system for ICU boarders. Our aim was to investigate the effect of this initiative on morbidity, mortality, and ICU usage.
Design:
Single-center, retrospective cohort study.
Setting:
Nonprofit, tertiary care, teaching hospital with greater than 100,000 emergency department visits per year.
Patients:
Emergency department patients with admission orders for the medical ICU, who spent more than 2 hours boarding in the emergency department after being accepted for admission to the medical ICU, were included in the study.
Interventions:
None.
Measurements and Main Results:
During the study period, a total of 314 patients were admitted to the medical ICU from the emergency department, 214 of whom were considered ICU boarders with a delay in medical ICU transfer over 2 hours. Of ICU boarders, 115 (53.7%) were enrolled in electronic ICU telemonitoring (electronic ICU care), and the rest received usual emergency department care (emergency department care). Age, mean illness severity (Acute Physiology and Chronic Health Evaluation IVa scores), and admitting diagnoses did not differ significantly between ICU boarders receiving electronic ICU care and emergency department care. Forty-one electronic ICU care patients (36%) were ultimately transitioned to a less intensive level of care in lieu of ICU admission while still in the emergency department, compared with zero patients in the emergency department care group. Among all ICU boarders transferred to the ICU, in-hospital mortality was lower in the electronic ICU care cohort when compared with the emergency department care cohort (5.4% vs 20.0%; adjusted odds ratio, 0.08).
Conclusions:
In critically ill patients awaiting transfer from the emergency department to the medical ICU, electronic ICU care was associated with decreased mortality and lower ICU resource utilization.
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A Multicenter Study of the Causes and Consequences of Optimistic Expectations About Prognosis by Surrogate Decision-Makers in ICUs
White, Douglas B.; Carson, Shannon; Anderson, Wendy; More
Critical Care Medicine. ., Post Author Corrections: May 31, 2019
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Objectives:
Optimistic expectations about prognosis by surrogate decision-makers in ICUs are common, but there are few data about the causes and clinical consequences. Our objective was to determine the causes of optimistic expectations about prognosis among surrogates and whether it is associated with more use of life support at the end of life.
Design:
Prospective, multicenter cohort study from 2009 to 2012.
Setting:
Twelve ICUs from multiple regions of the United States.
Subjects:
The surrogates and physicians of 275 incapacitated ICU patients at high risk of death.
Interventions:
None.
Measurements and Main Results:
Surrogates and physicians completed a validated instrument assessing their prognostic expectations for hospital survival. We determined the proportion of surrogates with optimistic expectations, defined as a prognostic estimate that was at least 20% more optimistic than the physician’s, then determined how frequently this arose from surrogates miscomprehending the physicians’ prognosis versus holding more hopeful beliefs compared with the physician. We used multivariable regression to examine whether optimistic expectations were associated with length of stay, stratified by survival status, and time to withdrawal of life support among nonsurvivors. Overall, 45% of surrogates (95% CI, 38–51%) held optimistic expectations about prognosis, which arose from a combination of misunderstanding the physician’s prognostic expectations and from holding more hopeful beliefs compared with the physician. Optimistic expectations by surrogates were associated with significantly longer duration of ICU treatment among nonsurvivors before death (β coefficient = 0.44; 95% CI, 0.05–0.83; p = 0.027), corresponding to a 56% longer ICU stay. This difference was associated with a significantly longer time to withdrawal of life support among dying patients whose surrogates had optimistic prognostic expectations compared with those who did not (β coefficient = 0.61; 95% CI, 0.16–1.07; p = 0.009).
Conclusions:
The prevalent optimism about prognosis among surrogates in ICUs arises both from surrogates’ miscomprehension of physicians’ prognostications and from surrogates holding more hopeful beliefs. This optimism is associated with longer duration of life support at the end of life.
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Impact of Early Acute Kidney Injury on Management and Outcome in Patients With Acute Respiratory Distress Syndrome A Secondary Analysis of a Multicenter Observational Study
McNicholas, Bairbre A.; Rezoagli, Emanuele; Pham, Tài; More
Critical Care Medicine. ., Post Author Corrections: May 31, 2019
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Objectives:
To understand the impact of mild-moderate and severe acute kidney injury in patients with acute respiratory distress syndrome.
Design:
Secondary analysis of the “Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure”, an international prospective cohort study of patients with severe respiratory failure.
Setting:
Four-hundred fifty-nine ICUs from 50 countries across five continents.
Subjects:
Patients with a glomerular filtration rate greater than 60 mL/min/1.73 m 2 prior to admission who fulfilled criteria of acute respiratory distress syndrome on day 1 and day 2 of acute hypoxemic respiratory failure.
Interventions:
Patients were categorized based on worst serum creatinine or urine output into: 1) no acute kidney injury (serum creatinine < 132 µmol/L or urine output ≥ 0.5 mL/kg/hr), 2) mild-moderate acute kidney injury (serum creatinine 132–354 µmol/L or minimum urine output between 0.3 and 0.5mL/kg/hr), or 3) severe acute kidney injury (serum creatinine > 354 µmol/L or renal replacement therapy or minimum urine output < 0.3 mL/kg/hr).
Measurements and Main Results:
The primary outcome was hospital mortality, whereas secondary outcomes included prevalence of acute kidney injury and characterization of acute respiratory distress syndrome risk factors and illness severity patterns, in patients with acute kidney injury versus no acute kidney injury. One-thousand nine-hundred seventy-four patients met inclusion criteria: 1,209 (61%) with no acute kidney injury, 468 (24%) with mild-moderate acute kidney injury, and 297 (15%) with severe acute kidney injury. The impact of acute kidney injury on the ventilatory management of patients with acute respiratory distress syndrome was relatively limited, with no differences in arterial CO 2 tension or in tidal or minute ventilation between the groups. Hospital mortality increased from 31% in acute respiratory distress syndrome patients with no acute kidney injury to 50% in mild-moderate acute kidney injury ( p ≤ 0.001 vs no acute kidney injury) and 58% in severe acute kidney injury ( p ≤ 0.001 vs no acute kidney injury and mild-moderate acute kidney injury). In multivariate analyses, both mild-moderate (odds ratio, 1.61; 95% CI, 1.24–2.09; p < 0.001) and severe (odds ratio, 2.13; 95% CI, 1.55–2.94; p < 0.001) acute kidney injury were independently associated with mortality.
Conclusions:
The development of acute kidney injury, even when mild-moderate in severity, is associated with a substantial increase in mortality in patients with acute respiratory distress syndrome.
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Factors Associated With Quality of Death in Korean ICUs As Perceived by Medical Staff A Multicenter Cross-Sectional Survey
Cho, Jun Yeun; Park, Ju-Hee; Kim, Junghyun; More
Critical Care Medicine. ., Post Author Corrections: May 29, 2019
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Objectives:
Facilitating a high quality of death is an important aspect of comfort care for patients in ICUs. The quality of death in ICUs has been rarely reported in Asian countries. Although Korea is currently in the early stage after the implementation of the “well-dying” law, this seems to have a considerable effect on practice. In this study, we aimed to understand the status of quality of death in Korean ICUs as perceived by medical staff, and to elucidate factors affecting patient quality of death.
Design:
A multicenter cross-sectional survey study.
Setting:
Medical ICUs of two tertiary-care teaching hospitals and two secondary-care hospitals.
Patients:
Deceased patients from June 2016 to May 2017.
Interventions:
Relevant medical staff were asked to complete a translated Quality of Dying and Death questionnaire within 48 hours after a patient’s death. A higher Quality of Dying and Death score (ranged from 0 to 100) corresponded to a better quality of death.
Measurements and Main Results:
Total 416 completed questionnaires were obtained from 177 medical staff (66 doctors and 111 nurses) of 255 patients. All 20 items of the Quality of Dying and Death received low scores. Quality of death perceived by nurses was better than that perceived by doctors (33.1 ± 18.4 vs 29.7 ± 15.3; p = 0.042). Performing cardiopulmonary resuscitation and using inotropes within 24 hours before death were associated with poorer quality of death, whereas using analgesics was associated with better quality of death.
Conclusions:
The quality of death of patients in Korean ICUs was considerably poorer than reported in other countries. Provision of appropriate comfort care, avoidance of unnecessary life-sustaining care, and permission for more frequent visits from patients’ families may correspond to better quality of death in Korean medical ICUs. It is also expected that the new legislation would positively affect the quality of death in Korean ICUs.
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Epidemiology of Hospital-Onset Versus Community-Onset Sepsis in U.S. Hospitals and Association With Mortality A Retrospective Analysis Using Electronic Clinical Data
Rhee, Chanu; Wang, Rui; Zhang, Zilu; More
Critical Care Medicine. ., Post Author Corrections: May 24, 2019
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Objectives:
Prior studies have reported that hospital-onset sepsis is associated with higher mortality rates than community-onset sepsis. Most studies, however, have used inconsistent case-finding methods and applied limited risk-adjustment for potential confounders. We used consistent sepsis criteria and detailed electronic clinical data to elucidate the epidemiology and mortality associated with hospital-onset sepsis.
Design:
Retrospective cohort study.
Setting:
136 U.S. hospitals in the Cerner HealthFacts dataset.
Patients:
Adults hospitalized in 2009–2015.
Interventions:
None.
Measurements and Main Results:
We identified sepsis using Centers for Disease Control and Prevention Adult Sepsis Event criteria and estimated the risk of in-hospital death for hospital-onset sepsis versus community-onset sepsis using logistic regression models. In patients admitted without community-onset sepsis, we estimated risk of death associated with hospital-onset sepsis using Cox regression models with sepsis as a time-varying covariate. Models were adjusted for baseline characteristics and severity of illness. Among 2.2 million hospitalizations, there were 95,154 sepsis cases: 83,620 (87.9%) community-onset sepsis and 11,534 (12.1%) hospital-onset sepsis (0.5% of hospitalized cohort). Compared to community-onset sepsis, hospital-onset sepsis patients were younger (median 66 vs 68 yr) but had more comorbidities (median Elixhauser score 14 vs 11), higher Sequential Organ Failure Assessment scores (median 4 vs 3), higher ICU admission rates (61% vs 44%), longer hospital length of stay (median 19 vs 8 d), and higher in-hospital mortality (33% vs 17%) ( p < 0.001 for all comparisons). On multivariate analysis, hospital-onset sepsis was associated with higher mortality versus community-onset sepsis (odds ratio, 2.1; 95% CI, 2.0–2.2) and patients admitted without sepsis (hazard ratio, 3.0; 95% CI, 2.9–3.2).
Conclusions:
Hospital-onset sepsis complicated one in 200 hospitalizations and accounted for one in eight sepsis cases, with one in three patients dying in-hospital. Hospital-onset sepsis preferentially afflicted ill patients but even after risk-adjustment, they were twice as likely to die as community-onset sepsis patients; in patients admitted without sepsis, hospital-onset sepsis tripled the risk of death. Hospital-onset sepsis is an important target for surveillance, prevention, and quality improvement initiatives.
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Lung Recruitability in Severe Acute Respiratory Distress Syndrome Requiring Extracorporeal Membrane Oxygenation
Camporota, Luigi; Caricola, Elena V.; Bartolomeo, Nicola; More
Critical Care Medicine. ., Post Author Corrections: May 20, 2019
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Objectives:
Quantification of potential for lung recruitment may guide the ventilatory strategy in acute respiratory distress syndrome. However, there are no quantitative data on recruitability in patients with severe acute respiratory distress syndrome who require extracorporeal membrane oxygenation. We sought to quantify potential for lung recruitment and its relationship with outcomes in this cohort of patients.
Design:
A single-center, retrospective, observational cohort study.
Setting:
Tertiary referral severe respiratory failure center in a university hospital in the United Kingdom.
Patients:
Forty-seven adults with severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation.
Intervention:
None.
Measurements and Main Results:
In patients with severe acute respiratory distress syndrome—mainly of pulmonary origin (86%)—the potential for lung recruitment and the weight of nonaerated, poorly aerated, normally aerated, and hyperaerated lung tissue were assessed at low (5 cmH 2 O) and high (45 cmH 2 O) airway pressures. Patients were categorized as high or low potential for lung recruitment based on the median potential for lung recruitment value of the study population. The median potential for lung recruitment was 24.3% (interquartile range = 11.4–37%) ranging from –2% to 76.3% of the total lung weight. Patients with potential for lung recruitment above the median had significantly shorter extracorporeal membrane oxygenation duration (8 vs 13 d; p = 0.013) and shorter ICU stay (15 vs 22 d; p = 0.028), but mortality was not statistically different (24% vs 46%; p = 0.159).
Conclusions:
We observed significant variability in potential for lung recruitment in patients with severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation. Patients with high potential for lung recruitment had a shorter ICU stay and shorter extracorporeal membrane oxygenation duration.
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Effect of a Multifaceted Performance Feedback Strategy on Length of Stay Compared With Benchmark Reports Alone A Cluster Randomized Trial in Intensive Care
van der Veer, Sabine N.; de Vos, Maartje L. G.; van der Voort, Peter H. J.; More
Critical Care Medicine. ., Post Author Corrections: June 12, 2013
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Objective:
To assess the impact of applying a multifaceted activating performance feedback strategy on intensive care patient outcomes compared with passively receiving benchmark reports.
Design:
The Information Feedback on Quality Indicators study was a cluster randomized trial, running from February 2009 to May 2011.
Setting:
Thirty Dutch closed-format ICUs that participated in the national registry. Study duration per ICU was sixteen months.
Patients:
We analyzed data on 25,552 admissions. Admissions after coronary artery bypass graft surgery were excluded.
Intervention:
The intervention aimed to activate ICUs to undertake quality improvement initiatives by formalizing local responsibility for acting on performance feedback, and supporting them with increasing the impact of their improvement efforts. Therefore, intervention ICUs established a local, multidisciplinary quality improvement team. During one year, this team received two educational outreach visits, monthly reports to monitor performance over time, and extended, quarterly benchmark reports. Control ICUs only received four standard quarterly benchmark reports.
Measurements and Results:
The extent to which the intervention was implemented in daily practice varied considerably among intervention ICUs: the average monthly time investment per quality improvement team member was 4.1 hours (SD,2.; range, 0.6–8.1); the average number of monthly meetings per quality improvement team was 5.7 (SD, 4.5; range, 0–12). ICU length of stay did not reduce significantly after 1 year in intervention units compared with controls (hazard ratio, 1.02 [95% CI, 0.92–1.12]). Furthermore, the strategy had no statistically significant impact on any of the secondary measures (duration of mechanical ventilation, proportion of out-of-range glucose measurements, and all-cause hospital mortality).
Conclusions:
In the context of ICUs participating in a national registry, applying a multifaceted activating performance feedback strategy did not lead to better patient outcomes than only receiving periodical registry reports.
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Bacteremia in the Patients With Acute Pancreatitis as Revealed by 16S Ribosomal RNA Gene-Based Techniques
Li, Qiurong; Wang, Chenyang; Tang, Chun; More
Critical Care Medicine. ., Post Author Corrections: June 12, 2013
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Objectives:
To define the characteristic of bacteremia in the patients with acute pancreatitis and determine its possible association with the disease severity.
Design:
A prospective controlled study.
Setting:
ICU of Jinling Hospital, China.
Patients:
A total of 48 patients with mild or severe acute pancreatitis were enrolled in this study.
Interventions:
None.
Measurements and Main Results:
Samples of peripheral blood were collected from the patients at 4 or 5 and 9 or 10 days after acute pancreatitis was definitely diagnosed. Resulting DNA from the blood was analyzed using denaturing gradient gel electrophoresis, and separated fragments were sequenced for identification of bacterial species. Bacterial DNA was detected in peripheral blood from 68.8% of patients with acute pancreatitis, and more than half (60.4%) of the patients encountered polymicrobial flora. Translocated bacteria in patients with acute pancreatitis were primarily constituted of opportunistic pathogens derived from the gut, including Escherichia coli , Shigella flexneri , Enterobacteriaceae bacterium , Acinetobacter lwoffii , Bacillus coagulans , and Enterococcus faecium . And the species of circulating bacteria shifted remarkably among the patients with different severity. The presence of the bacteremia correlated positively with the Acute Physiology and Chronic Health Evaluation-II scores of patients with acute pancreatitis ( r = 0.7918, p < 0.0001).
Conclusions:
This study provides a detailed description on the prevalence of bacteremia and characteristic of bacterial species in patients with acute pancreatitis. We demonstrate an association between the bacteremia and the disease severity, which enables us to better understand a potential role of bacterial translocation in the pathogenesis of septic complication in acute pancreatitis.
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Pleural Pressure and Optimal Positive End-Expiratory Pressure Based on Esophageal Pressure Versus Chest Wall Elastance Incompatible Results
Gulati, Gaurav; Novero, Aileen; Loring, Stephen H.; More
Critical Care Medicine. ., Post Author Corrections: June 12, 2013
Abstract
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Objectives:
1) To compare two published methods for estimating pleural pressure, one based on directly measured esophageal pressure and the other based on chest wall elastance. 2) To evaluate the agreement between two published positive end-expiratory pressure optimization strategies based on these methods, one targeting an end-expiratory esophageal pressure-based transpulmonary pressure of 0 cm H 2 O and the other targeting an end-inspiratory elastance-based transpulmonary pressure of 26 cm H 2 O.
Design:
Retrospective study using clinical data.
Setting:
Medical and surgical ICUs.
Patients:
Sixty-four patients mechanically ventilated for acute respiratory failure with esophageal balloons placed for clinical management.
Methods:
Esophageal pressure and chest wall elastance-based methods for estimating pleural pressure and setting positive end-expiratory pressure were retrospectively applied to each of 64 patients. In patients who were ventilated at two positive end-expiratory pressure levels, chest wall and respiratory system elastances were calculated at each positive end-expiratory pressure level.
Measurements and Main Results:
The pleural pressure estimates using both methods were discordant and differed by as much as 10 cm H 2 O for a given patient. The two positive end-expiratory pressure optimization strategies recommended positive end-expiratory pressure changes in opposite directions in % of patients. The ideal positive end-expiratory pressure levels recommended by the two methods for each patient were discordant and uncorrelated ( R 2 = 0.05). Chest wall and respiratory system elastances increased with increases in positive end-expiratory pressure in patients with positive end-expiratory esophageal pressure-based transpulmonary pressures ( p < 0.05).
Conclusions:
Esophageal pressure and chest wall elastance-based methods for estimating pleural pressure do not yield similar results. The strategies of targeting an end-expiratory esophageal pressure-based transpulmonary pressure of 0 cm H 2 O and targeting an end-inspiratory elastance-based transpulmonary pressure of 26 cm H 2 O cannot be considered interchangeable. Finally, chest wall and respiratory system elastances may vary unpredictably with changes in positive end-expiratory pressure. ( Crit Care Med 201;41:0–0)
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Atypical Sleep in Ventilated Patients Empirical Electroencephalography Findings and the Path Toward Revised ICU Sleep Scoring Criteria
Watson, Paula L.; Pandharipande, Pratik; Gehlbach, Brian K.; More
Critical Care Medicine. ., Post Author Corrections: June 12, 2013
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Objectives:
Standard sleep scoring criteria may be unreliable when applied to critically ill patients. We sought to quantify typical and atypical polysomnographic findings in critically ill patients and to begin development and reliability testing of methodology to characterize the atypical polysomnographic tracings that confound standard sleep scoring criteria.
Design:
Prospective convenience sample.
Setting:
Two academic, tertiary care medical centers.
Patients:
Thirty-seven critically ill, mechanically ventilated, medical ICU patients.
Interventions:
None.
Measurements and Main Results:
Mechanically ventilated subjects were monitored by continuous polysomnography. After noting frequent atypical polysomnographic findings (i.e., lack of stage N2 markers, the presence of polymorphic delta, burst suppression, or isoelectric electroencephalography), attempts to use standard sleep scoring criteria alone were abandoned. Atypical polysomnographic findings were characterized and used to develop a modified scoring system. Polysomnographic data were scored manually via this revised scoring scheme. Of 7 medical ICU patients enrolled, 6 experienced atypical sleep, which accounted for 85% of all recorded data, with 5.1% normal sleep and 9.4% wake. Coupling observed patient arousal levels with polysomnographic characteristics revealed that standard polysomnographic staging criteria did not reliably determine the presence or absence of sleep. Rapid eye movement occurred in only five patients (14%). The revised scoring system incorporating frequently seen atypical characteristics yielded very high interrater reliability (weighted κ = 0.80; bootstrapped 95% CI, [0.48, 0.89]).
Conclusions:
Analysis of polysomnographic data revealed profound deficiencies in standard scoring criteria due to a predominance of atypical polysomnographic findings in ventilated patients. The revised scoring scheme proved reliable in sleep staging and may serve as a building block in future work.
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External Validation of Two Models to Predict Delirium in Critically Ill Adults Using Either the Confusion Assessment Method-ICU or the Intensive Care Delirium Screening Checklist for Delirium Assessment
Wassenaar, Annelies; Schoonhoven, Lisette; Devlin, John W.; More
Critical Care Medicine. ., Post Author Corrections: July 15, 2019
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Objectives:
To externally validate two delirium prediction models (early prediction model for ICU delirium and recalibrated prediction model for ICU delirium) using either the Confusion Assessment Method-ICU or the Intensive Care Delirium Screening Checklist for delirium assessment.
Design:
Prospective, multinational cohort study.
Setting:
Eleven ICUs from seven countries in three continents.
Patients:
Consecutive, delirium-free adults admitted to the ICU for greater than or equal to 6 hours in whom delirium could be reliably assessed.
Interventions:
None.
Measurements and Main Results:
The predictors included in each model were collected at the time of ICU admission (early prediction model for ICU delirium) or within 24 hours of ICU admission (recalibrated prediction model for ICU delirium). Delirium was assessed using the Confusion Assessment Method-ICU or the Intensive Care Delirium Screening Checklist. Discrimination was determined using the area under the receiver operating characteristic curve. The predictive performance was determined for the Confusion Assessment Method-ICU and Intensive Care Delirium Screening Checklist cohort, and compared with both prediction models’ original reported performance. A total of 1,286 Confusion Assessment Method-ICU–assessed patients and 892 Intensive Care Delirium Screening Checklist–assessed patients were included. Compared with the area under the receiver operating characteristic curve of 0.75 (95% CI, 0.71–0.79) in the original study, the area under the receiver operating characteristic curve of the early prediction model for ICU delirium was 0.67 (95% CI, 0.64–0.71) for delirium as assessed using the Confusion Assessment Method-ICU and 0.70 (95% CI, 0.66–0.74) using the Intensive Care Delirium Screening Checklist. Compared with the original area under the receiver operating characteristic curve of 0.77 (95% CI, 0.74–0.79), the area under the receiver operating characteristic curve of the recalibrated prediction model for ICU delirium was 0.75 (95% CI, 0.72–0.78) for assessing delirium using the Confusion Assessment Method-ICU and 0.71 (95% CI, 0.67–0.75) using the Intensive Care Delirium Screening Checklist.
Conclusions:
Both the early prediction model for ICU delirium and recalibrated prediction model for ICU delirium are externally validated using either the Confusion Assessment Method-ICU or the Intensive Care Delirium Screening Checklist for delirium assessment. Per delirium prediction model, both assessment tools showed a similar moderate-to-good statistical performance. These results support the use of either the early prediction model for ICU delirium or recalibrated prediction model for ICU delirium in ICUs around the world regardless of whether delirium is evaluated with the Confusion Assessment Method-ICU or Intensive Care Delirium Screening Checklist.
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Antimicrobial Disposition During Pediatric Continuous Renal Replacement Therapy Using an Ex Vivo Model
Purohit, Prashant J.; Elkomy, Mohammed H.; Frymoyer, Adam; More
Critical Care Medicine. ., Post Author Corrections: July 15, 2019
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Objectives:
Little is known on the impact of continuous renal replacement therapy on antimicrobial dose requirements in children. In this study, we evaluated the pharmacokinetics of commonly administered antimicrobials in an ex vivo continuous renal replacement therapy model.
Design:
An ex vivo continuous renal replacement therapy circuit was used to evaluate drug-circuit interactions and determine the disposition of five commonly used antimicrobials (meropenem, piperacillin, liposomal amphotericin B, caspofungin, and voriconazole).
Setting:
University research laboratory.
Patients:
None.
Interventions:
Antimicrobials were administered into a reservoir containing whole human blood. The reservoir was connected to a pediatric continuous renal replacement therapy circuit programmed for a 10 kg child. Continuous renal replacement therapy was performed in the hemodiafiltration mode and in three phases correlating with three different continuous renal replacement therapy clearance rates: 1) no clearance (0 mL/kg/hr, to measure adsorption), 2) low clearance (20 mL/kg/hr), and 3) high clearance (40 mL/kg/hr). Blood samples were drawn directly from the reservoir at baseline and at 5, 20, 60, and 180 minutes during each phase. Five independent continuous renal replacement therapy runs were performed to assess inter-run variability. Antimicrobial concentrations were measured using validated liquid chromatography-mass spectrometry assays. A closed-loop, flow-through pharmacokinetic model was developed to analyze concentration-time profiles for each drug.
Measurements and Main Results:
Circuit adsorption of antimicrobials ranged between 13% and 27%. Meropenem, piperacillin, and voriconazole were cleared by the continuous renal replacement therapy circuit and clearance increased with increasing continuous renal replacement therapy clearance rates (7.66 mL/min, 4.97 mL/min, and 2.67 mL/min, respectively, for high continuous renal replacement therapy clearance). Amphotericin B and caspofungin had minimal circuit clearance and did not change with increasing continuous renal replacement therapy clearance rates.
Conclusions:
Careful consideration of drug-circuit interactions during continuous renal replacement therapy is essential for appropriate drug dosing in critically ill children. Antimicrobials have unique adsorption and clearance profiles during continuous renal replacement therapy, and this knowledge is important to optimize antimicrobial therapy.
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Effect of Prone Positioning on Intraocular Pressure in Patients With Acute Respiratory Distress Syndrome
Saran, Sai; Gurjar, Mohan; Kanaujia, Vikas; More
Critical Care Medicine. ., Post Author Corrections: July 11, 2019
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Objectives:
To evaluate the effect of prolonged duration of prone position (with head laterally rotated) on intraocular pressure in acute respiratory distress syndrome patients.
Design:
Prospective observational study.
Setting:
University hospital ICU.
Patients:
Twenty-five acute respiratory distress syndrome patients, age 60 years (51–67 yr), Sequential Organ Failure Assessment score 10 (10–12), PaO 2 /FIO 2 ratio of 90 (65–120), and all in septic shock.
Interventions:
None.
Measurements and Main Results:
Intraocular pressure (in mm Hg) measured by hand-held applanation tonometer, at different time points. Before prone (in both eyes): at 30–45° head-end elevation position (T HE pre-prone ), in supine position just before turning prone (T supine pre-prone ); during prone (in nondependent eye): at 10 minutes (T 10 prone ), 30 minutes (T 30 prone ), and at just before end of prone session (T end-prone ). After end of prone session (both eyes): at 5 minutes (T 5 supine post-prone ), 10 minutes (T 10 HE post-prone ), 15 minutes (T 15 HE post-prone ), and 30 minutes (T 30 HE post-prone ). Median duration of prone position was 14 hours (12–18 hr). Median intraocular pressure increased significantly ( p ≤ 0.001) in both eyes. In dependent eye, from 15 (12–19) at T HE pre-prone to 24, 21, 19, and 16 at T 5 supine post-prone , T 10 HE post-prone , T 15 HE post-prone , and T 30 HE post-prone respectively, whereas in nondependent eye from 14 (12–18.5) at T HE pre-prone to 23, 25, 32, 25, 22, 20, and 17 at T 10 prone , T 30 prone , T end-prone , T 5 supine post-prone , T 10 HE post-prone , T 15 HE post-prone , and T 30 HE post-prone respectively. Bland-Altman plot analysis showed significant linear relationship ( r = 0.789; p ≤ 0.001) with good agreement between rise in mean intraocular pressure of the both eyes (dependent eye and nondependent eye) with their paired differences after the end of different duration of prone session (T 5 supine post-prone ).
Conclusions:
There is significant increase in intraocular pressure due to prone positioning among acute respiratory distress syndrome patients. Intraocular pressure increases as early as 10 minutes after proning, with increasing trend during prone position, which persisted even at 30 minutes after the end of post prone session although with decreasing trend.
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Patient Outcomes and Cost-Effectiveness of a Sepsis Care Quality Improvement Program in a Health System
Afshar, Majid; Arain, Erum; Ye, Chen; More
Critical Care Medicine. ., Post Author Corrections: July 15, 2019
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Objectives:
Assess patient outcomes in patients with suspected infection and the cost-effectiveness of implementing a quality improvement program.
Design, Setting, and Participants:
We conducted an observational single-center study of 13,877 adults with suspected infection between March 1, 2014, and July 31, 2017. The 18-month period before and after the effective date for mandated reporting of the sepsis bundle was examined. The Sequential Organ Failure Assessment score and culture and antibiotic orders were used to identify patients meeting Sepsis-3 criteria from the electronic health record.
Interventions:
The following interventions were performed as follows: 1) multidisciplinary sepsis committee with sepsis coordinator and data abstractor; 2) education campaign; 3) electronic health record tools; and 4) a Modified Early Warning System.
Main Outcomes and Measures:
Primary health outcomes were in-hospital death and length of stay. The incremental cost-effectiveness ratio was calculated and the empirical 95% CI for the incremental cost-effectiveness ratio was estimated from 5,000 bootstrap samples.
Results:
In multivariable analysis, the odds ratio for in-hospital death in the post- versus pre-implementation periods was 0.70 (95% CI, 0.57–0.86) in those with suspected infection, and the hazard ratio for time to discharge was 1.25 (95% CI, 1.20–1.29). Similarly, a decrease in the odds for in-hospital death and an increase in the speed to discharge was observed for the subset that met Sepsis-3 criteria. The program was cost saving in patients with suspected infection (–$272,645.7; 95% CI, –$757,970.3 to –$79,667.7). Cost savings were also observed in the Sepsis-3 group.
Conclusions and Relevance:
Our health system’s program designed to adhere to the sepsis bundle metrics led to decreased mortality and length of stay in a cost-effective manner in a much larger catchment than just the cohort meeting the Centers for Medicare and Medicaid Services measures. Our single-center model of interventions may serve as a practice-based benchmark for hospitalized patients with suspected infection.
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Declining Mortality of Cirrhotic Variceal Bleeding Requiring Admission to Intensive Care A Binational Cohort Study
Majeed, Ammar; Majumdar, Avik; Bailey, Michael; More
Critical Care Medicine. ., Post Author Corrections: July 15, 2019
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Objectives:
We aimed to describe changes over time in admissions and outcomes, including length of stay, discharge destinations, and mortality of cirrhotic patients admitted to the ICU for variceal bleeding, and to compare it to the outcomes of those with other causes of ICU admissions.
Design:
Retrospective analysis of data captured prospectively in the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database.
Settings:
One hundred eighty-three ICUs in Australia and New Zealand.
Patients:
Consecutive admissions to these ICUs for upper gastrointestinal bleeding related to varices in patients with cirrhosis between January 1, 2005, and December 31, 2016.
Interventions:
None.
Measurements and Main Results:
ICU admissions for variceal bleeding in cirrhotic patients accounted for 4,003 (0.6%) of all 720,425 nonelective ICU admissions. The proportion of ICU admissions for variceal bleeding fell significantly from 0.8% (83/42,567) in 2005 to 0.4% (53/80,388) in 2016 ( p < 0.001). Hospital mortality rate was significantly higher within admissions for variceal bleeding compared with nonelective ICU admissions (20.0% vs 15.7%; p < 0.0001), but decreased significantly over time, from 24.6% in 2005 to 15.8% in 2016 (annual decline odds ratio, 0.93; 95% CI, 0.90–0.96). There was no difference in the reduction in mortality from variceal bleeding over time between liver transplant and nontransplant centers ( p = 0.26).
Conclusions:
Admission rate to ICU and mortality of cirrhotic patients with variceal bleeding has declined significantly over time compared with other causes of ICU admissions with the outcomes comparable between liver transplant and nontransplant centers.
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Implementation of a Bundled Consent Process in the ICU A Single-Center Experience
Anandaiah, Asha M.; Stevens, Jennifer P.; Sullivan,, Amy M.
Critical Care Medicine. ., Post Author Corrections: July 11, 2019
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Objectives:
A bundled consent process, where patients or surrogates provide consent for all commonly performed procedures on a single form at the time of ICU admission, has been advocated as a method for improving both rates of documented consent and patient/family satisfaction, but there has been little published literature about the use of bundled consent. We sought to determine how residents in an academic medical center with a required bundled consent process actually obtain consent and how they perceive the overall value, efficacy, and effects on families of this approach.
Design:
Single-center survey study.
Setting:
Medical ICUs in an urban academic medical center.
Subjects:
Internal medicine residents.
Interventions:
We administered an online survey about bundled consent use to all residents. Quantitative and qualitative data were analyzed.
Measurements and Main Results:
One-hundred two of 164 internal medicine residents (62%) completed the survey. A majority of residents (55%) reported grouping procedures and discussing general risks and benefits; 11% reported conducting a complete informed consent discussion for each procedure. Respondents were divided in their perception of the value of bundled consent, but most (78%) felt it scared or stressed families. A minority (26%) felt confident that they obtained valid informed consent for critical care procedures with the use of bundled consent. An additional theme that emerged from qualitative data was concern regarding the validity of anticipatory consent.
Conclusions:
Resident physicians experienced with the use of bundled consent in the ICU held variable perceptions of its value but raised concerns about the effect on families and the validity of consent obtained with this strategy. Further studies are necessary to further explore what constitutes best practice for informed consent in critical care.
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Agreement With Consensus Statements on End-of-Life Care A Description of Variability at the Level of the Provider, Hospital, and Country
Long, Ann C.; Brumback, Lyndia C.; Curtis, J. Randall; More
Critical Care Medicine. ., Post Author Corrections: July 11, 2019
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Objectives:
To develop an enhanced understanding of factors that influence providers’ views about end-of-life care, we examined the contributions of provider, hospital, and country to variability in agreement with consensus statements about end-of-life care.
Design and Setting:
Data were drawn from a survey of providers’ views on principles of end-of-life care obtained during the consensus process for the Worldwide End-of-Life Practice for Patients in ICUs study.
Subjects:
Participants in Worldwide End-of-Life Practice for Patients in ICUs included physicians, nurses, and other providers. Our sample included 1,068 providers from 178 hospitals and 31 countries.
Interventions:
None.
Measurements and Main Results:
We examined views on cardiopulmonary resuscitation and withholding/withdrawing life-sustaining treatments, using a three-level linear mixed model of responses from providers within hospitals within countries. Of 1,068 providers from 178 hospitals and 31 countries, 1% strongly disagreed, 7% disagreed, 11% were neutral, 44% agreed, and 36% strongly agreed with declining to offer cardiopulmonary resuscitation when not indicated. Of the total variability in those responses, 98%, 0%, and 2% were explained by differences among providers, hospitals, and countries, respectively. After accounting for provider characteristics and hospital size, the variance partition was similar. Results were similar for withholding/withdrawing life-sustaining treatments.
Conclusions:
Variability in agreement with consensus statements about end-of-life care is related primarily to differences among providers. Acknowledging the primary source of variability may facilitate efforts to achieve consensus and improve decision-making for critically ill patients and their family members at the end of life.
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Quantitative Electroencephalogram Trends Predict Recovery in Hypoxic-Ischemic Encephalopathy
Ghassemi, Mohammad M.; Amorim, Edilberto; Alhanai, Tuka; More
Critical Care Medicine. ., Post Author Corrections: June 21, 2019
Abstract
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Objectives:
Electroencephalogram features predict neurologic recovery following cardiac arrest. Recent work has shown that prognostic implications of some key electroencephalogram features change over time. We explore whether time dependence exists for an expanded selection of quantitative electroencephalogram features and whether accounting for this time dependence enables better prognostic predictions.
Design:
Retrospective.
Setting:
ICUs at four academic medical centers in the United States.
Patients:
Comatose patients with acute hypoxic-ischemic encephalopathy.
Interventions:
None.
Measurements and Main Results:
We analyzed 12,397 hours of electroencephalogram from 438 subjects. From the electroencephalogram, we extracted 52 features that quantify signal complexity, category, and connectivity. We modeled associations between dichotomized neurologic outcome (good vs poor) and quantitative electroencephalogram features in 12-hour intervals using sequential logistic regression with Elastic Net regularization. We compared a predictive model using time-varying features to a model using time-invariant features and to models based on two prior published approaches. Models were evaluated for their ability to predict binary outcomes using area under the receiver operator curve, model calibration (how closely the predicted probability of good outcomes matches the observed proportion of good outcomes), and sensitivity at several common specificity thresholds of interest. A model using time-dependent features outperformed (area under the receiver operator curve, 0.83 ± 0.08) one trained with time-invariant features (0.79 ± 0.07; p < 0.05) and a random forest approach (0.74 ± 0.13; p < 0.05). The time-sensitive model was also the best-calibrated.
Conclusions:
The statistical association between quantitative electroencephalogram features and neurologic outcome changed over time, and accounting for these changes improved prognostication performance.
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Enablers and Barriers to Implementing ICU Follow-Up Clinics and Peer Support Groups Following Critical Illness The Thrive Collaboratives
Haines, Kimberley J.; McPeake, Joanne; Hibbert, Elizabeth; More
Critical Care Medicine. ., Post Author Corrections: June 21, 2019
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Objectives:
Data are lacking regarding implementation of novel strategies such as follow-up clinics and peer support groups, to reduce the burden of postintensive care syndrome. We sought to discover enablers that helped hospital-based clinicians establish post-ICU clinics and peer support programs, and identify barriers that challenged them.
Design:
Qualitative inquiry. The Consolidated Framework for Implementation Research was used to organize and analyze data.
Setting:
Two learning collaboratives (ICU follow-up clinics and peer support groups), representing 21 sites, across three continents.
Subjects:
Clinicians from 21 sites.
Measurement and Main Results:
Ten enablers and nine barriers to implementation of “ICU follow-up clinics” were described. A key enabler to generate support for clinics was providing insight into the human experience of survivorship, to obtain interest from hospital administrators. Significant barriers included patient and family lack of access to clinics and clinic funding. Nine enablers and five barriers to the implementation of “peer support groups” were identified. Key enablers included developing infrastructure to support successful operationalization of this complex intervention, flexibility about when peer support should be offered, belonging to the international learning collaborative. Significant barriers related to limited attendance by patients and families due to challenges in creating awareness, and uncertainty about who might be appropriate to attend and target in advertising.
Conclusions:
Several enablers and barriers to implementing ICU follow-up clinics and peer support groups should be taken into account and leveraged to improve ICU recovery. Among the most important enablers are motivated clinician leaders who persist to find a path forward despite obstacles.
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Outcome Prediction in Postanoxic Coma With Deep Learning
Tjepkema-Cloostermans, Marleen C.; da Silva Lourenço, Catarina; Ruijter, Barry J.; More
Critical Care Medicine. ., Post Author Corrections: June 03, 2019
Abstract
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Objectives:
Visual assessment of the electroencephalogram by experienced clinical neurophysiologists allows reliable outcome prediction of approximately half of all comatose patients after cardiac arrest. Deep neural networks hold promise to achieve similar or even better performance, being more objective and consistent.
Design:
Prospective cohort study.
Setting:
Medical ICU of five teaching hospitals in the Netherlands.
Patients:
Eight-hundred ninety-five consecutive comatose patients after cardiac arrest.
Interventions:
None.
Measurements and Main Results:
Continuous electroencephalogram was recorded during the first 3 days after cardiac arrest. Functional outcome at 6 months was classified as good (Cerebral Performance Category 1–2) or poor (Cerebral Performance Category 3–5). We trained a convolutional neural network, with a VGG architecture (introduced by the Oxford Visual Geometry Group), to predict neurologic outcome at 12 and 24 hours after cardiac arrest using electroencephalogram epochs and outcome labels as inputs. Output of the network was the probability of good outcome. Data from two hospitals were used for training and internal validation ( n = 661). Eighty percent of these data was used for training and cross-validation, the remaining 20% for independent internal validation. Data from the other three hospitals were used for external validation ( n = 234). Prediction of poor outcome was most accurate at 12 hours, with a sensitivity in the external validation set of 58% (95% CI, 51–65%) at false positive rate of 0% (CI, 0–7%). Good outcome could be predicted at 12 hours with a sensitivity of 48% (CI, 45–51%) at a false positive rate of 5% (CI, 0–15%) in the external validation set.
Conclusions:
Deep learning of electroencephalogram signals outperforms any previously reported outcome predictor of coma after cardiac arrest, including visual electroencephalogram assessment by trained electroencephalogram experts. Our approach offers the potential for objective and real time, bedside insight in the neurologic prognosis of comatose patients after cardiac arrest.
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Impact of Telemonitoring of Critically Ill Emergency Department Patients Awaiting Intensive Care Unit Transfer
Kadar, Rachel B.; Amici, David R.; Hesse, Kathleen; More
Critical Care Medicine. ., Post Author Corrections: May 30, 2019
Abstract
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Objectives:
Because of overcrowding and limited critical care resources, critically ill patients in the emergency department may spend hours to days awaiting transfer to the ICU. In these patients, often termed “ICU boarders,” delayed ICU transfer is associated with poor outcomes. We implemented an emergency department–based, electronic ICU monitoring system for ICU boarders. Our aim was to investigate the effect of this initiative on morbidity, mortality, and ICU usage.
Design:
Single-center, retrospective cohort study.
Setting:
Nonprofit, tertiary care, teaching hospital with greater than 100,000 emergency department visits per year.
Patients:
Emergency department patients with admission orders for the medical ICU, who spent more than 2 hours boarding in the emergency department after being accepted for admission to the medical ICU, were included in the study.
Interventions:
None.
Measurements and Main Results:
During the study period, a total of 314 patients were admitted to the medical ICU from the emergency department, 214 of whom were considered ICU boarders with a delay in medical ICU transfer over 2 hours. Of ICU boarders, 115 (53.7%) were enrolled in electronic ICU telemonitoring (electronic ICU care), and the rest received usual emergency department care (emergency department care). Age, mean illness severity (Acute Physiology and Chronic Health Evaluation IVa scores), and admitting diagnoses did not differ significantly between ICU boarders receiving electronic ICU care and emergency department care. Forty-one electronic ICU care patients (36%) were ultimately transitioned to a less intensive level of care in lieu of ICU admission while still in the emergency department, compared with zero patients in the emergency department care group. Among all ICU boarders transferred to the ICU, in-hospital mortality was lower in the electronic ICU care cohort when compared with the emergency department care cohort (5.4% vs 20.0%; adjusted odds ratio, 0.08).
Conclusions:
In critically ill patients awaiting transfer from the emergency department to the medical ICU, electronic ICU care was associated with decreased mortality and lower ICU resource utilization.
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A Multicenter Study of the Causes and Consequences of Optimistic Expectations About Prognosis by Surrogate Decision-Makers in ICUs
White, Douglas B.; Carson, Shannon; Anderson, Wendy; More
Critical Care Medicine. ., Post Author Corrections: May 31, 2019
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Objectives:
Optimistic expectations about prognosis by surrogate decision-makers in ICUs are common, but there are few data about the causes and clinical consequences. Our objective was to determine the causes of optimistic expectations about prognosis among surrogates and whether it is associated with more use of life support at the end of life.
Design:
Prospective, multicenter cohort study from 2009 to 2012.
Setting:
Twelve ICUs from multiple regions of the United States.
Subjects:
The surrogates and physicians of 275 incapacitated ICU patients at high risk of death.
Interventions:
None.
Measurements and Main Results:
Surrogates and physicians completed a validated instrument assessing their prognostic expectations for hospital survival. We determined the proportion of surrogates with optimistic expectations, defined as a prognostic estimate that was at least 20% more optimistic than the physician’s, then determined how frequently this arose from surrogates miscomprehending the physicians’ prognosis versus holding more hopeful beliefs compared with the physician. We used multivariable regression to examine whether optimistic expectations were associated with length of stay, stratified by survival status, and time to withdrawal of life support among nonsurvivors. Overall, 45% of surrogates (95% CI, 38–51%) held optimistic expectations about prognosis, which arose from a combination of misunderstanding the physician’s prognostic expectations and from holding more hopeful beliefs compared with the physician. Optimistic expectations by surrogates were associated with significantly longer duration of ICU treatment among nonsurvivors before death (β coefficient = 0.44; 95% CI, 0.05–0.83; p = 0.027), corresponding to a 56% longer ICU stay. This difference was associated with a significantly longer time to withdrawal of life support among dying patients whose surrogates had optimistic prognostic expectations compared with those who did not (β coefficient = 0.61; 95% CI, 0.16–1.07; p = 0.009).
Conclusions:
The prevalent optimism about prognosis among surrogates in ICUs arises both from surrogates’ miscomprehension of physicians’ prognostications and from surrogates holding more hopeful beliefs. This optimism is associated with longer duration of life support at the end of life.
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Impact of Early Acute Kidney Injury on Management and Outcome in Patients With Acute Respiratory Distress Syndrome A Secondary Analysis of a Multicenter Observational Study
McNicholas, Bairbre A.; Rezoagli, Emanuele; Pham, Tài; More
Critical Care Medicine. ., Post Author Corrections: May 31, 2019
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Objectives:
To understand the impact of mild-moderate and severe acute kidney injury in patients with acute respiratory distress syndrome.
Design:
Secondary analysis of the “Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure”, an international prospective cohort study of patients with severe respiratory failure.
Setting:
Four-hundred fifty-nine ICUs from 50 countries across five continents.
Subjects:
Patients with a glomerular filtration rate greater than 60 mL/min/1.73 m 2 prior to admission who fulfilled criteria of acute respiratory distress syndrome on day 1 and day 2 of acute hypoxemic respiratory failure.
Interventions:
Patients were categorized based on worst serum creatinine or urine output into: 1) no acute kidney injury (serum creatinine < 132 µmol/L or urine output ≥ 0.5 mL/kg/hr), 2) mild-moderate acute kidney injury (serum creatinine 132–354 µmol/L or minimum urine output between 0.3 and 0.5mL/kg/hr), or 3) severe acute kidney injury (serum creatinine > 354 µmol/L or renal replacement therapy or minimum urine output < 0.3 mL/kg/hr).
Measurements and Main Results:
The primary outcome was hospital mortality, whereas secondary outcomes included prevalence of acute kidney injury and characterization of acute respiratory distress syndrome risk factors and illness severity patterns, in patients with acute kidney injury versus no acute kidney injury. One-thousand nine-hundred seventy-four patients met inclusion criteria: 1,209 (61%) with no acute kidney injury, 468 (24%) with mild-moderate acute kidney injury, and 297 (15%) with severe acute kidney injury. The impact of acute kidney injury on the ventilatory management of patients with acute respiratory distress syndrome was relatively limited, with no differences in arterial CO 2 tension or in tidal or minute ventilation between the groups. Hospital mortality increased from 31% in acute respiratory distress syndrome patients with no acute kidney injury to 50% in mild-moderate acute kidney injury ( p ≤ 0.001 vs no acute kidney injury) and 58% in severe acute kidney injury ( p ≤ 0.001 vs no acute kidney injury and mild-moderate acute kidney injury). In multivariate analyses, both mild-moderate (odds ratio, 1.61; 95% CI, 1.24–2.09; p < 0.001) and severe (odds ratio, 2.13; 95% CI, 1.55–2.94; p < 0.001) acute kidney injury were independently associated with mortality.
Conclusions:
The development of acute kidney injury, even when mild-moderate in severity, is associated with a substantial increase in mortality in patients with acute respiratory distress syndrome.
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Factors Associated With Quality of Death in Korean ICUs As Perceived by Medical Staff A Multicenter Cross-Sectional Survey
Cho, Jun Yeun; Park, Ju-Hee; Kim, Junghyun; More
Critical Care Medicine. ., Post Author Corrections: May 29, 2019
Abstract
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Objectives:
Facilitating a high quality of death is an important aspect of comfort care for patients in ICUs. The quality of death in ICUs has been rarely reported in Asian countries. Although Korea is currently in the early stage after the implementation of the “well-dying” law, this seems to have a considerable effect on practice. In this study, we aimed to understand the status of quality of death in Korean ICUs as perceived by medical staff, and to elucidate factors affecting patient quality of death.
Design:
A multicenter cross-sectional survey study.
Setting:
Medical ICUs of two tertiary-care teaching hospitals and two secondary-care hospitals.
Patients:
Deceased patients from June 2016 to May 2017.
Interventions:
Relevant medical staff were asked to complete a translated Quality of Dying and Death questionnaire within 48 hours after a patient’s death. A higher Quality of Dying and Death score (ranged from 0 to 100) corresponded to a better quality of death.
Measurements and Main Results:
Total 416 completed questionnaires were obtained from 177 medical staff (66 doctors and 111 nurses) of 255 patients. All 20 items of the Quality of Dying and Death received low scores. Quality of death perceived by nurses was better than that perceived by doctors (33.1 ± 18.4 vs 29.7 ± 15.3; p = 0.042). Performing cardiopulmonary resuscitation and using inotropes within 24 hours before death were associated with poorer quality of death, whereas using analgesics was associated with better quality of death.
Conclusions:
The quality of death of patients in Korean ICUs was considerably poorer than reported in other countries. Provision of appropriate comfort care, avoidance of unnecessary life-sustaining care, and permission for more frequent visits from patients’ families may correspond to better quality of death in Korean medical ICUs. It is also expected that the new legislation would positively affect the quality of death in Korean ICUs.
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Epidemiology of Hospital-Onset Versus Community-Onset Sepsis in U.S. Hospitals and Association With Mortality A Retrospective Analysis Using Electronic Clinical Data
Rhee, Chanu; Wang, Rui; Zhang, Zilu; More
Critical Care Medicine. ., Post Author Corrections: May 24, 2019
Abstract
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Objectives:
Prior studies have reported that hospital-onset sepsis is associated with higher mortality rates than community-onset sepsis. Most studies, however, have used inconsistent case-finding methods and applied limited risk-adjustment for potential confounders. We used consistent sepsis criteria and detailed electronic clinical data to elucidate the epidemiology and mortality associated with hospital-onset sepsis.
Design:
Retrospective cohort study.
Setting:
136 U.S. hospitals in the Cerner HealthFacts dataset.
Patients:
Adults hospitalized in 2009–2015.
Interventions:
None.
Measurements and Main Results:
We identified sepsis using Centers for Disease Control and Prevention Adult Sepsis Event criteria and estimated the risk of in-hospital death for hospital-onset sepsis versus community-onset sepsis using logistic regression models. In patients admitted without community-onset sepsis, we estimated risk of death associated with hospital-onset sepsis using Cox regression models with sepsis as a time-varying covariate. Models were adjusted for baseline characteristics and severity of illness. Among 2.2 million hospitalizations, there were 95,154 sepsis cases: 83,620 (87.9%) community-onset sepsis and 11,534 (12.1%) hospital-onset sepsis (0.5% of hospitalized cohort). Compared to community-onset sepsis, hospital-onset sepsis patients were younger (median 66 vs 68 yr) but had more comorbidities (median Elixhauser score 14 vs 11), higher Sequential Organ Failure Assessment scores (median 4 vs 3), higher ICU admission rates (61% vs 44%), longer hospital length of stay (median 19 vs 8 d), and higher in-hospital mortality (33% vs 17%) ( p < 0.001 for all comparisons). On multivariate analysis, hospital-onset sepsis was associated with higher mortality versus community-onset sepsis (odds ratio, 2.1; 95% CI, 2.0–2.2) and patients admitted without sepsis (hazard ratio, 3.0; 95% CI, 2.9–3.2).
Conclusions:
Hospital-onset sepsis complicated one in 200 hospitalizations and accounted for one in eight sepsis cases, with one in three patients dying in-hospital. Hospital-onset sepsis preferentially afflicted ill patients but even after risk-adjustment, they were twice as likely to die as community-onset sepsis patients; in patients admitted without sepsis, hospital-onset sepsis tripled the risk of death. Hospital-onset sepsis is an important target for surveillance, prevention, and quality improvement initiatives.
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Lung Recruitability in Severe Acute Respiratory Distress Syndrome Requiring Extracorporeal Membrane Oxygenation
Camporota, Luigi; Caricola, Elena V.; Bartolomeo, Nicola; More
Critical Care Medicine. ., Post Author Corrections: May 20, 2019
Abstract
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Objectives:
Quantification of potential for lung recruitment may guide the ventilatory strategy in acute respiratory distress syndrome. However, there are no quantitative data on recruitability in patients with severe acute respiratory distress syndrome who require extracorporeal membrane oxygenation. We sought to quantify potential for lung recruitment and its relationship with outcomes in this cohort of patients.
Design:
A single-center, retrospective, observational cohort study.
Setting:
Tertiary referral severe respiratory failure center in a university hospital in the United Kingdom.
Patients:
Forty-seven adults with severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation.
Intervention:
None.
Measurements and Main Results:
In patients with severe acute respiratory distress syndrome—mainly of pulmonary origin (86%)—the potential for lung recruitment and the weight of nonaerated, poorly aerated, normally aerated, and hyperaerated lung tissue were assessed at low (5 cmH 2 O) and high (45 cmH 2 O) airway pressures. Patients were categorized as high or low potential for lung recruitment based on the median potential for lung recruitment value of the study population. The median potential for lung recruitment was 24.3% (interquartile range = 11.4–37%) ranging from –2% to 76.3% of the total lung weight. Patients with potential for lung recruitment above the median had significantly shorter extracorporeal membrane oxygenation duration (8 vs 13 d; p = 0.013) and shorter ICU stay (15 vs 22 d; p = 0.028), but mortality was not statistically different (24% vs 46%; p = 0.159).
Conclusions:
We observed significant variability in potential for lung recruitment in patients with severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation. Patients with high potential for lung recruitment had a shorter ICU stay and shorter extracorporeal membrane oxygenation duration.
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Effect of a Multifaceted Performance Feedback Strategy on Length of Stay Compared With Benchmark Reports Alone A Cluster Randomized Trial in Intensive Care
van der Veer, Sabine N.; de Vos, Maartje L. G.; van der Voort, Peter H. J.; More
Critical Care Medicine. ., Post Author Corrections: June 12, 2013
Abstract
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Objective:
To assess the impact of applying a multifaceted activating performance feedback strategy on intensive care patient outcomes compared with passively receiving benchmark reports.
Design:
The Information Feedback on Quality Indicators study was a cluster randomized trial, running from February 2009 to May 2011.
Setting:
Thirty Dutch closed-format ICUs that participated in the national registry. Study duration per ICU was sixteen months.
Patients:
We analyzed data on 25,552 admissions. Admissions after coronary artery bypass graft surgery were excluded.
Intervention:
The intervention aimed to activate ICUs to undertake quality improvement initiatives by formalizing local responsibility for acting on performance feedback, and supporting them with increasing the impact of their improvement efforts. Therefore, intervention ICUs established a local, multidisciplinary quality improvement team. During one year, this team received two educational outreach visits, monthly reports to monitor performance over time, and extended, quarterly benchmark reports. Control ICUs only received four standard quarterly benchmark reports.
Measurements and Results:
The extent to which the intervention was implemented in daily practice varied considerably among intervention ICUs: the average monthly time investment per quality improvement team member was 4.1 hours (SD,2.; range, 0.6–8.1); the average number of monthly meetings per quality improvement team was 5.7 (SD, 4.5; range, 0–12). ICU length of stay did not reduce significantly after 1 year in intervention units compared with controls (hazard ratio, 1.02 [95% CI, 0.92–1.12]). Furthermore, the strategy had no statistically significant impact on any of the secondary measures (duration of mechanical ventilation, proportion of out-of-range glucose measurements, and all-cause hospital mortality).
Conclusions:
In the context of ICUs participating in a national registry, applying a multifaceted activating performance feedback strategy did not lead to better patient outcomes than only receiving periodical registry reports.
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Bacteremia in the Patients With Acute Pancreatitis as Revealed by 16S Ribosomal RNA Gene-Based Techniques
Li, Qiurong; Wang, Chenyang; Tang, Chun; More
Critical Care Medicine. ., Post Author Corrections: June 12, 2013
Abstract
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Objectives:
To define the characteristic of bacteremia in the patients with acute pancreatitis and determine its possible association with the disease severity.
Design:
A prospective controlled study.
Setting:
ICU of Jinling Hospital, China.
Patients:
A total of 48 patients with mild or severe acute pancreatitis were enrolled in this study.
Interventions:
None.
Measurements and Main Results:
Samples of peripheral blood were collected from the patients at 4 or 5 and 9 or 10 days after acute pancreatitis was definitely diagnosed. Resulting DNA from the blood was analyzed using denaturing gradient gel electrophoresis, and separated fragments were sequenced for identification of bacterial species. Bacterial DNA was detected in peripheral blood from 68.8% of patients with acute pancreatitis, and more than half (60.4%) of the patients encountered polymicrobial flora. Translocated bacteria in patients with acute pancreatitis were primarily constituted of opportunistic pathogens derived from the gut, including Escherichia coli , Shigella flexneri , Enterobacteriaceae bacterium , Acinetobacter lwoffii , Bacillus coagulans , and Enterococcus faecium . And the species of circulating bacteria shifted remarkably among the patients with different severity. The presence of the bacteremia correlated positively with the Acute Physiology and Chronic Health Evaluation-II scores of patients with acute pancreatitis ( r = 0.7918, p < 0.0001).
Conclusions:
This study provides a detailed description on the prevalence of bacteremia and characteristic of bacterial species in patients with acute pancreatitis. We demonstrate an association between the bacteremia and the disease severity, which enables us to better understand a potential role of bacterial translocation in the pathogenesis of septic complication in acute pancreatitis.
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Pleural Pressure and Optimal Positive End-Expiratory Pressure Based on Esophageal Pressure Versus Chest Wall Elastance Incompatible Results
Gulati, Gaurav; Novero, Aileen; Loring, Stephen H.; More
Critical Care Medicine. ., Post Author Corrections: June 12, 2013
Abstract
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Objectives:
1) To compare two published methods for estimating pleural pressure, one based on directly measured esophageal pressure and the other based on chest wall elastance. 2) To evaluate the agreement between two published positive end-expiratory pressure optimization strategies based on these methods, one targeting an end-expiratory esophageal pressure-based transpulmonary pressure of 0 cm H 2 O and the other targeting an end-inspiratory elastance-based transpulmonary pressure of 26 cm H 2 O.
Design:
Retrospective study using clinical data.
Setting:
Medical and surgical ICUs.
Patients:
Sixty-four patients mechanically ventilated for acute respiratory failure with esophageal balloons placed for clinical management.
Methods:
Esophageal pressure and chest wall elastance-based methods for estimating pleural pressure and setting positive end-expiratory pressure were retrospectively applied to each of 64 patients. In patients who were ventilated at two positive end-expiratory pressure levels, chest wall and respiratory system elastances were calculated at each positive end-expiratory pressure level.
Measurements and Main Results:
The pleural pressure estimates using both methods were discordant and differed by as much as 10 cm H 2 O for a given patient. The two positive end-expiratory pressure optimization strategies recommended positive end-expiratory pressure changes in opposite directions in % of patients. The ideal positive end-expiratory pressure levels recommended by the two methods for each patient were discordant and uncorrelated ( R 2 = 0.05). Chest wall and respiratory system elastances increased with increases in positive end-expiratory pressure in patients with positive end-expiratory esophageal pressure-based transpulmonary pressures ( p < 0.05).
Conclusions:
Esophageal pressure and chest wall elastance-based methods for estimating pleural pressure do not yield similar results. The strategies of targeting an end-expiratory esophageal pressure-based transpulmonary pressure of 0 cm H 2 O and targeting an end-inspiratory elastance-based transpulmonary pressure of 26 cm H 2 O cannot be considered interchangeable. Finally, chest wall and respiratory system elastances may vary unpredictably with changes in positive end-expiratory pressure. ( Crit Care Med 201;41:0–0)
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Atypical Sleep in Ventilated Patients Empirical Electroencephalography Findings and the Path Toward Revised ICU Sleep Scoring Criteria
Watson, Paula L.; Pandharipande, Pratik; Gehlbach, Brian K.; More
Critical Care Medicine. ., Post Author Corrections: June 12, 2013
Abstract
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Objectives:
Standard sleep scoring criteria may be unreliable when applied to critically ill patients. We sought to quantify typical and atypical polysomnographic findings in critically ill patients and to begin development and reliability testing of methodology to characterize the atypical polysomnographic tracings that confound standard sleep scoring criteria.
Design:
Prospective convenience sample.
Setting:
Two academic, tertiary care medical centers.
Patients:
Thirty-seven critically ill, mechanically ventilated, medical ICU patients.
Interventions:
None.
Measurements and Main Results:
Mechanically ventilated subjects were monitored by continuous polysomnography. After noting frequent atypical polysomnographic findings (i.e., lack of stage N2 markers, the presence of polymorphic delta, burst suppression, or isoelectric electroencephalography), attempts to use standard sleep scoring criteria alone were abandoned. Atypical polysomnographic findings were characterized and used to develop a modified scoring system. Polysomnographic data were scored manually via this revised scoring scheme. Of 7 medical ICU patients enrolled, 6 experienced atypical sleep, which accounted for 85% of all recorded data, with 5.1% normal sleep and 9.4% wake. Coupling observed patient arousal levels with polysomnographic characteristics revealed that standard polysomnographic staging criteria did not reliably determine the presence or absence of sleep. Rapid eye movement occurred in only five patients (14%). The revised scoring system incorporating frequently seen atypical characteristics yielded very high interrater reliability (weighted κ = 0.80; bootstrapped 95% CI, [0.48, 0.89]).
Conclusions:
Analysis of polysomnographic data revealed profound deficiencies in standard scoring criteria due to a predominance of atypical polysomnographic findings in ventilated patients. The revised scoring scheme proved reliable in sleep staging and may serve as a building block in future work.
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External Validation of Two Models to Predict Delirium in Critically Ill Adults Using Either the Confusion Assessment Method-ICU or the Intensive Care Delirium Screening Checklist for Delirium Assessment
Wassenaar, Annelies; Schoonhoven, Lisette; Devlin, John W.; More
Critical Care Medicine. ., Post Author Corrections: July 15, 2019
Abstract
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Objectives:
To externally validate two delirium prediction models (early prediction model for ICU delirium and recalibrated prediction model for ICU delirium) using either the Confusion Assessment Method-ICU or the Intensive Care Delirium Screening Checklist for delirium assessment.
Design:
Prospective, multinational cohort study.
Setting:
Eleven ICUs from seven countries in three continents.
Patients:
Consecutive, delirium-free adults admitted to the ICU for greater than or equal to 6 hours in whom delirium could be reliably assessed.
Interventions:
None.
Measurements and Main Results:
The predictors included in each model were collected at the time of ICU admission (early prediction model for ICU delirium) or within 24 hours of ICU admission (recalibrated prediction model for ICU delirium). Delirium was assessed using the Confusion Assessment Method-ICU or the Intensive Care Delirium Screening Checklist. Discrimination was determined using the area under the receiver operating characteristic curve. The predictive performance was determined for the Confusion Assessment Method-ICU and Intensive Care Delirium Screening Checklist cohort, and compared with both prediction models’ original reported performance. A total of 1,286 Confusion Assessment Method-ICU–assessed patients and 892 Intensive Care Delirium Screening Checklist–assessed patients were included. Compared with the area under the receiver operating characteristic curve of 0.75 (95% CI, 0.71–0.79) in the original study, the area under the receiver operating characteristic curve of the early prediction model for ICU delirium was 0.67 (95% CI, 0.64–0.71) for delirium as assessed using the Confusion Assessment Method-ICU and 0.70 (95% CI, 0.66–0.74) using the Intensive Care Delirium Screening Checklist. Compared with the original area under the receiver operating characteristic curve of 0.77 (95% CI, 0.74–0.79), the area under the receiver operating characteristic curve of the recalibrated prediction model for ICU delirium was 0.75 (95% CI, 0.72–0.78) for assessing delirium using the Confusion Assessment Method-ICU and 0.71 (95% CI, 0.67–0.75) using the Intensive Care Delirium Screening Checklist.
Conclusions:
Both the early prediction model for ICU delirium and recalibrated prediction model for ICU delirium are externally validated using either the Confusion Assessment Method-ICU or the Intensive Care Delirium Screening Checklist for delirium assessment. Per delirium prediction model, both assessment tools showed a similar moderate-to-good statistical performance. These results support the use of either the early prediction model for ICU delirium or recalibrated prediction model for ICU delirium in ICUs around the world regardless of whether delirium is evaluated with the Confusion Assessment Method-ICU or Intensive Care Delirium Screening Checklist.
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Antimicrobial Disposition During Pediatric Continuous Renal Replacement Therapy Using an Ex Vivo Model
Purohit, Prashant J.; Elkomy, Mohammed H.; Frymoyer, Adam; More
Critical Care Medicine. ., Post Author Corrections: July 15, 2019
Abstract
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Objectives:
Little is known on the impact of continuous renal replacement therapy on antimicrobial dose requirements in children. In this study, we evaluated the pharmacokinetics of commonly administered antimicrobials in an ex vivo continuous renal replacement therapy model.
Design:
An ex vivo continuous renal replacement therapy circuit was used to evaluate drug-circuit interactions and determine the disposition of five commonly used antimicrobials (meropenem, piperacillin, liposomal amphotericin B, caspofungin, and voriconazole).
Setting:
University research laboratory.
Patients:
None.
Interventions:
Antimicrobials were administered into a reservoir containing whole human blood. The reservoir was connected to a pediatric continuous renal replacement therapy circuit programmed for a 10 kg child. Continuous renal replacement therapy was performed in the hemodiafiltration mode and in three phases correlating with three different continuous renal replacement therapy clearance rates: 1) no clearance (0 mL/kg/hr, to measure adsorption), 2) low clearance (20 mL/kg/hr), and 3) high clearance (40 mL/kg/hr). Blood samples were drawn directly from the reservoir at baseline and at 5, 20, 60, and 180 minutes during each phase. Five independent continuous renal replacement therapy runs were performed to assess inter-run variability. Antimicrobial concentrations were measured using validated liquid chromatography-mass spectrometry assays. A closed-loop, flow-through pharmacokinetic model was developed to analyze concentration-time profiles for each drug.
Measurements and Main Results:
Circuit adsorption of antimicrobials ranged between 13% and 27%. Meropenem, piperacillin, and voriconazole were cleared by the continuous renal replacement therapy circuit and clearance increased with increasing continuous renal replacement therapy clearance rates (7.66 mL/min, 4.97 mL/min, and 2.67 mL/min, respectively, for high continuous renal replacement therapy clearance). Amphotericin B and caspofungin had minimal circuit clearance and did not change with increasing continuous renal replacement therapy clearance rates.
Conclusions:
Careful consideration of drug-circuit interactions during continuous renal replacement therapy is essential for appropriate drug dosing in critically ill children. Antimicrobials have unique adsorption and clearance profiles during continuous renal replacement therapy, and this knowledge is important to optimize antimicrobial therapy.
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Effect of Prone Positioning on Intraocular Pressure in Patients With Acute Respiratory Distress Syndrome
Saran, Sai; Gurjar, Mohan; Kanaujia, Vikas; More
Critical Care Medicine. ., Post Author Corrections: July 11, 2019
Abstract
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Objectives:
To evaluate the effect of prolonged duration of prone position (with head laterally rotated) on intraocular pressure in acute respiratory distress syndrome patients.
Design:
Prospective observational study.
Setting:
University hospital ICU.
Patients:
Twenty-five acute respiratory distress syndrome patients, age 60 years (51–67 yr), Sequential Organ Failure Assessment score 10 (10–12), PaO 2 /FIO 2 ratio of 90 (65–120), and all in septic shock.
Interventions:
None.
Measurements and Main Results:
Intraocular pressure (in mm Hg) measured by hand-held applanation tonometer, at different time points. Before prone (in both eyes): at 30–45° head-end elevation position (T HE pre-prone ), in supine position just before turning prone (T supine pre-prone ); during prone (in nondependent eye): at 10 minutes (T 10 prone ), 30 minutes (T 30 prone ), and at just before end of prone session (T end-prone ). After end of prone session (both eyes): at 5 minutes (T 5 supine post-prone ), 10 minutes (T 10 HE post-prone ), 15 minutes (T 15 HE post-prone ), and 30 minutes (T 30 HE post-prone ). Median duration of prone position was 14 hours (12–18 hr). Median intraocular pressure increased significantly ( p ≤ 0.001) in both eyes. In dependent eye, from 15 (12–19) at T HE pre-prone to 24, 21, 19, and 16 at T 5 supine post-prone , T 10 HE post-prone , T 15 HE post-prone , and T 30 HE post-prone respectively, whereas in nondependent eye from 14 (12–18.5) at T HE pre-prone to 23, 25, 32, 25, 22, 20, and 17 at T 10 prone , T 30 prone , T end-prone , T 5 supine post-prone , T 10 HE post-prone , T 15 HE post-prone , and T 30 HE post-prone respectively. Bland-Altman plot analysis showed significant linear relationship ( r = 0.789; p ≤ 0.001) with good agreement between rise in mean intraocular pressure of the both eyes (dependent eye and nondependent eye) with their paired differences after the end of different duration of prone session (T 5 supine post-prone ).
Conclusions:
There is significant increase in intraocular pressure due to prone positioning among acute respiratory distress syndrome patients. Intraocular pressure increases as early as 10 minutes after proning, with increasing trend during prone position, which persisted even at 30 minutes after the end of post prone session although with decreasing trend.
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