SCCMPediatric Critical Care MedicineCritical Care Explorations,
https://journals.lww.com/ccmjournal/toc/publishahead,
Online First - Last Updated: July 15, 2019
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Multi-Compartment Profiling of Bacterial and Host Metabolites Identifies Intestinal Dysbiosis and Its Functional Consequences in the Critically Ill Child
Wijeyesekera, Anisha; Wagner, Josef; De Goffau, Marcus; More
Critical Care Medicine. ., Post Author Corrections: June 04, 2019
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Objectives:
Adverse physiology and antibiotic exposure devastate the intestinal microbiome in critical illness. Time and cost implications limit the immediate clinical potential of microbial sequencing to identify or treat intestinal dysbiosis. Here, we examined whether metabolic profiling is a feasible method of monitoring intestinal dysbiosis in critically ill children.
Design:
Prospective multicenter cohort study.
Setting:
Three U.K.-based PICUs.
Patients:
Mechanically ventilated critically ill ( n = 60) and age-matched healthy children ( n = 55).
Interventions:
Collection of urine and fecal samples in children admitted to the PICU. A single fecal and urine sample was collected in healthy controls.
Measurements and Main Results:
Untargeted and targeted metabolic profiling using 1H-nuclear magnetic resonance spectroscopy and liquid chromatography-mass spectrometry or urine and fecal samples. This was integrated with analysis of fecal bacterial 16S ribosomal RNA profiles and clinical disease severity indicators. We observed separation of global urinary and fecal metabolic profiles in critically ill compared with healthy children. Urinary excretion of mammalian-microbial co-metabolites hippurate, 4-cresol sulphate, and formate were reduced in critical illness compared with healthy children. Reduced fecal excretion of short-chain fatty acids (including butyrate, propionate, and acetate) were observed in the patient cohort, demonstrating that these metabolites also distinguished between critical illness and health. Dysregulation of intestinal bile metabolism was evidenced by increased primary and reduced secondary fecal bile acid excretion. Fecal butyrate correlated with days free of intensive care at 30 days ( r = 0.38; p = 0.03), while urinary formate correlated inversely with vasopressor requirement ( r = –0.2; p = 0.037).
Conclusions:
Disruption to the functional activity of the intestinal microbiome may result in worsening organ failure in the critically ill child. Profiling of bacterial metabolites in fecal and urine samples may support identification and treatment of intestinal dysbiosis in critical illness.
This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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XueBiJing Injection Versus Placebo for Critically Ill Patients With Severe Community-Acquired Pneumonia A Randomized Controlled Trial
Song, Yuanlin; Yao, Chen; Yao, Yongming; More
Critical Care Medicine. ., Post Author Corrections: June 03, 2019
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Objectives:
To investigate whether XueBiJing injection improves clinical outcomes in critically ill patients with severe community-acquired pneumonia.
Design:
Prospective, randomized, controlled study.
Setting:
Thirty-three hospitals in China.
Patients:
A total of 710 adults 18–75 years old with severe community-acquired pneumonia.
Interventions:
Participants in the XueBiJing group received XueBiJing, 100 mL, q12 hours, and the control group received a visually indistinguishable placebo.
Measurements and Main Results:
The primary outcome was 8-day improvement in the pneumonia severity index risk rating. Secondary outcomes were 28-day mortality rate, duration of mechanical ventilation and total duration of ICU stay. Improvement in the pneumonia severity index risk rating, from a previously defined endpoint, occurred in 203 (60.78%) participants receiving XueBiJing and in 158 (46.33%) participants receiving placebo (between-group difference [95% CI], 14.4% [6.9–21.8%]; p < 0.001). Fifty-three (15.87%) XueBiJing recipients and 84 (24.63%) placebo recipients (8.8% [2.4–15.2%]; p = 0.006) died within 28 days. XueBiJing administration also decreased the mechanical ventilation time and the total ICU stay duration. The median mechanical ventilation time was 11.0 versus 16.5 days for the XueBiJing and placebo groups, respectively ( p = 0.012). The total duration of ICU stay was 12 days for XueBiJing recipients versus 16 days for placebo recipients ( p = 0.004). A total of 256 patients experienced adverse events (119 [35.63%] vs 137 [40.18%] in the XueBiJing and placebo groups, respectively [ p = 0.235]).
Conclusions:
In critically ill patients with severe community-acquired pneumonia, XueBiJing injection led to a statistically significant improvement in the primary endpoint of the pneumonia severity index as well a significant improvement in the secondary clinical outcomes of mortality, duration of mechanical ventilation and duration of ICU stay.
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
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Fluid Overload Associates With Major Adverse Kidney Events in Critically Ill Patients With Acute Kidney Injury Requiring Continuous Renal Replacement Therapy
Woodward, Connor W.; Lambert, Joshua; Ortiz-Soriano, Victor; More
Critical Care Medicine. ., Post Author Corrections: June 03, 2019
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Objectives:
We examined the association between fluid overload and major adverse kidney events in critically ill patients requiring continuous renal replacement therapy for acute kidney injury.
Design:
Retrospective cohort study.
Setting:
ICU in a tertiary medical center.
Patients:
Four-hundred eighty-one critically ill adults requiring continuous renal replacement therapy for acute kidney injury.
Interventions:
None.
Measurements and Main Results:
Fluid overload was assessed as fluid balance from admission to continuous renal replacement therapy initiation, adjusted for body weight. Major adverse kidney events were defined as a composite of mortality, renal replacement therapy-dependence or inability to recover 50% of baseline estimated glomerular filtration rate (if not on renal replacement therapy) evaluated up to 90 days after discharge. Patients with fluid overload less than or equal to 10% were less likely to experience major adverse kidney events than those with fluid overload greater than 10% (71.6% vs 79.4%; p = 0.047). Multivariable logistic regression showed that fluid overload greater than 10% was associated with a 58% increased odds of major adverse kidney events ( p = 0.046), even after adjusting for timing of continuous renal replacement therapy initiation. There was also a 2.7% increased odds of major adverse kidney events for every 1 day increase from ICU admission to continuous renal replacement therapy initiation ( p = 0.024). Fluid overload greater than 10% was also found to be independently associated with an 82% increased odds of hospital mortality ( p = 0.004) and 2.5 fewer ventilator-free days ( p = 0.044), compared with fluid overload less than or equal to 10%.
Conclusions:
In critically ill patients with acute kidney injury requiring continuous renal replacement therapy, greater than 10% fluid overload was associated with higher risk of 90-day major adverse kidney events, including mortality and decreased renal recovery. Increased time between ICU admission and continuous renal replacement therapy initiation was also associated with decreased renal recovery. Fluid overload represents a potentially modifiable risk factor, independent of timing of continuous renal replacement therapy initiation, that should be further examined in interventional studies.
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A Progressive Early Mobilization Program Is Significantly Associated With Clinical and Economic Improvement A Single-Center Quality Comparison Study
Liu, Keibun; Ogura, Takayuki; Takahashi, Kunihiko; More
Critical Care Medicine. ., Post Author Corrections: May 30, 2019
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Objectives:
To determine whether a progressive early mobilization protocol improves patient outcomes, including in-hospital mortality and total hospital costs.
Design:
Retrospective preintervention and postintervention quality comparison study.
Settings:
Single tertiary community hospital with a 12-bed closed-mixed ICU.
Patients:
All consecutive patients 18 years old or older were eligible. Patients who met exclusion criteria or were discharged from the ICU within 48 hours were excluded. Patients from January 2014 to May 2015 were defined as the preintervention group (group A) and from June 2015 to December 2016 was the postintervention group (group B).
Intervention:
Maebashi early mobilization protocol.
Measurements and Main Results:
Group A included 204 patients and group B included 187 patients. Baseline characteristics evaluated include age, severity, mechanical ventilation, and extracorporeal membrane oxygenation, and in group B additional comorbidities and use of steroids. Hospital mortality was reduced in group B (adjusted hazard ratio, 0.25; 95% CI, 0.13–0.49; p < 0.01). This early mobilization protocol is significantly associated with decreased mortality, even after adjusting for baseline characteristics such as sedation. Total hospital costs decreased from $29,220 to $22,706. The decrease occurred soon after initiating the intervention and this effect was sustained. The estimated effect was $–5,167 per patient, a 27% reduction. Reductions in ICU and hospital lengths of stay, time on mechanical ventilation, and improvement in physical function at hospital discharge were also seen. The change in Sequential Organ Failure Assessment score and Sequential Organ Failure Assessment score at ICU discharge were significantly reduced after the intervention, despite a similar Sequential Organ Failure Assessment score at admission and at maximum.
Conclusions:
In-hospital mortality and total hospital costs are reduced after the introduction of a progressive early mobilization program, which is significantly associated with decreased mortality. Cost savings were realized early after the intervention and sustained. Further prospective studies to investigate causality are warranted.
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Insights Into a “Negative” ICU Trial Derived From Gene Expression Profiling
Hoekstra, Mary; Maslove, David M.; Veldhoen, Richard A.; More
Critical Care Medicine. ., Post Author Corrections: February 26, 2019
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Objectives:
Randomized controlled trials in the ICU often fail to show differences in endpoints between groups. We sought to explore reasons for this at a molecular level by analyzing transcriptomic data from a recent negative trial. Our objectives were to determine if randomization successfully balanced transcriptomic features between groups, to assess transcriptomic heterogeneity among the study subjects included, and to determine if the study drug had any effect at the gene expression level.
Design:
Bioinformatics analysis of transcriptomic and clinical data collected in the course of a randomized controlled trial.
Setting:
Tertiary academic mixed medical-surgical ICU.
Patients:
Adult, critically ill patients expected to require invasive mechanical ventilation more than 48 hours.
Interventions:
Lactoferrin or placebo delivered enterally and via an oral swab for up to 28 days.
Measurements and Main Results:
We found no major imbalances in transcriptomic features between groups. Unsupervised analysis did not reveal distinct clusters among patients at the time of enrollment. There were marked differences in gene expression between early and later time points. Patients in the lactoferrin group showed changes in the expression of genes associated with immune pathways known to be associated with lactoferrin.
Conclusions:
In this clinical trial, transcriptomic data provided a useful complement to clinical data, suggesting that the reasons for the negative result were less likely related to the biological efficacy of the study drug, and may instead have been related to poor sensitivity of the clinical outcomes. In larger studies, transcriptomics may also prove useful in predicting response to treatment.
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Why My Steroid Trials in Septic Shock Were “Positive”?
Annane, Djillali
Critical Care Medicine. ., Post Author Corrections: June 27, 2019
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Limiting Treatment in Intensive Care Contributions and Limits of Ethics Consultation
Schildmann, Jan; Nadolny, Stephan; Haltaufderheide, Joschka; More
Critical Care Medicine. ., Post Author Corrections: June 03, 2019
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Why Understanding Sepsis Endotypes Is Important for Steroid Trials in Septic Shock?
Antcliffe, David B.; Gordon, Anthony C.
Critical Care Medicine. ., Post Author Corrections: June 03, 2019
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Why the Adjunctive Corticosteroid Treatment in Critically Ill Patients With Septic Shock (ADRENAL) Trial Did Not Show a Difference in Mortality?
Venkatesh, Balasubramanian; Cohen, Jeremy
Critical Care Medicine. ., Post Author Corrections: May 29, 2019
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Current Sepsis Mandates Are Overly Prescriptive, and Some Aspects May Be Harmful
Klompas, Michael; Rhee, Chanu
Critical Care Medicine. ., Post Author Corrections: December 04, 2018
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Enteral Nutrition Should Not Be Given to Patients on Vasopressor Agents
Arabi, Yaseen M.; McClave, Stephen A.
Critical Care Medicine. ., Post Author Corrections: August 21, 2018
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Hand Hygiene Compliance in the ICU A Systematic Review
Lambe, Kathryn Ann; Lydon, Sinéad; Madden, Caoimhe; More
Critical Care Medicine. ., Post Author Corrections: June 18, 2019
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Objectives:
To synthesize the literature describing compliance with World Health Organization hand hygiene guidelines in ICUs, to evaluate the quality of extant research, and to examine differences in compliance levels across geographical regions, ICU types, and healthcare worker groups, observation methods, and moments (indications) of hand hygiene.
Data Sources:
Electronic searches were conducted in August 2018 using Medline, CINAHL, PsycInfo, Embase, and Web of Science. Reference lists of included studies and related review articles were also screened.
Study Selection:
English-language, peer-reviewed studies measuring hand hygiene compliance by healthcare workers in an ICU setting using direct observation guided by the World Health Organization’s “Five Moments for Hand Hygiene,” published since 2009, were included.
Data Extraction:
Information was extracted on study location, research design, type of ICU, healthcare workers, measurement procedures, and compliance levels.
Data Synthesis:
Sixty-one studies were included. Most were conducted in high-income countries (60.7%) and in adult ICUs (85.2%). Mean hand hygiene compliance was 59.6%. Compliance levels appeared to differ by geographic region (high-income countries 64.5%, low-income countries 9.1%), type of ICU (neonatal 67.0%, pediatric 41.2%, adult 58.2%), and type of healthcare worker (nursing staff 43.4%, physicians 32.6%, other staff 53.8%).
Conclusions:
Mean hand hygiene compliance appears notably lower than international targets. The data collated may offer useful indicators for those evaluating, and seeking to improve, hand hygiene compliance in ICUs internationally.
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Interprofessional Shared Decision-Making in the ICU A Systematic Review and Recommendations From an Expert Panel
Michalsen, Andrej; Long, Ann C.; DeKeyser Ganz, Freda; More
Critical Care Medicine. ., Post Author Corrections: June 04, 2019
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Objectives:
There is growing recognition that high-quality care for patients and families in the ICU requires exemplary interprofessional collaboration and communication. One important aspect is how the ICU team makes complex decisions. However, no recommendations have been published on interprofessional shared decision-making. The aim of this project is to use systematic review and normative analysis by experts to examine existing evidence regarding interprofessional shared decision-making, describe its principles and provide ICU clinicians with recommendations regarding its implementation.
Data Sources:
We conducted a systematic review using MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases and used normative analyses to formulate recommendations regarding interprofessional shared decision-making.
Study Selection:
Three authors screened titles and abstracts in duplicate.
Data Synthesis:
Four papers assessing the effect of interprofessional shared decision-making on quality of care were identified, suggesting that interprofessional shared decision-making is associated with improved processes and outcomes. Five recommendations, largely based on expert opinion, were developed: 1) interprofessional shared decision-making is a collaborative process among clinicians that allows for shared decisions regarding important treatment questions; 2) clinicians should consider engaging in interprofessional shared decision-making to promote the most appropriate and balanced decisions; 3) clinicians and hospitals should implement strategies to foster an ICU climate oriented toward interprofessional shared decision-making; 4) clinicians implementing interprofessional shared decision-making should consider incorporating a structured approach; and 5) further studies are needed to evaluate and improve the quality of interprofessional shared decision-making in ICUs.
Conclusions:
Clinicians should consider an interprofessional shared decision-making model that allows for the exchange of information, deliberation, and joint attainment of important treatment decisions.
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Impact on Patient Outcomes of Pharmacist Participation in Multidisciplinary Critical Care Teams A Systematic Review and Meta-Analysis
Lee, Heeyoung; Ryu, Kyungwoo; Sohn, Youmin; More
Critical Care Medicine. ., Post Author Corrections: May 24, 2019
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Objectives:
The objective of this systematic review and meta-analysis was to assess the effects of including critical care pharmacists in multidisciplinary ICU teams on clinical outcomes including mortality, ICU length of stay, and adverse drug events.
Data Sources:
PubMed, EMBASE, and references from previous relevant systematic studies.
Study Selection:
We included randomized controlled trials and nonrandomized studies that reported clinical outcomes such as mortality, ICU length of stay, and adverse drug events in groups with and without critical care pharmacist interventions.
Data Extraction:
We extracted study details, patient characteristics, and clinical outcomes.
Data Synthesis:
From the 4,725 articles identified as potentially eligible, 14 were included in the analysis. Intervention of critical care pharmacists as part of the multidisciplinary ICU team care was significantly associated with the reduced likelihood of mortality (odds ratio, 0.78; 95% CI, 0.73–0.83; p < 0.00001) compared with no intervention. The mean difference in ICU length of stay was –1.33 days (95% CI, –1.75 to –0.90 d; p < 0.00001) for mixed ICUs. The reduction of adverse drug event prevalence was also significantly associated with multidisciplinary team care involving pharmacist intervention (odds ratio for preventable and nonpreventable adverse drug events, 0.26; 95% CI, 0.15–0.44; p < 0.00001 and odds ratio, 0.47; 95% CI, 0.28–0.77; p = 0.003, respectively).
Conclusions:
Including critical care pharmacists in the multidisciplinary ICU team improved patient outcomes including mortality, ICU length of stay in mixed ICUs, and preventable/nonpreventable adverse drug events.
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Management of Peripheral Venoarterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock
Keller, Steven P.
Critical Care Medicine. ., Post Author Corrections: June 18, 2019
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Objectives:
Cardiogenic shock is a highly morbid condition in which inadequate end-organ perfusion leads to death if untreated. Peripheral venoarterial extracorporeal membrane oxygenation is increasingly used to restore systemic perfusion despite limited understanding of how to optimally titrate support. This review provides insights into the physiologic basis of extracorporeal membrane oxygenation support and presents an approach to extracorporeal membrane oxygenation management in the cardiogenic shock patient.
Data Sources, Study Selection, and Data Extraction:
Data were obtained from a PubMed search of the most recent medical literature identified from MeSH terms: extracorporeal membrane oxygenation, cardiogenic shock, percutaneous mechanical circulatory support, and heart failure. Articles included original articles, case reports, and review articles.
Data Synthesis:
Current evidence detailing the use of extracorporeal membrane oxygenation to support patients in cardiogenic shock is limited to isolated case reports and single institution case series focused on patient outcomes but lacking in detailed approaches to extracorporeal membrane oxygenation management. Unlike medical therapy, in which dosages are either prescribed or carefully titrated to specific variables, extracorporeal membrane oxygenation is a mechanical support therapy requiring ongoing titration but without widely accepted variables to guide treatment. Similar to mechanical ventilation, extracorporeal membrane oxygenation can provide substantial benefit or induce significant harm. The widespread use and present lack of data to guide extracorporeal membrane oxygenation support demands that intensivists adopt a physiologically-based approach to management of the cardiogenic shock patient on extracorporeal membrane oxygenation.
Conclusions:
Extracorporeal membrane oxygenation is a powerful mechanical circulatory support modality capable of rapidly restoring systemic perfusion yet lacking in defined approaches to management. Adopting a management approach based physiologic principles provides a basis for care.
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Causes of Death in Status Epilepticus
Hawkes, Maximiliano A.; English, Stephen W.; Mandrekar, Jay N.; More
Critical Care Medicine. ., Post Author Corrections: June 14, 2019
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Objectives:
To determine the causes of death in patients with status epilepticus. To analyze the relative contributions of seizure etiology, seizure refractoriness, use of mechanical ventilation, anesthetic drugs for seizure control, and medical complications to in-hospital and 90-day mortality, hospital length of stay, and discharge disposition.
Design:
Retrospective cohort.
Setting:
Single-center neuroscience ICU.
Participants:
Patients with status epilepticus were identified by retrospective search of electronic database from January 1, 2011, to December 31, 2016.
Interventions:
Review of electronic medical records.
Measurements and Main Results:
Demographics, clinical characteristics, treatments, and outcomes were collected. Univariable and multivariable logistic regression analysis were used to determine whether the use of anesthetic drugs, mechanical ventilation, Status Epilepticus Severity Score, refractoriness of seizures, etiology of seizures, or medical complications were associated with in-hospital, 90-day mortality or discharge disposition. Among 244 patients with status epilepticus (mean age was 64 yr [interquartile range, 42–76], 55% male, median Status Epilepticus Severity Score 3 [interquartile range, 2–4]), 24 received anesthetic drug infusions for seizure control. In-hospital and 90-day mortality rates were 9.2% and 19.2%, respectively. Death was preceded by withdrawal of life-sustaining treatment in 19 patients (86.3%) and cardiac arrest in three (13.7%). Only Status Epilepticus Severity Score was associated with in-hospital and 90-day mortality, whereas the use of anesthetic drugs for seizure control, mechanical ventilation, medical complications, etiology, and refractoriness of seizures were not. Hospital length of stay was longer in patients with medical complications ( p = 0.0091), refractory seizures ( p = 0.0077), and in those who required anesthetic drugs for seizure control ( p = 0.0035). Patients who had refractory seizures were less likely to be discharged home (odds ratio, 0.295; CI, 0.143–0.608; p = 0.0009).
Conclusions:
In this cohort, death primarily resulted from the underlying neurologic disease and withdrawal of life-sustaining treatment and not from our treatment choices. Use of anesthetic drugs, medical complications, and mechanical ventilation were not associated with in-hospital and 90-day mortality.
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Impact of Critical Care Point-of-Care Ultrasound Short-Courses on Trainee Competence
Rajamani, Arvind; Miu, Michelle; Huang, Stephen; More
Critical Care Medicine. ., Post Author Corrections: June 03, 2019
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Objectives:
Competence in point-of-care ultrasound is recommended/mandated by several critical care specialties. Although doctors commonly attend point-of-care ultrasound short-courses for introductory training, there is little follow-up data on whether they eventually attain competence. This study was done to determine the impact of point-of-care ultrasound short-courses on point-of-care ultrasound competence.
Design:
Web-based survey.
Setting:
Follow-up after point-of-care ultrasound short-courses in the Asia-Pacific region.
Subjects:
Doctors who attended a point-of-care ultrasound short-course between December 2015 and February 2018.
Interventions:
Each subject was emailed a questionnaire on or after 6 months following their short-course. They were asked if they had performed at least 30 structured point-of-care ultrasound scans and/or reached point-of-care ultrasound competence and their perceived reasons/challenges/barriers. They were also asked if they used point-of-care ultrasound as a clinical diagnostic aid.
Measurements and Main Results:
The response rate was 74.9% (182/243). Among the 182 respondents, only 12 (6.6%) had attained competence in their chosen point-of-care ultrasound modality, attributing their success to self-motivation and time management. For the remaining doctors who did not attain competence (170/182, 93.4%), the common reasons were lack of time, change of priorities, and less commonly, difficulties in accessing an ultrasound machine/supervisor. Common suggestions to improve short-courses included requests for scanning practice on acutely ill ICU patients and prior information on the challenges regarding point-of-care ultrasound competence. Suggestions to improve competence pathways included regular supervision and protected learning time. All 12 credentialled doctors regularly used point-of-care ultrasound as a clinical diagnostic aid. Of the 170 noncredentialled doctors, 123 (72.4%) reported performing unsupervised point-of-care ultrasound for clinical management, either sporadically (42/170, 24.7%) or regularly (81/170, 47.7%).
Conclusions:
In this survey of doctors attending point-of-care ultrasound short-courses in Australasia, the majority of doctors did not attain competence. However, the practice of unsupervised point-of-care ultrasound use by noncredentialled doctors was common. Further research into effective strategies to improve point-of-care ultrasound competence is required.
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Individual Airway Closure Characterized In Vivo by Phase-Contrast CT Imaging in Injured Rabbit Lung
Broche, Ludovic; Pisa, Pauline; Porra, Liisa; More
Critical Care Medicine. ., Post Author Corrections: May 31, 2019
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Objectives:
Airway closure is involved in adverse effects of mechanical ventilation under both general anesthesia and in acute respiratory distress syndrome patients. However, direct evidence and characterization of individual airway closure is lacking. Here, we studied the same individual peripheral airways in intact lungs of anesthetized and mechanically ventilated rabbits, at baseline and following lung injury, using high-resolution synchrotron phase-contrast CT.
Design:
Laboratory animal investigation.
Setting:
European synchrotron radiation facility.
Subjects:
Six New-Zealand White rabbits.
Interventions:
The animals were anesthetized, paralyzed, and mechanically ventilated in pressure-controlled mode (tidal volume, 6 mL/kg; respiratory rate, 40; FIO 2 , 0.6; inspiratory:expiratory, 1:2; and positive end-expiratory pressure, 3 cm H 2 O) at baseline. Imaging was performed with a 47.5 × 47.5 × 47.5 μm voxel size, at positive end-expiratory pressure 12, 9, 6, 3, and 0 cm H 2 O. The imaging sequence was repeated after lung injury induced by whole-lung lavage and injurious ventilation in four rabbits. Cross-sections of the same individual airways were measured.
Measurements and Main Results:
The airways were measured at baseline ( n = 48; radius, 1.7 to 0.21 mm) and after injury ( n = 32). Closure was observed at 0 cm H 2 O in three of 48 airways (6.3%; radius, 0.35 ± 0.08 mm at positive end-expiratory pressure 12) at baseline and five of 32 (15.6%; radius, 0.28 ± 0.09 mm) airways after injury. Cross-section was significantly reduced at 3 and 0 cm H 2 O, after injury, with a significant relation between the relative change in cross-section and airway radius at 12 cm H 2 O in injured, but not in normal lung ( R = 0.60; p < 0.001).
Conclusions:
Airway collapsibility increases in the injured lung with a significant dependence on airway caliber. We identify “compliant collapse” as the main mechanism of airway closure in initially patent airways, which can occur at more than one site in individual airways.
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Comparison of Automated Activity Recognition to Provider Observations of Patient Mobility in the ICU
Rawat, Nishi; Rao, Vishal; Peven, Michael; More
Critical Care Medicine. ., Post Author Corrections: May 31, 2019
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Objectives:
To compare noninvasive mobility sensor patient motion signature to direct observations by physicians and nurses.
Design:
Prospective, observational study.
Setting:
Academic hospital surgical ICU.
Patients and Measurements:
A total of 2,426 1-minute clips from six ICU patients (development dataset) and 4,824 1-minute clips from five patients (test dataset).
Interventions:
None.
Main Results:
Noninvasive mobility sensor achieved a minute-level accuracy of 94.2% (2,138/2,272) and an hour-level accuracy of 81.4% (70/86).
Conclusions:
The automated noninvasive mobility sensor system represents a significant departure from current manual measurement and reporting used in clinical care, lowering the burden of measurement and documentation on caregivers.
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Clinician Perception of a Machine Learning–Based Early Warning System Designed to Predict Severe Sepsis and Septic Shock
Ginestra, Jennifer C.; Giannini, Heather M.; Schweickert, William D.; More
Critical Care Medicine. ., Post Author Corrections: May 24, 2019
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Objective:
To assess clinician perceptions of a machine learning–based early warning system to predict severe sepsis and septic shock (Early Warning System 2.0).
Design:
Prospective observational study.
Setting:
Tertiary teaching hospital in Philadelphia, PA.
Patients:
Non-ICU admissions November–December 2016.
Interventions:
During a 6-week study period conducted 5 months after Early Warning System 2.0 alert implementation, nurses and providers were surveyed twice about their perceptions of the alert’s helpfulness and impact on care, first within 6 hours of the alert, and again 48 hours after the alert.
Measurements and Main Results:
For the 362 alerts triggered, 180 nurses (50% response rate) and 107 providers (30% response rate) completed the first survey. Of these, 43 nurses (24% response rate) and 44 providers (41% response rate) completed the second survey. Few (24% nurses, 13% providers) identified new clinical findings after responding to the alert. Perceptions of the presence of sepsis at the time of alert were discrepant between nurses (13%) and providers (40%). The majority of clinicians reported no change in perception of the patient’s risk for sepsis (55% nurses, 62% providers). A third of nurses (30%) but few providers (9%) reported the alert changed management. Almost half of nurses (42%) but less than a fifth of providers (16%) found the alert helpful at 6 hours.
Conclusions:
In general, clinical perceptions of Early Warning System 2.0 were poor. Nurses and providers differed in their perceptions of sepsis and alert benefits. These findings highlight the challenges of achieving acceptance of predictive and machine learning–based sepsis alerts.
https://journals.lww.com/ccmjournal/toc/publishahead,
Online First - Last Updated: July 15, 2019
The editors of this journal are pleased to offer electronic publication of accepted papers prior to print publication. These papers can be cited using the date of access and the unique DOI number. Any final changes in manuscripts will be made at the time of print publication and will be reflected in the final electronic version of the issue.
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Multi-Compartment Profiling of Bacterial and Host Metabolites Identifies Intestinal Dysbiosis and Its Functional Consequences in the Critically Ill Child
Wijeyesekera, Anisha; Wagner, Josef; De Goffau, Marcus; More
Critical Care Medicine. ., Post Author Corrections: June 04, 2019
Abstract
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Objectives:
Adverse physiology and antibiotic exposure devastate the intestinal microbiome in critical illness. Time and cost implications limit the immediate clinical potential of microbial sequencing to identify or treat intestinal dysbiosis. Here, we examined whether metabolic profiling is a feasible method of monitoring intestinal dysbiosis in critically ill children.
Design:
Prospective multicenter cohort study.
Setting:
Three U.K.-based PICUs.
Patients:
Mechanically ventilated critically ill ( n = 60) and age-matched healthy children ( n = 55).
Interventions:
Collection of urine and fecal samples in children admitted to the PICU. A single fecal and urine sample was collected in healthy controls.
Measurements and Main Results:
Untargeted and targeted metabolic profiling using 1H-nuclear magnetic resonance spectroscopy and liquid chromatography-mass spectrometry or urine and fecal samples. This was integrated with analysis of fecal bacterial 16S ribosomal RNA profiles and clinical disease severity indicators. We observed separation of global urinary and fecal metabolic profiles in critically ill compared with healthy children. Urinary excretion of mammalian-microbial co-metabolites hippurate, 4-cresol sulphate, and formate were reduced in critical illness compared with healthy children. Reduced fecal excretion of short-chain fatty acids (including butyrate, propionate, and acetate) were observed in the patient cohort, demonstrating that these metabolites also distinguished between critical illness and health. Dysregulation of intestinal bile metabolism was evidenced by increased primary and reduced secondary fecal bile acid excretion. Fecal butyrate correlated with days free of intensive care at 30 days ( r = 0.38; p = 0.03), while urinary formate correlated inversely with vasopressor requirement ( r = –0.2; p = 0.037).
Conclusions:
Disruption to the functional activity of the intestinal microbiome may result in worsening organ failure in the critically ill child. Profiling of bacterial metabolites in fecal and urine samples may support identification and treatment of intestinal dysbiosis in critical illness.
This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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XueBiJing Injection Versus Placebo for Critically Ill Patients With Severe Community-Acquired Pneumonia A Randomized Controlled Trial
Song, Yuanlin; Yao, Chen; Yao, Yongming; More
Critical Care Medicine. ., Post Author Corrections: June 03, 2019
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Objectives:
To investigate whether XueBiJing injection improves clinical outcomes in critically ill patients with severe community-acquired pneumonia.
Design:
Prospective, randomized, controlled study.
Setting:
Thirty-three hospitals in China.
Patients:
A total of 710 adults 18–75 years old with severe community-acquired pneumonia.
Interventions:
Participants in the XueBiJing group received XueBiJing, 100 mL, q12 hours, and the control group received a visually indistinguishable placebo.
Measurements and Main Results:
The primary outcome was 8-day improvement in the pneumonia severity index risk rating. Secondary outcomes were 28-day mortality rate, duration of mechanical ventilation and total duration of ICU stay. Improvement in the pneumonia severity index risk rating, from a previously defined endpoint, occurred in 203 (60.78%) participants receiving XueBiJing and in 158 (46.33%) participants receiving placebo (between-group difference [95% CI], 14.4% [6.9–21.8%]; p < 0.001). Fifty-three (15.87%) XueBiJing recipients and 84 (24.63%) placebo recipients (8.8% [2.4–15.2%]; p = 0.006) died within 28 days. XueBiJing administration also decreased the mechanical ventilation time and the total ICU stay duration. The median mechanical ventilation time was 11.0 versus 16.5 days for the XueBiJing and placebo groups, respectively ( p = 0.012). The total duration of ICU stay was 12 days for XueBiJing recipients versus 16 days for placebo recipients ( p = 0.004). A total of 256 patients experienced adverse events (119 [35.63%] vs 137 [40.18%] in the XueBiJing and placebo groups, respectively [ p = 0.235]).
Conclusions:
In critically ill patients with severe community-acquired pneumonia, XueBiJing injection led to a statistically significant improvement in the primary endpoint of the pneumonia severity index as well a significant improvement in the secondary clinical outcomes of mortality, duration of mechanical ventilation and duration of ICU stay.
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
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Fluid Overload Associates With Major Adverse Kidney Events in Critically Ill Patients With Acute Kidney Injury Requiring Continuous Renal Replacement Therapy
Woodward, Connor W.; Lambert, Joshua; Ortiz-Soriano, Victor; More
Critical Care Medicine. ., Post Author Corrections: June 03, 2019
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Objectives:
We examined the association between fluid overload and major adverse kidney events in critically ill patients requiring continuous renal replacement therapy for acute kidney injury.
Design:
Retrospective cohort study.
Setting:
ICU in a tertiary medical center.
Patients:
Four-hundred eighty-one critically ill adults requiring continuous renal replacement therapy for acute kidney injury.
Interventions:
None.
Measurements and Main Results:
Fluid overload was assessed as fluid balance from admission to continuous renal replacement therapy initiation, adjusted for body weight. Major adverse kidney events were defined as a composite of mortality, renal replacement therapy-dependence or inability to recover 50% of baseline estimated glomerular filtration rate (if not on renal replacement therapy) evaluated up to 90 days after discharge. Patients with fluid overload less than or equal to 10% were less likely to experience major adverse kidney events than those with fluid overload greater than 10% (71.6% vs 79.4%; p = 0.047). Multivariable logistic regression showed that fluid overload greater than 10% was associated with a 58% increased odds of major adverse kidney events ( p = 0.046), even after adjusting for timing of continuous renal replacement therapy initiation. There was also a 2.7% increased odds of major adverse kidney events for every 1 day increase from ICU admission to continuous renal replacement therapy initiation ( p = 0.024). Fluid overload greater than 10% was also found to be independently associated with an 82% increased odds of hospital mortality ( p = 0.004) and 2.5 fewer ventilator-free days ( p = 0.044), compared with fluid overload less than or equal to 10%.
Conclusions:
In critically ill patients with acute kidney injury requiring continuous renal replacement therapy, greater than 10% fluid overload was associated with higher risk of 90-day major adverse kidney events, including mortality and decreased renal recovery. Increased time between ICU admission and continuous renal replacement therapy initiation was also associated with decreased renal recovery. Fluid overload represents a potentially modifiable risk factor, independent of timing of continuous renal replacement therapy initiation, that should be further examined in interventional studies.
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A Progressive Early Mobilization Program Is Significantly Associated With Clinical and Economic Improvement A Single-Center Quality Comparison Study
Liu, Keibun; Ogura, Takayuki; Takahashi, Kunihiko; More
Critical Care Medicine. ., Post Author Corrections: May 30, 2019
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Objectives:
To determine whether a progressive early mobilization protocol improves patient outcomes, including in-hospital mortality and total hospital costs.
Design:
Retrospective preintervention and postintervention quality comparison study.
Settings:
Single tertiary community hospital with a 12-bed closed-mixed ICU.
Patients:
All consecutive patients 18 years old or older were eligible. Patients who met exclusion criteria or were discharged from the ICU within 48 hours were excluded. Patients from January 2014 to May 2015 were defined as the preintervention group (group A) and from June 2015 to December 2016 was the postintervention group (group B).
Intervention:
Maebashi early mobilization protocol.
Measurements and Main Results:
Group A included 204 patients and group B included 187 patients. Baseline characteristics evaluated include age, severity, mechanical ventilation, and extracorporeal membrane oxygenation, and in group B additional comorbidities and use of steroids. Hospital mortality was reduced in group B (adjusted hazard ratio, 0.25; 95% CI, 0.13–0.49; p < 0.01). This early mobilization protocol is significantly associated with decreased mortality, even after adjusting for baseline characteristics such as sedation. Total hospital costs decreased from $29,220 to $22,706. The decrease occurred soon after initiating the intervention and this effect was sustained. The estimated effect was $–5,167 per patient, a 27% reduction. Reductions in ICU and hospital lengths of stay, time on mechanical ventilation, and improvement in physical function at hospital discharge were also seen. The change in Sequential Organ Failure Assessment score and Sequential Organ Failure Assessment score at ICU discharge were significantly reduced after the intervention, despite a similar Sequential Organ Failure Assessment score at admission and at maximum.
Conclusions:
In-hospital mortality and total hospital costs are reduced after the introduction of a progressive early mobilization program, which is significantly associated with decreased mortality. Cost savings were realized early after the intervention and sustained. Further prospective studies to investigate causality are warranted.
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Insights Into a “Negative” ICU Trial Derived From Gene Expression Profiling
Hoekstra, Mary; Maslove, David M.; Veldhoen, Richard A.; More
Critical Care Medicine. ., Post Author Corrections: February 26, 2019
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Objectives:
Randomized controlled trials in the ICU often fail to show differences in endpoints between groups. We sought to explore reasons for this at a molecular level by analyzing transcriptomic data from a recent negative trial. Our objectives were to determine if randomization successfully balanced transcriptomic features between groups, to assess transcriptomic heterogeneity among the study subjects included, and to determine if the study drug had any effect at the gene expression level.
Design:
Bioinformatics analysis of transcriptomic and clinical data collected in the course of a randomized controlled trial.
Setting:
Tertiary academic mixed medical-surgical ICU.
Patients:
Adult, critically ill patients expected to require invasive mechanical ventilation more than 48 hours.
Interventions:
Lactoferrin or placebo delivered enterally and via an oral swab for up to 28 days.
Measurements and Main Results:
We found no major imbalances in transcriptomic features between groups. Unsupervised analysis did not reveal distinct clusters among patients at the time of enrollment. There were marked differences in gene expression between early and later time points. Patients in the lactoferrin group showed changes in the expression of genes associated with immune pathways known to be associated with lactoferrin.
Conclusions:
In this clinical trial, transcriptomic data provided a useful complement to clinical data, suggesting that the reasons for the negative result were less likely related to the biological efficacy of the study drug, and may instead have been related to poor sensitivity of the clinical outcomes. In larger studies, transcriptomics may also prove useful in predicting response to treatment.
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Why My Steroid Trials in Septic Shock Were “Positive”?
Annane, Djillali
Critical Care Medicine. ., Post Author Corrections: June 27, 2019
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Limiting Treatment in Intensive Care Contributions and Limits of Ethics Consultation
Schildmann, Jan; Nadolny, Stephan; Haltaufderheide, Joschka; More
Critical Care Medicine. ., Post Author Corrections: June 03, 2019
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Why Understanding Sepsis Endotypes Is Important for Steroid Trials in Septic Shock?
Antcliffe, David B.; Gordon, Anthony C.
Critical Care Medicine. ., Post Author Corrections: June 03, 2019
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Why the Adjunctive Corticosteroid Treatment in Critically Ill Patients With Septic Shock (ADRENAL) Trial Did Not Show a Difference in Mortality?
Venkatesh, Balasubramanian; Cohen, Jeremy
Critical Care Medicine. ., Post Author Corrections: May 29, 2019
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Current Sepsis Mandates Are Overly Prescriptive, and Some Aspects May Be Harmful
Klompas, Michael; Rhee, Chanu
Critical Care Medicine. ., Post Author Corrections: December 04, 2018
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Enteral Nutrition Should Not Be Given to Patients on Vasopressor Agents
Arabi, Yaseen M.; McClave, Stephen A.
Critical Care Medicine. ., Post Author Corrections: August 21, 2018
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Hand Hygiene Compliance in the ICU A Systematic Review
Lambe, Kathryn Ann; Lydon, Sinéad; Madden, Caoimhe; More
Critical Care Medicine. ., Post Author Corrections: June 18, 2019
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Objectives:
To synthesize the literature describing compliance with World Health Organization hand hygiene guidelines in ICUs, to evaluate the quality of extant research, and to examine differences in compliance levels across geographical regions, ICU types, and healthcare worker groups, observation methods, and moments (indications) of hand hygiene.
Data Sources:
Electronic searches were conducted in August 2018 using Medline, CINAHL, PsycInfo, Embase, and Web of Science. Reference lists of included studies and related review articles were also screened.
Study Selection:
English-language, peer-reviewed studies measuring hand hygiene compliance by healthcare workers in an ICU setting using direct observation guided by the World Health Organization’s “Five Moments for Hand Hygiene,” published since 2009, were included.
Data Extraction:
Information was extracted on study location, research design, type of ICU, healthcare workers, measurement procedures, and compliance levels.
Data Synthesis:
Sixty-one studies were included. Most were conducted in high-income countries (60.7%) and in adult ICUs (85.2%). Mean hand hygiene compliance was 59.6%. Compliance levels appeared to differ by geographic region (high-income countries 64.5%, low-income countries 9.1%), type of ICU (neonatal 67.0%, pediatric 41.2%, adult 58.2%), and type of healthcare worker (nursing staff 43.4%, physicians 32.6%, other staff 53.8%).
Conclusions:
Mean hand hygiene compliance appears notably lower than international targets. The data collated may offer useful indicators for those evaluating, and seeking to improve, hand hygiene compliance in ICUs internationally.
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Interprofessional Shared Decision-Making in the ICU A Systematic Review and Recommendations From an Expert Panel
Michalsen, Andrej; Long, Ann C.; DeKeyser Ganz, Freda; More
Critical Care Medicine. ., Post Author Corrections: June 04, 2019
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Objectives:
There is growing recognition that high-quality care for patients and families in the ICU requires exemplary interprofessional collaboration and communication. One important aspect is how the ICU team makes complex decisions. However, no recommendations have been published on interprofessional shared decision-making. The aim of this project is to use systematic review and normative analysis by experts to examine existing evidence regarding interprofessional shared decision-making, describe its principles and provide ICU clinicians with recommendations regarding its implementation.
Data Sources:
We conducted a systematic review using MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases and used normative analyses to formulate recommendations regarding interprofessional shared decision-making.
Study Selection:
Three authors screened titles and abstracts in duplicate.
Data Synthesis:
Four papers assessing the effect of interprofessional shared decision-making on quality of care were identified, suggesting that interprofessional shared decision-making is associated with improved processes and outcomes. Five recommendations, largely based on expert opinion, were developed: 1) interprofessional shared decision-making is a collaborative process among clinicians that allows for shared decisions regarding important treatment questions; 2) clinicians should consider engaging in interprofessional shared decision-making to promote the most appropriate and balanced decisions; 3) clinicians and hospitals should implement strategies to foster an ICU climate oriented toward interprofessional shared decision-making; 4) clinicians implementing interprofessional shared decision-making should consider incorporating a structured approach; and 5) further studies are needed to evaluate and improve the quality of interprofessional shared decision-making in ICUs.
Conclusions:
Clinicians should consider an interprofessional shared decision-making model that allows for the exchange of information, deliberation, and joint attainment of important treatment decisions.
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Impact on Patient Outcomes of Pharmacist Participation in Multidisciplinary Critical Care Teams A Systematic Review and Meta-Analysis
Lee, Heeyoung; Ryu, Kyungwoo; Sohn, Youmin; More
Critical Care Medicine. ., Post Author Corrections: May 24, 2019
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Objectives:
The objective of this systematic review and meta-analysis was to assess the effects of including critical care pharmacists in multidisciplinary ICU teams on clinical outcomes including mortality, ICU length of stay, and adverse drug events.
Data Sources:
PubMed, EMBASE, and references from previous relevant systematic studies.
Study Selection:
We included randomized controlled trials and nonrandomized studies that reported clinical outcomes such as mortality, ICU length of stay, and adverse drug events in groups with and without critical care pharmacist interventions.
Data Extraction:
We extracted study details, patient characteristics, and clinical outcomes.
Data Synthesis:
From the 4,725 articles identified as potentially eligible, 14 were included in the analysis. Intervention of critical care pharmacists as part of the multidisciplinary ICU team care was significantly associated with the reduced likelihood of mortality (odds ratio, 0.78; 95% CI, 0.73–0.83; p < 0.00001) compared with no intervention. The mean difference in ICU length of stay was –1.33 days (95% CI, –1.75 to –0.90 d; p < 0.00001) for mixed ICUs. The reduction of adverse drug event prevalence was also significantly associated with multidisciplinary team care involving pharmacist intervention (odds ratio for preventable and nonpreventable adverse drug events, 0.26; 95% CI, 0.15–0.44; p < 0.00001 and odds ratio, 0.47; 95% CI, 0.28–0.77; p = 0.003, respectively).
Conclusions:
Including critical care pharmacists in the multidisciplinary ICU team improved patient outcomes including mortality, ICU length of stay in mixed ICUs, and preventable/nonpreventable adverse drug events.
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Management of Peripheral Venoarterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock
Keller, Steven P.
Critical Care Medicine. ., Post Author Corrections: June 18, 2019
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Objectives:
Cardiogenic shock is a highly morbid condition in which inadequate end-organ perfusion leads to death if untreated. Peripheral venoarterial extracorporeal membrane oxygenation is increasingly used to restore systemic perfusion despite limited understanding of how to optimally titrate support. This review provides insights into the physiologic basis of extracorporeal membrane oxygenation support and presents an approach to extracorporeal membrane oxygenation management in the cardiogenic shock patient.
Data Sources, Study Selection, and Data Extraction:
Data were obtained from a PubMed search of the most recent medical literature identified from MeSH terms: extracorporeal membrane oxygenation, cardiogenic shock, percutaneous mechanical circulatory support, and heart failure. Articles included original articles, case reports, and review articles.
Data Synthesis:
Current evidence detailing the use of extracorporeal membrane oxygenation to support patients in cardiogenic shock is limited to isolated case reports and single institution case series focused on patient outcomes but lacking in detailed approaches to extracorporeal membrane oxygenation management. Unlike medical therapy, in which dosages are either prescribed or carefully titrated to specific variables, extracorporeal membrane oxygenation is a mechanical support therapy requiring ongoing titration but without widely accepted variables to guide treatment. Similar to mechanical ventilation, extracorporeal membrane oxygenation can provide substantial benefit or induce significant harm. The widespread use and present lack of data to guide extracorporeal membrane oxygenation support demands that intensivists adopt a physiologically-based approach to management of the cardiogenic shock patient on extracorporeal membrane oxygenation.
Conclusions:
Extracorporeal membrane oxygenation is a powerful mechanical circulatory support modality capable of rapidly restoring systemic perfusion yet lacking in defined approaches to management. Adopting a management approach based physiologic principles provides a basis for care.
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Causes of Death in Status Epilepticus
Hawkes, Maximiliano A.; English, Stephen W.; Mandrekar, Jay N.; More
Critical Care Medicine. ., Post Author Corrections: June 14, 2019
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Objectives:
To determine the causes of death in patients with status epilepticus. To analyze the relative contributions of seizure etiology, seizure refractoriness, use of mechanical ventilation, anesthetic drugs for seizure control, and medical complications to in-hospital and 90-day mortality, hospital length of stay, and discharge disposition.
Design:
Retrospective cohort.
Setting:
Single-center neuroscience ICU.
Participants:
Patients with status epilepticus were identified by retrospective search of electronic database from January 1, 2011, to December 31, 2016.
Interventions:
Review of electronic medical records.
Measurements and Main Results:
Demographics, clinical characteristics, treatments, and outcomes were collected. Univariable and multivariable logistic regression analysis were used to determine whether the use of anesthetic drugs, mechanical ventilation, Status Epilepticus Severity Score, refractoriness of seizures, etiology of seizures, or medical complications were associated with in-hospital, 90-day mortality or discharge disposition. Among 244 patients with status epilepticus (mean age was 64 yr [interquartile range, 42–76], 55% male, median Status Epilepticus Severity Score 3 [interquartile range, 2–4]), 24 received anesthetic drug infusions for seizure control. In-hospital and 90-day mortality rates were 9.2% and 19.2%, respectively. Death was preceded by withdrawal of life-sustaining treatment in 19 patients (86.3%) and cardiac arrest in three (13.7%). Only Status Epilepticus Severity Score was associated with in-hospital and 90-day mortality, whereas the use of anesthetic drugs for seizure control, mechanical ventilation, medical complications, etiology, and refractoriness of seizures were not. Hospital length of stay was longer in patients with medical complications ( p = 0.0091), refractory seizures ( p = 0.0077), and in those who required anesthetic drugs for seizure control ( p = 0.0035). Patients who had refractory seizures were less likely to be discharged home (odds ratio, 0.295; CI, 0.143–0.608; p = 0.0009).
Conclusions:
In this cohort, death primarily resulted from the underlying neurologic disease and withdrawal of life-sustaining treatment and not from our treatment choices. Use of anesthetic drugs, medical complications, and mechanical ventilation were not associated with in-hospital and 90-day mortality.
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Impact of Critical Care Point-of-Care Ultrasound Short-Courses on Trainee Competence
Rajamani, Arvind; Miu, Michelle; Huang, Stephen; More
Critical Care Medicine. ., Post Author Corrections: June 03, 2019
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Objectives:
Competence in point-of-care ultrasound is recommended/mandated by several critical care specialties. Although doctors commonly attend point-of-care ultrasound short-courses for introductory training, there is little follow-up data on whether they eventually attain competence. This study was done to determine the impact of point-of-care ultrasound short-courses on point-of-care ultrasound competence.
Design:
Web-based survey.
Setting:
Follow-up after point-of-care ultrasound short-courses in the Asia-Pacific region.
Subjects:
Doctors who attended a point-of-care ultrasound short-course between December 2015 and February 2018.
Interventions:
Each subject was emailed a questionnaire on or after 6 months following their short-course. They were asked if they had performed at least 30 structured point-of-care ultrasound scans and/or reached point-of-care ultrasound competence and their perceived reasons/challenges/barriers. They were also asked if they used point-of-care ultrasound as a clinical diagnostic aid.
Measurements and Main Results:
The response rate was 74.9% (182/243). Among the 182 respondents, only 12 (6.6%) had attained competence in their chosen point-of-care ultrasound modality, attributing their success to self-motivation and time management. For the remaining doctors who did not attain competence (170/182, 93.4%), the common reasons were lack of time, change of priorities, and less commonly, difficulties in accessing an ultrasound machine/supervisor. Common suggestions to improve short-courses included requests for scanning practice on acutely ill ICU patients and prior information on the challenges regarding point-of-care ultrasound competence. Suggestions to improve competence pathways included regular supervision and protected learning time. All 12 credentialled doctors regularly used point-of-care ultrasound as a clinical diagnostic aid. Of the 170 noncredentialled doctors, 123 (72.4%) reported performing unsupervised point-of-care ultrasound for clinical management, either sporadically (42/170, 24.7%) or regularly (81/170, 47.7%).
Conclusions:
In this survey of doctors attending point-of-care ultrasound short-courses in Australasia, the majority of doctors did not attain competence. However, the practice of unsupervised point-of-care ultrasound use by noncredentialled doctors was common. Further research into effective strategies to improve point-of-care ultrasound competence is required.
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Individual Airway Closure Characterized In Vivo by Phase-Contrast CT Imaging in Injured Rabbit Lung
Broche, Ludovic; Pisa, Pauline; Porra, Liisa; More
Critical Care Medicine. ., Post Author Corrections: May 31, 2019
Abstract
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Objectives:
Airway closure is involved in adverse effects of mechanical ventilation under both general anesthesia and in acute respiratory distress syndrome patients. However, direct evidence and characterization of individual airway closure is lacking. Here, we studied the same individual peripheral airways in intact lungs of anesthetized and mechanically ventilated rabbits, at baseline and following lung injury, using high-resolution synchrotron phase-contrast CT.
Design:
Laboratory animal investigation.
Setting:
European synchrotron radiation facility.
Subjects:
Six New-Zealand White rabbits.
Interventions:
The animals were anesthetized, paralyzed, and mechanically ventilated in pressure-controlled mode (tidal volume, 6 mL/kg; respiratory rate, 40; FIO 2 , 0.6; inspiratory:expiratory, 1:2; and positive end-expiratory pressure, 3 cm H 2 O) at baseline. Imaging was performed with a 47.5 × 47.5 × 47.5 μm voxel size, at positive end-expiratory pressure 12, 9, 6, 3, and 0 cm H 2 O. The imaging sequence was repeated after lung injury induced by whole-lung lavage and injurious ventilation in four rabbits. Cross-sections of the same individual airways were measured.
Measurements and Main Results:
The airways were measured at baseline ( n = 48; radius, 1.7 to 0.21 mm) and after injury ( n = 32). Closure was observed at 0 cm H 2 O in three of 48 airways (6.3%; radius, 0.35 ± 0.08 mm at positive end-expiratory pressure 12) at baseline and five of 32 (15.6%; radius, 0.28 ± 0.09 mm) airways after injury. Cross-section was significantly reduced at 3 and 0 cm H 2 O, after injury, with a significant relation between the relative change in cross-section and airway radius at 12 cm H 2 O in injured, but not in normal lung ( R = 0.60; p < 0.001).
Conclusions:
Airway collapsibility increases in the injured lung with a significant dependence on airway caliber. We identify “compliant collapse” as the main mechanism of airway closure in initially patent airways, which can occur at more than one site in individual airways.
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Comparison of Automated Activity Recognition to Provider Observations of Patient Mobility in the ICU
Rawat, Nishi; Rao, Vishal; Peven, Michael; More
Critical Care Medicine. ., Post Author Corrections: May 31, 2019
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Objectives:
To compare noninvasive mobility sensor patient motion signature to direct observations by physicians and nurses.
Design:
Prospective, observational study.
Setting:
Academic hospital surgical ICU.
Patients and Measurements:
A total of 2,426 1-minute clips from six ICU patients (development dataset) and 4,824 1-minute clips from five patients (test dataset).
Interventions:
None.
Main Results:
Noninvasive mobility sensor achieved a minute-level accuracy of 94.2% (2,138/2,272) and an hour-level accuracy of 81.4% (70/86).
Conclusions:
The automated noninvasive mobility sensor system represents a significant departure from current manual measurement and reporting used in clinical care, lowering the burden of measurement and documentation on caregivers.
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Clinician Perception of a Machine Learning–Based Early Warning System Designed to Predict Severe Sepsis and Septic Shock
Ginestra, Jennifer C.; Giannini, Heather M.; Schweickert, William D.; More
Critical Care Medicine. ., Post Author Corrections: May 24, 2019
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Objective:
To assess clinician perceptions of a machine learning–based early warning system to predict severe sepsis and septic shock (Early Warning System 2.0).
Design:
Prospective observational study.
Setting:
Tertiary teaching hospital in Philadelphia, PA.
Patients:
Non-ICU admissions November–December 2016.
Interventions:
During a 6-week study period conducted 5 months after Early Warning System 2.0 alert implementation, nurses and providers were surveyed twice about their perceptions of the alert’s helpfulness and impact on care, first within 6 hours of the alert, and again 48 hours after the alert.
Measurements and Main Results:
For the 362 alerts triggered, 180 nurses (50% response rate) and 107 providers (30% response rate) completed the first survey. Of these, 43 nurses (24% response rate) and 44 providers (41% response rate) completed the second survey. Few (24% nurses, 13% providers) identified new clinical findings after responding to the alert. Perceptions of the presence of sepsis at the time of alert were discrepant between nurses (13%) and providers (40%). The majority of clinicians reported no change in perception of the patient’s risk for sepsis (55% nurses, 62% providers). A third of nurses (30%) but few providers (9%) reported the alert changed management. Almost half of nurses (42%) but less than a fifth of providers (16%) found the alert helpful at 6 hours.
Conclusions:
In general, clinical perceptions of Early Warning System 2.0 were poor. Nurses and providers differed in their perceptions of sepsis and alert benefits. These findings highlight the challenges of achieving acceptance of predictive and machine learning–based sepsis alerts.
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Why My Steroid Trials in Septic Shock Were “Positive”?
Critical Care Medicine. ., Post Author Corrections: June 27, 2019
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Limiting Treatment in Intensive Care Contributions and Limits of Ethics Consultation
Critical Care Medicine. ., Post Author Corrections: June 03, 2019
- PAP
Why Understanding Sepsis Endotypes Is Important for Steroid Trials in Septic Shock?
Critical Care Medicine. ., Post Author Corrections: June 03, 2019
- PAP
Why the Adjunctive Corticosteroid Treatment in Critically Ill Patients With Septic Shock (ADRENAL) Trial Did Not Show a Difference in Mortality?
Critical Care Medicine. ., Post Author Corrections: May 29, 2019
- PAP
Current Sepsis Mandates Are Overly Prescriptive, and Some Aspects May Be Harmful
Critical Care Medicine. ., Post Author Corrections: December 04, 2018
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Enteral Nutrition Should Not Be Given to Patients on Vasopressor Agents
Critical Care Medicine. ., Post Author Corrections: August 21, 2018
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