| Determining the Association Between End-of-Life Care Resources and Patient Outcomes in Pennsylvania ICUs Objectives: As ICUs are increasingly a site of end-of-life care, many have adopted end-of-life care resources. We sought to determine the association of such resources with outcomes of ICU patients. Design: Retrospective cohort study. Setting: Pennsylvania ICUs. Patients: Medicare fee-for-service beneficiaries. Interventions: Availability of any of one hospital-based resource ( palliative care consultants) or four ICU-based resources ( protocol for withdrawal of life-sustaining therapy, triggers for automated palliative care consultation, protocol for family meetings, and palliative care clinicians embedded in ICU rounds). Measurements and Main Results: In mixed-effects regression analyses, admission to a hospital with end-of-life resources was not associated with mortality, length of stay, or treatment intensity (mechanical ventilation, hemodialysis, tracheostomy, gastrostomy, artificial nutrition, or cardiopulmonary resuscitation); however, it was associated with a higher likelihood of discharge to hospice (odds ratio, 1.58; 95% CI, 1.11–2.24), an effect that was driven by ICU-based resources (odds ratio, 1.37; 95% CI, 1.04–1.81) rather than hospital-based resources (odds ratio, 1.19; 95% CI, 0.83–1.71). Instrumental variable analysis using differential distance (defined as the additional travel distance beyond the hospital closest to a patient’s home needed to reach a hospital with end-of-life resources) demonstrated that among those for whom differential distance would influence receipt of end-of-life resources, admission to a hospital with such resources was not associated with any outcome. Conclusions: ICU-based end-of-life care resources do not appear to change mortality but are associated with increased hospice utilization. Given that this finding was not confirmed by the instrumental variable analysis, future studies should attempt to verify this finding, and identify specific resources or processes of care that impact the care of ICU patients at the end of life. This work was performed at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Dr. Ashana’s institution received funding from the National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute (NHLBI) T32 HL007891. Drs. Ashana, Kohn, Madden, Harhay, and Kerlin received support for article research from the NIH. Dr. Umscheid’s institution received funding from Agency for Healthcare Research and Quality Evidence-based Practice Center contracts and the U.S. Food and Drug Administration, and he received funding from the Patient-Centered Outcomes Research Institute Advisory Panel. Dr. Stephens-Shields received funding from Juniper Pharmaceuticals, October 2016 to March 2017. Dr. Harhay’s institution received funding from the NIH/NHLBI K99 HL141678. Dr. Kerlin’s institution received funding from the NIH/NHLBI K08 HL116771. Dr. Chen disclosed that he does not have any potential conflicts of interest. For information regarding this article, E-mail: deepshikha.ashana@uphs.upenn.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. |
| Epidemiology and Outcome of Critically Ill Pediatric Cancer and Hematopoietic Stem Cell Transplant Patients Requiring Continuous Renal Replacement Therapy: A Retrospective Nationwide Cohort Study Objective: Acute kidney injury requiring continuous renal replacement therapy is a serious treatment-related complication in pediatric cancer and hematopoietic stem cell transplant patients. The purpose of this study was to assess epidemiology and outcome of these patients requiring continuous renal replacement therapy in the PICU. Design: A nationwide, multicenter, retrospective, observational study. Setting: Eight PICUs of a tertiary care hospitals in the Netherlands. Patients: Pediatric cancer and hematopoietic stem cell transplant patients (cancer and noncancer) who received continuous renal replacement therapy from January 2006 to July 2017 in the Netherlands. Interventions: None. Measurement and Main Results: Of 1,927 PICU admissions of pediatric cancer and hematopoietic stem cell transplant patients, 68 of 70 evaluable patients who received continuous renal replacement therapy were included. Raw PICU mortality was 11.2% (216/1,972 admissions). PICU mortality of patients requiring continuous renal replacement therapy was 54.4% (37/68 patients). Fluid overload (odds ratio, 1.08; 95% CI, 1.01–1.17) and need for inotropic support (odds ratio, 6.53; 95% CI, 1.86–23.08) at the start of continuous renal replacement therapy were associated with PICU mortality. Serum creatinine levels increased above 150% of baseline 3 days before the start of continuous renal replacement therapy. Urine production did not reach the critical limit of oliguria. In contrast, body weight (fluid overload) increased already 5 days prior to continuous renal replacement therapy initiation. Conclusions: PICU mortality of pediatric cancer and hematopoietic stem cell transplant patients requiring continuous renal replacement therapy is sadly high. Fluid overload at the initiation of continuous renal replacement therapy is the most important and earliest predictor of PICU mortality. Our results suggest that the most commonly used criteria of acute kidney injury, that is, serum creatinine and urine production, are not useful as a trigger to initiate continuous renal replacement therapy. This highlights the urgent need for prospective studies to generate recommendations for effective therapeutic interventions at an early phase in this specific patient population. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: p.a.m.a.raymakers-janssen@umcutrecht.nl 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. Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. |
| Nonpharmacologic Interventions to Prevent or Mitigate Adverse Long-Term Outcomes Among ICU Survivors: A Systematic Review and Meta-analysis Objective: ICU survivors suffer from long-lasting physical, mental, and cognitive health impairments, also called “postintensive care syndrome”. However, an overview of the effectiveness of interventions to prevent or mitigate these impairments is lacking. The aim of this study is to assess the effectiveness of nonpharmacologic interventions. Data Sources: PubMed, CINAHL, PsycINFO, Embase, and Cochrane Library were systematically searched from inception until July 19, 2018. Study Selection: (Non)randomized clinical trials, controlled before-after studies, and interrupted time series were included. Outcomes of interest included patients physical, mental and cognitive outcomes, quality of life, and outcomes such as social functioning and functional status, measured after hospital discharge. Data Extraction: Two independent reviewers selected studies, extracted data, and assessed the risk of bias. Pooled mean differences and standardized mean differences were calculated using random-effect meta-analyses. Data Synthesis: After screening 17,008 articles, 36 studies, including 10 pilot studies, were included (n = 5,165 ICU patients). Interventions were subdivided into six categories: 1) exercise and physical rehabilitation programs; 2) follow-up services; 3) psychosocial programs; 4) diaries; 5) information and education; and 6) other interventions. Many outcomes favored the interventions, but significant differences were only found for diaries in reducing depression (two studies, n = 88; standardized mean difference, 0.68; 95% CI, 0.14–1.21) and anxiety (two studies, n = 88; standardized mean difference, 0.44; 95% CI, 0.01–0.87) and exercise programs in improving the Short Form Health Survey-36 Mental Component Score (seven studies, n = 664; mean difference, 2.62; 95% CI, 0.92–4.32). Conclusions: There is thin evidence that diaries and exercise programs have a positive effective on mental outcomes. Despite outcomes favoring the intervention group, other commonly used nonpharmacologic interventions in daily ICU practice are not supported by conclusive evidence from this meta-analysis. To improve recovery programs for ICU survivors, more evidence is needed from robust intervention studies using standardized outcomes. Registration: International prospective register of systematic reviews (PROSPERO) NCT01738620. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: wytske.geense@radboudumc.nl Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. |
| Global and Regional Diagnostic Accuracy of Lung Ultrasound Compared to CT in Patients With Acute Respiratory Distress Syndrome Objectives: Lung CT is the reference imaging technique for acute respiratory distress syndrome, but requires transportation outside the intensive care and x-ray exposure. Lung ultrasound is a promising, inexpensive, radiation-free, tool for bedside imaging. Aim of the present study was to compare the global and regional diagnostic accuracy of lung ultrasound and CT scan. Design: A prospective, observational study. Setting: Intensive care and radiology departments of a University hospital. Patients: Thirty-two sedated, paralyzed acute respiratory distress syndrome patients (age 65 ± 14 yr, body mass index 25.9 ± 6.5 kg/m2, and PaO2/FIO2 139 ± 47). Interventions: Lung CT scan and lung ultrasound were performed at positive end-expiratory pressure 5 cm H2O. A standardized assessment of six regions per hemithorax was used; each region was classified for the presence of normal aeration, alveolar-interstitial syndrome, consolidation, and pleural effusion. Agreement between the two techniques was calculated, and diagnostic variables were assessed for lung ultrasound using lung CT as a reference. Measurements and Main Results: Global agreement between lung ultrasound and CT ranged from 0.640 (0.391–0.889) to 0.934 (0.605–1.000) and was on average 0.775 (0.577–0.973). The overall sensitivity and specificity of lung ultrasound ranged from 82.7% to 92.3% and from 90.2% to 98.6%, respectively. Similar results were found with regional analysis. The diagnostic accuracy of lung ultrasound was significantly higher when those patterns not reaching the pleural surface were excluded (area under the receiver operating characteristic curve: alveolar-interstitial syndrome 0.854 [0.821–0.887] vs 0.903 [0.852–0.954]; p = 0.049 and consolidation 0.851 [0.818–0.884] vs 0.896 [0.862–0.929]; p = 0.044). Conclusions: Lung ultrasound is a reproducible, sensitive, and specific tool, which allows for bedside detections of the morphologic patterns in acute respiratory distress syndrome. The presence of deep lung alterations may impact the diagnostic performance of this technique. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: chiumello@libero.it Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. |
| Quantifiable Bleeding in Children Supported by Extracorporeal Membrane Oxygenation and Outcome Objectives: To evaluate the association between bleeding from chest tubes and clinical outcomes in children supported by extracorporeal membrane oxygenation. Design: Secondary analysis of a large observational cohort study. Setting: Eight pediatric institutions within the Eunice Kennedy Shriver National Institute of Child Health and Human Development’s Collaborative Pediatric Critical Care Research Network. Patients: Critically ill children supported by extracorporeal membrane oxygenation. Interventions: None. Measurements and Main Results: Daily chest tube bleeding, results from hemostatic assays, transfusion volumes, 90-day PICU-free days, and mortality were collected prospectively by trained bedside extracorporeal membrane oxygenation specialists and research coordinators. Extracorporeal membrane oxygenation was employed in the care of 514 consecutive patients. Sixty percent of patients had at least one episode of chest tube bleeding (median chest tube blood volume over the entire extracorporeal membrane oxygenation course was 123 mL/kg [interquartile range, 47–319 mL/kg]). Twenty-six percent had at least 1 day of bleeding from the chest tube greater than 100 mL/kg/d. The number of days with chest tube bleeding greater than 60 mL/kg/d was independently associated with increased in-hospital mortality (adjusted odds ratio, 1.43; 95% CI, 1.05–1.97; p = 0.02) and decreased PICU-free days (beta coefficient, –4.2; 95% CI, –7.7 to –0.6; p = 0.02). The total amount of bleeding from chest tube were independently associated with increased mortality (per mL/kg/extracorporeal membrane oxygenation run; adjusted odds ratio, 1.002; 95% CI, 1.000–1.003; p = 0.04). Fibrinogen, weight, indication for extracorporeal membrane oxygenation, and need for hemodialysis were independently associated with chest tube bleeding, whereas platelet count, coagulation tests, heparin dose, and thrombotic events were not. Conclusions: In children supported by extracorporeal membrane oxygenation, chest tube bleeding above 60 mL/kg/d was independently associated with worse clinical outcome. Low fibrinogen was independently associated with chest tube bleeding, whereas platelet count and hemostatic tests were not. Further research is needed to evaluate if interventions to prevent or stop chest tube bleeding influence the clinical outcome. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). The Collaborative Pediatric Critical Care Research Network was funded by the National Institute of Child Health and Human Development (NICHD). This article does not necessarily reflect the opinions or views of the Bleeding and Thrombosis During Extracorporeal Membrane Oxygenation Investigators or the NICHD. Dr. Dalton received funding from Innovative Extracorporeal Membrane Oxygenation Concepts, and she received support for article research from the National Institutes of Health. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: man9026@med.cornell.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. |
| RBC Transfusion Strategies in the ICU: A Concise Review Objectives: To critically assess available high-level clinical studies regarding RBC transfusion strategies, with a focus on hemoglobin transfusion thresholds in the ICU. Data Sources: Source data were obtained from a PubMed literature review. Study Selection: English language studies addressing RBC transfusions in the ICU with a focus on the most recent relevant studies. Data Extraction: Relevant studies were reviewed and the following aspects of each study were identified, abstracted, and analyzed: study design, methods, results, and implications for critical care practice. Data Synthesis: Approximately 30–50% of ICU patients receive a transfusion during their hospitalization with anemia being the indication for 75% of transfusions. A significant body of clinical research evidence supports using a restrictive transfusion strategy (e.g., hemoglobin threshold < 7 g/dL) compared with a more liberal approach (e.g., hemoglobin threshold < 10 g/dL). A restrictive strategy (hemoglobin < 7 g/dL) is recommended in patients with sepsis and gastrointestinal bleeds. A slightly higher restrictive threshold is recommended in cardiac surgery (hemoglobin < 7.5 g/dL) and stable cardiovascular disease (hemoglobin < 8 g/dL). Although restrictive strategies are generally supported in hematologic malignancies, acute neurologic injury, and burns, more definitive studies are needed, including acute coronary syndrome. Massive transfusion protocols are the mainstay of treatment for hemorrhagic shock; however, the exact RBC to fresh frozen plasma ratio is still unclear. There are also emerging complimentary practices including nontransfusion strategies to avoid and treat anemia and the reemergence of whole blood transfusion. Conclusions: The current literature supports the use of restrictive transfusion strategies in the majority of critically ill populations. Continued studies of optimal transfusion strategies in various patient populations, coupled with the integration of novel complementary ICU practices, will continue to enhance our ability to treat critically ill patients. New affiliation for Dr. Murphy: Division of Pulmonary Diseases and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA. Drs. Cable and Murphy received support for article research from the National Institutes of Health (NIH). Dr. Cable’s institution received funding from NIH/National Institute of General Medical Sciences T32 GM-095442. Dr. Roback’s institution received funding from the NIH and Zipline Medical, and he received funding from CSL Plasma and Castle Medical. Dr. Murphy’s institution received funding from the NIH. Dr. Razavi disclosed that he does not have any potential conflicts of interest. For information regarding this article, E-mail: david.j.murphy@emory.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. |
| Enteral Nutrition Can Be Given to Patients on Vasopressors No abstract available |
| Nurse Practitioners and Physician Assistants in Acute and Critical Care: A Concise Review of the Literature and Data 2008–2018 Objectives: To provide a concise review of the literature and data pertaining to the use of nurse practitioners and physician assistants, collectively called advanced practice providers, in ICU and acute care settings. Data Sources: Detailed search strategy using the databases PubMed, Ovid MEDLINE, and the Cumulative Index of Nursing and Allied Health Literature for the time period from January 2008 to December 2018. Study Selection: Studies addressing nurse practitioner, physician assistant, or advanced practice provider care in the ICU or acute care setting. Data Extraction: Relevant studies were reviewed, and the following aspects of each study were identified, abstracted, and analyzed: study population, study design, study aims, methods, results, and relevant implications for critical care practice. Data Synthesis: Five systematic reviews, four literature reviews, and 44 individual studies were identified, reviewed, and critiqued. Of the research studies, the majority were retrospective with others being observational, quasi-experimental, or quality improvement, along with two randomized control trials. Overall, the studies assessed a variety of effects of advanced practice provider care, including on length of stay, mortality, and quality-related metrics, with a majority demonstrating similar or improved patient care outcomes. Conclusions: Over the past 10 years, the number of studies assessing the impact of advanced practice providers in acute and critical care settings continue to increase. Collectively, these studies identify the value of advanced practice providers in patient care management, continuity of care, improved quality and safety metrics, patient and staff satisfaction, and on new areas of focus including enhanced educational experience of residents and fellows. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Dr. Kleinpell received funding from the Society of Critical Care Medicine (SCCM) (past 2017 president). Dr. Constantine disclosed that he was on the Board of the Council of Surgical and Perioperative Safety and chaired the safety committee for the Surgery Section of the SCCM and the SCCM Advanced Practice Provider Resource Committee. The remaining authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Ruth M. Kleinpell, PhD, RN, Vanderbilt University School of Nursing, 461 21st Avenue, South 407 GH, Nashville, TN 37240. E-mail: ruth.kleinpell@vanderbilt.edu 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. Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. |
| National Trends in Timing of Death Among Patients With Septic Shock, 1994–2014 Objectives: To assess trends in timing of mortality among patients with septic shock. Design: Retrospective cohort study. Setting: Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project’s National Inpatient Sample, 1994–2014. Patients: Hospitalized adults (≥ 18 yr) with International Classification of Diseases, 9th Edition, Clinical Modification codes consistent with septic shock; secondary analysis: adults with International Classification of Diseases, 9th Edition, Clinical Modification codes consistent with acute respiratory failure receiving invasive mechanical ventilation and patients with both septic shock and acute respiratory failure receiving invasive mechanical ventilation. Interventions: None. Measurements and Main Results: From 1994 to 2014, 48-hour mortality rates decreased among patients with septic shock (21.2% to 10.8%) and septic shock with acute respiratory failure receiving invasive mechanical ventilation (19.1% to 13.4%) but increased among patients with acute respiratory failure receiving invasive mechanical ventilation (7.9% to 9.8%; p value for all trends, < 0.001). Three-to-14-day mortality decreased among patients with septic shock (22.1% to 15.5%), septic shock with acute respiratory failure receiving invasive mechanical ventilation (28.7% to 22.4%) and acute respiratory failure receiving invasive mechanical ventilation (16.8% to 15.0%; p value for all trends, < 0.001). Mortality after 14 days decreased among all groups (septic shock: 12.6% to 6.7%; septic shock with acute respiratory failure receiving invasive mechanical ventilation: 20.3% to 11.3%; and acute respiratory failure receiving invasive mechanical ventilation: 12.7% to 5.8%; p value for all trends, < 0.001). Cox proportional hazard ratio for declining risk in mortality per year (adjusted for patient and hospital characteristics) was 0.96 (95% CI, 0.96–0.96) for septic shock, 0.97 (0.97–0.97) for acute respiratory failure receiving invasive mechanical ventilation and septic shock, and 0.99 (0.99–0.99) for acute respiratory failure receiving invasive mechanical ventilation. Conclusions: Septic shock 48-hour, 3–14-day and greater than 14-day mortality declined markedly over two decades; in contrast, patients with acute respiratory failure only experienced marked decreases in greater than 14-day in-hospital mortality rates. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Dr. Law received funding from National Institutes of Health (NIH)/National Institute on Aging (1F32AG058352). Dr. Stevens received funding from Agency for Healthcare Research and Quality (5K08HS024288) and Doris Duke Charitable Foundation. Dr. Walkey received funding from NIH/National Heart, Lung, and Blood Institute (1R01HL136660 and 1R01HL139751) and Boston University School of Medicine Department of Medicine Career Investment Award. For information regarding this article, E-mail: alaw1@bidmc.harvard.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. |
| Antibiotic Exposure Profiles in Trials Comparing Intensity of Continuous Renal Replacement Therapy Objectives: To determine whether the probability of target attainment over 72 hours of initial therapy with beta-lactam (cefepime, ceftazidime, piperacillin/tazobactam) and carbapenem (imipenem, meropenem) antibiotics were substantially influenced between intensive and less-intensive continuous renal replacement therapy groups in the Acute Renal Failure Trial Network trial and The RENAL Replacement Therapy Study trial. Design: The probability of target attainment was calculated using pharmacodynamic targets of percentage of time that free serum concentrations (fT): 1) were above the target organism’s minimum inhibitory concentration (≥ fT > 1 × minimum inhibitory concentration); 2) were above four times the minimum inhibitory concentration (≥ % fT > 4 × minimum inhibitory concentration); and 3) were always above the minimum inhibitory concentration (≥ 100% fT > minimum inhibitory concentration) for the first 72 hours of antibiotic therapy. Demographic data and effluent rates from the Acute Renal Failure Trial Network and RENAL Replacement Therapy Study trials were used. Optimal doses were defined as the dose achieving greater than or equal to 90% probability of target attainment. Setting: Monte Carlo simulations using demographic data from Acute Renal Failure Trial Network and RENAL Replacement Therapy Study trials. Patients: Virtual critically ill patients requiring continuous renal replacement therapy. Interventions: None. Measurements and Main Results: The pharmacodynamic target of fT greater than 1 × minimum inhibitory concentration led to similarly high rates of predicted response with antibiotic doses often used in continuous renal replacement therapy. Achieving 100% fT greater than minimum inhibitory concentration is a more stringent benchmark compared with T greater than 4 × minimum inhibitory concentration with standard antibiotic dosing. The intensity of effluent flow rates (less intensive vs intensive) did not substantially influence the probability of target attainment of antibiotic dosing regimens regardless of pharmacodynamic target. Conclusions: Antibiotic pharmacodynamic target attainment rates likely were not meaningfully different in the low- and high-intensity treatment arms of the Acute Renal Failure Trial Network and RENAL Replacement Therapy Study Investigators trials. This work was performed at University of Michigan College of Pharmacy, Ann Arbor, MI. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: muellerb@umich.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. |
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