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Clinical practice guidelines: Red blood cell transfusion in adult trauma and critical care: Erratum
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No abstract available
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Intensive care unit quality improvement: A "how-to" guide for the interdisciplinary team *
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Objective: Quality improvement is an important activity for all members of the interdisciplinary critical care team. Although an increasing number of resources are available to guide clinicians, quality improvement activities can be overwhelming. Therefore, the Society of Critical Care Medicine charged this Outcomes Task Force with creating a "how-to" guide that focuses on critical care, summarizes key concepts, and outlines a practical approach to the development, implementation, evaluation, and maintenance of an interdisciplinary quality improvement program in the intensive care unit.
Data Sources and Methods: The task force met in person twice and by conference call twice to write this document. We also conducted a literature search on "quality improvement" and "critical care or intensive care" and searched online for additional resources.
Data Synthesis and Overview: We present an overview of quality improvement in the intensive care unit setting and then describe the following steps for initiating or improving an interdisciplinary critical care quality improvement program: a) identify local motivation, support teamwork, and develop strong leadership; b) prioritize potential projects and choose the first target; c) operationalize the measures, build support for the project, and develop a business plan; d) perform an environmental scan to better understand the problem, potential barriers, opportunities, and resources for the project; e) create a data collection system that accurately measures baseline performance and future improvements; f) create a data reporting system that allows clinicians and others to understand the problem; g) introduce effective strategies to change clinician behavior. In addition, we identify four steps for evaluating and maintaining this program: a) determine whether the target is changing with periodic data collection; b) modify behavior change strategies to improve or sustain improvements; c) focus on interdisciplinary collaboration; and d) develop and sustain support from the hospital leadership. We also identify a number of online resources to complement this overview.
Conclusions: This Society of Critical Care Medicine Task Force report provides an overview for clinicians interested in developing or improving a quality improvement program using a step-wise approach. Success depends not only on committed interdisciplinary work that is incremental and continuous but also on strong leadership. Further research is needed to refine the methods and identify the most cost-effective means of improving the quality of health care received by critically ill patients and their families.
(C) 2006 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Ventilator management for hypoxemic respiratory failure attributable to H1N1 novel swine origin influenza virus
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Novel H1N1 swine origin influenza virus has led to a worldwide pandemic. During the pandemic, a significant number of patients became critically ill primarily because of respiratory failure. Most of these patients required intubation and mechanical ventilation and were treated with conventional modes of mechanical ventilation using a lung-protective strategy with low tidal volumes, plateau pressures <30 to 35 cm H2O, and optimal positive end-expiratory pressure. In some patients with persistent hypoxemia, alternative modes of ventilation, such as high-frequency oscillatory ventilation and airway pressure release ventilation, were used. We review the ventilatory management, recruitment maneuvers, prone positioning, and goals of ventilatory therapy for hypoxemic respiratory failure in general, as well as lessons learned in the management of H1N1-related respiratory failure.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Influenza epidemiology-past, present, and future
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In April 2009, Mexican, American, and Canadian authorities announced that a novel influenza virus with pandemic potential had been identified in large segments of the population. Within weeks, it became apparent that the world was dealing with the first influenza pandemic in >40 yrs. Despite the unpredictable nature of influenza severity and spread in the pandemics of the 20th century, understanding the epidemiology of the past pandemics and current influenza pandemic will help prepare physicians, hospitals, and governments to predict and prepare for the subsequent waves and subsequent pandemics. We present a summary of the biology that predisposes influenza to cause sudden pandemics, as well as a summary of the epidemiology of the 20th century pandemics. We also report on the epidemiology, disease severity, and risk factors for severe disease and intensive care admission from the first wave of the current pandemic (April-August 2009). Last, we provide a mathematical model based on transmission dynamics of the H1N1 influenza virus that may provide some guidance in terms of disease incidence and hospital impact.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Delirium as a predictor of long-term cognitive impairment in survivors of critical illness
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Objective: To test the hypothesis that duration of delirium in the intensive care unit is an independent predictor of long-term cognitive impairment after critical illness requiring mechanical ventilation.
Design: Prospective cohort study.
Setting: Medical intensive care unit in a large community hospital in the United States.
Patients: Mechanically ventilated medical intensive care unit patients who were assessed daily for delirium while in the intensive care unit and who underwent comprehensive cognitive assessments 3 and 12 mos after discharge.
Measurements and Main Results: Of 126 eligible patients, 99 survived >=3 months after critical illness; long-term cognitive outcomes were obtained for 77 (78%) patients. Median age was 61 yrs, 51% were admitted with sepsis/acute respiratory distress syndrome, and median duration of delirium was 2 days. At 3-mo and 12-mo follow-up, 79% and 71% of survivors had cognitive impairment, respectively (with 62% and 36% being severely impaired). After adjusting for age, education, preexisting cognitive function, severity of illness, severe sepsis, and exposure to sedative medications in the intensive care unit, increasing duration of delirium was an independent predictor of worse cognitive performance-determined by averaging age-adjusted and education-adjusted T-scores from nine tests measuring seven domains of cognition-at 3-mo (p = .02) and 12-mo follow-up (p = .03). Duration of mechanical ventilation, alternatively, was not associated with long-term cognitive impairment (p = .20 and .58).
Conclusions: In this study of mechanically ventilated medical intensive care unit patients, duration of delirium (which is potentially modifiable) was independently associated with long-term cognitive impairment, a common public health problem among intensive care unit survivors. (Crit Care Med 2010; 38:1513-1520
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Laboratory diagnosis of 2009 H1N1 influenza A virus
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The emergence of 2009 pandemic influenza H1N1 has necessarily led to the rapid evolution of sensitive, specific, and high-throughput molecular diagnostic assays for this virus at the same time that clinical laboratories attempt to cope with increasing demands in the setting of resource limitations. This situation has given rise to testing algorithms focusing on priority, clinical relevance, and appropriate surveillance. We describe the current state of understanding around diagnostic testing and laboratory detection of 2009 H1N1 influenza A virus.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Therapeutic strategies for severe acute lung injury
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Objective: In the management of patients with severe acute lung injury and acute respiratory distress syndrome, clinicians are sometimes challenged to maintain acceptable gas exchange while avoiding harmful mechanical ventilation practices. In some of these patients, physicians may consider the use of "rescue therapies" to sustain life. Our goal is to provide a practical, evidence-based review to assist critical care physicians' care for patients with severe acute lung injury and acute respiratory distress syndrome.
Data Sources: We searched the PubMed database for clinical trials that examined the use of the following therapies in severe acute lung injury and acute respiratory distress syndrome: recruitment maneuvers, high positive end-expiratory pressure, prone position, high-frequency oscillatory ventilation, glucocorticoids, inhaled nitric oxide, buffer therapy, and extracorporeal life support.
Study Selection: All clinical trials that included patients with severe acute lung injury and acute respiratory distress syndrome were included in the review.
Data Synthesis: The primary author reviewed the aforementioned trials in depth and then disputed findings and conclusions with the other authors until consensus was achieved.
Conclusions: This article is designed to provide clinicians with a simple bedside definition for the diagnosis of severe acute respiratory distress syndrome; to describe several therapies that can be used for severe acute respiratory distress syndrome with an emphasis on the potential risks and the indications and benefits; and to offer practical guidelines for implementation of these therapies.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Clinical research ethics for critically ill patients: A pandemic proposal
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Pandemic H1N1 influenza is projected to be unprecedented in its scope, causing acute critical illness among thousands of young otherwise healthy adults, who will need advanced life support. Rigorous, relevant, timely, and ethical clinical and health services research is crucial to improve their care and outcomes. Studies designed and conducted during a pandemic should be held to the same high methodologic and implementation standards as during other times. However, unique challenges arise with the need to conduct investigations as efficiently as possible, focused on the optimal outcome for the individual patient, while balancing the need for maximal societal benefit. We believe that clinical critical care research during a pandemic must be approached differently from research undertaken under nonemergent circumstances. We propose recommendations to clinical investigators and research ethics committees regarding clinical and health services research on pandemic-related critical illness. We also propose strategies such as expedited and centralized research ethics committee reviews and alternate consent models.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Nursing implications for prevention of adverse drug events in the intensive care unit: Erratum
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No abstract available
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Complications of seasonal and pandemic influenza
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Influenza is a seasonal viral infection associated with significant morbidity and mortality. In 2009, a novel H1N1 influenza A virus emerged and has been classified as a pandemic. In contrast to seasonal influenza, severe disease from pandemic H1N1 seems concentrated in older children and young adults, with almost no cases reported in patients older than 60 yrs. Although patients with underlying cardiopulmonary disease remain at risk, most complications have occurred among previously healthy individuals, with obesity and respiratory disease as the strongest risk factors. Pulmonary complications are common. Primary influenza pneumonia occurs most commonly in adults and may progress rapidly to acute lung injury requiring mechanical ventilation. Secondary bacterial infection is more common in children. Staphylococcus aureus, including methicillin-resistant strains, is an important cause of secondary bacterial pneumonia with a high mortality rate. Treatment of pneumonia should include empirical coverage for this pathogen. Neuromuscular and cardiac complications are unusual but may occur.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Nurse staffing and patient outcomes in critical care: A concise review
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Background: Studies over the past several decades have shown an association between nurse staffing and patient outcomes. Most of those studies were generated from general acute care units. Critically ill patients demand increased nurse staffing resources and nurses who have specialized knowledge and skills. Appropriate nurse staffing in critical care units may improve the quality of care of critically ill patients.
Objectives: To review the literature evaluating the association of nurse staffing with patient outcomes in critical care units and populations.
Methods: An annotated review of major nursing and medical literature from 1998 to 2008 was performed to find research studies conducted in intensive care units or critical care populations where nurse staffing and patient outcomes were addressed.
Results: Twenty-six studies met inclusion for this review. Most were observational studies in which outcomes were retrieved from existing large databases. There was variation in the measurement of nurse staffing and outcomes. Outcomes most frequently studied were infections, mortality, postoperative complications, and unplanned extubation. Most studies suggested that decreased nurse staffing is associated with adverse outcomes in intensive care unit patients.
Conclusions: Findings from this review demonstrate an association of nurse staffing in the intensive care unit with patient outcomes and are consistent with findings in studies of the general acute care population. A better understanding of nurse staffing needs for intensive care unit patients is important to key stakeholders when making decisions about provision of nurse resources. Additional research is necessary to demonstrate the optimal nurse staffing ratios of intensive care units.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Different assessment tools for intensive care unit delirium: Which score to use?: Erratum
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No abstract available
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The 1918 influenza pandemic: Lessons for 2009 and the future
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The 1918 to 1919 H1N1 influenza pandemic is among the most deadly events in recorded human history, having killed an estimated 50 to 100 million persons. Recent H5N1 avian influenza epizootics associated with sporadic human fatalities have heightened concern that a new influenza pandemic, one at least as lethal as that of 1918, could be developing. In early 2009, a novel pandemic H1N1 influenza virus appeared, but it has not exhibited unusually high pathogenicity. Nevertheless, because this virus spreads globally, some scientists predict that mutations will increase its lethality. Therefore, to accurately predict, plan, and respond to current and future influenza pandemics, we must first better-understand the events and experiences of 1918.
Although the entire genome of the 1918 influenza virus has been sequenced, many questions about the pandemic it caused remain unanswered. In this review, we discuss the origin of the 1918 pandemic influenza virus, the pandemic's unusual epidemiologic features and the causes and demographic patterns of fatality, and how this information should impact our response to the current 2009 H1N1 pandemic and future pandemics. After 92 yrs of research, fundamental questions about influenza pandemics remain unanswered. Thus, we must remain vigilant and use the knowledge we have gained from 1918 and other influenza pandemics to direct targeted research and pandemic influenza preparedness planning, emphasizing prevention, containment, and treatment.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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H1N1 novel influenza A in pregnant and immunocompromised patients
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Objective: To describe the increased risk of severe disease and the appropriate management of patients at high risk such as pregnant women and immunosuppressed patients who acquire novel influenza A (H1N1).
Design: Review of the literature regarding influenza A in these patient groups, and review of published and unpublished data with regard to novel influenza A (H1N1).
Main Results: Pregnant women are at increased risk for severe pneumonitis and respiratory failure from influenza infection, particularly during pandemics, including the current pandemic. Fetal morbidity is significant, usually resulting from maternal fever and severe hypoxemia. Early antiviral therapy using oseltamivir may be beneficial, and intensive care unit support should target adequate oxygenation at all times. Immunosuppressed patients are at increased risk for influenza, as well as at risk for more severe or prolonged infection. Patients after hematopoietic stem cell transplantation, after lung transplantation, and those receiving chemotherapy for leukemia are at highest risk, whereas the risk for human immunodeficiency virus-infected individuals appears relatively low. Treatment with antiviral therapy may be beneficial, even after the usual cut-off of 48 hrs after symptom onset.
Conclusions: Optimal management of these patients is preventive by influenza vaccination, but the neuraminidase inhibitor antiviral agents provide effective treatment.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Influenza pathogenesis: Lessons learned from animal studies with H5N1, H1N1 Spanish, and pandemic H1N1 2009 influenza
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Because cases of highly pathogenic influenza are rare, no systematic clinical studies have evaluated different therapeutic approaches. Instead, treatment recommendations are aimed at the alleviation of clinical signs and symptoms, especially the restoration of respiratory function, and at the inhibition of virus replication, assuming viral load is responsible for disease phenotype. Studies of highly pathogenic influenza in different animal models, especially nonhuman primates and ferrets, reproduce many of the key observations from clinical cases. Host-response kinetics reveal a delayed but broad activation of genes involved in the innate and acquired immune responses (innate responses produce inflammatory responses), which continue after the virus has been cleared and may contribute importantly to the clinical signs observed.
Experimental animal models point to an important role for immune dysregulation in the pathogenesis of highly pathogenic influenza. The use of these models to develop and validate therapeutic approaches is just beginning, but published studies reveal the importance of early treatment with antivirals and show the potential and limitations of approaches aimed at the host response.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Nonventilatory strategies for patients with life-threatening 2009 H1N1 influenza and severe respiratory failure
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Severe respiratory failure (including acute lung injury and acute respiratory distress syndrome) caused by 2009 H1N1 influenza infection has been reported worldwide. Refractory hypoxemia is a common finding in these patients and can be challenging to manage. This review focuses on nonventilatory strategies in the advanced treatment of severe respiratory failure and refractory hypoxemia such as that seen in patients with severe acute respiratory distress syndrome attributable to 2009 H1N1 influenza. Specific modalities covered include conservative fluid management, prone positioning, inhaled nitric oxide, inhaled vasodilatory prostaglandins, and extracorporeal membrane oxygenation and life support. Pharmacologic strategies (including steroids) investigated for the treatment of severe respiratory failure are also reviewed.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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A history of resolving conflicts over end-of-life care in intensive care units in the United States *
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Objectives: To present a case of conflict over end-of-life care in the intensive care unit (ICU) and to describe how such conflicts have been resolved in the United States since the inception of ICUs.
Data Sources: A nonsystematically derived sample of published studies and professional and lay commentaries on end-of-life care, ethical principles, medical decision-making, medical futility, and especially conflict resolution in the ICU.
Study Selection: Some of those studies and commentaries dealing specifically with conflicts over end-of-life care in the ICU and their resolution.
Data Synthesis: An historical review of conflict resolution over end-of-life issues in U.S. ICUs.
Results and Conclusions: Conflict at the end of life in ICUs in the United States is relatively rare because most families and physicians agree about how patients should be treated. Nevertheless, conflict still exists over some patients whose families insist on care that physicians consider inappropriate and hence inadvisable, and over other patients whose families object to care that physicians prefer to provide. When such conflict occurs, mediation between families and physicians is usually successful in resolving it. Consultation from ethics committees also may be helpful in achieving resolution, and one state actually allows such committees to adjudicate disputes. Physicians who act unilaterally against family wishes run the risk of malpractice suits, although such suits usually are unsuccessful because the physicians are not shown to have violated standards of care.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Early observational research and registries during the 2009-2010 influenza A pandemic
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As a critical care community, we have an obligation to provide not only clinical care but also the research that guides initial and subsequent clinical responses during a pandemic. There are many challenges to conducting such research. The first is speed of response. However, given the near inevitability of certain events, for example, viral respiratory illness such as the 2009 pandemic, geographically circumscribed natural disasters, or acts of terror, many study and trial designs should be preplanned and modified quickly when specific events occur. Template case report forms should be available for modification and web entry; centralized research ethics boards and funders should have the opportunity to preview and advise on such research beforehand; and national and international research groups should be prepared to work together on common studies and trials for common challenges. We describe the early international critical care research response to the influenza A 2009 (H1N1) pandemic, including specifics of observational study case report form, registry, and clinical trial design, cooperation of international critical care research organizations, and the early results of these collaborations.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Mechanisms of action, physiological effects, and complications of hypothermia
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Background: Mild to moderate hypothermia (32-35[degrees]C) is the first treatment with proven efficacy for postischemic neurological injury. In recent years important insights have been gained into the mechanisms underlying hypothermia's protective effects; in addition, physiological and pathophysiological changes associated with cooling have become better understood.
Objective: To discuss hypothermia's mechanisms of action, to review (patho)physiological changes associated with cooling, and to discuss potential side effects.
Design: Review article.
Interventions: None.
Main Results: A myriad of destructive processes unfold in injured tissue following ischemia-reperfusion. These include excitotoxicty, neuroinflammation, apoptosis, free radical production, seizure activity, blood-brain barrier disruption, blood vessel leakage, cerebral thermopooling, and numerous others. The severity of this destructive cascade determines whether injured cells will survive or die. Hypothermia can inhibit or mitigate all of these mechanisms, while stimulating protective systems such as early gene activation. Hypothermia is also effective in mitigating intracranial hypertension and reducing brain edema. Side effects include immunosuppression with increased infection risk, cold diuresis and hypovolemia, electrolyte disorders, insulin resistance, impaired drug clearance, and mild coagulopathy. Targeted interventions are required to effectively manage these side effects. Hypothermia does not decrease myocardial contractility or induce hypotension if hypovolemia is corrected, and preliminary evidence suggests that it can be safely used in patients with cardiac shock. Cardiac output will decrease due to hypothermia-induced bradycardia, but given that metabolic rate also decreases the balance between supply and demand, is usually maintained or improved. In contrast to deep hypothermia (<=30[degrees]C), moderate hypothermia does not induce arrhythmias; indeed, the evidence suggests that arrhythmias can be prevented and/or more easily treated under hypothermic conditions.
Conclusions: Therapeutic hypothermia is a highly promising treatment, but the potential side effects need to be properly managed particularly if prolonged treatment periods are required. Understanding the underlying mechanisms, awareness of physiological changes associated with cooling, and prevention of potential side effects are all key factors for its effective clinical usage.
(C) 2009 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Infection control in mass respiratory failure: Preparing to respond to H1N1
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The first hints of a global public health crisis emerged with the identification of a new strain of H1N1 influenza A in March and April 2009 in Mexico City. By June 11, the World Health Organization had declared the outbreak of 2009 H1N1 a global pandemic. Now, with the continued growing presence of 2009 H1N1 on the global scene, much attention has been focused on the key role of personal protective equipment in healthcare infection control. Much less emphasis has been placed on specific interventions that may minimize the increased infectious risk commonly associated with critical care delivery. Given the frequency of high-risk respiratory procedures such as intubation and delivery of aerosolized medications in the intensive care unit, the delivery of critical care presents unique infection control challenges and unique opportunities to augment usual infection control practice with specific source-control efforts. Here, we summarize data regarding risks to critical care healthcare workers from previous respiratory virus outbreaks, discuss findings from the early 2009 H1N1 experience that suggest reasons for increased concern for those delivering critical care, and review best available evidence regarding strategies for source control in respiratory and critical care delivery.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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A survival benefit of combination antibiotic therapy for serious infections associated with sepsis and septic shock is contingent only on the risk of death: A meta-analytic/meta-regression study
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Objective: To assess whether a potential benefit with combination antibiotic therapy is restricted to the most critically ill subset of patients, particularly those with septic shock.
Data Sources: OVID MEDLINE (1950-October 2009), EMBASE (1980-October 2009), the Cochrane Central Register of Controlled Trials (to third quarter 2009), the ClinicalTrial.gov database, and the SCOPUS database.
Study Selection: Randomized or observational studies of antimicrobial therapy of serious bacterial infections potentially associated with sepsis or septic shock. Fifty studies met entry criteria.
Data Extraction: Study design, mortality/clinical response, and other variables were extracted independently by two reviewers. When possible, study datasets were split into mutually exclusive groups with and without shock or critical illness.
Data Synthesis: Although a pooled odds ratio indicated no overall mortality/clinical response benefit with combination therapy (odds ratio, 0.856; 95% confidence interval, 0.71-1.03; p = .0943; I2 = 45.1%), stratification of datasets by monotherapy mortality risk demonstrated substantial benefit in the most severely ill subset (monotherapy risk of death >25%; odds ratio of death, 0.51; 95% confidence interval, 0.41-0.64; I2 = 8.6%). Of those datasets that could be stratified by the presence of shock/critical illness, the more severely ill group consistently demonstrated increased efficacy of a combination therapy strategy (odds ratio, 0.49; 95% confidence interval, 0.35-0.70; p < .0001; I2 = 0%). An increased risk of death was found in low-risk patients (risk of death <=15% in the monotherapy arm) exposed to combination therapy (odds ratio, 1.53; 95% confidence interval, 1.16-2.03; p = .003; I2 = 8.2%). Meta-regression indicated that efficacy of combination therapy was dependent only on the risk of death in the monotherapy group.
Conclusion: Combination antibiotic therapy improves survival and clinical response of high-risk, life-threatening infections, particularly those associated with septic shock but may be detrimental to low-risk patients.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Healthcare personnel and nosocomial transmission of pandemic 2009 influenza
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Knowledge regarding the modes of transmission of pandemic 2009 H1N1 influenza continues to develop, as do recommendations for the prevention of spread within healthcare facilities. The adoption of the most prudent, multifaceted approaches is recommended until there is significant evidence to reduce protective measures. The greatest threat to healthcare personnel and patients appears to be exposure to patients, healthcare personnel, or visitors who have not been recognized as contagious. The processes used within healthcare facilities must hold this concept central to any infection control plan and act in a preventive manner. This article focuses on the development of an algorithm for intensive care unit intake precautions, based on the early identification of potential source patients, as well as appropriate selection and adequate use of personal protective equipment. Visitor management, hand and respiratory hygiene, and cough etiquette have been used as measures to decrease the spread of infection. Vaccination of healthcare personnel, combined with work furlough for ill workers, is also explored. Recommendations include the elimination of potential exposures, engineering and administrative controls, and utilization of personal protective equipment.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Practical lessons from the first outbreaks: Clinical presentation, obstacles, and management strategies for severe pandemic (pH1N1) 2009 influenza pneumonitis
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During the initial spring wave of novel influenza pH1N1 (2009), several North American cities experienced localized epidemics that served as a harbinger of the larger second Fall wave of infection. The city of Winnipeg, the capital of the province of Manitoba in central Canada, was one of the first in North America to deal with a rapid presentation of large numbers of patients requiring critical care services resulting from pandemic (pH1N1) 2009 influenza-associated respiratory failure. Mexico City, Orlando, FL, and Salt Lake City, UT, were other Northern Hemisphere sites of heavy disease activity during the spring wave of the pandemic. This article is written in a narrative format that allows the reader to understand the problems (both major and mundane, anticipated and unexpected) experienced by healthcare workers in these sites during this pandemic. Descriptions cover a range of issues and difficulties that caused significant stress to the operations of intensive care units in these cities. We hope to offer some insight into potential pitfalls and problems that may be experienced by other centers and provide some potential approaches to addressing these issues.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Probiotics to prevent ventilator-associated pneumonia: No robust evidence from randomized controlled trials: Erratum
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No abstract available
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The use of antiviral agents for the management of severe influenza
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The clinical course of pandemic H1N1 2009 influenza can be severe, particularly in the very young and patients with comorbidities. Pandemic H1N1 2009 is sensitive to the antiviral agents oseltamivir and zanamivir but is resistant to the M2 inhibitors. Although few clinical data are yet available, treatment of pandemic H1N1 2009 influenza in hospital settings with oseltamivir or zanamivir appears to be beneficial. In hospitalized patients with severe influenza treated with oseltamivir, mortality and length of stay are significantly reduced, and viral load is reduced more quickly than in untreated patients. In patients at high risk treated with oseltamivir or zanamivir, reductions in the risk of complications and mortality after treatment have been demonstrated with oseltamivir and zanamivir, although there are fewer data on the latter. There is no evidence yet that other antiviral agents are effective in severe or pandemic H1N1 2009 influenza. Current World Health Organization guidance strongly recommends the use of oseltamivir for severe or progressive infection with pandemic H1N1 2009, with zanamivir as an alternative if the infecting virus is oseltamivir-resistant. Very little resistance to oseltamivir has been found to date.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Preparing your intensive care unit for the second wave of H1N1 and future surges
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Faced with increased demands for critical care services as a result of the novel H1N1 pandemic, hospitals must prepare a surge response in an attempt to manage these needs. In preparing for a surge response, factors to consider are staff, stuff (supplies and equipment), space, and systems necessary to respond to the event. This article uses this general framework to discuss surge issues in the context of H1N1 challenges that we are facing currently and to provide specific advice for hospitals. Particular attention is given to how hospitals can estimate the potential impact of H1N1 and pharmaceutical stockpiling.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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A cost-minimization analysis of dexmedetomidine compared with midazolam for long-term sedation in the intensive care unit *
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Objective: To compare the intensive care unit costs and determine factors influencing these costs in mechanically ventilated patients randomized to dexmedetomidine or midazolam by continuous infusion.
Design: Cost minimization analysis of a double-blind, multicenter clinical trial randomizing patients 2:1 to receive dexmedetomidine or midazolam from the institutional perspective.
Setting: Sixty-eight intensive care units in the United States, Australia, New Zealand, Brazil, and Argentina.
Patients: A total of 366 intubated intensive care unit patients anticipated to require sedation for >24 hrs.
Measurements and Main Results: Intensive care unit resource use was compared within the two treatment arms, using the U.S. representative costs for these resources. The analyses characterized patient costs from start of study drug until intensive care unit discharge including costs associated with the intensive care unit stay, costs during mechanical ventilation, study drug acquisition cost, and costs of treating adverse drug reactions probably or possibly related to study drugs. Blinded to treatment group, costs were calculated using Medicare reimbursement schedules, average IMS drug costs, expert opinion, and peer-reviewed literature. Censored lengths of intensive care unit stay and mechanical ventilation were imputed, using a nonparametric adjustment algorithm. Crude and multivariate median regressions were performed to relate intensive care unit cost and treatment. Including drug acquisition cost, sedation with dexmedetomidine was associated with a median total intensive care unit cost savings of $9679 (confidence interval, $2314-$17,045) compared with midazolam. The primary cost drivers were reduced costs of intensive care unit stay (median savings, $6584, 95% confidence interval, $727-$12,440) and reduced costs of mechanical ventilation (median savings, $2958, 95% confidence interval, $698-$5219).
Conclusions: Continuous sedation with dexmedetomidine results in significantly lower total intensive care unit costs compared with midazolam infusion for intensive care unit sedation, primarily due to decreased intensive care unit stay costs and reduced mechanical ventilation costs.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Futility in the intensive care unit: Hard cases make bad law *
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No abstract available
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Response from the Editor-in-Chief of Critical Care Medicine
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No abstract available
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Hark back: Passive immunotherapy for influenza and other serious infections
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The world is experiencing a pandemic of swine-origin influenza virus H1N1. A vaccine to prevent disease is now available, and millions have or will become ill before they can be vaccinated. The ability to use swine-origin influenza virus vaccines as a public health tool has been described as a "race against time." Oseltamivir and related drugs are being used in an effort to reduce morbidity and mortality, but their efficacy for treating severe influenza is suboptimal, and possible wide-spread emergence of oseltamivir-resistant mutants is a concern. Another approach for prevention and treatment of serious influenza is infusion of hyperimmune plasma. The United States has thousands of licensed blood product collection centers that produce millions of liters of plasma licensed by the Food and Drug Administration on an annual basis for the treatment of serious conditions. Immunotherapy using infusion of convalescent plasma (or hyperimmune intravenous immunoglobulin) has been reported to be an effective treatment for severe influenza and other virulent pathogens in animal models and humans. Plasma obtained from those that have recovered or were early recipients of vaccine offers a resource for production of an immediately available and potentially effective therapy at the local, state, and national level. Past, current, and future uses of immunotherapy and current advisory body recommendations for this approach are presented.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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International authority on respiratory disease dies
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No abstract available
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Human immunodeficiency virus infection and hospital mortality in acute lung injury patients
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Objective: To evaluate the impact of human immunodeficiency virus infection on hospital mortality in patients with acute lung injury and to evaluate predictors of mortality among acute lung injury patients with human immunodeficiency virus.
Design, Setting, and Patients: Retrospective study of human immunodeficiency virus-infected patients enrolled in an ongoing prospective cohort study of acute lung injury patients conducted at 13 intensive care units in four teaching hospitals in Baltimore, Maryland.
Measurements and Main Results: Of 520 consecutive acute lung injury patients, 66 (13%) were human immunodeficiency virus-positive. In human immunodeficiency virus-positive vs. human immunodeficiency virus-negative patients, pneumonia was the most common acute lung injury risk factor (43 [65%] vs. 184 [41%]; p = .001), and the median (interquartile range) Acute Physiology and Chronic Health Evaluation II score was modestly higher (27 [22-33] vs. 26 [20-33]; p = .06). There was no difference in crude hospital mortality (44% vs. 46%; p = .78) between human immunodeficiency virus-positive and human immunodeficiency virus-negative acute lung injury patients. After adjustment for potential confounders, human immunodeficiency virus infection was not an independent predictor of hospital mortality (odds ratio, 1.39; 95% confidence interval, 0.69-2.78; p = .35). In the human immunodeficiency virus-infected acute lung injury patients, among 23 relevant measures of intensive care unit and human immunodeficiency virus severity of illness, only the presence of an opportunistic infection before hospital admission was independently associated with hospital mortality (odds ratio, 6.4; 95% confidence interval, 1.27-32.3; p = .025).
Conclusions: In patients with acute lung injury, human immunodeficiency virus-positive patients had similar hospital mortality as human immunodeficiency virus-negative patients; hence, human immunodeficiency virus status should not influence estimates of short-term prognosis for acute lung injury patients in the intensive care unit. Among human immunodeficiency virus-positive patients with acute lung injury, the presence of a previous opportunistic infection, rather than traditional measures of severity of illness, may be most strongly predictive of hospital mortality.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Errata
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No abstract available
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Preserved metabolic coupling and cerebrovascular reactivity during mild hypothermia after cardiac arrest *
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Objective: Although mild hypothermia improves outcome in patients after out-of-hospital cardiac arrest, the cardiodepressive effects of hypothermia may lead to secondary brain damage. This study was performed to assess the cerebral blood flow, cerebral oxygen extraction, and cerebrovascular reactivity to changes in partial pressure of carbon dioxide in the arterial blood in comatose patients after out-of-hospital cardiac arrest treated with mild hypothermia.
Design: Observational study.
Setting: Tertiary care university hospital.
Patients: Ten comatose patients after out-of-hospital cardiac arrest.
Interventions: All patients were cooled to 32-34[degrees]C for 24 hrs. Cerebrovascular reactivity to changes in carbon dioxide in the arterial blood was measured after increasing or decreasing the minute ventilation by 20%.
Measurements and Main Results: Mean flow velocity in the middle cerebral artery and pulsatility index were measured by transcranial Doppler at 0, 3, 6, 9, 12, 18, 24, and 48 hrs after admission. Jugular bulb oxygenation was measured at the same intervals. Cerebrovascular reactivity to changes in carbon dioxide in the arterial blood was studied on admission to the intensive care unit and at 6, 12, 18, and 24 hrs by measurement of mean flow velocity in the middle cerebral artery and jugular bulb oxygenation. Mean flow velocity in the middle cerebral artery was low (30.3 +/- 9.5 cm/sec) on admission and remained relatively stable for the first 24 hrs. After rewarming, it increased to 67.5 +/- 33.0 cm/sec at 48 hrs after admission from 30.3 +/- 9.5 at admission (p = .009). Jugular bulb oxygenation at the start of the study was 66.2 +/- 8.5% and gradually increased to 82.9 +/- 4.9% at 48 hrs (p < .001). Regression analysis showed a significant correlation between changes in carbon dioxide in the arterial blood, mean flow velocity in the middle cerebral artery (p < .001) and jugular bulb oxygenation (p < .001). The mean percentage change in mean flow velocity in the middle cerebral artery was 3.6 +/- 2.9% per 1-mm Hg change of carbon dioxide in the arterial blood.
Conclusions: The mean flow velocity in the middle cerebral artery, as a parameter of cerebral blood flow, was low during mild hypothermia, whereas cerebral oxygen extraction remained normal, suggesting decreased cerebral metabolic activity. We demonstrated that CO2 reactivity is preserved during hypothermia in these patients.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Common drug interactions leading to adverse drug events in the intensive care unit: Management and pharmacokinetic considerations
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Critically ill patients are predisposed to drug interactions because of the complexity of the drug regimens they receive in the intensive care setting. Drugs may affect the absorption, distribution, metabolism, and/or elimination of an object drug and consequently alter the intended pharmacologic response and potentially lead to an adverse event. Certain disease states that afflict critically ill patients may also amplify an intended pharmacologic response and potentially result in an unintended effect. A team approach is important to identify, prevent, and address drug interactions in the intensive care setting and optimize patient outcomes.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Continuing Medical Education Questions
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No abstract available
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Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care *
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Objective: To develop a clinical practice guideline for red blood cell transfusion in adult trauma and critical care.
Design: Meetings, teleconferences and electronic-based communication to achieve grading of the published evidence, discussion and consensus among the entire committee members.
Methods: This practice management guideline was developed by a joint taskforce of EAST (Eastern Association for Surgery of Trauma) and the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM). We performed a comprehensive literature review of the topic and graded the evidence using scientific assessment methods employed by the Canadian and U.S. Preventive Task Force (Grading of Evidence, Class I, II, III; Grading of Recommendations, Level I, II, III). A list of guideline recommendations was compiled by the members of the guidelines committees for the two societies. Following an extensive review process by external reviewers, the final guideline manuscript was reviewed and approved by the EAST Board of Directors, the Board of Regents of the ACCM and the Council of SCCM.
Results: Key recommendations are listed by category, including (A) Indications for RBC transfusion in the general critically ill patient; (B) RBC transfusion in sepsis; (C) RBC transfusion in patients at risk for or with acute lung injury and acute respiratory distress syndrome; (D) RBC transfusion in patients with neurologic injury and diseases; (E) RBC transfusion risks; (F) Alternatives to RBC transfusion; and (G) Strategies to reduce RBC transfusion.
Conclusions: Evidence-based recommendations regarding the use of RBC transfusion in adult trauma and critical care will provide important information to critical care practitioners.
(C) 2009 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Vancomycin plus rifampicin for methicillin-resistant Staphylococcus aureus pneumonia benefits only those who have no development of rifampicin resistance during treatment
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No abstract available
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Mechanical ventilation can cause changes in pulmonary circulation
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No abstract available
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Extracranial injuries are important in determining mortality of neurotrauma *
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Objective: This study aimed to assess the significance of extracranial injuries, as measured by Injury Severity Score, on 6-mo and 9-yr mortality of neurotrauma.
Design: Retrospective linked data cohort study.
Setting: A major neurotrauma center in Western Australia.
Patients: Six hundred eighty-three adult neurotrauma patients.
Measurements and Main Results: Data were first used to validate the largest published international neurotrauma "extended" mortality prognostic model, in which extracranial injuries are considered significant if the patient has hypoxemia or hypotension on admission. Logistic and Cox regression, incorporating bootstrap techniques to adjust for overfitting, were used to assess the significance of Injury Severity Score in determining 6-mo and 9-yr mortality, respectively. Among a total of 683 patients admitted between 1994 and 2002, 636 (93.1%) had extracranial injuries. The international neurotrauma "extended" mortality prognostic model was poorly calibrated and underestimated the observed mortality (slope and intercept of the calibration curve were 2.14 and 0.35, respectively) when applied to our patients. Incorporating Injury Severity Score into the model improved its calibration. Injury Severity Score accounted for 11% of the variability and was the third most important factor after Marshall computed tomographic grading (17.8%) and pupil reactivity (14.5%) in determining 6-mo mortality. There was a notable increase in mortality between 6-mo (19.2%) and 24-mo follow-up (25.8%). Injury Severity Score remained important and accounted for 9.2% of the variability in determining 9-yr mortality after the injury.
Conclusions: Hypotension and hypoxemia on admission were inadequate markers of extracranial injuries; incorporating more comprehensive extracranial injury assessment by the Injury Severity Score to the standard neurologic prognostic factors improved the accuracy of predictions on mortality after neurotrauma.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Health-related quality of life and return to work after critical illness in general intensive care unit patients: A 1-year follow-up study
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Objective: To study how health-related quality of life of intensive care unit survivors compares with the general population, changes over time, and association with an optimistic personality trait and posttraumatic stress. Further, to explore differences in health-related quality of life between medical, trauma, and surgical patients and to assess return to work/school at 1 yr.
Design: Prospective 1-yr follow-up study.
Setting: University-affiliated trauma center hospital.
Patients: At 1-yr, 194 patients participated. Mean age was 49 yrs and 60% were males.
Measurements and Main Results: Health-related quality of life was assessed by the Short Form 36, which measures health-related quality of life in eight separate dimensions (0 = worst health state, 100 = best health state). At 1 yr, significantly lower scores compared to the general population were seen in all eight scales (p < .001). The decrease in Short Form 36 scores between before intensive care unit and 1-yr measurements was significant for all eight dimensions (p < .01). The multivariate regression analyses adjusted for gender, age (beta, - 0.3), optimism (beta, 0.9), medical disease (beta, 12.2), length of stay in intensive care unit (beta, -0.4), being employed/student/retired before intensive care unit stay (beta, 12.5), and posttraumatic stress symptoms (beta, -9.1; all p < .05) were independent predictors of the dimension physical functioning (adjusted r2 = .22). For mental health, adjusted for age and gender, independent predictors were optimism (beta, 1.4), being employed/student/retired before intensive care unit stay (beta, 14.9), and posttraumatic stress symptoms (beta, -11.6; all p < .001; adjusted r2 = .35). Before intensive care unit admission, 122 (63%) patients were students/working, among these, 67 (55%) had returned to work/school at 1-yr follow-up.
Conclusion: Intensive care unit survivors had significantly lower health-related quality of life at 1 yr compared to the general population and significantly reduced compared to their states before intensive care unit admission. Less posttraumatic stress and optimism were predictors of higher health-related quality of life and return to work/school. Trauma patients had the largest decrease in both physical and mental scores. Only half of the patients had returned to work/school.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department *
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Objective: To study the association between time to antibiotic administration and survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department.
Design: Single-center cohort study.
Setting: The emergency department of an academic tertiary care center from 2005 through 2006.
Patients: Two hundred sixty-one patients undergoing early goal-directed therapy.
Interventions: None.
Measurements and Main Results: Effects of different time cutoffs from triage to antibiotic administration, qualification for early goal-directed therapy to antibiotic administration, triage to appropriate antibiotic administration, and qualification for early goal-directed therapy to appropriate antibiotic administration on in-hospital mortality were examined. The mean age of the 261 patients was 59 +/- 16 yrs; 41% were female. In-hospital mortality was 31%. Median time from triage to antibiotics was 119 mins (interquartile range, 76-192 mins) and from qualification to antibiotics was 42 mins (interquartile range, 0-93 mins). There was no significant association between time from triage or time from qualification for early goal-directed therapy to antibiotics and mortality when assessed at different hourly cutoffs. When analyzed for time from triage to appropriate antibiotics, there was a significant association at the <1 hr (mortality 19.5 vs. 33.2%; odds ratio, 0.30 [95% confidence interval, 0.11-0.83]; p = .02) time cutoff; similarly, for time from qualification for early goal-directed therapy to appropriate antibiotics, a significant association was seen at the <=1 hr (mortality 25.0 vs. 38.5%; odds ratio, 0.50 [95% confidence interval, 0.27-0.92]; p = .03) time cutoff.
Conclusions: Elapsed times from triage and qualification for early goal-directed therapy to administration of appropriate antimicrobials are primary determinants of mortality in patients with severe sepsis and septic shock treated with early goal-directed therapy.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Education is what remains after medical emergency teams are trained
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No abstract available
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Acute renal failure is NOT an "acute renal success"-a clinical study on the renal oxygen supply/demand relationship in acute kidney injury
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Objectives: Acute kidney injury occurs frequently after cardiac or major vascular surgery and is believed to be predominantly a consequence of impaired renal oxygenation. However, in patients with acute kidney injury, data on renal oxygen consumption (RVO2), renal blood flow, glomerular filtration, and renal oxygenation, i.e., the renal oxygen supply/demand relationship, are lacking and current views on renal oxygenation in the clinical situation of acute kidney injury are presumptive and largely based on experimental studies.
Design: Prospective, two-group comparative study.
Setting: Cardiothoracic intensive care unit of a tertiary center.
Patients: Postcardiac surgery patients with (n = 12) and without (n = 37) acute kidney injury were compared with respect to renal blood flow, glomerular filtration, RVO2, and renal oxygenation.
Interventions: None
Measurements and Main Results: Data on systemic hemodynamics (pulmonary artery catheter) and renal variables were obtained during two 30-min periods. Renal blood flow was measured using two independent techniques: the renal vein thermodilution technique and the infusion clearance of paraaminohippuric acid, corrected for renal extraction of paraaminohippuric acid. The filtration fraction was measured by the renal extraction of 51Cr-EDTA and the renal sodium resorption was measured as the difference between filtered and excreted sodium. Renal oxygenation was estimated from the renal oxygen extraction. Cardiac index and mean arterial pressure did not differ between the two groups. In the acute kidney injury group, glomerular filtration (-57%), renal blood flow (-40%), filtration fraction (-26%), and sodium resorption (-59%) were lower, renal vascular resistance (52%) and renal oxygen extraction (68%) were higher, whereas there was no difference in renal oxygen consumption between groups. Renal oxygen consumption for one unit of reabsorbed sodium was 2.4 times higher in acute kidney injury.
Conclusions: Renal oxygenation is severely impaired in acute kidney injury after cardiac surgery, despite the decrease in glomerular filtration and tubular workload. This was caused by a combination of renal vasoconstriction and tubular sodium resorption at a high oxygen demand.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Overture for growth hormone: Requiem for interleukin-6? *
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Background: Music has been used for therapeutic purposes since the beginning of cultural history. However, despite numerous descriptions of beneficial effects, the precise mechanisms by which music may improve human well-being remain unclear.
Methods: We conducted a randomized study in ten critically ill patients to identify mechanisms of music-induced relaxation using a special selection of slow movements of Mozart's piano sonatas. These sonatas were analyzed for compositional elements of relaxation. We measured circulatory variables, brain electrical activity, serum levels of stress hormones and cytokines, requirements for sedative drugs, and level of sedation before and at the end of a 1-hr therapeutic session.
Results: Compared with controls, we found that music application significantly reduced the amount of sedative drugs needed to achieve a comparable degree of sedation. Simultaneously, among those receiving the music intervention, plasma concentrations of growth hormone increased, whereas those of interleukin-6 and epinephrine decreased. The reduction in systemic stress hormone levels was associated with a significantly lower blood pressure and heart rate.
Conclusion: Based on the effects of slow movements of Mozart's piano sonatas, we propose a neurohumoral pathway by which music might exert its sedative action. This model includes an interaction of the hypothalamic-pituitary axis with the adrenal medulla via mediators of the unspecific immune system.
(C) 2007 Lippincott Williams & Wilkins, Inc.
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Influenza A pandemics: Clinical and organizational aspects: The experience in Chile
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Recently, the World Health Organization declared a pandemic mediated by the novel A H1N1 influenza virus. Soon after the first report from Mexico, the disease arrived in Chile, where it spread quickly from south to north, mimicking cold weather progression through the country. Between May and September 2009, 366,624 cases of H1N1 were reported; 12,248 were confirmed by real-time reverse-transcription polymerase chain reaction and 1562 were hospitalized. One hundred thirty-two deaths were attributable to the infection, creating a death rate of 0.78 per 100,000 inhabitants. Common comorbidities were present in 59%, including obesity, chronic obstructive pulmonary disease, hypertension, type II diabetes, and congestive heart failure. Nine percent were pregnant. Severe disease developed early; the median time to admittance was 5 days, and the most common clinical manifestations were cough, fever, dyspnea, and myalgia. Mean acute physiology and chronic health evaluation II and sequential organ failure assessment scores were 14 and 5, respectively. Highlighted laboratory data were lactate dehydrogenase and creatine kinase elevation, leukocytosis in 50%, elevated creatinine in a 25%, and thrombocytopenia in 20%. Severe respiratory failure requiring high-frequency oscillatory ventilation and extracorporeal membrane oxygenation as sophisticated modes of respiratory support was seen in 17%. Acute renal failure occurred in 25% of the intensive care unit patients, with death rates near 50%. Health systems reinforced outpatient guards with extra staff and extension of the duty schedules. Antivirals were supplied free for medically diagnosed cases. Admissions for severe cases were prioritized, reconverting hospital beds into advanced care ones; a central coordination station rationed their assignment. Recommendations for small hospitals include adding ventilators, using videoconferences, providing tutorial activity from experts, developing guidelines for disease management, and outlining criteria for transport.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Acute pulmonary hypertension: What is wrong on the right? *
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No abstract available
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Severe hypercortisolism: A medical emergency requiring urgent intervention
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Objectives: To illustrate the importance of recognizing symptoms of severe hypercortisolism in the intensive care unit and key emergency measures to reduce this extreme hypercortisolism.
Design: Case report.
Setting: Intensive care unit in a university hospital.
Patient: A 55-yr-old woman was admitted to the intensive care unit with multiorgan failure after perforation of the sigmoid. Recent-onset hypertension, spontaneous hypokalemia, and diabetes mellitus suggested severe Cushing's syndrome as the underlying disease. Markedly increased serum cortisol (5900 nmol/L) and adrenocorticotropic hormone (302 ng/L) levels were found, highly suggestive for ectopic adrenocorticotropic hormone secretion. Imaging studies failed to unequivocally establish a solitary source of ectopic adrenocorticotropic hormone secretion. The deteriorating condition of the patient urged rapid intervention.
Interventions: Etomidate was infused continuously to reduce endogenous adrenal cortisol secretion. Subsequently, a rescue bilateral adrenalectomy was undertaken.
Measurements and Results: Etomidate effectively reduced the cortisol level. Serial blood samples were obtained during the bilateral adrenalectomy. Plasma adrenocorticotropic hormone markedly decreased immediately after resection of the right adrenal gland. Histopathological examination revealed a tumor of the right adrenal gland identified as a pheochromocytoma and hyperplasia of the left adrenal gland, but no signs of malignancy. The patient recovered slowly.
Conclusion: This case illustrates that severe hypercortisolism is a medical emergency and that specific and prompt combined medical and surgical intervention can be life-saving.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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Early goal-directed therapy of septic shock in the emergency room: Who could honestly remain skeptical? *
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No abstract available
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Efficacy and safety of quetiapine in critically ill patients with delirium: A prospective, multicenter, randomized, double-blind, placebo-controlled pilot study *
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Objective: To compare the efficacy and safety of scheduled quetiapine to placebo for the treatment of delirium in critically ill patients requiring as-needed haloperidol.
Design: Prospective, randomized, double-blind, placebo-controlled study.
Setting: Three academic medical centers.
Patients: Thirty-six adult intensive care unit patients with delirium (Intensive Care Delirium Screening Checklist score >=4), tolerating enteral nutrition, and without a complicating neurologic condition.
Interventions: Patients were randomized to receive quetiapine 50 mg every 12 hrs or placebo. Quetiapine was increased every 24 hrs (50 to 100 to 150 to 200 mg every 12 hrs) if more than one dose of haloperidol was given in the previous 24 hrs. Study drug was continued until the intensive care unit team discontinued it because of delirium resolution, therapy >=10 days, or intensive care unit discharge.
Measurements and Main Results: Baseline characteristics were similar between the quetiapine (n = 18) and placebo (n = 18) groups. Quetiapine was associated with a shorter time to first resolution of delirium [1.0 (interquartile range [IQR], 0.5-3.0) vs. 4.5 days (IQR, 2.0-7.0; p =.001)], a reduced duration of delirium [36 (IQR, 12-87) vs. 120 hrs (IQR, 60-195; p =.006)], and less agitation (Sedation-Agitation Scale score >=5) [6 (IQR, 0-38) vs. 36 hrs (IQR, 11-66; p =.02)]. Whereas mortality (11% quetiapine vs. 17%) and intensive care unit length of stay (16 quetiapine vs. 16 days) were similar, subjects treated with quetiapine were more likely to be discharged home or to rehabilitation (89% quetiapine vs. 56%; p =.06). Subjects treated with quetiapine required fewer days of as-needed haloperidol [3 [(IQR, 2-4)] vs. 4 days (IQR, 3-8; p = .05)]. Whereas the incidence of QTc prolongation and extrapyramidal symptoms was similar between groups, more somnolence was observed with quetiapine (22% vs. 11%; p = .66).
Conclusions: Quetiapine added to as-needed haloperidol results in faster delirium resolution, less agitation, and a greater rate of transfer to home or rehabilitation. Future studies should evaluate the effect of quetiapine on mortality, resource utilization, post-intensive care unit cognition, and dependency after discharge in a broader group of patients.
(C) 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
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