Critical Care Research and Practice The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Impact of a 2-Day Critical Care Ultrasound Course during Fellowship Training: A Pilot Study Wed, 05 Aug 2015 11:59:08 +0000 Objectives. Despite the increasing utilization of point-of-care critical care ultrasonography (CCUS), standards establishing competency for its use are lacking. The purpose of this study was to evaluate the effectiveness of a 2-day CCUS course implementation on ultrasound-naïve critical care medicine (CCM) fellows. Methods. Prospective evaluation of the impact of a two-day CCUS course on eight CCM fellows’ attitudes, proficiency, and use of CCUS. Ultrasound competency on multiple organ systems was assessed including abdominal, pulmonary, vascular, and cardiac systems. Subjects served as self-controls and were assessed just prior to, within 1 week after, and 3 months after the course. Results. There was a significant improvement in CCM fellows’ written test scores, image acquisition ability, and pathologic image interpretation 1 week after the course and it was retained 3 months after the course. Fellows also had self-reported increased confidence and usage of CCUS applications after the course. Conclusions. Implementation of a 2-day critical care ultrasound course covering general CCUS and basic critical care echocardiography using a combination of didactics, live models, and ultrasound simulators is effective in improving critical care fellows’ proficiency and confidence with ultrasound use in both the short- and long-term settings. Vi Am Dinh, Paresh C. Giri, Inimai Rathinavel, Emilie Nguyen, David Hecht, Ihab Dorotta, H. Bryant Nguyen, and Ara A. Chrissian Copyright © 2015 Vi Am Dinh et al. All rights reserved. Lung Injury Prediction Score Is Useful in Predicting Acute Respiratory Distress Syndrome and Mortality in Surgical Critical Care Patients Sun, 02 Aug 2015 11:49:29 +0000 Background. Lung injury prediction score (LIPS) is valuable for early recognition of ventilated patients at high risk for developing acute respiratory distress syndrome (ARDS). This study analyzes the value of LIPS in predicting ARDS and mortality among ventilated surgical patients. Methods. IRB approved, prospective observational study including all ventilated patients admitted to the surgical intensive care unit at a single tertiary center over 6 months. ARDS was defined using the Berlin criteria. LIPS were calculated for all patients and analyzed. Logistic regression models evaluated the ability of LIPS to predict development of ARDS and mortality. A receiver operator characteristic (ROC) curve demonstrated the optimal LIPS value to statistically predict development of ARDS. Results. 268 ventilated patients were observed; 141 developed ARDS and 127 did not. The average LIPS for patients who developed ARDS was versus for those who did not (). An ROC area under the curve of 0.79 demonstrates LIPS is statistically powerful for predicting ARDS development. Furthermore, for every 1-unit increase in LIPS, the odds of developing ARDS increase by 1.50 () and odds of ICU mortality increase by 1.22 (). Conclusion. LIPS is reliable for predicting development of ARDS and predicting mortality in critically ill surgical patients. Zachary M. Bauman, Marika Y. Gassner, Megan A. Coughlin, Meredith Mahan, and Jill Watras Copyright © 2015 Zachary M. Bauman et al. All rights reserved. The Use of Sodium Bicarbonate in the Treatment of Acidosis in Sepsis: A Literature Update on a Long Term Debate Thu, 30 Jul 2015 11:31:20 +0000 Introduction. Sepsis and its consequences such as metabolic acidosis are resulting in increased mortality. Although correction of metabolic acidosis with sodium bicarbonate seems a reasonable approach, there is ongoing debate regarding the role of bicarbonates as a therapeutic option. Methods. We conducted a PubMed literature search in order to identify published literature related to the effects of sodium bicarbonate treatment on metabolic acidosis due to sepsis. The search included all articles published in English in the last 35 years. Results. There is ongoing debate regarding the use of bicarbonates for the treatment of acidosis in sepsis, but there is a trend towards not using bicarbonate in sepsis patients with arterial blood gas . Conclusions. Routine use of bicarbonate for treatment of severe acidemia and lactic acidosis due to sepsis is subject of controversy, and current opinion does not favor routine use of bicarbonates. However, available evidence is inconclusive, and more studies are required to determine the potential benefit, if any, of bicarbonate therapy in the sepsis patient with acidosis. Dimitrios Velissaris, Vasilios Karamouzos, Nikolaos Ktenopoulos, Charalampos Pierrakos, and Menelaos Karanikolas Copyright © 2015 Dimitrios Velissaris et al. All rights reserved. Impact of a Simulation-Based Communication Workshop on Resident Preparedness for End-of-Life Communication in the Intensive Care Unit Thu, 25 Jun 2015 12:30:38 +0000 Introduction. Although residents frequently lead end-of-life (EOL) discussions in the intensive care unit (ICU), training in EOL care during residency has been required only recently, and few educational interventions target EOL communication in the ICU. This study evaluated a simulation-based intervention designed to improve resident EOL communication skills with families in the ICU. Methods. Thirty-four second-year internal medicine residents at a large urban teaching hospital participated in small group sessions with faculty trained in the “VitalTalk” method. A Likert-type scale questionnaire measured self-assessed preparedness before, immediately following, and approximately 9 months after intervention. Data were analyzed using Wilcoxon rank-sum analysis. Results. Self-assessed preparedness significantly improved for all categories surveyed (preintervention mean; postintervention mean; p value), including discussing bad news (3.3; 4.2; ), conducting a family conference (3.1; 4.1; ), discussing treatment options (3.2; 3.9; ), discussing discontinuing ICU treatments (2.9; 3.5; ), and expressing empathy (3.9; 4.5; ). Improvement persisted at follow-up for all items except “expressing empathy.” Residents rated the educational quality highly. Conclusion. This study provides evidence that brief simulation-based interventions can produce lasting improvements in residents’ confidence to discuss EOL care with family members of patients in the ICU. Abraham Markin, Diego F. Cabrera-Fernandez, Rebecca M. Bajoka, Samantha M. Noll, Sean M. Drake, Rana L. Awdish, Dana S. Buick, Maria S. Kokas, Kristen A. Chasteen, and Michael P. Mendez Copyright © 2015 Abraham Markin et al. All rights reserved. Pressure Measurement Techniques for Abdominal Hypertension: Conclusions from an Experimental Model Sun, 31 May 2015 14:06:03 +0000 Introduction. Intra-abdominal pressure (IAP) measurement is an indispensable tool for the diagnosis of abdominal hypertension. Different techniques have been described in the literature and applied in the clinical setting. Methods. A porcine model was created to simulate an abdominal compartment syndrome ranging from baseline IAP to 30 mmHg. Three different measurement techniques were applied, comprising telemetric piezoresistive probes at two different sites (epigastric and pelvic) for direct pressure measurement and intragastric and intravesical probes for indirect measurement. Results. The mean difference between the invasive IAP measurements using telemetric pressure probes and the IVP measurements was −0.58 mmHg. The bias between the invasive IAP measurements and the IGP measurements was 3.8 mmHg. Compared to the realistic results of the intraperitoneal and intravesical measurements, the intragastric data showed a strong tendency towards decreased values. The hydrostatic character of the IAP was eliminated at high-pressure levels. Conclusion. We conclude that intragastric pressure measurement is potentially hazardous and might lead to inaccurately low intra-abdominal pressure values. This may result in missed diagnosis of elevated abdominal pressure or even ACS. The intravesical measurements showed the most accurate values during baseline pressure and both high-pressure plateaus. Sascha Santosh Chopra, Stefan Wolf, Veit Rohde, and Florian Baptist Freimann Copyright © 2015 Sascha Santosh Chopra et al. All rights reserved. Propofol Infusion Syndrome in Adults: A Clinical Update Sun, 12 Apr 2015 09:28:23 +0000 Propofol infusion syndrome is a rare but extremely dangerous complication of propofol administration. Certain risk factors for the development of propofol infusion syndrome are described, such as appropriate propofol doses and durations of administration, carbohydrate depletion, severe illness, and concomitant administration of catecholamines and glucocorticosteroids. The pathophysiology of this condition includes impairment of mitochondrial beta-oxidation of fatty acids, disruption of the electron transport chain, and blockage of beta-adrenoreceptors and cardiac calcium channels. The disease commonly presents as an otherwise unexplained high anion gap metabolic acidosis, rhabdomyolysis, hyperkalemia, acute kidney injury, elevated liver enzymes, and cardiac dysfunction. Management of overt propofol infusion syndrome requires immediate discontinuation of propofol infusion and supportive management, including hemodialysis, hemodynamic support, and extracorporeal membrane oxygenation in refractory cases. However, we must emphasize that given the high mortality of propofol infusion syndrome, the best management is prevention. Clinicians should consider alternative sedative regimes to prolonged propofol infusions and remain within recommended maximal dose limits. Aibek E. Mirrakhimov, Prakruthi Voore, Oleksandr Halytskyy, Maliha Khan, and Alaa M. Ali Copyright © 2015 Aibek E. Mirrakhimov et al. All rights reserved. Comment on “Management of Atrial Fibrillation in Critically Ill Patients” Sun, 12 Apr 2015 08:54:15 +0000 Sébastien Champion Copyright © 2015 Sébastien Champion. All rights reserved. Incidence and Risk Factors for Delirium among Mechanically Ventilated Patients in an African Intensive Care Setting: An Observational Multicenter Study Sun, 05 Apr 2015 08:45:13 +0000 Aim. Delirium is common among mechanically ventilated patients in the intensive care unit (ICU). There are little data regarding delirium among mechanically ventilated patients in Africa. We sought to determine the burden of delirium and associated factors in Uganda. Methods. We conducted a multicenter prospective study among mechanically ventilated patients in Uganda. Eligible patients were screened daily for delirium using the confusional assessment method (CAM-ICU). Comparisons were made using -test, chi-squares, and Fisher’s exact test. Predictors were assessed using logistic regression. The level of statistical significance was set at . Results. Of 160 patients, 81 (51%) had delirium. Median time to onset of delirium was 3.7 days. At bivariate analysis, history of mental illness, sedation, multiorgan dysfunction, neurosurgery, tachypnea, low mean arterial pressure, oliguria, fevers, metabolic acidosis, respiratory acidosis, anaemia, physical restraints, marital status, and endotracheal tube use were significant predictors. At multivariable analysis, having a history of mental illness, sedation, respiratory acidosis, higher PEEP, endotracheal tubes, and anaemia predicted delirium. Conclusion. The prevalence of delirium in a young African population is lower than expected considering the high mortality. A history of mental illness, anaemia, sedation, endotracheal tube use, and respiratory acidosis were factors associated with delirium. Arthur Kwizera, Jane Nakibuuka, Lameck Ssemogerere, Charles Sendikadiwa, Daniel Obua, Samuel Kizito, Janat Tumukunde, Agnes Wabule, and Noeline Nakasujja Copyright © 2015 Arthur Kwizera et al. All rights reserved. Is There Any Association between PEEP and Upper Extremity DVT? Thu, 02 Apr 2015 14:12:20 +0000 Background. We hypothesized that positive end-exploratory pressure (PEEP) may promote venous stasis in the upper extremities and predispose to upper extremity deep vein thrombosis (UEDVT). Methods. We performed a retrospective case control study of medical intensive care unit patients who required mechanical ventilation (MV) for >72 hours and underwent duplex ultrasound of their upper veins for suspected DVT between January 2011 and December 2013. Results. UEDVT was found in 32 (28.5%) of 112 patients. Nineteen (67.8%) had a central venous catheter on the same side. The mean ± SD duration of MV was days. Average PEEP was  cm H2O. Average PEEP was ≥10 cm H2O in 23 (20.5%) patients. Congestive heart failure (CHF) significantly increased the odds of UEDVT (OR 4.53, 95% CI 1.13–18.11; ) whereas longer duration of MV (≥13 vs. <13 days) significantly reduced it (OR 0.29, 95% CI 0.11–0.8; ). Morbid obesity showed a trend towards significance (OR 3.82, 95% CI 0.95–15.4; ). Neither PEEP nor any of the other analyzed predictors was associated with UEDVT. Conclusions. There is no association between PEEP and UEDVT. CHF may predispose to UEDVT whereas the risk of UEDVT declines with longer duration of MV. Farah Al-Saffar, Ena Gupta, Furqan Siddiqi, Muhammad Faisal, Lisa M. Jones, Vandana Seeram, Mariam Louis, James D. Cury, Abubakr A. Bajwa, and Adil Shujaat Copyright © 2015 Farah Al-Saffar et al. All rights reserved. Contemporary Trends of the Epidemiology, Clinical Characteristics, and Resource Utilization of Necrotizing Fasciitis in Texas: A Population-Based Cohort Study Sun, 29 Mar 2015 08:13:57 +0000 Introduction. There are limited population-level reports on the contemporary trends of the epidemiology, clinical features, resource utilization, and outcomes of necrotizing fasciitis (NF). Methods. We conducted a cohort study of Texas inpatient population, identifying hospitalizations with a diagnosis of NF during the years 2001–2010. The incidence, clinical features, resource utilization, and outcomes of NF hospitalizations were examined. Results. There were 12,172 NF hospitalizations during study period, with ICU admission in 50.3%. The incidence of NF rose 2.7%/year (). Key changes between 2001-2002 and 2009-2010 included rising incidence of NF (5.9 versus 7.6 per 100,000 []), chronic comorbidities (69.4% versus 76.7% []), and development of ≥1 organ failure (28.5% versus 51.7% []). Inflation-adjusted hospital charges rose 37% (). Hospital mortality (9.3%) remained unchanged during study period. Discharges to long-term care facilities rose from 12.2 to 30% (). Conclusions. The present cohort of NF is the largest reported to date. There has been increasing incidence, chronic illness, and severity of illness of NF over the past decade, with half of NF hospitalizations admitted to ICU. Hospital mortality remained unchanged, while need for long-term care rose nearly 2.5-fold among survivors, suggesting increasing residual morbidity. The sources of the observed findings require further study. Lavi Oud and Phillip Watkins Copyright © 2015 Lavi Oud and Phillip Watkins. All rights reserved. Mucolytics for Intubated Asthmatic Children: A National Survey of United Kingdom Paediatric Intensive Care Consultants Wed, 04 Feb 2015 10:56:12 +0000 Aim. The extent to which mucolytics are utilised in mechanically ventilated asthmatic children is unknown. We sought to establish current practice in the United Kingdom (UK) including choice of mucolytic, dose, and frequency of utilisation. Methods. A national electronic survey was distributed to UK consultants during April and May 2014. We were able to identify 168 PICU consultants at 25 institutions to whom we were able to electronically distribute a survey, representing an estimated 81% of UK NHS PICU consultants. Results. Replies were received from 87 consultants at 21 institutions (%). Recombinant human DNase (rhDNase) does get administered by 63% of clinicians, with 54% and 19% that administer hypertonic saline or N-acetylcysteine, respectively. Of those that do administer rhDNase the majority (48%) dilute it with 0.9% saline and blindly administer it, whereas 35% administer rhDNase under bronchoscopic guidance and 17% judge the necessity for bronchoscopy according to clinical severity. 25 respondents described 7 different methods to calculate rhDNase dose. A majority (87%) of respondents expressed an interest to consider enrolling patients into an RCT that evaluates rhDNase. Conclusion. Significant variation exists regarding the necessity for mucolytics, choice of agent, optimal route, and dose in intubated asthmatic children. Aarjan Peter Snoek and Joe Brierley Copyright © 2015 Aarjan Peter Snoek and Joe Brierley. All rights reserved. Postoperative Pulmonary Dysfunction and Mechanical Ventilation in Cardiac Surgery Tue, 03 Feb 2015 06:17:38 +0000 Postoperative pulmonary dysfunction (PPD) is a frequent and significant complication after cardiac surgery. It contributes to morbidity and mortality and increases hospitalization stay and its associated costs. Its pathogenesis is not clear but it seems to be related to the development of a systemic inflammatory response with a subsequent pulmonary inflammation. Many factors have been described to contribute to this inflammatory response, including surgical procedure with sternotomy incision, effects of general anesthesia, topical cooling, and extracorporeal circulation (ECC) and mechanical ventilation (VM). Protective ventilation strategies can reduce the incidence of atelectasis (which still remains one of the principal causes of PDD) and pulmonary infections in surgical patients. In this way, the open lung approach (OLA), a protective ventilation strategy, has demonstrated attenuating the inflammatory response and improving gas exchange parameters and postoperative pulmonary functions with a better residual functional capacity (FRC) when compared with a conventional ventilatory strategy. Additionally, maintaining low frequency ventilation during ECC was shown to decrease the incidence of PDD after cardiac surgery, preserving lung function. Rafael Badenes, Angels Lozano, and F. Javier Belda Copyright © 2015 Rafael Badenes et al. All rights reserved. Early Use of the NMDA Receptor Antagonist Ketamine in Refractory and Superrefractory Status Epilepticus Mon, 12 Jan 2015 06:57:55 +0000 Refractory status epilepticus (RSE) and superrefractory status epilepticus (SRSE) pose a difficult clinical challenge. Multiple cerebral receptor and transporter changes occur with prolonged status epilepticus leading to pharmacoresistance patterns unfavorable for conventional antiepileptics. In particular, n-methyl-d-aspartate (NMDA) receptor upregulation leads to glutamate mediated excitotoxicity. Targeting these NMDA receptors may provide a novel approach to otherwise refractory seizures. Ketamine has been utilized in RSE. Recent systematic review indicates 56.5% and 63.5% cessation in seizures in adults and pediatrics, respectively. No complications were described. We should consider earlier implementation of ketamine or other NMDA receptor antagonists, for RSE. Prospective study of early implementation of ketamine should shed light on the role of such medications in RSE. F. A. Zeiler Copyright © 2015 F. A. Zeiler. All rights reserved. Standardized Application of Laxatives and Physical Measures in Neurosurgical Intensive Care Patients Improves Defecation Pattern but Is Not Associated with Lower Intracranial Pressure Wed, 31 Dec 2014 11:54:51 +0000 Background. Inadequate bowel movements might be associated with an increase in intracranial pressure in neurosurgical patients. In this study we investigated the influence of a structured application of laxatives and physical measures following a strict standard operating procedure (SOP) on bowel movement, intracranial pressure (ICP), and length of hospital stay in patients with a serious acute cerebral disorder. Methods. After the implementation of the SOP patients suffering from a neurosurgical disorder received pharmacological and nonpharmacological measures to improve bowel movements in a standardized manner within the first 5 days after admission to the intensive care unit (ICU) starting on day of admission. We compared mean ICP levels, length of ICU stay, and mechanical ventilation to a historical control group. Results. Patients of the intervention group showed an adequate defecation pattern significantly more often than the patients of the control group. However, this was not associated with lower ICP values, fewer days of mechanical ventilation, or earlier discharge from ICU. Conclusions. The implementation of a SOP for bowel movement increases the frequency of adequate bowel movements in neurosurgical critical care patients. However, this seems not to be associated with reduced ICP values. Martin Kieninger, Barbara Sinner, Bernhard Graf, Astrid Grassold, Sylvia Bele, Milena Seemann, Holger Künzig, and Nina Zech Copyright © 2014 Martin Kieninger et al. All rights reserved. Propofol Infusion Syndrome: A Retrospective Analysis at a Level 1 Trauma Center Wed, 17 Dec 2014 00:10:17 +0000 Objectives. The propofol infusion syndrome (PRIS), a rare, often fatal, condition of unknown etiology, is defined by development of lipemic serum, metabolic acidosis, rhabdomyolysis, hepatomegaly, cardiac arrhythmias, and acute renal failure. Methods. To identify risk factors for and biomarkers of PRIS, a retrospective chart review of all possible PRIS cases during a 1-year period was conducted at a level 1 trauma hospital in ICU patients over 18 years of age receiving continuous propofol infusions for ≥3 days. Additional study inclusion criteria included vasopressor support and monitoring of serum triglycerides and creatinine. Results. Seventy-two patients, 61 males (84.7%) and 11 females (15.3%), satisfied study inclusion criteria; and of these, 3 males met the study definition for PRIS, with 1 case fatality. PRIS incidence was 4.1% with a case-fatality rate of 33%. The mean duration of propofol infusion was 6.96 days. A positive linear correlation was observed between increasing triglyceride levels and infusion duration, but no correlation was observed between increasing creatinine levels and infusion duration. Conclusions. Risk factors for PRIS were confirmed as high dose infusions over prolonged periods. Increasing triglyceride levels may serve as reliable biomarkers of impending PRIS, if confirmed in future investigations with larger sample sizes. James H. Diaz, Amit Prabhakar, Richard D. Urman, and Alan David Kaye Copyright © 2014 James H. Diaz et al. All rights reserved. A Newly Developed Sublingual Tonometric Method for the Evaluation of Tissue Perfusion and Its Validation In Vitro and in Healthy Persons In Vivo and the Results of the Measurements in COPD Patients Tue, 16 Dec 2014 07:13:15 +0000 Introduction. Since its first publication in the medical literature, an extremely large number of references have demonstrated that the tonometric measurement of tissue perfusion is a reliable indicator of the actual condition of critically ill patients. Later a new method was developed by the introduction of sublingual tonometry for the determination of tissue perfusion. In comparison with gastric tonometry, the new method was simpler and could even be used in awake patients. Unfortunately, at present, because of severe failures of manufacturing, the device is withdrawn from commerce. Materials and Methods. In this study, we present a new method using a newly developed tool for the PslCO2 measurement in sublingual tonometry as well as the data for its validation in vitro and in vivo and the results of 25 volunteers and 54 COPD patients belonging to different GOLD groups at their hospitalization due to the acute exacerbation of the disease but already in a stable condition at the time of the examination. Results and Conclusion. The results of the performed examinations showed that the method is suitable for monitoring the actual condition of the patients by mucosal perfusion tonometry in the sublingual region. Zoltán Rózsavölgyi, Domokos Boda, Andrea Hajnal, Krisztina Boda, and Attila Somfay Copyright © 2014 Zoltán Rózsavölgyi et al. All rights reserved. Heliox Improves Carbon Dioxide Removal during Lung Protective Mechanical Ventilation Sun, 07 Dec 2014 07:54:13 +0000 Introduction. Helium is a noble gas with low density and increased carbon dioxide (CO2) diffusion capacity. This allows lower driving pressures in mechanical ventilation and increased CO2 diffusion. We hypothesized that heliox facilitates ventilation in patients during lung-protective mechanical ventilation using low tidal volumes. Methods. This is an observational cohort substudy of a single arm intervention study. Twenty-four ICU patients were included, who were admitted after a cardiac arrest and mechanically ventilated for 3 hours with heliox (50% helium; 50% oxygen). A fixed protective ventilation protocol (6 mL/kg) was used, with prospective observation for changes in lung mechanics and gas exchange. Statistics was by Bonferroni post-hoc correction with statistical significance set at . Results. During heliox ventilation, respiratory rate decreased ( versus breaths min−1, ). Minute volume ventilation showed a trend to decrease compared to baseline ( versus  L min−1, ), while reducing PaCO2 levels ( versus  kPa, ) and peak pressures ( versus  cm H2O, ). Conclusions. Heliox improved CO2 elimination while allowing reduced minute volume ventilation in adult patients during protective mechanical ventilation. Charlotte J. Beurskens, Daniel Brevoord, Wim K. Lagrand, Walter M. van den Bergh, Margreeth B. Vroom, Benedikt Preckel, Janneke Horn, and Nicole P. Juffermans Copyright © 2014 Charlotte J. Beurskens et al. All rights reserved. Gram-Negative Infections in Adult Intensive Care Units of Latin America and the Caribbean Thu, 27 Nov 2014 12:02:44 +0000 This review summarizes recent epidemiology of Gram-negative infections in selected countries from Latin American and Caribbean adult intensive care units (ICUs). A systematic search of the biomedical literature (PubMed) was performed to identify articles published over the last decade. Where appropriate, data also were collected from the reference list of published articles, health departments of specific countries, and registries. Independent cohort data from all countries (Argentina, Brazil, Chile, Colombia, Cuba, Mexico, Trinidad and Tobago, and Venezuela) signified a high rate of ICU infections (prevalence: Argentina, 24%; Brazil, 57%). Gram-negative pathogens, predominantly Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli, accounted for 50% of ICU infections, which were often complicated by the presence of multidrug-resistant strains and clonal outbreaks. Empirical use of antimicrobial agents was identified as a strong risk factor for resistance development and excessive mortality. Infection control strategies utilizing hygiene measures and antimicrobial stewardship programs reduced the rate of device-associated infections. To mitigate the poor health outcomes associated with infections by multidrug-resistant Gram-negative bacteria, urgent focus must be placed on infection control strategies and local surveillance programs. Carlos M. Luna, Eduardo Rodriguez-Noriega, Luis Bavestrello, and Manuel Guzmán-Blanco Copyright © 2014 Carlos M. Luna et al. All rights reserved. Model Point-of-Care Ultrasound Curriculum in an Intensive Care Unit Fellowship Program and Its Impact on Patient Management Sun, 16 Nov 2014 08:37:51 +0000 Objectives. This study was designed to assess the clinical applicability of a Point-of-Care (POC) ultrasound curriculum into an intensive care unit (ICU) fellowship program and its impact on patient care. Methods. A POC ultrasound curriculum for the surgical ICU (SICU) fellowship was designed and implemented in an urban, academic tertiary care center. It included 30 hours of didactics and hands-on training on models. Minimum requirement for each ICU fellow was to perform 25–50 exams on respective systems or organs for a total not less than 125 studies on ICU. The ICU fellows implemented the POC ultrasound curriculum into their daily practice in managing ICU patients, under supervision from ICU staff physicians, who were instructors in POC ultrasound. Impact on patient care including finding a new diagnosis or change in patient management was reviewed over a period of one academic year. Results. 873 POC ultrasound studies in 203 patients admitted to the surgical ICU were reviewed for analysis. All studies included were done through the POC ultrasound curriculum training. The most common exams performed were 379 lung/pleural exams, 239 focused echocardiography and hemodynamic exams, and 237 abdominal exams. New diagnosis was found in 65.52% of cases (95% CI 0.590, 0.720). Changes in patient management were found in 36.95% of cases (95% CI 0.303, 0.435). Conclusions. Implementation of POC ultrasound in the ICU with a structured fellowship curriculum was associated with an increase in new diagnosis in about 2/3 and change in management in over 1/3 of ICU patients studied. Keith Killu, Victor Coba, Michael Mendez, Subhash Reddy, Tanja Adrzejewski, Yung Huang, Jessica Ede, and Mathilda Horst Copyright © 2014 Keith Killu et al. All rights reserved. A Multidisciplinary Approach to Unplanned Conversion from Off-Pump to On-Pump Beating Heart Coronary Artery Revascularization in Patients with Compromised Left Ventricular Function Wed, 12 Nov 2014 08:33:56 +0000 Aim. To comparably assess the perioperative risk factors that differentiate off-pump coronary artery bypass (OPCAB) grafting cases from those sustaining unplanned conversion to on-pump beating heart (ONCAB/BH) approach, in patients with left ventricular ejection fraction (LVEF) < 40%. Methods. Perioperative variables were retrospectively assessed in 216 patients with LVEF < 40%, who underwent myocardial revascularization with OPCAB () or ONCAB/BH () approach. The study endpoints were operative mortality (30-day) and morbidity assessed by length of intensive care unit stay (LOS-ICU), using 2 days as cut-off point. Results. Poor LVEF, increased EuroSCORE II, acute presentation, congestive heart failure, cerebrovascular disease, perioperative renal impairment, clinical status deterioration upon admission and during ICU stay, acute myocardial infarction, and low cardiac output syndrome supported by inotropes and/or balloon-pump counterpulsation were significantly related to ONCAB/BH group (). EuroSCORE II () and LVEF () were the most powerful discriminative predictors of intraoperative conversion to ONCAB/BH. Operative mortality was 2.9% in OPCAB and 6.6% in ONCAB/BH group (), while 23.4% participants in OPCAB and 42.2% in ONCAB/BH approach had a LOS-ICU > 2 days (). Conclusions. Patients with LVEF < 40% undergoing ONCAB/BH are subjected to more preoperative comorbidities and implicated ICU stay than their OPCAB counterparts, which influences adversely short-term morbidity, while operative mortality remains unaffected. Georgia Tsaousi, Antonis A. Pitsis, George D. Ioannidis, and Dimitrios G. Vasilakos Copyright © 2014 Georgia Tsaousi et al. All rights reserved. An In Vitro Analysis of the Effects of Intravenous Lipid Emulsion on Free and Total Local Anaesthetic Concentrations in Human Blood and Plasma Wed, 05 Nov 2014 06:26:10 +0000 Background. Intravenous lipid emulsion (ILE) is recommended as a “rescue” treatment for local anaesthetic (LA) toxicity. A purported mechanism of action suggests that lipophilic LAs are sequestered into an intravascular “lipid-sink,” thus reducing free drug concentration. There is limited data available correlating the effects of ILE on LAs. Aims. To compare the in vitro effect of ILE on LA concentrations in human blood/plasma and to correlate this reduction to LA lipophilicity. Method. One of four LAs (bupivacaine-most lipophilic-4 mg/L, ropivacaine-6 mg/L, lignocaine-14 mg/L, and prilocaine-least lipophilic-7 mg/L) was spiked into plasma or whole blood. ILE or control-buffer was added. Plasma was centrifuged to separate ILE and total-LA concentration assayed from the lipid-free fraction. Whole blood underwent equilibrium dialysis and free-LA concentration was measured. Percent reduction in LA concentration from control was compared between the LAs and correlated with lipophilicity. Results. ILE caused a significant reduction in total and free bupivacaine concentration compared with the other LAs. Ropivacaine had the least reduction in concentration, despite a lipophilicity similar to bupivacaine. The reduction in LA concentration correlated to increasing lipophilicity when ropivacaine was excluded from analysis. Conclusion. In this first in vitro model assessing both free- and total-LA concentrations exposed to ILE in human blood/plasma, ILE effect was linearly correlated with increasing lipophilicity for all but ropivacaine. Louise Ann Clark, Jochen Beyer, and Andis Graudins Copyright © 2014 Louise Ann Clark et al. All rights reserved. Dose-Dependent Hemodynamic, Biochemical, and Tissue Oxygen Effects of OC99 following Severe Oxygen Debt Produced by Hemorrhagic Shock in Dogs Mon, 27 Oct 2014 09:51:51 +0000 We determined the dose-dependent effects of OC99, a novel, stabilized hemoglobin-based oxygen-carrier, on hemodynamics, systemic and pulmonary artery pressures, surrogates of tissue oxygen debt (arterial lactate  mM/L and arterial base excess  mM/L), and tissue oxygen tension (tPO2) in a dog model of controlled severe oxygen-debt from hemorrhagic shock. The dose/rate for OC99 was established from a pilot study conducted in six bled dogs. Subsequently twenty-four dogs were randomly assigned to one of four groups ( per group) and administered: 0.0, 0.065, 0.325, or 0.65 g/kg of OC99 combined with 10 mL/kg lactated Ringers solution administered in conjunction with 20 mL/kg Hextend IV over 60 minutes. The administration of 0.325 g/kg and 0.65 g/kg OC99 produced plasma hemoglobin concentrations of and  g/dL, respectively, improved systemic hemodynamics, enhanced tPO2, and restored lactate and base excess values compared to 0.0 and 0.065 g/kg OC99. The administration of 0.65 g/kg OC99 significantly elevated pulmonary artery pressure. Plasma hemoglobin concentrations of OC99 ranging from 0.3 to 1.1 g/dL, in conjunction with colloid based fluid resuscitation, normalized clinical surrogates of tissue oxygen debt, improved tPO2, and avoided clinically relevant increases in pulmonary artery pressure. William W. Muir, Carlos L. del Rio, Yukie Ueyama, Bradley L. Youngblood, Robert S. George, Carl W. Rausch, Billy S. H. Lau, and Robert L. Hamlin Copyright © 2014 William W. Muir et al. All rights reserved. Early Critical Care Course in Children after Liver Transplant Thu, 25 Sep 2014 06:50:32 +0000 Objective. To review the critical care course of children receiving orthotopic liver transplantation (OLT). Methods. A retrospective chart review of patients admitted to the pediatric critical care following OLT performed in our center between 1988 and 2011. Results. A total of 149 transplants in 145 patients with a median age of 2.7 (IQR 0.9–7) years were analyzed. Mortality in the first 28 days was 8%. The median length of stay (LOS) was 7 (4.0–12.0) days. The median length of mechanical ventilation (MV) was 3 (1.0–6.2) days. Open abdomen, age, and oxygenation index on the 2nd day predicted LOS. Open abdomen, age, amount of blood transfused during surgery, and PRISM III predicted length of MV. 28% of patients had infection and 24% developed acute rejection. In recent group (2000–2011) OLT was performed in younger patients; the risk of infection and acute rejection was reduced and patients required longer LOS and MV compared with old group (1988–1999). Conclusion. The postoperative course of children after OLT is associated with multiple complications. In recent years OLT was performed in younger children; living donors were more common; the rate of postoperative infection and suspected rejection was reduced significantly; however patients required longer MV and LOS in the PCCU. Vinay Kukreti, Hani Daoud, Sundeep S. Bola, Ram N. Singh, Paul Atkison, and Alik Kornecki Copyright © 2014 Vinay Kukreti et al. All rights reserved. Timing of Tracheotomy in Mechanically Ventilated Critically Ill Morbidly Obese Patients Mon, 15 Sep 2014 00:00:00 +0000 Background. The optimal timing of tracheotomy and its impact on weaning from mechanical ventilation in critically ill morbidly obese patients remain controversial. Methods. We conducted a retrospective chart review of morbidly obese subjects (BMI ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 and one or more comorbid conditions) who underwent a tracheotomy between July 2008 and June 2013 at a medical intensive care unit (ICU). Clinical characteristics, rates of nosocomial pneumonia (NP), weaning from mechanical ventilation (MV), and mortality rates were analyzed. Results. A total of 102 subjects (42 men and 60 women) were included; their mean age and BMI were 56.3 ± 15.1 years and 53.3 ± 13.6 kg/m2, respectively. There was no difference in the rate of NP between groups stratified by successful weaning from MV (). Mortality was significantly higher in those who failed to wean (). A cutoff value of 9 days for the time to tracheotomy provided the best balanced sensitivity (72%) and specificity (59.8%) for predicting NP onset. Rates of NP and total duration of MV were significantly higher in those who had tracheostomy ≥ 9 days ( and , resp.). Conclusions. The study suggests that tracheotomy in morbidly obese subjects performed within the first 9 days may reduce MV and decrease NP but may not affect hospital mortality. Ahmad Alhajhusain, Ailia W. Ali, Asif Najmuddin, Kashif Hussain, Masooma Aqeel, and Ali A. El-Solh Copyright © 2014 Ahmad Alhajhusain et al. All rights reserved. The Effect of a Nurse-Led Multidisciplinary Team on Ventilator-Associated Pneumonia Rates Sun, 29 Jun 2014 11:33:22 +0000 Background. Ventilator-associated pneumonia (VAP) is a worrisome, yet potentially preventable threat in critically ill patients. Evidence-based clinical practices targeting the prevention of VAP have proven effective, but the most optimal methods to ensure consistent implementation and compliance remain unknown. Methods. A retrospective study of the trend in VAP rates in a community-hospital’s open medical intensive care unit (MICU) after the enactment of a nurse-led VAP prevention team. The period of the study was between April 1, 2009, and September 30, 2012. The team rounded on mechanically ventilated patients every Tuesday and Thursday. They ensured adherence to the evidence-based VAP prevention. A separate and independent infection control team monitored VAP rates. Results. Across the study period, mean VAP rate was 3.20/1000 ventilator days ±5.71 SD. Throughout the study time frame, there was an average monthly reduction in VAP rate of 0.27/1000 ventilator days, (CI: −0.40–−0.13). Conclusion. A nurse-led interdisciplinary team dedicated to VAP prevention rounding twice a week to ensure adherence with a VAP prevention bundle lowered VAP rates in a community-hospital open MICU. The team had interdepartmental and administrative support and addressed any deficiencies in the VAP prevention bundle components actively. W. Bradley Dosher, Elena C. Loomis, Sherry L. Richardson, Jennifer A. Crowell, Richard D. Waltman, Lisa D. Miller, Muhammad Nazim, and Faisal A. Khasawneh Copyright © 2014 W. Bradley Dosher et al. All rights reserved. A Comparison of the Glasgow Coma Scale Score with Full Outline of Unresponsiveness Scale to Predict Patients’ Traumatic Brain Injury Outcomes in Intensive Care Units Tue, 10 Jun 2014 06:49:56 +0000 Background. Neurological assessment is an essential element of early warning scores used to recognize critically ill patients. We compared the performance of the Glasgow Coma Scale (GCS) with Full Outline of Unresponsiveness (FOUR) scale as an alternative method in the identification of clinically relevant outcomes in traumatic brain injury. Objective. The purpose of this study was to compare the performance of GCS with FOUR scale. Methods. For this study 104 patients with brain injury were recruited from the ICU of Taleghani Hospital, a major teaching hospital in Kermanshah in the western part of Iran. Data was collected concurrently from the ICU admissions by three well-educated nurses and then checked for accuracy by the researcher. Patients were followed up until two weeks or hospital discharge to record their survival status. As a final point expected risk of mortality was calculated using the original formulas for each scale. Results. The mean age of 104 participants was 41.38 ± 18.22 (rang 17 to 86 years) mostly (81 patients 77.9%) males. The FOUR scale has a better prediction for death than GCS. Conclusion. It appears that FOUR scale had better predictive power for mortality and may be a suitable alternative or complementary tool for GCS. Rostam Jalali and Mansour Rezaei Copyright © 2014 Rostam Jalali and Mansour Rezaei. All rights reserved. Delirium during Weaning from Mechanical Ventilation Thu, 29 May 2014 09:34:34 +0000 Background. We compare the incidence of delirium before and after extubation and identify the risk factors and possible predictors for the occurrence of delirium in this group of patients. Methods. Patients weaned from mechanical ventilation (MV) and extubated were included. The assessment of delirium was conducted using the confusion assessment method for the ICU and completed twice per day until discharge from the intensive care unit. Results. Sixty-four patients were included in the study, 53.1% of whom presented with delirium. The risk factors of delirium were age (), SOFA score (), APACHE score (), and a neurological cause of admission (). The majority of the patients began with delirium before or on the day of extubation. Hypoactive delirium was the most common form. Conclusion. Acute (traumatic or medical) neurological injuries were important risk factors in the development of delirium. During the weaning process, delirium developed predominantly before or on the same day of extubation and was generally hypoactive (more difficult to detect). Therefore, while planning early prevention strategies, attention must be focused on neurological patients who are receiving MV and possibly even on patients who are still under sedation. Marcela Aparecida Leite, Erica Fernanda Osaku, Claudia Rejane Lima de Macedo Costa, Maria Fernanda Cândia, Beatriz Toccolini, Caroline Covatti, Nicolle Lamberti Costa, Sandy Teixeira Nogueira, Suely Mariko Ogasawara, Carlos Eduardo de Albuquerque, Cleverson Marcelo Pilatti, Pitágoras Augusto Piana, Amaury Cezar Jorge, and Péricles Almeida Delfino Duarte Copyright © 2014 Marcela Aparecida Leite et al. All rights reserved. An Observational Study on Early Empiric versus Culture-Directed Antifungal Therapy in Critically Ill with Intra-Abdominal Sepsis Thu, 15 May 2014 13:08:41 +0000 Objective. To compare early empiric antifungal treatment with culture-directed treatment in critically ill patients with intra-abdominal sepsis. Methods. A prospective observational cohort study was conducted between August 2010 and July 2011, on SICU patients admitted after surgery for gastrointestinal perforation, bowel obstruction or ischemia, malignancy and anastomotic leakages. Patients who received antifungal treatment within two days of sepsis onset were compared to patients who received culture-directed antifungal treatment in terms of mortality rate and clinical improvement. Patients’ demographics, comorbidities, severity-of-illness scores, and laboratory results were systematically collected and analysed. Results. Thirty-three patients received early empiric and 19 received culture-directed therapy. Of these, 30 from the early empiric group and 18 from culture-directed group were evaluable and analysed. Both groups had similar baseline characteristics and illness severity. Patients on empiric antifungal use had significantly lower 30-day mortality () as well as shorter median time to clinical improvement (). Early empiric antifungal therapy was independently associated with survival beyond 30 days (OR 0.131, 95% CI: 0.018 to 0.966; ). Conclusion. Early empiric antifungal therapy in surgical patients with intra-abdominal sepsis was associated with reduced mortality and warrants further evaluation in randomised controlled trials. Winnie Lee, Yixin Liew, Maciej Piotr Chlebicki, Sharon Ong, Pang Lee, and Andrea Kwa Copyright © 2014 Winnie Lee et al. All rights reserved. Suitability, Efficacy, and Safety of Vernakalant for New Onset Atrial Fibrillation in Critically Ill Patients Mon, 12 May 2014 10:11:17 +0000 Objectives. This study investigates the suitability, safety, and efficacy of vernakalant in critically ill patients with new onset atrial fibrillation (AF) after cardiac surgery. Methods. Patients were screened for inclusion and exclusion criteria according to the manufacturers’ recommendations. Included patients were treated with 3 mg/kg of vernakalant over 10 min and, if unsuccessful, a second dose of 2 mg/kg. Blood pressure was measured continuously for 2 hours after treatment. Results. Of the 191 patients screened, 159 (83%) were excluded, most importantly due to hemodynamic instability (59%). Vernakalant was administered to 32 (17% of the screened) patients. Within 6 hours, 17 (53%) patients converted to sinus rhythm. Blood pressure did not decrease significantly 10, 30, 60, and 120 minutes after the vernakalant infusion. However, 11 patients (34%) experienced a transient decrease in mean arterial blood pressure <60 mmHg. Other adverse events included nausea () and bradycardia (). Conclusions. Applying the strict inclusion and exclusion criteria provided by the manufacturer, only a minority of postoperative ICU patients with new onset AF qualified for vernakalant. Half of the treated patients converted to sinus rhythm. The drug was well tolerated, but close heart rate and blood pressure monitoring remains recommended. Alain Rudiger, Alexander Breitenstein, Mattia Arrigo, Sacha P. Salzberg, and Dominique Bettex Copyright © 2014 Alain Rudiger et al. All rights reserved. Bedside Assessment of Tissue Oxygen Saturation Monitoring in Critically Ill Adults: An Integrative Review of the Literature Thu, 08 May 2014 08:17:47 +0000 Objective. Tissue oxygen saturation (StO2) monitoring is a noninvasive technology with the purpose of alerting the clinician of peripheral hypoperfusion and the onset of tissue hypoxia. This integrative review examines the rigor and quality of studies focusing on StO2 monitoring in adult critically ill patients. Background. Clinicians must rapidly assess adverse changes in tissue perfusion while minimizing potential complications associated with invasive monitoring. The noninvasive measurement of tissue oxygen saturation is based on near-infrared spectroscopy (NIRS), an optical method of illuminating chemical compounds which absorb, reflect, and scatter light directed at that compound. Methods. An integrative review was conducted to develop a context of greater understanding about complex topics. An Integrative review draws on multiple experimental and nonexperimental research methodologies. Results. Fourteen studies were graded at the C category. None reported the use of probability sampling or demonstrated a cause-and-effect relationship between StO2 values and patient outcomes. Conclusions. Future research should be based on rigorous methods of sampling and design in order to enhance the internal and external validity of the findings. Carol Diane Epstein and Karen Toby Haghenbeck Copyright © 2014 Carol Diane Epstein and Karen Toby Haghenbeck. All rights reserved.