Critical Care Research and Practice The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Implementing a Collaborative Sepsis Protocol on the Time to Antibiotics in an Emergency Department of a Saudi Hospital: Quasi Randomized Study Tue, 08 Apr 2014 06:56:40 +0000 Background. The objective of this study is to evaluate the impact of an ED sepsis protocol on the time to antibiotics for emergency department (ED) patients with severe sepsis. Methods. Quasiexperimental prospective study was conducted at the emergency department. Consecutive patients with severe sepsis were included before and after the implementation of a sepsis protocol. The outcome measures were time from recognition of severe sepsis/septic shock to first antibiotic dose delivery and the appropriateness of initial choice of antibiotics based on the presumed source of infection. Results. There were 47 patients in preintervention group and 112 patients in postintervention group. Before implementation, mean time from severe sepsis recognition to delivery of antibiotics was 140 ± 97 minutes. During the intervention period, the mean time was 68 ± 67 minutes, with an overall reduction of 72 minutes. The protocol resulted in an overall improvement of 37% in the compliance, as 62% received appropriate initial antibiotics for the presumed source of infection as compared to 25% before the start of protocol. Conclusion. Implementation of ED sepsis protocol improved the time from recognition of severe sepsis/septic shock to first antibiotic dose delivery as well as the appropriateness of initial antibiotic therapy. Rifat S. Rehmani, Javed I. Memon, and Ayman Al-Gammal Copyright © 2014 Rifat S. Rehmani et al. All rights reserved. Potentially Ineffective Care: Time for Earnest Reexamination Sun, 06 Apr 2014 08:58:59 +0000 The rising costs and suboptimal quality throughout the American health care system continue to invite critical inquiry, and practice in the intensive care unit setting is no exception. Due to their relatively large impact, outcomes and costs in critical care are of significant interest to policymakers and health care administrators. Measurement of potentially ineffective care has been proposed as an outcome measure to evaluate critical care delivery, and the Patient Protection and Affordable Care Act affords the opportunity to reshape the care of the critically ill. Given the impetus of the PPACA, systematic formal measurement of potentially ineffective care and its clinical, economic, and societal impact merits timely reconsideration. William L. Jackson Jr. and Joseph F. Sales Copyright © 2014 William L. Jackson Jr. and Joseph F. Sales. All rights reserved. Acute Kidney Injury after Major Abdominal Surgery: A Retrospective Cohort Analysis Mon, 24 Feb 2014 14:10:53 +0000 Background. We analyzed the incidence, risk factors, and prognosis of acute kidney injury (AKI) in a cohort of patients undergoing major abdominal surgery. Methods. A total of 450 patients were retrospectively studied. AKI was defined by an increase in serum creatinine (SCr) ≥ 0.3 mg/dl or by an increase in SCr ≥ 50% and/or by a decrease in urine output to 0.5 ml/kg/hour for 6 hours, in the first 48 hours after surgery. Logistic regression method was used to determine predictors of AKI and in-hospital mortality. A two-tailed value <0.05 was considered significant. Results. One hundred one patients (22.4%) had postoperative AKI. Age (adjusted odds ratio (OR) 1.02, 95% confidence interval (CI) 1.01–1.05), nonrenal Revised Cardiac Risk Index score (adjusted OR 1.9, 95% CI 1.3–3.1, ), intraoperative erythrocytes transfusions (adjusted OR 2.2, 95% CI 1.4–3.5, ), and nonrenal Simplified Acute Physiology Score II (adjusted OR 1.03, 95% CI 1.01–1.06, ) were associated with postoperative AKI. AKI was associated with increased in-hospital mortality (20.8% versus 2.3%, ; unadjusted OR 11.2, 95% CI 4.8–26.2, ; adjusted OR 3.7, 95% CI 1.2–11.7, ). Conclusion. AKI was common in patients undergoing major abdominal surgery and was associated with in-hospital mortality. Catarina Teixeira, Rosário Rosa, Natacha Rodrigues, Inês Mendes, Lígia Peixoto, Sofia Dias, Maria João Melo, Marta Pereira, Henrique Bicha Castelo, and José António Lopes Copyright © 2014 Catarina Teixeira et al. All rights reserved. Procalcitonin Clearance for Early Prediction of Survival in Critically Ill Patients with Severe Sepsis Mon, 24 Feb 2014 08:12:36 +0000 Introduction. Serum procalcitonin (PCT) diagnosed sepsis in critically ill patients; however, its prediction for survival is not well established. We evaluated the prognostic value of dynamic changes of PCT in sepsis patients. Methods. A prospective observational study was conducted in adult ICU. Patients with systemic inflammatory response syndrome (SIRS) were recruited. Daily PCT were measured for 3 days. 48 h PCT clearance (PCTc-48) was defined as percentage of baseline PCT minus 48 h PCT over baseline PCT. Results. 95 SIRS patients were enrolled (67 sepsis and 28 noninfectious SIRS). 40% patients in the sepsis group died in hospital. Day 1-PCT was associated with diagnosis of sepsis (AUC 0.65 (95% CI, 0.55 to 0.76)) but was not predictive of mortality. In sepsis patients, PCTc-48 was associated with prediction of survival (AUC 0.69 (95% CI, 0.53 to 0.84)). Patients with PCTc-48 > 30% were independently associated with survival (HR 2.90 (95% CI 1.22 to 6.90)). Conclusions. PCTc-48 is associated with prediction of survival in critically ill patients with sepsis. This could assist clinicians in risk stratification; however, the small sample size, and a single-centre study, may limit the generalisability of the finding. This would benefit from replication in future multicentre study. Mohd Basri Mat Nor and Azrina Md Ralib Copyright © 2014 Mohd Basri Mat Nor and Azrina Md Ralib. All rights reserved. Respiratory Variations in Pulse Pressure Reflect Central Hypovolemia during Noninvasive Positive Pressure Ventilation Wed, 19 Feb 2014 00:00:00 +0000 Background. Correct volume management is essential in patients with respiratory failure. We investigated the ability of respiratory variations in noninvasive pulse pressure (ΔPP), photoplethysmographic waveform amplitude (ΔPOP), and pleth variability index (PVI) to reflect hypovolemia during noninvasive positive pressure ventilation by inducing hypovolemia with progressive lower body negative pressure (LBNP). Methods. Fourteen volunteers underwent LBNP of 0, −20, −40, −60, and −80 mmHg for 4.5 min at each level or until presyncope. The procedure was repeated with noninvasive positive pressure ventilation. We measured stroke volume (suprasternal Doppler), ΔPP (Finapres), ΔPOP, and PVI and assessed their association with LBNP-level using linear mixed model regression analyses. Results. Stroke volume decreased with each pressure level (−11.2 mL, 95% CI −11.8, −9.6, ), with an additional effect of noninvasive positive pressure ventilation (−3.0 mL, 95% CI −8.5, −1.3, ). ΔPP increased for each LBNP-level (1.2%, 95% CI 0.5, 1.8, ) and almost doubled during noninvasive positive pressure ventilation (additional increase 1.0%, 95% CI 0.1, 1.9, ). Neither ΔPOP nor PVI was significantly associated with LBNP-level. Conclusions. During noninvasive positive pressure ventilation, preload changes were reflected by ΔPP but not by ΔPOP or PVI. This implies that ΔPP may be used to assess volume status during noninvasive positive pressure ventilation. Ingrid Elise Hoff, Lars Øivind Høiseth, Jonny Hisdal, Jo Røislien, Svein Aslak Landsverk, and Knut Arvid Kirkebøen Copyright © 2014 Ingrid Elise Hoff et al. All rights reserved. Etiology and Outcomes of ARDS in a Rural-Urban Fringe Hospital of South India Mon, 10 Feb 2014 16:07:39 +0000 Objectives. Etiology and outcomes of acute lung injury in tropical countries may be different from those of western nations. We describe the etiology and outcomes of illnesses causing acute lung injury in a rural populace. Study Design. A prospective observational study. Setting. Medical ICU of a teaching hospital in a rural-urban fringe location. Patients. Patients ≥13 years, admitted between December 2011 and May 2013, satisfying AECC criteria for ALI/ARDS. Results. Study had 61 patients; 46 had acute lung injury at admission. Scrub typhus was the commonest cause (7/61) and tropical infections contributed to 26% of total cases. Increasing ARDS severity was associated with older age, higher FiO2 and APACHE/SOFA scores, and longer duration of ventilation. Nonsurvivors were generally older, had shorter duration of illness, a nontropical infection, and higher total WBC counts, required longer duration of ventilation, and had other organ dysfunction and higher mean APACHE scores. The mortality rate of ARDS was 36.6% (22/61) in our study. Conclusion. Tropical infections form a major etiological component of acute lung injury in a developing country like India. Etiology and outcomes of ARDS may vary depending upon the geographic location and seasonal illnesses. Tarun George, Stalin Viswanathan, Ali Hasan Faiz Karnam, and Georgi Abraham Copyright © 2014 Tarun George et al. All rights reserved. Management of Atrial Fibrillation in Critically Ill Patients Thu, 16 Jan 2014 15:02:46 +0000 Atrial fibrillation (AF) is common in ICU patients and is associated with a two- to fivefold increase in mortality. This paper provides a reappraisal of the management of AF with a special focus on critically ill patients with haemodynamic instability. AF can cause hypotension and heart failure with subsequent organ dysfunction. The underlying mechanisms are the loss of atrial contraction and the high ventricular rate. In unstable patients, sinus rhythm must be rapidly restored by synchronised electrical cardioversion (ECV). If pharmacological treatment is indicated, clinicians can choose between the rate control and the rhythm control strategy. The optimal substance should be selected depending on its potential adverse effects. A beta-1 antagonist with a very short half-life (e.g., esmolol) is an advantage for ICU patients because the effect of beta-blockade on cardiovascular stability is unpredictable in those patients. Amiodarone is commonly used in the ICU setting but has potentially severe cardiac and noncardiac side effects. Digoxin controls the ventricular response at rest, but its benefit decreases in the presence of adrenergic stress. Vernakalant converts new-onset AF to sinus rhythm in approximately 50% of patients, but data on its efficacy and safety in critically ill patients are lacking. Mattia Arrigo, Dominique Bettex, and Alain Rudiger Copyright © 2014 Mattia Arrigo et al. All rights reserved. Prehospital Intubation in Patients with Isolated Severe Traumatic Brain Injury: A 4-Year Observational Study Thu, 16 Jan 2014 00:00:00 +0000 Objectives. To study the effect of prehospital intubation (PHI) on survival of patients with isolated severe traumatic brain injury (ISTBI). Method. Retrospective analyses of all intubated patients with ISTBI between 2008 and 2011 were studied. Comparison was made between those who were intubated in the PHI versus in the trauma resuscitation unit (TRU). Results. Among 1665 TBI patients, 160 met the inclusion criteria (105 underwent PHI, and 55 patients were intubated in TRU). PHI group was younger in age and had lower median scene motor GCS (). Ventilator days and hospital length of stay ( and 0.006, resp.) were higher in TRUI group. Mean ISS, length of stay, initial blood pressure, pneumonia, and ARDS were comparable among the two groups. Mortality rate was higher in the PHI group (54% versus 31%, ). On multivariate regression analysis, scene motor GCS (OR 0.55; 95% CI 0.41–0.73) was an independent predictor for mortality. Conclusion. PHI did not offer survival benefit in our group of patients with ISTBI based on the head AIS and the scene motor GCS. However, more studies are warranted to prove this finding and identify patients who may benefit from this intervention. Mazin Tuma, Ayman El-Menyar, Husham Abdelrahman, Hassan Al-Thani, Ahmad Zarour, Ashok Parchani, Sherwan Khoshnaw, Ruben Peralta, and Rifat Latifi Copyright © 2014 Mazin Tuma et al. All rights reserved. Bedside Percutaneous Tracheostomy versus Open Surgical Tracheostomy in Non-ICU Patients Sun, 12 Jan 2014 13:44:08 +0000 Percutaneous bedside tracheostomy (PBT) is a one of the common and safe procedures in intensive care units through the world. In the present paper we published our clinical experience with a performance of PBTs in the regular ward by intensive care physicians’ team. We found it safe and similar outcome in comparison to open surgical tracheostomy method in operation room by ENT team. The performance of PBT in the regular ward showed potential economic advantages in saving medical staff and operating room resources. Evgeni Brotfain, Leonid Koyfman, Amit Frenkel, Michael Semyonov, Jochanan G. Peiser, Hagit Hayun-Maman, Matthew Boyko, Shaun E. Gruenbaum, Alexander Zlotnik, and Moti Klein Copyright © 2014 Evgeni Brotfain et al. All rights reserved. Diabetes and Hemoglobin A1c as Risk Factors for Nosocomial Infections in Critically Ill Patients Sun, 29 Dec 2013 17:16:22 +0000 Objective. To evaluate whether diabetes mellitus (DM) and hemoglobin A1c (HbA1c) are risk factors for ventilator-associated pneumonia (VAP) and bloodstream infections (BSI) in critically ill patients. Methods. Prospective observational study; patients were recruited from the intensive care unit (ICU) of a general district hospital between 2010 and 2012. Inclusion criteria: ICU hospitalization >72 hours and mechanical ventilation >48 hours. HbA1c was calculated for all participants. DM, HbA1c, and other clinical and laboratory parameters were assessed as risk factors for VAP or BSI in ICU. Results. The overall ICU incidence of VAP and BSI was 26% and 30%, respectively. Enteral feeding OR (95%CI) 6.20 (1.91–20.17; ) and blood transfusion 3.33 (1.23–9.02; ) were independent risk factors for VAP. BSI in ICU () and ICU mortality () were significantly increased in diabetics. Independent risk factors for BSI in ICU included BSI on admission 2.45 (1.14–5.29; ) and stroke on admission2.77 (1.12–6.88; ). Sepsis 3.34 (1.47–7.58; ) and parenteral feeding 6.29 (1.59–24.83; ) were independently associated with ICU mortality. HbA1c ≥ 8.1% presented a significant diagnostic performance in diagnosing repeated BSI in ICU. Conclusion. DM and HbA1c were not associated with increased VAP or BSI frequency. HbA1c was associated with repeated BSI episodes in the ICU. Eirini Tsakiridou, Demosthenes Makris, Vasiliki Chatzipantazi, Odysseas Vlachos, Grigorios Xidopoulos, Olympia Charalampidou, Georgios Moraitis, and Epameinondas Zakynthinos Copyright © 2013 Eirini Tsakiridou et al. All rights reserved. Is Vitamin D Insufficiency Associated with Mortality of Critically Ill Patients? Wed, 25 Dec 2013 14:05:59 +0000 Objective. To evaluate the vitamin D status of our critically ill patients and its relevance to mortality. Patients and Methods. We performed a prospective observational study in the medical intensive care unit of a university hospital between October 2009 and March 2011. Vitamin D levels were measured and insufficiency was defined as <20 ng/mL. Results. Two hundred and one patients were included in the study. The median age was 66 (56–77) and the majority of patients were male (56%). The median serum level of vitamin D was 14,9 ng/mL and 139 (69%) patients were vitamin D insufficient on admission. While we grouped the ICU patients as vitamin D insufficient and sufficient, vitamin D insufficient patients had more severe acute diseases and worse laboratory values on admission. These patients had more morbidities and were exposed to more invasive therapies during stay. The mortality rate was significantly higher in the vitamin D insufficient group compared to the vitamin D sufficient group (43% versus 26%, ). However, logistic regression analysis demonstrated that vitamin D insufficiency was not an independent risk factor for mortality. Conclusion. Vitamin D insufficiency is common in our critically ill patients (69%), but it is not an independent risk factor for mortality. Gulbin Aygencel, Melda Turkoglu, Ayse Fitnat Tuncel, Burcu Arslan Candır, Yelda Deligoz Bildacı, and Hatice Pasaoglu Copyright © 2013 Gulbin Aygencel et al. All rights reserved. Job Satisfaction and Burnout among Intensive Care Unit Nurses and Physicians Tue, 05 Nov 2013 15:10:20 +0000 Introduction. Nurses and physicians working in the intensive care unit (ICU) may be exposed to considerable job stress. The study aim was to assess the level of and the relationship between (1) job satisfaction, (2) job stress, and (3) burnout symptoms. Methods. A cross-sectional study was performed at ICUs at Oslo University Hospital. 145 of 196 (74%) staff members (16 physicians and 129 nurses) answered the questionnaire. The following tools were used: job satisfaction scale (scores 10–70), modified Cooper's job stress questionnaire (scores 1–5), and Maslach burnout inventory (scores 1–5); high score in the dimension emotional exhaustion (EE) indicates burnout. Personality was measured with the basic character inventory. Dimensions were neuroticism (vulnerability), extroversion (intensity), and control/compulsiveness with the range 0–9. Results. Mean job satisfaction among nurses was 43.9 (42.4–45.4) versus 51.1 (45.3–56.9) among physicians, . The mean burnout value (EE) was 2.3 (95% CI 2.2–2.4), and mean job stress was 2.6 (2.5–2.7), not significantly different between nurses and physicians. Females scored higher than males on vulnerability, 3.3 (2.9–3.7) versus 2.0 (1.1–2.9) (), and experienced staff were less vulnerable, 2.7 (2.2–3.2), than inexperienced staff, 3.6 (3.0–4.2) (). Burnout (EE) correlated with job satisfaction (, ), job stress (, ), and vulnerability (, ). Conclusions. The nurses were significantly less satisfied with their jobs compared to the physicians. Burnout mean scores are relatively low, but high burnout scores are correlated with vulnerable personality, low job satisfaction, and high degree of job stress. Hilde Myhren, Øivind Ekeberg, and Olav Stokland Copyright © 2013 Hilde Myhren et al. All rights reserved. Therapeutic Strategies for High-Dose Vasopressor-Dependent Shock Sun, 15 Sep 2013 14:10:51 +0000 There is no consensual definition of refractory shock. The use of more than 0.5 mcg/kg/min of norepinephrine or epinephrine to maintain target blood pressure is often used in clinical trials as a threshold. Nearly 6% of critically ill patients will develop refractory shock, which accounts for 18% of deaths in intensive care unit. Mortality rates are usually greater than 50%. The assessment of fluid responsiveness and cardiac function can help to guide therapy, and inotropes may be used if hypoperfusion signs persist after initial resuscitation. Arginine vasopressin is frequently used in refractory shock, although definite evidence to support this practice is still missing. Its associations with corticosteroids improved outcome in observational studies and are therefore promising alternatives. Other rescue therapies such as terlipressin, methylene blue, and high-volume isovolemic hemofiltration await more evidence before use in routine practice. Estevão Bassi, Marcelo Park, and Luciano Cesar Pontes Azevedo Copyright © 2013 Estevão Bassi et al. All rights reserved. Central Venous-to-Arterial Gap Is a Useful Parameter in Monitoring Hypovolemia-Caused Altered Oxygen Balance: Animal Study Thu, 29 Aug 2013 16:02:07 +0000 Monitoring hypovolemia is an everyday challenge in critical care, with no consensus on the best indicator or what is the clinically relevant level of hypovolemia. The aim of this experiment was to determine how central venous oxygen saturation (ScvO2) and central venous-to-arterial carbon dioxide difference (CO2 gap) reflect hypovolemia-caused changes in the balance of oxygen delivery and consumption. Anesthetized, ventilated Vietnamese minipigs () were given a bolus followed by a continuous infusion of furosemide. At baseline and then in five stages hemodynamic, microcirculatory measurements and blood gas analysis were performed. Oxygen extraction increased significantly, which was accompanied by a significant drop in ScvO2 and a significant increase in CO2 gap. There was a significant negative correlation between oxygen extraction and ScvO2 and significant positive correlation between oxygen extraction and CO2 gap. Taking % and CO2 gap >6 mmHg values together to predict an oxygen extraction >30%, the positive predictive value is 100%; negative predicted value is 72%. Microcirculatory parameters, capillary perfusion rate and red blood cell velocity, decreased significantly over time. Similar changes were not observed in the sham group. Our data suggest that % and CO2 gap >6 mmHg can be complementary tools in detecting hypovolemia-caused imbalance of oxygen extraction. Szilvia Kocsi, Gabor Demeter, Daniel Erces, Eniko Nagy, Jozsef Kaszaki, and Zsolt Molnar Copyright © 2013 Szilvia Kocsi et al. All rights reserved. High-Frequency Oscillatory Ventilation Combined with Volume Guarantee in a Neonatal Animal Model of Respiratory Distress Syndrome Thu, 18 Jul 2013 11:17:31 +0000 Objective. To assess volume guarantee (VG) ventilation combined with high-frequency oscillatory ventilation (HFOV) strategy on PaCO2 regulation in an experimental model of neonatal distress syndrome. Methods. Six 2-day-old piglets weighing  kg were used for this interventional experimental study. Animals were ventilated during physiologic lung conditions and after depletion of lung surfactant by bronchoalveolar lavage (BAL). The effect of HFOV combined with VG on PaCO2 was evaluated at different high-frequency expired tidal volume (VThf) at constant frequency () and mean airway pressure (mPaw). Fluctuations of the pressure (ΔPhf) around the mPaw and PaCO2 were analyzed before and after lung surfactant depletion. Results. PaCO2 levels were inversely proportional to VThf. In the physiological lung condition, an increase in VThf caused a significant decrease in PaCO2 and an increase in ΔPhf. After BAL, PaCO2 did not change as compared with pre-BAL situation as the VThf remained constant by the ventilator. Conclusions. In this animal model, using HFOV combined with VG, changes in the VThf settings induced significant modifications in PaCO2. After changing the lung condition by depletion of surfactant, PaCO2 remained unchanged, as the VThf setting was maintained constant by modifications in the ΔPhf done by the ventilator. Manuel Sánchez Luna, Martín Santos González, and Francisco Tendillo Cortijo Copyright © 2013 Manuel Sánchez Luna et al. All rights reserved. Validation of Computerized Automatic Calculation of the Sequential Organ Failure Assessment Score Tue, 09 Jul 2013 15:07:09 +0000 Purpose. To validate the use of a computer program for the automatic calculation of the sequential organ failure assessment (SOFA) score, as compared to the gold standard of manual chart review. Materials and Methods. Adult admissions (age > 18 years) to the medical ICU with a length of stay greater than 24 hours were studied in the setting of an academic tertiary referral center. A retrospective cross-sectional analysis was performed using a derivation cohort to compare automatic calculation of the SOFA score to the gold standard of manual chart review. After critical appraisal of sources of disagreement, another analysis was performed using an independent validation cohort. Then, a prospective observational analysis was performed using an implementation of this computer program in AWARE Dashboard, which is an existing real-time patient EMR system for use in the ICU. Results. Good agreement between the manual and automatic SOFA calculations was observed for both the derivation () and validation () cohorts: 0.02 ± 2.33 and 0.29 ± 1.75 points, respectively. These results were validated in AWARE (). Conclusion. This EMR-based automatic tool accurately calculates SOFA scores and can facilitate ICU decisions without the need for manual data collection. This tool can also be employed in a real-time electronic environment. Andrew M. Harrison, Hemang Yadav, Brian W. Pickering, Rodrigo Cartin-Ceba, and Vitaly Herasevich Copyright © 2013 Andrew M. Harrison et al. All rights reserved. Acute Kidney Injury in the Critically Ill Patient Sun, 23 Jun 2013 16:11:15 +0000 Manuel E. Herrera-Gutiérrez, Gemma Seller-Pérez, Javier Maynar-Moliner, José A. Sánchez-Izquierdo-Riera, Anibal Marinho, and José Luis Do pico Copyright © 2013 Manuel E. Herrera-Gutiérrez et al. All rights reserved. Outcomes of Chronic Hemodialysis Patients in the Intensive Care Unit Thu, 09 May 2013 08:23:30 +0000 Patients with end-stage renal disease (ESRD) experience higher rates of hospitalisation, cardiovascular events, and all-cause mortality and are more likely to require admission to the intensive care unit (ICU) than patients with normal renal function. Sepsis and cardiovascular diseases are the most common reasons for ICU admission. ICU mortality rates in patients requiring chronic hemodialysis are significantly higher than for patients without ESRD; however, dialysis patients have a better ICU outcome than those with acute kidney injury (AKI) requiring renal replacement therapy suggesting that factors other than loss of renal function contribute to their prognosis. Current evidence suggests, the longer-term outcomes after discharge from ICU may be favourable and that long-term dependence on dialysis should not prejudice against prompt referral or admission to ICU. Melanie Chan and Marlies Ostermann Copyright © 2013 Melanie Chan and Marlies Ostermann. All rights reserved. Estimating Kidney Function in the Critically Ill Patients Wed, 08 May 2013 11:18:03 +0000 Glomerular filtration rate (GFR) is an accepted measure for assessment of kidney function. For the critically ill patient, creatinine clearance is the method of reference for the estimation of the GFR, although this is often not measured but estimated by equations (i.e., Cockroft-Gault or MDRD) not well suited for the critically ill patient. Functional evaluation of the kidney rests in serum creatinine (Crs) that is subjected to multiple external factors, especially relevant overhydration and loss of muscle mass. The laboratory method used introduces variations in Crs, an important fact considering that small increases in Crs have serious repercussion on the prognosis of patients. Efforts directed to stratify the risk of acute kidney injury (AKI) have crystallized in the RIFLE or AKIN systems, based in sequential changes in Crs or urine flow. These systems have provided a common definition of AKI and, due to their sensitivity, have meant a considerable advantage for the clinical practice but, on the other side, have introduced an uncertainty in clinical research because of potentially overestimating AKI incidence. Another significant drawback is the unavoidable period of time needed before a patient is classified, and this is perhaps the problem to be overcome in the near future. Gemma Seller-Pérez, Manuel E. Herrera-Gutiérrez, Javier Maynar-Moliner, José A. Sánchez-Izquierdo-Riera, Anibal Marinho, and José Luis do Pico Copyright © 2013 Gemma Seller-Pérez et al. All rights reserved. The Extent of Ventilator-Induced Lung Injury in Mice Partly Depends on Duration of Mechanical Ventilation Wed, 17 Apr 2013 17:41:38 +0000 Background. Mechanical ventilation (MV) has the potential to initiate ventilator-induced lung injury (VILI). The pathogenesis of VILI has been primarily studied in animal models using more or less injurious ventilator settings. However, we speculate that duration of MV also influences severity and character of VILI. Methods. Sixty-four healthy C57Bl/6 mice were mechanically ventilated for 5 or 12 hours, using lower tidal volumes with positive end-expiratory pressure (PEEP) or higher tidal volumes without PEEP. Fifteen nonventilated mice served as controls. Results. All animals remained hemodynamically stable and survived MV protocols. In both MV groups, PaO2 to FiO2 ratios were lower and alveolar cell counts were higher after 12 hours of MV compared to 5 hours. Alveolar-capillary permeability was increased after 12 hours compared to 5 hours, although differences did not reach statistical significance. Lung levels of inflammatory mediators did not further increase over time. Only in mice ventilated with increased strain, lung compliance declined and wet to dry ratio increased after 12 hours of MV compared to 5 hours. Conclusions. Deleterious effects of MV are partly dependent on its duration. Even lower tidal volumes with PEEP may initiate aspects of VILI after 12 hours of MV. Maria A. Hegeman, Sabrine N. T. Hemmes, Maria T. Kuipers, Lieuwe D. J. Bos, Geartsje Jongsma, Joris J. T. H. Roelofs, Koenraad F. van der Sluijs, Nicole P. Juffermans, Margreeth B. Vroom, and Marcus J. Schultz Copyright © 2013 Maria A. Hegeman et al. All rights reserved. Epidemiology of Acute Kidney Injury in the Intensive Care Unit Thu, 21 Mar 2013 18:23:09 +0000 The incidence of acute kidney injury (AKI) in the intensive care unit (ICU) has increased during the past decade due to increased acuity as well as increased recognition. Early epidemiology studies were confounded by erratic definitions of AKI until recent consensus guidelines (RIFLE and AKIN) standardized its definition. This paper discusses the incidence of AKI in the ICU with focuses on specific patient populations. The overall incidence of AKI in ICU patients ranges from 20% to 50% with lower incidence seen in elective surgical patients and higher incidence in sepsis patients. The incidence of contrast-induced AKI is less (11.5%–19% of all admissions) than seen in the ICU population at large. AKI represents a significant risk factor for mortality and can be associated with mortality greater than 50%. James Case, Supriya Khan, Raeesa Khalid, and Akram Khan Copyright © 2013 James Case et al. All rights reserved. Neonatal Lung Disease and Respiratory Failure Tue, 12 Mar 2013 11:36:01 +0000 Hercília Guimarães, Anton van Kaam, Gustavo Rocha, and Manuel Sánchez Luna Copyright © 2013 Hercília Guimarães et al. All rights reserved. Simulations for Mechanical Ventilation in Children: Review and Future Prospects Thu, 07 Mar 2013 11:10:30 +0000 Mechanical ventilation is a very effective therapy, but with many complications. Simulators are used in many fields, including medicine, to enhance safety issues. In the intensive care unit, they are used for teaching cardiorespiratory physiology and ventilation, for testing ventilator performance, for forecasting the effect of ventilatory support, and to determine optimal ventilatory management. They are also used in research and development of clinical decision support systems (CDSSs) and explicit computerized protocols in closed loop. For all those reasons, cardiorespiratory simulators are one of the tools that help to decrease mechanical ventilation duration and complications. This paper describes the different types of simulators described in the literature for physiologic simulation and modeling of the respiratory system, including a new simulator (SimulResp), and proposes a validation process for these simulators. Olivier Flechelles, Annie Ho, Patrice Hernert, Guillaume Emeriaud, Nesrine Zaglam, Farida Cheriet, and Philippe A. Jouvet Copyright © 2013 Olivier Flechelles et al. All rights reserved. Anemia among Pediatric Critical Care Survivors: Prevalence and Resolution Wed, 27 Feb 2013 16:00:09 +0000 To determine the incidence of anemia among pediatric critical care survivors and to determine whether it resolves within 6 months of discharge. Design. A prospective observational study. Patients with anemia upon discharge from the pediatric critical care unit (PCCU) underwent in hospital and post hospital discharge followup (4–6 months) for hemoglobin (Hb) levels. Setting. A medical-surgical PCCU in a tertiary care center. Patients. Patients aged 28 days to 18 years who were treated in the PCCU for over 24 hours. Measurements and Main Results. 94 (24%) out of 392 eligible patients were anemic at time of discharge. Patients with anemia were older, median 8.0 yrs [(IQR 1.0–14.4) versus 3.2 yrs (IQR 0.65–9.9) ()], and had higher PeLOD [median 11 (IQR 10–12) versus 1.5 (1–4) ()], and PRISM [median 5 (IQR 2–11) versus 3 (IQR 0–6) ()] scores. The Hb level normalized in 32% of patients before discharge from hospital. Of the 28 patients who completed followup, all had normalization of their Hb in the absence of medical intervention. Conclusions. Anemia is not common among patients discharged from the PCCU and recovers spontaneously within 4–6 months. Quang N. Ngo, Doreen M. Matsui, Ram N. Singh, Shayna Zelcer, and Alik Kornecki Copyright © 2013 Quang N. Ngo et al. All rights reserved. From Macrohemodynamic to the Microcirculation Wed, 27 Feb 2013 13:53:30 +0000 ICU patients need a prompt normalization of macrohemodynamic parameters. Unfortunately, this optimization sometimes does not protect patients from organ failure development. Prevention or treatment of organ failure needs another target to be pursued: the microcirculatory restoration. Microcirculation is the ensemble of vessels of maximum 100 m in diameter. Nowadays the Sidestream Dark Field (SDF) imaging technique allows its bedside investigation and a recent round-table conference established the criteria for its evaluation. First, microcirculatory derangements have been studied in sepsis: they are mainly characterized by a reduction of vessel density, an alteration of flow, and a heterogeneous distribution of perfusion. Endothelial malfunction and glycocalyx rupture were proved to be the main reasons for the observed microthrombi, capillary leakage, leukocyte rolling, and rouleaux phenomenon, even if further studies are necessary for a better explanation. Therapeutic approaches targeting microcirculation are under investigation. Microcirculatory alterations have been recently demonstrated in other diseases such as hypovolemia and cardiac failure but this issue still needs to be explored. The aim of this paper is to gather the already known information, focus the reader’s attention on the importance of microvascular physiopathology in critical illness, and prompt him to actively participate to achieve a more comprehensive understanding of the issue. Abele Donati, Roberta Domizi, Elisa Damiani, Erica Adrario, Paolo Pelaia, and Can Ince Copyright © 2013 Abele Donati et al. All rights reserved. Noninvasive Monitoring during Interhospital Transport of Newborn Infants Sun, 24 Feb 2013 09:26:02 +0000 The main indications for interhospital neonatal transports are radiographic studies (e.g., magnet resonance imaging) and surgical interventions. Specialized neonatal transport teams need to be skilled in patient care, communication, and equipment management and extensively trained in resuscitation, stabilization, and transport of critically ill infants. However, there is increasing evidence that clinical assessment of heart rate, color, or chest wall movements is imprecise and can be misleading even in experienced hands. The aim of the paper was to review the current evidence on clinical monitoring equipment during interhospital neonatal transport. Georg M. Schmölzer, Megan O’Reilly, and Po-Yin Cheung Copyright © 2013 Georg M. Schmölzer et al. All rights reserved. Improved Outcome of Severe Acute Pancreatitis in the Intensive Care Unit Thu, 21 Feb 2013 10:17:49 +0000 Background. Severe acute pancreatitis (SAP) is associated with serious morbidity and mortality. Our objective was to describe the case mix, management, and outcome of patients with SAP receiving modern critical care in the Intensive Care Unit (ICU). Methods. Retrospective analysis of patients with SAP admitted to the ICU in a single tertiary care centre in the UK between January 2005 and December 2010. Results. Fifty SAP patients were admitted to ICU (62% male, mean age 51.7 (SD 14.8)). The most common aetiologies were alcohol (40%) and gallstones (30%). On admission to ICU, the median Acute Physiology and Chronic Health Evaluation (APACHE) II score was 17, the pancreatitis outcome prediction score was 8, and the median Computed Tomography Severity Index (CTSI) was 4. Forty patients (80%) tolerated enteral nutrition, and 46% received antibiotics for non-SAP reasons. Acute kidney injury was significantly more common among hospital nonsurvivors compared to survivors (100% versus 42%, ). ICU mortality and hospital mortality were 16% and 20%, respectively, and median lengths of stay in ICU and hospital were 13.5 and 30 days, respectively. Among hospital survivors, 27.5% developed diabetes mellitus and 5% needed long-term renal replacement therapy. Conclusions. The outcome of patients with SAP in ICU was better than previously reported but associated with a resource demanding hospital stay and long-term morbidity. Polychronis Pavlidis, Siobhan Crichton, Joanna Lemmich Smith, David Morrison, Simon Atkinson, Duncan Wyncoll, and Marlies Ostermann Copyright © 2013 Polychronis Pavlidis et al. All rights reserved. Interest of Monitoring Diaphragmatic Electrical Activity in the Pediatric Intensive Care Unit Thu, 21 Feb 2013 09:33:03 +0000 The monitoring of electrical activity of the diaphragm (EAdi) is a new minimally invasive bedside technology that was developed for the neurally adjusted ventilatory assist (NAVA) mode of ventilation. In addition to its role in NAVA ventilation, this technology provides the clinician with previously unavailable and essential information on diaphragm activity. In this paper, we review the clinical interests of EAdi in the pediatric intensive care setting. Firstly, the monitoring of EAdi allows the clinician to tailor the ventilatory settings on an individual basis, avoiding frequent overassistance leading potentially to diaphragmatic atrophy. Increased inspiratory EAdi levels can also suggest insufficient support, while a strong tonic activity may reflect the patient efforts to increase its lung volume. EAdi monitoring also allows detection of patient-ventilator asynchrony. It can play a role in evaluation of extubation readiness. Finally, EAdi monitoring provides the clinician with better understanding of the ventilatory capacity of patients with acute neuromuscular disease. Further studies are warranted to evaluate the clinical impact of these potential benefits. Laurence Ducharme-Crevier, Geneviève Du Pont-Thibodeau, and Guillaume Emeriaud Copyright © 2013 Laurence Ducharme-Crevier et al. All rights reserved. Outcomes of Severe Sepsis and Septic Shock Patients on Chronic Antiplatelet Treatment: A Historical Cohort Study Wed, 20 Feb 2013 15:02:27 +0000 Background. Sepsis is characterized by dysfunctional activation of platelets, and antiplatelet therapy could improve the outcomes of septic patients. Methods. We performed a retrospective cohort study of severe sepsis or septic shock adult patients. Outcomes of patients on antiplatelet therapy were compared to those that were not taking antiplatelet therapy by univariate analysis followed by a propensity score analysis based on the probability of receiving antiplatelet therapy. Results. Of 651 patients included in the study 272 (42.8%) were on antiplatelet therapy before the development of severe sepsis or septic shock. After adjusting for important confounding variables antiplatelet therapy was not associated with a decreased risk of hospital mortality (odds ratio 0.73, 95% confidence interval 0.46–1.16). Antiplatelet therapy was associated with a decreased incidence of acute respiratory distress syndrome/acute lung injury (odds ratio 0.50, 95% confidence interval 0.35–0.71) and reduced need of mechanical ventilation (odds ratio 0.62, 95% confidence interval 0.45–87). Incidence of acute kidney injury was similar between both groups (odds ratio 1.08, 95% confidence interval 0.73–1.59). Conclusions. The use of antiplatelet therapy before the diagnosis of severe sepsis or septic shock was not associated with decreased hospital mortality. Antiplatelet therapy was associated with a decreased incidence of acute lung injury/acute respiratory distress syndrome. Juan C. Valerio-Rojas, Insara J. Jaffer, Daryl J. Kor, Ognjen Gajic, and Rodrigo Cartin-Ceba Copyright © 2013 Juan C. Valerio-Rojas et al. All rights reserved. Volume Management in the Critically Ill Patient with Acute Kidney Injury Thu, 07 Feb 2013 12:11:26 +0000 Acute kidney injury (AKI) frequently occurs in the setting of critical illness and its management poses a challenge for the intensivist. Optimal management of volume status is critical in the setting of AKI in the ICU patient. The use of urine sodium, the fractional excretion of sodium (FeNa), and the fractional excretion of urea (FeUrea) are common clinical tools used to help guide fluid management especially further volume expansion but should be used in the context of the patient’s overall clinical scenario as they are not completely sensitive or specific for the finding of volume depletion and can be misleading. In the case of oliguric or anuric AKI, diuretics are often utilized to increase the urine output although current evidence suggests that they are best reserved for the treatment of volume overload and hyperkalemia in patients who are likely to respond to them. Management of volume overload in ICU patients with AKI is especially important as volume overload has several negative effects on organ function and overall morbidity and mortality. Mary Labib, Raeesa Khalid, Akram Khan, and Supriya Khan Copyright © 2013 Mary Labib et al. All rights reserved.