Critical Care Research and Practice The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . 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. Platelet Consumption and Filter Clotting Using Two Different Membrane Sizes during Continuous Venovenous Haemodiafiltration in the Intensive Care Unit Sun, 27 Apr 2014 09:04:57 +0000 Background. The aim of this study was to investigate whether different haemofilter surface areas affect clotting and platelet consumption in critically ill patients undergoing continuous venovenous haemodiafiltration (CVVHDF). Methods. CVVHDF was performed in postdilution technique using a capillary haemofilter with two different membrane sizes, Ultraflux AV 1000S (, surface 1.8 m2, volume 130 mL), and the smaller AV 600S (, surface 1.4 m2, volume 100 mL), respectively. Anticoagulation was performed with heparin. Results. No significant differences were found when the two filters were compared. CVVHDF was performed for 33 (7–128) hours with the filter AV 1000S and 39 (7–97) hours with AV 600S (). Two (1–4) filters were utilised in both groups over this observation period (). Platelets dropped by 52,000 (0–212,000) in AV 1000S group and by 89,500 (0–258,000) in AV 600S group (). Haemoglobin decreased by 1.2 (0–2.8) g/dL in AV 1000S group and by 1.65 (0–3.9) g/dL in AV 600S group (), leading to the transfusion of 1 (0–4) unit of blood in 19 patients (10 patients with AV 1000S and 9 with AV 600S). Filter observation was abandoned due to death (12.1%), need for systemic anticoagulation (12.1%), repeated clotting (36.4%), and recovery of renal function (39.4%). Conclusion. Our study showed that a larger filter surface area did neither reduce the severity of thrombocytopenia and anaemia, nor decrease the frequency of clotting events. Francesca Bonassin Tempesta, Alain Rudiger, Marco Previsdomini, and Marco Maggiorini Copyright © 2014 Francesca Bonassin Tempesta et al. All rights reserved. Influence of an Infectious Diseases Specialist on ICU Multidisciplinary Rounds Thu, 17 Apr 2014 13:05:38 +0000 Objective. To ascertain the influence of a physician infectious diseases specialist (IDS) on antibiotic use in a medical/surgical intensive care unit. Method. Over a 5-month period, the antibiotic regimens ordered by the ICU multidisciplinary team were studied. The days of antibiotic therapy (DOT) when management decisions included an IDS were compared to DOT in the absence of an IDS. The associated treatment expense was calculated. Results. Prior to multidisciplinary rounds (MDRs), 79-80% of the patients were receiving one or more antibiotic. IDS participation occurred in 61 multidisciplinary rounding sessions. There were 384 patients who before MDRs had orders for 669 days of antimicrobial therapy (DOT). After MDRs, the antimicrobial DOT were reduced to 511 with a concomitant cost saving of $3772. There were 51 MDR sessions that occurred in the absence of the IDS. There were 352 patients who before MDRs had orders for 593 DOT. After MDRs, the DOT were reduced to 572 with a cost savings of $727. The results were normalized by number of patients evaluated with statistically greater reductions when MDRs included the IDS. In addition, the number of rounding sessions with a reduction in DOT was greater with the participation of the IDS. Conclusion. The addition of an IDS to multidisciplinary ICU patient rounds resulted in a reduction in antibiotic DOT and attendant drug expense. David N. Gilbert Copyright © 2014 David N. Gilbert. 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.