Critical Care Research and Practice The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . 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. 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.