Critical Care Research and Practice The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. The Role of Mean Platelet Volume as a Predictor of Mortality in Critically Ill Patients: A Systematic Review and Meta-Analysis Thu, 04 Feb 2016 13:22:59 +0000 Background. An increase in the mean platelet volume (MPV) has been proposed as a novel prognostic indicator in critically ill patients. Objective. We conducted a systematic review and meta-analysis to determine whether there is an association between MPV and mortality in critically ill patients. Methods. We did electronic search in Medline, Scopus, and Embase up to November 2015. Results. Eleven observational studies, involving 3724 patients, were included. The values of initial MPV in nonsurvivors and survivors were not different, with the mean difference with 95% confident interval (95% CI) being 0.17 (95% CI: −0.04, 0.38; ). However, after small sample studies were excluded in sensitivity analysis, the pooling mean difference of MPV was 0.32 (95% CI: 0.04, 0.60; ). In addition, the MPV was observed to be significantly higher in nonsurvivor groups after the third day of admission. On the subgroup analysis, although patient types (sepsis or mixed ICU) and study type (prospective or retrospective study) did not show any significant difference between groups, the difference of MPV was significantly difference on the unit which had mortality up to 30%. Conclusions. Initial values of MPV might not be used as a prognostic marker of mortality in critically ill patients. Subsequent values of MPV after the 3rd day and the lower mortality rate unit might be useful. However, the heterogeneity between studies is high. Pattraporn Tajarernmuang, Arintaya Phrommintikul, Atikun Limsukon, Chaicharn Pothirat, and Kaweesak Chittawatanarat Copyright © 2016 Pattraporn Tajarernmuang et al. All rights reserved. Mechanical Ventilation Boot Camp: A Simulation-Based Pilot Study Mon, 01 Feb 2016 14:13:05 +0000 Objectives. Management of mechanically ventilated patients may pose a challenge to novice residents, many of which may not have received formal dedicated critical care instruction prior to starting their residency training. There is a paucity of data regarding simulation and mechanical ventilation training in the medical education literature. The purpose of this study was to develop a curriculum to educate first-year residents on addressing and troubleshooting ventilator alarms. Methods. Prospective evaluation was conducted of seventeen residents undergoing a twelve-hour three-day curriculum. Residents were assessed using a predetermined critical action checklist for each case, as well as pre- and postcurriculum multiple-choice cognitive knowledge questionnaires and confidence surveys. Results. Significant improvements in cognitive knowledge, critical actions, and self-reported confidence were demonstrated. The mean change in test score from before to after intervention was +26.8%, and a median score increase of 25% was noted. The ARDS and the mucus plugging cases had statistically significant improvements in critical actions, . A mean increase in self-reported confidence was realized (1.55 to 3.64), . Conclusions. A three-day simulation curriculum for residents was effective in increasing competency, knowledge, and confidence with ventilator management. Jennifer Yee, Charles Fuenning, Richard George, Rana Hejal, Nhi Haines, Diane Dunn, M. David Gothard, and Rami A. Ahmed Copyright © 2016 Jennifer Yee et al. All rights reserved. Review and Outcome of Prolonged Cardiopulmonary Resuscitation Thu, 14 Jan 2016 16:07:32 +0000 The maximal duration of cardiopulmonary resuscitation (CPR) is unknown. We report a case of prolonged CPR. We have then reviewed all published cases with CPR duration equal to or more than 20 minutes. The objective was to determine the survival rate, the neurological outcome, and the characteristics of the survivors. Measurements and Main Results. The CPR data for 82 patients was reviewed. The median duration of CPR was 75 minutes. Patients mean age was 43 ± 21 years with no significant comorbidities. The main causes of the cardiac arrests were myocardial infarction (29%), hypothermia (21%), and pulmonary emboli (12%). 74% of the arrests were witnessed, with a mean latency to CPR of 2 ± 6 minutes and good quality chest compression provided in 96% of the cases. Adjunct therapy included extracorporeal membrane oxygenation (18%), thrombolysis (15.8%), and rewarming for hypothermia (19.5%). 83% were alive at 1 year, with full neurological recovery reported in 63 patients. Conclusion. Patients undergoing prolonged CPR can survive with good outcome. Young age, myocardial infarction, and potentially reversible causes of cardiac arrest such as hypothermia and pulmonary emboli predict a favorable result, especially when the arrest is witnessed and followed by prompt and good resuscitative efforts. Houssein Youness, Tarek Al Halabi, Hussein Hussein, Ahmed Awab, Kellie Jones, and Jean Keddissi Copyright © 2016 Houssein Youness et al. All rights reserved. Spectrum of Intracerebral Hemorrhage in Children: A Report from PICU of a Resource Limited Country Sun, 03 Jan 2016 11:22:22 +0000 Intracerebral hemorrhage (ICH) in children is a rare but disabling disease that accounts for almost half cases of stroke. We report our experience of ICH in children. Retrospective review of medical records of children (1 month-16 years) admitted in Pediatric Intensive Care Unit between January 2007 and December 2014 was done. Data collected included age, gender, presentation, examination findings, neuroimaging done (CT, MRI, and angiography) management (conservative/intervention), and outcome. Results are presented as frequency and percentages. Of the total 50 patients, 58% were male and 26% were <1 year. On presentation 44% had vomiting, 42% had seizures, and GCS < 8 while 40% had altered level of consciousness. Single bleed was present in 88%, 94% had supratentorial bleed, and 32% had intraventricular extension. 72% had bleed volume of <30 mL and 8% had >60 mL. CT scan was done in 98% patients and MRI in 34%, while 6% underwent conventional angiography. 60% patients were managed conservatively, 36% underwent neurosurgical intervention, and 6% underwent radiological vascular intervention. Hematologic causes were identified in 52% patients and vascular malformations in 14% and in 26% no cause could be identified. 26% of patients expired. Qalab Abbas, Qurat ul Ain Merchant, Bushra Nasir, Anwar ul Haque, Basit Salam, and Gohar Javed Copyright © 2016 Qalab Abbas et al. All rights reserved. Clonal Relatedness among Imipenem-Resistant Pseudomonas aeruginosa Isolated from ICU-Hospitalized Patients Sun, 20 Dec 2015 13:09:17 +0000 Imipenem-resistant Pseudomonas aeruginosa (P. aeruginosa) has become an increasingly important problem in healthcare settings worldwide. The aim of the present study was to evaluate clonal spread among imipenem-resistant P. aeruginosa isolated from ICU-hospitalized patients. Totally, 150 wound specimens were analyzed. Antibiotic resistance profiles and clonal diversity were evaluated using Kirby-Bauer’s disk diffusion method and Random Amplified Polymorphic DNA- (RAPD-) PCR, respectively. The isolates showed a high frequency of antibiotic resistance against meropenem, and imipenem (100%) followed by ciprofloxacin, and ceftazidime (90%); meanwhile resistance to polymyxin B was not observed. Eighteen (40%) of P. aeruginosa isolates were MBL-positive via ethylenediaminetetraacetic acid (EDTA) combined disk test. Our findings showed high genetic diversity, with 37 different RAPD types detected. RAPD typing results showed cross-acquisition of P. aeruginosa in investigated hospital, suggesting failure in infection control practices. Incidence of MBL-positive isolates is high and should be regarded as a threat to hospitalized patients. Hamid Vaez, Sharareh Moghim, Bahram Nasr Esfahani, and Hajieh Ghasemian Safaei Copyright © 2015 Hamid Vaez et al. All rights reserved. Anemia and Blood Transfusion in Patients with Isolated Traumatic Brain Injury Wed, 28 Oct 2015 08:13:46 +0000 Rationale. By reducing cerebral oxygen delivery, anemia may aggravate traumatic brain injury (TBI) secondary insult. This study evaluated the impact of anemia and blood transfusion on TBI outcomes. Methods. This was a retrospective cohort study of adult patients with isolated TBI at a tertiary-care intensive care unit from 1/1/2000 to 31/12/2011. Daily hemoglobin level and packed red blood cell (PRBC) transfusion were recorded. Patients with hemoglobin < 10 g/dL during ICU stay (anemic group) were compared with other patients. Results. Anemia was present on admission in two (2%) patients and developed in 48% during the first week with hemoglobin < 7 g/dL occurring in 3.0%. Anemic patients had higher admission Injury Severity Score and underwent more craniotomy (50% versus 13%, ). Forty percent of them received PRBC transfusion (2.8 ± 1.5 units per patient, median pretransfusion hemoglobin = 8.8 g/dL). Higher hospital mortality was associated with anemia (25% versus 6% for nonanemic patients, ) and PRBC transfusion (38% versus 9% for nontransfused patients, ). On multivariate analysis, only PRBC transfusion independently predicted hospital mortality (odds ratio: 6.8; 95% confidence interval: 1.1–42.3). Conclusions. Anemia occurred frequently after isolated TBI, but only PRBC transfusion independently predicted mortality. Hasan M. Al-Dorzi, Waleed Al-Humaid, Hani M. Tamim, Samir Haddad, Ahmad Aljabbary, Abdulaziz Arifi, and Yaseen M. Arabi Copyright © 2015 Hasan M. Al-Dorzi et al. All rights reserved. Sedative and Analgesic Effects of Entonox Gas Compared with Midazolam and Fentanyl in Synchronized Cardioversion Tue, 20 Oct 2015 11:23:02 +0000 The purpose of this study was to determine if the Entonox gas could cause adequate analgesic and sedative effects in patients who need cardioversion. In this randomized not blinded clinical trial, the sedative and analgesic effects of midazolam and fentanyl were compared with Entonox. Eligible patients who need synchronized cardioversion because of dysrhythmia were randomly divided into two groups. The first group received intravenous midazolam and fentanyl; the second group received Entonox through a blower-dependent mask. Onset and end of sedation, sedation level, and pain score were recorded. There were nonsignificant differences between the two groups (22 patients in each group) regarding age, gender, weight, sedation level, and frequency and level of shock. The pain score recorded in the first group was 5.05 ± 1.32, and 3.9 ± 0.7 in the second group (). Furthermore, sedation duration and time to full recovery consciousness were shorter in the second group (). In the first group, seven patients needed additional doses to induce and maintain sedation. In addition, as a result of apnoea, four patients required airway support. None of them occurred in the second group. Entonox is a suitable medication in rapid cardioversion, as it has minimal side effects and adequate analgesic and sedative effects. Kambiz Masoumi, Arash Forouzan, Sina Saghari, Maryam Feli, Ali Reza Sattari, and Ali Asgari Darian Copyright © 2015 Kambiz Masoumi et al. All rights reserved. The Impact of Intravenous Lidocaine on ICP in Neurological Illness: A Systematic Review Thu, 10 Sep 2015 09:09:44 +0000 Background. The goal of our study was to perform a systematic review of the literature to determine the effect that intravenous (IV) lidocaine had on ICP in patients with neurological illness. Methods. All articles are from MEDLINE, BIOSIS, EMBASE, Global Health, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to March 2015). The strength of evidence was adjudicated using both the Oxford and GRADE methodology. Results. Ten original articles were considered for the final review. There were 189 patients studied. Seven studies focused on prophylactic pretreatment with IV lidocaine to determine if there would be an attenuation of ICP spikes during stimulation, with 4 displaying an attenuation of ICP. Three studies focused on a therapeutic administration of IV lidocaine in order to determine ICP reduction effects. All therapeutic studies displayed a reduction in ICP. Conclusions. We cannot make a strong definitive recommendation on the effectiveness of IV lidocaine on the attenuation of ICP spikes during stimulation. There currently exists both Oxford 2b and GRADE B literature to support and refute the attenuation of ICP spikes with IV lidocaine during stimulation. There currently exists Oxford 2b, GRADE B evidence to support ICP reduction with lidocaine when used as a therapeutic agent. F. A. Zeiler, N. Sader, and C. J. Kazina Copyright © 2015 F. A. Zeiler et al. All rights reserved. Open and Closed Endotracheal Suctioning and Arterial Blood Gas Values: A Single-Blind Crossover Randomized Clinical Trial Thu, 03 Sep 2015 06:28:55 +0000 Aim. This study was aimed at comparing the effects of the open and closed suctioning techniques on the arterial blood gas values in patients undergoing open-heart surgery. Methods. In a clinical trial, we recruited 42 patients after open-heart surgery in an educational hospital. Each patient randomly underwent both open and closed suctioning. ABGs, PaO2, SaO2, PaCO2, were analyzed before and one, five, and fifteen minutes after each suctioning episode. Results. At first the pressure of oxygen in arterial blood increased; however, this increase in the open technique was greater than that of the closed system . The pressure of oxygen decreased five and fifteen minutes after both suctioning techniques . The trends of carbon dioxide variations after the open and closed techniques were upward and downward, respectively. Moreover, the decrease in the level of oxygen saturation five and fifteen minutes after the open suctioning was greater than that of the closed suctioning technique .  Conclusion. Arterial blood gas disturbances in the closed suctioning technique were less than those of the open technique. Therefore, to eliminate the unwanted effects of endotracheal suctioning on the arterial blood gases, the closed suctioning technique is recommended. Azam Faraji, Alireza Khatony, Gholamreza Moradi, Alireza Abdi, and Mansour Rezaei Copyright © 2015 Azam Faraji et al. All rights reserved. Development of Delirium in the Intensive Care Unit in Patients after Endovascular Aortic Repair: A Retrospective Evaluation of the Prevalence and Risk Factors Wed, 02 Sep 2015 10:16:47 +0000 Delirium is an acute form of nervous system dysfunction often observed in patients in the intensive care unit. Endovascular aortic repair (EVAR) is considered a minimally invasive surgical treatment for abdominal aortic aneurysm. Although the operation method is widely used, there are few investigations of the rate and risk factors of delirium development after the operation. In this study, we retrospectively examined the rate of delirium development in the intensive care unit (ICU) after EVAR, as well as the associated preoperative risk factors and effects on the lengths of ICU and hospital stays. We examined the 81 consecutive patients who underwent elective EVAR between November 2013 and August 2014. The Intensive Care Delirium Screening Checklist was used to diagnose delirium. Twenty patients (24.7%) were diagnosed with delirium in this study. The ICU and hospital length of stays of patients with delirium were 3.3 ± 2.4 days and 14.5 ± 11.9 days, respectively, the latter of which was significantly longer than that of patients without delirium (). Additionally, renal dysfunction, preoperative benzodiazepine use, and intraoperative transfusion were found to be risk factors for the development of delirium after elective EVAR. Yohei Kawatani, Yoshitsugu Nakamura, Yujiro Hayashi, Tetsuyoshi Taneichi, Yujiro Ito, Hirotsugu Kurobe, Yuji Suda, and Takaki Hori Copyright © 2015 Yohei Kawatani et al. All rights reserved. Impact of a 2-Day Critical Care Ultrasound Course during Fellowship Training: A Pilot Study Wed, 05 Aug 2015 11:59:08 +0000 Objectives. Despite the increasing utilization of point-of-care critical care ultrasonography (CCUS), standards establishing competency for its use are lacking. The purpose of this study was to evaluate the effectiveness of a 2-day CCUS course implementation on ultrasound-naïve critical care medicine (CCM) fellows. Methods. Prospective evaluation of the impact of a two-day CCUS course on eight CCM fellows’ attitudes, proficiency, and use of CCUS. Ultrasound competency on multiple organ systems was assessed including abdominal, pulmonary, vascular, and cardiac systems. Subjects served as self-controls and were assessed just prior to, within 1 week after, and 3 months after the course. Results. There was a significant improvement in CCM fellows’ written test scores, image acquisition ability, and pathologic image interpretation 1 week after the course and it was retained 3 months after the course. Fellows also had self-reported increased confidence and usage of CCUS applications after the course. Conclusions. Implementation of a 2-day critical care ultrasound course covering general CCUS and basic critical care echocardiography using a combination of didactics, live models, and ultrasound simulators is effective in improving critical care fellows’ proficiency and confidence with ultrasound use in both the short- and long-term settings. Vi Am Dinh, Paresh C. Giri, Inimai Rathinavel, Emilie Nguyen, David Hecht, Ihab Dorotta, H. Bryant Nguyen, and Ara A. Chrissian Copyright © 2015 Vi Am Dinh et al. All rights reserved. Lung Injury Prediction Score Is Useful in Predicting Acute Respiratory Distress Syndrome and Mortality in Surgical Critical Care Patients Sun, 02 Aug 2015 11:49:29 +0000 Background. Lung injury prediction score (LIPS) is valuable for early recognition of ventilated patients at high risk for developing acute respiratory distress syndrome (ARDS). This study analyzes the value of LIPS in predicting ARDS and mortality among ventilated surgical patients. Methods. IRB approved, prospective observational study including all ventilated patients admitted to the surgical intensive care unit at a single tertiary center over 6 months. ARDS was defined using the Berlin criteria. LIPS were calculated for all patients and analyzed. Logistic regression models evaluated the ability of LIPS to predict development of ARDS and mortality. A receiver operator characteristic (ROC) curve demonstrated the optimal LIPS value to statistically predict development of ARDS. Results. 268 ventilated patients were observed; 141 developed ARDS and 127 did not. The average LIPS for patients who developed ARDS was versus for those who did not (). An ROC area under the curve of 0.79 demonstrates LIPS is statistically powerful for predicting ARDS development. Furthermore, for every 1-unit increase in LIPS, the odds of developing ARDS increase by 1.50 () and odds of ICU mortality increase by 1.22 (). Conclusion. LIPS is reliable for predicting development of ARDS and predicting mortality in critically ill surgical patients. Zachary M. Bauman, Marika Y. Gassner, Megan A. Coughlin, Meredith Mahan, and Jill Watras Copyright © 2015 Zachary M. Bauman et al. All rights reserved. The Use of Sodium Bicarbonate in the Treatment of Acidosis in Sepsis: A Literature Update on a Long Term Debate Thu, 30 Jul 2015 11:31:20 +0000 Introduction. Sepsis and its consequences such as metabolic acidosis are resulting in increased mortality. Although correction of metabolic acidosis with sodium bicarbonate seems a reasonable approach, there is ongoing debate regarding the role of bicarbonates as a therapeutic option. Methods. We conducted a PubMed literature search in order to identify published literature related to the effects of sodium bicarbonate treatment on metabolic acidosis due to sepsis. The search included all articles published in English in the last 35 years. Results. There is ongoing debate regarding the use of bicarbonates for the treatment of acidosis in sepsis, but there is a trend towards not using bicarbonate in sepsis patients with arterial blood gas . Conclusions. Routine use of bicarbonate for treatment of severe acidemia and lactic acidosis due to sepsis is subject of controversy, and current opinion does not favor routine use of bicarbonates. However, available evidence is inconclusive, and more studies are required to determine the potential benefit, if any, of bicarbonate therapy in the sepsis patient with acidosis. Dimitrios Velissaris, Vasilios Karamouzos, Nikolaos Ktenopoulos, Charalampos Pierrakos, and Menelaos Karanikolas Copyright © 2015 Dimitrios Velissaris et al. All rights reserved. Impact of a Simulation-Based Communication Workshop on Resident Preparedness for End-of-Life Communication in the Intensive Care Unit Thu, 25 Jun 2015 12:30:38 +0000 Introduction. Although residents frequently lead end-of-life (EOL) discussions in the intensive care unit (ICU), training in EOL care during residency has been required only recently, and few educational interventions target EOL communication in the ICU. This study evaluated a simulation-based intervention designed to improve resident EOL communication skills with families in the ICU. Methods. Thirty-four second-year internal medicine residents at a large urban teaching hospital participated in small group sessions with faculty trained in the “VitalTalk” method. A Likert-type scale questionnaire measured self-assessed preparedness before, immediately following, and approximately 9 months after intervention. Data were analyzed using Wilcoxon rank-sum analysis. Results. Self-assessed preparedness significantly improved for all categories surveyed (preintervention mean; postintervention mean; p value), including discussing bad news (3.3; 4.2; ), conducting a family conference (3.1; 4.1; ), discussing treatment options (3.2; 3.9; ), discussing discontinuing ICU treatments (2.9; 3.5; ), and expressing empathy (3.9; 4.5; ). Improvement persisted at follow-up for all items except “expressing empathy.” Residents rated the educational quality highly. Conclusion. This study provides evidence that brief simulation-based interventions can produce lasting improvements in residents’ confidence to discuss EOL care with family members of patients in the ICU. Abraham Markin, Diego F. Cabrera-Fernandez, Rebecca M. Bajoka, Samantha M. Noll, Sean M. Drake, Rana L. Awdish, Dana S. Buick, Maria S. Kokas, Kristen A. Chasteen, and Michael P. Mendez Copyright © 2015 Abraham Markin et al. All rights reserved. Pressure Measurement Techniques for Abdominal Hypertension: Conclusions from an Experimental Model Sun, 31 May 2015 14:06:03 +0000 Introduction. Intra-abdominal pressure (IAP) measurement is an indispensable tool for the diagnosis of abdominal hypertension. Different techniques have been described in the literature and applied in the clinical setting. Methods. A porcine model was created to simulate an abdominal compartment syndrome ranging from baseline IAP to 30 mmHg. Three different measurement techniques were applied, comprising telemetric piezoresistive probes at two different sites (epigastric and pelvic) for direct pressure measurement and intragastric and intravesical probes for indirect measurement. Results. The mean difference between the invasive IAP measurements using telemetric pressure probes and the IVP measurements was −0.58 mmHg. The bias between the invasive IAP measurements and the IGP measurements was 3.8 mmHg. Compared to the realistic results of the intraperitoneal and intravesical measurements, the intragastric data showed a strong tendency towards decreased values. The hydrostatic character of the IAP was eliminated at high-pressure levels. Conclusion. We conclude that intragastric pressure measurement is potentially hazardous and might lead to inaccurately low intra-abdominal pressure values. This may result in missed diagnosis of elevated abdominal pressure or even ACS. The intravesical measurements showed the most accurate values during baseline pressure and both high-pressure plateaus. Sascha Santosh Chopra, Stefan Wolf, Veit Rohde, and Florian Baptist Freimann Copyright © 2015 Sascha Santosh Chopra et al. All rights reserved. Propofol Infusion Syndrome in Adults: A Clinical Update Sun, 12 Apr 2015 09:28:23 +0000 Propofol infusion syndrome is a rare but extremely dangerous complication of propofol administration. Certain risk factors for the development of propofol infusion syndrome are described, such as appropriate propofol doses and durations of administration, carbohydrate depletion, severe illness, and concomitant administration of catecholamines and glucocorticosteroids. The pathophysiology of this condition includes impairment of mitochondrial beta-oxidation of fatty acids, disruption of the electron transport chain, and blockage of beta-adrenoreceptors and cardiac calcium channels. The disease commonly presents as an otherwise unexplained high anion gap metabolic acidosis, rhabdomyolysis, hyperkalemia, acute kidney injury, elevated liver enzymes, and cardiac dysfunction. Management of overt propofol infusion syndrome requires immediate discontinuation of propofol infusion and supportive management, including hemodialysis, hemodynamic support, and extracorporeal membrane oxygenation in refractory cases. However, we must emphasize that given the high mortality of propofol infusion syndrome, the best management is prevention. Clinicians should consider alternative sedative regimes to prolonged propofol infusions and remain within recommended maximal dose limits. Aibek E. Mirrakhimov, Prakruthi Voore, Oleksandr Halytskyy, Maliha Khan, and Alaa M. Ali Copyright © 2015 Aibek E. Mirrakhimov et al. All rights reserved. Comment on “Management of Atrial Fibrillation in Critically Ill Patients” Sun, 12 Apr 2015 08:54:15 +0000 Sébastien Champion Copyright © 2015 Sébastien Champion. All rights reserved. Incidence and Risk Factors for Delirium among Mechanically Ventilated Patients in an African Intensive Care Setting: An Observational Multicenter Study Sun, 05 Apr 2015 08:45:13 +0000 Aim. Delirium is common among mechanically ventilated patients in the intensive care unit (ICU). There are little data regarding delirium among mechanically ventilated patients in Africa. We sought to determine the burden of delirium and associated factors in Uganda. Methods. We conducted a multicenter prospective study among mechanically ventilated patients in Uganda. Eligible patients were screened daily for delirium using the confusional assessment method (CAM-ICU). Comparisons were made using -test, chi-squares, and Fisher’s exact test. Predictors were assessed using logistic regression. The level of statistical significance was set at . Results. Of 160 patients, 81 (51%) had delirium. Median time to onset of delirium was 3.7 days. At bivariate analysis, history of mental illness, sedation, multiorgan dysfunction, neurosurgery, tachypnea, low mean arterial pressure, oliguria, fevers, metabolic acidosis, respiratory acidosis, anaemia, physical restraints, marital status, and endotracheal tube use were significant predictors. At multivariable analysis, having a history of mental illness, sedation, respiratory acidosis, higher PEEP, endotracheal tubes, and anaemia predicted delirium. Conclusion. The prevalence of delirium in a young African population is lower than expected considering the high mortality. A history of mental illness, anaemia, sedation, endotracheal tube use, and respiratory acidosis were factors associated with delirium. Arthur Kwizera, Jane Nakibuuka, Lameck Ssemogerere, Charles Sendikadiwa, Daniel Obua, Samuel Kizito, Janat Tumukunde, Agnes Wabule, and Noeline Nakasujja Copyright © 2015 Arthur Kwizera et al. All rights reserved. Is There Any Association between PEEP and Upper Extremity DVT? Thu, 02 Apr 2015 14:12:20 +0000 Background. We hypothesized that positive end-exploratory pressure (PEEP) may promote venous stasis in the upper extremities and predispose to upper extremity deep vein thrombosis (UEDVT). Methods. We performed a retrospective case control study of medical intensive care unit patients who required mechanical ventilation (MV) for >72 hours and underwent duplex ultrasound of their upper veins for suspected DVT between January 2011 and December 2013. Results. UEDVT was found in 32 (28.5%) of 112 patients. Nineteen (67.8%) had a central venous catheter on the same side. The mean ± SD duration of MV was days. Average PEEP was  cm H2O. Average PEEP was ≥10 cm H2O in 23 (20.5%) patients. Congestive heart failure (CHF) significantly increased the odds of UEDVT (OR 4.53, 95% CI 1.13–18.11; ) whereas longer duration of MV (≥13 vs. <13 days) significantly reduced it (OR 0.29, 95% CI 0.11–0.8; ). Morbid obesity showed a trend towards significance (OR 3.82, 95% CI 0.95–15.4; ). Neither PEEP nor any of the other analyzed predictors was associated with UEDVT. Conclusions. There is no association between PEEP and UEDVT. CHF may predispose to UEDVT whereas the risk of UEDVT declines with longer duration of MV. Farah Al-Saffar, Ena Gupta, Furqan Siddiqi, Muhammad Faisal, Lisa M. Jones, Vandana Seeram, Mariam Louis, James D. Cury, Abubakr A. Bajwa, and Adil Shujaat Copyright © 2015 Farah Al-Saffar et al. All rights reserved. Contemporary Trends of the Epidemiology, Clinical Characteristics, and Resource Utilization of Necrotizing Fasciitis in Texas: A Population-Based Cohort Study Sun, 29 Mar 2015 08:13:57 +0000 Introduction. There are limited population-level reports on the contemporary trends of the epidemiology, clinical features, resource utilization, and outcomes of necrotizing fasciitis (NF). Methods. We conducted a cohort study of Texas inpatient population, identifying hospitalizations with a diagnosis of NF during the years 2001–2010. The incidence, clinical features, resource utilization, and outcomes of NF hospitalizations were examined. Results. There were 12,172 NF hospitalizations during study period, with ICU admission in 50.3%. The incidence of NF rose 2.7%/year (). Key changes between 2001-2002 and 2009-2010 included rising incidence of NF (5.9 versus 7.6 per 100,000 []), chronic comorbidities (69.4% versus 76.7% []), and development of ≥1 organ failure (28.5% versus 51.7% []). Inflation-adjusted hospital charges rose 37% (). Hospital mortality (9.3%) remained unchanged during study period. Discharges to long-term care facilities rose from 12.2 to 30% (). Conclusions. The present cohort of NF is the largest reported to date. There has been increasing incidence, chronic illness, and severity of illness of NF over the past decade, with half of NF hospitalizations admitted to ICU. Hospital mortality remained unchanged, while need for long-term care rose nearly 2.5-fold among survivors, suggesting increasing residual morbidity. The sources of the observed findings require further study. Lavi Oud and Phillip Watkins Copyright © 2015 Lavi Oud and Phillip Watkins. All rights reserved. Mucolytics for Intubated Asthmatic Children: A National Survey of United Kingdom Paediatric Intensive Care Consultants Wed, 04 Feb 2015 10:56:12 +0000 Aim. The extent to which mucolytics are utilised in mechanically ventilated asthmatic children is unknown. We sought to establish current practice in the United Kingdom (UK) including choice of mucolytic, dose, and frequency of utilisation. Methods. A national electronic survey was distributed to UK consultants during April and May 2014. We were able to identify 168 PICU consultants at 25 institutions to whom we were able to electronically distribute a survey, representing an estimated 81% of UK NHS PICU consultants. Results. Replies were received from 87 consultants at 21 institutions (%). Recombinant human DNase (rhDNase) does get administered by 63% of clinicians, with 54% and 19% that administer hypertonic saline or N-acetylcysteine, respectively. Of those that do administer rhDNase the majority (48%) dilute it with 0.9% saline and blindly administer it, whereas 35% administer rhDNase under bronchoscopic guidance and 17% judge the necessity for bronchoscopy according to clinical severity. 25 respondents described 7 different methods to calculate rhDNase dose. A majority (87%) of respondents expressed an interest to consider enrolling patients into an RCT that evaluates rhDNase. Conclusion. Significant variation exists regarding the necessity for mucolytics, choice of agent, optimal route, and dose in intubated asthmatic children. Aarjan Peter Snoek and Joe Brierley Copyright © 2015 Aarjan Peter Snoek and Joe Brierley. All rights reserved. Postoperative Pulmonary Dysfunction and Mechanical Ventilation in Cardiac Surgery Tue, 03 Feb 2015 06:17:38 +0000 Postoperative pulmonary dysfunction (PPD) is a frequent and significant complication after cardiac surgery. It contributes to morbidity and mortality and increases hospitalization stay and its associated costs. Its pathogenesis is not clear but it seems to be related to the development of a systemic inflammatory response with a subsequent pulmonary inflammation. Many factors have been described to contribute to this inflammatory response, including surgical procedure with sternotomy incision, effects of general anesthesia, topical cooling, and extracorporeal circulation (ECC) and mechanical ventilation (VM). Protective ventilation strategies can reduce the incidence of atelectasis (which still remains one of the principal causes of PDD) and pulmonary infections in surgical patients. In this way, the open lung approach (OLA), a protective ventilation strategy, has demonstrated attenuating the inflammatory response and improving gas exchange parameters and postoperative pulmonary functions with a better residual functional capacity (FRC) when compared with a conventional ventilatory strategy. Additionally, maintaining low frequency ventilation during ECC was shown to decrease the incidence of PDD after cardiac surgery, preserving lung function. Rafael Badenes, Angels Lozano, and F. Javier Belda Copyright © 2015 Rafael Badenes et al. All rights reserved. Early Use of the NMDA Receptor Antagonist Ketamine in Refractory and Superrefractory Status Epilepticus Mon, 12 Jan 2015 06:57:55 +0000 Refractory status epilepticus (RSE) and superrefractory status epilepticus (SRSE) pose a difficult clinical challenge. Multiple cerebral receptor and transporter changes occur with prolonged status epilepticus leading to pharmacoresistance patterns unfavorable for conventional antiepileptics. In particular, n-methyl-d-aspartate (NMDA) receptor upregulation leads to glutamate mediated excitotoxicity. Targeting these NMDA receptors may provide a novel approach to otherwise refractory seizures. Ketamine has been utilized in RSE. Recent systematic review indicates 56.5% and 63.5% cessation in seizures in adults and pediatrics, respectively. No complications were described. We should consider earlier implementation of ketamine or other NMDA receptor antagonists, for RSE. Prospective study of early implementation of ketamine should shed light on the role of such medications in RSE. F. A. Zeiler Copyright © 2015 F. A. Zeiler. All rights reserved. Standardized Application of Laxatives and Physical Measures in Neurosurgical Intensive Care Patients Improves Defecation Pattern but Is Not Associated with Lower Intracranial Pressure Wed, 31 Dec 2014 11:54:51 +0000 Background. Inadequate bowel movements might be associated with an increase in intracranial pressure in neurosurgical patients. In this study we investigated the influence of a structured application of laxatives and physical measures following a strict standard operating procedure (SOP) on bowel movement, intracranial pressure (ICP), and length of hospital stay in patients with a serious acute cerebral disorder. Methods. After the implementation of the SOP patients suffering from a neurosurgical disorder received pharmacological and nonpharmacological measures to improve bowel movements in a standardized manner within the first 5 days after admission to the intensive care unit (ICU) starting on day of admission. We compared mean ICP levels, length of ICU stay, and mechanical ventilation to a historical control group. Results. Patients of the intervention group showed an adequate defecation pattern significantly more often than the patients of the control group. However, this was not associated with lower ICP values, fewer days of mechanical ventilation, or earlier discharge from ICU. Conclusions. The implementation of a SOP for bowel movement increases the frequency of adequate bowel movements in neurosurgical critical care patients. However, this seems not to be associated with reduced ICP values. Martin Kieninger, Barbara Sinner, Bernhard Graf, Astrid Grassold, Sylvia Bele, Milena Seemann, Holger Künzig, and Nina Zech Copyright © 2014 Martin Kieninger et al. All rights reserved. Propofol Infusion Syndrome: A Retrospective Analysis at a Level 1 Trauma Center Wed, 17 Dec 2014 00:10:17 +0000 Objectives. The propofol infusion syndrome (PRIS), a rare, often fatal, condition of unknown etiology, is defined by development of lipemic serum, metabolic acidosis, rhabdomyolysis, hepatomegaly, cardiac arrhythmias, and acute renal failure. Methods. To identify risk factors for and biomarkers of PRIS, a retrospective chart review of all possible PRIS cases during a 1-year period was conducted at a level 1 trauma hospital in ICU patients over 18 years of age receiving continuous propofol infusions for ≥3 days. Additional study inclusion criteria included vasopressor support and monitoring of serum triglycerides and creatinine. Results. Seventy-two patients, 61 males (84.7%) and 11 females (15.3%), satisfied study inclusion criteria; and of these, 3 males met the study definition for PRIS, with 1 case fatality. PRIS incidence was 4.1% with a case-fatality rate of 33%. The mean duration of propofol infusion was 6.96 days. A positive linear correlation was observed between increasing triglyceride levels and infusion duration, but no correlation was observed between increasing creatinine levels and infusion duration. Conclusions. Risk factors for PRIS were confirmed as high dose infusions over prolonged periods. Increasing triglyceride levels may serve as reliable biomarkers of impending PRIS, if confirmed in future investigations with larger sample sizes. James H. Diaz, Amit Prabhakar, Richard D. Urman, and Alan David Kaye Copyright © 2014 James H. Diaz et al. All rights reserved. A Newly Developed Sublingual Tonometric Method for the Evaluation of Tissue Perfusion and Its Validation In Vitro and in Healthy Persons In Vivo and the Results of the Measurements in COPD Patients Tue, 16 Dec 2014 07:13:15 +0000 Introduction. Since its first publication in the medical literature, an extremely large number of references have demonstrated that the tonometric measurement of tissue perfusion is a reliable indicator of the actual condition of critically ill patients. Later a new method was developed by the introduction of sublingual tonometry for the determination of tissue perfusion. In comparison with gastric tonometry, the new method was simpler and could even be used in awake patients. Unfortunately, at present, because of severe failures of manufacturing, the device is withdrawn from commerce. Materials and Methods. In this study, we present a new method using a newly developed tool for the PslCO2 measurement in sublingual tonometry as well as the data for its validation in vitro and in vivo and the results of 25 volunteers and 54 COPD patients belonging to different GOLD groups at their hospitalization due to the acute exacerbation of the disease but already in a stable condition at the time of the examination. Results and Conclusion. The results of the performed examinations showed that the method is suitable for monitoring the actual condition of the patients by mucosal perfusion tonometry in the sublingual region. Zoltán Rózsavölgyi, Domokos Boda, Andrea Hajnal, Krisztina Boda, and Attila Somfay Copyright © 2014 Zoltán Rózsavölgyi et al. All rights reserved. Heliox Improves Carbon Dioxide Removal during Lung Protective Mechanical Ventilation Sun, 07 Dec 2014 07:54:13 +0000 Introduction. Helium is a noble gas with low density and increased carbon dioxide (CO2) diffusion capacity. This allows lower driving pressures in mechanical ventilation and increased CO2 diffusion. We hypothesized that heliox facilitates ventilation in patients during lung-protective mechanical ventilation using low tidal volumes. Methods. This is an observational cohort substudy of a single arm intervention study. Twenty-four ICU patients were included, who were admitted after a cardiac arrest and mechanically ventilated for 3 hours with heliox (50% helium; 50% oxygen). A fixed protective ventilation protocol (6 mL/kg) was used, with prospective observation for changes in lung mechanics and gas exchange. Statistics was by Bonferroni post-hoc correction with statistical significance set at . Results. During heliox ventilation, respiratory rate decreased ( versus breaths min−1, ). Minute volume ventilation showed a trend to decrease compared to baseline ( versus  L min−1, ), while reducing PaCO2 levels ( versus  kPa, ) and peak pressures ( versus  cm H2O, ). Conclusions. Heliox improved CO2 elimination while allowing reduced minute volume ventilation in adult patients during protective mechanical ventilation. Charlotte J. Beurskens, Daniel Brevoord, Wim K. Lagrand, Walter M. van den Bergh, Margreeth B. Vroom, Benedikt Preckel, Janneke Horn, and Nicole P. Juffermans Copyright © 2014 Charlotte J. Beurskens et al. All rights reserved. Gram-Negative Infections in Adult Intensive Care Units of Latin America and the Caribbean Thu, 27 Nov 2014 12:02:44 +0000 This review summarizes recent epidemiology of Gram-negative infections in selected countries from Latin American and Caribbean adult intensive care units (ICUs). A systematic search of the biomedical literature (PubMed) was performed to identify articles published over the last decade. Where appropriate, data also were collected from the reference list of published articles, health departments of specific countries, and registries. Independent cohort data from all countries (Argentina, Brazil, Chile, Colombia, Cuba, Mexico, Trinidad and Tobago, and Venezuela) signified a high rate of ICU infections (prevalence: Argentina, 24%; Brazil, 57%). Gram-negative pathogens, predominantly Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli, accounted for 50% of ICU infections, which were often complicated by the presence of multidrug-resistant strains and clonal outbreaks. Empirical use of antimicrobial agents was identified as a strong risk factor for resistance development and excessive mortality. Infection control strategies utilizing hygiene measures and antimicrobial stewardship programs reduced the rate of device-associated infections. To mitigate the poor health outcomes associated with infections by multidrug-resistant Gram-negative bacteria, urgent focus must be placed on infection control strategies and local surveillance programs. Carlos M. Luna, Eduardo Rodriguez-Noriega, Luis Bavestrello, and Manuel Guzmán-Blanco Copyright © 2014 Carlos M. Luna et al. All rights reserved. Model Point-of-Care Ultrasound Curriculum in an Intensive Care Unit Fellowship Program and Its Impact on Patient Management Sun, 16 Nov 2014 08:37:51 +0000 Objectives. This study was designed to assess the clinical applicability of a Point-of-Care (POC) ultrasound curriculum into an intensive care unit (ICU) fellowship program and its impact on patient care. Methods. A POC ultrasound curriculum for the surgical ICU (SICU) fellowship was designed and implemented in an urban, academic tertiary care center. It included 30 hours of didactics and hands-on training on models. Minimum requirement for each ICU fellow was to perform 25–50 exams on respective systems or organs for a total not less than 125 studies on ICU. The ICU fellows implemented the POC ultrasound curriculum into their daily practice in managing ICU patients, under supervision from ICU staff physicians, who were instructors in POC ultrasound. Impact on patient care including finding a new diagnosis or change in patient management was reviewed over a period of one academic year. Results. 873 POC ultrasound studies in 203 patients admitted to the surgical ICU were reviewed for analysis. All studies included were done through the POC ultrasound curriculum training. The most common exams performed were 379 lung/pleural exams, 239 focused echocardiography and hemodynamic exams, and 237 abdominal exams. New diagnosis was found in 65.52% of cases (95% CI 0.590, 0.720). Changes in patient management were found in 36.95% of cases (95% CI 0.303, 0.435). Conclusions. Implementation of POC ultrasound in the ICU with a structured fellowship curriculum was associated with an increase in new diagnosis in about 2/3 and change in management in over 1/3 of ICU patients studied. Keith Killu, Victor Coba, Michael Mendez, Subhash Reddy, Tanja Adrzejewski, Yung Huang, Jessica Ede, and Mathilda Horst Copyright © 2014 Keith Killu et al. All rights reserved. A Multidisciplinary Approach to Unplanned Conversion from Off-Pump to On-Pump Beating Heart Coronary Artery Revascularization in Patients with Compromised Left Ventricular Function Wed, 12 Nov 2014 08:33:56 +0000 Aim. To comparably assess the perioperative risk factors that differentiate off-pump coronary artery bypass (OPCAB) grafting cases from those sustaining unplanned conversion to on-pump beating heart (ONCAB/BH) approach, in patients with left ventricular ejection fraction (LVEF) < 40%. Methods. Perioperative variables were retrospectively assessed in 216 patients with LVEF < 40%, who underwent myocardial revascularization with OPCAB () or ONCAB/BH () approach. The study endpoints were operative mortality (30-day) and morbidity assessed by length of intensive care unit stay (LOS-ICU), using 2 days as cut-off point. Results. Poor LVEF, increased EuroSCORE II, acute presentation, congestive heart failure, cerebrovascular disease, perioperative renal impairment, clinical status deterioration upon admission and during ICU stay, acute myocardial infarction, and low cardiac output syndrome supported by inotropes and/or balloon-pump counterpulsation were significantly related to ONCAB/BH group (). EuroSCORE II () and LVEF () were the most powerful discriminative predictors of intraoperative conversion to ONCAB/BH. Operative mortality was 2.9% in OPCAB and 6.6% in ONCAB/BH group (), while 23.4% participants in OPCAB and 42.2% in ONCAB/BH approach had a LOS-ICU > 2 days (). Conclusions. Patients with LVEF < 40% undergoing ONCAB/BH are subjected to more preoperative comorbidities and implicated ICU stay than their OPCAB counterparts, which influences adversely short-term morbidity, while operative mortality remains unaffected. Georgia Tsaousi, Antonis A. Pitsis, George D. Ioannidis, and Dimitrios G. Vasilakos Copyright © 2014 Georgia Tsaousi et al. All rights reserved.