Critical Care Research and Practice The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Survey of Extent of Translation of Oral Healthcare Guidelines for ICU Patients into Clinical Practice by Nursing Staff Wed, 18 Oct 2017 00:00:00 +0000 Nosocomial infections in critically ill/ventilated patients result from bacterial load in oropharyngeal regions. Oral decontamination serves as the easiest effective means of controlling infections. Knowledge, attitude, and practices followed by healthcare personnel in intensive care settings need to be assessed to implement concrete measures in health-care. Survey questionnaire was constructed and implemented following its validation on seventy nursing and paramedical staff working in government and private intensive care units throughout Lucknow city. 21-item questionnaire consisted of three parts of seven questions each. 78% of respondents had knowledge regarding oral care and its importance in critical settings but 44% of respondents considered it to be unpleasant task. 36% of respondents claimed to have provided oral care to all patients in ICU. Uniform guidelines for translation of oral healthcare in ICU settings are not being implemented. Previous studies in literature from various geographic diverse regions also point out to similar lacunae. Based on present survey, most respondents were aware of importance of oral care with protocols covered in academic curriculum. Attitude towards oral care is positive but respondents feel a need for specialised training. Practice for oral care is not sufficient and needs improvement and proper implementation. Vivek Agarwal, Rameshwari Singhal, Richa Khanna, Pavitra Rastogi, Avinash Agarwal, and Shuchi Tripathi Copyright © 2017 Vivek Agarwal et al. All rights reserved. Challenges with Surveillance of Healthcare-Associated Infections in Intensive Care Units in South Africa Thu, 12 Oct 2017 00:00:00 +0000 Background. The incidence of healthcare-associated infections (HAIs) in the public health sector in South Africa is not known due to the lack of a surveillance system. We report on the challenges experienced in the implementation of a surveillance system for HAIs in intensive care units (ICUs). Methods. A passive, paper-based surveillance system was piloted in eight ICUs to measure the incidence of ventilator-associated pneumonia, catheter-associated urinary tract infection, and central line-associated bloodstream infection. Extensive consultation with the ICU clinical and nursing managers informed the development of the surveillance system. The Plan-Do-Study-Act method was utilized to guide the implementation of the surveillance. Results. The intended outputs of the surveillance system were not fully realized due to incomplete data. The organizational culture did not promote the collection of surveillance data. Nurses felt that the surveillance form added to their workload, and the infection control practitioners were unable to adequately supervise the process due to competing work demands. Conclusions. A manual system that adds to the administrative workload of nurses is not an effective method of measuring the burden of HAIs. Change management is required to promote an organizational culture that supports accurate data collection for HAIs. Saajida Mahomed, Ozayr Mahomed, A. Willem Sturm, Stephen Knight, and Prashini Moodley Copyright © 2017 Saajida Mahomed et al. All rights reserved. Improvement in Quality Metrics Outcomes and Patient and Family Satisfaction in a Neurosciences Intensive Care Unit after Creation of a Dedicated Neurocritical Care Team Sun, 08 Oct 2017 00:00:00 +0000 Introduction. Dedicated neurointensivists have been shown to improve outcome measurements in the neurosciences intensive care unit (NSICU). Quality outcome data in relation to patient and family satisfaction is lacking. This study evaluated the impact of newly appointed neurointensivists and creation of a neurocritical care team on quality outcome measures including patient satisfaction in a NSICU. Methods. This is a retrospective study of data over 36 months from a 14-bed NSICU evaluating quality outcome measures and anonymous patient satisfaction questionnaires before and after neurointensivists appointment. Results. After appointment of neurointensivists, patient acuity of the NSICU increased by 33.4% while LOS decreased by 3.5%. There was a decrease in neurosciences mortality (35.8%), catheter-associated urinary tract infection (50%), central line associated bloodstream infection (100%), and ventilator-associated pneumonia (50%). During the same time, patient satisfaction increased by 28.3% on physicians/nurses consistency (), by 69.5% in confidence/trust in physicians (), by 78.3% on physicians treated me with courtesy/respect (), and by 46.4% on physicians’ attentiveness (). Ultimately, patients recommending the hospital to others increased by 67.5% (). Conclusion. Dedicated neurointensivists and the subsequent development of a neurocritical care team positively impacted quality outcome metrics, particularly significantly improving patient satisfaction. Yaw Sarpong, Premkumar Nattanmai, Ginger Schelp, Robert Bell, Keerthivaas Premkumar, Erin Stapleton, Ashley McCormick, and Christopher R. Newey Copyright © 2017 Yaw Sarpong et al. All rights reserved. Variability in Glycemic Control with Temperature Transitions during Therapeutic Hypothermia Mon, 18 Sep 2017 08:21:49 +0000 Purpose. Patients treated with therapeutic hypothermia (TH) and continuous insulin may be at increased risk of hyperglycemia or hypoglycemia, particularly during temperature transitions. This study aimed to evaluate frequency of glucose excursions during each phase of TH and to characterize glycemic control patterns in relation to survival. Methods. Patients admitted to a tertiary care hospital for circulatory arrest and treated with both therapeutic hypothermia and protocol-based continuous insulin between January 2010 and June 2013 were included. Glucose measures, insulin, and temperatures were collected through 24 hours after rewarming. Results. 24 of 26 patients experienced glycemic excursions. Hyperglycemic excursions were more frequent during initiation versus remaining phases (36.3%, 4.3%, 2.5%, and 4.0%, ). Hypoglycemia occurred most often during rewarming (0%, 7.7%, 23.1%, and 3.8%, ). Patients who experienced hypoglycemia had higher insulin doses prior to rewarming (16.2 versus 2.1 units/hr, ). Glucose variation was highest during hypothermia and trended higher in nonsurvivors compared to survivors (13.38 versus 9.16, ). Frequency of excursions was also higher in nonsurvivors (32.3% versus 19.8%, ). Conclusions. Glycemic excursions are common and occur more often in nonsurvivors. Excursions differ by phase but risk of hypoglycemia is increased during rewarming. Krystal K. Haase, Jennifer L. Grelle, Faisal A. Khasawneh, and Chiamaka Ike Copyright © 2017 Krystal K. Haase et al. All rights reserved. Analysis of Adverse Events during Intrahospital Transportation of Critically Ill Patients Thu, 14 Sep 2017 06:55:48 +0000 Purpose. To describe adverse events occurring during intrahospital transportation of adult patients hospitalized in an Intensive Care Unit (ICU) and to evaluate the association with morbidity and mortality. Method. Prospective cohort study from July 2014 to July 2015. Data collection comprised clinical data, prognostic scores, length of stay, and outcome at hospital discharge. Data was collected on transport and adverse events. Adverse events were classified according to the World Health Organization following the degree of damage. The level of significance was set at 5%. Results. A total of 293 patients were analyzed with follow-up of 143 patient transportations and records of 86 adverse events. Of these events, 44.1% were related to physiological alterations, 23.5% due to equipment failure, 19.7% due to team failure, and 12.7% due to delays. Half of the events were classified as moderate. The mean time of hospital stay of the group with adverse events was higher compared to patients without adverse events (31.4 versus 16.6 days, resp., ). Conclusions. Physiological alterations were the most frequently encountered events, followed by equipment and team failures. The degree of damage associated with adverse events was classified as moderate and associated with an increase in the length of hospital stay. Francielli Mary Pereira Gimenez, Wesley Henrique Bueno de Camargo, Ana Clara Beraldo Gomes, Thaylla Sumyre Nihei, Monique Walicheki Maria Andrade, Maria Laura de A. F. Sé Valverde, Larissa D’ Epiro de Souza Campos, Debora Carvalho Grion, Josiane Festti, and Cintia Magalhães Carvalho Grion Copyright © 2017 Francielli Mary Pereira Gimenez et al. All rights reserved. A Retrospective, Pilot Study of De Novo Antidepressant Medication Initiation in Intensive Care Unit Patients and Post-ICU Depression Wed, 13 Sep 2017 06:17:55 +0000 Post-ICU Syndromes (PICS) remain a devastating problem for intensive care unit (ICU) survivors. It is currently unknown if de novo initiation of an antidepressant medication during ICU stay decreases the prevalence of post-ICU depression. We performed a retrospective, pilot study evaluating patients who had not previously been on an antidepressant medication and who were started on an antidepressant while in the trauma surgical, cardiothoracic, or medical intensive care unit (ICU). The PHQ-2 depression scale was used to ascertain the presence of depression after ICU discharge and compared this to historical controls. Of 2,988 patients admitted to the ICU, 69 patients had de novo initiation of an antidepressant medication and 27 patients were alive and available for study inclusion. We found the prevalence of depression in these patients to be 26%, which is not statistically different than the prevalence of post-ICU depression in historical controls [95% CI (27.6%, 51.6%)]. De novo initiation of an antidepressant medication did not substantially decrease the prevalence of post-ICU depression in this retrospective, pilot study. Daniel Haines, Johanna Hild, Jianghua He, Lucy Stun, Angie Ballew, Justin L. Green, Lewis Satterwhite, and Brigid C. Flynn Copyright © 2017 Daniel Haines et al. All rights reserved. IVC Measurements in Critically Ill Patients with Acute Renal Failure Tue, 05 Sep 2017 10:04:19 +0000 Objective. To determine whether the inferior vena cava (IVC) measurement by bedside ultrasound (US-IVC) predicts improvement in renal function in patients with acute kidney injury (AKI). Design. Prospective observational study. Setting. Medical intensive care unit. Patients. 33 patients with AKI were included. Intervention. US-IVC was done on admission. The patients’ management was done by the primary teams, who were unaware of the US-IVC findings. Two groups of patients were identified. Group 1 included patients who were managed in concordance with their US-IVC (potential volume responders who had a positive fluid balance at 48 h after admission and potential volume nonresponders who had an even or negative fluid balance at 48 hours after admission). Group 2 included patients in whom the fluid management was discordant with their US-IVC. Measurements and Main Results. At 48 hours, Group 1 patients had a greater improvement in creatinine [85% versus 31%, ], creatinine clearance (% versus %, ), and urine output ( versus  ml/Kg/h, ). Conclusion. In critically ill patients with AKI, concurrence of fluid therapy with IVC predicted fluid management, as assessed by bedside ultrasound, was associated with improved renal function at 48 hours. This trial is registered with registration number: NCT02064244. Rami Jambeih, Jean I. Keddissi, and Houssein A. Youness Copyright © 2017 Rami Jambeih et al. All rights reserved. Clinical Characteristics and Outcomes of Surgical Patients with Intensive Care Unit Lengths of Stay of 90 Days and Greater Sun, 30 Jul 2017 07:07:39 +0000 Background. The aim of this study was to evaluate the influence of prolonged length of stay in an intensive care unit (ICU) on the mortality and morbidity of surgical patients. Methods. We performed a monocentric and retrospective observational study in the surgical critical care unit of the department of surgery at the Medical Center of the University of Freiburg, Germany. Clinical data was collected from patients assigned to the ICU with a length of stay (LOS) of 90 days and greater. Results. From the total of the 19 patients with ICU LOS over 90 days, ten patients died in the ICU whereas nine patients were discharged to the normal ward. The ICU mortality rate was 52%. The overall survival one year after ICU discharge was 32%. Regarding factors affecting mortality of the patients, significantly higher mortality was associated with age of the patients at the time point of the ICU admission and with postoperative need of renal replacement therapy. Conclusions. We found a high but in our opinion acceptable mortality rate in surgical patients with ICU LOS of 90 days and greater. We identified age and the need of renal replacement therapy as risk factors for mortality. Verena Martini, Ann-Kathrin Lederer, Claudia Laessle, Frank Makowiec, Stefan Utzolino, Stefan Fichtner-Feigl, and Lampros Kousoulas Copyright © 2017 Verena Martini et al. All rights reserved. Utilisation of Intermediate Care Units: A Systematic Review Sun, 09 Jul 2017 06:58:36 +0000 Background. The diversity in formats of Intermediate Care Units (IMCUs) makes it difficult to compare data from different settings. The purpose of this article was to describe and quantify these different formations and utilisation. Methods. We performed a systematic review extracting geographic location, nomenclature used, admitting specialties, open (admitting specialist in charge) or closed (intensivist/generalist in charge) management format, location in hospital, number of beds, nursing workload, medical staff to patient ratios, and modalities—possibilities and limitations—implemented. Results. Nomenclature used was High Dependency Unit (56.8%) or Intermediate Care Unit (24.3%), with the latter one increasingly being used recently. The median number of beds was 6 (IQR 4–10). Location () and admitting specialties () were related to the management format. IMCUs integrated or adjacent to Intensive Care Units were more often capable of using single vasoactive medication (). The mean nurse to patient ratio was 1 to 2.5. Conclusions. IMCUs often have a specific task in a hospital, which is reflected in location, format, and utilisation. The management format depends on location and admitting specialist while incorporated supportive treatment modules reflect its function. Common IMCU denominators are continuous monitoring and respiratory support, without mechanical ventilation and multiple vasoactive medications. Joost D. J. Plate, Luke P. H. Leenen, Marijn Houwert, and Falco Hietbrink Copyright © 2017 Joost D. J. Plate et al. All rights reserved. Resurgence of Polymyxin B for MDR/XDR Gram-Negative Infections: An Overview of Current Evidence Thu, 06 Jul 2017 00:00:00 +0000 Polymyxin B has resurged in recent years as a last resort therapy for Gram-negative multidrug-resistant (MDR) and extremely drug resistant (XDR) infections. Understanding newer evidence on polymyxin B is necessary to guide clinical decision making. Here, we present a literature review of polymyxin B in Gram-negative infections with update on its pharmacology. Suneel Kumar Garg, Omender Singh, Deven Juneja, Niraj Tyagi, Amandeep Singh Khurana, Amit Qamra, Salman Motlekar, and Hanmant Barkate Copyright © 2017 Suneel Kumar Garg et al. All rights reserved. Factors Associated with the Incidence and Severity of New-Onset Atrial Fibrillation in Adult Critically Ill Patients Thu, 15 Jun 2017 00:00:00 +0000 Background. Acute Atrial Fibrillation (AF) is common in critically ill patients, with significant morbidity and mortality; however, its incidence and severity in Intensive Care Units (ICUs) from low-income countries are poorly studied. Additionally, impact of vasoactive drugs on its incidence and severity is still not understood. This study aimed to assess epidemiology and risk factors for acute new-onset AF in critically ill adult patients and the role of vasoactive drugs. Method. Cohort performed in seven general ICUs (including cardiac surgery) in three cities in Paraná State (southern Brazil) for 45 days. Patients were followed until hospital discharge. Results. Among 430 patients evaluated, the incidence of acute new-onset AF was 11.2%. Patients with AF had higher ICU and hospital mortality. Vasoactive drugs use (norepinephrine and dobutamine) was correlated with higher incidence of AF and higher mortality in patients with AF; vasopressin (though used in few patients) had no effect on development of AF. Conclusions. In general ICU patients, incidence of new-onset AF was 11.2% with a high impact on morbidity and mortality, particularly associated with the presence of Acute Renal Failure. The use of vasoactive drugs (norepinephrine and dobutamine) could lead to a higher incidence of new-onset AF-associated morbidity and mortality. Péricles A. D. Duarte, Gustavo Elias Leichtweis, Luiza Andriolo, Yasmim A. Delevatti, Amaury C. Jorge, Andreia C. Fumagalli, Luiz Claudio Santos, Cecilia K. Miura, and Sergio K. Saito Copyright © 2017 Péricles A. D. Duarte et al. All rights reserved. Melatonin Secretion Pattern in Critically Ill Patients: A Pilot Descriptive Study Thu, 11 May 2017 00:00:00 +0000 Critically ill patients have abnormal circadian and sleep homeostasis. This may be associated with higher morbidity and mortality. The aims of this pilot study were (1) to describe melatonin secretion in conscious critically ill mechanically ventilated patients and (2) to describe whether melatonin secretion and sleep patterns differed in these patients with and without remifentanil infusion. Eight patients were included. Blood-melatonin was taken every 4th hour, and polysomnography was carried out continually during a 48-hour period. American Academy of Sleep Medicine criteria were used for sleep scoring if sleep patterns were identified; otherwise, Watson’s classification was applied. As remifentanil was periodically administered during the study, its effect on melatonin and sleep was assessed. Melatonin secretion in these patients followed a phase-delayed diurnal curve. We did not observe any effect of remifentanil on melatonin secretion. We found that the risk of atypical sleep compared to normal sleep was significantly lower () under remifentanil infusion. Rapid Eye Movement (REM) sleep was only observed during the nonsedation period. We found preserved diurnal pattern of melatonin secretion in these patients. Remifentanil did not affect melatonin secretion but was associated with lower risk of atypical sleep pattern. REM sleep was only registered during the period of nonsedation. Yuliya Boyko, René Holst, Poul Jennum, Helle Oerding, Miki Nikolic, and Palle Toft Copyright © 2017 Yuliya Boyko et al. All rights reserved. Brain Multimodality Monitoring: A New Tool in Neurocritical Care of Comatose Patients Sun, 07 May 2017 00:00:00 +0000 Neurocritical care patients are at risk of developing secondary brain injury from inflammation, ischemia, and edema that follows the primary insult. Recognizing clinical deterioration due to secondary injury is frequently challenging in comatose patients. Multimodality monitoring (MMM) encompasses various tools to monitor cerebral metabolism, perfusion, and oxygenation aimed at detecting these changes to help modify therapies before irreversible injury sets in. These tools include intracranial pressure (ICP) monitors, transcranial Doppler (TCD), Hemedex™ (thermal diffusion probe used to measure regional cerebral blood flow), microdialysis catheter (used to measure cerebral metabolism), Licox™ (probe used to measure regional brain tissue oxygen tension), and continuous electroencephalography. Although further research is needed to demonstrate their impact on improving clinical outcomes, their contribution to illuminate the black box of the brain in comatose patients is indisputable. In this review, we further elaborate on commonly used MMM parameters, tools used to measure them, and the indications for monitoring per current consensus guidelines. Nudrat Tasneem, Edgar A. Samaniego, Connie Pieper, Enrique C. Leira, Harold P. Adams, David Hasan, and Santiago Ortega-Gutierrez Copyright © 2017 Nudrat Tasneem et al. All rights reserved. Impact of Delayed Admission to the Intensive Care Unit from the Emergency Department upon Sepsis Outcomes and Sepsis Protocol Compliance Sun, 12 Mar 2017 07:14:57 +0000 Rationale. The impact of emergency department length of stay (EDLOS) upon sepsis outcomes needs clarification. We sought to better understand the relationship between EDLOS and both outcomes and protocol compliance in sepsis. Methods. We performed a retrospective observational study of septic patients admitted to the ICU from the ED between January 2012 and December 2015 in a single tertiary care teaching hospital. 287 patients with severe sepsis and septic shock were included. Study population was divided into patients with EDLOS < 6 hrs (early admission) versus 6 hours (delayed admission). We assessed the impact of EDLOS on hospital mortality, compliance with sepsis protocol, and resuscitation. Statistical significance was determined by chi-square test. Results. Of the 287 septic ED patients, 137 (47%) were admitted to the ICU in <6 hours. There was no significant in-hospital mortality difference between early and delayed admissions (). Both groups have similar compliance with the 3-hour protocol (). There was no significant difference in achieving optimal resuscitation within 12 hours (). Conclusion. We found that clinical outcomes were not significantly different between early and delayed ICU admissions. Additionally, EDLOS did not impact compliance with the sepsis protocol with the exception of repeat lactate draw. Michael Agustin, Lori Lyn Price, Augustine Andoh-Duku, and Peter LaCamera Copyright © 2017 Michael Agustin et al. All rights reserved. The Benefit of Neuromuscular Blockade in Patients with Postanoxic Myoclonus Otherwise Obscuring Continuous Electroencephalography (CEEG) Mon, 06 Feb 2017 00:00:00 +0000 Introduction. Myoclonus status epilepticus is independently associated with poor outcome in coma patients after cardiac arrest. Determining if myoclonus is of cortical origin on continuous electroencephalography (CEEG) can be difficult secondary to the muscle artifact obscuring the underlying CEEG. The use of a neuromuscular blocker can be useful in these cases. Methods. Retrospective review of CEEG in patients with postanoxic myoclonus who received cisatracurium while being monitored. Results. Twelve patients (mean age: 53.3 years; 58.3% male) met inclusion criteria of clinical postanoxic myoclonus. The initial CEEG patterns immediately prior to neuromuscular blockade showed myoclonic artifact with continuous slowing (50%), burst suppression with myoclonic artifact (41.7%), and continuous myogenic artifact obscuring CEEG (8.3%). After intravenous administration of cisatracurium (0.1 mg–2 mg), reduction in artifact improved quality of CEEG recordings in 9/12 (75%), revealing previously unrecognized patterns: continuous EEG seizures (33.3%), lateralizing slowing (16.7%), burst suppression (16.7%), generalized periodic discharges (8.3%), and, in the patient who had an initially uninterpretable CEEG from myogenic artifact, continuous slowing. Conclusion. Short-acting neuromuscular blockade is useful in determining background cerebral activity on CEEG otherwise partially or completely obscured by muscle artifact in patients with postanoxic myoclonus. Fully understanding background cerebral activity is important in prognostication and treatment, particularly when there are underlying EEG seizures. Christopher R. Newey, Alejandro Hornik, Meziane Guerch, Anantha Veripuram, Sushma Yerram, and Agnieszka Ardelt Copyright © 2017 Christopher R. Newey et al. All rights reserved. Severe Tuberculosis Requiring Intensive Care: A Descriptive Analysis Mon, 30 Jan 2017 00:00:00 +0000 Background. This study aims to describe the characteristics of tuberculosis (TB) patients requiring intensive care and to determine the in-hospital mortality and the associated predictive factors. Methods. Retrospective cohort study of all TB patients admitted to the ICU of the Infectious Diseases Department of Centro Hospitalar de São João (Porto, Portugal) between January 2007 and July 2014. Comorbid diagnoses, clinical features, radiological and laboratory investigations, and outcomes were reviewed. Univariate analysis was performed to identify risk factors for death. Results. We included 39 patients: median age was 52.0 years and 74.4% were male. Twenty-one patients (53.8%) died during hospital stay (15 in the ICU). The diagnosis of isolated pulmonary TB, a positive smear for acid-fast-bacilli and a positive PCR for Mycobacterium tuberculosis in patients of pulmonary disease, severe sepsis/septic shock, acute renal failure and Multiple Organ Dysfunction Syndrome on admission, the need for mechanical ventilation or vasopressor support, hospital acquired infection, use of adjunctive corticotherapy, smoking, and alcohol abuse were significantly associated with mortality (). Conclusion. This cohort of TB patients requiring intensive care presented a high mortality rate. Most risk factors for mortality were related to organ failure, but others could be attributed to delay in the diagnostic and therapeutic approach, important targets for intervention. Raquel Pacheco Duro, Paulo Figueiredo Dias, Alcina Azevedo Ferreira, Sandra Margarida Xerinda, Carlos Lima Alves, António Carlos Sarmento, and Lurdes Campos dos Santos Copyright © 2017 Raquel Pacheco Duro et al. All rights reserved. Does Obesity Predispose Medical Intensive Care Unit Patients to Venous Thromboembolism despite Prophylaxis? A Retrospective Chart Review Wed, 23 Nov 2016 14:19:22 +0000 Background. Obesity is a significant issue in the critically ill population. There is little evidence directing the dosing of venous thromboembolism (VTE) prophylaxis within this population. We aimed to determine whether obesity predisposes medical intensive care unit patients to venous thromboembolism despite standard chemoprophylaxis with 5000 international units of subcutaneous heparin three times daily. Results. We found a 60% increased risk of venous thromboembolism in the body mass index (BMI) ≥ 30 kg/m2 group compared to the BMI < 30 kg/m2 group; however, this difference did not reach statistical significance. After further utilizing our risk model, neither obesity nor mechanical ventilation reached statistical significance; however, vasopressor administration was associated with a threefold risk. Conclusions. We can conclude that obesity did increase the rate of VTE, but not to a statistically significant level in this single center medical intensive care unit population. Bradley J. Peters, Ross A. Dierkhising, and Kristin C. Mara Copyright © 2016 Bradley J. Peters et al. All rights reserved. Impact of a Local Low-Cost Ward-Based Response System in a Canadian Tertiary Care Hospital Mon, 17 Oct 2016 09:51:13 +0000 Background. Medical emergency teams (METs) or rapid response teams (RRTs) facilitate early intervention for clinically deteriorating hospitalized patients. In healthcare systems where financial resources and intensivist availability are limited, the establishment of such teams can prove challenging. Objectives. A low-cost, ward-based response system was implemented on a medical clinical teaching unit in a Montreal tertiary care hospital. A prospective before/after study was undertaken to examine the system’s impact on time to intervention, code blue rates, and ICU transfer rates. Results. Ninety-five calls were placed for 82 patients. Median time from patient decompensation to intervention was 5 min (IQR 1–10), compared to 3.4 hours (IQR 0.6–12.4) before system implementation (). Total number of ICU admissions from the CTU was reduced from 4.8/1000 patient days () before intervention to 3.3/1000 patient days () after intervention (IRR: 0.82, (CI 95%: 0.69–0.99)). CTU code blue rates decreased from 2.2/1000 patient days () before intervention to 1.2/1000 patient days () after intervention (IRR: 0.51, (CI 95%: 0.30–0.89)). Conclusion. Our local ward-based response system achieved a significant reduction in the time of patient decompensation to initial intervention, in CTU code blue rates, and in CTU to ICU transfers without necessitating additional usage of financial or human resources. Andrea Blotsky, Louay Mardini, and Dev Jayaraman Copyright © 2016 Andrea Blotsky et al. All rights reserved. Correlation between Arterial Lactate and Central Venous Lactate in Children with Sepsis Sun, 16 Oct 2016 08:29:26 +0000 Introduction. Lactate is an important indicator of tissue perfusion. The objective of this study is to evaluate if there are significant differences between the arterial and central venous measurement of lactate in pediatric patients with sepsis and/or septic shock. Methods. Longitudinal retrospective observational study. Forty-two patients were included between the age of 1 month and 17 years, with a diagnosis of sepsis and septic shock, who were admitted to the intensive care unit of a university referral hospital. The lactate value obtained from an arterial blood sample and a central venous blood sample drawn simultaneously, and within 24 hours of admission to the unit, was recorded. Results. The median age was 2.3 years (RIC 0,3–15), with a predominance of males (71.4%), having a 2.5 : 1 ratio to females. Most of the patients had septic shock (78.5%) of pulmonary origin (50.0%), followed by those of gastrointestinal origin (26.1%). Using Spearman’s Rho, a 0.872 () correlation was found between arterial and venous lactate, which did not vary when adjusted for age () and the use of vasoactive drugs (). Conclusion. There is a good correlation between arterial and venous lactate in pediatric patients with sepsis and septic shock, which is not affected by demographic variables or type of vasoactive support. Jaime Fernández Sarmiento, Paula Araque, María Yepes, Hernando Mulett, Ximena Tovar, and Fabio Rodriguez Copyright © 2016 Jaime Fernández Sarmiento et al. All rights reserved. Clinical Characteristics and Short-Term Outcomes of HIV Patients Admitted to an African Intensive Care Unit Sun, 09 Oct 2016 07:37:03 +0000 Purpose. In high-income countries, improved survival has been documented among intensive care unit (ICU) patients infected with human immune deficiency virus (HIV). There are no data from low-income country ICUs. We sought to identify clinical characteristics and survival outcomes among HIV patients in a low-income country ICU. Materials and Methods. A retrospective cohort study of HIV infected patients admitted to a university teaching hospital ICU in Uganda. Medical records were reviewed. Primary outcome was survival to hospital discharge. Statistical significance was predetermined in reference to . Results. There were 101 HIV patients. Average length of ICU stay was 4 days and ICU mortality was 57%. Mortality in non-HIV patients was 28%. Commonest admission diagnoses were Acute Respiratory Distress Syndrome (ARDS) (58.4%), multiorgan failure (20.8%), and sepsis (20.8%). The mean Acute Physiologic and Chronic Health Evaluation (APACHE II) score was 24. At multivariate analysis, APACHE II (OR 1.24 (95% CI: 1.1–1.4, )), mechanical ventilation (OR 1.14 (95% CI: 0.09–0.76, )), and ARDS (OR 4.5 (95% CI: 1.07–16.7, )) had a statistically significant association with mortality. Conclusion. ICU mortality of HIV patients is higher than in higher income settings and the non-HIV population. ARDS, APACHE II, and need for mechanical ventilation are significantly associated with mortality. Arthur Kwizera, Mary Nabukenya, Agaba Peter, Lameck Semogerere, Emmanuel Ayebale, Catherine Katabira, Samuel Kizito, Cecilia Nantume, Ian Clarke, and Jane Nakibuuka Copyright © 2016 Arthur Kwizera et al. All rights reserved. Potentially Preventable Deaths by Intensive Care Medicine in Mongolian Hospitals Tue, 04 Oct 2016 13:08:58 +0000 Purpose. To evaluate the portion of hospitalized patients dying without prior intensive care unit (ICU) admission and assess whether death could have been prevented by intensive care. Methods. In this prospective, observational, multicenter study, data of adults dying in and outside the ICU in 5 tertiary and 14 secondary hospitals were collected during six months. A group of experts categorized patients dying without prior ICU admission as whether their death was potentially preventable or not. Results. 617 patients died (72.9% in and 27.1% outside the ICU) during the observation period. In 54/113 patients (32.3%) dying in the hospital without prior ICU admission, death was considered potentially preventable. The highest number of these deaths was seen in patients aged 16–30 years and those who suffered from an infection (83.3%), underwent surgery (58.3%), or sustained trauma (52%). Potentially preventable deaths resulted in a total number of 1,078 years of life lost and 709 productive years of life lost. Conclusions. Twenty-seven percent of adults dying in Mongolian secondary and tertiary level hospitals do so without prior ICU admission. One-third, mostly young patients suffering from acute reversible conditions, may have potentially been saved by intensive care medicine. Naranpurev Mendsaikhan, Tsolmon Begzjav, Ganbold Lundeg, and Martin W. Dünser Copyright © 2016 Naranpurev Mendsaikhan et al. All rights reserved. Abnormal Admission Chest X-Ray and MEWS as ICU Outcome Predictors in a Sub-Saharan Tertiary Hospital: A Prospective Observational Study Mon, 19 Sep 2016 09:24:59 +0000 Background. Critical care in Uganda is a neglected speciality and deemed costly with limited funding/prioritization. We studied admission X-ray and MEWS as mortality predictors of ICU patients requiring mechanical ventilation. Materials and Methods. We did a cross-sectional study in Mulago Hospital ICU and 87 patients for mechanical ventilation were recruited with mortality as the outcome of interest. Chest X-ray results were the main independent variable and MEWS was also gotten for all patients. Results. We recruited 87 patients; most were males (60.92%), aged between 16 and 45 years (59.77%), and most admissions for mechanical ventilation were from the Trauma Unit (30.77%). Forty-one (47.13%) of the 87 patients died and of these 34 (53.13%) had an abnormal CXR with an insignificant IRR = 1.75 (0.90–3.38) (). Patients with MEWS ≥ 5 ( values = 0.018) and/or having an abnormal superior mediastinum ( values = 0.013) showed a positive association with mortality while having a MEWS 5 had an incidence risk ratio = 3.29 (1.00–12.02) (). MEWS was a good predictor of mortality (predictive value = 0.6739). Conclusion. Trauma (31%) caused most ICU admissions, having an abnormal admission chest X-rays positively associated with mortality and a high MEWS was also a good predictor of mortality. Hannington Ssemmanda, Tonny Stone Luggya, Clare Lubulwa, Zeridah Muyinda, Pascal Kwitonda, Humphrey Wanzira, and Joseph Ejoku Copyright © 2016 Hannington Ssemmanda et al. All rights reserved. The Development of Intensive Care Unit Acquired Hypernatremia Is Not Explained by Sodium Overload or Water Deficit: A Retrospective Cohort Study on Water Balance and Sodium Handling Wed, 14 Sep 2016 13:14:05 +0000 Background. ICU acquired hypernatremia (IAH, serum sodium concentration (sNa) ≥ 143 mmol/L) is mainly considered iatrogenic, induced by sodium overload and water deficit. Main goal of the current paper was to answer the following questions: Can the development of IAH indeed be explained by sodium intake and water balance? Or can it be explained by renal cation excretion? Methods. Two retrospective studies were conducted: a balance study in 97 ICU patients with and without IAH and a survey on renal cation excretion in 115 patients with IAH. Results. Sodium intake within the first 48 hours of ICU admission was 12.5 [9.3–17.5] g in patients without IAH () and 15.8 [9–21.9] g in patients with IAH (), . Fluid balance was 2.3 [1–3.7] L and 2.5 [0.8–4.2] L, respectively, . Urine cation excretion (urine Na + K) was < sNa in 99 out of 115 patients with IAH. Severity of illness was the only independent variable predicting development of IAH and low cation excretion, respectively. Conclusion. IAH is not explained by sodium intake or fluid balance. Patients with IAH are characterized by low urine cation excretion, despite positive fluid balances. The current paradigm does not seem to explain IAH to the full extent and warrants further studies on sodium handling in ICU patients. M. C. O. van IJzendoorn, H. Buter, W. P. Kingma, G. J. Navis, and E. C. Boerma Copyright © 2016 M. C. O. van IJzendoorn et al. All rights reserved. Can Transcutaneous CO2 Tension Be Used to Calculate Ventilatory Dead Space? A Pilot Study Mon, 05 Sep 2016 13:29:40 +0000 Dead space fraction () measurement performed using volumetric capnography requires arterial blood gas (ABG) sampling to estimate the partial pressure of carbon dioxide (). In recent years, transcutaneous capnography () has emerged as a noninvasive method of estimating . We hypothesized that CO2 can be used as a substitute for in the calculation of . In this prospective pilot comparison study, 30 consecutive postcardiac surgery mechanically ventilated patients had calculated separately using volumetric capnography by substituting CO2 for . The mean calculated using and CO2 was 0.48 ± 0.09 and 0.53 ± 0.08, respectively, with a strong positive correlation between the two methods of calculation (Pearson’s correlation = 0.87, ). Bland-Altman analysis showed a mean difference of −0.05 (95% CI: −0.01 to −0.09) between the two methods. CO2 measurements can provide a noninvasive means to measure , thus accessing important physiologic information and prognostic assessment in patients receiving mechanical ventilation. Pradeep H. Lakshminarayana, Adiba A. Geeti, Umer M. Darr, and David A. Kaufman Copyright © 2016 Pradeep H. Lakshminarayana et al. All rights reserved. Response to: Comment on “Management of Atrial Fibrillation in Critically Ill Patients” Thu, 25 Aug 2016 14:36:26 +0000 Mattia Arrigo, Dominique Bettex, and Alain Rudiger Copyright © 2016 Mattia Arrigo et al. All rights reserved. Comment on “Management of Atrial Fibrillation in Critically Ill Patients” Wed, 24 Aug 2016 12:36:21 +0000 Roger Jelliffe Copyright © 2016 Roger Jelliffe. All rights reserved. Management of Maternal Cardiac Arrest in the Third Trimester of Pregnancy: A Simulation-Based Pilot Study Sun, 31 Jul 2016 08:24:04 +0000 Objective. To evaluate confidence, knowledge, and competence after a simulation-based curriculum on maternal cardiac arrest in an Obstetrics & Gynecologic (OBGYN) residency program. Methods. Four simulations with structured debriefing focusing on high yield causes and management of maternal cardiac arrest were executed. Pre- and post-individual knowledge tests (KT) and confidence surveys (CS) were collected along with group scores of critical performance steps evaluated by content experts for the first and final simulations. Results. Significant differences were noted in individual KT scores (pre: versus post: , ) and CS total scores (pre: versus post: , ). Significant differences were noted in airway management, ; appropriate cycles of drug/shock-CPR, ; left uterine displacement, ; and identifying causes of cardiac arrest, . Nonsignificant differences were noted for administration of appropriate drugs/doses, ; chest compressions, ; bag-mask ventilation before intubation, ; and return of spontaneous circulation identification, . Groups remained noncompetent in team leader tasks and considering therapeutic hypothermia. Conclusion. This study demonstrated improved OBGYN resident knowledge, confidence, and competence in the management of third trimester maternal cardiac arrest. Several skills, however, will likely require more longitudinal curricular exposure and training to develop and maintain proficiency. Jacquelyn Adams, Jose R. Cepeda Brito, Lauren Baker, Patrick G. Hughes, M. David Gothard, Michele L. McCarroll, Jocelyn Davis, Angela Silber, and Rami A. Ahmed Copyright © 2016 Jacquelyn Adams et al. All rights reserved. Survey of Oxygen Delivery Practices in UK Paediatric Intensive Care Units Tue, 19 Jul 2016 12:58:15 +0000 Purpose. Administration of supplemental oxygen is common in paediatric intensive care. We explored the current practice of oxygen administration using a case vignette in paediatric intensive care units (PICU) in the united kingdom. Methods. We conducted an online survey of Paediatric Intensive Care Society members in the UK. The survey outlined a clinical scenario followed by questions on oxygenation targets for 5 common diagnoses seen in critically ill children. Results. Fifty-three paediatric intensive care unit members from 10 institutions completed the survey. In a child with moderate ventilatory requirements, 21 respondents (42%) did not follow arterial partial pressure of oxygen (PaO2) targets. In acute respiratory distress syndrome, cardiac arrest, and sepsis, there was a trend to aim for lower PaO2 as the fraction of inspired oxygen (FiO2) increased. Conversely, in traumatic brain injury and pulmonary hypertension, respondents aimed for normal PaO2 even as the FiO2 increased. Conclusions. In this sample of clinicians PaO2 targets were not commonly used. Clinicians target lower PaO2 as FiO2 increases in acute respiratory distress syndrome, cardiac arrest, and sepsis whilst targeting normal range irrespective of FiO2 in traumatic brain injury and pulmonary hypertension. Sainath Raman, Samiran Ray, and Mark J. Peters Copyright © 2016 Sainath Raman et al. All rights reserved. Determinants of Deescalation Failure in Critically Ill Patients with Sepsis: A Prospective Cohort Study Thu, 14 Jul 2016 13:20:16 +0000 Introduction. Deescalation refers to either discontinuation or a step-down of antimicrobials. Despite strong recommendations in the Surviving Sepsis Guidelines (2012) to deescalate, actual practices can vary. Our objective was to identify variables that are associated with deescalation failure. Methods. In this prospective study of patients with sepsis/septic shock, patients were categorized into 4 groups based on antibiotic administration: no change in antibiotics, deescalation, escalation (where antibiotics were changed to those with a broader spectrum of antimicrobial coverage), or mixed changes (where both escalation to a broader spectrum of coverage and discontinuation of antibiotics were carried out). Results. 395 patients were studied; mean APACHE II score was . Antimicrobial deescalation occurred in 189 (48%) patients; no changes were made in 156 (39%) patients. On multivariate regression analysis, failure to deescalate was significantly predicted by hematologic malignancy OR 3.3 (95% CI 1.4–7.4) , fungal sepsis OR 2.7 (95% CI 1.2–5.8) , multidrug resistance OR 2.9 (95% CI 1.4–6.0) , baseline serum procalcitonin OR 1.01 (95% CI 1.003–1.016) , and SAPS II scores OR 1.01 (95% CI 1.004–1.02) . Conclusions. Current deescalation practices reflect physician reluctance when dealing with complicated, sicker patients or with drug-resistance or fungal sepsis. Integrating an antibiotic stewardship program may increase physician confidence and provide support towards increasing deescalation rates. Nawal Salahuddin, Lama Amer, Mini Joseph, Alya El Hazmi, Hassan Hawa, and Khalid Maghrabi Copyright © 2016 Nawal Salahuddin et al. All rights reserved. Antimicrobial Doses in Continuous Renal Replacement Therapy: A Comparison of Dosing Strategies Tue, 28 Jun 2016 17:29:51 +0000 Purpose. Drug dose recommendations are not well defined in patients undergoing continuous renal replacement therapy (CRRT) due to limited published data. Several guidelines and pharmacokinetic equations have been proposed as tools for CRRT drug dosing. Dose recommendations derived from these methods have yet to be compared or prospectively evaluated. Methods. A literature search of PubMed, Micromedex, and Embase was conducted for 40 drugs commonly used in the ICU to gather pharmacokinetic data acquired from patients with acute and chronic kidney disease as well as healthy volunteers. These data and that obtained from drug package inserts were gathered for use in three published CRRT drug dosing equations. Doses calculated for a model patient using each method were compared to doses suggested in a commonly used dosing text. Results. Full pharmacokinetic data was available for 18, 31, and 40 agents using acute kidney injury, end stage renal disease, and normal patient data, respectively. On average, calculated doses differed by 30% or more from the doses recommended by the renal dosing text for >50% of the medications. Conclusion. Wide variability in dose recommendations for patients undergoing CRRT exists when these equations are used. Alternate, validated dosing methods need to be developed for this at-risk patient population. Anna P. Kempke, Abbie S. Leino, Farzad Daneshvar, John Andrew Lee, and Bruce A. Mueller Copyright © 2016 Anna P. Kempke et al. All rights reserved.