Critical Care Research and Practice The latest articles from Hindawi © 2017 , Hindawi Limited . 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. Accuracy of Transcutaneous Carbon Dioxide Measurement in Premature Infants Wed, 08 Jun 2016 06:07:13 +0000 Background. In premature infants, maintaining blood partial pressure of carbon dioxide (pCO2) value within a narrow range is important to avoid cerebral lesions. The aim of this study was to assess the accuracy of a noninvasive transcutaneous method (TcpCO2), compared to blood partial pressure of carbon dioxide (pCO2). Methods. Retrospective observational study in a tertiary neonatal intensive care unit. We analyzed the correlation between blood pCO2 and transcutaneous values and the accuracy between the trends of blood pCO2 and TcpCO2 in all consecutive premature infants born at <33 weeks’ gestational age. Results. 248 infants were included (median gestational age: 29 + 5 weeks and median birth weight: 1250 g), providing 1365 pairs of TcpCO2 and blood pCO2 values. Pearson’s correlation between these values was 0.58. The mean bias was −0.93 kPa with a 95% confidence limit of agreement of −4.05 to +2.16 kPa. Correlation between the trends of TcpCO2 and blood pCO2 values was good in only 39.6%. Conclusions. In premature infants, TcpCO2 was poorly correlated to blood pCO2, with a wide limit of agreement. Furthermore, concordance between trends was equally low. We warn about clinical decision-making on TcpCO2 alone when used as continuous monitoring. Marie Janaillac, Sonia Labarinas, Riccardo E. Pfister, and Oliver Karam Copyright © 2016 Marie Janaillac et al. All rights reserved. Immunocompromised Children with Severe Adenoviral Respiratory Infection Sun, 08 May 2016 12:48:29 +0000 Purpose. To investigate the impact of severe respiratory adenoviral infection on morbidity and case fatality in immunocompromised children. Methods. Combined retrospective-prospective cohort study of patients admitted to the intensive care unit (ICU) in four children’s hospitals with severe adenoviral respiratory infection and an immunocompromised state between August 2009 and October 2013. We performed a secondary case control analysis, matching our cohort 1 : 1 by age and severity of illness score with immunocompetent patients also with severe respiratory adenoviral infection. Results. Nineteen immunocompromised patients were included in our analysis. Eleven patients (58%) did not survive to hospital discharge. Case fatality was associated with cause of immunocompromised state (), multiple organ dysfunction syndrome (), requirement of renal replacement therapy (), ICU admission severity of illness score (), and treatment with cidofovir (). Immunocompromised patients were more likely than matched controls to have multiple organ dysfunction syndrome (), require renal replacement therapy (), and not survive to hospital discharge (). One year after infection, 43% of immunocompromised survivors required chronic mechanical ventilator support. Conclusions. There is substantial case fatality as well as short- and long-term morbidity associated with severe adenoviral respiratory infection in immunocompromised children. Joanna C. Tylka, Michael C. McCrory, Shira J. Gertz, Jason W. Custer, and Michael C. Spaeder Copyright © 2016 Joanna C. Tylka et al. All rights reserved. Additional Analgesia for Central Venous Catheter Insertion: A Placebo Controlled Randomized Trial of Dexmedetomidine and Fentanyl Thu, 21 Apr 2016 07:47:42 +0000 We aimed to show that a single preprocedural dose of either dexmedetomidine or fentanyl reduces procedural pain and discomfort and provides clinically acceptable sedation. In this prospective, double-blind study, sixty patients scheduled for elective surgery and requiring planned central venous catheter insertion were randomized to receive dexmedetomidine (1 μg/kg), fentanyl (1 μg/kg), or 0.9% normal saline intravenously over ten minutes followed by local anesthetic field infiltration before attempting central venous catheterization. The primary outcome measures are assessment and analysis of pain, discomfort, and sedation level before, during, and after the central venous catheter insertion at five time points. The median (IQR) pain score is worst for normal saline group at local anaesthetic injection [6 (4–6.7)] which was significantly attenuated by addition of fentanyl [3 (2–4)] and dexmedetomidine [4 (3–5)] in the immediate postprocedural period (). However, the procedure related discomfort was significantly lower in dexmedetomidine group compared to fentanyl group in the first 10 min of procedure after local anaesthetic Injection (). Fentanyl is more analgesically efficient for central venous catheter insertion along with local anaesthetic injection. However, dexmedetomidine has the potential to be superior to fentanyl and placebo in terms of providing comfort to the patients during the procedure. Aloka Samantaray, Mangu Hanumantha Rao, and Chitta Ranjan Sahu Copyright © 2016 Aloka Samantaray et al. All rights reserved. Neutropenic Sepsis in the ICU: Outcome Predictors in a Two-Phase Model and Microbiology Findings Mon, 18 Apr 2016 13:37:19 +0000 Objective. Patients with neutropenic sepsis have a poor prognosis. We aimed to identify outcome predictors and generate hypotheses how the care for these patients may be improved. Methods. All 12.352 patients admitted between 2006 and 2011 to the medical ICUs of our tertiary university center were screened for neutropenia; out of 558 patients identified, 102 fulfilled the inclusion criteria and were analyzed. Severity markers and outcome predictors were assessed. Results. The overall ICU mortality was 54.9%. The severity of sepsis and the number of organ failures predicted survival of the primary septic episode (APACHE II 22.8 and 29.0; SOFA 7.3 and 10.1, resp.). In the recovery phase, persistent organ damage and higher persistent C-reactive protein levels were associated with a poor outcome. Blood transfusions and CMV infection correlated with an unfavorable prognosis. Ineffective initial antibiotic therapy, fungal infections, and detection of multiresistant bacteria displayed a particularly poor outcome. Infections with coagulase-negative staphylococci and enterococci were associated with a significantly higher mortality and a high degree of systemic inflammation. Conclusion. Patients with persistent organ dysfunction show an increased mortality in the further course of their ICU stay. Early antimicrobial treatment of Gram-positive cocci may improve the outcome of these patients. Jan M. Kruse, Thomas Jenning, Sibylle Rademacher, Renate Arnold, Clemens A. Schmitt, Achim Jörres, Philipp Enghard, and Michael Oppert Copyright © 2016 Jan M. Kruse et al. All rights reserved. Applicability of Pulse Pressure Variation during Unstable Hemodynamic Events in the Intensive Care Unit: A Five-Day Prospective Multicenter Study Thu, 31 Mar 2016 13:10:30 +0000 Pulse pressure variation can predict fluid responsiveness in strict applicability conditions. The purpose of this study was to describe the clinical applicability of pulse pressure variation during episodes of patient hemodynamic instability in the intensive care unit. We conducted a five-day, seven-center prospective study that included patients presenting with an unstable hemodynamic event. The six predefined inclusion criteria for pulse pressure variation applicability were as follows: mechanical ventilation, tidal volume >7 mL/kg, sinus rhythm, no spontaneous breath, heart rate/respiratory rate ratio >3.6, absence of right ventricular dysfunction, or severe valvulopathy. Seventy-three patients presented at least one unstable hemodynamic event, with a total of 163 unstable hemodynamic events. The six predefined criteria for the applicability of pulse pressure variation were completely present in only 7% of these. This data indicates that PPV should only be used alongside a strong understanding of the relevant physiology and applicability criteria. Although these exclusion criteria appear to be profound, they likely represent an absolute contraindication of use for only a minority of critical care patients. Bertrand Delannoy, Florent Wallet, Delphine Maucort-Boulch, Mathieu Page, Mahmoud Kaaki, Mathieu Schoeffler, Brenton Alexander, and Olivier Desebbe Copyright © 2016 Bertrand Delannoy et al. All rights reserved. Achievement of Vancomycin Therapeutic Goals in Critically Ill Patients: Early Individualization May Be Beneficial Thu, 17 Mar 2016 07:28:07 +0000 Objective. The aim of our study was to assess and validate the effectiveness of early dose adjustment of vancomycin based on first dose monitoring in achieving target recommended goal in critically ill patients. Methods. Twenty critically ill patients with sepsis received loading dose of 25 mg/kg of vancomycin and then were randomly assigned to 2 groups. Group 1 received maximum empirical doses of vancomycin of 15 mg/kg every 8 hrs. In group 2, the doses were individualized based on serum concentrations of vancomycin. First dose nonsteady state sampling was used to calculate pharmacokinetic parameters of the patients within 24 hours. Results. Steady state trough serum concentrations were significantly higher in group 2 in comparison with group 1 (19.4 ± 4.4 mg/L versus 14.4 ± 4.3 mg/L) (). Steady state AUCs were significantly higher in group 2 compared with group 1 (665.9 ± 136.5 mg·hr/L versus 490.7 ± 101.1 mg·hr/L) (). Conclusions. With early individualized dosing regimen, significantly more patients achieved peak and trough steady state concentrations. In the context of pharmacokinetic/pharmacodynamic goal of area under the time concentration curve to minimum inhibitory concentration (AUC/MIC) ≥400 and also to obtain trough serum concentration of vancomycin of ≥15 mg/L, it is necessary to individualize doses of vancomycin in critically ill patients. Bita Shahrami, Farhad Najmeddin, Sarah Mousavi, Arezoo Ahmadi, Mohammad Reza Rouini, Kourosh Sadeghi, and Mojtaba Mojtahedzadeh Copyright © 2016 Bita Shahrami et al. All rights reserved. Comment on “Sedative and Analgesic Effects of Entonox Gas Compared with Midazolam and Fentanyl in Synchronized Cardioversion” Tue, 15 Mar 2016 16:35:29 +0000 Henrique Horta Veloso Copyright © 2016 Henrique Horta Veloso. All rights reserved. Blood Lactate Is a Useful Indicator for the Medical Emergency Team Thu, 03 Mar 2016 06:49:20 +0000 Lactate has been thoroughly studied and found useful for stratification of patients with sepsis, in the Intensive Care Unit, and trauma care. However, little is known about lactate as a risk-stratification marker in the Medical Emergency Team- (MET-) call setting. We aimed to determine whether the arterial blood lactate level at the time of a MET-call is associated with increased 30-day mortality. This is an observational study on a prospectively gathered cohort at a regional secondary referral hospital. All MET-calls during the two-year study period were eligible. Beside blood lactate, age and vital signs were registered at the call. Among the 211 calls included, there were 64 deaths (30.3%). Median lactate concentration at the time of the MET-call was 1.82 mmol/L (IQR 1.16–2.7). We found differences between survivors and nonsurvivors for lactate and oxygen saturation, a trend for age, but no significant correlations between mortality and systolic blood pressure, respiratory rate, and heart rate. As compared to normal lactate (<2.44 mmol/L), OR for 30-day mortality was 3.54 () for lactate 2.44–5.0 mmol/L and 4.45 () for lactate > 5.0 mmol/L. The present results support that immediate measurement of blood lactate in MET call patients is a useful tool in the judgment of illness severity. Maria Schollin-Borg, Pär Nordin, Henrik Zetterström, and Joakim Johansson Copyright © 2016 Maria Schollin-Borg et al. All rights reserved. Identifying Prognostic Criteria for Survival after Resuscitation Assisted by Extracorporeal Membrane Oxygenation Tue, 23 Feb 2016 10:03:02 +0000 To improve survival rates during CPR, some patients are put on extracorporeal membrane oxygenation (ECMO). Among children who have undergone ECMO cardiopulmonary resuscitation (ECPR), the overall rate of survival to discharge is close to 40%. However, despite its wide acceptance and use, the appropriate indications and organizational requirements for ECPR have yet to be defined. Our objective was to assess the clinical outcomes of children after ECPR and to determine pre-ECPR prognostic factors for survival to guide its indication. Among the 19 patients who underwent ECPR between 2008 and 2014 in our center, 16 patients (84%, 95% confidence interval: 62–95%) died during their hospital stay, including nine (47%) who were on ECMO and seven (37%) after successful weaning from ECMO. All three survivors had normal cognitive status, but one child suffered from spastic quadriplegia. Survivors tended to have lower lactate, higher bicarbonate, and higher pH levels before ECMO initiation, as well as shorter length of resuscitation. In conclusion, in our center, ECPR has a poorer outcome than expected. Therefore, it might be important to identify, a priori, patients who might benefit from this treatment. Alexandrine Brunner, Natacha Dubois, Peter C. Rimensberger, and Oliver Karam Copyright © 2016 Alexandrine Brunner et al. All rights reserved. Perceived versus Observed Patient Safety Measures in a Critical Care Unit from a Teaching Hospital in Southern Colombia Thu, 18 Feb 2016 06:42:39 +0000 Introduction. Patient safety is an important topic. The purpose of this study is to evaluate the perceived versus observed patient safety measures (PSM) in critically ill patients in a teaching hospital in Latin America. Materials and Methods. The level of perceived patient safety was evaluated with the patient safety hospital survey. Three months later, a qualitative study was conducted, including video recording of procedures, graded according to adherence to PSM. Levels of adherence were scored during patient mobilization (PM), placement of central catheters (PCC), other invasive procedures (OIP), infection control (IC), and endotracheal intubation (ETI). Results. The perceived adherence of PSM in the prestudy survey was considered fair by 89.1% of the ICU staff. After the survey, 829 ICU procedures were video-recorded. Mean observed adherence for fair patient safety measures was 20.8%. Perceived adherence was higher than the real patient safety protocol measures observed in the videos. Conclusion. Perception of PSM was higher than observed in the management of critically ill patients in a teaching hospital in southern Colombia. Jorge Hernan Montenegro, Adriana Fernanda Romero, Paola Andrea Tejada, Sandra Ximena Olaya, and Andres Mariano Rubiano Copyright © 2016 Jorge Hernan Montenegro et al. 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.