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Sample records for critically ill elderly

  1. Prediction of critical illness in elderly outpatients using elder risk assessment: a population-based study

    PubMed Central

    Biehl, Michelle; Takahashi, Paul Y; Cha, Stephen S; Chaudhry, Rajeev; Gajic, Ognjen; Thorsteinsdottir, Bjorg

    2016-01-01

    Rationale Identifying patients at high risk of critical illness is necessary for the development and testing of strategies to prevent critical illness. The aim of this study was to determine the relationship between high elder risk assessment (ERA) score and critical illness requiring intensive care and to see if the ERA can be used as a prediction tool to identify elderly patients at the primary care visit who are at high risk of critical illness. Methods A population-based historical cohort study was conducted in elderly patients (age >65 years) identified at the time of primary care visit in Rochester, MN, USA. Predictors including age, previous hospital days, and comorbid health conditions were identified from routine administrative data available in the electronic medical record. The main outcome was critical illness, defined as sepsis, need for mechanical ventilation, or death within 2 years of initial visit. Patients with an ERA score of 16 were considered to be at high risk. The discrimination of the ERA score was assessed using area under the receiver operating characteristic curve. Results Of the 13,457 eligible patients, 9,872 gave consent for medical record review and had full information on intensive care unit utilization. The mean age was 75.8 years (standard deviation ±7.6 years), and 58% were female, 94% were Caucasian, 62% were married, and 13% were living in nursing homes. In the overall group, 417 patients (4.2%) suffered from critical illness. In the 1,134 patients with ERA >16, 154 (14%) suffered from critical illness. An ERA score ≥16 predicted critical illness (odds ratio 6.35; 95% confidence interval 3.51–11.48). The area under the receiver operating characteristic curve was 0.75, which indicated good discrimination. Conclusion A simple model based on easily obtainable administrative data predicted critical illness in the next 2 years in elderly outpatients with up to 14% of the highest risk population suffering from critical illness

  2. Studying Physically Ill Elderly.

    ERIC Educational Resources Information Center

    Young, Rosalie F.; Kahana, Eva

    Research with older persons suffering from physical illness presents numerous challenges to gerontologists. Issues of conceptualization pertaining to the definition of illness, its location in the research paradigm, and the context in which illness occurs must be addressed prior to dealing with methodological problems. Access to physically ill…

  3. A Prognostic Model for 6-Month Mortality in Elderly Survivors of Critical Illness

    PubMed Central

    Narain, Wazim R.; Wunsch, Hannah; Schluger, Neil W.; Cooke, Joseph T.; Maurer, Mathew S.; Rowe, John W.; Lederer, David J.; Bach, Peter B.

    2013-01-01

    Background: Although 1.4 million elderly Americans survive hospitalization involving intensive care annually, many are at risk for early mortality following discharge. No models that predict the likelihood of death after discharge exist explicitly for this population. Therefore, we derived and externally validated a 6-month postdischarge mortality prediction model for elderly ICU survivors. Methods: We derived the model from medical record and claims data for 1,526 consecutive patients aged ≥ 65 years who had their first medical ICU admission in 2006 to 2009 at a tertiary-care hospital and survived to discharge (excluding those patients discharged to hospice). We then validated the model in 1,010 patients from a different tertiary-care hospital. Results: Six-month mortality was 27.3% and 30.2% in the derivation and validation cohorts, respectively. Independent predictors of mortality (in descending order of contribution to the model’s predictive power) were a do-not-resuscitate order, older age, burden of comorbidity, admission from or discharge to a skilled-care facility, hospital length of stay, principal diagnoses of sepsis and hematologic malignancy, and male sex. For the derivation and external validation cohorts, the area under the receiver operating characteristic curve was 0.80 (SE, 0.01) and 0.71 (SE, 0.02), respectively, with good calibration for both (P = 0.31 and 0.43). Conclusions: Clinical variables available at hospital discharge can help predict 6-month mortality for elderly ICU survivors. Variables that capture elements of frailty, disability, the burden of comorbidity, and patient preferences regarding resuscitation during the hospitalization contribute most to this model’s predictive power. The model could aid providers in counseling elderly ICU survivors at high risk of death and their families. PMID:23632902

  4. The microbiome and critical illness.

    PubMed

    Dickson, Robert P

    2016-01-01

    The central role of the microbiome in critical illness is supported by a half century of experimental and clinical study. The physiological effects of critical illness and the clinical interventions of intensive care substantially alter the microbiome. In turn, the microbiome predicts patients' susceptibility to disease, and manipulation of the microbiome has prevented or modulated critical illness in animal models and clinical trials. This Review surveys the microbial ecology of critically ill patients, presents the facts and unanswered questions surrounding gut-derived sepsis, and explores the radically altered ecosystem of the injured alveolus. The revolution in culture-independent microbiology has provided the tools needed to target the microbiome rationally for the prevention and treatment of critical illness, holding great promise to improve the acute and chronic outcomes of the critically ill. PMID:26700442

  5. Protein requirement in critical illness.

    PubMed

    Hoffer, Leonard John

    2016-05-01

    How much protein do critically ill patients require? For the many decades that nutritional support has been used there was a broad consensus that critically ill patients need much more protein than required for normal health. Now, however, some clinical investigators recommend limiting all macronutrient provision during the early phase of critical illness. How did these conflicting recommendations emerge? Which of them is correct? This review explains the longstanding recommendation for generous protein provision in critical illness, analyzes the clinical trials now being claimed to refute it, and concludes with suggestions for clinical investigation and practice. PMID:26914090

  6. Experiencing Art with the Ill, the Elderly, and Their Caregivers

    ERIC Educational Resources Information Center

    Barrett, Terry

    2011-01-01

    This article is a personal narrative of a teaching artist reaching out to persons ill, elderly, and their caregivers because of his own experiences with cancer. As a teaching artist, the author serves schools and communities as an art critic, that is, one who facilitates discussions about works of art made by the learners or by established…

  7. The Liver in Critical Illness.

    PubMed

    Damm, Tessa W; Kramer, David J

    2016-07-01

    Caring for critically ill patients with acute and/or chronic liver dysfunction poses a unique challenge. Proper resuscitation and early consideration for transfer to liver transplant centers have resulted in improved outcomes. Liver support devices and cellular models have not yet shown mortality benefit, but they hold promise in the critical care of patients with liver disease. This article reviews pertinent anatomic and physiologic considerations of the liver in critical illness, followed by a selective review of associated organ dysfunction. PMID:27339681

  8. The critically ill immunosuppressed patient

    SciTech Connect

    Parrillo, J.E.; Masur, H. )

    1987-01-01

    This book discusses the papers on the diagnosis and management of immunosuppressed patient. Some of the topics are: life-threatening organ failure in immunosuppressed patients; diagnosis and therapy of respiratory disease in the immunosuppressed patient; CNS complication of immunosuppression; infections; antineoplastic therapy of immunosuppressed patient; radiation therapy-issues in critically ill patient; AIDS; and management of bone marrow transplant patients.

  9. Probiotics in critically ill children

    PubMed Central

    Singhi, Sunit C.; Kumar, Suresh

    2016-01-01

    Gut microflora contribute greatly to immune and nutritive functions and act as a physical barrier against pathogenic organisms across the gut mucosa. Critical illness disrupts the balance between host and gut microflora, facilitating colonization, overgrowth, and translocation of pathogens and microbial products across intestinal mucosal barrier and causing systemic inflammatory response syndrome and sepsis. Commonly used probiotics, which have been developed from organisms that form gut microbiota, singly or in combination, can restore gut microflora and offer the benefits similar to those offered by normal gut flora, namely immune enhancement, improved barrier function of the gastrointestinal tract (GIT), and prevention of bacterial translocation. Enteral supplementation of probiotic strains containing either Lactobacillus alone or in combination with Bifidobacterium reduced the incidence and severity of necrotizing enterocolitis and all-cause mortality in preterm infants. Orally administered Lactobacillus casei subspecies rhamnosus, Lactobacillus reuteri, and Lactobacillus rhamnosus were effective in the prevention of late-onset sepsis and GIT colonization by Candida in preterm very low birth weight infants. In critically ill children, probiotics are effective in the prevention and treatment of antibiotic-associated diarrhea. Oral administration of a mix of probiotics for 1 week to children on broad-spectrum antibiotics in a pediatric intensive care unit decreased GIT colonization by Candida, led to a 50% reduction in candiduria, and showed a trend toward decreased incidence of candidemia. However, routine use of probiotics cannot be supported on the basis of current scientific evidence. Safety of probiotics is also a concern; rarely, probiotics may cause bacteremia, fungemia, and sepsis in immunocompromised critically ill children. More studies are needed to answer questions on the effectiveness of a mix versus single-strain probiotics, optimum dosage regimens

  10. Probiotics in critically ill children.

    PubMed

    Singhi, Sunit C; Kumar, Suresh

    2016-01-01

    Gut microflora contribute greatly to immune and nutritive functions and act as a physical barrier against pathogenic organisms across the gut mucosa. Critical illness disrupts the balance between host and gut microflora, facilitating colonization, overgrowth, and translocation of pathogens and microbial products across intestinal mucosal barrier and causing systemic inflammatory response syndrome and sepsis. Commonly used probiotics, which have been developed from organisms that form gut microbiota, singly or in combination, can restore gut microflora and offer the benefits similar to those offered by normal gut flora, namely immune enhancement, improved barrier function of the gastrointestinal tract (GIT), and prevention of bacterial translocation. Enteral supplementation of probiotic strains containing either Lactobacillus alone or in combination with Bifidobacterium reduced the incidence and severity of necrotizing enterocolitis and all-cause mortality in preterm infants. Orally administered Lactobacillus casei subspecies rhamnosus, Lactobacillus reuteri, and Lactobacillus rhamnosus were effective in the prevention of late-onset sepsis and GIT colonization by Candida in preterm very low birth weight infants. In critically ill children, probiotics are effective in the prevention and treatment of antibiotic-associated diarrhea. Oral administration of a mix of probiotics for 1 week to children on broad-spectrum antibiotics in a pediatric intensive care unit decreased GIT colonization by Candida, led to a 50% reduction in candiduria, and showed a trend toward decreased incidence of candidemia. However, routine use of probiotics cannot be supported on the basis of current scientific evidence. Safety of probiotics is also a concern; rarely, probiotics may cause bacteremia, fungemia, and sepsis in immunocompromised critically ill children. More studies are needed to answer questions on the effectiveness of a mix versus single-strain probiotics, optimum dosage regimens

  11. Nutritional interventions in critical illness.

    PubMed

    Powell-Tuck, Jeremy

    2007-02-01

    The metabolism of critical illness is characterised by a combination of starvation and stress. There is increased production of cortisol, catecholamines, glucagon and growth hormone and increased insulin-like growth factor-binding protein-1. Phagocytic, epithelial and endothelial cells elaborate reactive oxygen and nitrogen species, chemokines, pro-inflammatory cytokines and lipid mediators, and antioxidant depletion ensues. There is hyperglycaemia, hyperinsulinaemia, hyperlactataemia, increased gluconeogenesis and decreased glycogen production. Insulin resistance, particularly in relation to the liver, is marked. The purpose of nutritional support is primarily to save life and secondarily to speed recovery by reducing neuropathy and maintaining muscle mass and function. There is debate about the optimal timing of nutritional support for the patient in the intensive care unit. It is generally agreed that the enteral route is preferable if possible, but the dangers of the parenteral route, a route of feeding that remains important in the context of critical illness, may have been over-emphasised. Control of hyperglycaemia is beneficial, and avoidance of overfeeding is emphasised. Growth hormone is harmful. The refeeding syndrome needs to be considered, although it has been little studied in the context of critical illness. Achieving energy balance may not be necessary in the early stages of critical illness, particularly in patients who are overweight or obese. Protein turnover is increased and N balance is often negative in the face of normal nutrient intake; optimal N intakes are the subject of some debate. Supplementation of particular amino acids able to support or regulate the immune response, such as glutamine, may have a role not only for their potential metabolic effect but also for their potential antioxidant role. Doubt remains in relation to arginine supplementation. High-dose mineral and vitamin antioxidant therapy may have a place. PMID:17343768

  12. Psychiatric disorders impacting critical illness.

    PubMed

    Struble, Laura M; Sullivan, Barbara J; Hartman, Laurie S

    2014-03-01

    An astounding 30% to 50% of older patients who are hospitalized for a medical condition also have a psychiatric disorder. The intent of this article is to prepare acute care nurses to meet the mental health needs of older adults with a critical illness and prevent untoward sequelae of medical events. The authors discuss the importance of baseline assessment data, issues related to informed consent, manifestations of common psychiatric disorders that may be seen in older adults in the acute care setting, as well as strategies to improve patient outcomes. PMID:24484928

  13. The Family physician and the Terminally Ill Elderly

    PubMed Central

    Eaton, Bill

    1989-01-01

    Palliative care rests on the three pillars of symptom control, communication, and family support. As our patient population ages, we family doctors will be increasingly involved in the care of the terminally ill elderly at home. Terminal illnesses are much more common in the elderly, and often death can be predicted. Family doctors have a most important role in co-ordinating the home-support services, in providing comfort care, and in supporting the family members who are caring for the terminally ill elderly at home. PMID:21248995

  14. Sexual abuse of the elderly mentally ill.

    PubMed Central

    Benbow, S. M.; Haddad, P. M.

    1993-01-01

    Sexual abuse of the elderly may occur more commonly than is recognized. Reasons for the neglect of this area and possible risk factors are discussed. A definition of elder sexual abuse is proposed, and four case histories, each of which raises various issues about the nature, detection and management of sexual abuse, are described. In the absence of procedures for dealing with elder sexual abuse, professional staff need to be open to its occurrence and to be prepared to carry out thorough, sympathetic, collaborative assessments of both parties involved where it is suspected. PMID:8290413

  15. Levosimendan in Critical Illness: A Literature Review

    PubMed Central

    Pierrakos, Charalampos; Velissaris, Dimitrios; Franchi, Federico; Muzzi, Luigi; Karanikolas, Menelaos; Scolletta, Sabino

    2014-01-01

    Levosimendan, the active enantiomer of simendan, is a calcium sensitizer developed for treatment of decompensated heart failure, exerts its effects independently of the beta adrenergic receptor and seems beneficial in cases of severe, intractable heart failure. Levosimendan is usually administered as 24-h infusion, with or without a loading dose, but dosing needs adjustment in patients with severe liver or renal dysfunction. Despite several promising reports, the role of levosimendan in critical illness has not been thoroughly evaluated. Available evidence suggests that levosimendan is a safe treatment option in critically ill patients and may reduce mortality from cardiac failure. However, data from well-designed randomized controlled trials in critically ill patients are needed to validate or refute these preliminary conclusions. This literature review is an attempt to synthesize available evidence on the role and possible benefits of levosimendan in critically ill patients with severe heart failure. PMID:24578748

  16. Monitoring sedation in the critically ill child.

    PubMed

    Lamas, A; López-Herce, Jesús

    2010-05-01

    Sedation is an essential part of the management of the critically ill child, and its monitoring must be individualised and continuous in order to adjust drug doses according to the clinical state. There is no ideal method for evaluating sedation in the critically ill child. Haemodynamic variables have not been found to be useful. Clinical scales are useful when sedation is moderate, but are limited by their subjective nature, the use of stimuli, and the impossibility of evaluating profoundly sedated patients or those receiving neuromuscular blocking drugs; in addition, many of these scales have not been evaluated in children. The COMFORT scale is the most appropriate, as it was designed and validated for critically ill children requiring mechanical ventilation. Electroencephalography-derived methods permit continuous monitoring, provide an early indication of changes in the level of sedation, and facilitate a rapid adjustment of medication. However, these methods were designed and validated for patients under anaesthesia and their results cannot be fully extrapolated to the critically ill patient; in addition, some of them have not been validated in small children and there is still little experience in critically ill children. The main indications for the use of these methods are in patients with deep sedation and/or neuromuscular blockade. The bispectral index is the most widely used method at the present time. Analysis and comparison of the efficacy of the different methods for evaluating sedation in the critically ill child is required. PMID:20175774

  17. Nutritional support in critical illness and recovery.

    PubMed

    Casaer, Michael P; Ziegler, Thomas R

    2015-09-01

    An adequate nutritional status is crucial for optimum function of cells and organs, and for wound healing. Options for artificial nutrition have greatly expanded in the past few decades, but have concomitantly shown limitations and potential side-effects. Few rigorous randomised controlled trials (RCTs) have investigated enteral or parenteral nutritional support, and evidence-based clinical guidance is largely restricted to the first week of critical illness. In the early stages of critical illness, whether artificial feeding is better than no feeding intervention has been given little attention in existing RCTs. Expected beneficial effects of various forms of early feeding interventions on rates of morbidity or mortality have generally not been supported by results of recent high-quality RCTs. Thus, whether nutritional interventions early in an intensive care unit (ICU) stay improve outcomes remains unclear. Trials assessing feeding interventions that continue after the first week of critical illness and into the post-ICU and post-hospital settings are clearly needed. Although acute morbidity and mortality will remain important safety parameters in such trials, primary outcomes should perhaps, in view of the adjunctive nature of nutritional intervention in critical illness, be focused on physical function and assessed months or even years after patients are discharged from the ICU. This Series paper is based on results of high-quality RCTs and provides new perspectives on nutritional support during critical illness and recovery. PMID:26071886

  18. Measurement of sleep in critically ill patients.

    PubMed

    Richards, K C; O'Sullivan, P S; Phillips, R L

    2000-01-01

    Research to evaluate interventions to promote sleep in critically ill patients has been restricted by the lack of brief, inexpensive outcome measures. This article describes the development and testing of an instrument to measure sleep in critically ill patients. A convenience sample of 70 alert, oriented, critically ill males was studied using polysomnography (PSG), the gold standard for sleep measurement, for one night. In the morning the patients completed the Richards-Campbell Sleep Questionnaire (RCSQ), a five-item visual analog scale. Internal consistency reliability of the RCSQ was .90 and principal components factor analysis revealed a single factor (Eigenvalue = 3.61, percent variance = 72.2). The RCSQ total score accounted for approximately 33% of the variance in the PSG indicator sleep efficiency index (p < .001). The data provide support for the reliability and validity of the RCSQ. PMID:11227580

  19. Methionine splanchnic uptake is increased in critically ill children

    Technology Transfer Automated Retrieval System (TEKTRAN)

    During critical illness the splanchnic area is profoundly affected. There is no information on splanchnic uptake of amino acids in vivo, in critically ill children. Methionine splanchnic uptake in critically ill children will differ from estimates in healthy adults. We studied 24 critically ill chil...

  20. Pain management in critically ill obese patients.

    PubMed

    Astle, Sonia M

    2009-09-01

    Achieving pain control in critically ill patients is a challenging problem for the health care team, which becomes more challenging in morbidly obese patients. Obese patients may experience drug malabsorption and distribution, which may lead to either subtherapeutic or toxic drug levels. To manage pain effectively for the critically ill obese patient, nurses must have an understanding of how obesity alters a patient's physiologic response to injury and illness. In addition, nurses must be knowledgeable about physiologic pain mechanisms, types and manifestations of pain, differing patterns of drug absorption and distribution, pharmacokinetic properties of analgesic medications, and pain management strategies. This article explores factors affecting pharmacokinetics in obese patients, trends in pain management, and treatment strategies for the obese patient. PMID:19840712

  1. The interfacility transport of critically ill newborns.

    PubMed

    Whyte, Hilary Ea; Jefferies, Ann L

    2015-01-01

    The practice of paediatric/neonatal interfacility transport continues to expand. Transport teams have evolved into mobile intensive care units capable of delivering state-of-the-art critical care during paediatric and neonatal transport. While outcomes are best for high-risk infants born in a tertiary care setting, high-risk mothers often cannot be safely transferred. Their newborns may then have to be transported to a higher level of care following birth. The present statement reviews issues relating to transport of the critically ill newborn population, including personnel, team competencies, skills, equipment, systems and processes. Six recommendations for improving interfacility transport of critically ill newborns are highlighted, emphasizing the importance of regionalized care for newborns. PMID:26175564

  2. The interfacility transport of critically ill newborns

    PubMed Central

    Whyte, Hilary EA; Jefferies, Ann L

    2015-01-01

    The practice of paediatric/neonatal interfacility transport continues to expand. Transport teams have evolved into mobile intensive care units capable of delivering state-of-the-art critical care during paediatric and neonatal transport. While outcomes are best for high-risk infants born in a tertiary care setting, high-risk mothers often cannot be safely transferred. Their newborns may then have to be transported to a higher level of care following birth. The present statement reviews issues relating to transport of the critically ill newborn population, including personnel, team competencies, skills, equipment, systems and processes. Six recommendations for improving interfacility transport of critically ill newborns are highlighted, emphasizing the importance of regionalized care for newborns. PMID:26175564

  3. [Sleep disturbances in critically ill patients].

    PubMed

    Walder, B; Haase, U; Rundshagen, I

    2007-01-01

    Sleep is an essential part of life with many important roles which include immunologic, cognitive and muscular functions. Of the working population 20% report sleep disturbances and in critically ill patients an incidence of more than 50% has been shown. However, sleep disturbances in the intensive care unit (ICU) population have not been investigated in detail. Sleep disturbances in ICU patients have a variety of reasons: e.g. patient-related pathologies like sepsis, acute or chronic pulmonary diseases, cardiac insufficiency, stroke or epilepsy, surgery, therapeutical interventions like mechanical ventilation, noise of monitors, pain or medication. Numerous scales and questionnaires are used to quantify sleep and the polysomnogramm is used to objectify sleep architecture. To improve sleep in ICU patients concepts are needed which include in addition to pharmacological treatment (pain reduction and sedation) synchronization of ICU activities with daylight, noise reduction and music for relaxation. In order to establish evidence-based guidelines, research activities about sleep and critical illness should be intensified. Questions to be answered are: 1) Which part of sleep disturbances in critically ill patients is directly related to the illness or trauma? 2) Is the grade of sleep disturbance correlated with the severity of the illness or trauma? 3) Which part is related to the medical treatment and can be modified or controlled? In order to define non-pharmacological and pharmacological concepts to improve sleep quality, studies need to be randomized and to include different ICU populations. The rate of nosocomial infections, cognitive function and respiratory muscle function should be considered in these studies as well. This will help to answer the question, whether it is useful to monitor sleep in ICU patients as a parameter to indicate therapeutical success and short-term quality of life. Follow-up needs to be long enough to detect adverse effects of

  4. [Role of anidulafungin in critically ill patients].

    PubMed

    Borges Sá, Márcio; Garnacho Montero, José

    2008-12-01

    The most frequent invasive fungal infections in critically ill patients are invasive candidiasis, among which is candidemia. In the last few years, these infections have become more common in intensive care units (ICU), including those produced by species other than Candida albicans. This phenomenon may lead to the development of species resistant to antifungal agents. To start the most appropriate treatment, early diagnosis of the infection is essential, which would reduce empirical antibiotic treatment and increase the proportion of advanced or directed antibiotic therapy. Given the poor reliability of the available diagnostic techniques, new strategies are currently being employed in the ICU, such as the use of scores to evaluate the presence of fungal infections. The therapeutic arsenal against these infections has been increased and the introduction of anidulafungin represents the addition of a highly appropriate drug for the treatment of invasive candidiasis in immunocompetent critically ill patients. PMID:19572433

  5. Percutaneous cholecystostomy in critically ill patients.

    PubMed

    Teplick, S K; Harshfield, D L; Brandon, J C; Broadwater, J R; Cone, J B

    1991-01-01

    Sixteen critically ill patients underwent percutaneous cholecystostomy because of suspected acute cholecystitis. The procedure was technically successful, although 11 of 16 patients died subsequently because of various complications of their underlying primary disorders. We reviewed this series to reassess the value of percutaneous cholecystostomy. Four of 11 patients with definite acute cholecystitis (group 1) were cured by this technique, but three required surgery because of gallbladder wall necrosis. Two of these were among four cases which had demonstrated pericholecystic fluid collections on computed tomography (CT) or ultrasound of the abdomen. There were also five patients (group 2) in whom acute cholecystitis or its relationship to patients' symptoms were not fully determined, and four of them did not improve after percutaneous cholecystostomy. We conclude that this technique has a lower success rate in critically ill patients than reported previously. PMID:2016030

  6. Early Psychological Therapy in Critical Illness.

    PubMed

    Karnatovskaia, Lioudmila V; Philbrick, Kemuel L; Parker, Ann M; Needham, Dale M

    2016-02-01

    Survivors of critical illness often experience long-lasting impairments in mental, cognitive, and physical functioning. Acute stress reactions and delusional memories appear to play an important role in psychological morbidity following critical illness, and few interventions exist to address these symptoms. This review elucidates acute psychological stressors experienced by the critically ill. The effects of psychological stress and state of mind on disease are discussed using examples from the non-intensive care unit (ICU) literature, including a review of placebo and nocebo effects. After reviewing the effect of the mind on both psychological and physiological outcomes, we then focus on the role of memories-including their malleable nature and the consequences of false memories. Memory may play a role in the genesis of subsequent psychological trauma. Traumatic memories may begin forming even before the patient arrives in the ICU and during their state of unconsciousness in the ICU. Hence, practical interventions for redirecting patients' thoughts, such as positive suggestion techniques and actively involving patients in the treatment process as early as possible, are worthy of further investigation. PMID:26820280

  7. Extracorporeal Life Support in Critically Ill Adults

    PubMed Central

    Muratore, Christopher S.

    2014-01-01

    Extracorporeal life support (ECLS) has become increasingly popular as a salvage strategy for critically ill adults. Major advances in technology and the severe acute respiratory distress syndrome that characterized the 2009 influenza A(H1N1) pandemic have stimulated renewed interest in the use of venovenous extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal to support the respiratory system. Theoretical advantages of ECLS for respiratory failure include the ability to rest the lungs by avoiding injurious mechanical ventilator settings and the potential to facilitate early mobilization, which may be advantageous for bridging to recovery or to lung transplantation. The use of venoarterial ECMO has been expanded and applied to critically ill adults with hemodynamic compromise from a variety of etiologies, beyond postcardiotomy failure. Although technology and general care of the ECLS patient have evolved, ECLS is not without potentially serious complications and remains unproven as a treatment modality. The therapy is now being tested in clinical trials, although numerous questions remain about the application of ECLS and its impact on outcomes in critically ill adults. PMID:25046529

  8. Probiotic use in the critically ill.

    PubMed

    Singhi, Sunit C; Baranwal, A

    2008-06-01

    Probiotics are "live microbes which when administered in adequate amounts confer a health benefit to the host" (FAO/WHO joint group). Their potential role in bio-ecological modification of pathological internal milieu of the critically ill is under evaluation. Probiotics are available as single microbial strain (e.g., Bacillus clausii, Lactobacillus) or as a mix of multiple strains of Lactobacillus (acidophilus, sporogenes, lactis, reuteri RC-14, GG, and L. plantarum 299v), Bifidobacterium (bifidum, longum, infantis), Streptococcus (thermophillus, lactis, fecalis), Saccharomyces boulardii etc. Lactobacilli and Bifidobacteria are gram-positive, anaerobic, lactic acid bacteria. These are normal inhabitant of human gut and colonize the colon better than others. Critical illness and its treatment create hostile environment in the gut and alters the micro flora favoring growth of pathogens. Therapy with probiotics is an effort to reduce or eliminate potential pathogens and toxins, to release nutrients, antioxidants, growth factors and coagulation factors, to stimulate gut motility and to modulate innate and adaptive immune defense mechanisms via the normalization of altered gut flora. Scientific evidence shows that use of probiotics is effective in prevention and therapy of antibiotic associated diarrhea. However, available probiotics strains in currently used doses do not provide much needed early benefits, and need long-term administration to have clinically beneficial effects (viz, a reduction in rate of infection, severe sepsis, ICU stay, ventilation days and mortality) in critically ill surgical and trauma patients. Possibly, available strains do not adhere to intestinal mucosa early, or may require higher dose than what is used. Gap exists in our knowledge regarding mechanisms of action of different probiotics, most effective strains--single or multiple, cost effectiveness, risk-benefit potential, optimum dose, frequency and duration of treatment etc. More

  9. Insulin therapy in critically ill patients

    PubMed Central

    Ellahham, Samer

    2010-01-01

    Hyperglycemia frequently occurs with acute medical illness, especially among patients with cardiovascular disease, and has been linked to increased morbidity and mortality in critically ill patients. Even patients who are normoglycemic can develop hyperglycemia in response to acute metabolic stress. An expanding body of literature describes the benefits of normalizing hyperglycemia with insulin therapy in hospitalized patients. As a result, both the American Diabetes Association and the American College of Endocrinology have developed guidelines for optimal control of hyperglycemia, specifically targeting critically ill, hospitalized patients. Conventional blood glucose values of 140–180 mg/dL are considered desirable and safely achievable in most patients. More aggressive control to <110 mg/dL remains controversial, but has shown benefits in certain patients, such as those in surgical intensive care. Intravenous infusion is often used for initial insulin administration, which can then be transitioned to subcutaneous insulin therapy in those patients who require continued insulin maintenance. This article reviews the data establishing the link between hyperglycemia and its risks of morbidity and mortality, and describes strategies that have proven effective in maintaining glycemic control in high-risk hospitalized patients. PMID:21191429

  10. Depression Strikes, Stays with Many Caregivers of Critically Ill

    MedlinePlus

    ... nlm.nih.gov/medlineplus/news/fullstory_158780.html Depression Strikes, Stays With Many Caregivers of Critically Ill ... News) -- Caregivers for the critically ill often suffer depression that lingers long after their loved one's hospital ...

  11. Nutritional assessment in the critically ill.

    PubMed

    Manning, E M; Shenkin, A

    1995-07-01

    Although many of the measurements and techniques outlined in this article may be epidemiologically useful and correlate with morbidity and mortality, no single indicator is of consistent value in the nutritional assessment of critically ill patients. Measurements such as anthropometrics, total body fat estimation, or delayed hypersensitivity skin testing either are liable to non-nutritional influences or lack accuracy and precision in individual patients. Plasma concentrations of hepatic proteins are affected significantly by the patient's underlying disease state and therapeutic interventions and therefore lack specificity. Although the measurement of these proteins is of little value in the initial nutritional assessment of the critically ill, serial measurement, particularly of plasma pre-albumin, may be useful in monitoring the response to nutritional support. Nitrogen balance is a widely used and valuable nutritional indicator in the critically ill. Direct measurement of urine nitrogen is the preferred test, although nitrogen excretion often is derived from 24-hour urine urea measurement, an inexpensive and easy procedure, but one that is less accurate. More accurate techniques of assessing change in nutritional status, such as IVNAA of total body nitrogen or isotopic measurement of exchangeable potassium or sodium, are more expensive, less available, unsuitable for repeated analyses, and less feasible in severely ill patients. Total body nitrogen measured using IVNAA and total-body potassium, however, are the most accurate ways of measuring body composition in the presence of large amounts of edema fluid. The application of body composition measurements to patient care remains poorly defined because of the many problems encountered with the various techniques, including cost, availability, and radiation exposure. Improved, more sensitive and, preferably, bedside methods for the measurement of body composition are needed. It is of paramount importance that

  12. [Extracorporeal membrane oxygenation for critically ill adults].

    PubMed

    Maekawa, Kunihiko; Gando, Satoshi

    2016-02-01

    Extracorporeal membrane oxygenation therapy (ECMO) is an artificial life support for severe respiratory and/or cardiac failure, and refractory cardiac arrest. It consists of a hollow-fiber membrane that oxygenates the blood and removes carbon dioxide and a centrifugal pump that drain blood from central venous circulation, pump through membrane, and return to the patients. Veno-venous ECMO provides gas change in hemodynamically stable patients with respiratory failure. Veno-arterial ECMO offers hemodynamic support in addition to gas change for cardiac failure or refractory cardiac arrest. We describe the physiological principles and the clinical evidence supporting the use of ECMO in critically ill adult patients. PMID:26915254

  13. Hypocaloric support in the critically ill.

    PubMed

    Patiño, J F; de Pimiento, S E; Vergara, A; Savino, P; Rodríguez, M; Escallón, J

    1999-06-01

    The critically ill patient exhibits a well defined endocrine and metabolic adaptive response to stressor agents, characterized by incremented resting energy expenditure (hypermetabolism, which is believed to signify increased energy requirements), accelerated whole-body proteolysis (hypercatabolism), and lipolysis. These phenomena occur in the acute stage, which is also characterized by hyperglycemia, typically accompanied by a hyperdynamic cardiovascular reaction manifested by high cardiac output, increased oxygen consumption, high body temperature, and decrease peripheral vascular resistance. High provisions of glucose-derived calories tend to accentuate these reactions and increase the degree of hyperglycemia. We have adopted a hypocaloric-hyperproteic regimen which is provided only during the first days of the flow phase of the adaptive response to injury, sepsis, or critical illness. Our regimen includes a daily supply of 100 to 200 g of glucose and 1.5 to 2.0 g of protein (synthetic amino acids) per kilogram of ideal body weight. We have analyzed the data on 107 critically ill patients, 70 men and 37 women, who were admitted to the surgical intensive care unit and who received nutritional support by the TPN hypocaloric modality for a minimum of 3 days. We found that the high caloric loads contained in TPN regimens results in additional metabolic stress, with consequent hyperdynamic cardiorespiratory repercussion, high CO2 production, and frequently hepatic steatosis. In contrast, our hypocaloric-hyperproteic approach has resulted in a more physiologic clinical course and considerable reduction in cost. The infusion of high glucose loads, such as those used in hypercaloric TPN, does not seem to suppress the excessive endogenous production of glucose but instead markedly exacerbates the hyperglycemia of the postinjury and acute stress condition. We believe that the hypocaloric-hyperproteic regimen we utilize during the first few days of the stress situation is

  14. Reversing oliguria in critically ill patients.

    PubMed

    DePriest, J

    1997-09-01

    Oliguria is a common occurrence in the ICU setting. In patients with preserved renal function, fluid challenges or low doses of diuretics are generally successful. In patients with oliguric renal failure, it is still essential to ensure adequate intravascular fluid volume, especially in critically ill patients. Loop diuretics remain the mainstay of treatment. When diuretic resistance is encountered, physicians should consider further optimization of hemodynamics, alternative loop diuretics, and combined drug therapy. In some cases, continuous renal replacement therapy can be very effective. Yet, while these interventions can help reduce the morbidity of severe volume overload, they have not been shown to improve mortality rates. PMID:9300031

  15. Management of Infections in Critically Ill Patients

    PubMed Central

    Hranjec, Tjasa

    2014-01-01

    Abstract Background: Critically ill patients have an increased risk of developing infections and infectious complications, sometimes followed by death. Despite a substantial investment of resources in outcomes improvement, optimum treatment for such patients remains unclear for practicing intensivists. Methods: We conducted a review that highlights the most recent developments in the prevention, diagnosis, and management of infection and the evaluation of its outcomes. The review examines the prevention of infection, such as through daily bathing with chlorhexidine and the addition of probiotics to treatment regimens, and questions the previous standards of care, including the monitoring of gastric residuals and treatment of severely ill patients with drotrecogin alfa (activated). It also discusses novel approaches to the treatment of severely ill infected patients with extra-corporeal membrane oxygenation and the earlier normalization of body temperature. Results: The development of new antibiotics continues at a slow pace, with the likelihood that alternative approaches to the management of infection, including changes in the quality of patient care, are producing needed improvements. Conclusions: Clinical outcomes of infection are improving slowly as medical teams strive for better patient care. Lack of reimbursement is unnecessary as a punitive approach to infectious diseases. PMID:24841214

  16. Optimizing antimicrobial therapy in critically ill patients.

    PubMed

    Vitrat, Virginie; Hautefeuille, Serge; Janssen, Cécile; Bougon, David; Sirodot, Michel; Pagani, Leonardo

    2014-01-01

    Critically ill patients with infection in the intensive care unit (ICU) would certainly benefit from timely bacterial identification and effective antimicrobial treatment. Diagnostic techniques have clearly improved in the last years and allow earlier identification of bacterial strains in some cases, but these techniques are still quite expensive and not readily available in all institutions. Moreover, the ever increasing rates of resistance to antimicrobials, especially in Gram-negative pathogens, are threatening the outcome for such patients because of the lack of effective medical treatment; ICU physicians are therefore resorting to combination therapies to overcome resistance, with the direct consequence of promoting further resistance. A more appropriate use of available antimicrobials in the ICU should be pursued, and adjustments in doses and dosing through pharmacokinetics and pharmacodynamics have recently shown promising results in improving outcomes and reducing antimicrobial resistance. The aim of multidisciplinary antimicrobial stewardship programs is to improve antimicrobial prescription, and in this review we analyze the available experiences of such programs carried out in ICUs, with emphasis on results, challenges, and pitfalls. Any effective intervention aimed at improving antibiotic usage in ICUs must be brought about at the present time; otherwise, we will face the challenge of intractable infections in critically ill patients in the near future. PMID:25349478

  17. Optimizing antimicrobial therapy in critically ill patients

    PubMed Central

    Vitrat, Virginie; Hautefeuille, Serge; Janssen, Cécile; Bougon, David; Sirodot, Michel; Pagani, Leonardo

    2014-01-01

    Critically ill patients with infection in the intensive care unit (ICU) would certainly benefit from timely bacterial identification and effective antimicrobial treatment. Diagnostic techniques have clearly improved in the last years and allow earlier identification of bacterial strains in some cases, but these techniques are still quite expensive and not readily available in all institutions. Moreover, the ever increasing rates of resistance to antimicrobials, especially in Gram-negative pathogens, are threatening the outcome for such patients because of the lack of effective medical treatment; ICU physicians are therefore resorting to combination therapies to overcome resistance, with the direct consequence of promoting further resistance. A more appropriate use of available antimicrobials in the ICU should be pursued, and adjustments in doses and dosing through pharmacokinetics and pharmacodynamics have recently shown promising results in improving outcomes and reducing antimicrobial resistance. The aim of multidisciplinary antimicrobial stewardship programs is to improve antimicrobial prescription, and in this review we analyze the available experiences of such programs carried out in ICUs, with emphasis on results, challenges, and pitfalls. Any effective intervention aimed at improving antibiotic usage in ICUs must be brought about at the present time; otherwise, we will face the challenge of intractable infections in critically ill patients in the near future. PMID:25349478

  18. Monitoring the microcirculation in critically ill patients.

    PubMed

    De Backer, Daniel; Durand, Arthur

    2014-12-01

    Alterations in microvascular perfusion have been identified in critically ill patients, especially in sepsis but also in cardiogenic shock, after cardiac arrest, and in high-risk surgery patients. These alterations seem to be implicated in the development of organ dysfunction and are associated with outcome. Even though microvascular perfusion can sometimes be homogenously decreased as in acute hemorrhage or in non-resuscitated cardiogenic shock, heterogeneity of perfusion is observed in sepsis and in resuscitated hemorrhagic/cardiogenic shock. Heterogeneity of perfusion has major implications for monitoring, as many techniques cannot detect microcirculatory alterations when heterogeneity of flow is present in significant amount. Indeed, devices such as laser Doppler or O2 electrodes and near-infrared spectroscopy have a relatively large sampling volume and measurements are affected by the highest values in the field. Using these techniques during a vascular occlusion test may help to characterize microvascular reactivity; however, microvascular reactivity sometimes fails to represent actual microvascular perfusion. Videomicroscopic techniques can nowadays be applied at bedside but are still restricted to some selected patients (quiet or sedated patients). Tissue PCO2 is an elegant alternative but is not yet broadly used. In this manuscript, we discuss the main advantages and limitations of the techniques available for bedside evaluation of the microcirculation in critically ill patients. PMID:25480773

  19. The Relationship Between Chronic Illness and Depression in a Community of Urban Black Elderly Persons

    PubMed Central

    Bazargan, Mohsen; Hamm-Baugh, Verneda P.

    2016-01-01

    The relationship between depression and chronic illness among the elderly population has often been investigated. However, the impact of individual chronic illnesses while controlling for the impact of various psychosocial factors is still not well understood. This is particularly true among Black elderly persons. In a cross-sectional study, the impact of selected chronic illnesses and psychosocial variables on depression was investigated among 1,022 Black urban elderly persons who reside in New Orleans, Louisiana. Depression was greatest among those with more financial difficulties, more stressful life events, lower self-perceptions, less support from friends, and less instrumental support. Multiple regression analysis determined that depression was greatest among elderly persons who reported kidney, vision, and/or circulation problems. These findings suggest that elderly persons may perceive these three illnesses as more debilitating than other chronic illnesses. PMID:7757840

  20. Alcoholism and critical illness: A review

    PubMed Central

    Mehta, Ashish Jitendra

    2016-01-01

    Alcohol is the most commonly used and abused drug in the world, and alcohol use disorders pose a tremendous burden to healthcare systems around the world. The lifetime prevalence of alcohol abuse in the United States is estimated to be around 18%, and the economic consequences of these disorders are staggering. Studies on hospitalized patients demonstrate that about one in four patients admitted to critical care units will have alcohol-related issues, and unhealthy alcohol consumption is responsible for numerous clinical problems encountered in intensive care unit (ICU) settings. Patients with alcohol use disorders are not only predisposed to developing withdrawal syndromes and other conditions that often require intensive care, they also experience a considerably higher rate of complications, longer ICU and hospital length of stay, greater resource utilization, and significantly increased mortality compared to similar critically ill patients who do not abuse alcohol. Specific disorders seen in the critical care setting that are impacted by alcohol abuse include delirium, pneumonia, acute respiratory distress syndrome, sepsis, gastrointestinal hemorrhage, trauma, and burn injuries. Despite the substantial burden of alcohol-induced disease in these settings, critical care providers often fail to identify individuals with alcohol use disorders, which can have significant implications for this vulnerable population and delay important clinical interventions. PMID:26855891

  1. Lung Ultrasound in the Critically Ill Neonate.

    PubMed

    Lichtenstein, Daniel A; Mauriat, Philippe

    2012-08-01

    Critical ultrasound is a new tool for first-line physicians, including neonate intensivists. The consideration of the lung as one major target allows to redefine the priorities. Simple machines work better than up-to-date ones. We use a microconvex probe. Ten standardized signs allow a majority of uses: the bat sign (pleural line), lung sliding and the A-line (normal lung surface), the quad sign and sinusoid sign indicating pleural effusion regardless its echogenicity, the tissue-like sign and fractal sign indicating lung consolidation, the B-line artifact and lung rockets (indicating interstitial syndrome), abolished lung sliding with the stratosphere sign, suggesting pneumothorax, and the lung point, indicating pneumothorax. Other signs are used for more sophisticated applications (distinguishing atelectasis from pneumonia for instance...). All these disorders were assessed in the adult using CT as gold standard with sensitivity and specificity ranging from 90 to 100%, allowing to consider ultrasound as a reasonable bedside gold standard in the critically ill. The same signs are found, with no difference in the critically ill neonate. Fast protocols such as the BLUE-protocol are available, allowing immediate diagnosis of acute respiratory failure using seven standardized profiles. Pulmonary edema e.g. yields anterior lung rockets associated with lung sliding, making the B-profile. The FALLS-protocol, inserted in a Limited Investigation including a simple model of heart and vessels, assesses acute circulatory failure using lung artifacts. Interventional ultrasound (mainly, thoracocenthesis) provides maximal safety. Referrals to CT can be postponed. CEURF proposes personnalized bedside trainings since 1990. Lung ultrasound opens physicians to a visual medicine. PMID:23255876

  2. Hemostasis and thrombosis in critically ill children.

    PubMed

    Kenet, Gili; Strauss, Tzipi; Kaplinsky, Chaim; Paret, Gideon

    2008-07-01

    Patients in the pediatric intensive care unit (PICU) often suffer from a variety of pathophysiologic conditions that are associated with abnormal hemostasis. Bleeding is a major complication of any surgery or trauma, thus patients with inherited or acquired coagulopathies or those experiencing massive trauma or undergoing major (especially cardiac) operations present a special challenge to the ICU experts as well as to the hematologist. Awareness of thromboembolic events in the pediatric population has been increasing in the past few years mainly due to improvement in diagnostic tools, advances in new therapy and procedures, together with an increased index of suspicion. Young infants are at greater risk for either bleeding or thromboembolic events, due to lower concentration of vitamin K-dependent procoagulant clotting factors, reduced thrombin potential, and altered fibrinolytic pathway with low levels of the coagulation inhibitors. The combination of infection, hypotension, acidosis, and release of activated substances, such as tumor necrosis factor, is common after severe trauma or in seriously ill ICU patients and often leads to disseminated intravascular coagulation, which may be complicated either by bleeding or thrombosis. The conditions, risk factors, and therapeutic options available for critically ill PICU patients are discussed in this review. PMID:18956285

  3. Hypercalcemia in critically ill surgical patients.

    PubMed Central

    Forster, J; Querusio, L; Burchard, K W; Gann, D S

    1985-01-01

    Critical surgical illness, commonly accompanied by shock, sepsis, multiple transfusions, and renal failure, is usually associated with low total calcium and/or low or normal ionized calcium. A seminal case of hypercalcemia in a surgical intensive care unit (SICU) patient prompted the review of 100 patients with longer than average SICU days (greater than 12) to determine the incidence, associated factors, and possible etiologies of this condition. Ten patients had elevated measured, and five others had elevated calculated, ionized calcium (5.9 +/- 0.25 mg%), an incidence of 15%. Compared to the 85 patients who did not develop hypercalcemia, this population had a significantly higher frequency of the following: renal failure, dialysis, total parenteral nutrition (TPN) usage greater than 21 days, bacteremic days greater than 1, transfusions greater than 24 units, shock greater than 1 day, SICU days greater than 36, and antibiotics used greater than 7. In addition, this group had significantly more days of hypocalcemia early in their hospital course. There was no difference in sex, age, mortality, or incidence of respiratory failure. Two patients studied in depth had renal failure requiring dialysis and no malignancy, milk-alkali syndrome, hyperthyroidism, or hypoadrenalism. Parathormone (PTH) concentrations were high normal or elevated (N terminal 20 and 21 pg/ml; C terminal 130 microliters Eq/ml and 1009 pg/ml) at the time of elevated calcium (total 9.2 to 14.6 mg%; ionized 4.9 to 8.2 mg%). Immobilization does not increase PTH. In renal failure, PTH elevation is a consequence of hypocalcemia rather than hypercalcemia. Moreover, five patients did not have renal failure. Shock, sepsis, and multiple transfusions containing citrate may lower total and/or ionized calcium and thus stimulate PTH secretion. Whatever the mechanism, approximately 15% of critically ill surgical patients develop hypercalcemia, which may represent a new form of hyperparathyroidism. PMID:3931594

  4. Nutritional Assessment in Critically Ill Patients

    PubMed Central

    Hejazi, Najmeh; Mazloom, Zohreh; Zand, Farid; Rezaianzadeh, Abbas; Amini, Afshin

    2016-01-01

    Background: Malnutrition is an important factor in the survival of critically ill patients. The purpose of the present study was to assess the nutritional status of patients in the intensive care unit (ICU) on the days of admission and discharge via a detailed nutritional assessment. Methods: Totally, 125 patients were followed up from admission to discharge at 8ICUs in Shiraz, Iran. The patients’ nutritional status was assessed using subjective global assessment (SGA), anthropometric measurements, biochemical indices, and body composition indicators. Diet prescription and intake was also evaluated. Results: Malnutrition prevalence significantly increased on the day of discharge (58.62%) compared to the day of admission (28.8%) according to SGA (P<0.001). The patients’ weight, mid-upper-arm circumference, mid-arm muscle circumference, triceps skinfold thickness, and calf circumference decreased significantly as well (P<0.001). Lean mass weight and body cell mass also decreased significantly (P<0.001). Biochemical indices showed no notable changes except for magnesium, which decreased significantly (P=0.013). A negative significant correlation was observed between malnutrition on discharge day and anthropometric measurements. Positive and significant correlations were observed between the number of days without enteral feeding, days delayed from ICU admission to the commencement of enteral feeding, and the length of ICU stay and malnutrition on discharge day. Energy and protein intakes were significantly less than the prescribed diet (26.26% and 26.48%, respectively). Conclusion: Malnutrition on discharge day increased in the patients in the ICU according to SGA. Anthropometric measurements were better predictors of the nutritional outcome of our critically ill patients than were biochemical tests. PMID:27217600

  5. Nutritional support in critically ill patients.

    PubMed Central

    Grant, J P

    1994-01-01

    OBJECTIVE: The author reviews the newer nutritional substrates in use or under investigation for enteral and parenteral nutrition. Management of the critically ill patient remains a significant challenge to clinicians, and it is hoped that dietary manipulations, such as those outlined, may augment host barriers and immune function and improve survival. SUMMARY BACKGROUND DATA: The role of nutrition in patient well-being has long been recognized, but until the past 25 years, the technology to artificially provide nutrients when patients could not eat was not developed. With current, new methods for enteral and vascular access, patients can be fed nonvolitionally with little difficulty. Continued efforts have been directed toward identifying optimal feeding formulations, which have resulted in a multitude of commercially available products. In the past several years, attention has been turned to evaluation of four specialized nutrients and the use of other substrates as pharmacologic agents. METHODS: Pertinent laboratory and clinical data were reviewed to present the pros and cons for each nutritive substrate. CONCLUSIONS: Medium-chain fatty acids, branched-chain amino acids, and glutamine have been shown to be of clinical benefit and should be in common use in the near future. Short-chain fatty acids still are under investigation. Albumin, vitamins E and C, arginine, glutamine, and omega-3 fatty acids show great promise as pharmacologic agents to manipulate the stress response. Nucleotides remain investigational. CONTENTS SUMMARY: The application of some new nutritional substrates for use in critically ill patients, both as caloric sources and as pharmacologic agents, are reviewed. PMID:7979608

  6. Nitrogen Balance and Protein Requirements for Critically Ill Older Patients

    PubMed Central

    Dickerson, Roland N.

    2016-01-01

    Critically ill older patients with sarcopenia experience greater morbidity and mortality than younger patients. It is anticipated that unabated protein catabolism would be detrimental for the critically ill older patient. Healthy older subjects experience a diminished response to protein supplementation when compared to their younger counterparts, but this anabolic resistance can be overcome by increasing protein intake. Preliminary evidence suggests that older patients may respond differently to protein intake than younger patients during critical illness as well. If sufficient protein intake is given, older patients can achieve a similar nitrogen accretion response as younger patients even during critical illness. However, there is concern among some clinicians that increasing protein intake in older patients during critical illness may lead to azotemia due to decreased renal functional reserve which may augment the propensity towards worsened renal function and worsened clinical outcomes. Current evidence regarding protein requirements, nitrogen balance, ureagenesis, and clinical outcomes during nutritional therapy for critically ill older patients is reviewed. PMID:27096868

  7. Nitrogen Balance and Protein Requirements for Critically Ill Older Patients.

    PubMed

    Dickerson, Roland N

    2016-01-01

    Critically ill older patients with sarcopenia experience greater morbidity and mortality than younger patients. It is anticipated that unabated protein catabolism would be detrimental for the critically ill older patient. Healthy older subjects experience a diminished response to protein supplementation when compared to their younger counterparts, but this anabolic resistance can be overcome by increasing protein intake. Preliminary evidence suggests that older patients may respond differently to protein intake than younger patients during critical illness as well. If sufficient protein intake is given, older patients can achieve a similar nitrogen accretion response as younger patients even during critical illness. However, there is concern among some clinicians that increasing protein intake in older patients during critical illness may lead to azotemia due to decreased renal functional reserve which may augment the propensity towards worsened renal function and worsened clinical outcomes. Current evidence regarding protein requirements, nitrogen balance, ureagenesis, and clinical outcomes during nutritional therapy for critically ill older patients is reviewed. PMID:27096868

  8. Infections in critically ill burn patients.

    PubMed

    Hidalgo, F; Mas, D; Rubio, M; Garcia-Hierro, P

    2016-04-01

    Severe burn patients are one subset of critically patients in which the burn injury increases the risk of infection, systemic inflammatory response and sepsis. The infections are usually related to devices and to the burn wound. Most infections, as in other critically ill patients, are preceded by colonization of the digestive tract and the preventative measures include selective digestive decontamination and hygienic measures. Early excision of deep burn wound and appropriate use of topical antimicrobials and dressings are considered of paramount importance in the treatment of burns. Severe burn patients usually have some level of systemic inflammation. The difficulty to differentiate inflammation from sepsis is relevant since therapy differs between patients with and those without sepsis. The delay in prescribing antimicrobials increases morbidity and mortality. Moreover, the widespread use of antibiotics for all such patients is likely to increase antibiotic resistance, and costs. Unfortunately the clinical usefulness of biomarkers for differential diagnosis between inflammation and sepsis has not been yet properly evaluated. Severe burn injury induces physiological response that significantly alters drug pharmacokinetics and pharmacodynamics. These alterations impact antimicrobials distribution and excretion. Nevertheless the current available literature shows that there is a paucity of information to support routine dose recommendations. PMID:27013315

  9. Secondary sclerosing cholangitis in a critically ill patient

    PubMed Central

    Weiss, Krista E.; Willmann, Juergen K.; Jeffrey, R. Brooke

    2016-01-01

    Critically ill patients are commonly imaged for liver dysfunction. An often fatal condition, secondary sclerosing cholangitis, is an important and likely under-recognized hepatic condition in these patients. In presenting this case report, we hope to raise awareness of this condition amongst radiologists as well as other physicians caring for the critically ill. PMID:27190777

  10. Understanding and Reducing Disability in Older Adults Following Critical Illness

    PubMed Central

    Brummel, N.E.; Balas, M.C.; Morandi, A.; Ferrante, L.E.; Gill, T.M.; Ely, E.W.

    2015-01-01

    Objective To review how disability can develop in older adults with critical illness and to explore ways to reduce long-term disability following critical illness. Data Sources Review of the literature describing post-critical illness disability in older adults and expert opinion. Results We identified 19 studies evaluating disability outcomes in critically ill patients age 65 years and older. Newly acquired disability in activities of daily living, instrumental activities of daily living and mobility activities was commonplace among older adults who survived a critical illness. Incident dementia and less-severe cognitive impairment was also highly prevalent. Factors related to the acute critical illness, intensive care unit practices such as heavy sedation, physical restraints and immobility as well as aging physiology and coexisting geriatric conditions can combine to result in these poor outcomes. Conclusion Older adults who survive critical illness suffer physical and cognitive declines resulting in disability at greater rates than hospitalized, non-critically ill and community dwelling older adults. Interventions derived from widely available geriatric care models in use outside of the ICU, which address modifiable risk factors including immobility and delirium, are associated with improved functional and cognitive outcomes and can be used to complement ICU-focused models such as the ABCDEs. PMID:25756418

  11. A challenge for public policy: the chronically ill elderly and nursing homes.

    PubMed

    Ricker-Smith, K L

    1982-11-01

    Data reported by skilled nursing facilities (SNFs) in an eight-county area in Northern California for 1977-78 indicate that the typical SNF resident was a impoverished female who was at least 75 years old. Her SNF stay was subsidized by MediCal, California's Medicaid program. She was in an urban, for-profit SNF for at least one year, during which time approximately one quarter of her co-residents died. She received about 2 hours of daily side-orderly-attendant care and almost 45 minutes of licensed nurse care. Although her most frequent contact was with aides-orderlies-attendants, a sustained relationship with the staff was not likely because of high employee turnover rate in the facility. This resident had a one-in-three chance of being in a SNF that had been cited (though the citation had not necessarily been upheld) for poor to life-threatening care. This information underscores the urgency of reorienting public policies so that they are based on the needs of the chronically ill elderly. Such a reorientation would I) ensure that people receive professional and paraprofessional services in the least restrictive environment; 2) preclude criticism of nursing homes for "warehousing" the elderly when there is actually little choice in the matter; and 3) enable the nation's elderly to live out their lives with sense of self-worth and dignity, and with the knowledge that they are valued members of society. PMID:6815387

  12. Lung ultrasound in the critically ill

    PubMed Central

    2014-01-01

    Lung ultrasound is a basic application of critical ultrasound, defined as a loop associating urgent diagnoses with immediate therapeutic decisions. It requires the mastery of ten signs: the bat sign (pleural line), lung sliding (yielding seashore sign), the A-line (horizontal artifact), the quad sign, and sinusoid sign indicating pleural effusion, the fractal, and tissue-like sign indicating lung consolidation, the B-line, and lung rockets indicating interstitial syndrome, abolished lung sliding with the stratosphere sign suggesting pneumothorax, and the lung point indicating pneumothorax. Two more signs, the lung pulse and the dynamic air bronchogram, are used to distinguish atelectasis from pneumonia. All of these disorders were assessed using CT as the “gold standard” with sensitivity and specificity ranging from 90% to 100%, allowing ultrasound to be considered as a reasonable bedside “gold standard” in the critically ill. The BLUE-protocol is a fast protocol (<3 minutes), which allows diagnosis of acute respiratory failure. It includes a venous analysis done in appropriate cases. Pulmonary edema, pulmonary embolism, pneumonia, chronic obstructive pulmonary disease, asthma, and pneumothorax yield specific profiles. Pulmonary edema, e.g., yields anterior lung rockets associated with lung sliding, making the “B-profile.” The FALLS-protocol adapts the BLUE-protocol to acute circulatory failure. It makes sequential search for obstructive, cardiogenic, hypovolemic, and distributive shock using simple real-time echocardiography (right ventricle dilatation, pericardial effusion), then lung ultrasound for assessing a direct parameter of clinical volemia: the apparition of B-lines, schematically, is considered as the endpoint for fluid therapy. Other aims of lung ultrasound are decreasing medical irradiation: the LUCIFLR program (most CTs in ARDS or trauma can be postponed), a use in traumatology, intensive care unit, neonates (the signs are the same than

  13. Lung ultrasound in the critically ill.

    PubMed

    Lichtenstein, Daniel A

    2014-01-01

    Lung ultrasound is a basic application of critical ultrasound, defined as a loop associating urgent diagnoses with immediate therapeutic decisions. It requires the mastery of ten signs: the bat sign (pleural line), lung sliding (yielding seashore sign), the A-line (horizontal artifact), the quad sign, and sinusoid sign indicating pleural effusion, the fractal, and tissue-like sign indicating lung consolidation, the B-line, and lung rockets indicating interstitial syndrome, abolished lung sliding with the stratosphere sign suggesting pneumothorax, and the lung point indicating pneumothorax. Two more signs, the lung pulse and the dynamic air bronchogram, are used to distinguish atelectasis from pneumonia. All of these disorders were assessed using CT as the "gold standard" with sensitivity and specificity ranging from 90% to 100%, allowing ultrasound to be considered as a reasonable bedside "gold standard" in the critically ill. The BLUE-protocol is a fast protocol (<3 minutes), which allows diagnosis of acute respiratory failure. It includes a venous analysis done in appropriate cases. Pulmonary edema, pulmonary embolism, pneumonia, chronic obstructive pulmonary disease, asthma, and pneumothorax yield specific profiles. Pulmonary edema, e.g., yields anterior lung rockets associated with lung sliding, making the "B-profile." The FALLS-protocol adapts the BLUE-protocol to acute circulatory failure. It makes sequential search for obstructive, cardiogenic, hypovolemic, and distributive shock using simple real-time echocardiography (right ventricle dilatation, pericardial effusion), then lung ultrasound for assessing a direct parameter of clinical volemia: the apparition of B-lines, schematically, is considered as the endpoint for fluid therapy. Other aims of lung ultrasound are decreasing medical irradiation: the LUCIFLR program (most CTs in ARDS or trauma can be postponed), a use in traumatology, intensive care unit, neonates (the signs are the same than in adults

  14. Nerve excitability changes in critical illness polyneuropathy.

    PubMed

    Z'Graggen, W J; Lin, C S Y; Howard, R S; Beale, R J; Bostock, H

    2006-09-01

    Patients in intensive care units frequently suffer muscle weakness and atrophy due to critical illness polyneuropathy (CIP), an axonal neuropathy associated with systemic inflammatory response syndrome and multiple organ failure. CIP is a frequent and serious complication of intensive care that delays weaning from mechanical ventilation and increases mortality. The pathogenesis of CIP is not well understood and no specific therapy is available. The aim of this project was to use nerve excitability testing to investigate the changes in axonal membrane properties occurring in CIP. Ten patients (aged 37-76 years; 7 males, 3 females) were studied with electrophysiologically proven CIP. The median nerve was stimulated at the wrist and compound action potentials were recorded from abductor pollicis brevis muscle. Strength-duration time constant, threshold electrotonus, current-threshold relationship and recovery cycle (refractoriness, superexcitability and late subexcitability) were recorded using a recently described protocol. In eight patients a follow-up investigation was performed. All patients underwent clinical examination and laboratory investigations. Compared with age-matched normal controls (20 subjects; aged 38-79 years; 7 males, 13 females), CIP patients exhibited reduced superexcitability at 7 ms, from -22.3 +/- 1.6% to -7.6 +/- 3.1% (mean +/- SE, P approximately 0.0001) and increased accommodation to depolarizing (P < 0.01) and hyperpolarizing currents (P < 0.01), indicating membrane depolarization. Superexcitability was reduced both in patients with renal failure and without renal failure. In the former, superexcitability correlated with serum potassium (R = 0.88), and late subexcitability was also reduced (as also occurs owing to hyperkalaemia in patients with chronic renal failure). In patients without renal failure, late subexcitability was normal, and the signs of membrane depolarization correlated with raised serum bicarbonate and base excess

  15. Ebola virus disease and critical illness.

    PubMed

    Leligdowicz, Aleksandra; Fischer, William A; Uyeki, Timothy M; Fletcher, Thomas E; Adhikari, Neill K J; Portella, Gina; Lamontagne, Francois; Clement, Christophe; Jacob, Shevin T; Rubinson, Lewis; Vanderschuren, Abel; Hajek, Jan; Murthy, Srinivas; Ferri, Mauricio; Crozier, Ian; Ibrahima, Elhadj; Lamah, Marie-Claire; Schieffelin, John S; Brett-Major, David; Bausch, Daniel G; Shindo, Nikki; Chan, Adrienne K; O'Dempsey, Tim; Mishra, Sharmistha; Jacobs, Michael; Dickson, Stuart; Lyon, G Marshall; Fowler, Robert A

    2016-01-01

    As of 20 May 2016 there have been 28,646 cases and 11,323 deaths resulting from the West African Ebola virus disease (EVD) outbreak reported to the World Health Organization. There continue to be sporadic flare-ups of EVD cases in West Africa.EVD presentation is nonspecific and characterized initially by onset of fatigue, myalgias, arthralgias, headache, and fever; this is followed several days later by anorexia, nausea, vomiting, diarrhea, and abdominal pain. Anorexia and gastrointestinal losses lead to dehydration, electrolyte abnormalities, and metabolic acidosis, and, in some patients, acute kidney injury. Hypoxia and ventilation failure occurs most often with severe illness and may be exacerbated by substantial fluid requirements for intravascular volume repletion and some degree of systemic capillary leak. Although minor bleeding manifestations are common, hypovolemic and septic shock complicated by multisystem organ dysfunction appear the most frequent causes of death.Males and females have been equally affected, with children (0-14 years of age) accounting for 19 %, young adults (15-44 years) 58 %, and older adults (≥45 years) 23 % of reported cases. While the current case fatality proportion in West Africa is approximately 40 %, it has varied substantially over time (highest near the outbreak onset) according to available resources (40-90 % mortality in West Africa compared to under 20 % in Western Europe and the USA), by age (near universal among neonates and high among older adults), and by Ebola viral load at admission.While there is no Ebola virus-specific therapy proven to be effective in clinical trials, mortality has been dramatically lower among EVD patients managed with supportive intensive care in highly resourced settings, allowing for the avoidance of hypovolemia, correction of electrolyte and metabolic abnormalities, and the provision of oxygen, ventilation, vasopressors, and dialysis when indicated. This experience emphasizes that

  16. [Progress and living situations among the elderly with severe mental illness: perspectives of psychosocial services].

    PubMed

    Dallaire, Bernadette; McCubbin, Michael; Provost, Mélanie; Carpentier, Normand; Clément, Michèle

    2010-06-01

    Services for elders with severe mental illness (SMI) have major deficiencies, among them a lack of adequate psychosocial services. Some analysts have attributed this situation to "double stigmatization" targeting both ageing and mental illness in our societies. Using qualitative methods (23 semi-directed interviews, theme-based content analysis), our exploratory research aims to understand better the perceptions of psychosocial practitioners working in community and institutional settings about the elderly with SMI and their living situations. Our informants evoke living situations marked by a lack of support (isolation), of resources (financial precariousness/poverty) and of power (learned passivity), traits that are related not only to mental illness per se, but also to long term psychiatric institutionalization. For them, the current situation of elders with SMI is the end product of biographies in which life-course, illness-course and life in services and/or institutions join and, sometimes, become indistinguishable. Implications for psychosocial practices are discussed. PMID:20420749

  17. When Is It Appropriate to Use Arginine in Critical Illness?

    PubMed

    Patel, Jayshil J; Miller, Keith R; Rosenthal, Cameron; Rosenthal, Martin D

    2016-08-01

    In health, arginine is considered a nonessential amino acid but can become an essential amino acid (ie, conditionally essential amino acid) during periods of metabolic or traumatic stress as endogenous arginine supply is inadequate to meet physiologic demands. Arginine depletion in critical illness is associated with impairments in microcirculatory blood flow, impaired wound healing, and T-cell dysfunction. The purpose of this review is to (1) describe arginine metabolism and role in health and critical illness, (2) describe the relationship between arginine and asymmetric dimethylarginine, and (3) review studies of supplemental arginine in critically ill patients. PMID:27252277

  18. Redefining the gut as the motor of critical illness

    PubMed Central

    Mittal, Rohit; Coopersmith, Craig M.

    2013-01-01

    The gut is hypothesized to play a central role in the progression of sepsis and multiple organ dysfunction syndrome. Critical illness alters gut integrity by increasing epithelial apoptosis and permeability and by decreasing epithelial proliferation and mucus integrity. Additionally, toxic gut-derived lymph induces distant organ injury. Although the endogenous microflora ordinarily exist in a symbiotic relationship with the gut epithelium, severe physiologic insults alter this relationship, leading to induction of virulence factors in the microbiome, which, in turn, can perpetuate or worsen critical illness. This review highlights newly discovered ways in which the gut acts as the motor that perpetuates the systemic inflammatory response in critical illness. PMID:24055446

  19. Redefining the gut as the motor of critical illness.

    PubMed

    Mittal, Rohit; Coopersmith, Craig M

    2014-04-01

    The gut is hypothesized to play a central role in the progression of sepsis and multiple organ dysfunction syndrome. Critical illness alters gut integrity by increasing epithelial apoptosis and permeability and by decreasing epithelial proliferation and mucus integrity. Additionally, toxic gut-derived lymph induces distant organ injury. Although the endogenous microflora ordinarily exist in a symbiotic relationship with the gut epithelium, severe physiological insults alter this relationship, leading to induction of virulence factors in the microbiome, which, in turn, can perpetuate or worsen critical illness. This review highlights newly discovered ways in which the gut acts as the motor that perpetuates the systemic inflammatory response in critical illness. PMID:24055446

  20. Vitamin D metabolism and deficiency in critical illness.

    PubMed

    Lee, Paul

    2011-10-01

    Vitamin D deficiency is highly prevalent and has been associated with a diverse range of chronic medical conditions in the general population. In contrast, the prevalence, pathogenesis and significance of vitamin D deficiency have received little attention in acute medicine. Vitamin D deficiency is seldom considered and rarely corrected adequately, if at all, in critically ill patients. Recent recognition of the extra-skeletal, pleiotropic actions of vitamin D in immunity, epithelial function and metabolic regulation may underlie the previously under-recognized contribution of vitamin D deficiency to typical co-morbidities in critically ill patients, including sepsis, systemic inflammatory response syndrome and metabolic dysfunction. Improved understanding of vitamin D metabolism and regulation in critical illness may allow therapeutic exploitation of vitamin D to improve outcome in critically ill patients. PMID:21925077

  1. [Chronic critically ill patients from a gastroenterological perspective].

    PubMed

    Bittinger, M; Messmann, H

    2013-05-01

    From a gastroenterological point of view, for chronic critically ill patients a differentiation has to be made between general gastroenterological problems, which are important in many or all chronic critically ill patients and patients with gastroenterological diseases which are the reason for the chronic critically ill status. General gastroenterological problems are, for example the nutrition of these patients and also considerations about ulcer prophylaxis or gastroenterological complications, such as antibiotic-associated colitis. Gastroenterological diseases as the reason for a chronic critically ill status are more in the minority. Diseases which should be taken into consideration are advanced liver cirrhosis and short bowel syndrome. This manuscript is intended to discuss gastroenterological problems in this selected group of patients and to show possible solutions and treatment options. PMID:23423578

  2. Context-sensitive fluid therapy in critical illness.

    PubMed

    Tatara, Tsuneo

    2016-01-01

    Microcirculatory alterations are frequently observed in critically ill patients undergoing major surgery and those who suffer from trauma or sepsis. Despite the need for adequate fluid administration to restore microcirculation, there is no consensus regarding optimal fluid therapy for these patients. The recent recognition of the importance of the endothelial glycocalyx layer in capillary fluid and solute exchange has largely changed our views on fluid therapy in critical illness. Given that disease status largely differs among critically ill patients, fluid therapy must not be considered generally, but rather tailored to the clinical condition of each patient. This review outlines the current understanding of context-sensitive volume expansion by fluid solutions and considers its clinical implications for critically ill patients. The modulation of capillary hydrostatic pressure through the appropriate use of vasopressors may increase the effectiveness of fluid infusion and thereby reduce detrimental effects resulting from excessive fluid administration. PMID:26985394

  3. The pharmacologic approach to the critically ill patient

    SciTech Connect

    Chernow, B. )

    1988-01-01

    This book contains papers addressing the pharmacologic approach to the critically ill patient. Chapter topics include: Radiation injury; Red cell substitutes: a current appraisal; and Psychopharmacology in the ICU.

  4. Monitoring of the respiratory muscles in the critically ill.

    PubMed

    Doorduin, Jonne; van Hees, Hieronymus W H; van der Hoeven, Johannes G; Heunks, Leo M A

    2013-01-01

    Evidence has accumulated that respiratory muscle dysfunction develops in critically ill patients and contributes to prolonged weaning from mechanical ventilation. Accordingly, it seems highly appropriate to monitor the respiratory muscles in these patients. Today, we are only at the beginning of routinely monitoring respiratory muscle function. Indeed, most clinicians do not evaluate respiratory muscle function in critically ill patients at all. In our opinion, however, practical issues and the absence of sound scientific data for clinical benefit should not discourage clinicians from having a closer look at respiratory muscle function in critically ill patients. This perspective discusses the latest developments in the field of respiratory muscle monitoring and possible implications of monitoring respiratory muscle function in critically ill patients. PMID:23103733

  5. Heat-related illness: a hot topic in critical care.

    PubMed

    Krau, Stephen D

    2013-06-01

    With current predictions of climate change, the incidence of heat-related illnesses is projected to increase. Heat-related illnesses occur on a continuum from mild symptoms to fatalities. To prevent heat-related illnesses, nurses should have comprehension of persons at risk. Primary treatment of heat-related illness centers on cooling, but not overcooling, the patient. Heatstroke involves coagulopathies and cytokines, and can result in systemic inflammatory response syndrome and multiple organ dysfunction. Critical care nursing intervention requires more than effective cooling to support bodily processes that have been damaged or destroyed by the pathophysiology of heatstroke. PMID:23692942

  6. Delirium: An Emerging Frontier in Management of Critically Ill Children

    PubMed Central

    Smith, Heidi A.B.; Fuchs, D. Catherine; Pandharipande, Pratik P.; Barr, Frederick E.; Ely, E. Wesley

    2009-01-01

    OBJECTIVES Introduce pediatric delirium and provide understanding of acute brain dysfunction with its classification and clinical presentations. Understand how delirium is diagnosed and discuss current modes of delirium diagnosis in the critically ill adult population and translation to pediatrics. Understand the prevalence and prognostic significance of delirium in the adult and pediatric critically ill population. Discuss the pathophysiology of delirium as currently understood. Provide general management guidelines for delirium. PMID:19576533

  7. Splanchnic ischaemia and multiple organ failure in the critically ill.

    PubMed Central

    Fiddian-Green, R. G.

    1988-01-01

    The development of a safe and simple tonometric method of monitoring the adequacy of gastrointestinal mucosal perfusion has provided a new perspective of splanchnic ischaemia in the critically ill. It would appear that splanchnic hypoxia, identified by the presence of intramucosal acidosis in the gut, may be one of the most consistent and earliest indications of impaired tissue perfusion in the critically ill and be causally related to the development of sepsis and multiple organ failure. PMID:3044239

  8. Clinical review: Special populations--critical illness and pregnancy.

    PubMed

    Neligan, Patrick J; Laffey, John G

    2011-01-01

    Critical illness is an uncommon but potentially devastating complication of pregnancy. The majority of pregnancy-related critical care admissions occur postpartum. Antenatally, the pregnant patient is more likely to be admitted with diseases non-specific to pregnancy, such as pneumonia. Pregnancy-specific diseases resulting in ICU admission include obstetric hemorrhage, pre-eclampsia/eclampsia, HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, amniotic fluid embolus syndrome, acute fatty liver of pregnancy, and peripartum cardiomyopathy. Alternatively, critical illness may result from pregnancy-induced worsening of pre-existing diseases (for example, valvular heart disease, myasthenia gravis, and kidney disease). Pregnancy can also predispose women to diseases seen in the non-pregnant population, such as acute respiratory distress syndrome (for example, pneumonia and aspiration), sepsis (for example, chorioamnionitis and pyelonephritis) or pulmonary embolism. The pregnant patient may also develop conditions co-incidental to pregnancy such as trauma or appendicitis. Hemorrhage, particularly postpartum, and hypertensive disorders of pregnancy remain the most frequent indications for ICU admission. This review focuses on pregnancy-specific causes of critical illness. Management of the critically ill mother poses special challenges. The physiologic changes in pregnancy and the presence of a second, dependent, patient may necessitate adjustments to therapeutic and supportive strategies. The fetus is generally robust despite maternal illness, and therapeutically what is good for the mother is generally good for the fetus. For pregnancy-induced critical illnesses, delivery of the fetus helps resolve the disease process. Prognosis following pregnancy-related critical illness is generally better than for age-matched non-pregnant critically ill patients. PMID:21888683

  9. Disability and quality of life among elderly persons with mental illness.

    PubMed

    Ramaprasad, Dharitri; Rao, N Suryanarayana; Kalyanasundaram, S

    2015-12-01

    The present study was undertaken to understand the level of disability and quality of life of elderly persons with chronic and persistent mental illnesses and to compare it with those who were elderly but well with no illness. For the purpose 200 elderly persons with mental illness (PMI), attending psychiatric services were included in the study. A comparison group of 103 well elderly persons was drawn from the same study area as control group (CG). They were assessed using WHO-DAS and WHOQOL-BREF. Results revealed that PMI experienced higher disability compared to the CG. Deficits in the domain of moving around, getting along with people, engaging in life activities and participation in society contributed most to the high level of disability in the PMI group. PMI from rural area had higher disability compared to the urban group. As for QOL, elderly PMI had a poor quality of life compared to the CG. Quality of life was found to be negatively associated with level of disability. Higher the level of disability, lower was the quality of life. The authors opine that persons with chronic mental illness continue to experience psychiatric disability in old age and this cannot be attributed to normal aging. Level of disability has a negative impact on their quality of life. PMID:26573889

  10. Return Migration among Elderly, Chronically Ill Bosnian Refugees: Does Health Matter?

    PubMed Central

    Handlos, Line Neerup; Olwig, Karen Fog; Bygbjerg, Ib Christian; Kristiansen, Maria; Norredam, Marie Louise

    2015-01-01

    Elderly migrants constitute a considerable share of global return migration; nevertheless, literature on the health aspects of the return migration among these migrants is still scarce. This study explores the significance of return migration among elderly, chronically ill Bosnian refugees from Denmark and the role of health issues in their decision to return. It is based on semi-structured interviews with 33 elderly, chronically ill Bosnian refugees who have moved back to Bosnia and Herzegovina, and 10 elderly, chronically ill Bosnian refugees who have remained in Denmark. The interviews show that physical health, in the sense of the absence of illness and easy access to necessary health-care services and medicines, was not highly prioritized when the decision was made whether or not to return. However, if health is regarded more broadly as involving more than mere physical health and the absence of illness, health did matter. Viewed as physical, social and mental well-being in line with WHO’s definition of health, health was indeed one of the most important factors when the decision to return was made. PMID:26473899

  11. Return Migration among Elderly, Chronically Ill Bosnian Refugees: Does Health Matter?

    PubMed

    Handlos, Line Neerup; Olwig, Karen Fog; Bygbjerg, Ib Christian; Kristiansen, Maria; Norredam, Marie Louise

    2015-10-01

    Elderly migrants constitute a considerable share of global return migration; nevertheless, literature on the health aspects of the return migration among these migrants is still scarce. This study explores the significance of return migration among elderly, chronically ill Bosnian refugees from Denmark and the role of health issues in their decision to return. It is based on semi-structured interviews with 33 elderly, chronically ill Bosnian refugees who have moved back to Bosnia and Herzegovina, and 10 elderly, chronically ill Bosnian refugees who have remained in Denmark. The interviews show that physical health, in the sense of the absence of illness and easy access to necessary health-care services and medicines, was not highly prioritized when the decision was made whether or not to return. However, if health is regarded more broadly as involving more than mere physical health and the absence of illness, health did matter. Viewed as physical, social and mental well-being in line with WHO's definition of health, health was indeed one of the most important factors when the decision to return was made. PMID:26473899

  12. Shoshin Beriberi in Critically-Ill patients: case series.

    PubMed

    Dabar, George; Harmouche, Carine; Habr, Bassem; Riachi, Moussa; Jaber, Bertrand

    2015-01-01

    Thiamine plays a fundamental role in cellular metabolism. The classical syndrome caused by thiamine deficiency is beriberi, and its fulminant variant, once considered an uncommon finding, is now encountered among the critically ill.We present a case series of four critically ill non-septic non-alcoholic patients with severe lactic acidosis and refractory cardio-circulatory collapse caused by acute fulminant beriberi, which drastically responded to thiamine administration.In critical care settings, increased awareness of this life-threatening but reversible condition is a requirement, especially among patients receiving parenteral nutrition and those with unexplained recalcitrant lactic acidosis. PMID:25982313

  13. Common complications in critically ill patients.

    PubMed

    Wollschlager, C M; Conrad, A R; Khan, F A

    1988-05-01

    Patients in intensive care units (ICUs) are subject to many complications connected with the advanced therapy required for their serious illnesses. Complications of ventilatory support include problems associated with short-term and long-term intubation, barotrauma, gastrointestinal tract bleeding, and weaning errors. Cardiac tachyarrhythmias can arise from a patient's intrinsic cardiac disease, as well as from drug therapy itself. Hemodynamic monitoring is crucial to careful patient management, but it is associated with technical complications during insertion such as pneumothorax, as well as interpretive errors such as those caused by positive end-inspiratory pressure. Acute renal failure can develop as a result both of therapy with drugs such as aminoglycosides and hypotension of many etiologies, as well as the use of contrast media. Nosocomial infection, which is a dreaded complication in ICU patients, usually arises from sources in the urinary tract, bloodstream, or lung. Complications frequently can arise if the interactions of drugs commonly used in the ICU are not recognized. Further, the ICU patient is subject to nutritional complications, acid base problems, and psychological disturbances. This monograph deals with the frequency, etiology, and prevention of these common ICU complications. PMID:3286162

  14. Early Mobilization and Rehabilitation of Patients Who Are Critically Ill.

    PubMed

    Hashem, Mohamed D; Parker, Ann M; Needham, Dale M

    2016-09-01

    Neuromuscular disorders are increasingly recognized as a cause of both short- and long-term physical morbidity in survivors of critical illness. This recognition has given rise to research aimed at better understanding the risk factors and mechanisms associated with neuromuscular dysfunction and physical impairment associated with critical illness, as well as possible interventions to prevent or treat these issues. Among potential risk factors, bed rest is an important modifiable risk factor. Early mobilization and rehabilitation of patients who are critically ill may help prevent or mitigate the sequelae of bed rest and improve patient outcomes. Research studies and quality improvement projects have demonstrated that early mobilization and rehabilitation are safe and feasible in patients who are critically ill, with potential benefits including improved physical functioning and decreased duration of mechanical ventilation, intensive care, and hospital stay. Despite these findings, early mobilization and rehabilitation are still uncommon in routine clinical practice, with many perceived barriers. This review summarizes potential risk factors for neuromuscular dysfunction and physical impairment associated with critical illness, highlights the potential role of early mobilization and rehabilitation in improving patient outcomes, and discusses some of the commonly perceived barriers to early mobilization and strategies for overcoming them. PMID:26997241

  15. Introduction to drug pharmacokinetics in the critically ill patient.

    PubMed

    Smith, Brian S; Yogaratnam, Dinesh; Levasseur-Franklin, Kimberly E; Forni, Allison; Fong, Jeffrey

    2012-05-01

    Despite regular use of drugs for critically ill patients, overall data are limited regarding the impact of critical illness on pharmacokinetics (PK). Designing safe and effective drug regimens for patients with critical illness requires an understanding of PK. This article reviews general principles of PK, including absorption, distribution, metabolism, and elimination, and how critical illness can influence these parameters. In the area of drug absorption, we discuss the impact of vasopressor use, delayed gastric emptying and feeding tubes, and nutrient interactions. On the topic of drug distribution, we review fluid resuscitation, alterations in plasma protein binding, and tissue perfusion. With drug metabolism, we discuss hepatic enzyme activity, protein binding, and hepatic blood flow. Finally, we review drug elimination in the critically ill patient and discuss the impact of augmented renal clearance and acute kidney injury on drug therapies. In each section, we highlight select literature reviewing the PK impact of these conditions on a drug PK profile and, where appropriate, provide general suggestions for clinicians on how to modify drug regimens to manage PK challenges. PMID:22553267

  16. Providing care for critically ill surgical patients: challenges and recommendations.

    PubMed

    Tisherman, Samuel A; Kaplan, Lewis; Gracias, Vicente H; Beilman, Gregory J; Toevs, Christine; Byrnes, Matthew C; Coopersmith, Craig M

    2013-07-01

    Providing optimal care for critically ill and injured surgical patients will become more challenging with staff shortages for surgeons and intensivists. This white paper addresses the historical issues behind the present situation, the need for all intensivists to engage in dedicated critical care per the intensivist model, and the recognition that intensivists from all specialties can provide optimal care for the critically ill surgical patient, particularly with continuing involvement by the surgeon of record. The new acute care surgery training paradigm (including trauma, surgical critical care, and emergency general surgery) has been developed to increase interest in trauma and surgical critical care, but the number of interested trainees remains too few. Recommendations are made for broadening the multidisciplinary training and practice opportunities in surgical critical care for intensivists from all base specialties and for maintaining the intensivist model within acute care surgery practice. Support from academic and administrative leadership, as well as national organizations, will be needed. PMID:23754675

  17. Implementation of Discharge Plans for Chronically Ill Elders Discharged Home.

    ERIC Educational Resources Information Center

    Proctor, Enola K.; And Others

    1996-01-01

    Addresses the extent to which discharge plans for elderly patients with congestive heart failure were implemented as planned, tested the consequences of implementation problems, and identified factors associated with implementation problems. Implications for hospital discharge planners and home health care are discussed. (KW)

  18. Discontinuing treatment in children with chronic, critical illnesses.

    PubMed

    Mahon, M M; Deatrick, J A; McKnight, H J; Mohr, W K

    2000-03-01

    Decisions about optimal treatment for critically ill children are qualitatively different from those related to adults. Technological advances over the past several decades have resulted in myriad treatment options that leave many children chronically, critically ill. These children are often technology dependent. With new technologies and new patient populations comes the responsibility to understand how, when, and why these technologies are applied and when technology should not be used or should be withdrawn. Much has been written about ethical decision making in the care of chronically, critically ill adults and newborns. In this article, relevant factors about the care of children older than neonates are described: standards, decision makers, age of the child, and pain management. A case study is used as a mechanism to explore these issues. Dimensions of futility, discontinuing aggressive treatment, and a consideration of benefits and burdens are integrated throughout the discussion to inform nurse practitioner practice. PMID:11219897

  19. Human factors in the management of the critically ill patient.

    PubMed

    Bion, J F; Abrusci, T; Hibbert, P

    2010-07-01

    Unreliable delivery of best practice care is a major component of medical error. Critically ill patients are particularly susceptible to error and unreliable care. Human factors analysis, widely used in industry, provides insights into how interactions between organizations, tasks, and the individual worker impact on human behaviour and affect systems reliability. We adopt a human factors approach to examine determinants of clinical reliability in the management of critically ill patients. We conducted a narrative review based on a Medline search (1950-March 2010) combining intensive/critical care (units) with medical errors, patient safety, or delivery of healthcare; keyword and Internet search 'human factors' or 'ergonomics'. Critical illness represents a high-risk, complex system spanning speciality and geographical boundaries. Substantial opportunities exist for improving the safety and reliability of care of critically ill patients at the level of the task, the individual healthcare provider, and the organization or system. Task standardization (best practice guidelines) and simplification (bundling or checklists) should be implemented where scientific evidence is strong, or adopted subject to further research ('dynamic standardization'). Technical interventions should be embedded in everyday practice by the adjunctive use of non-technical (behavioural) interventions. These include executive 'adoption' of clinical areas, systematic methods for identifying hazards and reflective learning from error, and a range of techniques for improving teamworking and communication. Human factors analysis provides a useful framework for understanding and rectifying the causes of error and unreliability, particularly in complex systems such as critical care. PMID:20511333

  20. The recognition and early management of critical illness.

    PubMed Central

    Ridley, Saxon

    2005-01-01

    INTRODUCTION: Critical illness is an emergency because the inflammatory response has redundant multiple pathways; once triggered, it is difficult to control or suppress. Infection is a potent precursor of critical illness and increasing organ dysfunction has a synergistic, rather than purely additive, adverse effect on mortality. The longer the inflammatory process continues unabated, the more advanced and unrecoverable the pathophysiological processes become resulting in a high mortality. METHODS: The review is a statement of the author's opinion supported by selected references. The content of the review was presented as the Tutor Edwards Lecture at The Royal College of Surgeons of England in December 2004. RESULTS: Critical illness is preceded by prodromal signs warning of impending physiological catastrophe. These simple physiological signs, the most sensitive of which is the respiratory rate can be quantified using Early Warning Scores. If patients trigger the Early Warning Score, emergency management is required to reverse the abnormal physiological decline or to prompt admission to a critical care area. The emergency management principles include removal or reversal of the cause so shutting down the inflammatory response, appropriate antibiotic therapy and general organ support. CONCLUSIONS: Formalising measurement of physiological (in)stability on the general ward using Early Warning Scores improves recognition of unstable and potentially critically ill patients. Prompt intervention will either reverse further physiological decline or facilitate timely referral to the critical care service for further, more invasive, organ support. PMID:16176687

  1. Antioxidant Vitamins and Trace Elements in Critical Illness.

    PubMed

    Koekkoek, W A C Kristine; van Zanten, Arthur R H

    2016-08-01

    This comprehensive narrative review summarizes relevant antioxidant mechanisms, the antioxidant status, and effects of supplementation in critically ill patients for the most studied antioxidant vitamins A, C, and E and the enzyme cofactor trace elements selenium and zinc. Over the past 15 years, oxidative stress-mediated cell damage has been recognized to be fundamental to the pathophysiology of various critical illnesses such as acute respiratory distress syndrome, ischemia-reperfusion injury, and multiorgan dysfunction in sepsis. Related to these conditions, low plasma levels of antioxidant enzymes, vitamins, and trace elements have been frequently reported, and thus supplementation seems logical. However, low antioxidant plasma levels per se may not indicate low total body stores as critical illness may induce redistribution of antioxidants. Furthermore, low antioxidant levels may even be beneficial as pro-oxidants are essential in bacterial killing. The reviewed studies in critically ill patients show conflicting results. This may be due to different patient populations, study designs, timing, dosing regimens, and duration of the intervention and outcome measures evaluated. Therefore, at present, it remains unclear whether supplementation of antioxidant micronutrients has any clinical benefit in critically ill patients as some studies show clear benefits, whereas others demonstrate neutral outcomes and even harm. Combination therapy of antioxidants seems logical as they work in synergy and function as elements of the human antioxidant network. Further research should focus on defining the normal antioxidant status for critically ill patients and to study optimal supplement combinations either by nutrition enrichment or by enteral or parenteral pharmacological interventions. PMID:27312081

  2. Nutritional support in critically ill patients with cancer.

    PubMed

    Wong, P W; Enriquez, A; Barrera, R

    2001-07-01

    Nutritional depletion is a common problem seen in critically ill patients with cancer and is associated with increased morbidity and mortality. Infection and injury activate a cascade of metabolic events that leads to a poor nutritional state and wasteful energy consumption. The goals of nutritional support entail minimizing starvation, preventing nutrient deficiencies, supporting or improving immune function, and facilitating tissue repair and wound healing. Further understanding of the metabolic changes of illness will improve effective regulation of the inflammatory events occurring in critically ill patients. Multiple clinical parameters are available to assess the nutritional status in critically ill patients, but no standard recommendations can be made at this time. The use of these parameters can be appropriate, provided that their limitations are understood clearly. The development and standardization of objective parameters to identify patients at risk or with subclinical malnutrition are needed. Enteral and parenteral feedings are safe and effective methods to deliver nutrients to critically ill patients with cancer who are unable to ingest adequate amounts orally. Early nutritional support should be instituted in the appropriate clinical setting. Specialized nutritional solutions and supplements require careful consideration in patients with renal, hepatic, cardiac, or pulmonary disorders. The unselective use of nutritional support is not indicated in well-nourished patients with cancer undergoing surgery, chemotherapy, or radiotherapy in whom adequate oral intake is anticipated. Nutritional support remains an important adjunctive therapy in the overall management of critically ill patients. Continued clinical investigations in nutrition are necessary to identify other groups of patients who can benefit from nutritional interventions. PMID:11525056

  3. Complications of Sedation in Critical Illness: An Update.

    PubMed

    Foster, Jan

    2016-06-01

    Sedation is a necessary component of care for the critically ill. Oversedation, however, is associated with immediate complications and long-term problems, termed post-intensive care unit syndrome. It also contributes to unnecessary costs of care. This article describes the physical, functional, psychiatric, and cognitive complications of oversedation, and multiple research-based strategies that minimize complications. PMID:27215360

  4. Bicarbonate kinetics and predicted energy expenditure in critically ill children

    Technology Transfer Automated Retrieval System (TEKTRAN)

    To determine nutrient requirements by the carbon oxidation techniques, it is necessary to know the fraction of carbon dioxide produced during the oxidative process but not excreted. This fraction has not been described in critically ill children. By measuring the dilution of (13)C infused by metabol...

  5. [Glucose control in the critically ill. Innovations and contemporary strategies].

    PubMed

    Holzinger, U

    2013-06-01

    Glucose control should be part of standard therapy in intensive care units (ICU) due to the proven association of hyperglycemia with increased morbidity and mortality. Due to the results of the latest randomized controlled multicentre trials blood glucose target levels of 140-180 mg/dl are currently recommended. In critically ill patients glucose monitoring should not be performed using point of care (POC) devices because of inacceptable inaccuracies. Blood gas analyzers have been shown to be accurate and are mostly available nearly at the bedside. Currently new continuous glucose monitoring devices for critically ill patients using multiple technologies are under development. Depending on the accuracy and reliability these new devices will add to selective blood glucose measurements to close the time gap between measurements or will even replace these measurements. Continuous, intravenous insulin therapy according to an algorithm should be performed by nursing staff. Computerized algorithms followed by so-called dynamic paper algorithms yield the best results. Besides mean glucose levels, glucose variability and glucose complexity are also associated with outcome in critically ill patients and might therefore be future target parameters. Critically ill diabetic patients might benefit from different glucose target levels depending on the preadmission glucose control. Hypoglycemic events <80 mg/dl should be avoided because of the association with poor outcome. PMID:23686019

  6. United States Critical Illness and Injury Trials Group.

    PubMed

    Blum, James M; Morris, Peter E; Martin, Greg S; Gong, Michelle N; Bhagwanjee, Satish; Cairns, Charles B; Cobb, J Perren

    2013-03-01

    The United States Critical Illness and Injury Trials (USCIIT) Group is an inclusive, grassroots "network of networks" with the dual missions of fostering investigator-initiated hypothesis testing and developing recommendations for strategic plans at a national level. The USCIIT Group's transformational approach enlists multidisciplinary investigative teams across institutions, critical illness and injury professional organizations, federal agencies that fund clinical and translational research, and industry partners. The USCIIT Group is endorsed by all major critical illness and injury professional organizations spanning the specialties of anesthesiology, emergency medicine, internal medicine, neurology, nursing, pediatrics, pharmacy and nutrition, surgery and trauma, and respiratory and physical therapy. Recent successes provide the opportunity to significantly increase the dialogue necessary to advance clinical and translational research on behalf of our community. More than 200 investigators are now involved across > 30 academic and community hospitals. Collectively, USCIIT Group investigators have enrolled > 10,000 patients from academic and community hospitals in studies during the last 3 years. To keep our readership "ahead of the curve," this article provides a vision for critical illness and injury research based on (1) programmatic organization of large-scale, multicentered collaborative studies and (2) annual strategic planning at a national scale across disciplines and stakeholders. PMID:23460158

  7. Monitoring and optimising outcomes of survivors of critical illness.

    PubMed

    Aitken, Leanne M; Marshall, Andrea P

    2015-02-01

    Recovery after critical illness can be protracted and challenging. Compromise of physical, psychological, cognitive and social function is experienced by some patients and may persist for a number of years. Measurement of recovery outcomes at regular time points throughout the critical illness and recovery pathway is necessary to identify problems and guide selection of interventions to prevent, minimise or overcome that compromise. Optimisation of factors that enhance recovery, such as sleep, nutrition and memories of intensive care, will also assist with promotion of recovery. Effective assessment of recovery requires integration of assessment of outcomes into routine clinical practice by all members of the interdisciplinary team. There must be agreement of appropriate measures and measurement timeframes alongside relevant education and training to ensure optimal assessment and use of the information gained. Assessment outcomes need to be communicated to interdisciplinary team members across the critical illness and recovery trajectory. Adequate resourcing for both the assessment activities and subsequent care is essential to improve patient outcomes after critical illness. PMID:25466983

  8. Parenteral amino acid intakes in critically ill children

    Technology Transfer Automated Retrieval System (TEKTRAN)

    Parenteral amino acid formulas used in parenteral nutrition have a variable composition. To determine the amino acid intake of parenterally fed, critically ill children, and compare it with recommended dietary allowances (RDA) established by the Institute of Medicine (IOM), we retrospectively review...

  9. Growth factors in critical illness: regulation and therapeutic aspects.

    PubMed

    Frost, R A; Lang, C H

    1998-03-01

    The erosion of lean body mass observed during catabolic illness is still a major cause of morbidity and mortality. The known anabolic actions of growth hormone and insulin-like growth factor-I have stimulated interest in the use of these agents to mitigate the loss of muscle protein after injury. This review summarizes advances in our understanding of how nutrition, hormones and proinflammatory cytokines regulate the somatotropic axis in health and disease, and recent studies involving the use of growth hormone or insulin-like growth factor-I in the treatment of critically ill patients. PMID:10565348

  10. Differences in hospital glycemic control and insulin requirements in patients recovering from critical illness and those without prior critical illness

    PubMed Central

    Miller, April D; Phillips, Leslie M; Schulz, Richard M; Bookstaver, P Brandon; Rudisill, Celeste N

    2010-01-01

    Introduction Hospital patients recovering from critical illness on general floors often receive insulin therapy based on protocols designed for patients admitted directly to general floors. The objective of this study is to compare glycemic control and insulin dosing in patients recovering from critical illness and those without prior critical illness. Methods Medical record review of blood glucose measurements and insulin dosing in 25 patients under general ward care while transitioning from the intensive care unit (transition group) and 25 patients admitted directly to the floor (direct floor group). Results Average blood glucose did not differ significantly between groups (transition group 9.49 mmol/L, direct floor group 9.6 mmol/L; P = 0.83). Significant differences in insulin requirements were observed between groups with average daily doses of 55.9 units in patients transitioning from the intensive care unit (ICU) versus 25.6 units in the direct floor group (P = 0.004). Conclusions Patients recovering from critical illness required significantly larger doses of insulin than those patients admitted directly to the floor. Managing insulin therapy in patients transitioning from the ICU may require greater insulin doses. PMID:22291498

  11. Psychiatric complications in the critically ill cardiac patient.

    PubMed Central

    Sanders, K M; Cassem, E H

    1993-01-01

    Psychiatric consultation to the critically ill cardiac patient focuses on several common problems: anxiety, delirium, depression, personality reactions, and behavioral disturbances. A review of the causes and treatment of anxiety in the coronary care unit is followed by a discussion of delirium in the critically ill cardiac patient. A description of delirium associated with the use of the intraaortic balloon pump and its treatment with high doses of intravenous haloperidol is also included. After the initial crisis has been stabilized in the critical care unit, the premorbid personality traits of the patient may emerge as behavioral disturbances--particularly as the duration of stay increases. The use of psychiatric consultation completes the discussion. PMID:8219821

  12. Gastric Versus Small Bowel Feeding in Critically Ill Adults.

    PubMed

    Schlein, Kirsten

    2016-08-01

    Critically ill patients often require enteral feedings as a primary supply of nutrition. Whether enteral nutrition (EN) should be delivered as a gastric versus small bowel feeding in the critically ill patient population remains a contentious topic. The Society of Critical Care Medicine (SCCM)/American Society for Parenteral and Enteral Nutrition (ASPEN), the European Society for Parenteral and Enteral Nutrition (ESPEN), and the Canadian Clinical Practice Guidelines (CCPG) are not in consensus on this topic. No research to date demonstrates a significant difference between the two feeding routes in terms of patient mortality, ventilator days, or length of stay in the intensive care unit (ICU); however, studies provide some evidence that there may be other benefits to using a small bowel feeding route in critically ill patients. The purpose of this paper is to examine both sides of this debate and review advantages and disadvantages of both small bowel and gastric routes of EN. Practical issues and challenges to small bowel feeding tube placement are also addressed. Finally, recommendations are provided to help guide the clinician when selecting a feeding route, and suggestions are made for future research. PMID:26920643

  13. Association between recognizing dementia as a mental illness and dementia knowledge among elderly Chinese Americans

    PubMed Central

    Zheng, Xin; Woo, Benjamin K P

    2016-01-01

    AIM: To investigate whether older Chinese Americans perceive dementia as a mental illness and the relationship between such perception and their general understanding of dementia remains unclear. Our study aims to understand this relationship and its future implication on improving dementia literacy among ethnic minorities. METHODS: Elderly Chinese American participants from the Greater Los Angeles were asked to complete an 11-item dementia questionnaire, following a community health seminar. Cross-sectional survey data was analyzed using standard statistical methods. RESULTS: The questionnaire received an 88.3% response rate. Among 316 responders, only 28.8% (n = 91) of elderly Chinese Americans identified dementia as a mental illness, and 71.2% (n = 225) did not recognize its mental disease origin. Furthermore, in comparison between these two groups, the first group demonstrated significantly higher level of baseline knowledge of the disease. CONCLUSION: This study reveals that only approximately 1 out of 4 older Chinese Americans recognized dementia as a mental illness, consistent with previous studies on Asian Americans. Our study however showed that when dementia was being perceived as a mental illness, such perception was associated with a higher level of baseline dementia understanding. The current study suggested the potential of improving older Chinese Americans dementia literacy by increasing awareness of its mental illness origin. PMID:27354966

  14. Sedation in Critically Ill Children with Respiratory Failure

    PubMed Central

    Vet, Nienke J.; Kleiber, Niina; Ista, Erwin; de Hoog, Matthijs; de Wildt, Saskia N.

    2016-01-01

    This article discusses the rationale of sedation in respiratory failure, sedation goals, how to assess the need for sedation as well as effectiveness of interventions in critically ill children, with validated observational sedation scales. The drugs and non-pharmacological approaches used for optimal sedation in ventilated children are reviewed, and specifically the rationale for drug selection, including short- and long-term efficacy and safety aspects of the selected drugs. The specific pharmacokinetic and pharmacodynamic aspects of sedative drugs in the critically ill child and consequences for dosing are presented. Furthermore, we discuss different sedation strategies and their adverse events, such as iatrogenic withdrawal syndrome and delirium. These principles can guide clinicians in the choice of sedative drugs in pediatric respiratory failure. PMID:27606309

  15. Hematologic and oncologic complications in the critically ill child.

    PubMed Central

    McIntosh, S.

    1984-01-01

    Admission of a patient to an intensive care unit for management of direct consequences of a hematologic or oncologic disease is occasionally necessary. Such problems included exchange transfusion, sepsis, compression of vital structures by malignant tumor, metabolic derangements, leukostasis, post-operative care, major sickling episodes in vital organs, and disseminated coagulopathy. More often, however, hematologic complications arise in the child critically ill from other causes, such as trauma or infections. The first two sections of this review address blood transfusion and hemostasis, topics likely to have wide application in the care of critically ill children. The last portion discusses problems unique to patients with sickling or malignant disease. Images FIG. 3 FIG. 4 FIG. 5 FIG. 6 PMID:6382836

  16. The GH/IGF-1 System in Critical Illness

    PubMed Central

    Elijah, Itoro; Branski, Ludwik K.; Finnerty, Celeste F.; Herndon, David N.

    2013-01-01

    The Growth Hormone and Insulin-like Growth Factor-1 axis plays a pivotal role in critical illness, with a derangement leading to profound changes in metabolism. Protein wasting with skeletal muscle loss, delayed wound healing, and impaired recovery of organ systems are some of the most feared consequences. The use of human recombinant Growth Hormone (rhGH) and Insulin-like Growth Factor-1 (IGF-1) - alone and in combination - has been studied extensively in preclinical and clinical trials. This article reviews the current knowlegde and clinical practice of the use of rhGh and IGF-1 in critically ill patients, with a special focus on the trauma and burns patient population. PMID:21925076

  17. Measuring sleep in critically ill patients: beware the pitfalls.

    PubMed

    Watson, Paula L

    2007-01-01

    Survivors of critical illness frequently report poor sleep while in the intensive care unit (ICU), and sleep deprivation has been hypothesized to lead to emotional distress, ICU delirium and neurocognitive dysfunction, prolongation of mechanical ventilation, and decreased immune function. Thus, the careful study of sleep in the ICU is essential to understanding possible relationships with adverse clinical outcomes. Such research, however, must be conducted using sleep measurement techniques that have important limitations in this unique setting. Polysomnography (PSG) is considered the gold standard but is cumbersome, time consuming, and expensive. As such, alternative methods of sleep measurement such as actigraphy, processed electroencephalography monitors, and subjective observation are often used. Though helpful in some instances, data obtained using these methods can often be inaccurate and misleading. Even PSG itself must be interpreted with caution in this population due to effects of critical illness and associated treatments. PMID:17850679

  18. Clinical use of lactate monitoring in critically ill patients

    PubMed Central

    2013-01-01

    Increased blood lactate levels (hyperlactataemia) are common in critically ill patients. Although frequently used to diagnose inadequate tissue oxygenation, other processes not related to tissue oxygenation may increase lactate levels. Especially in critically ill patients, increased glycolysis may be an important cause of hyperlactataemia. Nevertheless, the presence of increased lactate levels has important implications for the morbidity and mortality of the hyperlactataemic patients. Although the term lactic acidosis is frequently used, a significant relationship between lactate and pH only exists at higher lactate levels. The term lactate associated acidosis is therefore more appropriate. Two recent studies have underscored the importance of monitoring lactate levels and adjust treatment to the change in lactate levels in early resuscitation. As lactate levels can be measured rapidly at the bedside from various sources, structured lactate measurements should be incorporated in resuscitation protocols. PMID:23663301

  19. [ABCDE--a systematic approach to critically ill patients].

    PubMed

    Thim, Troels; Krarup, Niels Henrik; Grove, Erik Lerkevang; Løfgren, Bo

    2010-11-22

    This systematic approach to the immediate assessment and treatment of the critically ill or injured patient is applicable in all clinical emergencies. The aim of the ABCDE approach is to facilitate immediate life-saving treatment and thus buy time for definite diagnosis and treatment by breaking down complex clinical situations into manageable parts. Application of the ABCDE approach may improve treatment quality. PMID:21092723

  20. Hyperglycemia and acute kidney injury in critically ill children

    PubMed Central

    Gordillo, Roberto; Ahluwalia, Tania; Woroniecki, Robert

    2016-01-01

    Background Hyperglycemia and acute kidney injury (AKI) are common in critically ill children and have been associated with higher morbidity and mortality. The incidence of AKI in children is difficult to estimate because of the lack of a standard definition for AKI. The pediatric RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease) criteria can be used to define AKI in children. Various biomarkers in urine and blood have been studied to detect AKI in critically ill children. However, it is not clear whether hyperglycemia is associated with AKI. Our objective was to evaluate the effect of hyperglycemia on kidney function and its effect on neutrophil gelatinase-associated lipocalin (NGAL) in children. Methods We studied retrospective and prospective cohorts of pediatric critically ill subjects admitted to the pediatric intensive care unit (PICU). We analyzed data from admission that included estimated glomerular filtration rate, plasma and urine NGAL, serum glucose and peak glycemia (highest glycemia during PICU admission), and length of hospital and PICU stay from two different institutions. Results We found that the prevalence of hyperglycemia was 89% in the retrospective cohort and 86% in the prospective cohort, P=0.99. AKI was associated with peak glycemia, P=0.03. There was a statistically significant correlation between peak glycemia and hospital and PICU stays, P=<0.001 and P<0.001, respectively. Urine NGAL and plasma NGAL were not statistically different in subjects with and without hyperglycemia, P=0.99 and P=0.85, respectively. Subjects on vasopressors had lower estimated glomerular filtration rate and higher glycemia, P=0.01 and P=0.04, respectively. Conclusion We conclude that in critically ill children, hyperglycemia is associated with AKI and longer PICU stays. PMID:27601931

  1. Severity of illness, race, and choice of local versus distant hospitals among the elderly.

    PubMed

    Basu, Jayasree

    2005-05-01

    This study examines travel patterns for hospitalization among elderly patients to address whether there are differences by age and race/ethnicity, and whether the differences persist even when a severe illness occurs. Using the Healthcare Cost and Utilization Project (HCUP) State Inpatient database (SID) of the Agency for Healthcare Research and Quality, the study focuses on New York residents in the 65-and-over age group who are hospitalized in New York or neighboring states. Two types of hospital admissions are used: referral-sensitive admissions (fairly discretionary, high-technology procedures) and ambulatory care-sensitive admissions (avoidable with appropriate primary care). The study found that, after adjusting for other covariates, travel progressively declines with age among the elderly. Travel patterns across elderly age cohorts were not significantly different when patients were more severely ill. Members of racial/ethnic minority groups were less likely to travel than whites, and this gap persisted even when a severe illness occurred. PMID:15937400

  2. Nursing students identify fears regarding working with diverse critically ill patients: development of guidelines for caring for diverse critically ill older adults.

    PubMed

    Grossman, Sheila

    2013-01-01

    Undergraduate students need to gain more exposure to communicating, assessing, and planning appropriate care and evaluating outcomes of care with diverse critically ill geriatric patients. This project developed teaching strategies that facilitated additional opportunities for gaining these valuable learning experiences for students. Nurse educators can use the Guidelines for Caring for Diverse Critically Ill Older Adults, the case study and simulation examples, and topical outline to assist them in teaching critical care students and nurses about diverse critically ill older adults. PMID:23933642

  3. Pain assessment and management in critically ill older adults.

    PubMed

    Kirksey, Kenn M; McGlory, Gayle; Sefcik, Elizabeth F

    2015-01-01

    Older adults comprise approximately 50% of patients admitted to critical care units in the United States. This population is particularly susceptible to multiple morbidities that can be exacerbated by confounding factors like age-related safety risks, polypharmacy, poor nutrition, and social isolation. The elderly are particularly vulnerable to health conditions (heart disease, stroke, and diabetes) that put them at greater risk of morbidity and mortality. When an older adult presents to the emergency department with 1 or more of these life-altering diagnoses, an admission to the intensive care unit is often inevitable. Pain is one of the most pervasive manifestations exhibited by intensive care unit patients. There are myriad challenges for critical care nurses in caring for patients experiencing pain-inadequate communication (cognitively impaired or intubated patients), addressing the concerns of family members, or gaps in patients' knowledge. The purpose of this article was to discuss the multidimensional nature of pain and identify concepts innate to pain homeostenosis for elderly patients in the critical care setting. Evidence-based strategies, including an interprofessional team approach and best practice recommendations regarding pharmacological and nonpharmacological pain management, are presented. PMID:26039645

  4. Critical illness-induced dysglycaemia: diabetes and beyond.

    PubMed

    Smith, Fang Gao; Sheehy, Ann M; Vincent, Jean-Louis; Coursin, Douglas B

    2010-01-01

    Type 2 diabetes has reached epidemic proportions in many parts of the world. The disease is projected to continue to increase and double within the foreseeable future. Dysglycaemia develops in the form of hyperglycaemia, hypoglycaemia and marked glucose variability in critically ill adults whether they are known to have premorbid diabetes or not. Patients with such glucose dysregulation have increased morbidity and mortality. Whether this is secondary to cause and effect from dysglycaemia or is just related to critical illness remains under intense investigation. Identification of intensive care unit (ICU) patients with unrecognised diabetes remains a challenge. Further, there are few data regarding the development of type 2 diabetes in survivors after hospital discharge. This commentary introduces the concept of critical illness-induced dysglycaemia as an umbrella term that includes the spectrum of abnormal glucose homeostasis in the ICU. We outline the need for further studies in the area of glucose regulation and for follow-up of the natural history of abnormal glucose control during ICU admission and beyond. PMID:21067560

  5. Gastroesophageal reflux in critically ill children: a review.

    PubMed

    Solana García, Maria José; López-Herce Cid, Jesús; Sánchez Sánchez, César

    2013-01-01

    Gastroesophageal reflux (GER) is very common in children due to immaturity of the antireflux barrier. In critically ill patients there is also a high incidence due to a partial or complete loss of pressure of the lower esophageal sphincter though other factors, such as the use of nasogastric tubes, treatment with adrenergic agonists, bronchodilators, or opiates and mechanical ventilation, can further increase the risk of GER. Vomiting and regurgitation are the most common manifestations in infants and are considered pathological when they have repercussions on the nutritional status. In critically ill children, damage to the esophageal mucosa predisposes to digestive tract hemorrhage and nosocomial pneumonia secondary to repeated microaspiration. GER is mainly alkaline in children, as is also the case in critically ill pediatric patients. pH-metry combined with multichannel intraluminal impedance is therefore the technique of choice for diagnosis. The proton pump inhibitors are the drugs of choice for the treatment of GER because they have a greater effect, longer duration of action, and a good safety profile. PMID:23431462

  6. Basal glucosuria is ubiquitous in critically ill patients.

    PubMed

    Brunner, Richard; Kurz, Annabella; Adelsmayr, Gabriel; Holzinger, Ulrike

    2015-04-01

    The 'renal threshold for glucose' has never been evaluated in critically ill patients. Therefore, we aimed to investigate the renal glucose threshold in this patient group using high-sensitivity urine glucose assays. In this retrospective analysis of prospectively collected data, we analysed 100 consecutive critically ill patients from a medical intensive care unit (ICU). Arterial blood glucose and spot urine glucose were simultaneously quantified daily during the first week after ICU admission. Three hundred seventy-three pairs of blood/urine glucose were plotted in five pre-defined categories of blood glucose (<80, 80-109, 110-139, 140-179 and ≥180 mg/dL). Urine glucose values of the five categories were compared using the Kruskal-Wallis test to assess the relation with blood glucose. Urine glucose was detected in virtually all of the urine samples. Urine glucose showed a positive nonlinear correlation with blood glucose and was significantly elevated at blood glucose levels of 140-179 and ≥180 mg/dL compared with lower blood glucose ranges. Basal glucosuria is ubiquitous in critically ill patients. A 'soft' renal threshold for glucose is present at blood glucose levels in the range of 140-179 mg/dL. PMID:25810226

  7. Gastroesophageal Reflux in Critically Ill Children: A Review

    PubMed Central

    Solana García, Maria José; López-Herce Cid, Jesús; Sánchez Sánchez, César

    2013-01-01

    Gastroesophageal reflux (GER) is very common in children due to immaturity of the antireflux barrier. In critically ill patients there is also a high incidence due to a partial or complete loss of pressure of the lower esophageal sphincter though other factors, such as the use of nasogastric tubes, treatment with adrenergic agonists, bronchodilators, or opiates and mechanical ventilation, can further increase the risk of GER. Vomiting and regurgitation are the most common manifestations in infants and are considered pathological when they have repercussions on the nutritional status. In critically ill children, damage to the esophageal mucosa predisposes to digestive tract hemorrhage and nosocomial pneumonia secondary to repeated microaspiration. GER is mainly alkaline in children, as is also the case in critically ill pediatric patients. pH-metry combined with multichannel intraluminal impedance is therefore the technique of choice for diagnosis. The proton pump inhibitors are the drugs of choice for the treatment of GER because they have a greater effect, longer duration of action, and a good safety profile. PMID:23431462

  8. Evidence to Support Tooth Brushing in Critically Ill Patients

    PubMed Central

    Ames, Nancy J.

    2012-01-01

    Tooth brushing in critically ill patients has been advocated by many as a standard of care despite the limited evidence to support this practice. Attention has been focused on oral care as the evidence accumulates to support an association between the bacteria in the oral microbiome and those respiratory pathogens that cause pneumonia. It is plausible to assume that respiratory pathogens originating in the oral cavity are aspirated into the lungs, causing infection. A recent study of the effects of a powered toothbrush on the incidence of ventilator-associated pneumonia was stopped early because of a lack of effect in the treatment group. This review summarizes the evidence that supports the effectiveness of tooth brushing in critically ill adults and children receiving mechanical ventilation. Possible reasons for the lack of benefit of tooth brushing demonstrated in clinical trials are discussed. Recommendations for future trials in critically ill patients are suggested. With increased emphasis being placed on oral care, the evidence that supports this intervention must be evaluated carefully. PMID:21532045

  9. An Overview of Hypoglycemia in the Critically Ill

    PubMed Central

    Lacherade, Jean-Claude; Jacqueminet, Sophie; Preiser, Jean-Charles

    2009-01-01

    Hypoglycemia is a common and serious problem among patients with diabetes mellitus. It is also perceived as the most important obstacle to tight glucose control using intensive insulin therapy in critically ill patients. Because glucose is an obligatory metabolic fuel for the brain, hypoglycemia always represents an emergency that signals the inability of the brain to meet its energy needs. When left untreated, hypoglycemia can result in permanent brain damage and ultimately, death. In the context of critical illness that limits endogenous glucose production and increases glucose utilization, inadequate nutrition, or insufficient provision of glucose, intensive insulin therapy is the most frequent cause of hypoglycemia. Neurogenic and neuroglycopenic symptoms of hypoglycemia can remain unknown because of the underlying critical illness and sedation. Thus, close and reliable monitoring of the glycemic level is crucial in detecting hypoglycemia. In prospective randomized controlled studies comparing the effects of two glucose regimens, intensive insulin therapy aimed to reach strict glucose control (<110 mg/dl) but increased the incidence of severe hypoglycemia (<40 mg/dl) by four- to sixfold. Severe hypoglycemia is statistically associated with adverse outcomes in intensive care unit patients, although a direct causal relationship has not been demonstrated. PMID:20144377

  10. Extreme Dysbiosis of the Microbiome in Critical Illness.

    PubMed

    McDonald, Daniel; Ackermann, Gail; Khailova, Ludmila; Baird, Christine; Heyland, Daren; Kozar, Rosemary; Lemieux, Margot; Derenski, Karrie; King, Judy; Vis-Kampen, Christine; Knight, Rob; Wischmeyer, Paul E

    2016-01-01

    Critical illness is hypothesized to associate with loss of "health-promoting" commensal microbes and overgrowth of pathogenic bacteria (dysbiosis). This dysbiosis is believed to increase susceptibility to nosocomial infections, sepsis, and organ failure. A trial with prospective monitoring of the intensive care unit (ICU) patient microbiome using culture-independent techniques to confirm and characterize this dysbiosis is thus urgently needed. Characterizing ICU patient microbiome changes may provide first steps toward the development of diagnostic and therapeutic interventions using microbiome signatures. To characterize the ICU patient microbiome, we collected fecal, oral, and skin samples from 115 mixed ICU patients across four centers in the United States and Canada. Samples were collected at two time points: within 48 h of ICU admission, and at ICU discharge or on ICU day 10. Sample collection and processing were performed according to Earth Microbiome Project protocols. We applied SourceTracker to assess the source composition of ICU patient samples by using Qiita, including samples from the American Gut Project (AGP), mammalian corpse decomposition samples, childhood (Global Gut study), and house surfaces. Our results demonstrate that critical illness leads to significant and rapid dysbiosis. Many taxons significantly depleted from ICU patients versus AGP healthy controls are key "health-promoting" organisms, and overgrowth of known pathogens was frequent. Source compositions of ICU patient samples are largely uncharacteristic of the expected community type. Between time points and within a patient, the source composition changed dramatically. Our initial results show great promise for microbiome signatures as diagnostic markers and guides to therapeutic interventions in the ICU to repopulate the normal, "health-promoting" microbiome and thereby improve patient outcomes. IMPORTANCE Critical illness may be associated with the loss of normal, "health

  11. Extreme Dysbiosis of the Microbiome in Critical Illness

    PubMed Central

    McDonald, Daniel; Ackermann, Gail; Khailova, Ludmila; Baird, Christine; Heyland, Daren; Kozar, Rosemary; Lemieux, Margot; Derenski, Karrie; King, Judy; Vis-Kampen, Christine; Knight, Rob

    2016-01-01

    ABSTRACT Critical illness is hypothesized to associate with loss of “health-promoting” commensal microbes and overgrowth of pathogenic bacteria (dysbiosis). This dysbiosis is believed to increase susceptibility to nosocomial infections, sepsis, and organ failure. A trial with prospective monitoring of the intensive care unit (ICU) patient microbiome using culture-independent techniques to confirm and characterize this dysbiosis is thus urgently needed. Characterizing ICU patient microbiome changes may provide first steps toward the development of diagnostic and therapeutic interventions using microbiome signatures. To characterize the ICU patient microbiome, we collected fecal, oral, and skin samples from 115 mixed ICU patients across four centers in the United States and Canada. Samples were collected at two time points: within 48 h of ICU admission, and at ICU discharge or on ICU day 10. Sample collection and processing were performed according to Earth Microbiome Project protocols. We applied SourceTracker to assess the source composition of ICU patient samples by using Qiita, including samples from the American Gut Project (AGP), mammalian corpse decomposition samples, childhood (Global Gut study), and house surfaces. Our results demonstrate that critical illness leads to significant and rapid dysbiosis. Many taxons significantly depleted from ICU patients versus AGP healthy controls are key “health-promoting” organisms, and overgrowth of known pathogens was frequent. Source compositions of ICU patient samples are largely uncharacteristic of the expected community type. Between time points and within a patient, the source composition changed dramatically. Our initial results show great promise for microbiome signatures as diagnostic markers and guides to therapeutic interventions in the ICU to repopulate the normal, “health-promoting” microbiome and thereby improve patient outcomes. IMPORTANCE Critical illness may be associated with the loss of

  12. New-onset atrial fibrillation in critically ill patients

    PubMed Central

    Sibley, Stephanie; Muscedere, John

    2015-01-01

    New-onset atrial fibrillation is a common problem in critically ill patients, with reported incidence ranging from 5% to 46%. It is associated with significant morbidity and mortality. The present review summarizes studies investigating new-onset atrial fibrillation conducted in the critical care setting, focusing on the etiology, management of the hemodynamically unstable patient, rate versus rhythm control, ischemic stroke risk and anticoagulation. Recommendations for an approach to management in the intensive care unit are drawn from the results of these studies. PMID:26057373

  13. Prevalence of Psychiatric Illnesses among Ethnic Minority Elderly

    PubMed Central

    Alegría, Margarita; Chen, Chih-nan; Chan, Domin; Laderman, Mara

    2010-01-01

    OBJECTIVES To compare lifetime and 12-month prevalence of DSM-IV psychiatric disorders among a national representative sample of older Latinos, Asians, African-Americans, and Afro-Caribbean to non-Latino Whites. DESIGN Cross-sectional study conducted in 2001 through 2004. SETTING Urban and rural households in the contiguous United States. PARTICIPANTS A total of 4,245 community-dwelling residents aged 50 and older living in non-institutional settings. Data are from the NIMH Collaborative Psychiatric Epidemiology Surveys. METHODS The World Health Organization Composite International Diagnostic Interview assessed lifetime and 12-month psychiatric disorders. Interviewers matched the cultural background and language preference of participants. Bayesian estimates compared psychiatric disorder prevalence rates among ethnic/racial groups. RESULTS After gender adjustments, older non-Latino Whites had higher lifetime rates of any depressive disorder than African-Americans but were no different than older Latinos. Older Asians and Afro-Caribbean had significantly lower lifetime rates of any depressive, anxiety, and substance use disorders than non-Latino Whites. Immigrant Asians had higher lifetime rates of GAD than the U.S.-born Asians and immigrant Latinos had higher lifetime rates of dysthymia and GAD than U. S.-born Latinos. U.S. born Latinos had higher lifetime rates of substance abuse, especially alcohol abuse, than immigrant Latinos. There were no significant differences in the rates of 12-month psychiatric disorders between non-Latino whites and ethnic/racial minorities, except that older African-Americans had higher 12-month rates of any substance use disorder compared to non-Latino Whites. CONCLUSION Prevalence rates vary considerably by ethnicity and race as well as by nativity for older minorities, suggesting different patterns of illness and risk. PMID:20374401

  14. Focus on peripherally inserted central catheters in critically ill patients

    PubMed Central

    Cotogni, Paolo; Pittiruti, Mauro

    2014-01-01

    Venous access devices are of pivotal importance for an increasing number of critically ill patients in a variety of disease states and in a variety of clinical settings (emergency, intensive care, surgery) and for different purposes (fluids or drugs infusions, parenteral nutrition, antibiotic therapy, hemodynamic monitoring, procedures of dialysis/apheresis). However, healthcare professionals are commonly worried about the possible consequences that may result using a central venous access device (CVAD) (mainly, bloodstream infections and thrombosis), both peripherally inserted central catheters (PICCs) and centrally inserted central catheters (CICCs). This review aims to discuss indications, insertion techniques, and care of PICCs in critically ill patients. PICCs have many advantages over standard CICCs. First of all, their insertion is easy and safe -due to their placement into peripheral veins of the arm- and the advantage of a central location of catheter tip suitable for all osmolarity and pH solutions. Using the ultrasound-guidance for the PICC insertion, the risk of hemothorax and pneumothorax can be avoided, as well as the possibility of primary malposition is very low. PICC placement is also appropriate to avoid post-procedural hemorrhage in patients with an abnormal coagulative state who need a CVAD. Some limits previously ascribed to PICCs (i.e., low flow rates, difficult central venous pressure monitoring, lack of safety for radio-diagnostic procedures, single-lumen) have delayed their start up in the intensive care units as common practice. Though, the recent development of power-injectable PICCs overcomes these technical limitations and PICCs have started to spread in critical care settings. Two important take-home messages may be drawn from this review. First, the incidence of complications varies depending on venous accesses and healthcare professionals should be aware of the different clinical performance as well as of the different risks

  15. [Endoscopic treatment in critically ill patients with upper gastrointestinal bleeding].

    PubMed

    Kheladze, Z S; Dzhaiani, S V; Tsutskiridze, B N; Kheladze, Zv Z; Chakhunashvili, G K; Chakhunashvili, D K

    2010-03-01

    The goal of the current research was to ascertain the optimal methods of an endoscopic haemostasis in critical care patients with GDB. The research was conducted on critically ill patients. The different endoscopic methods of treatment: injectional hemostasis, irrigation with local hemostatics, thermo coagulation, and combined method were used. Treatment with injectional hemostasis resulted in hemostasis in 75% of patients. Irrigation with local hemostatics was conducted using the local hemostatic agent caprofer and (or) 10% solution of epsylonaminocapronal acid. The final hemostasis was achieved in the 90% of the cases; bleeding was stopped in 85% of the cases when the hemorrhages occurred from chronic ulcers. The effect of thermo coagulation method was 80-85%. Combined method of treatment (combination of the irrigation with caprofer and thermo coagulation) helped to achieve 95% of the final hemostasis in critically ill patients. The achieved results certify that the combined use of caprofer and method of electro coagulation in critical care patients with GDB is very perspective. Simultaneously with this, it is also recommended to use anti-segregation therapy with blockers of proton pomp and boosting the defense of the mucous tissue with high doses of mucogen. PMID:20413810

  16. Mead Johnson Critical Care Symposium for the Practising Surgeon. 1. Transport of critically ill adult patients.

    PubMed

    Girotti, M J; Pagliarello, G

    1988-09-01

    Interhospital transportation of critically ill patients over long distances is common in the tiered health care systems of North America. The authors describe their 1-year experience with a physician-assisted transport system, operating out of the surgical intensive care unit at the Toronto General Hospital. The application of a well-known severity of illness measure (therapeutic intervention scoring system) allowed them to correlate severity of illness, as assessed over the telephone before patient transfer, with eventual outcome after admission to the surgical intensive care unit. Their analysis of 107 critically ill patients transported by this system led them to conclude that the system is reliable and is associated with acceptable morbidity and mortality. PMID:3138018

  17. Bleeding complications in critically ill patients with liver cirrhosis

    PubMed Central

    Cho, Jaeyoung; Choi, Sun Mi; Yu, Su Jong; Park, Young Sik; Lee, Chang-Hoon; Lee, Sang-Min; Yim, Jae-Joon; Yoo, Chul-Gyu; Kim, Young Whan; Han, Sung Koo; Lee, Jinwoo

    2016-01-01

    Background/Aims: Patients with liver cirrhosis (LC) are at risk for critical events leading to Intensive Care Unit (ICU) admission. Coagulopathy in cirrhotic patients is complex and can lead to bleeding as well as thrombosis. The aim of this study was to investigate bleeding complications in critically ill patients with LC admitted to a medical ICU (MICU). Methods: All adult patients admitted to our MICU with a diagnosis of LC from January 2006 to December 2012 were retrospectively assessed. Patients with major bleeding at the time of MICU admission were excluded from the analysis. Results: A total of 205 patients were included in the analysis. The median patient age was 62 years, and 69.3% of the patients were male. The most common reason for MICU admission was acute respiratory failure (45.4%), followed by sepsis (27.3%). Major bleeding occurred in 25 patients (12.2%). The gastrointestinal tract was the most common site of bleeding (64%), followed by the respiratory tract (20%). In a multivariate analysis, a low platelet count at MICU admission (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.97 to 0.99) and sepsis (OR, 8.35; 95% CI, 1.04 to 67.05) were independent risk factors for major bleeding. The ICU fatality rate was significantly greater among patients with major bleeding (84.0% vs. 58.9%, respectively; p = 0.015). Conclusions: Major bleeding occurred in 12.2% of critically ill cirrhotic patients admitted to the MICU. A low platelet count at MICU admission and sepsis were associated with an increased risk of major bleeding during the MICU stay. Further study is needed to better understand hemostasis in critically ill patients with LC. PMID:26805633

  18. Recombinant human erythropoietin therapy in critically ill Jehovah's Witnesses.

    PubMed

    Ball, Amanda M; Winstead, P Shane

    2008-11-01

    Blood transfusions and blood products are often given as a life-saving measure in patients with critical illness. However, some patients, such as Jehovah's Witnesses, may refuse their administration due to religious beliefs. Jehovah's Witnesses accept most available medical treatments, but not blood transfusions or blood products due to their religion's interpretation of several passages from the Bible. Since recombinant human erythropoietin (rHuEPO) became available, several cases have been reported in which rHuEPO was successfully administered to critically ill Jehovah's Witnesses. Administration of rHuEPO in combination with other blood conservation techniques has been shown to increase hemoglobin levels and survival in patients who experienced trauma, burns, general surgery, or gastrointestinal hemorrhage. We performed a literature search of the MEDLINE and International Pharmaceutical Abstracts databases of rHuEPO therapy in the Jehovah's Witness population. Fourteen cases were identified in which rHuEPO was administered to Jehovah's Witnesses who required the drug for critical care resuscitation as an alternative to blood products. In each clinical situation, rHuEPO enhanced erythropoiesis; however, time to the start of treatment, dosages, route of administration, and treatment duration varied widely. Supplementation with adjunctive agents, such as iron, folic acid, and vitamin B12, was also beneficial. Use of rHuEPO in Jehovah's Witnesses may provide an alternative to blood transfusions or blood products. Other alternatives, such as hemoglobin-based oxygen carriers and perfluorocarbons, are also being explored. PMID:18956998

  19. Critical care in the emergency department: monitoring the critically ill patient

    PubMed Central

    Andrews, F J; Nolan, J P

    2006-01-01

    The aim of monitoring patients is to detect organ dysfunction and guide the restoration and maintenance of tissue oxygen delivery. Monitoring is a crucial part of the care of the critically ill patient in the emergency department as the physiological response to critical illness is linked strongly to outcome. As it is important to appreciate the limitations of monitoring systems and monitored data, and to understand that invasive monitoring may be hazardous, this review concentrates on the techniques used to monitor critically ill patients in the emergency department. End tidal carbon dioxide monitoring, pulse oximetry, arterial blood pressure monitoring, central venous pressure monitoring, continuous central venous oxygenation saturation monitoring, temperature monitoring, and urine output are discussed. Practitioners should be familiar with the physiology and technology underlying these monitoring techniques and be aware of the pitfalls in interpretation of monitored data. PMID:16794104

  20. Inflammation biomarkers and delirium in critically ill patients

    PubMed Central

    2014-01-01

    Introduction Delirium is a common occurrence in critically ill patients and is associated with an increase in morbidity and mortality. Septic patients with delirium may differ from a general critically ill population. The aim of this investigation was to study the relationship between systemic inflammation and the development of delirium in septic and non-septic critically ill patients. Methods We performed a prospective cohort study in a 20-bed mixed intensive care unit (ICU) including 78 (delirium = 31; non-delirium = 47) consecutive patients admitted for more than 24 hours. At enrollment, patients were allocated to septic or non-septic groups according to internationally agreed criteria. Delirium was diagnosed using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) during the first 72 hours of ICU admission. Blood samples were collected within 12 hours of enrollment for determination of tumor necrosis factor (TNF)-α, soluble TNF Receptor (STNFR)-1 and -2, interleukin (IL)-1β, IL-6, IL-10 and adiponectin. Results Out of all analyzed biomarkers, only STNFR1 (P = 0.003), STNFR2 (P = 0.005), adiponectin (P = 0.005) and IL-1β (P < 0.001) levels were higher in delirium patients. Adjusting for sepsis and sedation, these biomarkers were also independently associated with delirium occurrence. However, none of them were significant influenced by sepsis. Conclusions STNFR1, STNFR2, adiponectin and IL-1β were associated with delirium. Sepsis did not modify the relationship between the biomarkers and delirium occurrence. PMID:24886875

  1. A Multinational Study of Thromboprophylaxis Practice in Critically Ill Children*

    PubMed Central

    Faustino, Edward Vincent S.; Hanson, Sheila; Spinella, Philip C.; Tucci, Marisa; O'Brien, Sarah H.; Nunez, Antonio Rodriguez; Yung, Michael; Truemper, Edward; Qin, Li; Li, Simon; Marohn, Kimberly; Randolph, Adrienne G.

    2015-01-01

    Objectives Although critically ill children are at increased risk for developing deep venous thrombosis, there are few pediatric studies establishing the prevalence of thrombosis or the efficacy of thromboprophylaxis. We tested the hypothesis that thromboprophylaxis is infrequently used in critically ill children even for those in whom it is indicated. Design Prospective multinational cross-sectional study over four study dates in 2012. Setting Fifty-nine PICUs in Australia, Canada, New Zealand, Portugal, Singapore, Spain, and the United States. Patients All patients less than 18 years old in the PICU during the study dates and times were included in the study, unless the patients were 1) boarding in the unit waiting for a bed outside the PICU or 2) receiving therapeutic anticoagulation. Interventions None. Measurements and Main Results Of 2,484 children in the study, 2,159 (86.9%) had greater than or equal to 1 risk factor for thrombosis. Only 308 children (12.4%) were receiving pharmacologic thromboprophylaxis (e.g., aspirin, low-molecular-weight heparin, or unfractionated heparin). Of 430 children indicated to receive pharmacologic thromboprophylaxis based on consensus recommendations, only 149 (34.7%) were receiving it. Mechanical thromboprophylaxis was used in 156 of 655 children (23.8%) 8 years old or older, the youngest age for that device. Using nonlinear mixed effects model, presence of cyanotic congenital heart disease (odds ratio, 7.35; p < 0.001) and spinal cord injury (odds ratio, 8.85; p = 0.008) strongly predicted the use of pharmacologic and mechanical thromboprophylaxis, respectively. Conclusions Thromboprophylaxis is infrequently used in critically ill children. This is true even for children at high risk of thrombosis where consensus guidelines recommend pharmacologic thromboprophylaxis. PMID:24351371

  2. Intravenous arginine vasopressin in critically ill children: is it beneficial?

    PubMed

    Efrati, Ori; Modan-Moses, Dalit; Vardi, Amir; Matok, Ilan; Bazilay, Zohar; Paret, Gideon

    2004-09-01

    Arginine-vasopressin (AVP) may be more effective than epinephrine in shock states and as an end-of-life salvage maneuver. However, there is only limited experience using AVP in children. Our study aim was to evaluate the effect of AVP administration on hemodynamic and ventilatory parameters in critically ill children. Eight critically ill children (1 month to 12 years old) were treated with AVP during the years 2000-2001. Two patients had had head trauma, and six had surgical correction of congenital heart disease. All patients suffered severe septic or cardiogenic shock with a low cardiac output state and were considered to be near death. AVP was administered continuously at a dose of 0.0003-0.002 U/kg/min. Hemodynamic and ventilatory parameters and vasopressor doses were compared before and after AVP initiation. One patient survived with a good neurologic outcome. Seven patients succumbed while receiving AVP. Systolic and diastolic blood pressure increased significantly (P < 0.03) following AVP initiation. The epinephrine requirement decreased from 2.3 to 1.7 microg/kg/min. Blood gases improved with a significant (P < 0.05) increase of PaO2. Oxygenation index and PaO2/FiO2 ratio improved significantly, and ventilatory support requirements and positive inspiratory pressure (PIP) decreased significantly. Despite a significant improvement in hemodynamic and ventilatory support parameters, survival to hospital discharge was not achieved when AVP was used in critically ill pediatric patients. We hypothesize that earlier administration of AVP may be more beneficial. PMID:15316389

  3. Thromboprophylaxis in critically ill children in Spain and Portugal

    PubMed Central

    Nñnez, A. Rodríguez; Fonte, M.; Faustino, E.V.S.

    2015-01-01

    Introduction Although critically ill children may be at risk from developing deep venous thrombosis (DVT), data on its incidence and effectiveness of thromboprophylaxis are lacking. Objective To describe the use of thromboprophylaxis in critically ill children in Spain and Portugal, and to compare the results with international data. Material and methods Secondary analysis of the multinational study PROTRACT, carried out in 59 PICUs from 7 developed countries (4 from Portugal and 6 in Spain). Data were collected from patients less than 18 years old, who did not receive therapeutic thromboprophylaxis. Results A total of 308 patients in Spanish and Portuguese (Iberian) PICUS were compared with 2176 admitted to international PICUs. Risk factors such as femoral vein (P = .01), jugular vein central catheter (P < .001), cancer (P = .03), and sepsis (P < .001), were more frequent in Iberian PICUs. The percentage of patients with pharmacological thromboprophylaxis was similar in both groups (15.3% vs. 12.0%). Low molecular weight heparin was used more frequently in Iberian patients (P < .001). In treated children, prior history of thrombosis (P = .02), femoral vein catheter (P < .001), cancer (P = .02) and cranial trauma or craniectomy (P = .006), were more frequent in Iberian PICUs. Mechanical thromboprophylaxis was used in only 6.8% of candidates in Iberian PICUs, compared with 23.8% in the international PICUs (P < .001). Conclusions Despite the presence of risk factors for DVT in many patients, thromboprophylaxis is rarely prescribed, with low molecular weight heparin being the most used drug. Passive thromboprophylaxis use is anecdotal. There should be a consensus on guidelines of thromboprophylaxis in critically ill children. PMID:24907863

  4. Selective Plasma Exchange for Critically Ill Patients Accompanied With Thrombocytopenia.

    PubMed

    Nakae, Hajime; Fukuda, Hirokazu; Okuyama, Manabu; Igarashi, Toshiko

    2016-08-01

    Selective plasma exchange is a blood purification therapy in which simple plasma exchange is performed using a selective membrane plasma separator (pore size of 0.03 µm). Seven critically ill patients accompanied with thrombocytopenia were treated with selective plasma exchange using fresh frozen plasma. The total bilirubin levels and prothrombin time international normalized ratios decreased significantly after treatment. The total protein, albumin, and fibrinogen levels increased significantly after treatment. Selective plasma exchange may be a useful blood purification therapy for removing causal substances and retaining coagulation factors in patients accompanied with thrombocytopenia. PMID:27523072

  5. Community trial on heat related-illness prevention behaviors and knowledge for the elderly.

    PubMed

    Takahashi, Noriko; Nakao, Rieko; Ueda, Kayo; Ono, Masaji; Kondo, Masahide; Honda, Yasushi; Hashizume, Masahiro

    2015-03-01

    This study aims to explore whether broadcasting heat health warnings (HHWs), to every household and whether the additional home delivery of bottled water labeled with messages will be effective in improving the behaviors and knowledge of elderly people to prevent heat-related illness. A community trial on heat-related-illness-prevention behaviors and knowledge for people aged between 65 and 84 years was conducted in Nagasaki, Japan. Five hundred eight subjects were selected randomly from three groups: heat health warning (HHW), HHW and water delivery (HHW+W), and control groups. Baseline and follow-up questionnaires were conducted in June and September 2012, respectively. Of the 1524 selected subjects, the 1072 that completed both questionnaires were analyzed. The HHW+W group showed improvements in nighttime AC use (p=0.047), water intake (p=0.003), cooling body (p=0.002) and reduced activities in heat (p=0.047) compared with the control, while the HHW group improved hat or parasol use (p=0.008). An additional effect of household water delivery was observed in water intake (p=0.067) and cooling body (p=0.095) behaviors. HHW and household bottled water delivery improved heat-related-illness-prevention behaviors. The results indicate that home water delivery in addition to a HHW may be needed to raise awareness of the elderly. PMID:25789456

  6. Community Trial on Heat Related-Illness Prevention Behaviors and Knowledge for the Elderly

    PubMed Central

    Takahashi, Noriko; Nakao, Rieko; Ueda, Kayo; Ono, Masaji; Kondo, Masahide; Honda, Yasushi; Hashizume, Masahiro

    2015-01-01

    This study aims to explore whether broadcasting heat health warnings (HHWs), to every household and whether the additional home delivery of bottled water labeled with messages will be effective in improving the behaviors and knowledge of elderly people to prevent heat-related illness. A community trial on heat-related-illness-prevention behaviors and knowledge for people aged between 65 and 84 years was conducted in Nagasaki, Japan. Five hundred eight subjects were selected randomly from three groups: heat health warning (HHW), HHW and water delivery (HHW+W), and control groups. Baseline and follow-up questionnaires were conducted in June and September 2012, respectively. Of the 1524 selected subjects, the 1072 that completed both questionnaires were analyzed. The HHW+W group showed improvements in nighttime AC use (p = 0.047), water intake (p = 0.003), cooling body (p = 0.002) and reduced activities in heat (p = 0.047) compared with the control, while the HHW group improved hat or parasol use (p = 0.008). An additional effect of household water delivery was observed in water intake (p = 0.067) and cooling body (p = 0.095) behaviors. HHW and household bottled water delivery improved heat-related-illness-prevention behaviors. The results indicate that home water delivery in addition to a HHW may be needed to raise awareness of the elderly. PMID:25789456

  7. Distinct Features of Nonthyroidal Illness in Critically Ill Patients With Infectious Diseases

    PubMed Central

    Lee, Woo Kyung; Hwang, Sena; Kim, Daham; Lee, Seul Gi; Jeong, Seonhyang; Seol, Mi-Youn; Kim, Hyunji; Ku, Cheol Ryong; Shin, Dong Yeop; Chung, Woong Youn; Lee, Eun Jig; Lee, Jandee; Jo, Young Suk

    2016-01-01

    Abstract Nonthyroidal illness (NTI), often observed in critically ill patients, arises through diverse alterations in the hypothalamus-pituitary-thyroid (HPT) axis. However, the causal relationship between underlying disease and NTI diversity in critically ill patients is poorly understood. The aim of this study was to examine NTI severity and adverse outcomes in critically ill patients with respect to their underlying disease(s). The medical records of 616 patients admitted to the intensive care unit (ICU) between January 2009 and October 2014 were retrospectively reviewed. Patients with known diseases or taking medications that affect thyroid function were excluded. All-cause mortality (ACM) and length of stay (LOS) in the ICU were assessed as adverse outcomes. The enrolled patients (n = 213) were divided into the following 4 groups according to the severity of NTI at the nadir of their thyroid function test (TFT): normal (n = 11, 5.2%), mild NTI (n = 113, 53.1%), moderate NTI (n = 78, 36.6%), and severe NTI (n = 11, 5.2%). There was no significant difference between the groups in terms of age and gender. NTI severity showed a significantly strong association with ACM (P < 0.0001) and a significant positive association with LOS in the ICU (P = 0.031). After adjusting for age, gender, and current medications affecting TFT, increasing NTI severity led to increased ACM (odds ratio = 3.101; 95% confidence interval = 1.711–5.618; P < 0.0001). Notably, the prevalence of moderate-to-severe NTI was markedly higher in patients with infectious disease than in those with noninfectious disease (P = 0.012). Consistent with this, serum C-reactive protein levels were higher in patients with moderate-to-severe NTI (P = 0.016). NTI severity is associated with increased ACM, LOS, and underlying infectious disease. Future studies will focus on the biological and clinical implications of infectious disease on the HPT axis. PMID

  8. Management of Acute Alcohol Withdrawal Syndrome in Critically Ill Patients.

    PubMed

    Dixit, Deepali; Endicott, Jeffrey; Burry, Lisa; Ramos, Liz; Yeung, Siu Yan Amy; Devabhakthuni, Sandeep; Chan, Claire; Tobia, Anthony; Bulloch, Marilyn N

    2016-07-01

    Approximately 16-31% of patients in the intensive care unit (ICU) have an alcohol use disorder and are at risk for developing alcohol withdrawal syndrome (AWS). Patients admitted to the ICU with AWS have an increased hospital and ICU length of stay, longer duration of mechanical ventilation, higher costs, and increased mortality compared with those admitted without an alcohol-related disorder. Despite the high prevalence of AWS among ICU patients, no guidelines for the recognition or management of AWS or delirium tremens in the critically ill currently exist, leading to tremendous variability in clinical practice. Goals of care should include immediate management of dehydration, nutritional deficits, and electrolyte derangements; relief of withdrawal symptoms; prevention of progression of symptoms; and treatment of comorbid illnesses. Symptom-triggered treatment of AWS with γ-aminobutyric acid receptor agonists is the cornerstone of therapy. Benzodiazepines (BZDs) are most studied and are often the preferred first-line agents due to their efficacy and safety profile. However, controversy still exists as to who should receive treatment, how to administer BZDs, and which BZD to use. Although most patients with AWS respond to usual doses of BZDs, ICU clinicians are challenged with managing BZD-resistant patients. Recent literature has shown that using an early multimodal approach to managing BZD-resistant patients appears beneficial in rapidly improving symptoms. This review highlights the results of recent promising studies published between 2011 and 2015 evaluating adjunctive therapies for BZD-resistant alcohol withdrawal such as antiepileptics, baclofen, dexmedetomidine, ethanol, ketamine, phenobarbital, propofol, and ketamine. We provide guidance on the places in therapy for select agents for management of critically ill patients in the presence of AWS. PMID:27196747

  9. Tolerance to enteral tube feeding diets in hypoalbuminemic critically ill, geriatric patients.

    PubMed

    Borlase, B C; Bell, S J; Lewis, E J; Swails, W; Bistrian, B R; Forse, R A; Blackburn, G L

    1992-03-01

    Tolerance of elemental (for example, Peptamen [PEP]) or free amino acid (for example, Vivonex TEN [VIV]) tube feeding diets is controversial, especially in the critically ill patient who is hypoalbuminemic. A prospective, randomized trial was conducted to compare differences between feeding PEP (n = 8) or VIV (n = 8) in critically ill, elderly (average age of 66 years) patients. Diets were administered through nasogastric or postpyloric feeding tubes. Eleven patients had diseases of the gastrointestinal tract; all underwent surgical treatment. Patients were fed each diet at full strength, beginning with 20 to 30 milliliters per hour and advancing by 10 to 20 milliliters every day until goal rate was reached, usually on day 4. Assessment was made for ability to comply with rate of tube feeding ordered, compliance with caloric goal and tolerance (as evidenced by abdominal discomfort and diarrhea). Diarrhea was qualitatively defined as more than three stools per day and then quantitatively as the mean number of stools daily. There were no significant differences between the two groups in terms of compliance with prescribed tube feeding order or caloric goal or the presence of diarrhea and abdominal discomfort. There was a significant difference between the two groups in terms of the actual number of stools per day (PEP equals 1.38 versus VIV equals 2.25, p less than 0.02). Serum albumin concentrations upon initiation of the diets were 2.3 grams per deciliter in both groups. We conclude that tolerance to the two diets were similar because it was possible to feed enterally either PEP or VIV in critically ill, hypoalbuminemic patients (serum albumin concentrations of less than 2.5 grams per deciliter) successfully, irrespective of diet. Although there were more stools in the VIV group, this did not reduce compliance with the goals. PMID:1542832

  10. Practice of strict glycemic control in critically ill patients.

    PubMed

    Schultz, Marcus J; de Graaff, Mart J; Royakkers, Annic A N M; van Braam Houckgeest, Floris; van der Sluijs, Johannes P; Kieft, Hans; Spronk, Peter E

    2008-11-01

    Blood glucose control aiming at normoglycemia, frequently referred to as "strict glycemic control", decreases mortality and morbidity of critically ill patients. We searched the medical literature for export opinions, surveys, and clinical reports on blood glucose control in intensive care medicine. While strict glycemic control has been recommended standard of care for critically ill patients, the risk of severe hypoglycemia with strict glycemic control is frequently mentioned by experts. Some rationalize this risk, though others strongly point out the high incidence of hypoglycemia to be (one) reason not to perform strict glycemic control. Implementation of strict glycemic control is far from complete in intensive care units across the world. Frequently local guidelines accept higher blood glucose levels than those with strict glycemic control. Only a minority of retrieved manuscripts are on blood glucose regimens with the lower targets as with strict glycemic control. Hypoglycemia certainly is encountered with blood glucose control, in particular with strict glycemic control. Reports show intensive care-nurses can adequately and safely perform strict glycemic control. Implementation of strict glycemic control is far from complete, at least in part because of the feared risks of hypoglycemia. The preference for hyperglycemia over intermittent hypoglycemia is irrational, however, because there is causal evidence of harm for the former but only associative evidence of harm for the latter. For several reasons it is wise to have strict glycemic control being a nurse-based strategy. PMID:18971884

  11. Microcirculatory dysfunction and tissue oxygenation in critical illness.

    PubMed

    Østergaard, L; Granfeldt, A; Secher, N; Tietze, A; Iversen, N K; Jensen, M S; Andersen, K K; Nagenthiraja, K; Gutiérrez-Lizardi, P; Mouridsen, K; Jespersen, S N; Tønnesen, E K

    2015-11-01

    Severe sepsis is defined by organ failure, often of the kidneys, heart, and brain. It has been proposed that inadequate delivery of oxygen, or insufficient extraction of oxygen in tissue, may explain organ failure. Despite adequate maintenance of systemic oxygen delivery in septic patients, their morbidity and mortality remain high. The assumption that tissue oxygenation can be preserved by maintaining its blood supply follows from physiological models that only apply to tissue with uniformly perfused capillaries. In sepsis, the microcirculation is profoundly disturbed, and the blood supply of individual organs may therefore no longer reflect their access to oxygen. We review how capillary flow patterns affect oxygen extraction efficacy in tissue, and how the regulation of tissue blood flow must be adjusted to meet the metabolic needs of the tissue as capillary flows become disturbed as observed in critical illness. Using the brain, heart, and kidney as examples, we discuss whether disturbed capillary flow patterns might explain the apparent mismatch between organ blood flow and organ function in sepsis. Finally, we discuss diagnostic means of detecting capillary flow disturbance in animal models and in critically ill patients, and address therapeutic strategies that might improve tissue oxygenation by modifying capillary flow patterns. PMID:26149711

  12. Myoclonus in the critically ill: Diagnosis, management, and clinical impact.

    PubMed

    Sutter, Raoul; Ristic, Anette; Rüegg, Stephan; Fuhr, Peter

    2016-01-01

    Myoclonus is the second most common involuntary non-epileptic movement in intensive care units following tremor-like gestures. Although there are several types of myoclonus, they remain underappreciated, and their diagnostic and prognostic associations are largely ignored. This review discusses clinical, electrophysiological, neuroanatomical, and neuroimaging characteristics of different types of myoclonus in critically ill adults along with their prognostic impact and treatment options. Myoclonus is characterized by a sudden, brief, and sometimes repetitive muscle contraction of body parts, or a brief and sudden cessation of tonic muscle innervation followed by a rapid recovery of tonus. Myoclonus can resemble physiologic and other pathologic involuntary movements. Neurologic injuries, anesthetics, and muscle relaxants interfere with the typical appearance of myoclonus. Identifying "real myoclonus" and determining the neuroanatomical origin are important, as treatment responses depend on the involved neuroanatomical structures. The identification of the type of myoclonus, the involved neuroanatomical structures, and the associated illnesses is essential to direct treatment. In conclusion, the combined clinical, electrophysiological, and neuroradiological examination reliably uncovers the neuroanatomical sources and the pathophysiology of myoclonus. Recognizing cortical myoclonus is critical, as it is treatable and may progress to generalized convulsive seizures or status epilepticus. PMID:26428447

  13. Bacteriological culture of blood from critically ill neonatal calves.

    PubMed Central

    Fecteau, G; Van Metre, D C; Paré, J; Smith, B P; Higgins, R; Holmberg, C A; Jang, S; Guterbock, W

    1997-01-01

    The objectives of this study were to estimate the prevalence of bacteremia in critically ill, neonatal calves with severe diarrhea or depression, and to describe the variety of bacteria involved. Two studies were conducted in the summers of 1991 and 1993 involving 190 neonatal calves, 1-day to 19-days-old. Bacteremia was detected by blood culture in 31% (28/90) of calves in study 1, and in 24% (19/79) of ill calves and 0% (0/21) of control calves in study 2. Bacteria cultured from blood included Escherichia coli (51% of all isolates), other gram-negative enterics (25.5%), gram-negative anaerobes (5.9%), gram-positive cocci (11.8%), and gram-positive rods (5.9%). Among clinically ill calves, the average age was significantly lower in the blood culture-negative group (5.5 d) than in the blood culture-positive group (7.5 d) (P = 0.004). Mean serum IgG concentration was significantly (P = 0.0001) lower in blood culture-positive calves (1.146 g/L) than in blood culture-negative calves (3.077 g/L). The mortality rate was significantly (P < 0.0001) higher in the blood culture-positive group (57.4%) than in the blood culture-negative group (15.1%). Bacteremia appeared to be a frequent entity in this particular rearing situation. Early recognition of the problem, as well as appropriate treatment, may be beneficial in increasing survival rates. Results also support the need to address the failure of passive transfer of maternal antibodies to prevent bacteremia in calves. Images Figure 1. PMID:9028592

  14. From data patterns to mechanistic models in acute critical illness.

    PubMed

    Aerts, Jean-Marie; Haddad, Wassim M; An, Gary; Vodovotz, Yoram

    2014-08-01

    The complexity of the physiologic and inflammatory response in acute critical illness has stymied the accurate diagnosis and development of therapies. The Society for Complex Acute Illness was formed a decade ago with the goal of leveraging multiple complex systems approaches to address this unmet need. Two main paths of development have characterized the society's approach: (i) data pattern analysis, either defining the diagnostic/prognostic utility of complexity metrics of physiologic signals or multivariate analyses of molecular and genetic data and (ii) mechanistic mathematical and computational modeling, all being performed with an explicit translational goal. Here, we summarize the progress to date on each of these approaches, along with pitfalls inherent in the use of each approach alone. We suggest that the next decade holds the potential to merge these approaches, connecting patient diagnosis to treatment via mechanism-based dynamical system modeling and feedback control and allowing extrapolation from physiologic signals to biomarkers to novel drug candidates. As a predicate example, we focus on the role of data-driven and mechanistic models in neuroscience and the impact that merging these modeling approaches can have on general anesthesia. PMID:24768566

  15. The Critically Ill Kidney Transplant Recipient: A Narrative Review.

    PubMed

    Canet, Emmanuel; Zafrani, Lara; Azoulay, Élie

    2016-06-01

    Kidney transplantation is the most common solid organ transplantation performed worldwide. Up to 6% of kidney transplant recipients experience a life-threatening complication that requires ICU admission, chiefly in the late posttransplantation period (≥ 6 months). Acute respiratory failure and septic shock are the main reasons for ICU admission. Cardiac pulmonary edema, bacterial pneumonia, acute graft pyelonephritis, and bloodstream infections account for the vast majority of diagnoses in the ICU. Pneumocystis jirovecii pneumonia is the most common opportunistic infection, and one-half of the patients so infected require mechanical ventilation. The incidence of cytomegalovirus visceral infections in the era of preemptive therapy has dramatically decreased. Drug-related neutropenia, sirolimus-related pneumonitis, and posterior reversible encephalopathy syndrome are among the most common immunosuppression-associated toxic effects. Importantly, the impact of critical illness on graft function is worrisome. Throughout the ICU stay, acute kidney injury is common, and about 40% of the recipients require renal replacement therapy. One-half of the patients are discharged alive and free from dialysis. Hospital mortality can reach 30% and correlates with acute illness severity and reason for ICU admission. Transplant characteristics are not predictors of short-term survival. Graft survival depends on pre-ICU graft function, disease severity, and renal toxicity of ICU investigations and treatments. PMID:26836919

  16. Treatment of affective illness in the elderly with drugs and electroconvulsive therapy.

    PubMed

    Jenike, M A

    1989-01-01

    Affective illness is common, frequently debilitating, and sometimes life-threatening in the elderly. Considerations pertaining to treatment with heterocyclic drugs, MAOIs, lithium, psychostimulants and thyroid hormone, as well as ECT, have been reviewed. Amitriptyline and imipramine cause significant orthostatic hypotension and probably should be avoided in the elderly. In addition, amitriptyline is extremely anticholinergic. Amoxapine is essentially a neuroleptic sequelae, including tardive dyskinesia. If a patient has had a prior positive response or has a relative who had a good outcome from a particular drug, it may be best to begin treatment with that drug. Initial choice of antidepressant can be based largely on the clinical picture. For example, if a depressed patient is sleeping much more than usual, try a potentially activating agent like desipramine or protriptyline. if, on the other hand, the patient is unable to sleep, a more sedating agent like nortriptyline, maprotiline, trimipramine, or trazodone should be tried. Risks and side effects of these drugs, as well as their use in cardiac patients, have been reviewed in detail. Many clinicians avoid MAOIs in elderly patients because of fear of adverse reactions. This fear is largely unfounded. Precautions, side effects, and specific recommendations have been outlined. Using lithium in the elderly requires special precautions because of decreased GFR and potential interactions with concomitantly used drugs. This paper has discussed possible side effects and toxicity. The usage of psychostimulants, such as methylphenidate and amphetamine, to treat medically ill depressed patients is reviewed. These agents are also sometimes useful in demented individuals or in patients with abulic frontal lobe syndromes. Poststroke depressions are common, and recent evidence indicates that they can be adequately treated. Stroke patients have many difficulties dealing with rehabilitation and should not be forced to suffer

  17. Pain and Agitation Management in Critically Ill Patients.

    PubMed

    Stephens, Julie; Wright, Michael

    2016-03-01

    Pain and agitation may be difficult to assess in a critically ill patient. Pain is best assessed by self-reporting pain scales; but in patients who are unable to communicate, behavioral pain scales seem to have benefit. Patients' sedation level should be assessed each shift and preferably by a validated ICU tool, such as the RASS or SAS scale. Pain is most appropriately treated with the use of opiates, and careful consideration should be given to the pharmacokinetic and pharmacodynamic properties of various analgesics to determine the optimal agent for each individual patient. Sedation levels should preferably remain light or with the use of a daily awakening trial. Preferred treatment of agitation is analgosedation with the addition of nonbenzodiazepine sedatives if necessary. There are risks associated with each agent used in the treatment of pain and agitation, and it is important to monitor patients for effectiveness, signs of toxicity, and adverse drug reactions. PMID:26897427

  18. Can nutrition support interfere with recovery from acute critical illness?

    PubMed

    Schulman, Rifka C; Mechanick, Jeffrey I

    2013-01-01

    Malnutrition, following critical illness-related metabolic and immune neuroendocrine derangements, is exacerbated by energy and protein deficits beginning early in the intensive care unit (ICU) stay. While nutrition support is an important component of ICU care, adverse effects can occur. Underfeeding, due to insufficient energy and/or protein is associated with poor patient outcomes. Overfeeding carbohydrates, lipids, and/or protein can result in hyperglycemia, hypertriglyceridemia, hepatic dysfunction, and/or azotemia. Individualization of the nutritional prescription with clinical monitoring and repeated adjustment is necessary to avoid harm. Appropriate use of tight glycemic control protocols in combination with nutrition support can prevent hyperglycemia, while minimizing glycemic variability and hypoglycemic events. While the enteral route is favored for nutrition support, early supplemental parenteral nutrition should be considered in selected high-risk patients. Thus, risk stratification of patients upon admission to the ICU can be helpful to design individualized nutritional prescriptions maximizing benefit while avoiding potential interference with recovery. PMID:23075588

  19. Drug dosage in continuous venoveno hemofiltration in critically ill children.

    PubMed

    Assadi, Farahnak; Shahrbaf, Fatemeh Ghane

    2016-01-01

    The dosage of drugs in patients requiring continuous renal replacement therapy need to be adjusted based on a number of variables that that affect pharmacokinetics (PK) including patient weight, CRRT modality (convention, vs. diffusion), blood and/or effluent flow, hemofilter characteristics, physiochemical drug properties, volume of distribution, protein binding and half-life as well as residual renal function. There is a paucity of data on PK studies in children with acute kidney injury requiring CRRT. When possible, therapeutic drug monitoring should be utilized for those medications where serum drug concentrations can be obtained in a clinically relevant time frame. Also, a patient-centered team approach that includes an intensive care unit pharmacist is recommended to prevent medication-related errors and enhance safe and effective medication use is highly recommended. The aim of this article is to review the current guidelines for drug dosing in critically ill children who require continuous venovenous hemofiltration. PMID:26709896

  20. Bilateral Diaphragmatic Paralysis in a Patient With Critical Illness Polyneuropathy

    PubMed Central

    Chen, Hsuan-Yu; Chen, Hung-Chen; Lin, Meng-Chih; Liaw, Mei-Yun

    2015-01-01

    Abstract Bilateral diaphragmatic paralysis (BDP) manifests as respiratory muscle weakness, and its association with critical illness polyneuropathy (CIP) was rarely reported. Here, we present a patient with BDP related to CIP, who successfully avoided tracheostomy after diagnosis and management. A 71-year-old male presented with acute respiratory failure after sepsis adequately treated. Repeated intubation occurred because of carbon dioxide retention after each extubation. After eliminating possible factors, septic shock-induced respiratory muscle weakness was suspected. Physical examination, a nerve conduction study, and chest ultrasound confirmed our impression. Pulmonary rehabilitation and reconditioning exercises were arranged, and the patient was discharged with a diagnosis of BDP. The diagnosis of BDP is usually delayed, and there are only sporadic reports on its association with polyneuropathy, especially in patients with preserved limb muscle function. Therefore, when physicians encounter patients that are difficult to wean from mechanical ventilation, CIP associated with BDP should be considered in the differential diagnosis. PMID:26252301

  1. Echocardiographic Hemodynamic Monitoring in the Critically Ill Patient

    PubMed Central

    Romero-Bermejo, Francisco J; Ruiz-Bailén, Manuel; Guerrero-De-Mier, Manuel; López-Álvaro, Julián

    2011-01-01

    Echocardiography has shown to be an essential diagnostic tool in the critically ill patient's assessment. In this scenario the initial fluid therapy, such as it is recommended in the actual clinical guidelines, not always provides the desired results and maintains a considerable incidence of cardiorrespiratory insufficiency. Echocardiography can council us on these patients' clinical handling, not only the initial fluid therapy but also on the best-suited election of the vasoactive/inotropic treatment and the early detection of complications. It contributes as well to improving the etiological diagnosis, allowing one to know the heart performance with more precision. The objective of this manuscript is to review the more important parameters that can assist the intensivist in theragnosis of hemodynamically unstable patients. PMID:22758613

  2. [Opinions on the prevention and treatment of chronic critical illness].

    PubMed

    An, Youzhong

    2016-07-01

    Chronic critical illness (CCI) is an inevitable result of overpopulation and aging, as well as the development of medicine. The number of CCI patients will constantly increase and become an unaffordable economic burden for families, societies and countries. CCI could be prevented by multiple measures. Firstly, doctors must know about the pathophysiology and etiology of the disease. When providing organ function support for CCI patient, we have to know and treat the cause of the disease as early as possible. Secondly, we need to precisely monitor the insults caused by the disease and/or improper host response to the disease, evaluate the organ reserve function, and predict the outcomes and life quality after discharging from hospital. In addition, it is necessary to strengthen the humanity training of health care workers, publicize the correct thanatopsis in the whole society that every life is "born to die", and define the core role of medicine as "to comfort always". PMID:27452750

  3. Control of hypertension in the critically ill: a pathophysiological approach

    PubMed Central

    2013-01-01

    Severe acute arterial hypertension can be associated with significant morbidity and mortality. After excluding a reversible etiology, choice of therapeutic intervention should be based on evaluation of a number of factors, such as age, comorbidities, and other ongoing therapies. A rational pathophysiological approach should then be applied that integrates the effects of the drug on blood volume, vascular tone, and other determinants of cardiac output. Vasodilators, calcium channel blockers, and beta-blocking agents can all decrease arterial pressure but by totally different modes of action, which may be appropriate or contraindicated in individual patients. There is no preferred agent for all situations, although some drugs may have a more attractive profile than others, with rapid onset action, short half-life, and fewer adverse reactions. In this review, we focus on the main mechanisms underlying severe hypertension in the critically ill and how using a pathophysiological approach can help the intensivist decide on treatment options. PMID:23806076

  4. Unmeasured anions and mortality in critically ill patients in 2016.

    PubMed

    Kotake, Yoshifumi

    2016-01-01

    The presence of acid-base disturbances, especially metabolic acidosis may negatively affect the outcome of critically ill patients. Lactic acidosis is the most frequent etiology and has largest impact on the prognosis. Since lactate measurement might not have always been available at bedside, it had been regarded as one of the unmeasured anions. Therefore, anion gap and strong ion gap has been used to as a surrogate of lactate concentration. From this perspective, the relationship between either anion gap or strong ion gap and mortality has been explored. Then, lactate became routinely measurable at bedside and the direct comparison between directly measured lactate and these surrogate parameters can be possible. Currently available evidence suggests that directly measured lactate has larger prognostic ability for mortality than albumin-corrected anion gap and strong ion gap without lactate. In this commentary, the rationale and possible clinical implications of these findings are discussed. PMID:27429758

  5. Is glycemic control of the critically ill cost-effective?

    PubMed

    Krinsley, James S

    2014-10-01

    Intensive monitoring of blood glucose levels and treatment of hyperglycemia have been associated with significant improvements in morbidity and mortality in the critically ill. In contrast to the large prospective and observational body of data relating glycemic control and clinical outcomes, the financial impact of glycemic control implementation has not been as well described. This article details data from interventional trials of intensive insulin therapy; investigations that relate dysglycemia to morbidity, particularly intensive care unit (ICU)-acquired infections and increased ICU length of stay; and evaluations of the attributable cost of nosocomial infection in order to construct a sensitivity analysis of the net economic impact of glycemic control. It concludes that glycemic control is associated with positive financial outcomes, even using very conservative assumptions, and provides the reader with an automated spreadsheet to estimate the financial implications of glycemic control using assumptions based on locally derived data. PMID:25502129

  6. "You really do something useful with kids": mothering and experienced health and illness in a group of elderly Swedish women.

    PubMed

    Forssén, Annika S K; Carlstedt, Gunilla

    2008-01-01

    This article is based on in-dept interviews with 20 elderly Swedish women, and deals with mother's child-caring work and related health and illness. Mothering included invisible work as well as physically heavy tasks, both aspects often neglected in research. The attitude of the children's father had a great impact on the work. Feelings of success or failure at bringing up their children affected the women's experience of health/ill health throughout their lives. Their health as elderly women depended on the health and happiness of their, now adult, children. PMID:18821212

  7. Critical Pertussis Illness in Children, A Multicenter Prospective Cohort Study

    PubMed Central

    Berger, John T.; Carcillo, Joseph A.; Shanley, Thomas P.; Wessel, David L.; Clark, Amy; Holubkov, Richard; Meert, Kathleen L.; Newth, Christopher J.L.; Berg, Robert A.; Heidemann, Sabrina; Harrison, Rick; Pollack, Murray; Dalton, Heidi; Harvill, Eric; Karanikas, Alexia; Liu, Teresa; Burr, Jeri S.; Doctor, Allan; Dean, J. Michael; Jenkins, Tammara L.; Nicholson, Carol E.

    2013-01-01

    Objective Pertussis persists in the United States despite high immunization rates. The present report characterizes the presentation and acute course of critical pertussis by quantifying demographic data, laboratory findings, clinical complications, and critical care therapies required among children requiring admission to the pediatric intensive care unit (PICU). Design Prospective cohort study. Setting Eight PICUs comprising the Eunice Kennedy Shriver National Institute for Child Health and Human Development Collaborative Pediatric Critical Care Research Network and 17 additional PICUs across the United States. Patients Eligible patients had laboratory confirmation of pertussis infection, were < 18 years of age, and died in the PICU or were admitted to the PICU for at least 24 hours between June 2008 and August 2011. Interventions None. Measurements and Main Results 127 patients were identified. Median age was 49 days, and 105 (83%) patients were < 3 months of age. Fifty-five (43%) required mechanical ventilation. Twelve (9.4%) died during initial hospitalization. Pulmonary hypertension was found in 16 patients (12.5%), and was present in 75% of patients who died, compared with 6% of survivors (p< 0.001). Median white blood cell count (WBC) was significantly higher in those requiring mechanical ventilation (p<0.001), those with pulmonary hypertension (p<0.001) and non-survivors (p<0.001). Age, sex and immunization status did not differ between survivors and non-survivors. Fourteen patients received leukoreduction therapy (exchange transfusion (12), leukopheresis (1) or both (1)). Survival benefit was not apparent. Conclusions Pulmonary hypertension may be associated with mortality in pertussis critical illness. Elevated WBC is associated with the need for mechanical ventilation, pulmonary hypertension, and mortality risk. Research is indicated to elucidate how pulmonary hypertension, immune responsiveness, and elevated WBC contribute to morbidity and mortality

  8. Mechanical Signaling in the Pathophysiology of Critical Illness Myopathy

    PubMed Central

    Kalamgi, Rebeca C.; Larsson, Lars

    2016-01-01

    The complete loss of mechanical stimuli of skeletal muscles, i.e., the loss of external strain, related to weight bearing, and internal strain, related to the contraction of muscle cells, is uniquely observed in pharmacologically paralyzed or deeply sedated mechanically ventilated intensive care unit (ICU) patients. The preferential loss of myosin and myosin associated proteins in limb and trunk muscles is a significant characteristic of critical illness myopathy (CIM) which separates CIM from other types of acquired muscle weaknesses in ICU patients. Mechanical silencing is an important factor triggering CIM. Microgravity or ground based microgravity models form the basis of research on the effect of muscle unloading-reloading, but the mechanisms and effects may differ from the ICU conditions. In order to understand how mechanical tension regulates muscle mass, it is critical to know how muscles sense mechanical information and convert stimulus to intracellular biochemical actions and changes in gene expression, a process called cellular mechanotransduction. In adult skeletal muscles and muscle fibers, this process may differ, the same stimulus can cause divergent response and the same fiber type may undergo opposite changes in different muscles. Skeletal muscle contains multiple types of mechano-sensors and numerous structures that can be affected differently and hence respond differently in distinct muscles. PMID:26869939

  9. Metabolic Management during Critical Illness: Glycemic Control in the ICU.

    PubMed

    Honiden, Shyoko; Inzucchi, Silvio E

    2015-12-01

    Hyperglycemia is a commonly encountered metabolic derangement in the ICU. Important cellular pathways, such as those related to oxidant stress, immunity, and cellular homeostasis, can become deranged with prolonged and uncontrolled hyperglycemia. There is additionally a complex interplay between nutritional status, ambient glucose concentrations, and protein catabolism. While the nuances of glucose management in the ICU have been debated, results from landmark studies support the notion that for most critically ill patients moderate glycemic control is appropriate, as reflected by recent guidelines. Beyond the target population and optimal glucose range, additional factors such as hypoglycemia and glucose variability are important metrics to follow. In this regard, new technologies such as continuous glucose sensors may help alleviate the risks associated with such glucose fluctuations in the ICU. In this review, we will explore the impact of hyperglycemia upon critical cellular pathways and how nutrition provided in the ICU affects blood glucose. Additionally, important clinical trials to date will be summarized. A practical and comprehensive approach to glucose management in the ICU will be outlined, touching upon important issues such as glucose variability, target population, and hypoglycemia. PMID:26595046

  10. [Fish oil containing lipid emulsions in critically ill patients: Critical analysis and future perspectives].

    PubMed

    Manzanares, W; Langlois, P L

    2016-01-01

    Third-generation lipid emulsions (LE) are soybean oil sparing strategies with immunomodulatory and antiinflammatory effects. Current evidence supporting the use of intravenous (i.v) fish oil (FO) LE in critically ill patients requiring parenteral nutrition or receiving enteral nutrition (pharmaconutrient strategy) mainly derives from small phase ii clinical trials in heterogenous intensive care unit patient's population. Over the last three years, there have been published different systematic reviews and meta-analyses evaluating the effects of FO containing LE in the critically ill. Recently, it has been demonstrated that i.v FO based LE may be able to significantly reduce the incidence of infections as well as mechanical ventilation days and hospital length of stay. Nonetheless, more robust evidence is required before giving a definitive recommendation. Finally, we strongly believe that a dosing study is required before new phase iii clinical trials comparing i.v FO containing emulsions versus other soybean oil strategies can be conducted. PMID:26403991

  11. Functional Trajectories Among Older Persons Before and After Critical Illness

    PubMed Central

    Ferrante, Lauren E.; Pisani, Margaret A.; Murphy, Terrence E.; Gahbauer, Evelyne A.; Leo-Summers, Linda S.; Gill, Thomas M.

    2015-01-01

    IMPORTANCE Little is known about functional trajectories of older persons in the year before and after admission to the intensive care unit (ICU) or how pre-ICU functional trajectories affect post-ICU functional trajectories and death. OBJECTIVES To characterize functional trajectories in the year before and after ICU admission and to evaluate the associations among pre-ICU functional trajectories and post-ICU functional trajectories, short-term mortality, and long-term mortality. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study of 754 community-dwelling persons 70 years or older, conducted between March 23, 1998, and December 31, 2012, in greater New Haven, Connecticut. The analytic sample included 291 participants who had at least 1 admission to an ICU through December 2011. MAIN OUTCOMES AND MEASURES Functional trajectories in the year before and after an ICU admission based on 13 basic, instrumental, and mobility activities. Additional outcomes included short-term (30 day) and long-term (1 year) mortality. RESULTS The mean (SD) age of participants was 83.7 (5.5) years. Three distinct pre-ICU functional trajectories identified were minimal disability (29.6%), mild to moderate disability (44.0%), and severe disability (26.5%). Seventy participants (24.1%) experienced early death, defined as death in the hospital (50 participants [17.2%]) or death after hospital discharge but within 30 days of admission (20 participants [6.9%]). Among the remaining 221 participants, 3 distinct post-ICU functional trajectories identified were minimal disability (20.8%), mild to moderate disability (28.1%), and severe disability (51.1%). More than half of the participants (53.4%) experienced functional decline or early death after critical illness. The pre-ICU functional trajectories of mild to moderate disability and severe disability were associated with more than double (adjusted hazard ratio [HR], 2.41; 95%CI, 1.29–4.50) and triple (adjusted HR, 3.84; 95%CI, 1.84–8

  12. Altered sodium channel-protein associations in critical illness myopathy

    PubMed Central

    2012-01-01

    Background During the acute phase of critical illness myopathy (CIM) there is inexcitability of skeletal muscle. In a rat model of CIM, muscle inexcitability is due to inactivation of sodium channels. A major contributor to this sodium channel inactivation is a hyperpolarized shift in the voltage dependence of sodium channel inactivation. The goal of the current study was to find a biochemical correlate of the hyperpolarized shift in sodium channel inactivation. Methods The rat model of CIM was generated by cutting the sciatic nerve and subsequent injections of dexamethasone for 7 days. Skeletal muscle membranes were prepared from gastrocnemius muscles, and purification and biochemical analyses carried out. Immunoprecipitations were performed with a pan-sodium channel antibody, and the resulting complexes probed in Western blots with various antibodies. Results We carried out analyses of sodium channel glycosylation, phosphorylation, and association with other proteins. Although there was some loss of channel glycosylation in the disease, as assessed by size analysis of glycosylated and de-glycosylated protein in control and CIM samples, previous work by other investigators suggest that such loss would most likely shift channel inactivation gating in a depolarizing direction; thus such loss was viewed as compensatory rather than causative of the disease. A phosphorylation site at serine 487 was identified on the NaV 1.4 sodium channel α subunit, but there was no clear evidence of altered phosphorylation in the disease. Co-immunoprecipitation experiments carried out with a pan-sodium channel antibody confirmed that the sodium channel was associated with proteins of the dystrophin associated protein complex (DAPC). This complex differed between control and CIM samples. Syntrophin, dystrophin, and plectin associated strongly with sodium channels in both control and disease conditions, while β-dystroglycan and neuronal nitric oxide synthase (nNOS) associated

  13. Decision making in interhospital transport of critically ill patients: national questionnaire survey among critical care physicians

    PubMed Central

    de Vos, Rien; Binnekade, Jan M.; de Haan, Rob; Schultz, Marcus J.; Vroom, Margreeth B.

    2008-01-01

    Objective This study assessed the relative importance of clinical and transport-related factors in physicians' decision-making regarding the interhospital transport of critically ill patients. Methods The medical heads of all 95 ICUs in The Netherlands were surveyed with a questionnaire using 16 case vignettes to evaluate preferences for transportability; 78 physicians (82%) participated. The vignettes varied in eight factors with regard to severity of illness and transport conditions. Their relative weights were calculated for each level of the factors by conjoint analysis and expressed in β. The reference value (β = 0) was defined as the optimal conditions for critical care transport; a negative β indicated preference against transportability. Results The type of escorting personnel (paramedic only: β = –3.1) and transport facilities (standard ambulance β = –1.21) had the greatest negative effect on preference for transportability. Determinants reflecting severity of illness were of relative minor importance (dose of noradrenaline β = –0.6, arterial oxygenation β = –0.8, level of peep β = –0.6). Age, cardiac arrhythmia, and the indication for transport had no significant effect. Conclusions Escorting personnel and transport facilities in interhospital transport were considered as most important by intensive care physicians in determining transportability. When these factors are optimal, even severely critically ill patients are considered able to undergo transport. Further clinical research should tailor transport conditions to optimize the use of expensive resources in those inevitable road trips. PMID:18283432

  14. [Influenza-related respiratory illnesses and associated causes among the elderly in a city in Northeast Brazil].

    PubMed

    Gomes, Aline de Andrade; Nunes, Marco Antônio Prado; Oliveira, Cristiane Costa da Cunha; Lima, Sônia Oliveira

    2013-01-01

    Nationwide influenza vaccination campaigns are held annually in Brazil during the same time of the year. This study aimed to analyze deaths from respiratory illnesses and influenza-related causes among the elderly in the city of Aracaju, capital of Sergipe State, Brazil. Data were analyzed from the following databases: Information System on Influenza Epidemiological Surveillance (SIVEP_GRIPE), Hospital Information System (SIH), Mortality Information System (SIM), and Health Informatics Department (DATASUS), from 1998 to 2007, Sergipe State Central Laboratory (LACEN-SE), and rainfall data from the National Meteorology Institute (INMET). The year 2007 showed the highest mortality rate from influenza and related causes in elderly individuals. From 1998 to 2007, mortality rates from influenza-related respiratory illnesses and associated causes in Aracaju city were higher than in the States of Brazil, indicating the need to reformulate the influenza vaccination schedule in elderly residents of this city. PMID:23370031

  15. Acute kidney injury in critically ill cancer patients: an update.

    PubMed

    Lameire, Norbert; Vanholder, Raymond; Van Biesen, Wim; Benoit, Dominique

    2016-01-01

    Patients with cancer represent a growing group among actual ICU admissions (up to 20 %). Due to their increased susceptibility to infectious and noninfectious complications related to the underlying cancer itself or its treatment, these patients frequently develop acute kidney injury (AKI). A wide variety of definitions for AKI are still used in the cancer literature, despite existing guidelines on definitions and staging of AKI. Alternative diagnostic investigations such as Cystatin C and urinary biomarkers are discussed briefly. This review summarizes the literature between 2010 and 2015 on epidemiology and prognosis of AKI in this population. Overall, the causes of AKI in the setting of malignancy are similar to those in other clinical settings, including preexisting chronic kidney disease. In addition, nephrotoxicity induced by the anticancer treatments including the more recently introduced targeted therapies is increasingly observed. However, data are sometimes difficult to interpret because they are often presented from the oncological rather than from the nephrological point of view. Because the development of the acute tumor lysis syndrome is one of the major causes of AKI in patients with a high tumor burden or a high cell turnover, the diagnosis, risk factors, and preventive measures of the syndrome will be discussed. Finally, we will briefly discuss renal replacement therapy modalities and the emergence of chronic kidney disease in the growing subgroup of critically ill post-AKI survivors. PMID:27480256

  16. Daptomycin Pharmacokinetics and Pharmacodynamics in Septic and Critically Ill Patients.

    PubMed

    D'Avolio, Antonio; Pensi, Debora; Baietto, Lorena; Pacini, Giovanni; Di Perri, Giovanni; De Rosa, Francesco Giuseppe

    2016-08-01

    Infections, including sepsis, are associated with high mortality rates in critically ill patients in the intensive care unit (ICU). Appropriate antibiotic selection and adequate dosing are important for improving patient outcomes. Daptomycin is bactericidal in bloodstream infections caused by Staphylococcus aureus and other Gram-positive pathogens cultured in ICU patients. The drug has concentration-dependent activity, and the area under the curve/minimum inhibitory concentration ratio is the pharmacokinetic/pharmacodynamic (PK/PD) index that best correlates with daptomycin activity, whereas toxicity correlates well with daptomycin plasma trough concentrations (or minimum concentration [C min]). Adequate daptomycin exposure can be difficult to achieve in ICU patients; multiple PK alterations can result in highly variable plasma concentrations, which are difficult to predict. For this reason, therapeutic drug monitoring could help clinicians optimize daptomycin dosing, thus improving efficacy while decreasing the likelihood of serious adverse events. This paper reviews the literature on daptomycin in ICU patients with sepsis, focusing on dosing and PK and PD parameters. PMID:27412121

  17. Hemodynamic patterns in shock and critically ill patients.

    PubMed

    Villazón, S A; Sierra, U A; López, S F; Rolando, M A

    1975-01-01

    Nine variables were studied in 56 patients to analyze hemodynamic patterns of critically ill and shock patients. The variables were central venous pressure, mean arterial pressure, heart rate, cardiac index, left ventricular stroke work, strok index, total peripheral resistance, arteriovenous oxygen difference, and oxygen consumption. We observed six patterns; three with low cardiac index (hypodynamic) and three with high cardiac index (hyperdynamic). Group IA: Low cardiac index with increased central venous pressure and arteriovenous oxygen differences associated with myocardial infarction, cardiac insufficiency, and postoperative cardiac surgery: Group IB: Low cardiac index with normal arteriovenous oxygen difference associated with myocardial infarction or hypovolemia. Group IC: Low cardiac index and decreased arteriovenous oxygen difference in patients with hypodynamic septic shock. Group IID: High cardiac index and increased arteriovenous oxygen difference in patients with sepsis and stable hemodynamic conditions. Groups IIE and IIF: Increased cardiac index and normal or increased arteriovenous oxygen difference in septic patients, who were hemodymamically unstable or in shock. These hemodynamic observations were found to be useful for understanding physiological compensations, for deciding on therapy, and in evaluating the effectiveness of therapy. PMID:1201657

  18. Caloric requirement of the critically ill septic patient

    SciTech Connect

    Shizgal, H.M.; Martin, M.F.

    1988-04-01

    The caloric requirement of the critically ill septic patient was determined by measuring body composition, by multiple isotope dilution, before and at 2-wk intervals while receiving total parenteral nutrition (TPN) in 86 septic and 57 nonseptic malnourished patients. All patients received a TPN solution containing 25% dextrose and 2.75% crystalline amino acids. The body composition of the nonseptic patients, who received 51.9 +/- 1.5 kcal/kg.day, improved significantly, while that of the septic patients, receiving 46.8 +/- 1.1 kcal/kg.day was only maintained. The relationship between caloric intake and the restoration of a malnourished body cell mass (BCM) was determined for each group by correlating, using multiple linear regression, the mean daily change in the BCM with the caloric intake and the nutritional state, as determined by body composition. According to the resultant regressions, an intake of 35.1 and 50.7 kcal/kg.day was required to maintain the BCM of the septic and nonseptic patients, respectively. To restore a depleted BCM, caloric intakes in excess of this amount are required.

  19. [Delirium and delirium management in critically ill patients].

    PubMed

    Kersten, A; Reith, S

    2016-02-01

    Delirium in critically ill patients is a common entity in the intensive care unit (ICU) and is an expression of the cerebral organ dysfunction of the patient. The hallmark signs are disturbed consciousness and cognition in combination with inattentiveness and alterations in perception, which are manifested within a time interval of hours to days during treatment on the ICU. Delirium has been shown to have negative effects on patient short-term and long-term outcome parameters and increases morbidity and mortality. Despite its significance in many cases delirium remains inadequately diagnosed during routine treatment by ICU personnel. There are two validated and easily applicable scales for the standardized diagnosis of delirium: the confusion assessment method for the ICU (CAM-ICU) and the intensive care delirium screening checklist (ICDSC). These are simple to apply by medical as well as non-medical personnel. The therapy of delirium is mostly determined by non-pharmacological measures aiming at early identification, reorientation and mobilization of the patient, improving cerebral activity and establishing adequate wake-sleep cycles. There is only sparse evidence for pharmacological treatment of delirium; however, the choice of sedative agent has a proven effect on the incidence and duration of delirium in the ICU. PMID:26795215

  20. RISK FACTORS FOR CANDIDEMIA IN CRITICALLY ILL INFANTS

    PubMed Central

    Feja, Kristina N.; Wu, Fann; Roberts, Kevin; Loughrey, Maureen; Nesin, Mirjana; Larson, Elaine; Della-Latta, Phyllis; Haas, Janet; Cimiotti, Jeannie; Saiman, Lisa

    2007-01-01

    Objective To determine risk factors for late-onset candidemia among infants in the neonatal intensive care unit (NICU). Study design We performed a matched case-control study from March 2001 to January 2003 in 2 level III-IV NICUs. Case subjects had candidemia diagnosed more than 48 hours after hospitalization. Control subjects (3 per case) were matched by study site, birth weight, study year, and date of enrollment. Potential risk factors included medical devices, medications, gastrointestinal (GI) pathology (congenital anomalies or necrotizing enterocolitis) and previous bacterial bloodstream infections (BSIs). Results Forty-five cases of candidemia occurred during the study period and accounted for 15% of BSIs. C. albicans caused 62% of infections (28/45); C. parapsilosis, 31% (14/45). Multivariate analysis revealed that catheter use (odds ratio [OR] = 1.06 per day of use; 95% confidence interval [CI] = 1.02 to 1.10), previous bacterial BSIs (OR = 8.02; 95% CI = 2.76 to 23.30) and GI pathology (OR = 4.57; 95% CI = 1.62 to 12.92) were significantly associated with candidemia. In all, 26/45 cases (58%) of candidemia occurred in infants who would not have qualified for fluconazole prophylaxis according to the Kaufman criteria. Conclusions We confirmed previous risk factors (catheter-days) and identified novel risk factors (previous BSI and GI pathology) for candidemia in critically ill infants that could guide future targeted antifungal prophylaxis strategies. PMID:16126040

  1. Synchronization of Cardio-Respiratory Dynamics in Critically Ill Patients.

    NASA Astrophysics Data System (ADS)

    Burykin, Anton; Buchman, Timothy

    2008-03-01

    We studied changes in cardio-respiratory synchronization and dynamics of cardiovascular system during transition from mechanical ventilation to spontaneous respiration in critically ill patients. This observational study exploits a standard clinical practice---the spontaneous breathing trial (SBT). The SBT consists of a period of mechanical ventilation, followed by a period of spontaneous breathing, followed by resumption of mechanical ventilation. We collected continuous respiratory, cardiac (EKG), and blood pressure signals of mechanically ventilated patients before, during and after SBT. The data were analyzed by means of spectral analysis, phase dynamics, and entropy measures. Mechanical ventilation appears to affect not only the lungs but also the cardiac and vascular systems. Spontaneous cardiovascular rhythms are entrained by the mechanical ventilator and are drawn into synchrony. Sudden interruption of mechanical ventilation causes gross desynchronization, which is restored by reinstitution of mechanical ventilation. The data suggest (1) therapies intended to support one organ system may propagate unanticipated effects to other organ systems and (2) sustained therapies may adversely affect recovery of normal organ system interactions.

  2. Pharmacological therapy of feed intolerance in the critically ills

    PubMed Central

    Nguyen, Nam Q

    2014-01-01

    Feed intolerance in the setting of critical illness is associated with higher morbidity and mortality, and thus requires promptly and effective treatment. Prokinetic agents are currently considered as the first-line therapy given issues relating to parenteral nutrition and post-pyloric placement. Currently, the agents of choice are erythromycin and metoclopramide, either alone or in combination, which are highly effective with relatively low incidence of cardiac, hemodynamic or neurological adverse effects. Diarrhea, however, can occur in up to 49% of patients who are treated with the dual prokinetic therapy, which is not associated with Clostridium difficile infection and settled soon after the cessation of the drugs. Hence, the use of prokinetic therapy over a long period or for prophylactic purpose must be avoided, and the indication for ongoing use of the drug(s) must be reviewed frequently. Second line therapy, such as total parenteral nutrition and post-pyloric feeding, must be considered once adverse effects relating the prokinetic therapy develop. PMID:25133043

  3. Enteral nutrition intolerance in critically ill septic burn patients.

    PubMed

    Lavrentieva, Athina; Kontakiotis, Theodore; Bitzani, Militsa

    2014-01-01

    The purpose of this study was to investigate the frequency of enteral feeding intolerance in critically ill septic burn patients, the effect of enteral feeding intolerance on the efficacy of feeding, the correlation between the infection marker (procalcitonin [PCT]) and the nutrition status marker (prealbumin) and the impact of feeding intolerance on the outcome of septic burn patients. From January 2009 to December 2012 the data of all burn patients with the diagnosis of sepsis who were placed on enteral nutrition were analyzed. Septic patients were divided into two groups: group A, septic patients who developed feeding intolerance; group B, septic patients who did not develop feeding intolerance. Demographic and clinical characteristics of patients were analyzed and compared. The diagnosis of sepsis was applied to 29% of all patients. Of these patients 35% developed intolerance to enteral feeding throughout the septic period. A statistically significant increase in mean PCT level and a decrease in prealbumin level was observed during the sepsis period. Group A patients had statistically significant lower mean caloric intake, higher PCT:prealbumin ratio, higher pneumonia incidence, higher Sequential Organ Failure Assessment Maximum Score, a longer duration of mechanical ventilation, and a higher mortality rate in comparison with the septic patients without gastric feeding intolerance. The authors concluded that a high percentage of septic burn patients developed enteral feeding intolerance. Enteral feeding intolerance seems to have a negative impact on the patients' nutritional status, morbidity, and mortality. PMID:24879397

  4. Complications of tracheal intubation in critically ill pediatric cancer patients

    PubMed Central

    Siddiqui, Suhail Sarwar; Janarthanan, S.; Harish, M. M.; Chaudhari, Harish; Prabu, R. Natesh; Divatia, Jigeeshu V.; Kulkarni, Atul Prabhakar

    2016-01-01

    Background and Aims: The oncologists are treating cancer more aggressively, leading to increase in number of pediatric admissions to the ICU. Due to anatomical and physiological differences, pediatric patients are at high risk of complications during intubation. We evaluated the incidence of complications during intubations in pediatric patients in our ICU. Subjects and Methods: We performed retrospective analysis of complications occurring during intubation in 42 pediatric patients. All intubations were orotracheal. We recorded number of attempts at intubation, need for use of intubation adjuncts and complications during laryngoscopy and intubation. The incidence of difficult intubation, hypoxia, and severe cardiovascular collapse was also noted. Results: Complications occurred during 13 (31%) intubations. Hypoxia and severe cardiovascular collapse occurred in during 7 (16.7%) intubations each, while 4 patients (9.5%) (n=4) had cardiac arrest during intubation. Thirty three (78.6%) intubations were successful in first attempt and difficult intubation was recorded in 4 patients. Conclusion: Critically ill pediatric cancer patients have a high rate of complications during intubation. PMID:27555695

  5. How could we reduce antibiotic use in critically ill patients?

    PubMed

    De Angelis, Giulia; Restuccia, Giovanni; Cauda, Roberto; Tacconelli, Evelina

    2011-08-01

    The role of antibiotic pressure in the selection of antibiotic-resistant bacteria is still under debate in the scientific community and often confounded by scarce data on antibiotic usage. Several studies demonstrated that prior antibiotic exposure is likely to increase patient's colonization and infection by antimicrobial-resistant bacteria. Of even more concern is the significant mortality associated with these infections, in particular in critically ill patients. Therefore, the control of antibiotic usage in intensive care units (ICUs) is of paramount importance. Antibiotic stewardship programmes (ASP) have been demonstrated to represent a useful intervention to reduce the inappropriate antibiotic usage in hospitalized patients. A few trials were performed in ICU population with positive results. The major risk we foresee for the implementation of ASP for ICU patients is the lack of consideration of local ecology and strict quality indicators. The development of new pattern of antimicrobial resistance might be ascribed to an inappropriate ASP. European networks to define best strategies and antibiotic-care bundles need to be supported at national and international level. To optimize antibiotic use in the ICU and to fight against the spread of resistance, it is extremely important to adopt a multifaceted approach including ASP. PMID:21679144

  6. When Is It Appropriate to Use Glutamine in Critical Illness?

    PubMed

    Mundi, Manpreet S; Shah, Meera; Hurt, Ryan T

    2016-08-01

    Glutamine is a nonessential amino acid, which under trauma or critical illness can become essential. A number of historic small single-center randomized controlled trials (RCTs) have demonstrated positive treatment effects on clinical outcomes with glutamine supplementation. Meta-analyses based on these trials demonstrated a significant reduction in hospital mortality, intensive care unit (ICU) length of stay (LOS), and hospital LOS with intravenous (IV) glutamine. Similar results were not noted in 2 large multicenter RCTs (REDOXS and MetaPlus) assessing the efficacy of glutamine supplementation in ventilated ICU patients. The REDOXS trial of 40 ICUs randomized 1223 ventilated ICU patients to glutamine (IV and enteral), antioxidants, both glutamine and antioxidants, or placebo. The main conclusions were a trend toward increased 28-day mortality and significant increased hospital and 6-month mortality in those who received glutamine. The MetaPlus trial of 14 ICUs, which randomized 301 ventilated ICU patients to glutamine-enriched enteral vs an isocaloric diet, noted increased 6-month mortality in the glutamine-supplemented group. Newer RCTs have focused on specific populations and have demonstrated benefits in burn and elective surgery patients with glutamine supplementation. Whether larger studies will confirm these findings is yet to be determined. Recent American Society for Parenteral and Enteral Nutrition guidelines recommend that IV and enteral glutamine should not be used in the critical care setting based on the moderate quality of evidence available. We agree with these recommendations and would encourage larger multicenter studies to evaluate the risks and benefits of glutamine in burn and elective surgery patients. PMID:27246308

  7. Protein in nutritional support: the newborn hero for the critically ill?

    PubMed

    Oshima, Taku; Heidegger, Claudia P; Pichard, Claude

    2014-01-01

    In their current review, Weijs and colleagues highlight the importance of protein and amino acid provision for improving clinical outcome in critically ill patients. The interdependence between energy and protein is highlighted. They call for urgent research to develop new methods to evaluate protein and amino acid requirements, accurately and conveniently, in order to optimize nutrition support for critically ill patients. PMID:25672435

  8. Clinical review: Emergency department overcrowding and the potential impact on the critically ill

    PubMed Central

    Cowan, Robert M; Trzeciak, Stephen

    2005-01-01

    Critical care constitutes a significant and growing proportion of the practice of emergency medicine. Emergency department (ED) overcrowding in the USA represents an emerging threat to patient safety and could have a significant impact on the critically ill. This review describes the causes and effects of ED overcrowding; explores the potential impact that ED overcrowding has on care of the critically ill ED patient; and identifies possible solutions, focusing on ED based critical care. PMID:15987383

  9. The Use of Acute Peritoneal Dialysis in Critically Ill Newborns

    PubMed Central

    Ustyol, Lokman; Peker, Erdal; Demir, Nihat; Agengin, Kemal; Tuncer, Oguz

    2016-01-01

    Background To evaluate the efficacy, complications, and mortality rate of acute peritoneal dialysis (APD) in critically ill newborns. Material/Methods The study included 31 newborns treated in our center between May 2012 and December 2014. Results The mean birth weight, duration of peritoneal dialysis, and gestational age of the patients were determined as 2155.2±032.2 g (580–3900 g), 4 days (1–20 days), and 34 weeks (24–40 weeks), respectively. The main reasons for APD were sepsis (35.5%), postoperative cardiac surgery (16%), hypoxic ischemic encephalopathy (13%), salting of the newborn (9.7%), congenital metabolic disorders (6.1%), congenital renal diseases (6.5%), nonimmune hydrops fetalis (6.5%), and acute kidney injury (AKI) due to severe dehydration (3.2%). APD-related complications were observed in 48.4% of the patients. The complications encountered were catheter leakages in nine patients, catheter obstruction in three patients, peritonitis in two patients, and intestinal perforation in one patient. The general mortality rate was 54.8%, however, the mortality rate in premature newborns was 81.3%. Conclusions APD can be an effective, simple, safe, and important therapy for renal replacement in many neonatal diseases and it can be an appropriate treatment, where necessary, for newborns. Although it may cause some complications, they are not common. However, it should be used carefully, especially in premature newborns who are vulnerable and have a high mortality risk. The recommendation of APD therapy in such cases needs to be verified by further studies in larger patient populations. PMID:27121012

  10. Adaptation to different noninvasive ventilation masks in critically ill patients*

    PubMed Central

    da Silva, Renata Matos; Timenetsky, Karina Tavares; Neves, Renata Cristina Miranda; Shigemichi, Liane Hirano; Kanda, Sandra Sayuri; Maekawa, Carla; Silva, Eliezer; Eid, Raquel Afonso Caserta

    2013-01-01

    OBJECTIVE: To identify which noninvasive ventilation (NIV) masks are most commonly used and the problems related to the adaptation to such masks in critically ill patients admitted to a hospital in the city of São Paulo, Brazil. METHODS: An observational study involving patients ≥ 18 years of age admitted to intensive care units and submitted to NIV. The reason for NIV use, type of mask, NIV regimen, adaptation to the mask, and reasons for non-adaptation to the mask were investigated. RESULTS: We evaluated 245 patients, with a median age of 82 years. Acute respiratory failure was the most common reason for NIV use (in 71.3%). Total face masks were the most commonly used (in 74.7%), followed by full face masks and near-total face masks (in 24.5% and 0.8%, respectively). Intermittent NIV was used in 82.4% of the patients. Adequate adaptation to the mask was found in 76% of the patients. Masks had to be replaced by another type of mask in 24% of the patients. Adequate adaptation to total face masks and full face masks was found in 75.5% and 80.0% of the patients, respectively. Non-adaptation occurred in the 2 patients using near-total facial masks. The most common reason for non-adaptation was the shape of the face, in 30.5% of the patients. CONCLUSIONS: In our sample, acute respiratory failure was the most common reason for NIV use, and total face masks were the most commonly used. The most common reason for non-adaptation to the mask was the shape of the face, which was resolved by changing the type of mask employed. PMID:24068269

  11. Prevalence of carnitine depletion in critically ill patients with undernutrition.

    PubMed

    Wennberg, A; Hyltander, A; Sjöberg, A; Arfvidsson, B; Sandström, R; Wickström, I; Lundholm, K

    1992-02-01

    The aim of this study was to evaluate to what extent secondary carnitine deficiency may exist based on the prevalence of subnormal carnitine status in patients with critical illness and abnormal nutritional state. Healthy control patients (n = 12) were investigated and compared with patients with possible secondary carnitine deficiency, ie, patients with overt severe protein-energy malnutrition (PEM, n = 28), postoperative long-term (greater than 14 days) parenteral glucose feeding (250 g glucose/d, n = 7), severe liver disease (n = 10), renal insufficiency (n = 7), and sustained septicemia with increased metabolic rate (n = 8). Nutritional status, energy expenditure, creatinine excretion, and blood biochemical tests were measured in relationship to free and total carnitine concentrations in plasma and skeletal muscle tissue, as well as urinary excretion of free and total carnitine. The overall mortality rate was 48% within 30 days of the investigation in study patients with the highest mortality in liver disease (90%). The hospitalization range was 14 to 129 days in study patients. Most study patients had lost weight (4% to 19%) and had abnormal body composition. Patients with liver disease, septicemia, renal insufficiency, and those on long-term glucose feeding had significantly higher than predicted metabolic rate (+25% +/- 3%), while patients with severe malnutrition had decreased metabolic rate compared with controls. Patients with liver disease had increased plasma concentrations of free (96 +/- 16 mumol/L) and total (144 +/- 27 mumol/L) carnitine compared with controls (45 +/- 3, 58 +/- 7 mumol/L, respectively).(ABSTRACT TRUNCATED AT 250 WORDS) PMID:1736038

  12. Pathophysiology of airway colonization in critically ill COPD patient.

    PubMed

    Nseir, Saad; Ader, Florence; Lubret, Rémy; Marquette, Charles-Hugo

    2011-04-01

    Although noninvasive ventilation (NIV) use in severe acute exacerbation of COPD has substantially reduced the need for intubation, an important number of COPD patients still are mechanically ventilated through a tracheal tube in the ICU. Intubation is a major risk factor for lower respiratory tract colonization (LRTC) in ICU patients. Other risk factors for LRTC include colonization of the oral cavity, nasopharynx, and gastric content. Aspiration of contaminated oropharyngeal secretions is increased by supine position, underinflation of tracheal cuff, coma, and sedation. Tracheal tube biofilm formation plays an important role as a reservoir for microorganisms. Reduced cough reflex, altered mucocilliary clearance, hypersecretion and retention of mucus are frequent in COPD patients. In addition, malnutrition and corticosteroid use are common in this population resulting in altered cellular, and humoral immunity and higher risk for LRTC. Incidence of LRTC varies from 22-95% of intubated patients. Pseudomonas aeruginosa is the most frequently isolated microorganism at day 3 after intubation in COPD patients. LRTC is a major risk factor for ventilator-associated pneumonia, which is associated with increased mortality and morbidity in ICU patients. Several measures could be suggested to reduce LRTC in critically ill COPD patients. NIV use in severe acute exacerbations reduces the need for intubation. In addition, the early use of NIV averts respiratory failure after extubation and could reduce the duration of invasive mechanical ventilation. Other measures might be efficient in preventing LRTC such as semirecumbent position, avoidance of gastric distension, polyurethane-cuffed tracheal tubes, silver-coated tracheal tubes, subglottic aspiration, and continuous control of cuff pressure. Further studies should determine the impact of preventive measures aiming at preventing LRTC on outcome of COPD patients requiring intubation and mechanical ventilation in the ICU. PMID

  13. The role of thyroid dysfunction in the critically ill: a review of the literature.

    PubMed

    Bello, G; Ceaichisciuc, I; Silva, S; Antonelli, M

    2010-11-01

    During critical illness, patients with no known history of thyroid disorders may experience multiple alterations in their serum thyroid hormone levels. Such alterations have been termed sick euthyroid syndrome or, more recently, non-thyroidal illness syndrome (NTIS). The laboratory parameters of NTIS usually include low serum levels of triiodothyronine (T3), normal or low serum levels of thyroxine (T4) and normal or low serum levels of thyroid-stimulating hormone (TSH). The magnitude of the alteration in thyroid function correlates with the severity of the illness and its outcomes in critically ill patients with NTIS. The pathogenetic mechanisms involved in NTIS include a decreased conversion of T4 to T3 in extrathyroidal tissues and alterations in thyroid hormones' binding to serum proteins. In cases of protracted critical illness, a decrease in the pulsatile frequency of TSH secretion, resulting from reduced thyrotropin-re leasing hormone (TRH) release by the hypothalamus, may also occur. Several medications or clinical conditions that are commonly present in critically ill patients may be responsible for lowering serum concentrations of thyroid hormone. Among those who study the condition, the question of whether NTIS is a protective adaptation of the organism to illness or a maladaptive response to a stressful insult remains unanswered. In either case, thyroid hormone abnormalities are likely to play a role in the critically ill patient.However, there is currently no convincing evidence to suggest that restoring physiological thyroid hormone concentrations in unselected patients with NTIS would be beneficial. PMID:20935602

  14. Critical illness myopathy: sepsis-mediated failure of the peripheral nervous system.

    PubMed

    Friedrich, O

    2008-01-01

    With better survival of critically ill patients, 'de novo' arising neuromuscular complications like critical illness myopathy or polyneuropathy have been increasingly observed. Prolonged hospitalization not only imposes risks like pneumonia or thrombosis on patients but also represents a real budget threat to modern intensive-care medicine. Clinical symptoms like muscle weakness and weaning failure are common to critical illness myopathy and critical illness polyneuropathy and do not allow for distinction. Specific therapies are not yet available, and the quest for the pathomechanisms has proved more complicated than anticipated. Especially for critical illness myopathy, multiple sites of disturbances to the excitation-contraction coupling cascade are possible causes of muscle weakness. The present review summarizes the epidemiological, clinical and diagnostic features of critical illness myopathy and then focuses on current concepts of the presumed pathomechanisms of critical illness myopathy. Sepsis was shown to be a major cause of critical illness myopathy and special emphasis will be placed on how sepsis and inflammatory mediators influence (i) the membrane excitability at the level of voltage-gated ion channels and (ii) the intracellular protein signalling that results in selective loss of myosin protein content and muscle wasting. For (i), critical illness myopathy represents a new type of acquired channelopathy affecting the inactivation properties of Na+ channels. For (ii), both protein proteolysis and protein build up at the transcriptional level seem to be involved. Findings from different studies are put into a common context to propose a model for cytokine-mediated failure of muscle in severe sepsis. This can open a series of new possible trials to test specific therapeutic strategies in the future. PMID:18289421

  15. Sleep deprivation in critical illness: its role in physical and psychological recovery.

    PubMed

    Kamdar, Biren B; Needham, Dale M; Collop, Nancy A

    2012-01-01

    Critically ill patients frequently experience poor sleep, characterized by frequent disruptions, loss of circadian rhythms, and a paucity of time spent in restorative sleep stages. Factors that are associated with sleep disruption in the intensive care unit (ICU) include patient-ventilator dysynchrony, medications, patient care interactions, and environmental noise and light. As the field of critical care increasingly focuses on patients' physical and psychological outcomes following critical illness, understanding the potential contribution of ICU-related sleep disruption on patient recovery is an important area of investigation. This review article summarizes the literature regarding sleep architecture and measurement in the critically ill, causes of ICU sleep fragmentation, and potential implications of ICU-related sleep disruption on patients' recovery from critical illness. With this background information, strategies to optimize sleep in the ICU are also discussed. PMID:21220271

  16. Sleep Deprivation in Critical Illness: Its Role in Physical and Psychological Recovery

    PubMed Central

    Kamdar, Biren B.; Needham, Dale M.; Collop, Nancy A.

    2012-01-01

    Critically ill patients frequently experience poor sleep, characterized by frequent disruptions, loss of circadian rhythms, and a paucity of time spent in restorative sleep stages. Factors that are associated with sleep disruption in the intensive care unit (ICU) include patient-ventilator dysynchrony, medications, patient care interactions, and environmental noise and light. As the field of critical care increasingly focuses on patients' physical and psychological outcomes following critical illness, understanding the potential contribution of ICU-related sleep disruption on patient recovery is an important area of investigation. This review article summarizes the literature regarding sleep architecture and measurement in the critically ill, causes of ICU sleep fragmentation, and potential implications of ICU-related sleep disruption on patients' recovery from critical illness. With this background information, strategies to optimize sleep in the ICU are also discussed. PMID:21220271

  17. When the severely ill elderly patient refuses food. Ethical reasoning among nurses.

    PubMed

    Jansson, L; Norberg, A; Sandman, P O; Aström, G

    1995-02-01

    Forty registered nurses (RNs) regarded as "good and experienced" in either cancer or dementia care, were asked about their decision to feed or not feed a severely ill elderly woman (a hypothetical case). In order to compare ethical reasoning in the two groups of nurses and to illuminate what it means to RNs to face a situation where the patients can/cannot decide for themselves, a phenomenological hermeneutic approach was used for the analysis. Both groups saw themselves as the advocate for their patients but in different ways. The RNs who talked about a mentally alert patient emphasized that they encouraged their patient to speak up for herself, while the RNs who talked about a severely demented patient emphasized that they tried very hard to interpret their patient's vague and unclear communicative cues and to act as her advocate, especially in relation to physicians. Transcending experiences of dying relatives and patients as well as role models helped them to achieve their ambition of putting themselves in the patient's shoes in order to respect and understand her or his wish and/or what was best for them. The majority of RNs strongly rejected active euthanasia. PMID:7730007

  18. Psycho-physical and neurophysiological effects of qigong on depressed elders with chronic illness.

    PubMed

    Tsang, Hector W H; Tsang, William W N; Jones, Alice Y M; Fung, Kelvin M T; Chan, Alan H L; Chan, Edward P; Au, Doreen W H

    2013-01-01

    This randomized controlled trial examined the psychological, physical, and neurophysiological effects of a qigong exercise program on depressed elders with chronic medical illness. The experimental group (n = 21, 80 ± 7 years) was given a 12-week qigong exercise program, while the comparison group (n = 17, 81 ± 8 years) participated in a newspaper reading program with the same duration and frequency. Measurement of depression symptoms, psychosocial functioning, muscle strengths, salivary cortisol, and serum serotonin was conducted. At 12 weeks, the qigong group had significant reduction in depressive symptoms (F = 11.68; p < 0.025). Improvement in self-efficacy (F = 4.30; p < 0.050), self-concept of physical well-being (F = 6.82; p < 0.025), and right-hand grip strength (F = 5.25; p = 0.034) was also found when compared with the comparison group. A change in salivary cortisol level was found marginally insignificant between groups (F = 3.16; p = 0.087). However, a decreasing trend of cortisol level was observed. The results provided preliminary evidence for the hypotheses that the antidepressive effect of qigong exercise could be explained by improvement in psychosocial functioning and possibly down-regulation of hyperactivity of the hypothalamic-pituitary-adrenal axis. PMID:23072658

  19. What to Expect When a Loved One Is Critically Ill

    MedlinePlus

    ... Program Director Portal Education NTI-National Teaching Institute & Critical Care Exposition E-Learning Continuing Education CE Program Approval ... Academy Webinar Series Conferences NTI-National Teaching Institute & Critical Care Exposition Webinar Series Chapter Events Other Events Clinical ...

  20. Concept of Care, Caring Expectations, and Caring Frustrations of the Elderly Suffering from Chronic Illness

    ERIC Educational Resources Information Center

    de Guzman, Allan B.; Santos, Charisse Izobelle Q.; Santos, Ivan Benedict A.; Santos, Jedda A.; Santos, Justin E.; Santos, Justo Martin S.; Santos, Vincent Emmanuelle E.

    2012-01-01

    While it is true that elderly concepts of care and caring expectations have been ascertained in previous literatures, little is known about how the elderly population views caring frustrations--particularly that of the Filipino elderly. This study purports to surface the lebenswelt of healthcare expectations and frustrations based on the…

  1. Postpyloric enteral nutrition in the critically ill child with shock: a prospective observational study

    PubMed Central

    López-Herce, Jesús; Mencía, Santiago; Sánchez, César; Santiago, Maria J; Bustinza, Amaya; Vigil, Dolores

    2008-01-01

    Background Tolerance to enteral nutrition in the critically ill child with shock has not been studied. The purpose of the study was to analyze the characteristics of enteral nutrition and its tolerance in the critically ill child with shock and to compare this with non-shocked patients. Methods A prospective, observational study was performed including critically ill children with shock who received postpyloric enteral nutrition (PEN). The type of nutrition used, its duration, tolerance, and gastrointestinal complications were assessed. The 65 children with shock who received PEN were compared with 461 non-shocked critically ill children who received PEN. Results Sixty-five critically ill children with shock, aged between 21 days and 22 years, received PEN. 75.4% of patients with shock received PEN exclusively. The mean duration of the PEN was 25.2 days and the maximum calorie intake was 79.4 kcal/kg/day. Twenty patients with shock (30.7%) presented gastrointestinal complications, 10 (15.4%) abdominal distension and/or excessive gastric residue, 13 (20%) diarrhoea, 1 necrotising enterocolitis, and 1 duodenal perforation due to the postpyloric tube. The frequency of gastrointestinal complications was significantly higher than in the other 461 critically ill children (9.1%). PEN was suspended due to gastrointestinal complications in 6 patients with shock (9.2%). There were 18 deaths among the patients with shock and PEN (27.7%). In only one patient was the death related to complications of the nutrition. Conclusion Although most critically ill children with shock can tolerate postpyloric enteral nutrition, the incidence of gastrointestinal complications is higher in this group of patients than in other critically ill children. PMID:18237381

  2. Immunoinflammatory Response in Critically Ill Patients: Severe Sepsis and/or Trauma

    PubMed Central

    Popovic, Nada; Djordjevic, Dragan

    2013-01-01

    Immunoinflammatory response in critically ill patients is very complex. This review explores some of the new elements of immunoinflammatory response in severe sepsis, tumor necrosis factor-alpha in severe acute pancreatitis as a clinical example of immune response in sepsis, immune response in severe trauma with or without secondary sepsis, and genetic aspects of host immuno-inflammatory response to various insults in critically ill patients. PMID:24371374

  3. The growth hormone/insulin-like growth factor axis in critical illness.

    PubMed

    Gelato, M C

    2000-09-01

    Over the past several years, we have studied a variety of clinical conditions that are characterized by significant alterations in the GH/IGF system that might contribute to catabolism. Our studies have focused in detail on IGF-I and -II and the major IGFBPs in the circulation, IGFBP-3, -1, and -2; GH was also measured in some of these studies. In light of a recent study that has raised concerns about the use of GH in critically ill patients, we now review the changes in the GH/IGF axis during critical illness, the interaction between cytokines and the GH/IGF axis, and the safety and efficacy of GH therapy in critical illness. We conclude that it is premature to recommend interruption of GH therapy in patients with documented GH deficiency during periods of acute illness. PMID:11086657

  4. Caring for the critically ill patient with tuberculosis.

    PubMed

    York, Nancy L; Kane, Christy

    2013-01-01

    Pulmonary tuberculosis is still a major health problem in the United States as well as around the world. The purpose of this article is to provide critical care nursing staff as well as other healthcare providers with a foundation to recognize and manage patients with pulmonary tuberculosis. Topics discussed include etiology, risk factors, pathophysiology, multidrug-resistant tuberculosis, extrapulmonary tuberculosis, signs and symptoms, diagnostic testing, and the role of the critical care nurse in the management of these patients. PMID:23222220

  5. Use of Platelet Indices for Determining Illness Severity and Predicting Prognosis in Critically Ill Patients

    PubMed Central

    Zhang, Sheng; Cui, Yun-Liang; Diao, Meng-Yuan; Chen, Deng-Chang; Lin, Zhao-Fen

    2015-01-01

    Background: Decreased platelet (PLT) count is one of the independent risk factors for mortality in intensive care unit (ICU) patients. This study was to investigate the relationship between PLT indices and illness severity and their performances in predicting hospital mortality. Methods: Adult patients who admitted to ICU of Changzheng Hospital from January 2011 to September 2012 and met inclusion criteria were included in this study. Univariate analysis was used to identify potential independent risk factors for mortality. Multiple logistic regression analysis was used to calculate adjusted odds ratio for mortality in patients with normal or abnormal PLT indices. The relationship between PLT indices and illness severity were assessed by the Acute Physiology and Chronic Health Evaluation II (APACHE II) scores or sequential organ failure assessment (SOFA) scores in patients with normal and abnormal PLT indices. The performances of PLT indices in predicting mortality were assessed by receiver operating curves and diagnostic parameters. The survival curves between patients with normal and abnormal PLT indices were compared using Kaplan–Meier method. Results: From January 2011 to September 2012, 261 of 361 patients (204 survivors and 57 nonsurvivors) met the inclusion criteria. After adjustment for clinical variables, PLT count <100 × 1012/L (P = 0.011), plateletcrit (PCT) <0.108 (P = 0.002), mean platelet volume (MPV) >11.3 fL (P = 0.023) and platelet distribution width (PDW) percentage >17% (P = 0.009) were identified as independent risk factors for mortality. The APACHE II and SOFA scores were 14.0 (9.0–20.0) and 7.0 (5.0–10.5) in the “low PLT” tertile, 13.0 (8.0–16.0) and 7.0 (4.0–11.0) in the “low PCT” tertile, 14.0 (9.3–19.0) and 7.0 (4.0–9.8) in the “high MPV” tertile, 14.0 (10.5–20.0) and 7.0 (5.0–11.0) in the “high PDW” tertile, all of which were higher than those in patients with normal indices. Patients with decreased PLT

  6. Diaphragm Muscle Fiber Weakness and Ubiquitin–Proteasome Activation in Critically Ill Patients

    PubMed Central

    Hooijman, Pleuni E.; Beishuizen, Albertus; Witt, Christian C.; de Waard, Monique C.; Girbes, Armand R. J.; Spoelstra-de Man, Angelique M. E.; Niessen, Hans W. M.; Manders, Emmy; van Hees, Hieronymus W. H.; van den Brom, Charissa E.; Silderhuis, Vera; Lawlor, Michael W.; Labeit, Siegfried; Stienen, Ger J. M.; Hartemink, Koen J.; Paul, Marinus A.; Heunks, Leo M. A.

    2015-01-01

    Rationale: The clinical significance of diaphragm weakness in critically ill patients is evident: it prolongs ventilator dependency, and increases morbidity and duration of hospital stay. To date, the nature of diaphragm weakness and its underlying pathophysiologic mechanisms are poorly understood. Objectives: We hypothesized that diaphragm muscle fibers of mechanically ventilated critically ill patients display atrophy and contractile weakness, and that the ubiquitin–proteasome pathway is activated in the diaphragm. Methods: We obtained diaphragm muscle biopsies from 22 critically ill patients who received mechanical ventilation before surgery and compared these with biopsies obtained from patients during thoracic surgery for resection of a suspected early lung malignancy (control subjects). In a proof-of-concept study in a muscle-specific ring finger protein-1 (MuRF-1) knockout mouse model, we evaluated the role of the ubiquitin–proteasome pathway in the development of contractile weakness during mechanical ventilation. Measurements and Main Results: Both slow- and fast-twitch diaphragm muscle fibers of critically ill patients had approximately 25% smaller cross-sectional area, and had contractile force reduced by half or more. Markers of the ubiquitin–proteasome pathway were significantly up-regulated in the diaphragm of critically ill patients. Finally, MuRF-1 knockout mice were protected against the development of diaphragm contractile weakness during mechanical ventilation. Conclusions: These findings show that diaphragm muscle fibers of critically ill patients display atrophy and severe contractile weakness, and in the diaphragm of critically ill patients the ubiquitin–proteasome pathway is activated. This study provides rationale for the development of treatment strategies that target the contractility of diaphragm fibers to facilitate weaning. PMID:25760684

  7. The relevance of drug clearance to antibiotic dosing in critically ill patients.

    PubMed

    Roberts, Darren M

    2011-12-01

    To maximise the effect of an antibiotic it is necessary to pay careful attention to dosing. The maintenance dose is determined by antibiotic clearance which is usually determined in young healthy adults with normal physiology. Antibiotic clearance in critically ill patients may increase or decrease due to altered physiology and the treatments that are administered. Clearance may also vary significantly over time in patients with critical illness. Advancing age and comorbidities, in particular chronic kidney disease, can also decrease antibiotic clearance. Therefore, it is complicated and arguably impossible to suggest generic guidelines for the dosing of antibiotics in critically ill patients. Factors that influence clearance must be identified and accounted for in each patient for a rational approach to dose adjustment of antibiotics in patients with critical illness. The necessary changes can be predicted by understanding pharmacokinetic concepts. It is necessary to quantify organ function in patients at multiple time points because this can be used to estimate antibiotic clearance and guide dose selection. For example, creatinine clearance should be calculated but methods used in ambulatory patients may not apply to patients with critical illness. If possible, therapeutic drug monitoring should be conducted to ensure that antibiotic concentration targets are achieved and also to guide titration of subsequent doses. If blood sampling is carefully planned it may be possible to directly measure antibiotic clearance for dose adjustment. The purpose of this article is to review the concept of clearance and to highlight circumstances where antibiotic clearance may be altered in patients with critical illness. Strategies for dose modification of antibiotics in critically ill patients will be discussed. PMID:21554217

  8. Use of virtual reality gaming systems for children who are critically ill.

    PubMed

    Salem, Yasser; Elokda, Ahmed

    2014-01-01

    Children who are critically ill are frequently viewed as "too sick" to tolerate physical activity. As a result, these children often fail to develop strength or cardiovascular endurance as compared to typically developing children. Previous reports have shown that early participation in physical activity in is safe and feasible for patients who are critically ill and may result in a shorter length of stay and improved functional outcomes. The use of the virtual reality gaming systems has become a popular form of therapy for children with disabilities and has been supported by a growing body of evidence substantiating its effectiveness with this population. The use of the virtual reality gaming systems in pediatric rehabilitation provides the children with opportunity to participate in an exercise program that is fun, enjoyable, playful, and at the same time beneficial. The integration of those systems in rehabilitation of children who are critically ill is appealing and has the potential to offer the possibility of enhancing physical activities. The lack of training studies involving children who are critically ill makes it difficult to set guidelines on the recommended physical activities and virtual reality gaming systems that is needed to confer health benefits. Several considerations should be taken into account before recommended virtual reality gaming systems as a training program for children who are critically ill. This article highlighted guidelines, limitations and challenges that need to be considered when designing exercise program using virtual reality gaming systems for critically ill children. This information is helpful given the popular use of virtual reality gaming systems in rehabilitation, particularly in children who are critically ill. PMID:25260510

  9. Tracheostomy in special groups of critically ill patients: Who, when, and where?

    PubMed Central

    Longworth, Aisling; Veitch, David; Gudibande, Sandeep; Whitehouse, Tony; Snelson, Catherine; Veenith, Tonny

    2016-01-01

    Tracheostomy is one of the most common procedures undertaken in critically ill patients. It offers many theoretical advantages over translaryngeal intubation. Recent evidence in a heterogeneous group of critically ill patients, however, has not demonstrated a benefit for tracheostomy, in terms of mortality, length of stay in Intensive Care Unit (ICU), or incidence of ventilator-associated pneumonia. It may be a beneficial intervention in articular subsets of ICU patients. In this article, we will focus on the evidence for the timing of tracheostomy and its effect on various subgroups of patients in critical care. PMID:27275076

  10. Instructional Effects on Critical Thinking: Performance on Ill-Defined Issues

    ERIC Educational Resources Information Center

    Angeli, Charoula; Valanides, Nicos

    2009-01-01

    Undergraduate students in dyads (N = 72) were randomly and equally assigned to four groups, namely three teaching groups (General, Infusion, and Immersion) and the control group. Students were initially administered the California Critical Thinking Skills Test (CCTST). After instruction, each dyad's critical-thinking performance on an ill-defined…

  11. Intensive care unit acquired weakness in children: Critical illness polyneuropathy and myopathy

    PubMed Central

    Kukreti, Vinay; Shamim, Mosharraf; Khilnani, Praveen

    2014-01-01

    Background and Aims: Intensive care unit acquired weakness (ICUAW) is a common occurrence in patients who are critically ill. It is most often due to critical illness polyneuropathy (CIP) or to critical illness myopathy (CIM). ICUAW is increasingly being recognized partly as a consequence of improved survival in patients with severe sepsis and multi-organ failure, partly related to commonly used agents such as steroids and muscle relaxants. There have been occasional reports of CIP and CIM in children, but little is known about their prevalence or clinical impact in the pediatric population. This review summarizes the current understanding of pathophysiology, clinical presentation, diagnosis and treatment of CIP and CIM in general with special reference to published literature in the pediatric age group. Subjects and Methods: Studies were identified through MedLine and Embase using relevant MeSH and Key words. Both adult and pediatric studies were included. Results: ICUAW in children is a poorly described entity with unknown incidence, etiology and unclear long-term prognosis. Conclusions: Critical illness polyneuropathy and myopathy is relatively rare, but clinically significant sequelae of multifactorial origin affecting morbidity, length of intensive care unit (ICU) stay and possibly mortality in critically ill children admitted to pediatric ICU. PMID:24678152

  12. Long-term psychosocial impact reported by childhood critical illness survivors: a systematic review

    PubMed Central

    Manning, Joseph C; Hemingway, Pippa; Redsell, Sarah A

    2014-01-01

    Aim To undertake a qualitative systematic review that explores psychological and social impact, reported directly from children and adolescents at least 6 months after their critical illness. Background Significant advances in critical care have reduced mortality from childhood critical illness, with the majority of patients being discharged alive. However, it is widely reported that surviving critical illness can be traumatic for both children and their family. Despite a growing body of literature in this field, the psychological and social impact of life threatening critical illness on child and adolescent survivors, more than 6 months post event, remains under-reported. Data sources Searches of six online databases were conducted up to February 2012. Review methods Predetermined criteria were used to select studies. Methodological quality was assessed using a standardized checklist. An adapted version of the thematic synthesis approach was applied to extract, code and synthesize data. Findings Three studies met the inclusion criteria, which were all of moderate methodological quality. Initial coding and synthesis of data resulted in five descriptive themes: confusion and uncertainty, other people's narratives, focus on former self and normality, social isolation and loss of identity, and transition and transformation. Further synthesis culminated in three analytical themes that conceptualize the childhood survivors' psychological and social journey following critical illness. Conclusions Critical illness in childhood can expose survivors to a complex trajectory of recovery, with enduring psychosocial adversity manifesting in the long term. Nurses and other health professionals must be aware and support the potential multifaceted psychosocial needs that may arise. Parents and families are identified as fundamental in shaping psychological and social well-being of survivors. Therefore intensive care nurses must take opportunities to raise parents' awareness of the

  13. Feeding the critically ill obese patient: the role of hypocaloric nutrition support.

    PubMed

    Miller, Jerad P; Choban, Patricia Smith

    2006-12-01

    Obesity and its many metabolic and physiologic comorbidities are becoming more common. Thus, a strategy to approach the nutritional needs of obese critically ill patients is warranted. The adverse effect of obesity on the respiratory system is well established. The obesity may be an inciting event or merely an additional burden in the obese critically ill patient. A strategy of hypocaloric nutrition support avoids the many detrimental effects of overfeeding and has been considered for all critically ill patients. In the obese patient, the strategy addresses the additional problem of the excessive fat store and has the additional benefit of fat reduction while sparing lean body mass. In the patient with normal renal and hepatic function, hypocaloric nutrition support simplifies care and may improve outcome. PMID:17150433

  14. The Gut as the Motor of Multiple Organ Dysfunction in Critical Illness.

    PubMed

    Klingensmith, Nathan J; Coopersmith, Craig M

    2016-04-01

    All elements of the gut - the epithelium, the immune system, and the microbiome - are impacted by critical illness and can, in turn, propagate a pathologic host response leading to multiple organ dysfunction syndrome. Preclinical studies have demonstrated that this can occur by release of toxic gut-derived substances into the mesenteric lymph where they can cause distant damage. Further, intestinal integrity is compromised in critical illness with increases in apoptosis and permeability. There is also increasing recognition that microbes alter their behavior and can become virulent based upon host environmental cues. Gut failure is common in critically ill patients; however, therapeutics targeting the gut have proven to be challenging to implement at the bedside. Numerous strategies to manipulate the microbiome have recently been used with varying success in the ICU. PMID:27016162

  15. Propofol-Related Infusion Syndrome in Critically Ill Pediatric Patients: Coincidence, Association, or Causation?

    PubMed Central

    Timpe, Erin M.; Eichner, Samantha F.; Phelps, Stephanie J.

    2006-01-01

    Over the past two decades numerous reports have described the development of a propofol-related infusion syndrome (PRIS) in critically ill adult and pediatric patients who received continuous infusion propofol for anesthesia or sedation. The syndrome is generally characterized by progressive metabolic acidosis, hemodynamic instability and bradyarrhythmias that are refractory to aggressive pharmacological treatments. PRIS may occur with or without the presence of hepatomegaly, rhabdomyolysis or lipemia. To date, the medical literature contains accounts of 20 deaths in critically ill pediatric patients who developed features consistent with PRIS. These reports have generated considerable discussion and debate regarding the relationship, if any, between propofol and a constellation of clinical symptoms and features that have been attributed to its use in critically ill pediatric patients. This paper reviews the literature concerning PRIS, its clinical presentation, proposed mechanisms for the syndrome, and potential management should the syndrome occur. PMID:23118644

  16. Early and Late Unplanned Rehospitalizations for Survivors of Critical Illness*

    PubMed Central

    Hua, May; Gong, Michelle Ng; Brady, Joanne; Wunsch, Hannah

    2015-01-01

    Objectives Preventing rehospitalizations for patients with serious chronic illnesses is a focus of national quality initiatives. Although 8 million people are admitted yearly to an ICU, the frequency of rehospitalizations (readmissions to the hospital after discharge) is unknown. We sought to determine the frequency of rehospitalization after an ICU stay, outcomes for rehospitalized patients, and factors associated with rehospitalization. Design Retrospective cohort study using the New York Statewide Planning and Research Cooperative System, an administrative database of all hospital discharges in New York State. Setting ICUs in New York State. Patients ICU patients who survived to hospital discharge in 2008–2010. Interventions None. Measurements and Main Results Primary outcome was the cumulative incidence of first early rehospitalization (within 30 days of discharge), and secondary outcome was the cumulative incidence of late rehospitalization (between 31 and 180 d). Factors associated with rehospitalization within both time periods were identified using competing risk regression models. Of 492,653 ICU patients, 79,960 had a first early rehospitalization (cumulative incidence, 16.2%) and an additional 73,250 late rehospitalizations (cumulative incidence, 18.9%). Over one quarter of all rehospitalizations (28.6% for early; 26.7% for late) involved ICU admission. Overall hospital mortality for rehospitalized patients was 7.6% for early and 4.6% for late rehospitalizations. Longer index hospitalization (adjusted hazard ratio, 1.61; 95% CI, 1.57–1.66 for 7–13 dvs < 3 d), discharge to a skilled nursing facility versus home (adjusted hazard ratio, 1.54; 95% CI, 1.51–1.58), and having metastatic cancer (adjusted hazard ratio, 1.46; 95% CI, 1.41–1.51) were associated with the greatest hazard of early rehospitalization. Conclusions Approximately 16% of ICU survivors were rehospitalized within 30 days of hospital discharge; rehospitalized patients had high rates

  17. The Critically Ill Infant with Congenital Heart Disease.

    PubMed

    Strobel, Ashley M; Lu, Le N

    2015-08-01

    This article presents an approach for identification of infants with congenital heart disorders. These disorders are difficult to diagnose because of the complexity and variety of cardiac malformations; additionally presentation can be complicated by age-dependent physiology. By compiling data from the history and the physical examination, the emergency physician can identify lesion category and initiate stabilization procedures. Critical congenital cardiac lesions can be classified as left-sided obstructive ductal dependent, right-sided obstructive ductal dependent, and shunting or mixing. The simplified approach categorizes infants with these lesions respectively as "pink," "blue," or "gray." The emergency provider can provide life-saving stabilization until specialized care can be obtained. PMID:26226862

  18. Pharmacological and nonpharmacological management of delirium in critically ill patients.

    PubMed

    Hipp, Dustin M; Ely, E Wesley

    2012-01-01

    Delirium is a common yet under-diagnosed syndrome of acute brain dysfunction, which is characterized by inattention, fluctuating mental status, altered level of consciousness, or disorganized thinking. Although our recognition of risk factors for delirium has progressed, our understanding of the underlying pathophysiologic mechanisms remains limited. Improvements in monitoring and assessment for delirium (particularly in the intensive care setting) have resulted in validated and reliable tools such as arousal scales and bedside delirium monitoring instruments. Once delirium is recognized and the modifiable risk factors are addressed, the next step in management (if delirium persists) is often pharmacological intervention. The sedatives, analgesics, and hypnotics most often used in the intensive care unit (ICU) to achieve patient comfort are all too frequently deliriogenic, resulting in a longer duration of ICU and hospital stay, and increased costs. Therefore, identification of safe and efficacious agents to reduce the incidence, duration, and severity of ICU delirium is a hot topic in critical care. Recognizing that there are no medications approved by the Food and Drug Administration (FDA) for the prevention or treatment of delirium, we chose anti-psychotics and alpha-2 agonists as the general pharmacological focus of this article because both were subjects of relatively recent data and ongoing clinical trials. Emerging pharmacological strategies for addressing delirium must be combined with nonpharmacological approaches (such as daily spontaneous awakening trials and spontaneous breathing trials) and early mobility (combined with the increasingly popular approach called: Awakening and Breathing Coordination, Delirium Monitoring, Early Mobility, and Exercise [ABCDE] of critical care) to develop evidence-based approaches that will ensure safer and faster recovery of the sickest patients in our healthcare system. PMID:22270810

  19. Acidosis in the critically ill - balancing risks and benefits to optimize outcome

    PubMed Central

    2014-01-01

    Acidosis is associated with poor outcome in critical illness. However, acidosis - both hypercapnic and metabolic - has direct effects that can limit tissue injury induced by many causes. There is also a clear potential for off-target harm with acute exposure (for example, raised intracranial pressure, pulmonary hypertension), and with exposure for prolonged periods (for example, increased risk of infection) or at high doses. Ongoing comprehensive determination of molecular, cellular and physiologic impact across a range of representative pathologies will allow us to understand better the risks and benefits of hypercapnia and acidosis during critical illness. PMID:25029442

  20. Critical illness myopathy and polyneuropathy - A challenge for physiotherapists in the intensive care units.

    PubMed

    Pattanshetty, Renu B; Gaude, Gajanan S

    2011-04-01

    The development of critical patient related generalized neuromuscular weakness, referred to as critical illness polyneuropathy (CIP) and critical illness myopathy (CIM), is a major complication in patients admitted to intensive care units (ICU). Both CIP and CIM cause muscle weakness and paresis in critically ill patients during their ICU stay. Early mobilization or kinesiotherapy have shown muscle weakness reversion in critically ill patients providing faster return to function, reducing weaning time, and length of hospitalization. Exercises in the form of passive, active, and resisted forms have proved to improve strength and psychological well being. Clinical trials using neuromuscular electrical stimulation to increase muscle mass, muscle strength and improve blood circulation to the surrounding tissue have proved beneficial. The role of electrical stimulation is unproven as yet. Recent evidence indicates no difference between treated and untreated muscles. Future research is recommended to conduct clinical trials using neuromuscular electrical stimulation, exercises, and early mobilization as a treatment protocol in larger populations of patients in ICU. PMID:21814370

  1. A single nucleotide polymorphism in the corticotropin receptor gene is associated with a blunted cortisol response during pediatric critical illness

    PubMed Central

    Jardine, David; Emond, Mary; Meert, Kathleen L.; Harrison, Rick; Carcillo, Joseph A.; Anand, Kanwaljeet J. S.; Berger, John; Newth, Christopher J. L.; Willson, Douglas F.; Nicholson, Carol; Dean, J. Michael; Zimmerman, Jerry J.

    2016-01-01

    Objective The cortisol response during critical illness varies widely among patients. Our objective was to examine single nucleotide polymorphisms (SNPs) in candidate genes regulating cortisol synthesis, metabolism, and activity to determine if genetic differences were associated with variability in the cortisol response among critically ill children. Design This was a prospective observational study employing tag SNP methodology to examine genetic contributions to the variability of the cortisol response in critical illness. Thirty-one candidate genes and 31 ancestry markers were examined. Setting Patients were enrolled from 7 pediatric critical care units that constitute the Eunice Kennedy Shriver Collaborative Pediatric Critical Care Research Network. Subjects Critically ill children (n=92), ages 40 weeks gestation to 18 years of age were enrolled. Interventions Blood samples were obtained from all patients for serum cortisol measurements and DNA isolation. Demographic and illness severity data were collected. Measurements and Main Results SNPs were tested for association with serum free cortisol (FC) concentrations in context of higher illness severity as quantified by PRISM III score > 7. A SNP (rs1941088) in the MC2R gene was strongly associated (p =0.0005) with a low FC response to critical illness. Patients with the AA genotype were over seven times more likely to have a low FC response to critical illness than those with a GG genotype. Patients with the GA genotype exhibited an intermediate FC response to critical illness. Conclusions The A allele at rs1941088 in the MC2R gene, that encodes the ACTH (corticotropin) receptor, is associated with a low cortisol response in critically ill children. These data provide evidence for a genetic basis for a portion of the variability in cortisol production during critical illness. Independent replication of these findings will be important and could facilitate development of personalized treatment for patients with

  2. Use of complementary and alternative therapies to promote sleep in critically ill patients.

    PubMed

    Richards, Kathy; Nagel, Corey; Markie, Megan; Elwell, Jean; Barone, Claudia

    2003-09-01

    The efficacy of complementary and alternative therapies for sleep promotion in critically ill patients is largely unexamined. We found only seven studies (three on environmental interventions and one each on massage, music therapy, therapeutic touch, and, melatonin) that examined the effect of complementary and alternative therapies. A number of studies, however, have shown that massage, music therapy. and therapeutic touch promote relaxation and comfort in critically ill patients, which likely leads to improved sleep. Massage, music therapy, and therapeutic touch are safe for critically ill patients and should be routinely applied by ICU nurses who have received training on how to administer these specialized interventions. Environmental interventions, such as reducing noise, playing white noise such as ocean sounds, and decreasing interruptions to sleep for care, also are safe and logical interventions that ICU nurses should use to help patients sleep. Progressive muscle relaxation has been extensively studied and shown to be efficacious for improving sleep in persons with insomnia; however, progressive muscle relaxation requires that patients consciously attend to relaxing specific muscle groups and practice these techniques, which may be difficult for critically 11 patients. We do not currently recommend aromatherapy and alternative sedatives, such as valerian and melatonin, for sleep promotion in critically ill patients because the safety of these substances is unclear. In summary, we recommend that ICU nurses implement music therapy, environmental interventions, therapeutic touch, and relaxing massage to promote sleep in critically ill patients. These interventions are safe and may improve patient sleep, although randomized controlled trials are needed to test their efficacy. Aromatherapy and alternative sedatives require further investigation to determine their safety and efficacy. PMID:12943139

  3. Surviving Critical Illness: The Acute Respiratory Distress Syndrome as Experienced by Patients and Their Caregivers

    PubMed Central

    Cox, Christopher E.; Docherty, Sharron L.; Brandon, Debra H.; Whaley, Christie; Attix, Deborah K.; Clay, Alison S.; Dore, Daniel V.; Hough, Catherine L.; White, Douglas B.; Tulsky, James A.

    2009-01-01

    Objective Survivors of the acute respiratory distress syndrome (ARDS), a systemic critical illness, often report poor quality of life based on responses to standardized questionnaires. However, the experiences of ARDS survivors have not been reported. Our objective was to characterize the effects of critical illness in the daily lives and functioning of ARDS survivors. Design, Setting, and Patients We recruited consecutively 31 ARDS survivors and their informal caregivers from medical and surgical intensive care units of an academic medical center and a community hospital. Eight patients died before completing interviews. We conducted semi-structured interviews with 23 ARDS survivors and 24 caregivers three to nine months after ICU admission, stopping enrollment after thematic saturation was reached. Transcripts were analyzed using Colaizzi’s qualitative methodology to identify significant ways in which survivors’ critical illness experience impacted their lives. Measurements and Main Results Participants related five key elements of experience as survivors of ARDS: pervasive memories of critical care, day to day impact of new disability, critical illness defining the sense of self, relationship strain and change, and ability to cope with disability. Survivors described remarkable disability that persisted for months. Caregivers’ interviews revealed substantial strain from caregiving responsibilities, as well as frequent symptom minimization by patients. Conclusions The diverse and unique experiences of ARDS survivors reflect the global impact of severe critical illness. We have identified symptom domains important to ARDS patients that are not well represented in existing health outcomes measures. These insights may aid the development of targeted interventions to enhance recovery and return of function after ARDS. PMID:19865004

  4. Therapeutic monitoring of amikacin and gentamicin in critically and noncritically ill patients

    PubMed Central

    Kovačević, Tijana; Avram, Sanja; Milaković, Dragana; Špirić, Nikolina; Kovačević, Pedja

    2016-01-01

    Objective: Therapeutic drug monitoring (TDM) enables individualization in the treatment to optimize clinical benefit and minimize drugs' side effects. Critically ill septic patients represent a challenge for antimicrobial treatment because of pathophysiological impact of sepsis on pharmacokinetics of drugs. The aim of this study was to assess the appropriateness of gentamicin and amikacin dosing in critically and noncritically ill patients, as well as to estimate the need for its regular therapeutic monitoring. Subjects and Methods: It was a prospective study which included 31 patients on gentamicin and 16 patients on amikacin from four different units who met the inclusion criteria. Trough concentrations of drugs were measured in serum just before third or fourth dose of antibiotic, whereas peak concentrations were measured in serum 1 h after the completion of drug administration (steady state). Relevant data on patients' clinical course of disease, comorbidities, and concomitant medication were collected from medical charts in order to identify their possible influence on drugs' concentrations. Results: Peak concentrations of amikacin were in reference range in 81.8% critically ill and in 80% of noncritically ill patients (P = 0.931). Peak concentrations of gentamicin were in reference range in 88.9% critically ill and in 77.3% of noncritically ill patients (P = 0.457). Conclusion: Serum concentrations of aminoglycosides (amikacin and gentamicin) were in reference range in most of the patients in our study, suggesting that dosing of these drugs in the University Hospital Clinical Center, Banja Luka, was adequate. In patients without kidney or liver disease, regular TDM of aminoglycosides is not necessary. PMID:27330257

  5. Separating wheat from chaff: examining the obesity paradox in the critically ill

    PubMed Central

    2013-01-01

    Obesity is an increasing burden globally. In the general population, the obese have an increased mortality risk. Regarding the critically ill, a growing body of literature supports the obesity paradox, the notion that obesity confers a protective effect in certain disease states. However, the paucity of methodologically sound trials prevents definitive interpretation and may obscure risks. PMID:23890365

  6. Gut Microbial Translocation in Critically Ill Children and Effects of Supplementation with Pre- and Pro Biotics

    PubMed Central

    Papoff, Paola; Ceccarelli, Giancarlo; d'Ettorre, Gabriella; Cerasaro, Carla; Caresta, Elena; Midulla, Fabio; Moretti, Corrado

    2012-01-01

    Bacterial translocation as a direct cause of sepsis is an attractive hypothesis that presupposes that in specific situations bacteria cross the intestinal barrier, enter the systemic circulation, and cause a systemic inflammatory response syndrome. Critically ill children are at increased risk for bacterial translocation, particularly in the early postnatal age. Predisposing factors include intestinal obstruction, obstructive jaundice, intra-abdominal hypertension, intestinal ischemia/reperfusion injury and secondary ileus, and immaturity of the intestinal barrier per se. Despite good evidence from experimental studies to support the theory of bacterial translocation as a cause of sepsis, there is little evidence in human studies to confirm that translocation is directly correlated to bloodstream infections in critically ill children. This paper provides an overview of the gut microflora and its significance, a focus on the mechanisms employed by bacteria to gain access to the systemic circulation, and how critical illness creates a hostile environment in the gut and alters the microflora favoring the growth of pathogens that promote bacterial translocation. It also covers treatment with pre- and pro biotics during critical illness to restore the balance of microbial communities in a beneficial way with positive effects on intestinal permeability and bacterial translocation. PMID:22934115

  7. New insights into the controversy of adrenal function during critical illness.

    PubMed

    Boonen, Eva; Bornstein, Stefan R; Van den Berghe, Greet

    2015-10-01

    Critical illness represents a life-threatening disorder necessitating recruitment of defence mechanisms for survival. Herein, the hypothalamic-pituitary-adrenal axis is essential. However, the relevance of a relative insufficiency of the hypothalamic-pituitary-adrenal axis in critical illness, which is diagnosed by a suppressed cortisol response to exogenous adrenocorticotropic hormone (ACTH) irrespective of the plasma cortisol concentration, is controversial. Findings from several studies have provided insights that clarify at least part of this controversy. Rather than an activated hypothalamic-pituitary-adrenal axis, ACTH-independent regulators have been reported to contribute to increased cortisol availability during critical illness. One of these regulators is reduced cortisol breakdown, mediated by suppressed expression and activity of cortisol metabolising enzymes in the liver and kidneys. This downstream mechanism increases concentrations of plasma cortisol, but the ensuing feedback-inhibited ACTH release, when sustained for more than 1 week, has been shown to negatively affect adrenocortical integrity and function. Reduced adrenocortical ACTH signalling could explain reduced cortisol responses to exogenous ACTH. Whether such reduced cortisol responses in the presence of raised plasma (free) cortisol identifies adrenal failure needing treatment is unlikely. Additionally, reduced cortisol breakdown affects the optimum dose of hydrocortisone treatment during critical illness. Identification of patients with an insufficient hypothalamic-pituitary-adrenal axis response and the optimum treatment for this disorder clearly need more well designed preclinical and clinical studies. PMID:26071883

  8. A new approach to defining and diagnosing malnutrition in adult critical illness

    Technology Transfer Automated Retrieval System (TEKTRAN)

    This review will highlight a new approach to defining malnutrition syndromes for critically ill adults that incorporates a modern understanding of the contributions of inflammatory response. A systematic approach to nutrition assessment is described to help support diagnosis. Recent findings sugges...

  9. How much does it cost to identify a critically ill child experiencing electrographic seizures?

    PubMed Central

    Abend, Nicholas S.; Topjian, Alexis A; Williams, Sankey

    2015-01-01

    Objectives Electrographic seizures in critically ill children may be identified by continuous electroencephalographic (EEG) monitoring. We evaluated the cost-effectiveness of four electrographic seizure identification strategies (no EEG monitoring and EEG monitoring for 1 hour, 24 hours, or 48 hours). Methods We created a decision tree to model the relationships among variables from a societal perspective. To provide input for the model, we estimated variable costs directly related to EEG monitoring from their component parts, and we reviewed the literature to estimate the probabilities of outcomes. We calculated incremental cost-effectiveness ratios to identify the tradeoff between cost and effectiveness at different willingness-to-pay values. Results Our analysis found that the preferred strategy was EEG monitoring for 1 hour, 24 hours, and 48 hours if the decision maker was willing to pay <$1,666, $1,666–$22,648, and >$22,648 per critically ill child identified with electrographic seizures, respectively. The 48 hour strategy only identified 4% more children with electrographic seizures at substantially higher cost. Sensitivity analyses found that all three strategies were acceptable at lower willingness-to-pay values when children with higher electrographic seizure risk were monitored. Conclusions Our results support monitoring of critically ill children for 24 hours because the cost to identify a critically ill child with electrographic seizures is modest. Further study is needed to predict better which children may benefit from 48 hours of EEG monitoring since the costs are much higher. PMID:25626776

  10. Critically Ill Patients and End-of-Life Decision-Making: The Senior Medical Resident Experience

    ERIC Educational Resources Information Center

    Ahern, Stephane P.; Doyle, Tina K.; Marquis, Francois; Lesk, Corey; Skrobik, Yoanna

    2012-01-01

    In order to improve the understanding of educational needs among residents caring for the critically ill, narrative accounts of 19 senior physician trainees participating in level of care decision-making were analyzed. In this multicentre qualitative study involving 9 university centers in Canada, in-depth interviews were conducted in either…

  11. Relationship Between Upper Respiratory Tract Influenza Test Result and Clinical Outcomes Among Critically Ill Influenza Patients

    PubMed Central

    Reddy, Krishna P.; Bajwa, Ednan K.; Parker, Robert A.; Onderdonk, Andrew B.; Walensky, Rochelle P.

    2016-01-01

    Among critically ill patients with lower respiratory tract (LRT)-confirmed influenza, we retrospectively observed worse 28-day clinical outcomes in upper respiratory tract (URT)-negative versus URT-positive subjects. This finding may reflect disease progression and highlights the need for influenza testing of both URT and LRT specimens to improve diagnostic yield and possibly inform prognosis. PMID:26966696

  12. Vitamin D deficiency in critically ill children: A roadmap to interventional research

    Technology Transfer Automated Retrieval System (TEKTRAN)

    Two studies published this month in Pediatrics provide new and unique information regarding the relationship between vitamin D status and critical illnesses in children admitted to PICUs in the United States and Canada. These two studies, from Boston Children's Hospital and six PICUs in Canada, demo...

  13. Enteral Glutamine Administration in Critically Ill Nonseptic Patients Does Not Trigger Arginine Synthesis

    PubMed Central

    Vermeulen, Mechteld A. R.; Brinkmann, Saskia J. H.; Buijs, Nikki; Beishuizen, Albertus; Bet, Pierre M.; Houdijk, Alexander P. J.; van Goudoever, Johannes B.; van Leeuwen, Paul A. M.

    2016-01-01

    Glutamine supplementation in specific groups of critically ill patients results in favourable clinical outcome. Enhancement of citrulline and arginine synthesis by glutamine could serve as a potential mechanism. However, while receiving optimal enteral nutrition, uptake and enteral metabolism of glutamine in critically ill patients remain unknown. Therefore we investigated the effect of a therapeutically relevant dose of L-glutamine on synthesis of L-citrulline and subsequent L-arginine in this group. Ten versus ten critically ill patients receiving full enteral nutrition, or isocaloric isonitrogenous enteral nutrition including 0.5 g/kg L-alanyl-L-glutamine, were studied using stable isotopes. A cross-over design using intravenous and enteral tracers enabled splanchnic extraction (SE) calculations. Endogenous rate of appearance and SE of glutamine citrulline and arginine was not different (SE controls versus alanyl-glutamine: glutamine 48 and 48%, citrulline 33 versus 45%, and arginine 45 versus 42%). Turnover from glutamine to citrulline and arginine was not higher in glutamine-administered patients. In critically ill nonseptic patients receiving adequate nutrition and a relevant dose of glutamine there was no extra citrulline or arginine synthesis and glutamine SE was not increased. This suggests that for arginine synthesis enhancement there is no need for an additional dose of glutamine when this population is adequately fed. This trial is registered with NTR2285. PMID:27200186

  14. Facial expression and pain in the critically ill non-communicative patient: State of science review

    PubMed Central

    Arif-Rahu, Mamoona; Grap, Mary Jo

    2013-01-01

    Summary The aim of this review is to analyse the evidence related to the relationship between facial expression and pain assessment tools in the critically ill non-communicative patients. Pain assessment is a significant challenge in critically ill adults, especially those who are unable to communicate their pain level. During critical illness, many factors alter verbal communication with patients including tracheal intubation, reduced level of consciousness and administration of sedation and analgesia. The first step in providing adequate pain relief is using a systematic, consistent assessment and documentation of pain. However, no single tool is universally accepted for use in these patients. A common component of behavioural pain tools is evaluation of facial behaviours. Although use of facial expression is an important behavioural measure of pain intensity, there are inconsistencies in defining descriptors of facial behaviour. Therefore, it is important to understand facial expression in non-communicative critically ill patients experiencing pain to assist in the development of concise descriptors to enhance pain evaluation and management. This paper will provide a comprehensive review of the current state of science in the study of facial expression and its application in pain assessment tools. PMID:21051234

  15. Physical, Cognitive, and Psychological Disability Following Critical Illness: What Is the Risk?

    PubMed

    Jutte, Jennifer E; Erb, Christopher T; Jackson, James C

    2015-12-01

    Critical illnesses affect millions of individuals annually in the United States. As advances in patient care continue to improve, the number of survivors is rapidly growing. Critical illness survivors endure profoundly severe illnesses and live through often frightening experiences throughout the course of ICU hospitalization, resulting in a variety of "survivorship" challenges, expressed through a condition known as post-intensive care syndrome (PICS). Questions abound regarding the ideal protocols for ensuring the best physical, cognitive, and psychological outcomes for these survivors. Organizational change is likely to be a key factor, though the specific components have not yet been established. Throughout this article, we highlight some of the barriers and facilitators to enhancing patient care across the spectrum of critical care environments, while also highlighting the challenges inherent to studying a complex patient population. We address each of the areas potentially affected by critical illness and ICU hospitalization--physical, cognitive, and psychological functional domains--experienced by patients as well as their family caregivers. PMID:26595053

  16. Ontogeny of methionine utilization and splanchnic uptake in critically ill children

    Technology Transfer Automated Retrieval System (TEKTRAN)

    To determine the rates of methionine splanchnic uptake and utilization in critically ill pediatric patients, we used two kinetic models: the plasma methionine enrichment,and the "intracellular" homocysteine enrichment. Twenty-four patients, eight infants, eight children, and eight adolescents, were ...

  17. Effects of acute critical illnesses on the performance of interferon-gamma release assay

    PubMed Central

    Huang, Chun-Ta; Ruan, Sheng-Yuan; Tsai, Yi-Ju; Kuo, Ping-Hung; Ku, Shih-Chi; Lee, Pei-Lin; Kuo, Lu-Cheng; Hsu, Chia-Lin; Huang, Chun-Kai; Yang, Ching-Yao; Chien, Ying-Chun; Wang, Jann-Yuan; Yu, Chong-Jen

    2016-01-01

    Performance of interferon-gamma release assays (IGRAs) is influenced by preanalytical, laboratory and host factors. The data regarding how critical illnesses influence IGRA results are limited. This study aimed to investigate IGRA performance among critically ill patients. Patients admitted to intensive care unit (ICU) were prospectively enrolled, and underwent QuantiFERON-TB Gold In-Tube testing on admission and discharge. The associations between patient factors and IGRA results were explored. In total, 118 patients were included. IGRA results on admission were positive, negative and indeterminate for 10(9%), 36(31%) and 72(61%) patients. All indeterminate results were due to a low mitogen response. Indeterminate results were associated with higher disease severity and lower serum albumin levels. Ninety(76%) patients survived to ICU discharge and had repeat IGRA testing 13.3 ± 10.1 days after first ones. Of those, 43(48%) had indeterminate results, and no IGRA conversion or reversion was observed. The majority (35/51, 69%) of ICU survivors with initial indeterminate results still had indeterminates on follow-up testing. Acute critical illnesses exert a significant impact on IGRA performance and a high proportion of indeterminate results was seen in ICU patients. This study highlights limitation of IGRAs in the critically ill and judicious selection of patients to be tested should be considered. PMID:26804487

  18. Effects of acute critical illnesses on the performance of interferon-gamma release assay.

    PubMed

    Huang, Chun-Ta; Ruan, Sheng-Yuan; Tsai, Yi-Ju; Kuo, Ping-Hung; Ku, Shih-Chi; Lee, Pei-Lin; Kuo, Lu-Cheng; Hsu, Chia-Lin; Huang, Chun-Kai; Yang, Ching-Yao; Chien, Ying-Chun; Wang, Jann-Yuan; Yu, Chong-Jen

    2016-01-01

    Performance of interferon-gamma release assays (IGRAs) is influenced by preanalytical, laboratory and host factors. The data regarding how critical illnesses influence IGRA results are limited. This study aimed to investigate IGRA performance among critically ill patients. Patients admitted to intensive care unit (ICU) were prospectively enrolled, and underwent QuantiFERON-TB Gold In-Tube testing on admission and discharge. The associations between patient factors and IGRA results were explored. In total, 118 patients were included. IGRA results on admission were positive, negative and indeterminate for 10 (9%), 36 (31%) and 72 (61%) patients. All indeterminate results were due to a low mitogen response. Indeterminate results were associated with higher disease severity and lower serum albumin levels. Ninety (76%) patients survived to ICU discharge and had repeat IGRA testing 13.3 ± 10.1 days after first ones. Of those, 43 (48%) had indeterminate results, and no IGRA conversion or reversion was observed. The majority (35/51, 69%) of ICU survivors with initial indeterminate results still had indeterminates on follow-up testing. Acute critical illnesses exert a significant impact on IGRA performance and a high proportion of indeterminate results was seen in ICU patients. This study highlights limitation of IGRAs in the critically ill and judicious selection of patients to be tested should be considered. PMID:26804487

  19. Continuous renal replacement therapy amino acid, trace metal and folate clearance in critically ill children

    Technology Transfer Automated Retrieval System (TEKTRAN)

    We hypothesized that continuous veno-venous hemodialysis (CVVHD) results in amino acid, trace metals, and folate losses, thereby adversely impacting nutrient balance. Critically ill children receiving CVVHD were studied prospectively for 5 days. Blood concentrations, amino acids, copper, zinc, man...

  20. Rehabilitation of Critical Illness Polyneuropathy and Myopathy Patients: An Observational Study

    ERIC Educational Resources Information Center

    Novak, Primoz; Vidmar, Gaj; Kuret, Zala; Bizovicar, Natasa

    2011-01-01

    Critical illness polyneuropathy and myopathy (CIPNM) frequently develops in patients hospitalized in intensive care units. The number of patients with CIPNM admitted to inpatient rehabilitation is increasing. The aim of this study was to comprehensively evaluate the outcome of their rehabilitation. Twenty-seven patients with CIPNM were included in…

  1. Kinetic Patterns of Candida albicans Germ Tube Antibody in Critically Ill Patients: Influence on Mortality▿

    PubMed Central

    Zaragoza, Rafael; Pemán, Javier; Quindós, Guillermo; Iruretagoyena, Jose R.; Cuétara, María S.; Ramírez, Paula; Gómez, Maria D.; Camarena, Juan J.; Viudes, Angel; Pontón, José

    2009-01-01

    The influence of kinetic patterns of Candida albicans germ tube antibodies (CAGTA) on mortality was analyzed in six intensive care units. Statistically significant lower mortality rates were found in patients with patterns of increasing CAGTA titers who had been treated with antifungal agents. Thus, antifungal treatment should be considered when CAGTA titers are increasing in critically ill patients. PMID:19675223

  2. The effectiveness of assertive community treatment for elderly patients with severe mental illness: a randomized controlled trial

    PubMed Central

    2014-01-01

    Background Due to fragmented mental, somatic, and social healthcare services, it can be hard to engage into care older patients with severe mental illness (SMI). In adult mental health care, assertive community treatment (ACT) is an organizational model of care for treating patients with SMI who are difficult to engage. So far all outcome studies of assertive community treatment have been conducted in adults. Methods In a randomized controlled trial design we compared the effectiveness of ACT for elderly patients with that of treatment as usual (TAU). Sixty-two outpatients (60 years and older) with SMI who were difficult to engage in psychiatric treatment were randomly assigned to the intervention or control group (32 to ACT for elderly patients and 30 to TAU). Primary outcomes included number of patients who had a first treatment contact within 3 months, the number of dropouts (i.e. those discharged from care due to refusing care or those who unintentionally lost contact with the service over a period of at least 3 months); and patients’ psychosocial functioning (HoNOS65+ scores) during 18 months follow-up. Secondary outcomes included the number of unmet needs and mental health care use. Analyses were based on intention-to-treat. Results Of the 62 patients who were randomized, 26 were lost to follow-up (10 patients in ACT for elderly patients and 16 in TAU). Relative to patients with TAU, more patients allocated to ACT had a first contact within three months (96.9 versus 66.7%; X2 (df = 1) = 9.68, p = 0.002). ACT for elderly patients also had fewer dropouts from treatment (18.8% of assertive community treatment for elderly patients versus 50% of TAU patients; X2 (df = 1) = 6.75, p = 0.009). There were no differences in the other primary and secondary outcome variables. Conclusions These findings suggest that ACT for elderly patients with SMI engaged patients in treatment more successfully. Trial registration NTR1620 PMID:24528604

  3. [Meanings of falling ill: what the main caretakers of elderly patients with cancer think].

    PubMed

    Vieira, Maria Cristina Umpierrez; Marcon, Sonia Silva

    2008-12-01

    The goal of the study was to understand the social representations of the main caretakers about the process of a acquiring cancer and to relate them with her therapeutic choices when caring for an elderly bearer of this pathology at his home. Four main caretakers of elderly cancer patients participated in the study. Data collection occurred from March to November, 2005, using semi-structured interviews and participative observation. The data analysis was accomplished through the method of thematic analysis. The explanations for the disease found by the caretakers were opposite to the medical explanations, because theytryto identify the mechanisms that led the elderly patients to acquire the disease in their lifestyle. The therapeutic practices at home are eminently cultural, considering socially-built beliefs and values. The need of recognizing the socio-cultural dimension of healthcare within the formal healthcare service was emphasized. PMID:19192911

  4. Effect of obesity on the pharmacokinetics of antimicrobials in critically ill patients: A structured review.

    PubMed

    Alobaid, Abdulaziz S; Hites, Maya; Lipman, Jeffrey; Taccone, Fabio Silvio; Roberts, Jason A

    2016-04-01

    The increased prevalence of obesity presents challenges for clinicians aiming to provide optimised antimicrobial dosing in the intensive care unit. Obesity is likely to exacerbate the alterations to antimicrobial pharmacokinetics when the chronic diseases associated with obesity exist with the acute pathophysiological changes associated with critical illness. The purpose of this paper is to review the potential pharmacokinetic (PK) changes of antimicrobials in obese critically ill patients and the implications for appropriate dosing. We found that hydrophilic antimicrobials (e.g. β-lactams, vancomycin, daptomycin) were more likely to manifest altered pharmacokinetics in critically ill patients who are obese. In particular for β-lactam antibiotics, obesity is associated with a larger volume of distribution (Vd). In obese critically ill patients, piperacillin is also associated with a lower drug clearance (CL). For doripenem, these PK changes have been associated with reduced achievement of pharmacodynamic (PD) targets when standard drug doses are used. For vancomycin, increases in Vd are associated with increasing total body weight (TBW), meaning that the loading dose should be based on TBW even in obese patients. For daptomycin, an increased Vd is not considered to be clinically relevant. For antifungals, little data exist in obese critically ill patients; during fluconazole therapy, an obese patient had a lower Vd and higher CL than non-obese comparators. Overall, most studies suggested that standard dosage regimens of most commonly used antimicrobials are sufficient to achieve PD targets. However, it is likely that larger doses would be required for pathogens with higher minimum inhibitory concentrations. PMID:26988339

  5. Individualization of piperacillin dosing for critically ill patients: dosing software to optimize antimicrobial therapy.

    PubMed

    Felton, T W; Roberts, J A; Lodise, T P; Van Guilder, M; Boselli, E; Neely, M N; Hope, W W

    2014-07-01

    Piperacillin-tazobactam is frequently used for empirical and targeted therapy of infections in critically ill patients. Considerable pharmacokinetic (PK) variability is observed in critically ill patients. By estimating an individual's PK, dosage optimization Bayesian estimation techniques can be used to calculate the appropriate piperacillin regimen to achieve desired drug exposure targets. The aim of this study was to establish a population PK model for piperacillin in critically ill patients and then analyze the performance of the model in the dose optimization software program BestDose. Linear, with estimated creatinine clearance and weight as covariates, Michaelis-Menten (MM) and parallel linear/MM structural models were fitted to the data from 146 critically ill patients with nosocomial infection. Piperacillin concentrations measured in the first dosing interval, from each of 8 additional individuals, combined with the population model were embedded into the dose optimization software. The impact of the number of observations was assessed. Precision was assessed by (i) the predicted piperacillin dosage and by (ii) linear regression of the observed-versus-predicted piperacillin concentrations from the second 24 h of treatment. We found that a linear clearance model with creatinine clearance and weight as covariates for drug clearance and volume of distribution, respectively, best described the observed data. When there were at least two observed piperacillin concentrations, the dose optimization software predicted a mean piperacillin dosage of 4.02 g in the 8 patients administered piperacillin doses of 4.00 g. Linear regression of the observed-versus-predicted piperacillin concentrations for 8 individuals after 24 h of piperacillin dosing demonstrated an r(2) of >0.89. In conclusion, for most critically ill patients, individualized piperacillin regimens delivering a target serum piperacillin concentration is achievable. Further validation of the dosage

  6. Retrospective review on obstetric cases of critically ill and dead patients in Dongguan.

    PubMed

    Shen, Li-Han; Fang, Yun-Yong; Zheng, Yan-Bing; Xiao, Li-Juan; Huang, Su-Ran; Liu, Xi-Zhen; Cai, Li-Hua

    2015-03-01

    This retrospective analysis was set to understand the epidemiological status of the critically ill obstetric patients in Dongguan city, Guangdong, China. Understanding the risk factors for the death cases can provide scientific evidences for future preventive strategies to decrease the maternal mortality rate. This retrospective included the statistical data and clinical data on the cases of critically ill and dead obstetric patients admitted to Dongguan People's Hospital and Dongguan Maternal & Child Health Hospital from September 1st, 2009 to August 31st, 2013. Data included numbers of the critically ill maternal and obstetric women, common obstetric and maternal comorbidities and complications in the critically ill patients, the basic characteristics of maternal and obstetric deaths, records of regular prenatal examinations, the time intervals between onset of acute symptoms and ICU admission, blood purification, and the acute physiology and chronic health evaluation II (APACHE II) score. During the 5-year period, there were increasing trend of critically ill pregnant and obstetric patients, and the prevalence rate of critically ill obstetric patients was 8.99-9.28 %. The most common obstetric causes of admission were massive postpartum hemorrhage (63.54 %), followed by pregnancy-associated hypertension (15.85 %) and placenta previa (8.92 %). The most common non-obstetric causes of admission were acute heart failure (1.98 %). In the observed period, 20 critically ill obstetric patients died in these two hospitals (mortality rate 0.24 %, 20/8,129). The mean age of dead women was (30.3 ± 6.6) years old and mean gestational age was (30.1 ± 9.3) weeks. 75 % of the patient had more than two pregnancies. Over 90 % of the patients received education below junior high school level. 85 % of the patients were non-Dongguan natives and regular prenatal care rate was only 15 % on dead cases. The most common causes of death were pregnancy-associated hypertension, acute

  7. Immunonutrients in critically ill patients: an analysis of the most recent literature.

    PubMed

    Annetta, Maria G; Pittiruti, Mauro; Vecchiarelli, Pietro; Silvestri, Davide; Caricato, Anselmo; Antonelli, Massimo

    2016-03-01

    Modulation of inflammatory and immune response to critical illness has been the goal of much research in the last decade and a variety of drugs and nutrients (so called "immunonutrients") have been tested in experimental models with promising results. Though, in the clinical setting of intensive care, their efficacy have been inconsistently proven, most likely because the effects of each drug may vary in relation to the timing, the dose, the route of administration, the interaction with other nutrients, the severity of illness and many other factors. Though the early studies of the beginning of this century (2000-2009) have shown some clinical benefits, recent multicenter trials (2011-2015) have failed to prove a consistent benefit of immunonutrition in terms of mortality or other clinical endpoints. Reviewing the latest evidence-based documents on this subject (multicenter trials, systematic reviews, meta-analyses and international guidelines), there is no convincing evidence that immunonutrients may be beneficial in the critically ill. Considering that these substances invariably increase the costs of health care and may be unsafe or even harmful in some subgroups, particularly in septic patients, we conclude that routine administration of immune-nutrients (glutamine, arginine, omega-3 fatty acids, selenium, etc.) cannot be currently recommended in the critically ill. PMID:25969140

  8. Corticotropin-releasing factor: a possible key to gut dysfunction in the critically ill.

    PubMed

    Hill, Lauren T; Kidson, Susan H; Michell, William L

    2013-01-01

    Critically ill patients frequently display unexplained or incompletely explained features of gastrointestinal (GI) dysfunction, including gastric stasis, ileus, and diarrhea. This makes nutrition delivery challenging, and may contribute to poor outcomes. The typical bowel dysfunction seen in severely ill patients includes retarded gastric emptying, unsynchronized intestinal motility, and intestinal hyperpermeability. These functional changes appear similar to the corticotropin-releasing factor (CRF)-mediated bowel dysfunctions associated with stress of various types and some GI disorders and diseases. CRF has been shown to be present within the GI tract and its action on CRF receptors within the gut have been shown to reduce gastric emptying, alter intestinal motility, and increase intestinal permeability. However, the precise role of CRF in the GI dysfunction in critical illness remains unclear. In this short review, we provide an update on GI dysfunction during stress and review the possible role of CRF in the aetiology of gut dysfunction. We suggest that activation of CRF signaling pathways in critical illness might be key to understanding the mechanisms underlying the gut dysfunction that impairs enteral feeding in the intensive care unit. PMID:23484741

  9. Use of Accelerometry to Monitor Physical Activity in Critically Ill Subjects: A Systematic Review.

    PubMed

    Verceles, Avelino C; Hager, Erin R

    2015-09-01

    Medical management of critically ill patients often incorporates prolonged bed rest, which, in combination with the underlying illness, results in global muscle weakness and atrophy. Recent evidence has demonstrated improvements in clinical and functional outcomes when exercise and physical activity are incorporated early in the management of ICU patients. Accurate monitoring of ICU patients' physical activity is essential for proper prescription and escalation of activity levels. Accelerometry is a technique used to measure physical activity and has been validated in several ambulatory populations. However, its use in critically ill, hospitalized patients with poor functional mobility is limited. In this review, we focus on the few studies assessing the use of accelerometry to measure physical activity in the care of mechanically ventilated adult ICU patients. The selected literature demonstrates that accelerometry correlates well with direct observation in reporting frequency and duration of various types of physical activity (rolling, sitting up, transferring, walking), but cannot differentiate various intensities of activity or whether movements are voluntary or involuntary with respect to effort. Thus, although accelerometry may serve as a useful adjunct in reporting temporality of physical activity in critically ill patients, other objective information may be needed to accurately record frequency, duration, and intensity of activity in this population. PMID:25852167

  10. Considerations in the construction of an instrument to assess attitudes regarding critical illness gene variation research.

    PubMed

    Freeman, Bradley D; Kennedy, Carie R; Bolcic-Jankovic, Dragana; Eastman, Alexander; Iverson, Ellen; Shehane, Erica; Celious, Aaron; Barillas, Jennifer; Clarridge, Brian

    2012-02-01

    Clinical studies conducted in intensive care units are associated with logistical and ethical challenges. Diseases investigated are precipitous and life-threatening, care is highly technological, and patients are often incapacitated and decision-making is provided by surrogates. These investigations increasingly involve collection of genetic data. The manner in which the exigencies of critical illness impact attitudes regarding genetic data collection is unstudied. Given interest in understanding stakeholder preferences as a foundation for the ethical conduct of research, filling this knowledge gap is timely. The conduct of opinion research in the critical care arena is novel. This brief report describes the development of parallel patient/surrogate decision-maker quantitative survey instruments for use in this environment. Future research employing this instrument or a variant of it with diverse populations promises to inform research practices in critical illness gene variation research. PMID:22378135

  11. Considerations in the Construction of an Instrument to Assess Attitudes Regarding Critical Illness Gene Variation Research

    PubMed Central

    Freeman, Bradley D.; Kennedy, Carie R.; Bolcic-Jankovic, Dragana; Eastman, Alexander; Iverson, Ellen; Shehane, Erica; Celious, Aaron; Barillas, Jennifer; Clarridge, Brian

    2012-01-01

    Clinical studies conducted in intensive care units are associated with logistical and ethical challenges. Diseases investigated are precipitous and life-threatening, care is highly technological, and patients are often incapacitated and decision-making is provided by surrogates. These investigations increasingly involve collection of genetic data. The manner in which the exigencies of critical illness impact attitudes regarding genetic data collection is unstudied. Given interest in understanding stakeholder preferences as a foundation for the ethical conduct of research, filling this knowledge gap is timely. The conduct of opinion research in the critical care arena is novel. This brief report describes the development of parallel patient/surrogate decision-maker quantitative survey instruments for use in this environment. Future research employing this instrument or a variant of it with diverse populations promises to inform research practices in critical illness gene variation research. PMID:22378135

  12. Impaired High-Density Lipoprotein Anti-Oxidant Function Predicts Poor Outcome in Critically Ill Patients

    PubMed Central

    Schrutka, Lore; Goliasch, Georg; Meyer, Brigitte; Wurm, Raphael; Koller, Lorenz; Kriechbaumer, Lukas; Heinz, Gottfried; Pacher, Richard; Lang, Irene M

    2016-01-01

    Introduction Oxidative stress affects clinical outcome in critically ill patients. Although high-density lipoprotein (HDL) particles generally possess anti-oxidant capacities, deleterious properties of HDL have been described in acutely ill patients. The impact of anti-oxidant HDL capacities on clinical outcome in critically ill patients is unknown. We therefore analyzed the predictive value of anti-oxidant HDL function on mortality in an unselected cohort of critically ill patients. Method We prospectively enrolled 270 consecutive patients admitted to a university-affiliated intensive care unit (ICU) and determined anti-oxidant HDL function using the HDL oxidant index (HOI). Based on their HOI, the study population was stratified into patients with impaired anti-oxidant HDL function and the residual study population. Results During a median follow-up time of 9.8 years (IQR: 9.2 to 10.0), 69% of patients died. Cox regression analysis revealed a significant and independent association between impaired anti-oxidant HDL function and short-term mortality with an adjusted HR of 1.65 (95% CI 1.22–2.24; p = 0.001) as well as 10-year mortality with an adj. HR of 1.19 (95% CI 1.02–1.40; p = 0.032) when compared to the residual study population. Anti-oxidant HDL function correlated with the amount of oxidative stress as determined by Cu/Zn superoxide dismutase (r = 0.38; p<0.001). Conclusion Impaired anti-oxidant HDL function represents a strong and independent predictor of 30-day mortality as well as long-term mortality in critically ill patients. PMID:26978526

  13. Analysis of Critical Incidents and Shifting Perspectives: Transitions in Illness Careers Among Adolescents with ADHD

    PubMed Central

    Williamson, Pamela; Koro-Ljungberg, Mirka; Bussing, Regina

    2013-01-01

    Adolescence represents a developmental period for children with attention-deficit hyperactivity disorder (ADHD) during which the severity of mental health problems may change at a time when teens are consolidating their self identify and possibly questioning the label of an ADHD diagnosis, treatment, and types of interventions. This study investigates the shared critical events related to help-seeking reported by eight teenagers with ADHD, their mothers, and teachers and how the reported events and constructed shared focus on specific problems might explain teenagers’ transitions in their illness careers. Data collected through a qualitative application of the experience sampling method illuminated diverse illness career transitions including continuing treatment, transitioning from being treated to untreated, from being untreated to treated, and remaining untreated. Our findings support a model of shifting perspectives on illness and wellness among adolescents with ADHD, rather than a staged progression of adaptation to a chronic disorder. PMID:19224878

  14. Intestinal crosstalk: a new paradigm for understanding the gut as the "motor" of critical illness.

    PubMed

    Clark, Jessica A; Coopersmith, Craig M

    2007-10-01

    For more than 20 years, the gut has been hypothesized to be the "motor" of multiple organ dysfunction syndrome. As critical care research has evolved, there have been multiple mechanisms by which the gastrointestinal tract has been proposed to drive systemic inflammation. Many of these disparate mechanisms have proved to be important in the origin and propagation of critical illness. However, this has led to an unusual situation where investigators describing the gut as a "motor" revving the systemic inflammatory response syndrome are frequently describing wholly different processes to support their claim (i.e., increased apoptosis, altered tight junctions, translocation, cytokine production, crosstalk with commensal bacteria, etc). The purpose of this review is to present a unifying theory as to how the gut drives critical illness. Although the gastrointestinal tract is frequently described simply as "the gut," it is actually made up of (1) an epithelium; (2) a diverse and robust immune arm, which contains most of the immune cells in the body; and (3) the commensal bacteria, which contain more cells than are present in the entire host organism. We propose that the intestinal epithelium, the intestinal immune system, and the intestine's endogenous bacteria all play vital roles driving multiple organ dysfunction syndrome, and the complex crosstalk between these three interrelated portions of the gastrointestinal tract is what cumulatively makes the gut a "motor" of critical illness. PMID:17577136

  15. Managing atrial fibrillation in the elderly: critical appraisal of dronedarone

    PubMed Central

    Trigo, Paula; Fischer, Gregory W

    2012-01-01

    Atrial fibrillation is the most commonly seen arrhythmia in the geriatric population and is associated with increased cardiovascular morbidity and mortality. Treatment of the elderly with atrial fibrillation remains challenging for physicians, because this unique subpopulation is characterized by multiple comorbidities requiring chronic use of numerous medications, which can potentially lead to severe drug interactions. Furthermore, age-related changes in the cardiovascular system as well as other physiological changes result in altered drug pharmacokinetics. Dronedarone is a new drug recently approved for the treatment of arrhythmias, such as atrial fibrillation and/or atrial flutter. Dronedarone is a benzofuran amiodarone analog which lacks the iodine moiety and contains a methane sulfonyl group that decreases its lipophilicity. These differences in chemical structure are responsible for making dronedarone less toxic than amiodarone which, in turn, results in fewer side effects. Adverse events for dronedarone include gastrointestinal side effects and rash. No dosage adjustments are required for patients with renal impairment. However, the use of dronedarone is contraindicated in the presence of severe hepatic dysfunction. PMID:22291468

  16. Diabetes Intrusiveness and Wellness among Elders: A Test of the Illness Intrusiveness Model

    ERIC Educational Resources Information Center

    DeCoster, Vaughn A.; Killian, Tim; Roessler, Richard T.

    2013-01-01

    Using data collected from 147 predominately African American senior citizens in Arkansas, this research examined the Illness Intrusiveness Model (Devins, 1991; Devins & Seland, 1987; Devins & Shnek, 2000) to explain variations in wellness specifically related to participants' adaptation to diabetes. The theoretical model hypothesized…

  17. Yeast central nervous system infection in a critically ill patient: a case report

    PubMed Central

    2014-01-01

    Introduction Invasive fungal infections are alarmingly common in intensive care unit patients; invasive fungal infections are associated with increased morbidity and mortality. Risk factors are the increased use of indwelling central venous catheters, the use of broad spectrum antibiotics, parenteral nutrition, renal replacement therapy and immunosuppression. Diagnosis of these infections might be complicated, requiring tissue cultures. In addition, therapy of invasive fungal infections might be difficult, given the rising resistance of fungi to antifungal agents. Case presentation We describe the case of a 28-year-old Greek man with yeast central nervous system infection. Conclusions Difficult-to-treat fungal infections may complicate the clinical course of critically ill patients and render their prognosis unfavorable. This report presents a case that was rare and difficult to treat, along with a thorough review of the investigation and treatment of these kinds of fungal infections in critically ill patients. PMID:25026870

  18. DANGER IN THE INTENSIVE CARE UNIT: DAMPS IN CRITICALLY ILL PATIENTS

    PubMed Central

    Timmermans, Kim; Kox, Matthijs; Scheffer, Gert Jan; Pickkers, Peter

    2016-01-01

    ABSTRACT Danger-associated molecular patterns (DAMPs) that are released by injured, threatened, or dead cells, or that originate from the extracellular matrix, influence the immune system. This is of great relevance in critically ill patients, in whom trauma or surgery-related cell damage, hypoxia, ischemia, and infections can result in extensive release of DAMPs. As many patients at the intensive care unit suffer from immune system-related complications, DAMPs could serve as markers for the prognosis of these patients and represent possible therapeutic targets. In the present review, we provide an overview of several well known DAMPs (high-mobility group box 1, heat-shock proteins, s100 proteins, nucleic acids, and hyaluronan) and their effects on the immune system. Furthermore, we discuss the role of DAMPs as markers or therapeutic targets in several conditions frequently encountered in critically ill patients, such as sepsis, trauma, ventilator-induced lung injury, and cardiac arrest. PMID:26513703

  19. Malnutrition in the Critically Ill Child: The Importance of Enteral Nutrition

    PubMed Central

    Prieto, Marta Botrán; Cid, Jesús López-Herce

    2011-01-01

    Malnutrition affects 50% of hospitalized children and 25–70% of the critically ill children. It increases the incidence of complications and mortality. Malnutrition is associated with an altered metabolism of certain substrates, increased metabolism and catabolism depending on the severity of the lesion, and reduced nutrient delivery. The objective should be to administer individualized nutrition to the critically ill child and to be able to adjust the nutrition continuously according to the metabolic changes and evolving nutritional status. It would appear reasonable to start enteral nutrition within the first 24 to 48 hours after admission, when oral feeding is not possible. Parenteral nutrition should only be used when enteral nutrition is contraindicated or is not tolerated. Energy delivery must be individually adjusted to energy expenditure (40–65 kcal/100 calories metabolized/day) with a protein delivery of 2.5–3 g/kg/day. Frequent monitoring of nutritional and metabolic parameters should be performed. PMID:22163211

  20. Redox Changes Induced by General Anesthesia in Critically Ill Patients with Multiple Traumas

    PubMed Central

    Papurica, Marius; Rogobete, Alexandru Florin; Sandesc, Dorel; Dumache, Raluca; Nartita, Radu; Sarandan, Mirela; Cradigati, Alina Carmen; Luca, Loredana; Vernic, Corina; Bedreag, Ovidiu Horea

    2015-01-01

    The critically ill polytrauma patient is a constant challenge for the trauma team due to the complexity of the complications presented. Intense inflammatory response and infections, as well as multiple organ dysfunctions, significantly increase the rate of morbidity and mortality in these patients. Moreover, due to the physiological and biochemical imbalances present in this type of patients, the bioproduction of free radicals is significantly accelerated, thus installing the oxidative stress. In the therapeutic management of such patients, multiple surgical interventions are required and therefore they are being subjected to repeated general anesthesia. In this paper, we want to present the pathophysiological implications of oxidative stress in critically ill patients with multiple traumas and the implications of general anesthesia on the redox mechanisms of the cell. We also want to summarize the antioxidant treatments able to reduce the intensity of oxidative stress by modulating the biochemical activity of some cellular mechanisms. PMID:26693352

  1. Combining nutrition and exercise to optimize survival and recovery from critical illness: Conceptual and methodological issues.

    PubMed

    Heyland, Daren K; Stapleton, Renee D; Mourtzakis, Marina; Hough, Catherine L; Morris, Peter; Deutz, Nicolaas E; Colantuoni, Elizabeth; Day, Andrew; Prado, Carla M; Needham, Dale M

    2016-10-01

    Survivors of critical illness commonly experience neuromuscular abnormalities, including muscle weakness known as ICU-acquired weakness (ICU-AW). ICU-AW is associated with delayed weaning from mechanical ventilation, extended ICU and hospital stays, more healthcare-related hospital costs, a higher risk of death, and impaired physical functioning and quality of life in the months after ICU admission. These observations speak to the importance of developing new strategies to aid in the physical recovery of acute respiratory failure patients. We posit that to maintain optimal muscle mass, strength and physical function, the combination of nutrition and exercise may have the greatest impact on physical recovery of survivors of critical illness. Randomized trials testing this and related hypotheses are needed. We discussed key methodological issues and proposed a common evaluation framework to stimulate work in this area and standardize our approach to outcome assessments across future studies. PMID:26212171

  2. [Respiratory care with prone position for diffuse atelectasis in critically ill patients].

    PubMed

    Shichinohe, Y; Ujike, Y; Kurihara, M; Yamamoto, S; Oota, K; Tsukamoto, M; Imaizumi, H; Kaneko, M

    1991-01-01

    Diffuse atelectasis often occurs in the dorsal region of the lung of critically ill patients under long term mechanical ventilation. Conventional physical therapies (ex. PEEP, Sigh) have little effect on diffuse dorsal atelectasis. We provided respiratory care with prone position for 7 patients with severe respiratory distress (Two patients were treated twice). Improvement of their Respiratory Indexes (RI, mean 2.97) was obtained in the prone position for 6-163 (mean 35.8) hours. Ventilation efficiency also improved. Static lung compliance didn't change. It was assumed that the prone position was the factor responsible for the improvement of pulmonary V/Q ratio, the change of movement pattern of the diaphragm, and the ease of postural drainage of sputum. There were no complications. We conclude that prone position respiratory care has high utility for critically ill patients with diffuse dorsal atelectasis. PMID:2024073

  3. Challenges and opportunities associated with studying sleep in critically ill adults.

    PubMed

    Redeker, Nancy S

    2008-01-01

    Disturbances in sleep associated with sleep deprivation, disorders in circadian rhythms, and sleep-disordered breathing are common in critical care settings and may have a significant impact on physiologic, behavioral, and functional outcomes, as well as patient satisfaction and utilization of healthcare resources. Despite growth in awareness of the potential importance of sleep in the critical setting over the past 30 years, many questions about the nature of sleep, the predictors and consequences of sleep disturbance, and the efficacy of sleep promotion interventions in critically ill patients remain unanswered. Most of the studies of sleep in critical care settings have used small, nonrandom samples and descriptive or explanatory designs; many have not considered multifactorial explanatory variables; and clinical trials are rare. These gaps in quantity and quality of research findings are barriers to the delivery of evidence-based sleep promotion interventions and may be partially explained by conceptual and methodological challenges associated primarily with the nature of sleep measurement and characteristics of critically ill patients and the critical care environment. This article will explore these concerns and propose strategies to deal with them. Research exemplars from the literature will be used to illustrate key points. PMID:18560287

  4. Pro/con debate: Is etomidate safe in hemodynamically unstable critically ill patients?

    PubMed

    Flynn, Gordon; Shehabi, Yahya

    2012-01-01

    Etomidate is an induction agent known for its smooth intubating conditions and cardiovascular stability. Studies, however, have shown that a single dose of etomidate can result in a prolonged adrenal insufficiency. The impact of this in patients with sepsis has been a matter for debate. This review presents a pro/con case for using etomidate in hemodynamically unstable critically ill patients and provides guidance for alternative induction techniques and when the use of etomidate might be justified despite these concerns. PMID:22809235

  5. C5a Mediates Peripheral Blood Neutrophil Dysfunction in Critically Ill Patients

    PubMed Central

    Morris, Andrew Conway; Kefala, Kallirroi; Wilkinson, Thomas S.; Dhaliwal, Kevin; Farrell, Lesley; Walsh, Tim; Mackenzie, Simon J.; Reid, Hamish; Davidson, Donald J.; Haslett, Chris; Rossi, Adriano G.; Sallenave, Jean-Michel; Simpson, A. John

    2010-01-01

    Rationale Critically ill patients are highly susceptible to hospital-acquired infection. Neutrophil function in critical illness remains poorly understood. Objectives To characterize and define mechanisms of peripheral blood neutrophil (PBN) dysfunction in critically ill patients. To determine whether the inflamed lung contributes additional phagocytic impairment. Methods Prospective collection of blood and bronchoalveolar lavage fluid from patients with suspected ventilator-associated pneumonia and from age- and sex-matched volunteers; laboratory analysis of neutrophil functions. Measurements and Main Results Seventy-two patients and 21 volunteers were included. Phagocytic capacity of PBNs was 36% lower in patients than in volunteers (P < 0.0001). From several biologically plausible candidates only activated complement was significantly associated with impaired PBN phagocytosis (P < 0.0001). Phagocytosis was negatively correlated with serum C3a and positively correlated with expression of C5a receptor type 1 (CD88) on PBNs. C5a recapitulated impaired PBN phagocytosis and significantly down-regulated CD88 expression in vitro. C5a-mediated phagocytic impairment was prevented by blocking either CD88 or phosphoinositide 3-kinase, and completely reversed by granulocyte-macrophage colony-stimulating factor. C5a also impaired killing of Pseudomonas aeruginosa by, and migration of, PBNs, indicating that effects were not restricted to phagocytosis. Bronchoalveolar lavage fluid leukocytes from patients also demonstrated significantly impaired function, and lavage supernatant reduced phagocytosis in healthy neutrophils by 43% (P = 0.0001). However, lavage fluid did not affect CD88 expression and lavage-mediated impairment of phagocytosis was not blocked by anti-CD88 antibody. Conclusions Critically ill patients have significant dysfunction of PBNs, which is mediated predominantly by activated complement. Further, profound complement-independent neutrophil dysfunction occurs

  6. Electroencephalographic Monitoring in Critically Ill Children: Current Practice and Implications for Future Study Design

    PubMed Central

    Sánchez, Sarah M; Arndt, Daniel H.; Carpenter, Jessica L.; Chapman, Kevin E; Cornett, Karen M.; Dlugos, Dennis J.; Gallentine, William B.; Giza, Christopher C; Goldstein, Joshua L; Hahn, Cecil D; Lerner, Jason T; Loddenkemper, Tobias; Matsumoto, Joyce H; McBain, Kristin; Nash, Kendall B; Payne, Eric; Sánchez Fernández, Iván; Shults, Justine; Williams, Korwyn; Yang, Amy; Abend, Nicholas S.

    2014-01-01

    Purpose Survey data indicate that continuous EEG (CEEG) monitoring is used with increasing frequency to identify electrographic seizures in critically ill children, but studies of current CEEG practice have not been conducted. We aimed to describe the clinical utilization of CEEG in critically ill children at tertiary care hospitals with a particular focus on variables essential for designing feasible prospective multi-center studies evaluating the impact of electrographic seizures on outcome. Methods Eleven North American centers retrospectively enrolled 550 consecutive critically ill children who underwent CEEG. We collected data regarding subject characteristics, CEEG indications, and CEEG findings. Key Findings CEEG indications were encephalopathy with possible seizures in 67% of subjects, event characterization in 38% of subjects, and management of refractory status epilepticus in 11% of subjects. CEEG was initiated outside routine work hours in 47% of subjects. CEEG duration was <12 hours in 16%, 12-24 hours in 34%, and >24 hours in 48%. Substantial variability existed among sites in CEEG indications and neurologic diagnoses, yet within each acute neurologic diagnosis category a similar proportion of subjects at each site had electrographic seizures. Electrographic seizure characteristics including distribution and duration varied across sites and neurologic diagnoses. Significance These data provide a systematic assessment of recent CEEG use in critically ill children and indicate variability in practice. The results suggest that multi-center studies are feasible if CEEG monitoring pathways can be standardized. However, the data also indicate that electrographic seizure variability must be considered when designing studies addressing the impact of electrographic seizures on outcome. PMID:23848569

  7. Use of intravenous propranolol for control of a large cervicofacial hemangioma in a critically ill neonate.

    PubMed

    Fernando, Shanik J; Leitenberger, Sabra; Majerus, Matt; Krol, Alfons; MacArthur, Carol J

    2016-05-01

    Cervicofacial segmental infantile hemangiomas (IH) may result in airway obstruction requiring use of propranolol to induce hemangioma regression and reestablish the airway. We present the first case using intravenous (IV) propranolol for control of airway obstruction and rapid expansion of cervicofacial IH in the setting of necrotizing enterocolitis (NEC) impaired gastrointestinal function. Intravenous dosing of propranolol was tolerated well in a critically ill neonate with multisystem complications of prematurity. PMID:27063753

  8. Effect of Obesity on the Population Pharmacokinetics of Meropenem in Critically Ill Patients.

    PubMed

    Alobaid, Abdulaziz S; Wallis, Steven C; Jarrett, Paul; Starr, Therese; Stuart, Janine; Lassig-Smith, Melissa; Ordóñez Mejia, Jenny Lisette; Roberts, Michael S; Lipman, Jeffrey; Roberts, Jason A

    2016-08-01

    Severe pathophysiological changes in critical illness can lead to dramatically altered antimicrobial pharmacokinetics (PK). The additional effect of obesity on PK potentially increases the challenge for effective dosing. The aim of this prospective study was to describe the population PK of meropenem for a cohort of critically ill patients, including obese and morbidly obese patients. Critically ill patients prescribed meropenem were recruited into the following three body mass index (BMI) groups: nonobese (18.5 to 29.9 kg/m(2)), obese (30.0 to 39.9 kg/m(2)), and morbidly obese (≥40 kg/m(2)). Serial plasma samples were taken, and meropenem concentrations were determined using a validated chromatographic method. Population PK analysis and Monte Carlo dosing simulations were undertaken with Pmetrics. Nineteen critically ill patients with different BMI categories were enrolled. The patients' mean ± standard deviation (SD) age, weight, and BMI were 49 ± 15.9 years, 95 ± 22.0 kg, and 33 ± 7.0 kg/m(2), respectively. A two-compartment model described the data adequately. The mean ± SD parameter estimates for the final covariate model were as follows: clearance (CL), 15.5 ± 6.0 liters/h; volume of distribution in the central compartment (V1), 11.7 ± 5.8 liters; intercompartmental clearance from the central compartment to the peripheral compartment, 25.6 ± 35.1 liters h(-1); and intercompartmental clearance from the peripheral compartment to the central compartment, 8.32 ± 12.24 liters h(-1) Higher creatinine clearance (CLCR) was associated with a lower probability of target attainment, with BMI having little effect. Although obesity was found to be associated with an increased V1, dose adjustment based on CLCR appears to be more important than patient BMI. PMID:27185798

  9. Multiple Biomarkers to Assess the Pathophysiological State in Critically Ill Patients with Sepsis.

    PubMed

    Ashok Kumar, Prashanth; Anand, Usha

    2016-07-01

    Sepsis is associated with various metabolic derangements as a consequence of inflammatory response, ischemia and oxidative stress. Four parameters of relevance are procalcitonin (PCT), ischemia modified albumin (IMA) pH and lactate. The study was carried out to highlight the concomitant occurrence of sepsis, ischemia and lactic acidosis, all of which could have deleterious effects on organ function. 26 critically ill patients with a provisional diagnosis of sepsis were the test subjects. The control group had 25 apparently healthy volunteers. PCT, lactate and IMA were assayed. PCT was estimated on an automated analyser using electro-chemiluminescence. Lactate and pH were estimated on a blood gas analyzer. Serum IMA was estimated spectrophotometrically by Albumin Cobalt Binding Test. Statistical tools like students 't' test and Venn diagram were employed to depict the outcome of the study. All critically ill patients had significantly higher IMA levels (0.96746 ± 0.73407) as compared to the control group (0.00728 ± 0.00895) with a p value of <0.0001. The Venn diagram was used to depict the finding that all 26 test subjects had elevated levels of IMA, of which PCT was elevated in 22 and lactate in 20. Both PCT and lactate were abnormal in 17 patients. The most significant observation was that all critically ill patients, irrespective of the presence of sepsis or lactic acidosis had elevated levels of IMA which is clearly indicative of the ubiquitous presence of oxidative stress. The Venn diagram is an elegant representation of the concurrent multiple pathophysiological processes which occur in critically ill patients. PMID:27382202

  10. Screening and risk factors of exocrine pancreatic insufficiency in critically ill adult patients receiving enteral nutrition

    PubMed Central

    2013-01-01

    Introduction Malnutrition is a frequent problem associated with detrimental clinical outcomes in critically ill patients. To avoid malnutrition, most studies focus on the prevention of inadequate nutrition delivery, whereas little attention is paid to the potential role of exocrine pancreatic insufficiency (EPI). In this trial, we aim to evaluate the prevalence of EPI and identify its potential risk factors in critically ill adult patients without preexisting pancreatic diseases. Methods In this prospective cross-sectional study, we recruited 563 adult patients with critical illnesses. All details of the patients were documented, stool samples were collected three to five days following the initiation of enteral nutrition, and faecal elastase 1 (FE-1) concentrations were assayed using an enzyme-linked immunosorbent assay kit. Blood samples were also taken to determine serum amylase and lipase activity. Results The percentages of recruited patients with EPI (FE-1 concentration <200 μg/g) and severe EPI (FE-1 concentration <100 μg/g) were 52.2% and 18.3%, respectively. The incidences of steatorrhea were significantly different (P < 0.05) among the patients without EPI, with moderate EPI (FE-1 concentration = 100 to 200 μg/g) and severe EPI (FE-1 concentration < 100 μg/g). Both multivariate logistic regression analysis and z-tests indicated that the occurrence of EPI was closely associated with shock, sepsis, diabetes, cardiac arrest, hyperlactacidemia, invasive mechanical ventilation and haemodialysis. Conclusions More than 50% of critically ill adult patients without primary pancreatic diseases had EPI, and nearly one-fifth of them had severe EPI. The risk factors for EPI included shock, sepsis, diabetes, cardiac arrest, hyperlactacidemia, invasive mechanical ventilation and haemodialysis. Trial registration NCT01753024 PMID:23924602

  11. Perspectives of Decisional Surrogates and Patients Regarding Critical Illness Genetic Research

    PubMed Central

    Freeman, Bradley D.; Bolcic-Jankovic, Dragana; Kennedy, Carie R.; LeBlanc, Jessica; Eastman, Alexander; Barillas, Jennifer; Wittgen, Catherine M.; indsey, Kathryn; Mahmood, Rumel S.; Clarridge, Brian R.

    2015-01-01

    Background Critical illness research is challenging due to disease severity and because patients are frequently incapacitated. Surrogates called upon to provide consent might not accurately represent patient preferences. Though commonplace, genetic data collection adds complexity in this context. We undertook this investigation to understand whether surrogate decision makers would be receptive to permitting participation in a critical illness genetics study and whether their decision making was consistent with that of the patient represented. Methods We invited individuals identified as surrogates for critically ill adults, if required, as well as patients once recovered to participate in a survey designed to understand attitudes about genetic research. Associations between dependent (receptivity to participation, concordance of responses) and independent variables were tested using bivariate and multivariate logistic regression analyses. Results Most of the entire surrogate sample (n=439) reported familiarity with research, including genetic research; tended to view research as useful; and were receptive to allowing their family member participate (with 39.6% and 38.1% stating that this would be “very” and “somewhat likely,” respectively) even absent direct benefit. Willingness to participate was similar comparing genetic and non-genetic studies (χ2 [1,n=439]=0.00127, p=0.972), though respondents expressed worry regarding lack of confidentiality of genetic data. Responses were concordant in 70.8% of the 192 surrogate-patient pairs analyzed. In multivariate analysis, African American race was associated with less receptivity to genetic data collection (p<0.05). No factors associated with concordance of surrogate-patient response were identified. Conclusions Surrogates’ receptivity to critical illness research was not influenced by whether the study entailed collection of genetic data. While more than two-thirds of surrogate-patient responses for

  12. The Sick and the Weak: Neuropathies/Myopathies in the Critically Ill

    PubMed Central

    Friedrich, O.; Reid, M. B.; Van den Berghe, G.; Vanhorebeek, I.; Hermans, G.; Rich, M. M.; Larsson, L.

    2015-01-01

    Critical illness polyneuropathies (CIP) and myopathies (CIM) are common complications of critical illness. Several weakness syndromes are summarized under the term intensive care unit-acquired weakness (ICUAW). We propose a classification of different ICUAW forms (CIM, CIP, sepsis-induced, steroid-denervation myopathy) and pathophysiological mechanisms from clinical and animal model data. Triggers include sepsis, mechanical ventilation, muscle unloading, steroid treatment, or denervation. Some ICUAW forms require stringent diagnostic features; CIM is marked by membrane hypoexcitability, severe atrophy, preferential myosin loss, ultrastructural alterations, and inadequate autophagy activation while myopathies in pure sepsis do not reproduce marked myosin loss. Reduced membrane excitability results from depolarization and ion channel dysfunction. Mitochondrial dysfunction contributes to energy-dependent processes. Ubiquitin proteasome and calpain activation trigger muscle proteolysis and atrophy while protein synthesis is impaired. Myosin loss is more pronounced than actin loss in CIM. Protein quality control is altered by inadequate autophagy. Ca2+ dysregulation is present through altered Ca2+ homeostasis. We highlight clinical hallmarks, trigger factors, and potential mechanisms from human studies and animal models that allow separation of risk factors that may trigger distinct mechanisms contributing to weakness. During critical illness, altered inflammatory (cytokines) and metabolic pathways deteriorate muscle function. ICUAW prevention/treatment is limited, e.g., tight glycemic control, delaying nutrition, and early mobilization. Future challenges include identification of primary/secondary events during the time course of critical illness, the interplay between membrane excitability, bioenergetic failure and differential proteolysis, and finding new therapeutic targets by help of tailored animal models. PMID:26133937

  13. Bioelectrical impedance vector analysis in the critically ill: cool tool or just another 'toy'?

    PubMed

    Forni, Lui G; Hasslacher, Julia; Joannidis, Michael

    2015-01-01

    Assessment of volume and hydration status is far from easy and therefore technology such as bioelectrical impedance vector analysis (BIVA) may complement our examination techniques. This study highlights the fact that clinical assessment of volume balance and BIVA may correlate, but whether the routine use of BIVA will avoid significant volume overload in the critically ill remains unknown. Further studies are needed but at the moment appear a little way off. PMID:26556282

  14. Age of red blood cells and mortality in the critically ill

    PubMed Central

    2011-01-01

    Introduction In critically ill patients, it is uncertain whether exposure to older red blood cells (RBCs) may contribute to mortality. We therefore aimed to evaluate the association between the age of RBCs and outcome in a large unselected cohort of critically ill patients in Australia and New Zealand. We hypothesized that exposure to even a single unit of older RBCs may be associated with an increased risk of death. Methods We conducted a prospective, multicenter observational study in 47 ICUs during a 5-week period between August 2008 and September 2008. We included 757 critically ill adult patients receiving at least one unit of RBCs. To test our hypothesis we compared hospital mortality according to quartiles of exposure to maximum age of RBCs without and with adjustment for possible confounding factors. Results Compared with other quartiles (mean maximum red cell age 22.7 days; mortality 121/568 (21.3%)), patients treated with exposure to the lowest quartile of oldest RBCs (mean maximum red cell age 7.7 days; hospital mortality 25/189 (13.2%)) had an unadjusted absolute risk reduction in hospital mortality of 8.1% (95% confidence interval = 2.2 to 14.0%). After adjustment for Acute Physiology and Chronic Health Evaluation III score, other blood component transfusions, number of RBC transfusions, pretransfusion hemoglobin concentration, and cardiac surgery, the odds ratio for hospital mortality for patients exposed to the older three quartiles compared with the lowest quartile was 2.01 (95% confidence interval = 1.07 to 3.77). Conclusions In critically ill patients, in Australia and New Zealand, exposure to older RBCs is independently associated with an increased risk of death. PMID:21496231

  15. Endocrine emergencies in critically ill patients: Challenges in diagnosis and management

    PubMed Central

    Bajwa, Sukhminder Jit Singh; Jindal, Ravi

    2012-01-01

    Endocrine emergencies pose unique challenges for the attending intensivist while managing critically ill patients. Besides taking care of primary disease state, one has to divert an equal attention to the possible associated endocrinopathies also. One of the common reasons for inability to timely diagnose an endocrinal failure in critically ill patients being the dominance of other severe systemic diseases and their clinical presentation. The timely diagnosis and administration of therapeutic interventions for these endocrine disorders can improve the outcome in critically ill patients. The timely diagnosis and administration of timely therapeutics in common endocrine disorders like severe thyroid disease, acute adrenal insufficiency and diabetic ketoacidosis significantly influence the outcome and prognosis. Careful evaluation of clinical history and a high degree of suspicion are the corner stone to diagnose such problems. Aggressive management of the patient is equally important as the complications are devastating and can prove highly fatal. The present article is an attempt to review some of the common endocrine emergencies in intensive care unit and the challenges associated with their diagnosis and management. PMID:23087855

  16. Antibiotics for the critically ill: more than just selecting appropriate initial therapy

    PubMed Central

    2013-01-01

    Critically ill patients with infection provide a number of challenges to clinicians in terms of optimizing their antimicrobial treatment. Of foremost importance, initial antibiotic treatment should be selected as to provide coverage for the causative pathogens. However, the administration of those antibiotics (dosing, interval of administration, duration of infusion, route of administration) should be prescribed in a manner to ensure optimal drug delivery to the site of infection. This is a challenge given the characteristics of many infected critically ill patients (shock, elevated cardiac output in the resuscitated state, supranormal creatinine clearance, increased volume of distribution). Intensive care unit practitioners should utilize treatment strategies that strive to deliver antibiotics in an individualized manner aimed at attaining desired pharmacokinetic/pharmacodynamic targets. The goal of such a treatment strategy is to maximize the likelihood of curing the infection and allowing the critically ill patient the best opportunity for recovery. Effective implementation of antimicrobial optimization delivery strategies will likely require a multi-disciplinary approach including intensivists, pharmacists, and infectious disease specialists. PMID:23714588

  17. Recommendations for the intra-hospital transport of critically ill patients

    PubMed Central

    2010-01-01

    Introduction This study was conducted to provide Intensive Care Units and Emergency Departments with a set of practical procedures (check-lists) for managing critically-ill adult patients in order to avoid complications during intra-hospital transport (IHT). Methods Digital research was carried out via the MEDLINE, EMBASE, CINAHL and HEALTHSTAR databases using the following key words: transferring, transport, intrahospital or intra-hospital, and critically ill patient. The reference bibliographies of each of the selected articles between 1998 and 2009 were also studied. Results This review focuses on the analysis and overcoming of IHT-related risks, the associated adverse events, and their nature and incidence. The suggested preventive measures are also reviewed. A check-list for quick execution of IHT is then put forward and justified. Conclusions Despite improvements in IHT practices, significant risks are still involved. Basic training, good clinical sense and a risk-benefit analysis are currently the only deciding factors. A critically ill patient, prepared and accompanied by an inexperienced team, is a risky combination. The development of adapted equipment and the widespread use of check-lists and proper training programmes would increase the safety of IHT and reduce the risks in the long-term. Further investigation is required in order to evaluate the protective role of such preventive measures. PMID:20470381

  18. The Role of Time-Limited Trials in Dialysis Decision Making in Critically Ill Patients.

    PubMed

    Scherer, Jennifer S; Holley, Jean L

    2016-02-01

    Technologic advances, such as continuous RRT, provide lifesaving therapy for many patients. AKI in the critically ill patient, a fatal diagnosis in the past, is now often a survivable condition. Dialysis decision making for the critically ill patient with AKI is complex. What was once a question solely of survival now is nuanced by an individual's definition of quality of life, personal values, and short- and long-term prognoses. Clinical evaluation of AKI in the critically ill is multifaceted. Treatment decision making requires consideration of the natural evolution of the patient's AKI within the context of the global prognosis. Situations are often marked by prognostic uncertainty and clinical unknowns. In the face of these uncertainties, establishment of patient-directed therapies is imperative. A time-limited trial of continuous RRT in this setting is often appropriate but difficult to execute. Using patient preferences as a clinical guide, a proper time-limited trial requires assessment of prognosis, elicitation of patient values, strong communication skills, clear documentation, and often, appropriate integration of palliative care services. A well conducted time-limited trial can avoid interprofessional conflict and provide support for the patient, family, and staff. PMID:26450932

  19. Contributions of Intestinal Bacteria to Nutrition and Metabolism in the Critically Ill

    PubMed Central

    Morowitz, Michael J.; Carlisle, Erica; Alverdy, John C.

    2011-01-01

    SYNOPSIS Important advances in the study of bacteria associated with the human gastrointestinal tract have significant implications for clinicians striving to meet the metabolic and nutritional needs of critically ill patients. A transition from culture-based to culture-independent studies of the intestinal microbiota has ushered in a new era of laboratory and clinical studies in this field. These studies are helping to clarify the important role of bacteria in carbohydrate metabolism, and are providing new evidence that highlights the role of bacteria in protein and lipid homeostasis. We know that during periods of caloric excess or deprivation, microbial populations in the GI tract are clearly altered; however the molecular etiology for such changes remains elusive. Similarly, little is known about how microbial ecology changes before, during, and after critical illness. Nevertheless, several approaches, e.g. probiotic administration, have been employed to manipulate gut microbial communities in the ICU. In this review we offer a broad overview of the importance of the host-microbe relationship, discuss what is currently known about the role of gut microbes in nutrition and metabolism in the healthy human host, review how gut microbes are impacted by critical illness, and discuss interventions that have already been utilized to manipulate the gut microbiome in ICU patients. PMID:21787967

  20. Supplemental Parenteral Nutrition Is the Key to Prevent Energy Deficits in Critically Ill Patients.

    PubMed

    Oshima, Taku; Heidegger, Claudia-Paula; Pichard, Claude

    2016-08-01

    This review emphasizes the role of a timely supplemental parenteral nutrition (PN) for critically ill patients. It contradicts the recommendations of current guidelines to avoid the use of PN, as it is associated with risk. Critical illness results in severe metabolic stress. During the early phase, inflammatory cytokines and mediators induce catabolism to meet the increased body energy demands by endogenous sources. This response is not suppressed by exogenous energy administration, and the early use of PN to reach the energy target leads to overfeeding. On the other hand, early and progressive enteral nutrition (EN) is less likely to cause overfeeding because of variable gastrointestinal tolerance, a factor frequently associated with significant energy deficit. Recent studies demonstrate that adequate feeding is beneficial during and after the intensive care unit (ICU) stay. Supplemental PN allows for timely adequate feeding, if sufficient precautions are taken to avoid overfeeding. Indirect calorimetry can precisely define the adequate energy prescription. Our pragmatic approach is to start early EN to progressively test the gut tolerance and add supplemental PN on day 3 or 4 after ICU admission, only if EN does not meet the measured energy target. We believe that supplemental PN plays a pivotal role in the achievement of adequate feeding in critically ill patients with intolerance to EN and does not cause harm if overfeeding is avoided by careful prescription, ideally based on energy expenditure measured by indirect calorimetry. PMID:27256992

  1. Individualised antibiotic dosing for patients who are critically ill: challenges and potential solutions.

    PubMed

    Roberts, Jason A; Abdul-Aziz, Mohd H; Lipman, Jeffrey; Mouton, Johan W; Vinks, Alexander A; Felton, Timothy W; Hope, William W; Farkas, Andras; Neely, Michael N; Schentag, Jerome J; Drusano, George; Frey, Otto R; Theuretzbacher, Ursula; Kuti, Joseph L

    2014-06-01

    Infections in critically ill patients are associated with persistently poor clinical outcomes. These patients have severely altered and variable antibiotic pharmacokinetics and are infected by less susceptible pathogens. Antibiotic dosing that does not account for these features is likely to result in suboptimum outcomes. In this Review, we explore the challenges related to patients and pathogens that contribute to inadequate antibiotic dosing and discuss how to implement a process for individualised antibiotic therapy that increases the accuracy of dosing and optimises care for critically ill patients. To improve antibiotic dosing, any physiological changes in patients that could alter antibiotic concentrations should first be established; such changes include altered fluid status, changes in serum albumin concentrations and renal and hepatic function, and microvascular failure. Second, antibiotic susceptibility of pathogens should be confirmed with microbiological techniques. Data for bacterial susceptibility could then be combined with measured data for antibiotic concentrations (when available) in clinical dosing software, which uses pharmacokinetic/pharmacodynamic derived models from critically ill patients to predict accurately the dosing needs for individual patients. Individualisation of dosing could optimise antibiotic exposure and maximise effectiveness. PMID:24768475

  2. Hemodynamic Monitoring in the Critically Ill Patient – Current Status and Perspective

    PubMed Central

    Sakka, Samir G.

    2015-01-01

    In the critically ill patient, early and effective hemodynamic management including fluid therapy and administration of vasoactive drugs to maintain vital organ perfusion and oxygen delivery is mandatory. Understanding the different approaches in the management of critically ill patients during the resuscitation and further management is essential to initiate adequate context- and time-specific interventions. Treatment of hemodynamic variables to achieve a balance between organ oxygen delivery and consumption is the cornerstone. In general, cardiac output is considered a major determinant of oxygen supply and thus its monitoring is regarded helpful. However, indicators of oxygen requirements are equally necessary to assess adequacy of oxygen supply. Currently, more and more less or even totally non-invasive monitoring systems have been developed and clinically introduced, but require validation in this particular patient population. Cardiac output monitors and surrogates of organ oxygenation only enable to adequately guide management, as patient’s outcome is determined by acquisition and interpretation of accurate data, and finally suitable management decisions. This mini-review presents the currently available techniques in the field of hemodynamic monitoring in critically ill patients and briefly summarizes their advantages and limitations. PMID:26284244

  3. Diastolic dysfunction and heart failure with a preserved ejection fraction: Relevance in critical illness and anaesthesia

    PubMed Central

    Maharaj, R.

    2012-01-01

    Epidemiological and clinical studies suggest that HF with a preserved ejection fraction will become the more common form of HF which clinicians will encounter. The spectrum of diastolic disease extends from the asymptomatic phase to fulminant cardiac failure. These patients are commonly encountered in operating rooms and critical care units. A clearer understanding of the underlying pathophysiology and clinical implications of HF with a preserved ejection fraction is fundamental to directing further research and to evaluate interventions. This review highlights the impact of diastolic dysfunction and HF with a preserved ejection fraction during the perioperative period and during critical illness. PMID:23960679

  4. Mental ill health in the elderly: medical students' social representations in the United Kingdom.

    PubMed

    Medeiros, Bruno; Foster, Juliet

    2014-12-01

    Objective This study aims to explore medical students' social representations of mental ill health in older adults. Method It comprises an exploratory and qualitative investigation based on the theory of social representations. Two focus groups with pre-clinical medics (group 1, N=4; group 2, N=4) and 10 individual interviews with clinical medical students were conducted. Thematic analysis at a latent level explored meanings and differences between groups. Results Three overarching themes reflect participants' representations of mental health problems in later life - mental ill health in old age, polarisation of care, and challenges to care. Primary health care appears as an important strategy to overcome barriers to mental health care in the community. Nevertheless, disqualifying representations, stigma and organization of services constitute the main challenges to quality mental health care in later life. Conclusion This paper highlights the need to address cultural and organizational barriers to promote quality care. PMID:25830747

  5. Structure, process and annual intensive care unit mortality across 69 centers: United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study (USCIITG-CIOS)

    PubMed Central

    Checkley, William; Martin, Greg S; Brown, Samuel M; Chang, Steven Y; Dabbagh, Ousama; Fremont, Richard D; Girard, Timothy D; Rice, Todd W; Howell, Michael D; Johnson, Steven B; O'Brien, James; Park, Pauline K; Pastores, Stephen M; Patil, Namrata T; Pietropaoli, Anthony P; Putman, Maryann; Rotello, Leo; Siner, Jonathan; Sajid, Sahul; Murphy, David J; Sevransky, Jonathan E

    2014-01-01

    Objective Hospital-level variations in structure and process may affect clinical outcomes in intensive care units (ICUs). We sought to characterize the organizational structure, processes of care, use of protocols and standardized outcomes in a large sample of U.S. ICUs. Design We surveyed 69 ICUs about organization, size, volume, staffing, processes of care, use of protocols, and annual ICU mortality. Setting ICUs participating in the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study (USCIITG-CIOS). Measurements and Main Results We characterized structure and process variables across ICUs, investigated relationships between these variables and annual ICU mortality, and adjusted for illness severity using APACHE II. Ninety-four ICU directors were invited to participate in the study and 69 ICUs (73%) were enrolled, of which 25 (36%) were medical, 24 were surgical (35%) and 20 (29%) were of mixed type, and 64 (93%) were located in teaching hospitals with a median number of 5 trainees per ICU. Average annual ICU mortality was 10.8%, average APACHE II score was 19.3, 58% were closed units and 41% had a 24-hour in-house intensivist. In multivariable linear regression adjusted for APACHE II and multiple ICU structure and process factors, annual ICU mortality was lower in surgical ICUs than in medical ICUs (5.6% lower, 95% CI 2.4%–8.8%) or mixed ICUs (4.5% lower, 95% CI 0.4%–8.7%). We also found a lower annual ICU mortality among ICUs that had a daily plan of care review (5.8% lower, 95% CI 1.6%–10.0%) and a lower bed-to-nurse ratio (1.8% lower when the ratio decreased from 2:1 to 1.5:1; 95% CI 0.25%–3.4%). In contrast, 24-hour intensivist coverage (p=0.89) and closed ICU status (p=0.16) were not associated with a lower annual ICU mortality. Conclusions In a sample of 69 ICUs, a daily plan of care review and a lower bed-to-nurse ratio were both associated with a lower annual ICU mortality. In contrast to 24-hour intensivist

  6. Sedation for critically ill or injured adults in the intensive care unit: a shifting paradigm.

    PubMed

    Roberts, Derek J; Haroon, Babar; Hall, Richard I

    2012-10-01

    As most critically ill or injured patients will require some degree of sedation, the goal of this paper was to comprehensively review the literature associated with use of sedative agents in the intensive care unit (ICU). The first and selected latter portions of this article present a narrative overview of the shifting paradigm in ICU sedation practices, indications for uninterrupted or prolonged ICU sedation, and the pharmacology of sedative agents. In the second portion, we conducted a structured, although not entirely systematic, review of the available evidence associated with use of alternative sedative agents in critically ill or injured adults. Data sources for this review were derived by searching OVID MEDLINE and PubMed from their first available date until May 2012 for relevant randomized controlled trials (RCTs), systematic reviews and/or meta-analyses and economic evaluations. Advances in the technology of mechanical ventilation have permitted clinicians to limit the use of sedation among the critically ill through daily sedative interruptions or other means. These practices have been reported to result in improved mortality, a decreased length of ICU and hospital stay and a lower risk of drug-associated delirium. However, in some cases, prolonged or uninterrupted sedation may still be indicated, such as when patients develop intracranial hypertension following traumatic brain injury. The pharmacokinetics of sedative agents have clinical importance and may be altered by critical illness or injury, co-morbid conditions and/or drug-drug interactions. Although use of validated sedation scales to monitor depth of sedation is likely to reduce adverse events, they have no utility for patients receiving neuromuscular receptor blocking agents. Depth of sedation monitoring devices such as the Bispectral Index (BIS©) also have limitations. Among existing RCTs, no sedative agent has been reported to improve the risk of mortality among the critically ill or

  7. Functional Recovery following Critical Illness in Children: the “Wee-cover” Pilot Study

    PubMed Central

    Choong, Karen; Al-Harbi, Samah; Siu, Katie; Wong, Katie; Cheng, Ji; Baird, Burke; Pogorzelski, David; Timmons, Brian; Gorter, Jan-Willem; Thabane, Lehana; Khetani, Mary

    2015-01-01

    Objective To determine the feasibility of conducting a longitudinal prospective study to evaluate functional recovery and predictors of impaired functional recovery in critically ill children. Design Prospective pilot study. Setting Single center Pediatric Intensive Care Unit (PICU) at McMaster Children’s Hospital, Hamilton, Canada. Patients Children aged 12 months to 17 years, with at least one organ dysfunction, limited mobility or bed-rest during the first 48 hours of PICU admission, and a minimum 48 hour PICU length of stay, were eligible. Patients transferred from a neonatal intensive care unit prior to ever being discharged home, already mobilizing well or at baseline functional status at time of screening, with an English language barrier, and prior enrollment into this study were excluded. Measurements The primary outcome was feasibility, as defined by the ability to screen, enroll eligible patients, and execute the study procedures and measurements on participants. Secondary outcomes included functional status at baseline, 3 and 6 months, PICU morbidity and mortality. Functional status was measured using the Pediatric Evaluation of Disability Inventory (PEDI), and the Participation and Environment Measure for Children and Youth (PEM-CY). Main results Thirty-three patients were enrolled between October 2012 and April 2013. Consent rate was 85%, follow-up rates 93% at 3 months, and 71% at 6 months. We were able to execute the study procedures and measurements, demonstrating feasibility of conducting a future longitudinal study. Functional status deteriorated following critical illness. Recovery appears to be influenced by baseline health or functional status, and severity of illness. Conclusion Longitudinal research is needed to understand how children recover after a critical illness. Our results suggest factors that may influence the recovery trajectory, and were used to inform the methodology, outcomes of interest, and appropriate sample size of a

  8. Muscle chemistry of critically ill surgical patients and the effects of a course of intravenous nutrition.

    PubMed

    King, R F; Collins, J P; Morgan, D B; Hill, G L

    1978-07-01

    The water, electrolyte and nitrogen contents of muscle were measured in 15 critically ill surgical patients before and after a course (approximately 2 weeks) of intravenous nutrition and in 8 normal individuals. The muscle from the surgical patients contained a significantly increased ratio of water to fat-free dry weight (P less than 0.01) due to an increase in the proportion of extracellular to intracellular water, and this was not corrected by intravenous nutrition. These changes could be due to an accumulation of extracellular fluid alone or to a loss of cell cytoplasm or a loss of whole muscle fibres. Intracellular chemistry was normal in the ill surgical patients and was not changed by intravenous nutrition. PMID:96905

  9. Transport of critically ill children: how to utilize resources in the developing world.

    PubMed

    Khilnani, Praveen; Chhabra, Rajiv

    2008-06-01

    Safe transport of critically ill children remains a globally important issue, particularly in the developing countries such as India and Africa where the high risk mortality and morbidity exists during the transport process that may be less than optimal due to personnel and resource limitation. This article is intended to familiarize the reader with essential components of a good ground pediatric critical care transport program with special reference to developing countries. Essential equipment, medications, training requirement and responsibilities of transport team have been discussed in detail. In addition, recommendations from American (American academy of pediatrics-Transport section) and British pediatric critical care transport systems have been included, keeping in mind the practical feasibility in the Indian scenario where resources are limited. PMID:18759088

  10. Risk factors for invasive fungal disease in critically ill adult patients: a systematic review

    PubMed Central

    2011-01-01

    Introduction Over 5,000 cases of invasive Candida species infections occur in the United Kingdom each year, and around 40% of these cases occur in critical care units. Invasive fungal disease (IFD) in critically ill patients is associated with increased morbidity and mortality at a cost to both the individual and the National Health Service. In this paper, we report the results of a systematic review performed to identify and summarise the important risk factors derived from published multivariable analyses, risk prediction models and clinical decision rules for IFD in critically ill adult patients to inform the primary data collection for the Fungal Infection Risk Evaluation Study. Methods An internet search was performed to identify articles which investigated risk factors, risk prediction models or clinical decisions rules for IFD in critically ill adult patients. Eligible articles were identified in a staged process and were assessed by two investigators independently. The methodological quality of the reporting of the eligible articles was assessed using a set of questions addressing both general and statistical methodologies. Results Thirteen articles met the inclusion criteria, of which eight articles examined risk factors, four developed a risk prediction model or clinical decision rule and one evaluated a clinical decision rule. Studies varied in terms of objectives, risk factors, definitions and outcomes. The following risk factors were found in multiple studies to be significantly associated with IFD: surgery, total parenteral nutrition, fungal colonisation, renal replacement therapy, infection and/or sepsis, mechanical ventilation, diabetes, and Acute Physiology and Chronic Health Evaluation II (APACHE II) or APACHE III score. Several other risk factors were also found to be statistically significant in single studies only. Risk factor selection process and modelling strategy also varied across studies, and sample sizes were inadequate for obtaining

  11. Cardiac Troponin Measurement in the Critically Ill: Potential for Guiding Clinical Management

    PubMed Central

    Poe, Stacy; Vandivier-Pletsch, Robin H.; Clay, Michael; Wong, Hector R.; Haynes, Erin; Rothenberg, Florence G.

    2015-01-01

    Background Elevated cardiac troponin (cTn) in the absence of acute coronary syndromes (ACS) is associated with increased mortality in critically ill patients. There are no evidence-based interventions that reduce mortality in this group. Objectives We performed a retrospective investigation of the Veterans Administration Inpatient Evaluation Center database to determine whether drugs used in ACS (β-blockers, aspirin, and statins) are associated with reduced mortality in critically ill patients. Methods Thirty-day mortality was determined for non-ACS patients admitted to any Veterans Administration Intensive Care Unit between October 1, 2007, and September 30, 2008, adjusted for severity of illness. Troponin assay values were normalized across institutions. Results Multivariate analyses for 30-day mortality showed an odds ratio (OR) of 1.82 for patients with high cTn (P < 0.0001, cTn > 10% coefficient of variation) and 1.18 for intermediate cTn (P = 0.0021, cTn between lowest limit detectable and 10% coefficient of variation) compared with patients with no elevation, adjusting for severity of illness (n = 19,979). Logistic regression models showed that patients with no or intermediate elevations of cTn taking statins within 24 hours of cTn measurement had a lower mortality than patients not taking statins (OR, 0.66; 95% confidence interval [95% CI], 0.53–0.82; P = 0.0003), whereas patients with high cTn had a lower mortality if they were taking β-blockers or aspirin within 24 hours of cTn measurement compared to patients not taking β-blockers or aspirin (β-blockers: OR, 0.80; 95% CI, 0.68–0.94; P = 0.0077; aspirin: OR, 0.81;95% CI, 0.69–0.96; P = 0.0134). Conclusions This retrospective study confirms an association between elevated troponin and outcomes in critically ill patients without ACS and identifies statins, β-blockers, and aspirin as potential outcome modifiers in a cTn-dependent manner. PMID:26425879

  12. Pain assessment in the critically ill adult: Recent evidence and new trends.

    PubMed

    Gélinas, Céline

    2016-06-01

    Pain assessment in the critically ill adult remains a daily clinical challenge. Position statements and practice guidelines exist to guide the ICU care team in the pain assessment process. The patient's self-report of pain remains the gold standard measure for pain and should be obtained as often as possible. When self-report is impossible to obtain, observational pain scales including the Behavioural Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT) have been recommended for clinical use in the critically ill adult. However, their adaptation and validation in brain-injured and burn ICU patients is required. Family caregivers may help in the identification of pain-related behaviours and should be more involved in the ICU pain assessment process. Fluctuations in vital signs should only be considered as cues for further assessment of pain with appropriate tools, and may better represent adverse events of severe pain. Other physiologic measures of pain should be explored in the ICU, and pupillometry appears as a promising technique to further study. Implementation of systematic pain assessment approaches using tools adapted to the patient's ability to communicate and condition has shown positive effects on ICU pain practices and patient outcomes, but randomised control trials are needed to confirm these conclusions. PMID:27067745

  13. Invasive candidiasis as a cause of sepsis in the critically ill patient

    PubMed Central

    Delaloye, Julie; Calandra, Thierry

    2014-01-01

    Invasive fungal infections are an increasingly frequent etiology of sepsis in critically ill patients causing substantial morbidity and mortality. Candida species are by far the predominant agent of fungal sepsis accounting for 10% to 15% of health-care associated infections, about 5% of all cases of severe sepsis and septic shock and are the fourth most common bloodstream isolates in the United States. One-third of all episodes of candidemia occur in the intensive care setting. Early diagnosis of invasive candidiasis is critical in order to initiate antifungal agents promptly. Delay in the administration of appropriate therapy increases mortality. Unfortunately, risk factors, clinical and radiological manifestations are quite unspecific and conventional culture methods are suboptimal. Non-culture based methods (such as mannan, anti-mannan, β-d-glucan, and polymerase chain reaction) have emerged but remain investigational or require additional testing in the ICU setting. Few prophylactic or pre-emptive studies have been performed in critically ill patients. They tended to be underpowered and their clinical usefulness remains to be established under most circumstances. The antifungal armamentarium has expanded considerably with the advent of lipid formulations of amphotericin B, the newest triazoles and the echinocandins. Clinical trials have shown that the triazoles and echinocandins are efficacious and well tolerated antifungal therapies. Clinical practice guidelines for the management of invasive candidiasis have been published by the European Society for Clinical Microbiology and Infectious Diseases and the Infectious Diseases Society of North America. PMID:24157707

  14. Cultural implications of managing chronic illness: treating elderly Chinese patients with heart failure.

    PubMed

    Jiang, Ru-Shang; Wu, Shu-Mei; Che, Hui-Lian; Yeh, Mei-Yu

    2013-01-01

    Dietary patterns are associated with morbidity and mortality of heart failure. Volume overload was the most common cause for re-hospitalization for heart failure patients. However, recommended preventive strategies of restricting excessive dietary sodium and fluid intake were found to be in vain. This study looks at the preventive dietary instructions from a cultural context, and examined the effects of sodium and fluid restriction on twelve elderly Chinese patients hospitalized with heart failure through a qualitative design. Four themes emerged from the data: medicine-food homology, salt and sodium as synonymous, activity intolerance but still wanting social connections, and barriers to asking questions. Results suggested that living with heart failure is a complex and changeable process for both patients and caregivers. Many patients reported low levels of understanding concerning their symptoms and heart function deterioration. The findings found that good communication requires cultural sensitivity, objective listening to the patient's narrative, and helping patients find meaning between their experiences and symptom control. PMID:23473648

  15. The Association Between Admission Magnesium Concentrations and Lactic Acidosis in Critical Illness

    PubMed Central

    Moskowitz, Ari; Lee, Joon; Donnino, Michael W.; Mark, Roger; Celi, Leo Anthony; Danziger, John

    2016-01-01

    Introduction Although magnesium plays an important role in aerobic metabolism and magnesium deficiency is a common phenomenon in critical illness, the association between magnesium deficiency and lactic acidosis in the intensive care unit (ICU) has not been defined. Methods This was a retrospective, cross-sectional study conducted at a 77 ICU bed tertiary medical center. Data pertaining to the first unique admission of any ICU patient between 2001 and 2008 were extracted from the Multiparameter Intelligent Monitoring in Intensive Care database. Hypomagnesemia was defined as serum magnesium <1.6 mg/dL. Mild and severe lactic acidosis were defined as lactate concentrations of >2 and > 4 mmol/L, respectively. Multivariate modeling was used to explore the association between magnesium and lactate concentrations. Results Of 8922 critically ill patients, 22.6% were hypomagnesemic. Hypomagnesemia was associated with an increased adjusted risk of mild lactic acidosis (odds ratio [OR] 1.71, 95% confidence interval [95%CI] 1.51–1.94, P < .001) and severe lactic acidosis (OR 1.56, 95%CI 1.32–1.84, P < .001) than the reference quartile. The association between hypomagnesemia and mild lactic acidosis was stronger in those at risk of magnesium deficiency, including diabetics (OR 2.02, 95%CI 1.51–2.72, P < .001) and alcoholics (OR 1.92, 95%CI 1.16–3.19, P = .01). As an internal model control, hypokalemia was not associated with an increased risk of lactic acidosis. Conclusions Magnesium deficiency is a common finding in patients admitted to the ICU and is associated with lactic acidosis. Our findings support the biologic role of magnesium in metabolism and raise the possibility that hypomagnesemia is a correctable risk factor for lactic acidosis in critical illness. PMID:24733810

  16. Population Pharmacokinetics of Doripenem in Critically Ill Patients with Sepsis in a Malaysian Intensive Care Unit

    PubMed Central

    Abd Rahman, Azrin N.; Mat-Nor, Mohd-Basri; Sulaiman, Helmi; Wallis, Steven C.; Lipman, Jeffrey; Roberts, Jason A.; Staatz, Christine E.

    2015-01-01

    Doripenem has been recently introduced in Malaysia and is used for severe infections in the intensive care unit. However, limited data currently exist to guide optimal dosing in this scenario. We aimed to describe the population pharmacokinetics of doripenem in Malaysian critically ill patients with sepsis and use Monte Carlo dosing simulations to develop clinically relevant dosing guidelines for these patients. In this pharmacokinetic study, 12 critically ill adult patients with sepsis receiving 500 mg of doripenem every 8 h as a 1-hour infusion were enrolled. Serial blood samples were collected on 2 different days, and population pharmacokinetic analysis was performed using a nonlinear mixed-effects modeling approach. A two-compartment linear model with between-subject and between-occasion variability on clearance was adequate in describing the data. The typical volume of distribution and clearance of doripenem in this cohort were 0.47 liters/kg and 0.14 liters/kg/h, respectively. Doripenem clearance was significantly influenced by patients' creatinine clearance (CLCR), such that a 30-ml/min increase in the estimated CLCR would increase doripenem CL by 52%. Monte Carlo dosing simulations suggested that, for pathogens with a MIC of 8 mg/liter, a dose of 1,000 mg every 8 h as a 4-h infusion is optimal for patients with a CLCR of 30 to 100 ml/min, while a dose of 2,000 mg every 8 h as a 4-h infusion is best for patients manifesting a CLCR of >100 ml/min. Findings from this study suggest that, for doripenem usage in Malaysian critically ill patients, an alternative dosing approach may be meritorious, particularly when multidrug resistance pathogens are involved. PMID:26482304

  17. Levosimendan versus dobutamine in critically ill patients: a meta-analysis of randomized controlled trials

    PubMed Central

    Huang, Xuan; Lei, Shu; Zhu, Mei-fei; Jiang, Rong-lin; Huang, Li-quan; Xia, Guo-lian; Zhi, Yi-hui

    2013-01-01

    Objective: To evaluate the clinical efficacy of levosimendan versus dobutamine in critically ill patients requiring inotropic support. Methods: Clinical trials were searched in PubMed, EMBASE, and the Cochrane Central Registry of Clinical Trials, as well as Web of Science. Studies were included if they compared levosimendan with dobutamine in critically ill patients requiring inotropic support, and provided at least one outcome of interest. Outcomes of interest included mortality, incidence of hypotension, supraventricular arrhythmias, and ventricular arrhythmias. Results: Data from a total of 3 052 patients from 22 randomized controlled trials (RCTs) were included in the analysis. Overall analysis showed that the use of levosimendan was associated with a significant reduction in mortality (269 of 1 373 [19.6%] in the levosimendan group, versus 328 of 1 278 [25.7%] in the dobutamine group, risk ratio (RR)=0.81, 95% confidence interval (CI) 0.70–0.92, P for effect=0.002). Subgroup analysis indicated that the benefit from levosimendan could be found in the subpopulations of cardiac surgery, ischemic heart failure, and concomitant β-blocker therapy in comparison with dobutamine. There was no significant difference in the incidence of hypotension, supraventricular arrhythmias, or ventricular arrhythmias between the two drugs. Conclusions: In contrast with dobutamine, levosimendan is associated with a significant improvement in mortality in critically ill patients requiring inotropic support. Patients having cardiac surgery, with ischemic heart failure, and receiving concomitant β-blocker therapy may benefit from levosimendan. More RCTs are required to address the questions about no positive outcomes in the subpopulation in a cardiology setting, and to confirm the advantages in long-term prognosis. PMID:23645177

  18. Engaging Critically Ill Patients in Symptom Management: Thinking Outside the Box!

    PubMed

    Chlan, Linda L

    2016-07-01

    Caring for critically ill patients receiving mechanical ventilation in the intensive care unit (ICU) is an immense challenge for clinicians. Interventions to maintain physiological stability and life itself can cause a number of adverse effects that have a marked impact on patients beyond the period of critical illness or injury. These ICU-acquired conditions include but are not limited to weakness, depression, and post-intensive care syndrome, all of which markedly affect patients' quality of life after they leave the unit. How best to manage the many symptoms experienced by patients undergoing mechanical ventilation without contributing to adverse ICU-acquired sequelae remains a daunting charge for clinicians and requires innovative "out of the box" approaches to address these complex issues. Systematic, cutting-edge research is needed to challenge the "usual" way of managing ICU patients in order to provide the best available evidence for practice integration that minimizes adverse, ICU-acquired sequelae and improves outcomes for the most vulnerable patients. This article highlights a program of research focused on interventions for managing symptoms in critically ill patients receiving mechanical ventilatory support, including the appropriate empowerment of symptom self-management by patients undergoing mechanical ventilation. Development and testing of innovative, nontraditional interventions specifically tailored for ICU patients receiving mechanical ventilatory support are presented. Music listening is highlighted as a nonpharmacological, adjunctive intervention to reduce anxiety associated with mechanical ventilation. Patient-controlled sedation is discussed as an alternative method to meet patients' highly individual needs for sedative therapy to promote comfort. PMID:27369026

  19. Plasticity of the Systemic Inflammatory Response to Acute Infection during Critical Illness: Development of the Riboleukogram

    PubMed Central

    Burykin, Anton; Ruan, Jianhua; Li, Qing; Schierding, William; Lin, Nan; Dixon, David; Zhang, Weixiong; Coopersmith, Craig M.; Dunne, W. Michael; Colonna, Marco; Ghosh, Bijoy K.; Cobb, J. Perren

    2008-01-01

    Background Diagnosis of acute infection in the critically ill remains a challenge. We hypothesized that circulating leukocyte transcriptional profiles can be used to monitor the host response to and recovery from infection complicating critical illness. Methodology/Principal Findings A translational research approach was employed. Fifteen mice underwent intratracheal injections of live P. aeruginosa, P. aeruginosa endotoxin, live S. pneumoniae, or normal saline. At 24 hours after injury, GeneChip microarray analysis of circulating buffy coat RNA identified 219 genes that distinguished between the pulmonary insults and differences in 7-day mortality. Similarly, buffy coat microarray expression profiles were generated from 27 mechanically ventilated patients every two days for up to three weeks. Significant heterogeneity of VAP microarray profiles was observed secondary to patient ethnicity, age, and gender, yet 85 genes were identified with consistent changes in abundance during the seven days bracketing the diagnosis of VAP. Principal components analysis of these 85 genes appeared to differentiate between the responses of subjects who did versus those who did not develop VAP, as defined by a general trajectory (riboleukogram) for the onset and resolution of VAP. As patients recovered from critical illness complicated by acute infection, the riboleukograms converged, consistent with an immune attractor. Conclusions/Significance Here we present the culmination of a mouse pneumonia study, demonstrating for the first time that disease trajectories derived from microarray expression profiles can be used to quantitatively track the clinical course of acute disease and identify a state of immune recovery. These data suggest that the onset of an infection-specific transcriptional program may precede the clinical diagnosis of pneumonia in patients. Moreover, riboleukograms may help explain variance in the host response due to differences in ethnic background, gender, and

  20. New Colistin Population Pharmacokinetic Data in Critically Ill Patients Suggesting an Alternative Loading Dose Rationale

    PubMed Central

    Grégoire, N.; Mimoz, O.; Mégarbane, B.; Comets, E.; Chatelier, D.; Lasocki, S.; Gauzit, R.; Balayn, D.; Gobin, P.; Marchand, S.

    2014-01-01

    Colistin is an old antibiotic that has recently gained a considerable renewal of interest as the last-line defense therapy against multidrug-resistant Gram-negative bacteria. It is administered as colistin methanesulfonate (CMS), an inactive prodrug, and it was shown that due to slow CMS conversion, colistin plasma concentrations increase very slowly after treatment initiation, which constitutes the rationale for a loading dose in critically ill patients. However, faster CMS conversion was observed in healthy volunteers but using a different CMS brand, which may also have a major impact on colistin pharmacokinetics. Seventy-three critically ill patients not undergoing dialysis received multiple doses of CMS. The CMS concentrations were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS), and a pharmacokinetic analysis was conducted using a population approach. We confirmed that CMS renal clearance and colistin concentrations at steady state are mostly governed by creatinine clearance, but we predict a typical maximum concentration of drug in serum (Cmax) of colistin close to 2 mg/liter, occurring 3 h after an initial dose of 2 million international units (MIU) of CMS. Accordingly, the estimated colistin half-life (t1/2) was relatively short (3.1 h), with rapid attainment of steady state. Our results are only partially consistent with other recently published results. We confirm that the CMS maintenance dose should be adjusted according to renal function in critically ill patients. However, much higher than expected colistin concentrations were observed after the initial CMS dose, with rapid steady-state achievement. These discrepancies challenge the pharmacokinetic rationale for a loading dose, which may still be appropriate for rapid bacterial eradication and an improved clinical cure rate. PMID:25267662

  1. Adverse events during intrahospital transport of critically ill patients: incidence and risk factors

    PubMed Central

    2013-01-01

    Background Transport of critically ill patients for diagnostic or therapeutic procedures is at risk of complications. Adverse events during transport are common and may have significant consequences for the patient. The objective of the study was to collect prospectively adverse events that occurred during intrahospital transports of critically ill patients and to determine their risk factors. Methods This prospective, observational study of intrahospital transport of consecutively admitted patients with mechanical ventilation was conducted in a 38-bed intensive care unit in a university hospital from May 2009 to March 2010. Results Of 262 transports observed (184 patients), 120 (45.8%) were associated with adverse events. Risk factors were ventilation with positive end-expiratory pressure >6 cmH2O, sedation before transport, and fluid loading for intrahospital transports. Within these intrahospital transports with adverse events, 68 (26% of all intrahospital transports) were associated with an adverse event affecting the patient. Identified risk factors were: positive end-expiratory pressure >6 cmH2O, and treatment modification before transport. In 44 cases (16.8% of all intrahospital transports), adverse event was considered serious for the patient. In our study, adverse events did not statistically increase ventilator-associated pneumonia, time spent on mechanical ventilation, or length of stay in the intensive care unit. Conclusions This study confirms that the intrahospital transports of critically ill patients leads to a significant number of adverse events. Although in our study adverse events have not had major consequences on the patient stay, efforts should be made to decrease their incidence. PMID:23587445

  2. Population Pharmacokinetics of Doripenem in Critically Ill Patients with Sepsis in a Malaysian Intensive Care Unit.

    PubMed

    Abdul-Aziz, Mohd H; Abd Rahman, Azrin N; Mat-Nor, Mohd-Basri; Sulaiman, Helmi; Wallis, Steven C; Lipman, Jeffrey; Roberts, Jason A; Staatz, Christine E

    2016-01-01

    Doripenem has been recently introduced in Malaysia and is used for severe infections in the intensive care unit. However, limited data currently exist to guide optimal dosing in this scenario. We aimed to describe the population pharmacokinetics of doripenem in Malaysian critically ill patients with sepsis and use Monte Carlo dosing simulations to develop clinically relevant dosing guidelines for these patients. In this pharmacokinetic study, 12 critically ill adult patients with sepsis receiving 500 mg of doripenem every 8 h as a 1-hour infusion were enrolled. Serial blood samples were collected on 2 different days, and population pharmacokinetic analysis was performed using a nonlinear mixed-effects modeling approach. A two-compartment linear model with between-subject and between-occasion variability on clearance was adequate in describing the data. The typical volume of distribution and clearance of doripenem in this cohort were 0.47 liters/kg and 0.14 liters/kg/h, respectively. Doripenem clearance was significantly influenced by patients' creatinine clearance (CL(CR)), such that a 30-ml/min increase in the estimated CL(CR) would increase doripenem CL by 52%. Monte Carlo dosing simulations suggested that, for pathogens with a MIC of 8 mg/liter, a dose of 1,000 mg every 8 h as a 4-h infusion is optimal for patients with a CL(CR) of 30 to 100 ml/min, while a dose of 2,000 mg every 8 h as a 4-h infusion is best for patients manifesting a CL(CR) of >100 ml/min. Findings from this study suggest that, for doripenem usage in Malaysian critically ill patients, an alternative dosing approach may be meritorious, particularly when multidrug resistance pathogens are involved. PMID:26482304

  3. Achievement of Vancomycin Therapeutic Goals in Critically Ill Patients: Early Individualization May Be Beneficial

    PubMed Central

    Shahrami, Bita; Najmeddin, Farhad; Mousavi, Sarah; Ahmadi, Arezoo; Rouini, Mohammad Reza; Sadeghi, Kourosh; Mojtahedzadeh, Mojtaba

    2016-01-01

    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) (P = 0.03). 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) (P = 0.008). 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. PMID:27073695

  4. Utility of flexible fiberoptic bronchoscopy for critically ill pediatric patients: A systematic review

    PubMed Central

    Field-Ridley, Aida; Sethi, Viyeka; Murthi, Shweta; Nandalike, Kiran; Li, Su-Ting T

    2015-01-01

    AIM: To investigate the diagnostic yield, therapeutic efficacy, and rate of adverse events related to flexible fiberoptic bronchoscopy (FFB) in critically ill children. METHODS: We searched PubMed, SCOPUS, OVID, and EMBASE databases through July 2014 for English language publications studying FFB performed in the intensive care unit in children < 18 years old. We identified 666 studies, of which 89 full-text studies were screened for further review. Two reviewers independently determined that 27 of these studies met inclusion criteria and extracted data. We examined the diagnostic yield of FFB among upper and lower airway evaluations, as well as the utility of bronchoalveolar lavage (BAL). RESULTS: We found that FFB led to a change in medical management in 28.9% (range 21.9%-69.2%) of critically ill children. The diagnostic yield of FFB was 82% (range 45.2%-100%). Infectious organisms were identified in 25.7% (17.6%-75%) of BALs performed, resulting in a change of antimicrobial management in 19.1% (range: 12.2%-75%). FFB successfully re-expanded atelectasis or removed mucus plugs in 60.3% (range: 23.8%-100%) of patients with atelectasis. Adverse events were reported in 12.9% (range: 0.5%-71.4%) of patients. The most common adverse effects of FFB were transient hypotension, hypoxia and/or bradycardia that resolved with minimal intervention, such as oxygen supplementation or removal of the bronchoscope. Serious adverse events were uncommon; 2.1% of adverse events required intervention such as bag-mask ventilation or intubation and atropine for hypoxia and bradycardia, normal saline boluses for hypotension, or lavage and suctioning for hemorrhage. CONCLUSION: FFB is safe and effective for diagnostic and therapeutic use in critically ill pediatric patients. PMID:25685726

  5. A Prospective Multicenter Study of Adrenal Function in Critically Ill Children

    PubMed Central

    Menon, Kusum; Ward, Roxanne E.; Lawson, Margaret L.; Gaboury, Isabelle; Hutchison, James S.; Hébert, Paul C.

    2016-01-01

    Rationale Adrenal insufficiency is a clinical condition associated with fluid- and catecholamine-resistant hypotension. Objectives The objectives of this study were to determine the prevalence of adrenal insufficiency, risk factors and potential mechanisms for its development, and its association with clinically important outcomes in critically ill children. Methods A prospective, cohort study was conducted from 2005 to 2008 in seven tertiary-care, pediatric intensive care units in Canada on patients up to 17 years of age with existing vascular access. Adrenocorticotropic hormone stimulation tests (1 μg) were performed and adrenocorticotropic hormone levels measured in all participants. Measurements and Main Results A total of 381 patients had adrenal testing on admission. The prevalence of adrenal insufficiency was 30.2% (95% confidence interval, 25.9–35.1). Patients with adrenal insufficiency had higher baseline cortisol levels (28.6 μg/dl vs. 16.7 μg/dl, P < 0.001) and were significantly older (11.5 yr vs. 2.3 yr, P < 0.001) than those without adrenal insufficiency. Adrenal insufficiency was associated with an increased need for catecholamines (P <0.001) and more fluid boluses (P = 0.026). The sensitivity and specificity of the low-dose adrenocorticotropic hormone stimulation test were 100% and 84%, respectively. Conclusions Adrenal insufficiency occurs in many disease conditions in critically ill children and is associated with an increased use of catecholamines and fluid boluses. It is likely multifactorial in etiology and is associated with high baseline cortisol levels. Further research is necessary to determine which of these critically ill children are truly cortisol deficient before any treatment recommendations can be made. PMID:20299532

  6. New colistin population pharmacokinetic data in critically ill patients suggesting an alternative loading dose rationale.

    PubMed

    Grégoire, N; Mimoz, O; Mégarbane, B; Comets, E; Chatelier, D; Lasocki, S; Gauzit, R; Balayn, D; Gobin, P; Marchand, S; Couet, W

    2014-12-01

    Colistin is an old antibiotic that has recently gained a considerable renewal of interest as the last-line defense therapy against multidrug-resistant Gram-negative bacteria. It is administered as colistin methanesulfonate (CMS), an inactive prodrug, and it was shown that due to slow CMS conversion, colistin plasma concentrations increase very slowly after treatment initiation, which constitutes the rationale for a loading dose in critically ill patients. However, faster CMS conversion was observed in healthy volunteers but using a different CMS brand, which may also have a major impact on colistin pharmacokinetics. Seventy-three critically ill patients not undergoing dialysis received multiple doses of CMS. The CMS concentrations were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS), and a pharmacokinetic analysis was conducted using a population approach. We confirmed that CMS renal clearance and colistin concentrations at steady state are mostly governed by creatinine clearance, but we predict a typical maximum concentration of drug in serum (Cmax) of colistin close to 2 mg/liter, occurring 3 h after an initial dose of 2 million international units (MIU) of CMS. Accordingly, the estimated colistin half-life (t1/2) was relatively short (3.1 h), with rapid attainment of steady state. Our results are only partially consistent with other recently published results. We confirm that the CMS maintenance dose should be adjusted according to renal function in critically ill patients. However, much higher than expected colistin concentrations were observed after the initial CMS dose, with rapid steady-state achievement. These discrepancies challenge the pharmacokinetic rationale for a loading dose, which may still be appropriate for rapid bacterial eradication and an improved clinical cure rate. PMID:25267662

  7. Venous Thromboembolism in Critically Ill Cirrhotic Patients: Practices of Prophylaxis and Incidence

    PubMed Central

    Al-Dorzi, Hasan M.; Tamim, Hani M.; Aldawood, Abdulaziz S.; Arabi, Yaseen M.

    2013-01-01

    Objectives. We compared venous thromboembolism (VTE) prophylaxis practices and incidence in critically ill cirrhotic versus noncirrhotic patients and evaluated cirrhosis as a VTE risk factor. Methods. A cohort of 798 critically ill patients followed for the development of clinically detected VTE were categorized according to the diagnosis of cirrhosis. VTE prophylaxis practices and incidence were compared. Results. Seventy-five (9.4%) patients had cirrhosis with significantly higher INR (2.2 ± 0.9 versus 1.3 ± 0.6, P < 0.0001), lower platelet counts (115,000 ± 90,000 versus 258,000 ± 155,000/μL, P < 0.0001), and higher creatinine compared to noncirrhotic patients. Among cirrhotics, 31 patients received only mechanical prophylaxis, 24 received pharmacologic prophylaxis, and 20 did not have any prophylaxis. Cirrhotic patients were less likely to receive pharmacologic prophylaxis (odds ratio, 0.08; 95% confidence interval (CI), 0.04–0.14). VTE occurred in only two (2.7%) cirrhotic patients compared to 7.6% in noncirrhotic patients (P = 0.11). The incidence rate was 2.2 events per 1000 patient-ICU days for cirrhotic patients and 3.6 events per 1000 patient-ICU days for noncirrhotics (incidence rate ratio, 0.61; 95% CI, 0.15–2.52). On multivariate Cox regression analysis, cirrhosis was not associated with VTE risk (hazard ratio, 0.40; 95% CI, 0.10–1.67). Conclusions. In critically ill cirrhotic patients, VTE incidence did not statistically differ from that in noncirrhotic patients. PMID:24386564

  8. Stress ulcer prophylaxis in critically ill patients: review of the evidence.

    PubMed

    Alhazzani, Waleed; Alshahrani, Mohammed; Moayyedi, Paul; Jaeschke, Roman

    2012-01-01

    Critically ill patients are at risk of developing stress ulcers in the upper digestive tract. Multiple risk factors have been associated with the development of this condition, with variable risk of association. Decades of research have suggested the benefit of using pharmacologic prophylaxis to reduce the incidence of clinically important upper gastrointestinal bleeding, with no reduction in overall mortality. It has been the standard of care to provide prophylaxis to patients at risk. Options for prophylaxis include: proton‑pump inhibitors, histamine(2)‑receptor antagonists, or sucralfate. The choice of prophylaxis depends on multiple factors including the presence of risk factors, risk for nosocomial pneumonia, and possibly cost. PMID:22354363

  9. Highly Sensitive Troponin and Critical Illness Insurance: Have the Goalposts Moved Again?

    PubMed

    Senn, Alban; Meagher, Timothy

    2015-01-01

    An elevated cardiac troponin is a sine qua non for the clinical diagnosis of myocardial infarction. The sensitivity of troponin assays has improved repeatedly since troponin entered clinical use in the late 1990s. Its most recent iteration, "highly sensitive" troponin will shortly enter clinical use in North America. It is able to detect amounts of troponin 10 times smaller than the current assay. As a result, more myocardial infarctions will be diagnosed. This may have an impact on the number of critical illness claims for heart attack. PMID:27584922

  10. Superficial Temporal Artery Pseudoaneurysm: A Conservative Approach in a Critically Ill Patient

    SciTech Connect

    Grasso, Rosario Francesco Quattrocchi, Carlo Cosimo; Crucitti, Pierfilippo; Carboni, Giampiero; Coppola, Roberto; Zobel, Bruno Beomonte

    2007-04-15

    A 71-year-old man affected by cardio- and cerebrovascular disease experienced an accidental fall and trauma to the fronto-temporal area of the head. A few weeks later a growing mass appeared on his scalp. A diagnosis of superficial temporal artery pseudoaneurysm was made following CT and color Doppler ultrasound. His clinical condition favoured a conservative approach by ultrasound-guided compression and subsequent surgical resection. A conservative approach should be considered the treatment of choice in critically ill patients affected by superficial temporal artery pseudoaneurysm.

  11. The role of Vitamin B12 in the critically ill-a review.

    PubMed

    Romain, M; Sviri, S; Linton, D M; Stav, I; van Heerden, P V

    2016-07-01

    Vitamin B12 is an essential micronutrient, as humans have no capacity to produce the vitamin and it needs to be ingested from animal proteins. The ingested Vitamin B12 undergoes a complex process of absorption and assimilation. Vitamin B12 is essential for cellular function. Deficiency affects 15% of patients older than 65 and results in haematological and neurological disorders. Low levels of Vitamin B12 may also be an independent risk factor for coronary artery disease. High levels of Vitamin B12 are associated with inflammation and represent a poor outlook for critically ill patients. Treatment of Vitamin B12 deficiency is simple, but may be lifelong. PMID:27456173

  12. Vitamin B deficiencies in a critically ill autistic child with a restricted diet.

    PubMed

    Baird, J Scott; Ravindranath, Thyyar M

    2015-02-01

    An 11-year-old male with autism became less responsive and was hospitalized with hepatomegaly and liver dysfunction, as well as severe lactic acidosis. His diet for several years was self-limited exclusively to a single "fast food"-a particular type of fried chicken-and was deficient in multiple micronutrients, including the B vitamins thiamine and pyridoxine. Lactic acidosis improved rapidly with thiamine; 2 weeks later, status epilepticus-with low serum pyridoxine-resolved rapidly with pyridoxine. Dietary B vitamin deficiencies complicated the care of this critically ill autistic child and should be considered in this setting. PMID:25112945

  13. Usefulness of Glycemic Gap to Predict ICU Mortality in Critically Ill Patients With Diabetes

    PubMed Central

    Liao, Wen-I.; Wang, Jen-Chun; Chang, Wei-Chou; Hsu, Chin-Wang; Chu, Chi-Ming; Tsai, Shih-Hung

    2015-01-01

    Abstract Stress-induced hyperglycemia (SIH) has been independently associated with an increased risk of mortality in critically ill patients without diabetes. However, it is also necessary to consider preexisting hyperglycemia when investigating the relationship between SIH and mortality in patients with diabetes. We therefore assessed whether the gap between admission glucose and A1C-derived average glucose (ADAG) levels could be a predictor of mortality in critically ill patients with diabetes. We retrospectively reviewed the Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores and clinical outcomes of patients with diabetes admitted to our medical intensive care unit (ICU) between 2011 and 2014. The glycosylated hemoglobin (HbA1c) levels were converted to the ADAG by the equation, ADAG = [(28.7 × HbA1c) − 46.7]. We also used receiver operating characteristic (ROC) curves to determine the optimal cut-off value for the glycemic gap when predicting ICU mortality and used the net reclassification improvement (NRI) to measure the improvement in prediction performance gained by adding the glycemic gap to the APACHE-II score. We enrolled 518 patients, of which 87 (17.0%) died during their ICU stay. Nonsurvivors had significantly higher APACHE-II scores and glycemic gaps than survivors (P < 0.001). Critically ill patients with diabetes and a glycemic gap ≥80 mg/dL had significantly higher ICU mortality and adverse outcomes than those with a glycemic gap <80 mg/dL (P < 0.001). Incorporation of the glycemic gap into the APACHE-II score increased the discriminative performance for predicting ICU mortality by increasing the area under the ROC curve from 0.755 to 0.794 (NRI = 13.6%, P = 0.0013). The glycemic gap can be used to assess the severity and prognosis of critically ill patients with diabetes. The addition of the glycemic gap to the APACHE-II score significantly improved its ability to predict ICU mortality. PMID

  14. Effect of Antiplatelet Therapy on Acute Respiratory Distress Syndrome and Mortality in Critically Ill Patients: A Meta-Analysis

    PubMed Central

    Wang, Lijun; Li, Heng; Gu, Xiaofei; Wang, Zhen; Liu, Su; Chen, Liyong

    2016-01-01

    Background Antiplatelet agents are commonly used for cardiovascular diseases, but their pleiotropic effects in critically ill patients are controversial. We therefore performed a meta-analysis of cohort studies to investigate the effect of antiplatelet therapy in the critically ill. Methods Nine cohort studies, retrieved from PubMed and Embase before November 2015, involving 14,612 critically ill patients and 4765 cases of antiplatelet users, were meta-analysed. The main outcome was hospital or 30-day mortality. Secondary outcome was acute respiratory distress syndrome (ARDS) or acute lung injury (ALI). Random- or fixed-effect models were taken for quantitative synthesis of the data. Results Antiplatelet therapy was associated with decreased mortality (odds ratio (OR) 0.61; 95% confidence interval (CI), 0.52–0.71; I2 = 0%; P <0. 001) and ARDS/ALI (OR 0.64; 95% CI, 0.50–0.82; I2 = 0%; P <0. 001). In every stratum of subgroups, similar findings on mortality reduction were consistently observed in critically ill patients. Conclusions Antiplatelet therapy is associated with reduced mortality and lower incidence of ARDS/ALI in critically ill patients, particularly those with predisposing conditions such as high-risk surgery, trauma, pneumonia, and sepsis. However, it remains unclear whether similar findings can be observed in the unselected and broad population with critical illness. PMID:27182704

  15. Drinking water quality and hospital admissions of elderly people for gastrointestinal illness in Eastern Massachusetts, 1998-2008.

    PubMed

    Beaudeau, Pascal; Schwartz, Joel; Levin, Ronnie

    2014-04-01

    We used a Poisson regression to compare daily hospital admissions of elderly people for acute gastrointestinal illness in Boston against daily variations in drinking water quality over an 11-year period, controlling for weather, seasonality and time trends. The Massachusetts Water Resources Authority (MWRA), which provides non-filtered water to 1.5 million people in the greater Boston area, changed its disinfection method from chlorination to ozonation during the study period so we were also able to evaluate changes in risk associated with the change in disinfection method. Other available water quality data from the MWRA included turbidity, fecal coliforms, UV-absorbance, and planktonic algae and cyanobacteriae concentrations. Daily weather, rainfall data and water temperature were also available. Low water temperature, increases in turbidity and, to a lesser extent, in fecal coliform and cyanobacteriae were associated with a higher risk of hospital admissions, while the shift from chlorination to ozonation has possibly reduced the health risk. The MWRA complied with US drinking water regulations throughout the study period. PMID:24486855

  16. Height measurement in the critically ill patient: A tall order in the critical care unit.

    PubMed

    Venkataraman, Ramesh; Ranganathan, Lakshmi; Nirmal, Vipin; Kameshwaran, J; Sheela, C V; Renuka, M V; Ramakrishnan, Nagarajan

    2015-11-01

    Height measurement in the critical care unit is necessary for estimating ideal body weight and providing titrated patient care. In this study, we compare three methods of height assessment and evaluate their level of correlation and inter-observer reproducibility. Heights of 100 consecutive patients were assessed independently by two nurses by supine, four point, and arm span methods. Paired sample t-test, one-way analysis of variance, Tukey's honestly significant difference post-hoc analysis and Bland-Altman plots were performed to assess agreement between measurements. Arm span method showed higher mean height compared to supine and four point methods. Mean heights derived by supine and four point measurements were similar to each other but were significantly different from that of arm span method (P < 0.001). Inter-observer correlation of the measured heights was very good among all three methods. The supine method seems to be easy, accurate, and reproducible in our study. PMID:26730118

  17. Automated pupillometer for monitoring the critically ill patient: a critical appraisal.

    PubMed

    Zafar, Sahar F; Suarez, Jose I

    2014-08-01

    Abnormalities in the pupillary light reflex are an important prognostic indicator for patients in the intensive care unit (ICU). Manual pupillary examination is confounded by interobserver discrepancies and errors in detecting a reflex under certain conditions. The automated pupillometer is a computer-based infrared digital video device that can obtain objective measurements of pupillary size and reactivity. We performed an electronic literature search to identify original studies on the use of the automated pupillometer in the ICU. We identified 7 articles that met the inclusion criteria and reviewed them critically and assessed the quality of evidence by using the Grading of Recommendations Assessment, Development, and Evaluation approach. We found that the study grade was low, and study quality was low to moderate for all the reviewed manuscripts. Pupillometric measurements had better precision and reproducibility compared with the manual pupillary examination. Based on these data, we conclude that pupillometry monitoring can serve as an important tool in the ICU. Further large scale studies on patients in the neurocritical care unit and medical ICU are needed to support the routine use of automated pupillometry. PMID:24613394

  18. PHARMACOEPIDEMIOLOGY OF QT-INTERVAL PROLONGING DRUG ADMINISTRATION IN CRITICALLY ILL PATIENTS

    PubMed Central

    Freeman, Bradley D.; Dixon, David J.; Coopersmith, Craig M.; Zehnbauer, Barbara A.; Buchman, Timothy G.

    2008-01-01

    Purpose Commonly prescribed medications produce QT-prolongation and are associated with torsades de pointes in non-acutely ill patients. We examined patterns of QT-prolonging drug use in critically ill individuals. Methods An administrative critical care database was utilized to identify patients receiving drugs associated with QT-interval prolongation or torsades de pointes for ≥24 hours. Results Data from 212,016 individuals collected over a 63-month period was examined to identify 6,125 patients (2.9%) receiving QT-interval prolonging drugs. These individuals had a mean (±SE) age of 63.0 (±0.2) years, were predominately male (55.4%) and Caucasian (84.4%), and were exposed to QT-interval prolonging agents for a mean (±SE) 53.1 (±0.4) % of their ICU length of stay. Respiratory and cardiovascular illnesses were the most common reasons for ICU admission (17.2%, 12.0%, respectively). The most frequently administered agents were Amiodarone (23.5%), Haloperidol (19.8%), and Levofloxacin (19.7%); no other single agent accounted for more than 10% of QT-interval prolonging drugs prescribed. Coadministration of QT-prolonging drugs occurred in 1,139 patients (18.6%). These patients had higher ICU mortality rate and longer ICU lengths of stay, compared to patients not receiving coadministered drugs (p<0.001 for both). For patients receiving coadministered drugs, overlap occurred for 71.4 (±0.8) % of the time that the drugs were given. Amiodarone coadministration with antibiotics, Haloperidol coadministration with antibiotics, and Haloperidol coadministration with Amiodarone, comprised 15.2%, 13.7%, and 9.4%, of all coadministered agents, respectively. Conclusions QT-prolonging drugs were used in a minority of critically ill patients. Prospective evaluation in the ICU environment is necessary to determine whether administration of these agents is associated with adverse cardiac events comparable to those reported in ambulatory patients. PMID:18693297

  19. Achieving glycemic control in elderly patients with type 2 diabetes: a critical comparison of current options

    PubMed Central

    Du, Ye-Fong; Ou, Horng-Yih; Beverly, Elizabeth A; Chiu, Ching-Ju

    2014-01-01

    The prevalence of type 2 diabetes mellitus (T2DM) is increasing in the elderly. Because of the unique characteristics of elderly people with T2DM, therapeutic strategy and focus should be tailored to suit this population. This article reviews the guidelines and studies related to older people with T2DM worldwide. A few important themes are generalized: 1) the functional and cognitive status is critical for older people with T2DM considering their life expectancy compared to younger counterparts; 2) both severe hypoglycemia and persistent hyperglycemia are deleterious to older adults with T2DM, and both conditions should be avoided when determining therapeutic goals; 3) recently developed guidelines emphasize the avoidance of hypoglycemic episodes in older people, even in the absence of symptoms. In addition, we raise the concern of glycemic variability, and discuss the rationale for the selection of current options in managing this patient population. PMID:25429208

  20. Pain assessment and management in the critically ill: wizardry or science?

    PubMed

    Puntillo, Kathleen

    2003-07-01

    Assessment and management of patients' pain across practice settings have recently received the increased attention of providers, patients, patients' families, and regulatory agencies. Scientific advances in understanding pain mechanisms, multidimensional methods of pain assessment, and analgesic pharmacology have aided in the improvement of pain management practices. However, pain assessment and management for critical care patients, especially those with communication barriers, continue to present challenges to clinicians and researchers. The state of nursing science of pain in critically ill patients, including development and testing of pain assessment methods and clinical trials of pharmacological interventions, is described. Special emphasis is placed on results from the Thunder Project II, a major multisite investigation of procedural pain. PMID:12882060

  1. Alcohol Withdrawal Syndrome in Critically Ill Patients: Identification, Assessment, and Management.

    PubMed

    Sutton, Lynsey J; Jutel, Annemarie

    2016-02-01

    Management of alcohol withdrawal in critically ill patients is a challenge. The alcohol consumption histories of intensive care patients are often incomplete, limiting identification of patients with alcohol use disorders. Abrupt cessation of alcohol places these patients at risk for alcohol withdrawal syndrome. Typically benzodiazepines are used as first-line therapy to manage alcohol withdrawal. However, if patients progress to more severe withdrawal or delirium tremens, extra adjunctive medications in addition to benzodiazepines may be required. Sedation and mechanical ventilation may also be necessary. Withdrawal assessment scales such as the Clinical Institute of Withdrawal Assessment are of limited use in these patients. Instead, general sedation-agitation scales and delirium detection tools have been used. The important facets of care are the rapid identification of at-risk patients through histories of alcohol consumption, management with combination therapies, and ongoing diligent assessment and evaluation. (Critical Care Nurse. 2016;36[1]:28-39). PMID:26830178

  2. Associations of Markers of Inflammation and Coagulation with Delirium during Critical Illness

    PubMed Central

    Girard, Timothy D; Ware, Lorraine B; Bernard, Gordon R; Pandharipande, Pratik P; Thompson, Jennifer L; Shintani, Ayumi K; Jackson, James C; Dittus, Robert S; Ely, E Wesley

    2012-01-01

    Purpose To assess the associations between a priori-selected markers of inflammation and coagulation and delirium during critical illness. Methods In this prospective cohort study, we collected blood from mechanically ventilated medical intensive care unit (ICU) patients and measured nine plasma markers of inflammation and coagulation. We assessed patients daily for delirium using the Confusion Assessment Method for the ICU and used multivariable regression to analyze the associations between plasma markers and subsequent delirium, after adjusting for age, severity of illness, and sepsis. Results Among the 138 patients studied, with a median age of 66 years and median APACHE II of 27, 107 (78%) were delirious at some point during the study. Two markers of inflammation and one of coagulation were significantly associated with delirium. After adjusting for covariates, lower plasma concentrations of matrix metalloproteinase-9 (MMP-9) and protein C were associated with an increased probability of delirium (p=0.04 and 0.01, respectively), and higher concentrations of soluble tumor necrosis factor receptor-1 (sTNFR1) were associated with an increased probability of delirium (p<0.01). Concentrations of C-reactive protein (p=0.82), myeloperoxidase (p=0.11), neutrophil gelatinase-associated lipocalin (p=0.70), D-dimer (p=0.83), plasminogen activator inhibitor type 1 (p=0.98), and Von Willebrand Factor antigen (p=0.65) were not associated with delirium. Conclusions In this study, MMP-9, protein C, and sTNFR1 were independently associated with subsequent ICU delirium. These results suggest that specific aspects of inflammation and coagulation may play a role in the evolution of delirium during critical illness and that these markers should be examined in larger studies of ICU patients. PMID:22903241

  3. The physiologic meaning of the respiratory index in various types of critical illness.

    PubMed

    Sganga, G; Siegel, J H; Coleman, B; Giovannini, I; Boldrini, G; Pittiruti, M

    1985-01-01

    Seven hundred and sixty cardiorespiratory studies, from 151 critically ill or high-risk general surgical patients with extrapulmonary (S) or pulmonary (P) sepsis, cirrhotic liver disease (L), or cardiac failure (C), were analyzed to assess the determinants of a simple, easily obtained measure of respiratory oxygen exchange, the respiratory index (RI). The pattern of cardiorespiratory abnormalities was studied and correlated with the change in RI. The most important relations were with shunt (QS/QT), mixed venous O2 (PvO2), VD, and VE. Higher F1O2 and positive end-expiratory pressure (PEEP) were needed as the RI rose, indicating a greater severity of illness. Regression analysis of all types of critically ill patients and surgical controls showed that QS/QT, PvO2, and F1O2 interacted together to explain most of the variability of the RI. The regressions in each homogeneous patient disease category were all highly significant (p less than .0001) but had somewhat similar coefficients and explained the variability in RI to different degrees. The data suggest that patients with extrapulmonary sepsis or cirrhotic liver disease have an increase in RI (over that in controls) primarily due to a large increase in CI at the high QS/QT caused by the ventilation/perfusion (VA/QT) maldistribution characteristic of these diseases. However, patients with P or C have a disproportionate rise in RI at any given QS/QT compared to that in high-flow states alone, suggesting in P a direct alveolar limitation of oxygen exchange over and above any level of VA/QT mismatching, and suggesting in C a disproportionate decrease in PvO2 that magnifies the QS/QT effect even though VA/QT is more uniform. PMID:4075505

  4. Dyschloremia Is a Risk Factor for the Development of Acute Kidney Injury in Critically Ill Patients

    PubMed Central

    Shao, Min; Li, Guangxi; Sarvottam, Kumar; Wang, Shengyu; Thongprayoon, Charat; Dong, Yue; Gajic, Ognjen

    2016-01-01

    Introduction Dyschloremia is common in critically ill patients, although its impact has not been well studied. We investigated the epidemiology of dyschloremia and its associations with the incidence of acute kidney injury and other intensive care unit outcomes. Material and Methods This is a single-center, retrospective cohort study at Mayo Clinic Hospital—Rochester. All adult patients admitted to intensive care units from January 1st, 2006, through December 30th, 2012 were included. Patients with known acute kidney injury and chronic kidney disease stage 5 before intensive care unit admission were excluded. We evaluated the association of dyschloremia with ICU outcomes, after adjustments for the effect of age, gender, Charlson comorbidity index and severity of illness score. Results A total of 6,025 patients were enrolled in the final analysis following the implementation of eligibility criteria. From the cohort, 1,970 patients (33%) developed acute kidney injury. Of the total patients enrolled, 4,174 had a baseline serum chloride. In this group, 1,530 (37%) had hypochloremia, and 257 (6%) were hyperchloremic. The incidence of acute kidney injury was higher in hypochloremic and hyperchloremic patients compared to those with a normal serum chloride level (43% vs.30% and 34% vs. 30%, respectively; P < .001). Baseline serum chloride was lower in the acute kidney injury group vs. the non-acute kidney injury group [100 mmol/L (96–104) vs. 102 mmol/L (98–105), P < .0001]. In a multivariable logistic regression model, baseline serum chloride of ≤94 mmol/L found to be independently associated with the risk of acute kidney injury (OR 1.7, 95% CI 1.1–2.6; P = .01). Discussion Dyschloremia is common in critically ill patients, and severe hypochloremia is independently associated with an increased risk of development of acute kidney injury. PMID:27490461

  5. Optimizing Sedation Management to Promote Early Mobilization for Critically Ill Children

    PubMed Central

    Saliski, Mary; Kudchadkar, Sapna R.

    2015-01-01

    Achieving successful early mobilization for the intubated, critically ill child is dependent on optimizing sedation and analgesia. Finding the fine balance between oversedation and undersedation can be challenging. The ideal is for a child to be lucid and interactive during the daytime and demonstrate normal circadian rhythm for sleep with rest at night. Being alert during the day facilitates active participation in therapy including potential ambulation, while decreasing the risk of delirium during mechanical ventilation. An active state during the day with frequent mobilization promotes restorative sleep at night, which brings with it multiple benefits for healing and recovery. Indeed, this ideal may not be physiologically feasible given a child’s critical illness and trajectory, but defining it as the “gold standard” for early mobilization provides a consistent goal for the pediatric intensive care unit (PICU) hospitalization. As such, goal-directed, patient-specific sedation plans are integral to creating a culture of mobility in the PICU. We review currently available sedation strategies for mechanically ventilated children for successful implementation of early mobilization in the PICU, as well as pharmacologic considerations for specific classes of sedative-analgesics. PMID:26702363

  6. Correlation between the severity of critically ill patients and clinical predictors of bronchial aspiration

    PubMed Central

    de Medeiros, Gisele Chagas; Sassi, Fernanda Chiarion; Zambom, Lucas Santos; de Andrade, Claudia Regina Furquim

    2016-01-01

    Objective: To determine whether the severity of non-neurological critically ill patients correlates with clinical predictors of bronchial aspiration. Methods: We evaluated adults undergoing prolonged orotracheal intubation (> 48 h) and bedside swallowing assessment within the first 48 h after extubation. We collected data regarding the risk of bronchial aspiration performed by a speech-language pathologist, whereas data regarding the functional level of swallowing were collected with the American Speech-Language-Hearing Association National Outcome Measurement System (ASHA NOMS) scale and those regarding health status were collected with the Sequential Organ Failure Assessment (SOFA). Results: The study sample comprised 150 patients. For statistical analyses, the patients were grouped by ASHA NOMS score: ASHA1 (levels 1 and 2), ASHA2 (levels 3 to 5); and ASHA3 (levels 6 and 7). In comparison with the other patients, those in the ASHA3 group were significantly younger, remained intubated for fewer days, and less severe overall clinical health status (SOFA score). The clinical predictors of bronchial aspiration that best characterized the groups were abnormal cervical auscultation findings and cough after swallowing. None of the patients in the ASHA 3 group presented with either of those signs. Conclusions: Critically ill patients 55 years of age or older who undergo prolonged orotracheal intubation (≥ 6 days), have a SOFA score ≥ 5, have a Glasgow Coma Scale score ≤ 14, and present with abnormal cervical auscultation findings or cough after swallowing should be prioritized for a full speech pathology assessment. PMID:27167432

  7. Indirect calorimetry in critically ill patients: role of the clinical dietitian in interpreting results.

    PubMed

    Porter, C; Cohen, N H

    1996-01-01

    Evaluation and interpretation of energy needs of critically ill patients require the expertise of clinical dietitians: Dietitians must be knowledgeable about the methods available to quantify energy needs and able to communicate effectively with physicians and nurses regarding nutritional requirements. Several prediction equations are available for calculating energy needs of critically ill patients. Indirect calorimetry is also used frequently to measure energy requirements in this patient population. This article defines when energy expenditure measured by indirect calorimetry may provide clinically useful information. Data obtained by indirect calorimetry must be interpreted carefully. Indirect calorimetry is based on the equations for oxidation of carbohydrate, protein, and fat. Errors in interpretation can be made when metabolic pathways other than oxidation dominate or when clinical conditions exist that affect carbon dioxide excretion from the lungs. Before incorporating data obtained from indirect calorimetry into a nutrition care plan, the clinical dietitian should carefully evaluate the following factors for a patient: clinical conditions when the measurement was made, desired weight loss or gain, tolerance to food or nutrition support, relationship between protein intake and energy need, and need for anabolism or growth. This article provides clinical examples illustrating how measured values compare with calculated values and recommendations for how to incorporate measured values into nutrition care plans. PMID:8537570

  8. Long- and medium-chain triglycerides during parenteral nutrition in critically ill patients.

    PubMed

    Delafosse, B; Viale, J P; Pachiaudi, C; Normand, S; Goudable, J; Bouffard, Y; Annat, G; Bertrand, O

    1997-04-01

    Due to their special metabolic pathway, medium-chain triglycerides (MCT) have been claimed to be oxidized more extensively, compared with long-chain triglycerides (LCT), when administered as a parenteral nutritional support. This enhanced lipid oxidation rate of MCT emulsions could be particularly disclosed in hyperglycemic and hyperinsulinemic conditions. In an attempt to further elucidate this question, we measured substrate oxidation rates in critically ill patients liable to experience such metabolic conditions, that is to say postoperative patients after esophageal resection receiving 1.5 times their measured energy expenditure (n = 12) or after liver transplantation (n = 8). These patients received either LCT or MCT-LCT emulsions. The metabolic measurements were performed simultaneously by two methods, namely indirect calorimetry and isotopic methods based on natural abundance of nutrients. Although both groups of patients were hyperglycemic and hyperinsulinemic, the measured carbohydrate and lipid oxidation rates were not different with whatever type of lipid was administered. The MCT-LCT emulsions did not offer clear-cut advantages over LCT emulsions in critically ill patients when lipid energetic fate was considered. PMID:9142873

  9. A comparison of arterial lines and insertion techniques in critically ill patients.

    PubMed

    Beards, S C; Doedens, L; Jackson, A; Lipman, J

    1994-11-01

    We compared three arterial line insertion techniques and two types of arterial catheters in 69 critically ill patients. Use of the direct-puncture technique (method A) was associated with a significantly higher failure rate (23%) than use of a catheter with a separate guide wire (method B, 'classical' Seldinger technique, p < 0.001) or a catheter with an integral guide wire (method C, 'modified' Seldinger technique, p < 0.02). Operators randomly allocated to using method A took significantly longer to perform the procedure than those using method C (p < 0.01), used significantly more catheters (p < 0.0001) and made significantly more punctures in achieving a successful insertion than those using either methods B (p < 0.001) or C (p < 0.001). Both catheter types B and C (polyurethane) were significantly less likely to block, thus requiring less likely to block, thus requiring re-insertion, than catheter type A (Teflon) (p < 0.02, p < 0.01 respectively). We recommend the use of a 'classical' Seldinger technique (method B) for arterial line insertion in critically ill patients and the use of a polyurethane catheter, in preference to Teflon, to maximise catheter life after insertion. PMID:7802244

  10. Methods to measure target site penetration of antibiotics in critically ill patients.

    PubMed

    Schwameis, Richard; Zeitlinger, Markus

    2013-02-01

    While several tools are necessary to repair a car, the engineer knows exactly which instrument he has to utilize at different parts of the broken machine. Likewise, depending on the information we are interested in, we have to choose different tools to investigate and consecutively understand the multiple aspects that are involved in pharmacokinetics of antimicrobial agents in critically ill patients. Some techniques, like blood sampling, microdialysis or positrons emission tomography (PET) will allow for obtaining continues concentration time profiles while others like bronchoalveolar lavage (BAL), biopsy or surgical tissue samples can only be used a limited number of times per subject. PET and methods based on tissue homogenization will deliver an average of the actual concentrations in intra - and extracellular compartments while investigations in isolated blood cells or microdialysis allow for more distinguished allocation of a concentration to a defined compartment. The present review aims at discussing the advantages and disadvantages of the various methods used for assessing pharmacokinetics in critically ill patients with regard to specific aspects of pharmacokinetic research and further reviews data of selected antibiotics as examples for applications of the individual techniques. PMID:22946872

  11. Haemodynamic effects of parenteral vs. enteral paracetamol in critically ill patients: a randomised controlled trial.

    PubMed

    Kelly, S J; Moran, J L; Williams, P J; Burns, K; Rowland, A; Miners, J O; Peake, S L

    2016-10-01

    Paracetamol is a commonly used drug in the intensive care unit. There have been reports in the literature of an association with significant hypotension, a potentially important interaction for labile critically ill patients. Route of administration may influence the incidence of hypotension. This single-centre, prospective, open-label, randomised, parallel-arm, active-control trial was designed to determine the incidence of hypotension following the administration of paracetamol to critically ill patients. Fifty adult patients receiving paracetamol for analgesia or pyrexia were randomly assigned to receive either the parenteral or enteral formulation of the drug. Paracetamol concentrations were measured at baseline and at multiple time points over 24 h. The maximal plasma paracetamol concentration was significantly different between routes; 156 vs. 73 micromol.l(-1) [p = 0.0005] following the first dose of parenteral or enteral paracetamol, respectively. Sixteen hypotensive events occurred in 12 patients: parenteral n = 12; enteral n = 4. The incident rate ratio for parenteral vs. enteral paracetamol was 2.94 (95% CI 0.97-8.92; p = 0.06). The incidence of hypotension associated with paracetamol administration is higher than previously reported and tends to be more frequent with parenteral paracetamol. PMID:27611038

  12. Transcriptomic analysis reveals abnormal muscle repair and remodeling in survivors of critical illness with sustained weakness.

    PubMed

    Walsh, Christopher J; Batt, Jane; Herridge, Margaret S; Mathur, Sunita; Bader, Gary D; Hu, Pingzhao; Dos Santos, Claudia C

    2016-01-01

    ICU acquired weakness (ICUAW) is a common complication of critical illness characterized by structural and functional impairment of skeletal muscle. The resulting physical impairment may persist for years after ICU discharge, with few patients regaining functional independence. Elucidating molecular mechanisms underscoring sustained ICUAW is crucial to understanding outcomes linked to different morbidity trajectories as well as for the development of novel therapies. Quadriceps muscle biopsies and functional measures of muscle strength and mass were obtained at 7 days and 6 months post-ICU discharge from a cohort of ICUAW patients. Unsupervised co-expression network analysis of transcriptomic profiles identified discrete modules of co-expressed genes associated with the degree of muscle weakness and atrophy in early and sustained ICUAW. Modules were enriched for genes involved in skeletal muscle regeneration and extracellular matrix deposition. Collagen deposition in persistent ICUAW was confirmed by histochemical stain. Modules were further validated in an independent cohort of critically ill patients with sepsis-induced multi-organ failure and a porcine model of ICUAW, demonstrating disease-associated conservation across species and peripheral muscle type. Our findings provide a pathomolecular basis for sustained ICUAW, implicating aberrant expression of distinct skeletal muscle structural and regenerative genes in early and persistent ICUAW. PMID:27411715

  13. To Trach or not to Trach: Uncertainty in the Care of the Chronically Critically Ill

    PubMed Central

    Bice, Thomas; Nelson, Judith E.; Carson, Shannon S.

    2016-01-01

    The number of chronically critically ill patients requiring prolonged mechanical ventilation and receiving a tracheostomy is steadily increasing. Early tracheostomy in patients requiring prolonged mechanical ventilation has been proposed to decrease duration of mechanical ventilation and ICU stay, reduce mortality, and improve patient comfort. However, these benefits have been difficult to demonstrate in clinical trials. So how does one determine the appropriate timing for tracheostomy placement in your patient? Here we review the potential benefits and consequences of tracheostomy, the available evidence for tracheostomy timing, communication surrounding the tracheostomy decision, and a patient-centered approach to tracheostomy. Patients requiring >10 days of mechanical ventilation who are expected to survive their hospitalization likely benefit from tracheostomy, but protocols involving routine early tracheostomy placement do not improve patient outcomes. However patients with neurologic injury, provided they have a good prognosis for meaningful recovery, may benefit from early tracheostomy. In chronically critically ill patients with poor prognosis, tracheostomy is unlikely to provide benefit and should only be pursued if it is consistent with the patient's values, goals and preferences. In this setting, communication with patients and surrogates regarding tracheostomy and prognosis becomes paramount. For the foreseeable future, decisions surrounding tracheostomy will remain relevant and challenging. PMID:26595045

  14. The effect of famotidine on gastroesophageal and duodeno-gastro-esophageal refluxes in critically ill patients

    PubMed Central

    Xin, Ying; Dai, Ning; Zhao, Lan; Wang, Jian-Guo; Si, Jian-Ming

    2003-01-01

    AIM: To investigate the effect of famotidine on gastroesophageal reflux (GER) and duodeno-gastro-esophageal reflux (DGER) and to explore it's possible mechanisms. To identify the relevant factors of the reflux. METHODS: Ninteen critically ill patients were consecutively enrolled in the study. Dynamic 24 h monitoring of GER and DGER before and after administration of famotidine was performed. The parameters of gastric residual volume,multiple organ disorder syndrome (MODS) score, acute physiology and chronic health evaluation II (APACHE II) score and PEEP were recorded. Paired t test; Wilcoxon signed ranks test and Univariate analysis with Spearman's rank correlation were applied to analyse the data. RESULTS: Statistical significance of longest acid reflux, reflux time of pH < 4 and fraction time of acid reflux was observed in ten critically ill patients before and after administration. P value is 0.037, 0.005, 0.005 respectively. Significance change of all bile reflux parameters was observed before and after administration. P value is 0.007, 0.024, 0.005, 0.007, 0.005. GER has positive correlation with APACHE II score and gastric residual volume with correlation coefficient of 0.720, 0.932 respectively. CONCLUSION: GER and DGER are much improved after the administration of famotidine. GER is correlated with APACHE II score and gastric residual volume. PMID:12532466

  15. Reliability of the Identification of the Systemic Inflammatory Response Syndrome in Critically Ill Infants and Children

    PubMed Central

    Juskewitch, Justin E.; Prasad, Swati; Santillan Salas, Carlos F.; Huskins, W. Charles

    2011-01-01

    Objective To assess inter-observer reliability of the identification of episodes of the systemic inflammatory response syndrome (SIRS) in critically ill hospitalized infants and children. Design Retrospective cross-sectional study of the application of the 2005 consensus definition of SIRS in infants and children by two independent trained reviewers using information in the electronic medical record. Setting 18-bed pediatric multidisciplinary medical/surgical pediatric intensive care unit (PICU). Patients A randomly selected sample of children admitted consecutively to the PICU between May 1 and September 30, 2009. Measurements and Main Results 60 infants and children were selected from a total of 343 admitted patients. Their median age was 3.9 years (interquartile range [IQR], 1.5–12.7), 57% were female, and 68% were Caucasian. 19 (32%) children were identified by both reviewers as having an episode of SIRS (88% agreement, 95% confidence interval [CI] 78–94; κ = 0.75, 95% CI, 0.59–0.92). Amongst those 19 children, agreement between the reviewers for individual SIRS criteria was: temperature (84%, 95% CI 60–97); white blood cell count (89%, 95% CI 67–99); respiratory rate (84%, 95% CI 60–97); heart rate (68%, 95% CI 33–87). Conclusions Episodes of SIRS in critically ill infants and children can be identified reproducibly using the consensus definition. PMID:21926661

  16. Candidemia in the critically ill: initial therapy and outcome in mechanically ventilated patients

    PubMed Central

    2013-01-01

    Background Mortality among critically ill patients with candidemia is very high. We sought to determine whether the choice of initial antifungal therapy is associated with survival among these patients, using need for mechanical ventilatory support as a marker of critical illness. Methods Cohort analysis of outcomes among mechanically ventilated patients with candidemia from the 24 North American academic medical centers contributing to the Prospective Antifungal Therapy (PATH) Alliance registry. Patients were included if they received either fluconazole or an echinocandin as initial monotherapy. Results Of 5272 patients in the PATH registry at the time of data abstraction, 1014 were ventilated and concomitantly had candidemia, with 689 eligible for analysis. 28-day survival was higher among the 374 patients treated initially with fluconazole than among the 315 treated with an echinocandin (66% versus 51%, P < .001). Initial fluconazole therapy remained associated with improved survival after adjusting for non-treatment factors in the overall population (hazard ratio .75, 95% CI .59–.96), and also among patients with albicans infection (hazard ratio .62, 95% CI .44–.88). While not statistically significant, fluconazole appeared to be associated with higher mortality among patients infected with glabrata (HR 1.13, 95% CI .70–1.84). Conclusions Among ventilated patients with candidemia, those receiving fluconazole as initial monotherapy were significantly more likely to survive than those treated with an echinocandin. This difference persisted after adjustment for non-treatment factors. PMID:24172136

  17. Gastrointestinal ischemia monitoring through impedance spectroscopy as a tool for the management of the critically ill.

    PubMed

    Beltran, Nohra E; Sacristan, Emilio

    2015-07-01

    Impedance spectroscopy (IS) has been proposed as a tool for monitoring mucosal tissue ischemia and damage in the gut of critically ill patients resulting from shock and hypoperfusion. A specific device and system have been developed and tested for this specific application over the past 12 years by our research group. This paper reviews previously published studies as well as unpublished experimental results, and puts the whole in context and perspective to help understand this technology. Results presented include summaries of gastric reactance measurement understanding, in vivo measurements in animal models, clinical significance of the measurement, and future perspectives of clinical use of this technology. All of the experimental work done to date has been designed to determine the evolving device prototypes' performance and limitations from an instrumentation point of view. Although there are still questions to be answered with regard to the IS measurement, we conclude that we have reached enough confidence in the measurement and the device's performance and safety to begin clinically oriented research to learn how this technology may be useful in the diagnosis and management of different populations of the critically ill. PMID:25711880

  18. Regional citrate anticoagulation for RRTs in critically ill patients with AKI.

    PubMed

    Morabito, Santo; Pistolesi, Valentina; Tritapepe, Luigi; Fiaccadori, Enrico

    2014-12-01

    Hemorrhagic complications have been reported in up to 30% of critically ill patients with AKI undergoing RRT with systemic anticoagulation. Because bleeding is associated with significantly increased mortality risk, strategies aimed at reducing hemorrhagic complications while maintaining extracorporeal circulation should be implemented. Among the alternatives to systemic anticoagulation, regional citrate anticoagulation has been shown to prolong circuit life while reducing the incidence of hemorrhagic complications and lowering transfusion needs. For these reasons, the recently published Kidney Disease Improving Global Outcomes Clinical Practice Guidelines for Acute Kidney Injury have recommended regional citrate anticoagulation as the preferred anticoagulation modality for continuous RRT in critically ill patients in whom it is not contraindicated. However, the use of regional citrate anticoagulation is still limited because of concerns related to the risk of metabolic complications, the complexity of the proposed protocols, and the need for customized solutions. The introduction of simplified anticoagulation protocols based on citrate and the development of dialysis monitors with integrated infusion systems and dedicated software could lead to the wider use of regional citrate anticoagulation in upcoming years. PMID:24993448

  19. Cerebral near-infrared spectroscopy as a measure of nociceptive evoked activity in critically ill infants.

    PubMed

    Ranger, Manon; Johnston, Celeste C; Limperopoulos, Catherine; Rennick, Janet E; du Plessis, Adre J

    2011-01-01

    Signs of pain may be subtle or absent in a critically ill infant. The complex nature of pain may further obscure its identification and measurement. Because the use of monitoring and neuroimaging techniques has become more common in pain research, an understanding of these specialized technologies is important. Near-infrared spectroscopy (NIRS) is a noninvasive technique for monitoring tissue hemodynamics and oxygenation. There are indications that NIRS is capable of detecting the cerebral hemodynamic changes associated with sensory stimuli, including pain, in infants. These developments suggest that NIRS may play an important role in research focusing on pain perception in critically ill infants. The present review briefly describes the cortical responses to noxious stimuli, which parallel cerebral hemodynamic responses to various stimuli. This is followed by an overview of NIRS technology including a summary of the literature on functional studies that have used NIRS in infants. Current NIRS techniques have well-recognized limitations that must be considered carefully during the measurement and interpretation of the signals. Nonetheless, until more advanced NIRS techniques emerge, the current devices have strengths that should be exploited. PMID:22059205

  20. Negative pressure wound therapy for inguinal lymphatic complications in critically ill patients

    PubMed Central

    Cheong, Yong-Kyu; Jun, Heungman; Song, Gi-Won; Moon, Ki-Myung; Kwon, Tae-Won; Lee, Sung-Gyu

    2013-01-01

    Purpose In this study, we investigated the therapeutic potential of regulated negative pressure vacuum-assisted wound therapy for inguinal lymphatic complications in critically ill, liver transplant recipients. Methods The great saphenous vein was harvested for hepatic vein reconstruction during liver transplantation in 599 living-donor liver transplant recipients. Fourteen of the recipients (2.3%) developed postoperative inguinal lymphatic complications and were treated with negative pressure wound therapy, and they were included in this study. Results The average total duration of negative pressure wound therapy was 23 days (range, 11 to 42 days). Complete resolution of the lymphatic complications and wound healing were achieved in all 14 patients, 5 of whom were treated in hospital and 9 as outpatients. There was no clinically detectable infection, bleeding or recurrence after an average follow-up of 27 months (range, 7 to 36 months). Conclusion Negative pressure wound therapy is an effective, readily-available treatment option that is less invasive than exploration and ligation of leaking lymphatics and provides good control of drainage and rapid wound closure in critically ill patients. PMID:24020023

  1. Transcriptomic analysis reveals abnormal muscle repair and remodeling in survivors of critical illness with sustained weakness

    PubMed Central

    Walsh, Christopher J.; Batt, Jane; Herridge, Margaret S.; Mathur, Sunita; Bader, Gary D.; Hu, Pingzhao; dos Santos, Claudia C.

    2016-01-01

    ICU acquired weakness (ICUAW) is a common complication of critical illness characterized by structural and functional impairment of skeletal muscle. The resulting physical impairment may persist for years after ICU discharge, with few patients regaining functional independence. Elucidating molecular mechanisms underscoring sustained ICUAW is crucial to understanding outcomes linked to different morbidity trajectories as well as for the development of novel therapies. Quadriceps muscle biopsies and functional measures of muscle strength and mass were obtained at 7 days and 6 months post-ICU discharge from a cohort of ICUAW patients. Unsupervised co-expression network analysis of transcriptomic profiles identified discrete modules of co-expressed genes associated with the degree of muscle weakness and atrophy in early and sustained ICUAW. Modules were enriched for genes involved in skeletal muscle regeneration and extracellular matrix deposition. Collagen deposition in persistent ICUAW was confirmed by histochemical stain. Modules were further validated in an independent cohort of critically ill patients with sepsis-induced multi-organ failure and a porcine model of ICUAW, demonstrating disease-associated conservation across species and peripheral muscle type. Our findings provide a pathomolecular basis for sustained ICUAW, implicating aberrant expression of distinct skeletal muscle structural and regenerative genes in early and persistent ICUAW. PMID:27411715

  2. The role of endocrine mechanisms in ventilator-associated lung injury in critically ill patients.

    PubMed

    Penesova, A; Galusova, A; Vigas, M; Vlcek, M; Imrich, R; Majek, M

    2012-07-01

    The critically ill subjects are represented by a heterogeneous group of patients suffering from a life-threatening event of different origin, e.g. trauma, cardiopulmonary failure, surgery or sepsis. The majority of these patients are dependent on the artificial lung ventilation, which means a life-saving chance for them. However, the artificial lung ventilation may trigger ventilation-associated lung injury (VALI). The mechanical ventilation at higher volumes (volutrauma) and pressure (barotrauma) can cause histological changes in the lungs including impairments in the gap and adherens junctions and desmosomes. The injured lung epithelium may lead to an impairment of the surfactant production and function, and this may not only contribute to the pathophysiology of VALI but also to acute respiratory distress syndrome. Other components of VALI are atelectrauma and toxic effects of the oxygen. Collectively, all these effects may result in a lung inflammation associated with a subsequent profibrotic changes, endothelial dysfunction, and activation of the local and systemic endocrine responses such as the renin-angiotensin system (RAS). The present review is aimed to describe some of the pathophysiologic aspects of VALI providing a basis for novel therapeutic strategies in the critically ill patients. PMID:22808908

  3. Flucytosine Pharmacokinetics in a Critically Ill Patient Receiving Continuous Renal Replacement Therapy

    PubMed Central

    Kunka, Megan E.; Cady, Elizabeth A.; Woo, Heejung C.; Thompson Bastin, Melissa L.

    2015-01-01

    Purpose. A case report evaluating flucytosine dosing in a critically ill patient receiving continuous renal replacement therapy. Summary. This case report outlines an 81-year-old male who was receiving continuous venovenous hemofiltration (CVVH) for acute renal failure and was being treated with flucytosine for the treatment of disseminated Cryptococcus neoformans infection. Due to patient specific factors, flucytosine was empirically dose adjusted approximately 50% lower than intermittent hemodialysis (iHD) recommendations and approximately 33% lower than CRRT recommendations. Peak and trough levels were obtained, which were supratherapeutic, and pharmacokinetic parameters were calculated. The patient experienced thrombocytopenia, likely due to elevated flucytosine levels, and flucytosine was ultimately discontinued. Conclusion. Despite conservative flucytosine dosing for a patient receiving CVVH, peak and trough serum flucytosine levels were supratherapeutic (120 μg/mL at 2 hours and 81 μg/mL at 11.5 hours), which increased drug-related adverse effects. The results indicate that this conservative dosing regimen utilizing the patient's actual body weight was too aggressive. This case report provides insight into flucytosine dosing in CVVH, a topic that has not been investigated previously. Further pharmacokinetic studies of flucytosine dosing in critically ill patients receiving CVVH are needed in order to optimize pharmacokinetic and pharmacodynamic parameters while avoiding toxic flucytosine exposure. PMID:26246919

  4. Lactate as a marker of energy failure in critically ill patients: hypothesis

    PubMed Central

    Valenza, Franco; Aletti, Gabriele; Fossali, Tommaso; Chevallard, Giorgio; Sacconi, Francesca; Irace, Manuela; Gattinoni, Luciano

    2005-01-01

    Lactate measurement in the critically ill has been traditionally used to stratify patients with poor outcome. However, plasma lactate levels are the result of a finely tuned interplay of factors that affect the balance between its production and its clearance. When the oxygen supply does not match its consumption, organisms such as man who are forced to produce ATP for their integrity adapt in many different ways up to the point when energy failure occurs. Lactate, being part of the adaptive response, may then be used to assess the severity of the supply/demand imbalance. In such a scenario, the time to intervention becomes relevant: early and effective treatment may allow the cell to revert to a normal state, as long as the oxygen machinery (i.e. mithocondria) is intact. Conversely, once the mithocondria are deranged, energy failure occurs even in the presence of normoxia. The lactate increase in critically ill patients may therefore be viewed as an early marker of a potentially reversible state. PMID:16356243

  5. Systematic review: The relation between nutrition and nosocomial pneumonia: randomized trials in critically ill patients

    PubMed Central

    1997-01-01

    Objective To review the effect of enteral nutrition on nosocomial pneumonia in critically ill patients as summarized in randomized clinical trials. Study identification and selection Studies were identified through MEDLINE, SCISEARCH, EMBASE, the Cochrane Library, bibliographies of primary and review articles, and personal files. Through duplicate independent review, we selected randomized trials evaluating approaches to nutrition and their relation to nosocomial pneumonia. Data abstraction In duplicate, independently, we abstracted key data on the design features, population, intervention and outcomes of the studies. Results We identified four trials of enteral vs total parenteral nutrition, one trial of early enteral nutrition vs delayed enteral nutrition, one trial of gastric vs jejunal tube feeding, one trial of intermittent vs continuous enteral feeding, and three trials evaluating different enteral feeding formulae. Sample sizes were small, pneumonia definitions were variable and blinded outcome assessment was infrequent. Randomized trial evidence is insufficient to draw conclusions about the relation between enteral nutrition and nosocomial pneumonia. Conclusions Nutritional interventions in critically ill patients appear to have a modest and inconsistent effect on nosocomial pneumonia. This body of evidence neither supports nor refutes the gastropulmonary route of infection. PMID:11094461

  6. [Prevention and management of refeeding syndrome in patients with chronic critical illness].

    PubMed

    Chen, Jun; Fan, Chaogang

    2016-07-01

    Nutritional support is an important means to treat the patients with chronic critical illness for commonly associated malnutrition. Refeeding syndrome is a serious complication during the process, mainly manifested as severe electrolyte with hypophosphataemia being the most common. Refeeding syndrome is not uncommon but it is often ignored. In our future clinical work, we need to recognize this chinical situation and use preventative and treatment measures. According to NICE clinical nutrition guideline, we discussed the risk factors, treatment methods and preventive measures of refeeding syndrome in patients with chronic critical illness. We argued that for patients with high risk refeeding syndrome, nutritional support treatment should be initially low calorie and slowly increased to complete requirement. Circulation capacity should be recovered, fluid balance must be closely monitored and supplement of vitamins, microelement, electrolytes should be noted. After the emergence of refeeding syndrome, we should reduce or even stop the calorie intake, give an active treatment for electrolyte disorder, provide vitamin B, and maintain the functions of multiple organs. PMID:27452747

  7. Proton Pump Inhibitor Use Is not Associated with Cardiac Arrhythmia in Critically Ill Patients

    PubMed Central

    Chen, Kenneth P.; Lee, Joon; Mark, Roger G.; Feng, Mornin; Celi, Leo A.; Danziger, John

    2016-01-01

    Hypomagnesemia can lead to cardiac arrhythmias. Recently, observational data has linked chronic proton pump inhibitor (PPI) exposure to hypomagnesemia. Whether PPI exposure increases the risk for arrhythmias has not been well studied. Using a large, single center inception cohort of critically ill patients, we examined whether PPI exposure was associated with admission electrocardiogram (ECG) readings of a cardiac arrhythmia in over 8000 patients. There were 24.5% PPI users while 6% were taking a histamine 2 antagonist. 14.3% had a cardiac arrhythmia. PPI use was associated with a 1.18 (95% CI=1.02–1.36, p=0.02) unadjusted and 0.96 (95% CI=0.83–1.12, p=0.62) adjusted risk of arrhythmia. Amongst diuretic users (n=2468), PPI use was similarly not associated with an increased risk of cardiac arrhythmia. In summary, in a large cohort of critically ill patients, PPI exposure is not associated with an increased risk of cardiac arrhythmia. PMID:25655574

  8. Preventive and therapeutic strategies in critically ill patients with highly resistant bacteria.

    PubMed

    Bassetti, Matteo; De Waele, Jan J; Eggimann, Philippe; Garnacho-Montero, Josè; Kahlmeter, Gunnar; Menichetti, Francesco; Nicolau, David P; Paiva, Jose Arturo; Tumbarello, Mario; Welte, Tobias; Wilcox, Mark; Zahar, Jean Ralph; Poulakou, Garyphallia

    2015-05-01

    The antibiotic pipeline continues to diminish and the majority of the public remains unaware of this critical situation. The cause of the decline of antibiotic development is multifactorial and currently most ICUs are confronted with the challenge of multidrug-resistant organisms. Antimicrobial multidrug resistance is expanding all over the world, with extreme and pandrug resistance being increasingly encountered, especially in healthcare-associated infections in large highly specialized hospitals. Antibiotic stewardship for critically ill patients translated into the implementation of specific guidelines, largely promoted by the Surviving Sepsis Campaign, targeted at education to optimize choice, dosage, and duration of antibiotics in order to improve outcomes and reduce the development of resistance. Inappropriate antimicrobial therapy, meaning the selection of an antibiotic to which the causative pathogen is resistant, is a consistent predictor of poor outcomes in septic patients. Therefore, pharmacokinetically/pharmacodynamically optimized dosing regimens should be given to all patients empirically and, once the pathogen and susceptibility are known, local stewardship practices may be employed on the basis of clinical response to redefine an appropriate regimen for the patient. This review will focus on the most severely ill patients, for whom substantial progress in organ support along with diagnostic and therapeutic strategies markedly increased the risk of nosocomial infections. PMID:25792203

  9. Clustering analysis to identify distinct spectral components of encephalogram burst suppression in critically ill patients.

    PubMed

    Zhou, David W; Westover, M Brandon; McClain, Lauren M; Nagaraj, Sunil B; Bajwa, Ednan K; Quraishi, Sadeq A; Akeju, Oluwaseun; Cobb, J Perren; Purdon, Patrick L

    2015-01-01

    Millions of patients are admitted each year to intensive care units (ICUs) in the United States. A significant fraction of ICU survivors develop life-long cognitive impairment, incurring tremendous financial and societal costs. Delirium, a state of impaired awareness, attention and cognition that frequently develops during ICU care, is a major risk factor for post-ICU cognitive impairment. Recent studies suggest that patients experiencing electroencephalogram (EEG) burst suppression have higher rates of mortality and are more likely to develop delirium than patients who do not experience burst suppression. Burst suppression is typically associated with coma and deep levels of anesthesia or hypothermia, and is defined clinically as an alternating pattern of high-amplitude "burst" periods interrupted by sustained low-amplitude "suppression" periods. Here we describe a clustering method to analyze EEG spectra during burst and suppression periods. We used this method to identify a set of distinct spectral patterns in the EEG during burst and suppression periods in critically ill patients. These patterns correlate with level of patient sedation, quantified in terms of sedative infusion rates and clinical sedation scores. This analysis suggests that EEG burst suppression in critically ill patients may not be a single state, but instead may reflect a plurality of states whose specific dynamics relate to a patient's underlying brain function. PMID:26737967

  10. Clustering analysis to identify distinct spectral components of encephalogram burst suppression in critically ill patients

    PubMed Central

    Zhou, David W.; Westover, M. Brandon; McClain, Lauren M.; Nagaraj, Sunil B.; Bajwa, Ednan K.; Quraishi, Sadeq A.; Akeju, Oluwaseun; Cobb, J. Perren; Purdon, Patrick L.

    2016-01-01

    Millions of patients are admitted each year to intensive care units (ICUs) in the United States. A significant fraction of ICU survivors develop life-long cognitive impairment, incurring tremendous financial and societal costs. Delirium, a state of impaired awareness, attention and cognition that frequently develops during ICU care, is a major risk factor for post-ICU cognitive impairment. Recent studies suggest that patients experiencing electroencephalogram (EEG) burst suppression have higher rates of mortality and are more likely to develop delirium than patients who do not experience burst suppression. Burst suppression is typically associated with coma and deep levels of anesthesia or hypothermia, and is defined clinically as an alternating pattern of high-amplitude “burst” periods interrupted by sustained low-amplitude “suppression” periods. Here we describe a clustering method to analyze EEG spectra during burst and suppression periods. We used this method to identify a set of distinct spectral patterns in the EEG during burst and suppression periods in critically ill patients. These patterns correlate with level of patient sedation, quantified in terms of sedative infusion rates and clinical sedation scores. This analysis suggests that EEG burst suppression in critically ill patients may not be a single state, but instead may reflect a plurality of states whose specific dynamics relate to a patient’s underlying brain function. PMID:26737967

  11. Enteral feeding in the critically ill: the role of the gastroenterologist.

    PubMed

    Fang, John C; Delegge, Mark H

    2011-06-01

    Expertise in enteral nutrition (EN) is an important aspect of the skill set of the clinical gastroenterologist. Delivery of adequate EN in critically ill patients is an active therapy that attenuates the metabolic response to stress and favorably modulates the immune system. EN is less expensive than parenteral nutrition and is favored in most cases because of improvement in patient outcomes, including infections and length of stay. Newer endoscopic techniques for placing nasoenteric feeding tubes have been developed, which improve placement success and efficiency. It appears that there is an ideal window period of 24-48 h when enteral feeding should be started in critically ill patients. Most patients can be fed into the stomach, but certain groups may benefit from small bowel feeding. Protocols on how to start and monitor enteral feeding have been developed. Immune-modulating feeding formulations also appear to be beneficial in specific patient populations. The gastroenterologist is a crucial member of the multidisciplinary team for nutritional support in the intensive care unit patient, with his knowledge of gastrointestinal pathophysiology, nutrition, and endoscopic feeding-tube placement. PMID:21468014

  12. Oxygen supply dependency in the critically ill--a continuing conundrum.

    PubMed

    Cain, S M

    1992-01-01

    There was little dispute that endotoxin treatment of experimental animals could recreate the O2 extraction defect that had been observed in critically ill patients. The remaining question was whether or not this necessarily signified pervasive tissue hypoxia. Some limitation to O2 diffusion in the tissues had been postulated because of known effects of endotoxin that ultimately result in damage to endothelium. We were unable to alter the critical DO2 or 0(2)ER in endotoxic dogs by manipulating the arterial PO2. This tended to rule against there being a diffusion limitation created by the endotoxin as a result of endothelial disruption or microvascular dysfunction. The results of the DCA and dopexamine experiments served to remind us that arterial lactate measurements may or may not indicate widespread tissue hypoxia. Sepsis, as emulated by endotoxin infusions, is also a metabolic disease that can cause inactivation of PDH and thus cause lactacidosis without tissue hypoxia. Regional measurements of lactate flux indicated that gut was hypoxic in spite of DO2 above critical because of maldistribution of blood flow between muscularis and mucosa. The questions persist of how much tissue hypoxia is caused by sepsis or endotoxin when DO2 is supported at supposedly adequate levels and whether there are marked regional differences. Such questions still await answers. Newer technological advances that permit assessment of tissue oxygenation by noninvasive methods, such as near infrared spectrophotometry or nuclear magnetic resonance measurement of tissue energy potential, may soon be feasible in critically ill patients. This kind of information will be of vast importance in designing the most effective therapeutic regimen. PMID:1288144

  13. Clinical review: practical approach to hyponatraemia and hypernatraemia in critically ill patients.

    PubMed

    Overgaard-Steensen, Christian; Ring, Troels

    2013-01-01

    Disturbances in sodium concentration are common in the critically ill patient and associated with increased mortality. The key principle in treatment and prevention is that plasma [Na+] (P-[Na+]) is determined by external water and cation balances. P-[Na+] determines plasma tonicity. An important exception is hyperglycaemia, where P-[Na+] may be reduced despite plasma hypertonicity. The patient is first treated to secure airway, breathing and circulation to diminish secondary organ damage. Symptoms are critical when handling a patient with hyponatraemia. Severe symptoms are treated with 2 ml/kg 3% NaCl bolus infusions irrespective of the supposed duration of hyponatraemia. The goal is to reduce cerebral symptoms. The bolus therapy ensures an immediate and controllable rise in P-[Na+]. A maximum of three boluses are given (increases P-[Na+] about 6 mmol/l). In all patients with hyponatraemia, correction above 10 mmol/l/day must be avoided to reduce the risk of osmotic demyelination. Practical measures for handling a rapid rise in P-[Na+] are discussed. The risk of overcorrection is associated with the mechanisms that cause hyponatraemia. Traditional classifications according to volume status are notoriously difficult to handle in clinical practice. Moreover, multiple combined mechanisms are common. More than one mechanism must therefore be considered for safe and lasting correction. Hypernatraemia is less common than hyponatraemia, but implies that the patient is more ill and has a worse prognosis. A practical approach includes treatment of the underlying diseases and restoration of the distorted water and salt balances. Multiple combined mechanisms are common and must be searched for. Importantly, hypernatraemia is not only a matter of water deficit, and treatment of the critically ill patient with an accumulated fluid balance of 20 litres and corresponding weight gain should not comprise more water, but measures to invoke a negative cation balance. Reduction of

  14. Clinical review: Practical approach to hyponatraemia and hypernatraemia in critically ill patients

    PubMed Central

    2013-01-01

    Disturbances in sodium concentration are common in the critically ill patient and associated with increased mortality. The key principle in treatment and prevention is that plasma [Na+] (P-[Na+]) is determined by external water and cation balances. P-[Na+] determines plasma tonicity. An important exception is hyperglycaemia, where P-[Na+] may be reduced despite plasma hypertonicity. The patient is first treated to secure airway, breathing and circulation to diminish secondary organ damage. Symptoms are critical when handling a patient with hyponatraemia. Severe symptoms are treated with 2 ml/kg 3% NaCl bolus infusions irrespective of the supposed duration of hyponatraemia. The goal is to reduce cerebral symptoms. The bolus therapy ensures an immediate and controllable rise in P-[Na+]. A maximum of three boluses are given (increases P-[Na+] about 6 mmol/l). In all patients with hyponatraemia, correction above 10 mmol/l/day must be avoided to reduce the risk of osmotic demyelination. Practical measures for handling a rapid rise in P-[Na+] are discussed. The risk of overcorrection is associated with the mechanisms that cause hyponatraemia. Traditional classifications according to volume status are notoriously difficult to handle in clinical practice. Moreover, multiple combined mechanisms are common. More than one mechanism must therefore be considered for safe and lasting correction. Hypernatraemia is less common than hyponatraemia, but implies that the patient is more ill and has a worse prognosis. A practical approach includes treatment of the underlying diseases and restoration of the distorted water and salt balances. Multiple combined mechanisms are common and must be searched for. Importantly, hypernatraemia is not only a matter of water deficit, and treatment of the critically ill patient with an accumulated fluid balance of 20 litres and corresponding weight gain should not comprise more water, but measures to invoke a negative cation balance. Reduction of

  15. Timing of (supplemental) parenteral nutrition in critically ill patients: a systematic review

    PubMed Central

    2014-01-01

    Supplemental parenteral nutrition (SPN) is used in a step-up approach when full enteral support is contraindicated or fails to reach caloric targets. Recent nutrition guidelines present divergent advices regarding timing of SPN in critically ill patients ranging from early SPN (<48 h after admission; EPN) to postponing initiation of SPN until day 8 after Intensive Care Unit (ICU) admission (LPN). This systematic review summarizes results of prospective studies among adult ICU patients addressing the best timing of (supplemental) parenteral nutrition (S)PN. A structured PubMed search was conducted to identify eligible articles. Articles were screened and selected using predetermined criteria and appraised for relevance and validity. After critical appraisal, four randomized controlled trials (RCTs) and two prospective observational studies remained. One RCT found a higher percentage of alive discharge from the ICU at day 8 in the LPN group compared to EPN group (p = 0.007) but no differences in ICU and in-hospital mortality. None of the other RCTs found differences in ICU or in-hospital mortality rates. Contradicting or divergent results on other secondary outcomes were found for ICU length of stay, hospital length of stay, infection rates, nutrition targets, duration of mechanical ventilation, glucose control, duration of renal replacement therapy, muscle wasting and fat loss. Although the heterogeneity in quality and design of relevant studies precludes firm conclusions, it is reasonable to assume that in adult critically ill patients, there are no clinically relevant benefits of EPN compared with LPN with respect to morbidity or mortality end points, when full enteral support is contraindicated or fails to reach caloric targets. However, considering that infectious morbidity and resolution of organ failure may be negatively affected through mechanisms not yet clearly understood and acquisition costs of parenteral nutrition are higher, the early

  16. Development and psychometric properties of a questionnaire to assess barriers to feeding critically ill patients

    PubMed Central

    2013-01-01

    Background To successfully implement the recommendations of critical care nutrition guidelines, one potential approach is to identify barriers to providing optimal enteral nutrition (EN) in the intensive care unit (ICU), and then address these barriers systematically. Therefore, the purpose of this study was to develop a questionnaire to assess barriers to enterally feeding critically ill patients and to conduct preliminary validity testing of the new instrument. Methods The content of the questionnaire was guided by a published conceptual framework, literature review, and consultation with experts. The questionnaire was pre-tested on a convenience sample of 32 critical care practitioners, and then field tested with 186 critical care providers working at 5 hospitals in North America. The revised questionnaire was pilot tested at another ICU (n = 43). Finally, the questionnaire was distributed to a random sample of ICU nurses twice, two weeks apart, to determine test retest reliability (n = 17). Descriptive statistics, exploratory factor analysis, Cronbach alpha, intraclass correlations (ICC), and kappa coefficients were conducted to assess validity and reliability. Results We developed a questionnaire with 26 potential barriers to delivery of EN asking respondents to rate their importance as barriers in their ICU. Face and content validity of the questionnaire was established through literature review and expert input. The factor analysis indicated a five-factor solution and accounted for 72% of the variance in barriers: guideline recommendations and implementation strategies, delivery of EN to the patient, critical care provider attitudes and behavior, dietitian support, and ICU resources. Overall, the indices of internal reliability for the derived factor subscales and the overall instrument were acceptable (subscale Cronbach alphas range 0.84 – 0.89). However, the test retest reliability was variable and below acceptable thresholds for the majority of

  17. Co-enrollment of critically ill patients into multiple studies: patterns, predictors and consequences

    PubMed Central

    2013-01-01

    Introduction Research on co-enrollment practices and their impact are limited in the ICU setting. The objectives of this study were: 1) to describe patterns and predictors of co-enrollment of patients in a thromboprophylaxis trial, and 2) to examine the consequences of co-enrollment on clinical and trial outcomes. Methods In an observational analysis of an international thromboprophylaxis trial in 67 ICUs, we examined the co-enrollment of critically ill medical-surgical patients into more than one study, and examined the clinical and trial outcomes among co-enrolled and non-co-enrolled patients. Results Among 3,746 patients enrolled in PROTECT (Prophylaxis for ThromboEmbolism in Critical Care Trial), 713 (19.0%) were co-enrolled in at least one other study (53.6% in a randomized trial, 37.0% in an observational study and 9.4% in both). Six factors independently associated with co-enrollment (all P < 0.001) were illness severity (odds ratio (OR) 1.35, 95% confidence interval (CI) 1.19 to 1.53 for each 10-point Acute Physiology and Chronic Health Evaluation (APACHE) II score increase), substitute decision-makers providing consent, rather than patients (OR 3.31, 2.03 to 5.41), experience of persons inviting consent (OR 2.67, 1.74 to 4.11 for persons with > 10 years' experience compared to persons with none), center size (all ORs > 10 for ICUs with > 15 beds), affiliation with trials groups (OR 5.59, 3.49 to 8.95), and main trial rather than pilot phase (all ORs > 8 for recruitment year beyond the pilot). Co-enrollment did not influence clinical or trial outcomes or risk of adverse events. Conclusions Co-enrollment was strongly associated with features of the patients, research personnel, setting and study. Co-enrollment had no impact on trial results, and appeared safe, acceptable and feasible. Transparent reporting, scholarly discourse, ethical analysis and further research are needed on the complex topic of co-enrollment during critical illness. PMID:23298553

  18. Urinary Biomarkers Indicative of Apoptosis and Acute Kidney Injury in the Critically Ill

    PubMed Central

    Vaara, Suvi T.; Lakkisto, Päivi; Immonen, Katariina; Tikkanen, Ilkka; Ala-Kokko, Tero; Pettilä, Ville

    2016-01-01

    Background Apoptosis is a key mechanism involved in ischemic acute kidney injury (AKI), but its role in septic AKI is controversial. Biomarkers indicative of apoptosis could potentially detect developing AKI prior to its clinical diagnosis. Methods As a part of the multicenter, observational FINNAKI study, we performed a pilot study among critically ill patients who developed AKI (n = 30) matched to critically ill patients without AKI (n = 30). We explored the urine and plasma levels of cytokeratin-18 neoepitope M30 (CK-18 M30), cell-free DNA, and heat shock protein 70 (HSP70) at intensive care unit (ICU) admission and 24h thereafter, before the clinical diagnosis of AKI defined by the Kidney Disease: Improving Global Outcomes -creatinine and urine output criteria. Furthermore, we performed a validation study in 197 consecutive patients in the FINNAKI cohort and analyzed the urine sample at ICU admission for CK-18 M30 levels. Results In the pilot study, the urine or plasma levels of measured biomarkers at ICU admission, at 24h, or their maximum value did not differ significantly between AKI and non-AKI patients. Among 20 AKI patients without severe sepsis, the urine CK-18 M30 levels were significantly higher at 24h (median 116.0, IQR [32.3–233.0] U/L) than among those 20 patients who did not develop AKI (46.0 [0.0–54.0] U/L), P = 0.020. Neither urine cell-free DNA nor HSP70 levels significantly differed between AKI and non-AKI patients regardless of the presence of severe sepsis. In the validation study, urine CK-18 M30 level at ICU admission was not significantly higher among patients developing AKI compared to non-AKI patients regardless of the presence of severe sepsis or CKD. Conclusions Our findings do not support that apoptosis detected with CK-18 M30 level would be useful in assessing the development of AKI in the critically ill. Urine HSP or cell-free DNA levels did not differ between AKI and non-AKI patients. PMID:26918334

  19. Construct validity of the Chelsea critical care physical assessment tool: an observational study of recovery from critical illness

    PubMed Central

    2014-01-01

    Introduction Intensive care unit-acquired weakness (ICU-AW) is common in survivors of critical illness, resulting in global weakness and functional deficit. Although ICU-AW is well described subjectively in the literature, the value of objective measures has yet to be established. This project aimed to evaluate the construct validity of the Chelsea Critical Care Physical Assessment tool (CPAx) by analyzing the association between CPAx scores and hospital-discharge location, as a measure of functional outcome. Methods The CPAx was integrated into practice as a service-improvement initiative in an 11-bed intensive care unit (ICU). For patients admitted for more than 48 hours, between 10 May 2010 and 13 November 2013, the last CPAx score within 24 hours of step down from the ICU or death was recorded (n = 499). At hospital discharge, patients were separated into seven categories, based on continued rehabilitation and care needs. Descriptive statistics were used to explore the association between ICU discharge CPAx score and hospital-discharge location. Results Of the 499 patients, 171 (34.3%) returned home with no ongoing rehabilitation or care input; 131 (26.2%) required community support; 28 (5.6%) went to inpatient rehabilitation for <6 weeks; and 25 (5.0%) went to inpatient rehabilitation for >6 weeks; 27 (5.4%) required nursing home level of care; 80 (16.0%) died in the ICU, and 37 (7.4%) died in hospital. A significant difference was found in the median CPAx score between groups (P < 0.0001). Four patients (0.8%) scored full marks (50) on the CPAx, all of whom went home with no ongoing needs; 16 patients (3.2%) scored 0 on the CPAx, all of whom died within 24 hours. A 0.8% ceiling effect and a 3.2% floor effect of the CPAx is found in the ICU. Compliance with completion of the CPAx stabilized at 78% of all ICU admissions. Conclusion The CPAx score at ICU discharge has displayed construct validity by crudely discriminating between groups with

  20. [Elder].

    PubMed

    Arroyo, Pedro; Gutiérrez-Robledo, Luis Miguel

    2016-09-01

    The aim of this review is to present scientific evidence on the biological, dietary, cultural and economic advantages of cow´s milk and dairy products intake in adults, with emphasis on the elderly. The role of milk and dairy products as part of the regular diet, as well as their contribution to a healthy diet for the aged population is described. The updated scientific references on the importance of milk and dairy products on the dietary management of the most prevalent diseases of the eldery -among these energy-protein malnutrition, sarcopenia, obesity, sarcopenic obesity, osteoporosis, diabetes and cardiovascular diseases- are presented. PMID:27603886

  1. "CAN WE FEED?" A mnemonic to merge nutrition and intensive care assessment of the critically ill patient.

    PubMed

    Miller, Keith R; Kiraly, Laszlo N; Lowen, Cynthia C; Martindale, Robert G; McClave, Stephen A

    2011-09-01

    As care of the critically ill patient grows more complex, so does the breadth of knowledge required of the intensivist to deliver quality service. Nutrition is one area of many where the complexity of care has grown and the opportunity for improving patient outcomes has become evident. The use of mnemonics has proven successful in compartmentalizing information that must be considered in complex decision-making processes. The authors propose one such mnemonic, "CAN WE FEED?" to assist in the development and initiation of early enteral nutrition therapy in the intensive care unit (ICU). Critical illness severity (C), age (A), and nutrition risk screening (N) are considered when performing a baseline evaluation of the critically ill patient upon presentation to the ICU. Wait for resuscitation (W) is a key component in the care of most critically ill patients and is an important consideration prior to the initiation of feeding. Energy requirements (E) are determined using conventional weight-based equations, indirect calorimetry, or combinations of both techniques. The more practical aspects of support that follow include formula selection (F), enteral access (E), efficacy (E), and the determination of tolerance (D). With careful consideration of these components through the use of the mnemonic "CAN WE FEED?" the intensivist can successfully implement a nutrition plan, and the clinical nutritionist can appreciate where nutrition therapy appropriately intervenes in the initial resuscitation and management of the critically ill patient. PMID:21881012

  2. Pharmacokinetics of sufentanil during long-term infusion in critically ill pediatric patients.

    PubMed

    Bartkowska-Śniatkowska, Alicja; Bienert, Agnieszka; Wiczling, Paweł; Rosada-Kurasińska, Jowita; Zielińska, Marzena; Warzybok, Justyna; Borsuk, Agnieszka; Tibboel, Dick; Kaliszan, Roman; Grześkowiak, Edmund

    2016-01-01

    The aim of this study was to develop a population pharmacokinetic model of sufentanil and to assess the influence of covariates in critically ill children admitted to a pediatric intensive care unit. After institutional approval, 41 children were enrolled in the study. Blood samples for pharmacokinetic (PK) assessment were collected from routinely placed arterial catheters during and after discontinuation of infusion. Population nonlinear mixed-effects modeling was performed using NONMEM. A 2-compartment model described sufentanil PK sufficiently. Typical values of the central and peripheral volume of distribution and the metabolic and intercompartmental clearance for a theoretical patient weighing 70 kg were VC = 7.90 l, VT  = 481 L, Cl =  5.3 L/h, and Q = 38.3 L/h, respectively. High interindividual variability of all PK parameters was noted. Allometric/isometric principles to scale sufentanil PK revealed that to achieve the same steady-state sufentanil concentrations in plasma for pediatric patients of different body weights, the infusion rate should follow the formula (infusion rate for a 70-kg adult patient, μg/h) × (body weight/70 kg)(0.75). Severity of illness described by PRISM score, the monitored physiological and laboratory parameters, and coadministered drugs such as vasopressors were not found to be significant covariates. PMID:26105145

  3. Cytomegalovirus Colitis in a Critically Ill Patient Following Severe Legionella Pneumonia with Multiple Organ Failure.

    PubMed

    Nakashima, Kei; Aoshima, Masahiro; Suzuki, Fumi; Watanabe, Junko; Otsuka, Yoshihito

    2016-01-01

    A 68-year-old man visited an emergency department complaining of dyspnea. He was diagnosed to have Legionella pneumonia with multiple organ failure. Although his multiple organ failure improved, he suffered from persistent abdominal pain and diarrhea with continuous minor bleeding. Colonoscopy revealed a longitudinal ulcer of the rectum, below the peritoneal reflection. He was diagnosed with cytomegalovirus (CMV) colitis. Antiviral therapy with ganciclovir was initiated. He finally underwent a colostomy after a bowel stricture caused an intestinal outlet obstruction, which made oral intake impossible. Based on the present case, we believe that CMV colitis must be considered as one of the differential diagnoses when critically ill patients develop continuous diarrhea and abdominal pain. PMID:26935377

  4. Bypassing non-adherence via PEG in a critically ill HIV-1-infected patient.

    PubMed

    Leipe, J; Hueber, A J; Rech, J; Harrer, T

    2008-08-01

    This case study describes a 44-year-old, chronically non-adherent, HIV-infected male with relapsing, life threatening toxoplasmic encephalitis (TE) and other recurring opportunistic infections. Non-adherence resulted in critical illness, suppressed CD4 lymphocyte count and elevated viral load. In order to bypass the patient's complete psychological aversion to taking medication, and after exhausting various psychological interventions, a percutaneous endoscopic gastronomy (PEG) tube was inserted for delivery of indispensable medication. During the 15-month follow-up the patient was adherent, exhibiting a consistently undetectable viral load, high CD4 count and a remission of the opportunistic infections. This is an interesting case study demonstrating life-saving and long-term benefit of PEG in an exceptional setting, which has implications for future research and treatment of non-adherent HIV-infected patients. PMID:18608059

  5. Cytomegalovirus reactivation in critically ill immunocompetent hosts: A decade of progress and remaining challenges

    PubMed Central

    Cook, Charles H.; Trgovcich, Joanne

    2011-01-01

    Human cytomegalovirus (HCMV) is an undisputed pathogen in humans with severe immunocompromise that has historically been thought to carry little consequence in immunecompetent hosts. During the past decade, however, accumulating data suggest that significant numbers of immunocompetent humans reactivate HCMV during critical illness, and that these reactivation episodes are associated with worsened outcomes. Because most people are infected with this ubiquitous virus by adulthood, confirming pathogenicity has now become a clinical priority. In this article, we will review the incidence and implications of reactivation, the relevant immune responses and reactivation triggers relevant to the immunocompetent host. We will summarize the progress made during the past ten years, outline work ongoing in this field, and identify the major gaps remaining in our emerging understanding of this phenomenon. PMID:21439328

  6. A Tool for Music Preference Assessment in Critically Ill Patients Receiving Mechanical Ventilatory Support

    PubMed Central

    CHLAN, LINDA; HEIDERSCHEIT, ANNIE

    2010-01-01

    Music is an ideal intervention to reduce anxiety and promote relaxation in critically ill patients. This article reviews the research studies on music-listening interventions to manage distressful symptoms in this population, and describes the development and implementation of the Music Assessment Tool (MAT) to assist professionals in ascertaining patients’ music preferences in the challenging, dynamic clinical environment of the intensive care unit (ICU). The MAT is easy to use with these patients who experience profound communication challenges due to fatigue and inability to speak because of endotracheal tube placement. The music therapist and ICU nursing staff are encouraged to work collaboratively to implement music in a personalized manner to ensure the greatest benefit for mechanically ventilated patients. PMID:24489432

  7. [Hepatotoxicity in the critically ill patient. The liver under an acute severe insult].

    PubMed

    García de Lorenzo y Mateos, A; Rodríguez Montes, J A

    2008-05-01

    The liver plays an essential role in the metabolism of most of the nutrients since it is a mainly metabolic organ carrying out a series of physiological and metabolic processes related with protein and energy metabolism. The intestinal tract is considered a key element in the development of Multiorgan Dysfunction (MOD) or failure by loosing its barrier function (impaired permeability) against toxins, bio-products and occasionally intraluminal bacteria secondary to hypoxia, one of the main pathophysiogenic mechanisms being the insufficient blood flow to splacnic organs. Liver dysfunction and/or impairment of liver function test are a common event in critically ill patients. They may be due to previous liver cirrhosis or to more immediate causes of liver failure such as sepsis, drugs, liver transplant or any of the multiple etiologies for hepatitis. PMID:18714407

  8. Nutrition Support Team-Led Glycemic Control Program for Critically Ill Patients.

    PubMed

    Dickerson, Roland N; Maish, George O; Minard, Gayle; Brown, Rex O

    2014-04-21

    Glycemic control is an important component of the metabolic management of the critically ill patient. Nutrition support teams are frequently challenged by complicated patients who exhibit multiple concurrent etiologies for hyperglycemia. Nutrition support teams can serve in a pivotal role in the development and evaluation of safe and effective techniques for achieving glycemic control. This review describes the efforts of a nutrition support team in achieving safe and effective glycemic control at their institution. Identification of target blood glucose concentration range, development, initiation, monitoring of a continuous intravenous insulin infusion algorithm, nursing adherence to the algorithm, modification of the algorithm based on the presence of conditions that alter insulin metabolism and glucose homeostasis, and transition of the patient who receives continuous enteral nutrition from a continuous intravenous insulin infusion to intermittent subcutaneous insulin therapy are discussed. PMID:24751550

  9. Complications during intrahospital transport of critically ill patients: Focus on risk identification and prevention

    PubMed Central

    Knight, Patrick H; Maheshwari, Neelabh; Hussain, Jafar; Scholl, Michael; Hughes, Michael; Papadimos, Thomas J; Guo, Weidun Alan; Cipolla, James; Stawicki, Stanislaw P; Latchana, Nicholas

    2015-01-01

    Intrahospital transportation of critically ill patients is associated with significant complications. In order to reduce overall risk to the patient, such transports should well organized, efficient, and accompanied by the proper monitoring, equipment, and personnel. Protocols and guidelines for patient transfers should be utilized universally across all healthcare facilities. Care delivered during transport and at the site of diagnostic testing or procedure should be equivalent to the level of care provided in the originating environment. Here we review the most common problems encountered during transport in the hospital setting, including various associated adverse outcomes. Our objective is to make medical practitioners, nurses, and ancillary health care personnel more aware of the potential for various complications that may occur during patient movement from the intensive care unit to other locations within a healthcare facility, focusing on risk reduction and preventive strategies. PMID:26807395

  10. Intensify, resuscitate or palliate: decision making in the critically ill patient with haematological malignancy.

    PubMed

    Hill, Quentin A

    2010-01-01

    The survival prospects of critically ill patients with haematological malignancy (HM) are reviewed, as are the variables which might influence decisions about the limitation of life sustaining therapies (LLST). Approximately 40% of patients with HM admitted to ICU survive to hospital discharge and a broad admission policy is warranted. Short term survival is predicted by the severity of the underlying physiological disturbance rather than cancer specific characteristics, although the prognostic importance of neutropenia and prior stem cell transplantation remains to be clarified. Survival to hospital discharge in cancer patients following cardio-pulmonary resuscitation (CPR) is only 6-8%. Poor performance status and progressive deterioration despite ICU support appear to predict worse outcome. Patients should be provided with realistic information in order to make an informed decision about CPR. Decisions about LLST must be individualised. Consideration should be given to the patient's wishes and prognosis, the immediate clinical circumstances and their potential reversibility. PMID:19913962

  11. Respiratory muscle dysfunction: a multicausal entity in the critically ill patient undergoing mechanical ventilation.

    PubMed

    Díaz, Magda C; Ospina-Tascón, Gustavo A; Salazar C, Blanca C

    2014-02-01

    Respiratory muscle dysfunction, particularly of the diaphragm, may play a key role in the pathophysiological mechanisms that lead to difficulty in weaning patients from mechanical ventilation. The limited mobility of critically ill patients, and of the diaphragm in particular when prolonged mechanical ventilation support is required, promotes the early onset of respiratory muscle dysfunction, but this can also be caused or exacerbated by other factors that are common in these patients, such as sepsis, malnutrition, advanced age, duration and type of ventilation, and use of certain medications, such as steroids and neuromuscular blocking agents. In this review we will study in depth this multicausal origin, in which a common mechanism is altered protein metabolism, according to the findings reported in various models. The understanding of this multicausality produced by the same pathophysiological mechanism could facilitate the management and monitoring of patients undergoing mechanical ventilation. PMID:23669061

  12. Evaluation of the pressure ulcers risk scales with critically ill patients: a prospective cohort study 1

    PubMed Central

    Borghardt, Andressa Tomazini; do Prado, Thiago Nascimento; de Araújo, Thiago Moura; Rogenski, Noemi Marisa Brunet; Bringuente, Maria Edla de Oliveira

    2015-01-01

    AIMS: to evaluate the accuracy of the Braden and Waterlow risk assessment scales in critically ill inpatients. METHOD: this prospective cohort study, with 55 patients in intensive care units, was performed through evaluation of sociodemographic and clinical variables, through the application of the scales (Braden and Waterlow) upon admission and every 48 hours; and through the evaluation and classification of the ulcers into categories. RESULTS: the pressure ulcer incidence was 30.9%, with the Braden and Waterlow scales presenting high sensitivity (41% and 71%) and low specificity (21% and 47%) respectively in the three evaluations. The cut off scores found in the first, second and third evaluations were 12, 12 and 11 in the Braden scale, and 16, 15 and 14 in the Waterlow scale. CONCLUSION: the Braden scale was shown to be a good screening instrument, and the Waterlow scale proved to have better predictive power. PMID:25806628

  13. [Update on invasive candidiasis in non-neutropenic critically ill adult patients].

    PubMed

    Zaragoza, Rafael; Ramírez, Paula; Borges, Marcio; Pemán, Javier

    2016-01-01

    Invasive candidiasis in non-neutropenic critically ill patients remains a challenge for clinicians due to its association with high morbidity and mortality rates, increased incidence, and health-care costs. It is well known that early diagnosis and treatment are associated with a better prognosis. For these reasons a thorough update has been performed in this setting focused on recent Spanish epidemiology, new predictive scores and microbiological tests such as mannan antigen, mannan antibodies, Candida albicans germ-tube antibodies or (1→3)-β-D-glucan detection, molecular techniques for the detection of fungal-specific DNA, advances in antifungal treatment and educational programs in Spain. An early diagnostic and therapeutic algorithm is proposed based on the combination of scores and microbiological test. The aim of this review is to provide physicians with the best information available in order to improve the prognosis of these patients. PMID:27395022

  14. Should We Aim for Full Enteral Feeding in the First Week of Critical Illness?

    PubMed

    McClave, Stephen A; Codner, Panna; Patel, Jayshil; Hurt, Ryan T; Allen, Karen; Martindale, Robert G

    2016-08-01

    Recent clinical trials have challenged the concept that aggressive full feeding as close to goal requirements as possible is necessary in the first week following admission to the intensive care unit. While the data suggesting that permissive underfeeding is better than full feeds are methodologically flawed, other data do indicate that in certain well-defined patient populations, outcomes may be similar. The most important issues for clinicians in determining optimal nutrition therapy for critically ill patients are to carefully determine nutrition risk and differentiate nutrition from nonnutrition benefits of early enteral feeding. Management decisions in the first week of hospitalization should be made in the context of both short- and long-term outcomes. Patients at highest nutrition risk may require advancement to goal feeds as soon as tolerated to maximize benefit from nutrition therapy. PMID:27317613

  15. [Effect of exercise training on rehabilitation of the chronic critical illness patients].

    PubMed

    Gu, Guosheng; Ren, Jianan

    2016-07-01

    Over the past decades, the evolution of the techniques used in the intensive care has led on one side to better survival rates in ICU patients. On the other side, it has resulted in a growing number of patients who survive an acute event to chronic condition, and who then become dependent on one or more life support treatments. Such patients are called chronic critical illness(CCI) patients. Even these patients can dismiss from intensive care unit (ICU) or transfer to specialized rehabilitation care settings, the mortality of these patients is still very high. Therefore, how to promote the rehabilitation of CCI patients is one of the most important research points of epidemiology, public health and social economics. Exercise training can promote rehabilitation, improve quality of life and independent functional status in these patients, which should be used as one of the standard treatment protocols for CCI patients. PMID:27452749

  16. Prognostic value of circulating DNA levels in critically ill and trauma patients.

    PubMed

    Rodrigues Filho, Edison Moraes; Ikuta, Nilo; Simon, Daniel; Regner, Andrea Pereira

    2014-01-01

    The number of studies investigating circulating nucleic acids as potential biomarkers has increased in recent years. The detection of such biomarkers is a minimally invasive alternative for the diagnosis and prognosis of various clinical conditions. The value of circulating DNA levels as a predictive biomarker has been demonstrated in patients suffering from numerous acute pathologies that have a high risk of intensive care needs and in-hospital deaths. The mechanism by which circulating DNA levels increase in patients with these conditions remains unclear. In this review, we focused on the potential use of this biomarker for prognosis prediction in critically ill and trauma patients. The literature review was performed by searching MedLine using PubMed in the English language. PMID:25295826

  17. Assessment and Utility of Frailty Measures in Critical Illness, Cardiology, and Cardiac Surgery.

    PubMed

    Rajabali, Naheed; Rolfson, Darryl; Bagshaw, Sean M

    2016-09-01

    Frailty is a clearly emerging theme in acute care medicine, with obvious prognostic and health resource implications. "Frailty" is a term used to describe a multidimensional syndrome of loss of homeostatic reserves that gives rise to a vulnerability to adverse outcomes after relatively minor stressor events. This is conceptually simple, yet there has been little consensus on the operational definition. The gold standard method to diagnose frailty remains a comprehensive geriatric assessment; however, a variety of validated physical performance measures, judgement-based tools, and multidimensional scales are being applied in critical care, cardiology, and cardiac surgery settings, including open cardiac surgery and transcatheter aortic value replacement. Frailty is common among patients admitted to the intensive care unit and correlates with an increased risk for adverse events, increased resource use, and less favourable patient-centred outcomes. Analogous findings have been described across selected acute cardiology and cardiac surgical settings, in particular those that commonly intersect with critical care services. The optimal methods for screening and diagnosing frailty across these settings remains an active area of investigation. Routine assessment for frailty conceivably has numerous purported benefits for patients, families, health care providers, and health administrators through better informed decision-making regarding treatments or goals of care, prognosis for survival, expectations for recovery, risk of complications, and expected resource use. In this review, we discuss the measurement of frailty and its utility in patients with critical illness and in cardiology and cardiac surgery settings. PMID:27476983

  18. Are the Dysnatremias a Permanent Threat to the Critically Ill Patients?

    PubMed Central

    Basile-Filho, Anibal; Menegueti, Mayra Goncalves; Nicolini, Edson Antonio; Lago, Alessandra Fabiane; Martinez, Edson Zangiacomi; Auxiliadora-Martins, Maria

    2016-01-01

    Backgroud The dysnatremias (hyponatremia and hypernatremia) are relatively common findings on admission of intensive care unit (ICU) patients and may represent a major risk. The aim of the study was to assess the ability of serum sodium levels and the Acute Physiology and Chronic Health Evaluation II (APACHE II) to predict mortality of surgical critically ill patients. Methods One hundred and ninety-five surgical patients (62% males and 38% females; mean age of 51.8 ± 17.3 years) admitted to the ICU in the postoperative phase were retrospectively studied. The patients were divided into survivors (n = 152) and non-survivors (n = 43). APACHE II, and serum sodium levels at admission, 48 h and discharge were analyzed by generation of receiver operating characteristic (ROC) curves. Results The mean APACHE II was 16.3 ± 8.3 (13.6 ± 6.1 for survivors and 25.5 ± 8.5 for non-survivors). The area under the ROC curve for APACHE II was 0.841 (0.782 - 0.889) and 0.721 (0.653 - 0.783), 0.754 (0.653 - 0.783) and 0.720 (0.687 - 0.812) for serum sodium level at admission, 48 h and discharge, respectively. Conclusion Even though APACHE II scoring system was the most effective index to predict mortality in the surgical critically ill patients, the serum sodium levels on admission may also be used as an independent predictor of outcome. PMID:26767083

  19. Ultrasound-guided internal jugular vein catheterization in critically ill pediatric patients

    PubMed Central

    Yang, Eu Jeen; Ha, Hyeong Seok; Kong, Young Hwa

    2015-01-01

    Purpose Continuous intravenous access is imperative in emergency situations. Ultrasound-guided internal jugular vein (IJV) catheterization was investigated in critically ill pediatric patients to assess the feasibility of the procedure. Methods Patients admitted to the pediatric intensive care unit between February 2011 and September 2012 were enrolled in this study. All patients received a central venous catheter from attending house staff under ultrasound guidance. Outcome measures included successful insertion of the catheter, cannulation time, number of cannulation attempts, and number and type of resulting complications. Results Forty-one central venous catheters (93.2%) were successfully inserted into 44 patients (21 males and 23 females; mean age, 6.54±1.06 years). Thirty-three patients (75.0%) had neurological disorders. The right IJV was used for catheter insertion in 34 cases (82.9%). The mean number of cannulation attempts and the mean cannulation time was 1.57±0.34 and 14.07±1.91 minutes, respectively, the mean catheter dwell time was 14.73±2.5 days. Accidental catheter removal was observed in 9 patients (22.0%). Six patients (13.6%) reported complications, the most serious being catheter-related sepsis, which affected 1 patient (2.3%). Other complications included 2 reported cases of catheter malposition (4.6%), and 1 case each of arterial puncture (2.3%), pneumothorax (2.3%), and skin infection (2.3%). Conclusion The results suggest that ultrasound-guided IJV catheterization can be performed easily and without any serious complications in pediatric patients, even when performed by visiting house staff. Therefore, ultrasound-guided IJV catheterization is strongly recommended for critically ill pediatric patients. PMID:25932035

  20. The Effect of Nutritional Status in the Pathogenesis of Critical Illness Myopathy (CIM)

    PubMed Central

    Ogilvie, Hannah; Larsson, Lars

    2014-01-01

    The muscle wasting and loss of specific force associated with Critical Illness Myopathy (CIM) is, at least in part, due to a preferential loss of the molecular motor protein myosin. This acquired myopathy is common in critically ill immobilized and mechanically ventilated intensive care patients (ICU). There is a growing understanding of the mechanisms underlying CIM, but the role of nutritional factors triggering this serious complication of modern intensive care remains unknown. This study aims at establishing the effect of nutritional status in the pathogenesis of CIM. An experimental ICU model was used where animals are mechanically ventilated, pharmacologically paralysed post-synaptically and extensively monitored for up to 14 days. Due to the complexity of the experimental model, the number of animals included is small. After exposure to this ICU condition, animals develop a phenotype similar to patients with CIM. The results from this study show that the preferential myosin loss, decline in specific force and muscle fiber atrophy did not differ between low vs. eucaloric animals. In both experimental groups, passive mechanical loading had a sparing effect of muscle weight independent on nutritional status. Thus, this study confirms the strong impact of the mechanical silencing associated with the ICU condition in triggering CIM, overriding any potential effects of caloric intake in triggering CIM. In addition, the positive effects of passive mechanical loading on muscle fiber size and force generating capacity was not affected by the nutritional status in this study. However, due to the small sample size these pilot results need to be validated in a larger cohort. PMID:24887774

  1. The Prevalence and Characteristics of Pain in Critically Ill Cancer Patients: A Prospective Nonrandomized Observational Study

    PubMed Central

    Gupta, Mayank; Sahi, Malvinder Singh; Bhargava, AK; Talwar, Vineet

    2015-01-01

    Context: Pain is a distressing symptom common to all stages and ubiquitous at all levels of care in cancer patients. However, there is a lack of scientific literature on prevalence, severity, predictors, and the quality of pain in cancer patients admitted to an Intensive Care Unit (ICU). Objectives: To elucidate the prevalence of pain, moderate to severe pain, neuropathic pain, chronic pain, and pain as the most distressing symptom in critically ill-cancer patients at the time of ICU admission. Methods: We prospectively interviewed 126 patients within first 24 h of admission to a medical ICU. The patients were assessed for the presence of pain, its severity, sites, duration, nature, and its impact as a distressing symptom. Numerical Rating Scale and self-report version of Leeds Assessment of Neuropathic Signs and Symptoms were used to elucidate intensity of pain and neuropathic pain, respectively. Demographic characteristics such as age and sex, primary site, and stage of cancer were considered for a possible correlation with the prevalence of pain. Results: Of 126 patients included in the study 95 (75.40%), 79 (62.70%), 34 (26.98%), and 17 (13.49%) patients had pain, moderate-severe, chronic, and neuropathic pain, respectively. The average duration of pain was 171.16 ± 716.50 days. Totally, 58 (46.03%) and 42 (42.01%) patients had at least one and more than equal to 2 neuropathic pain symptoms, respectively. The primary malignancies associated with the highest prevalence of pain were genitourinary, hematological, and head and neck whereas breast and lung cancers were associated with the highest prevalence of neuropathic and chronic pain, respectively. Conclusion: The prevalence of pain among critically ill-cancer patients is high. Assessment for pain at the time of ICU admission would ensure appropriate assessment for the presence, type, severity, and the significance imparted to it. PMID:26600692

  2. Accuracy of a Novel Noninvasive Transdermal Continuous Glucose Monitor in Critically Ill Patients

    PubMed Central

    Saur, Nicole M.; England, Michael R.; Menzie, Wayne; Melanson, Ann Marie; Trieu, My-Quyen; Berlin, Jason; Hurley, James; Krystyniak, Keith; Kongable, Gail L.

    2014-01-01

    Stress hyperglycemia and hypoglycemia are associated with increased morbidity and mortality in the critically ill. Intermittent, random blood glucose (BG) measurements can miss episodes of hyper- and hypoglycemia. The purpose of this study was to determine the accuracy of the Symphony® continuous glucose monitor (CGM) in critically ill cardiac surgery patients. Fifteen adult cardiac surgery patients were evaluated immediately postoperatively in the intensive care unit. Prelude® SkinPrep prepared the skin and a sensor was applied to 2 test sites on each subject to monitor interstitial fluid glucose. Reference BG was sampled at 30- to 60-minute intervals. The skin at the test sites was inspected for adverse effects. Accuracy of the retrospectively analyzed CGM data relative to reference BG values was determined using continuous glucose-error grid analysis (CG-EGA) and mean absolute relative difference (MARD). Using 570 Symphony CGM glucose readings paired with reference BG measurements, CG-EGA showed that 99.6% of the readings were within zones A and B. BG measurements ranged from 73 to 251 mg/dL. The MARD was 12.3%. No adverse device effects were reported. The Symphony CGM system is able to safely, continuously, and noninvasively monitor glucose in the transdermal interstitial fluid of cardiac surgery intensive care unit patients with accuracy similar to that reported with other CGM systems. Future versions of the system will need real-time data analysis, fast warm-up, and less frequent calibrations to be used in the clinical setting. PMID:24876448

  3. Complications of continuous renal replacement therapy in critically ill children: a prospective observational evaluation study

    PubMed Central

    2009-01-01

    Introduction Continuous renal replacement therapy (CRRT) frequently gives rise to complications in critically ill children. However, no studies have analyzed these complications prospectively. The purpose of this study was to analyze the complications of CRRT in children and to study the associated risk factors. Methods A prospective, single-centre, observational study was performed in all critically ill children treated using CRRT in order to determine the incidence of complications related to the technique (problems of catheterization, hypotension at the time of connection to the CRRT, hemorrhage, electrolyte disturbances) and their relationship with patient characteristics, clinical severity, need for vasoactive drugs and mechanical ventilation, and the characteristics of the filtration techniques. Results Of 174 children treated with CRRT, 13 (7.4%) presented problems of venous catheterization; this complication was significantly more common in children under 12 months of age and in those weighing less than 10 kg. Hypotension on connection to CRRT was detected in 53 patients (30.4%). Hypotension was not associated with any patient or CRRT characteristics. Clinically significant hemorrhage occurred in 18 patients (10.3%); this complication was not related to any of the variables studied. The sodium, chloride, and phosphate levels fell during the first 72 hours of CRRT; the changes in electrolyte levels during the course of treatment were not found to be related to any of the variables analyzed, nor were they associated with mortality. Conclusions CRRT-related complications are common in children and some are potentially serious. The most common are hypotension at the time of connection and electrolyte disturbances. Strict control and continuous monitoring of the technique are therefore necessary in children on CRRT. PMID:19925648

  4. Parenteral polymyxins: Assessing efficacy and safety in critically ill patients with renal dysfunction

    PubMed Central

    Sekhri, Kavita; Nandha, Ruchika; Mandal, Amit; Bhasin, Deepak; Singh, Harpal

    2013-01-01

    Objectives: Studies have established the effectiveness and safety of polymyxins in treating multidrug resistant (MDR) pathogens. However, the challenge is whether these nephrotoxic drugs can be administered in compromised renal states. The present study was undertaken to establish their role in such patients. The effectiveness and nephrotoxicity of polymyxins in critically ill-patients harboring MDR Gram-negative bacteria with already compromised renal functions was compared with those with normal renal functions. Materials and Methods: This retrospective cohort study (March 2008-March 2010) was conducted in the intensive care unit of a tertiary care hospital. A total of 48 eligible critically ill-patients receiving polymyxins were enrolled. A comparison was carried out (length of stay in hospital, mortality, renal function) between patients with acute kidney injury (AKI, n = 18; defined by the RIFLE classification) and patients with normal renal function (non-AKI, n = 30). Results: Patients with baseline AKI had a significantly higher adjusted mortality rate at admission when compared with the non-AKI group. At the end of therapy with polymyxins, 26.66% non-AKI patients developed renal dysfunction while 38.88% of patients in the AKI group had worsening of renal function (P = 0.006). However, there was no significant difference in the length of hospital stay (23.9 ± 13.24 vs. 30.5 ± 22.50; P = 0.406) and overall mortality (44.4% vs. 36.7%; P = 0.76) between two groups. Conclusion: Polymyxins can be administered in AKI patients with favorable results provided used judiciously with strict monitoring of renal functions, dose modification according to creatinine clearance and aggressive fluid management. PMID:24347770

  5. Innate immunity gene expression changes in critically ill patients with sepsis and disease-related malnutrition

    PubMed Central

    Sarnecka, Agnieszka; Dąbrowska, Aleksandra; Kosałka, Katarzyna; Wachowska, Ewelina; Bałan, Barbara J.; Jankowska, Marta; Korta, Teresa; Niewiński, Grzegorz; Kański, Andrzej; Mikaszewska-Sokolewicz, Małgorzata; Omidi, Mohammad; Majewska, Krystyna; Słotwińska, Sylwia M.

    2015-01-01

    The aim of this study was an attempt to determine whether the expression of genes involved in innate antibacterial response (TL R2, NOD 1, TRAF6, HMGB 1 and Hsp70) in peripheral blood leukocytes in critically ill patients, may undergo significant changes depending on the severity of the infection and the degree of malnutrition. The study was performed in a group of 128 patients with infections treated in the intensive care and surgical ward. In 103/80.5% of patients, infections had a severe course (sepsis, severe sepsis, septic shock, mechanical ventilation of the lungs). Clinical monitoring included diagnosis of severe infection (according to the criteria of the ACC P/SCC M), assessment of severity of the patient condition and risk of death (APACHE II and SAPS II), nutritional assessment (NRS 2002 and SGA scales) and the observation of the early results of treatment. Gene expression at the mRNA level was analyzed by real-time PCR. The results of the present study indicate that in critically ill patients treated in the IC U there are significant disturbances in the expression of genes associated with innate antimicrobial immunity, which may have a significant impact on the clinical outcome. The expression of these genes varies depending on the severity of the patient condition, severity of infection and nutritional status. Expression disorders of genes belonging to innate antimicrobial immunity should be diagnosed as early as possible, monitored during the treatment and taken into account during early therapeutic treatment (including early nutrition to support the functions of immune cells). PMID:26648775

  6. Bioelectrical impedance spectroscopy to estimate fluid balance in critically ill patients.

    PubMed

    Dewitte, Antoine; Carles, Pauline; Joannès-Boyau, Olivier; Fleureau, Catherine; Roze, Hadrien; Combe, Christian; Ouattara, Alexandre

    2016-04-01

    Fluid management is a crucial issue in intensive-care medicine. This study evaluated the feasibility and reproducibility of bioimpedance spectroscopy to measure body-water composition in critically ill patients, and compared fluid balance and daily changes in total body water (TBW) measured by bioimpedance. This observational study included 25 patients under mechanical ventilation. Fluid balance and bioimpedance measurements were recorded on 3 consecutive days. Whole-body bioimpedance spectroscopy was performed with exact or ideal body weights entered into the device, and with or without ICU monitoring. Reproducibility of bioimpedance spectroscopy was very good in all conditions despite ICU monitoring and mechanical ventilation. Bioimpedance measurements using an ideal body weight varied significantly, making the weighing procedure necessary. Comparison of fluid balance and daily changes in body weight provided the best correlation (ρ = 0.74; P < 0.0001). Daily changes in TBW were correlated with fluid balance (Spearman coefficient ρ = 0.31; P = 0.003) and this correlation was improved after exclusion of patients with a SOFA score >10 (ρ = 0.36; P = 0.05) and with extracorporeal circulation (ρ = 0.50; P = 0.005). Regardless of the technique used to estimate volume status, important limits of agreement were observed. Non-invasive determination of body-water composition using bioimpedance spectroscopy is feasible in critically ill patients but requires knowledge of the patient's weight. The best method to assess volume status after fluid resuscitation and the value gained from information about body composition provided by bioimpedance techniques needs further evaluation. PMID:26018457

  7. Furosemide is associated with acute kidney injury in critically ill patients

    PubMed Central

    Levi, T.M.; Rocha, M.S.; Almeida, D.N.; Martins, R.T.C.; Silva, M.G.C.; Santana, N.C.P.; Sanjuan, I.T.; Cruz, C.M.S.

    2012-01-01

    Acute kidney injury (AKI) is common in critically ill patients. Diuretics are used without any evidence demonstrating a beneficial effect on renal function. The objective of the present study is to determine the incidence of AKI in an intensive care unit (ICU) and if there is an association between the use of furosemide and the development of AKI. The study involved a hospital cohort in which 344 patients were consecutively enrolled from January 2010 to January 2011. A total of 132 patients (75 females and 57 males, average age 64 years) remained for analysis. Most exclusions were related to ICU discharge in the first 24 h. Laboratory, sociodemographic and clinical data were collected until the development of AKI, medical discharge or patient death. The incidence of AKI was 55% (95%CI = 46-64). The predictors of AKI found by univariate analysis were septic shock: OR = 3.12, 95%CI = 1.36-7.14; use of furosemide: OR = 3.27, 95%CI = 1.57-6.80, and age: OR = 1.02, 95%CI = 1.00-1.04. Analysis of the subgroup of patients with septic shock showed that the odds ratio of furosemide was 5.5 (95%CI = 1.16-26.02) for development of AKI. Age, use of furosemide, and septic shock were predictors of AKI in critically ill patients. Use of furosemide in the subgroup of patients with sepsis/septic shock increased (68.4%) the chance of development of AKI when compared to the sample as a whole (43.9%) PMID:22641414

  8. Critical COPD respiratory illness is linked to increased transcriptomic activity of neutrophil proteases genes

    PubMed Central

    2012-01-01

    Background Gene expression profiling (GEP) in cells obtained from peripheral blood has shown that this is a very useful approach for biomarker discovery and for studying molecular pathogenesis of prevalent diseases. While there is limited literature available on gene expression markers associated with Chronic Obstructive Pulmonary Disease (COPD), the transcriptomic picture associated with critical respiratory illness in this disease is not known at the present moment. Findings By using Agilent microarray chips, we have profiled gene expression signatures in the whole blood of 28 COPD patients hospitalized with different degrees of respiratory compromise.12 of them needed of admission to the ICU, whilst 16 were admitted to the Respiratory Medicine Service. GeneSpring GX 11.0 software was used for performing statistical comparisons of transcript levels between ICU and non-ICU patients. Ingenuity pathway analysis 8.5 (IPA) and the Kyoto Encyclopedia of Genes and Genomes (KEGG) were used to select, annotate and visualize genes by function and pathway (gene ontology). T-test showed evidence of 1501 genes differentially expressed between ICU and non-ICU patients. IPA and KEGG analysis of the most representative biological functions revealed that ICU patients had increased levels of neutrophil gene transcripts, being [cathepsin G (CTSG)], [elastase, neutrophil expressed (ELANE)], [proteinase 3 (PRTN3)], [myeloperoxidase (MPO)], [cathepsin D (CTSD)], [defensin, alpha 3, neutrophil-specific (DEFA3)], azurocidin 1 (AZU1)], and [bactericidal/permeability-increasing protein (BPI)] the most representative ones. Proteins codified by these genes form part of the azurophilic granules of neutrophils and are involved in both antimicrobial defence and tissue damage. This “neutrophil signature” was paralleled by the necessity of advanced respiratory and vital support, and the presence of bacterial infection. Conclusion Study of transcriptomic signatures in blood suggests an

  9. Conflicts in Learning to Care for Critically Ill Newborns: "It Makes Me Question My Own Morals".

    PubMed

    Boss, Renee D; Geller, Gail; Donohue, Pamela K

    2015-09-01

    Caring for critically ill and dying patients often triggers both professional and personal growth for physician trainees. In pediatrics, the neonatal intensive care unit (NICU) is among the most distressing settings for trainees. We used longitudinal narrative writing to gain insight into how physician trainees are challenged by and make sense of repetitive, ongoing conflicts experienced as part of caring for very sick and dying babies. The study took place in a 45-bed, university-based NICU in an urban setting in the United States. From November 2009 to June 2010 we enrolled pediatric residents and neonatology fellows at the beginning of their NICU rotations. Participants were asked to engage in individual, longitudinal narrative writing about their "experience in the NICU." Thematic narrative analysis was performed. Thirty-seven physician trainees participated in the study. The mean number of narratives per trainee was 12; a total of 441 narratives were available for analysis. Conflict was the most pervasive theme in the narratives. Trainees experienced conflicts with families and conflicts with other clinicians. Trainees also described multiple conflicts of identity as members of the neonatology team, as members of the medical profession, as members of their own families, and as members of society. Physician trainees experience significant conflict and distress while learning to care for critically ill and dying infants. These conflicts often led them to question their own morals and their role in the medical profession. Physician trainees should be educated to expect various types of distress during intensive care rotations, encouraged to identify their own sources of distress, and supported in mitigating their effects. PMID:25656132

  10. Carbon dioxide in the critically ill: too much or too little of a good thing?

    PubMed

    Marhong, Jonathan; Fan, Eddy

    2014-10-01

    Hypercapnia and hypocapnia commonly complicate conditions that are present in critically ill patients. Both conditions have important physiologic effects that may impact the clinical management of these patients. For instance, hypercapnia results in bronchodilation and enhanced hypoxic vasoconstriction, leading to improved ventilation/perfusion matching. Hypocapnia reduces cerebral blood volume through arterial vasoconstriction. These effects have also been exploited for therapeutic aims. In patients with traumatic brain injury (TBI), hypocapnia is often utilized to control intracranial pressure. However, this effect is not sustained, and prolonged hypocapnia increases the risk of mortality and severe disability in patients with TBI. Hypercapnia and hypercapnic acidosis are common consequences of lung-protective ventilation in ARDS. Hypercapnic acidosis reduces ischemic lung injury and preserves lung compliance, but concern has arisen over hypercapnia-induced immunosuppression and the potential for bacterial proliferation in sepsis. Experimental studies suggest that buffering hypercapnic acidosis attenuates these effects, whereas hypocapnia appears to potentiate lung injury through increased capillary permeability and decreased lung compliance. Several areas of uncertainty surround the role of hypercapnia/hypocapnia in treating TBI and ARDS. Current data support recommendations to avoid hypocapnia in treating TBI, with the exception of emergent treatment of elevated intracranial pressure, while awaiting definitive management. Permissive hypercapnia is commonly accepted as a consequence of lung-protective ventilation in ARDS, but there is insufficient evidence to support the induction of hypercapnic acidosis in clinical practice. Buffering hypercapnic acidosis should be considered only for a specific clinical indication (eg, hemodynamic instability). For clinicians choosing to buffer hypercapnic acidosis, tris-hydroxymethyl aminomethane is recommended over sodium

  11. Safety of performing fiberoptic bronchoscopy in critically ill hypoxemic patients with acute respiratory failure

    PubMed Central

    Cracco, Christophe; Fartoukh, Muriel; Prodanovic, Hélène; Azoulay, Elie; Chenivesse, Cécile; Lorut, Christine; Beduneau, Gaëtan; Bui, Hoang Nam; Taille, Camille; Brochard, Laurent; Demoule, Alexandre; Maitre, Bernard

    2013-01-01

    Background Safety of fibreoptic bronchoscopy (FOB) in nonintubated critically ill patients with acute respiratory failure have not been extensively evaluated. We aimed to measure the incidence of intubation and need to increase ventilatory support following FOB and to identify predictive factors of this event. Methods A prospective multicenter observational study was carried out in 8 French adult intensive care units. 169 FOB performed in patients with a PaO2/FiO2 ratio equal or less than 300 were analyzed. Our main end point was intubation rate. The secondary end point was rate of increased ventilatory support defined as greater than a 50% increase in oxygen requirement, the need to start non invasive-positive pressure ventilation (NI-PPV) or increase NI-PPV support. Results Within 24 hours, an increase in ventilatory support was required following 59 (35%) bronchoscopies, of which 25 (15%) led to endotracheal intubation. The existence of chronic obstructive pulmonary disease (COPD) (OR:5.2 [1.6–17.8], p=0.007) or immunosuppression (OR : 5.4 [1.7–17.2], p=0.004) were significantly associated with the need for intubation in multivariable analysis. None of the baseline physiological parameters including the PaO2/FiO2 ratio was associated with intubation. Conclusion Bronchoscopy is often followed by an increase in ventilatory support in hypoxemic critically ill patients, but less frequently by the need for intubation. COPD, immunosuppression are associated with a need for invasive ventilation in the following 24 hours. PMID:23070123

  12. Facial Expression as an Indicator of Pain in Critically Ill Intubated Adults During Endotracheal Suctioning

    PubMed Central

    Rahu, Mamoona Arif; Grap, Mary Jo; Cohn, Jeffrey F.; Munro, Cindy L.; Lyon, Debra E.; Sessler, Curtis N.

    2013-01-01

    Background Facial expression is often used to evaluate pain in noncommunicative critically ill patients. Objectives To describe facial behavior during endotracheal suctioning, determine facial behaviors that characterize the pain response, and describe the effect of patient factors on facial behavior during pain response. Methods Fifty noncommunicative patients receiving mechanical ventilation were video recorded during 2 phases (rest and endotracheal suctioning). Pain ratings were gathered by using the Behavioral Pain Scale. Facial behaviors were coded by using the Facial Action Coding System for 30 seconds for each phase. Results Fourteen facial actions were associated more with endotracheal suctioning than with rest (z = 5.78; P < .001). The sum of intensity of the 14 actions correlated with total mean scores on the Behavioral Pain Scale (ρ = 0.71; P < .001) and with the facial expression component of the scale (ρ = 0.67; P < .001) during suctioning. In stepwise multivariate analysis, 5 pain-relevant facial behaviors (brow raiser, brow lower, nose wrinkling, head turned right, and head turned up) accounted for 71% of the variance (adjusted R2 = 0.682; P < .001) in pain response. The sum of intensity of the 5 actions correlated with total mean scores on the behavioral scale (ρ = 0.72; P < .001) and with the facial expression component of that scale (ρ = 0.61; P < .001) during suctioning. Patient factors had no association with pain intensity scores. Conclusions Upper facial expressions are most frequently activated during pain response in noncommunicative critically ill patients and might be a valid alternative to self-report ratings. PMID:23996421

  13. Can Transthoracic Echocardiography Be Used to Predict Fluid Responsiveness in the Critically Ill Patient? A Systematic Review

    PubMed Central

    Mandeville, Justin C.; Colebourn, Claire L.

    2012-01-01

    Introduction. We systematically evaluated the use of transthoracic echocardiography in the assessment of dynamic markers of preload to predict fluid responsiveness in the critically ill adult patient. Methods. Studies in the critically ill using transthoracic echocardiography (TTE) to predict a response in stroke volume or cardiac output to a fluid load were selected. Selection was limited to English language and adult patients. Studies on patients with an open thorax or abdomen were excluded. Results. The predictive power of diagnostic accuracy of inferior vena cava diameter and transaortic Doppler signal changes with the respiratory cycle or passive leg raising in mechanically ventilated patients was strong throughout the articles reviewed. Limitations of the technique relate to patient tolerance of the procedure, adequacy of acoustic windows, and operator skill. Conclusions. Transthoracic echocardiographic techniques accurately predict fluid responsiveness in critically ill patients. Discriminative power is not affected by the technique selected. PMID:22400109

  14. Identifying critically ill patients with acute kidney injury for whom renal replacement therapy is inappropriate: an exercise in futility?

    PubMed Central

    Gabbay, Ezra; Meyer, Klemens B.

    2009-01-01

    Clinicians treating critically ill patients must consider the possibility that painful and expensive aggressive treatments might confer negligible benefit. Such treatments are often described as futile or inappropriate. We discuss the problem of deciding whether to initiate renal replacement therapy (RRT) for critically ill patients with acute kidney injury (AKI) in the context of the debate surrounding medical futility. The main problems in deciding when such treatment would be futile are that the concept itself is controversial and eludes quantitative definition, that available outcome data do not allow confident identification of patients who will not benefit from treatment and that the decision on RRT in a critically ill patient with AKI is qualitatively different from decisions on other modalities of intensive care and resuscitation, as well as from decisions on dialysis for chronic kidney disease. Despite these difficulties, nephrologists need to identify circumstances in which continued aggressive care would be futile before proceeding to initiate RRT. PMID:25949304

  15. Resistance training exercise program for intervention to enhance gait function in elderly chronically ill patients: multivariate multiscale entropy for center of pressure signal analysis.

    PubMed

    Chen, Ming-Shu; Jiang, Bernard C

    2014-01-01

    Falls are unpredictable accidents, and the resulting injuries can be serious in the elderly, particularly those with chronic diseases. Regular exercise is recommended to prevent and treat hypertension and other chronic diseases by reducing clinical blood pressure. The "complexity index" (CI), based on multiscale entropy (MSE) algorithm, has been applied in recent studies to show a person's adaptability to intrinsic and external perturbations and widely used measure of postural sway or stability. The multivariate multiscale entropy (MMSE) was advanced algorithm used to calculate the complexity index (CI) values of the center of pressure (COP) data. In this study, we applied the MSE & MMSE to analyze gait function of 24 elderly, chronically ill patients (44% female; 56% male; mean age, 67.56 ± 10.70 years) with either cardiovascular disease, diabetes mellitus, or osteoporosis. After a 12-week training program, postural stability measurements showed significant improvements. Our results showed beneficial effects of resistance training, which can be used to improve postural stability in the elderly and indicated that MMSE algorithms to calculate CI of the COP data were superior to the multiscale entropy (MSE) algorithm to identify the sense of balance in the elderly. PMID:25295070

  16. Resistance Training Exercise Program for Intervention to Enhance Gait Function in Elderly Chronically Ill Patients: Multivariate Multiscale Entropy for Center of Pressure Signal Analysis

    PubMed Central

    Jiang, Bernard C.

    2014-01-01

    Falls are unpredictable accidents, and the resulting injuries can be serious in the elderly, particularly those with chronic diseases. Regular exercise is recommended to prevent and treat hypertension and other chronic diseases by reducing clinical blood pressure. The “complexity index” (CI), based on multiscale entropy (MSE) algorithm, has been applied in recent studies to show a person's adaptability to intrinsic and external perturbations and widely used measure of postural sway or stability. The multivariate multiscale entropy (MMSE) was advanced algorithm used to calculate the complexity index (CI) values of the center of pressure (COP) data. In this study, we applied the MSE & MMSE to analyze gait function of 24 elderly, chronically ill patients (44% female; 56% male; mean age, 67.56 ± 10.70 years) with either cardiovascular disease, diabetes mellitus, or osteoporosis. After a 12-week training program, postural stability measurements showed significant improvements. Our results showed beneficial effects of resistance training, which can be used to improve postural stability in the elderly and indicated that MMSE algorithms to calculate CI of the COP data were superior to the multiscale entropy (MSE) algorithm to identify the sense of balance in the elderly. PMID:25295070

  17. Can we protect the gut in critical illness? The role of growth factors and other novel approaches.

    PubMed

    Dominguez, Jessica A; Coopersmith, Craig M

    2010-07-01

    The intestine plays a central role in the pathophysiology of critical illness and is frequently called the "motor" of the systemic inflammatory response. Perturbations to the intestinal barrier can lead to distant organ damage and multiple organ failure. Therefore, identifying ways to preserve intestinal integrity may be of paramount importance. Growth factors and other peptides have emerged as potential tools for modulation of intestinal inflammation and repair due to their roles in cellular proliferation, differentiation, migration, and survival. This review examines the involvement of growth factors and other peptides in intestinal epithelial repair during critical illness and their potential use as therapeutic targets. PMID:20643306

  18. Can We Protect the Gut in Critical Illness: The Role of Growth Factors and Other Novel Approaches

    PubMed Central

    Dominguez, Jessica A.; Coopersmith, Craig M.

    2010-01-01

    Synopsis The intestine plays a central role in the pathophysiology of critical illness and is frequently called the “motor” of the systemic inflammatory response. Perturbations to the intestinal barrier can lead to distant organ damage and multiple organ failure. Therefore, identifying ways to preserve intestinal integrity may be of paramount importance. Growth factors and other peptides have emerged as potential tools for modulation of intestinal inflammation and repair due to their roles in cellular proliferation, differentiation, migration, and survival. In this review, we will examine the involvement of growth factors and other peptides in intestinal epithelial repair during critical illness and their potential use as therapeutic targets. PMID:20643306

  19. Pharmacokinetics and pharmacodynamics of biapenem in critically ill patients under continuous venovenous hemodiafiltration.

    PubMed

    Suyama, Hidemichi; Ikawa, Kazuro; Morikawa, Norifumi; Ikeda, Kayo; Fujiue, Yoshihiro; Morikawa, Shingo; Kaneko, Kotaro; Kuwabara, Masao; Yamanoue, Takao

    2008-10-01

    To characterize the PK/PD of biapenem (BIPM) in critically ill patients under continuous venovenous hemodiafiltration (CVVHDF), we conducted a prospective, open-label study in nine adult CVVHDF patients with acute renal failure at the Critical Care Medical Center, Hiroshima Prefectural Hospital. Plasma and filtrate samples were obtained at six time points. The concentrations of BIPM in plasma and filtrate were determined by HPLC. PK parameters were analyzed using Monte Carlo simulation with MIC data. BIPM concentrations in the plasma and CVVHDF filtrate peaked at the end of infusion, and the values were similar. The drug clearance by CVVHDF and non-CVVHDF was 1.28 +/- 0.14 and 9.05 +/- 4.05 L/h, respectively. Monte Carlo simulation showed that the more administration times, there were the higher the probability. In conclusion, a dosing regimen of 300 mg BIPM q8h had a higher probability of therapeutic efficacy than q12h in patients with severe sepsis under CVVHDF. PMID:19260350

  20. Body cell mass evaluation in critically ill patients: killing two birds with one stone.

    PubMed

    Fiaccadori, Enrico; Morabito, Santo; Cabassi, Aderville; Regolisti, Giuseppe

    2014-01-01

    Body cell mass (BCM) is the metabolically active cell mass involved in O₂ consumption, CO₂ production and energy expenditure. BCM measurement has been suggested as a tool for the evaluation of nutritional status. Since BCM is closely related to energy expenditure, it could also represent a good reference value for the calculation of nutrient needs. In a recent issue of Critical Care, Ismael and colleagues used bioelectrical impedance analysis parameters and anthropometric variables to evaluate BCM in patients with acute kidney injury, before and after a hemodialysis session. The results of this study suggest that BCM is relatively insensitive to major body fluid shifts, a well known factor interfering with nutritional evaluation/monitoring and energy need calculations in the ICU. Thus, BCM seems to be a more 'stable' nutritional variable, as it is apparently less influenced by non-nutritional factors. The results of this paper emphasize the need to identify biologically sound parameters for nutritional status evaluation and energy need calculation in critically ill patients; in this regard, BCM could fulfill these expectations. PMID:25033220

  1. The meaning of posttraumatic stress-reactions following critical illness or injury and intensive care treatment.

    PubMed

    Corrigan, Ingrid; Samuelson, Karin A M; Fridlund, Bengt; Thomé, Bibbi

    2007-08-01

    Traumatic events connected with a critical condition and treatment in the intensive care unit (ICU) may result in subsequent posttraumatic stress-reactions. The aim of this phenomenological study was to describe the meaning of posttraumatic stress-reactions as experienced by individuals following a critical illness or injury and intensive care. Fourteen informants, testing positive for posttraumatic stress-reactions as a clinical concern, were interviewed. The data was analysed following the principles indicated by Giorgi [Giorgi A. The theory, practice, and evaluation of the phenomenological method as a qualitative research procedure. J Phenomenol Psychol 1997;28:235-61]. The essence of the phenomenon of posttraumatic stress-reactions was understood as a transition to a life-situation beyond control, where the traumatic experiences have a profound impact and are ever-present. The variations of the phenomenon presented themselves as a need to make sense of the traumatic memories, which live on; being haunted by the trauma; a need to escape; distress and strain in the life-situation; transformation of self and, finally, interactions with others affected. The need for caring strategies and support is emphasised, both in the ICU and afterwards, thus preventing or alleviating some of the suffering. PMID:17449252

  2. Relationship Between Beta Cell Dysfunction and Severity of Disease Among Critically Ill Children

    PubMed Central

    Liu, Ping-Ping; Lu, Xiu-Lan; Xiao, Zheng-Hui; Qiu, Jun; Zhu, Yi-Min

    2016-01-01

    Abstract Although beta cell dysfunction has been proved to predict prognosis among humans and animals, its prediction on severity of disease remains unclear among children. The present study was aimed to examine the relationship between beta cell dysfunction and severity of disease among critically ill children. This prospective study included 1146 critically ill children, who were admitted to Pediatric Intensive Care Unit (PICU) of Hunan Children's Hospital from November 2011 to August 2013. Information on characteristics, laboratory tests, and prognostic outcomes was collected. Homeostasis model assessment (HOMA)-β, evaluating beta cell function, was used to divide all participants into 4 groups: HOMA-β = 100% (group I, n = 339), 80% ≤ HOMA-β < 100% (group II, n = 71), 40% ≤ HOMA-β < 80% (group III, n = 293), and HOMA-β < 40% (group IV, n = 443). Severity of disease was assessed using the worst Sequential Organ Failure Assessment (SOFA) score, Pediatric Risk of Mortality (PRISM) III score, incidence of organ damage, septic shock, multiple organ dysfunction syndrome (MODS), mechanical ventilation (MV) and mortality. Logistic regression analysis was used to evaluate the risk of developing poor outcomes among patients in different HOMA-β groups, with group I as the reference group. Among 1146 children, incidence of HOMA-β < 100% was 70.41%. C-peptide and insulin declined with the decrement of HOMA-β (P < 0.01). C-reactive protein and procalcitonin levels, rather than white blood cell, were significantly different among 4 groups (P < 0.01). In addition, the worst SOFA score and the worst PRISMIII score increased with declined HOMA-β. For example, the worst SOFA score in group I, II, III, and IV was 1.55 ± 1.85, 1.71 ± 1.93, 1.92 ± 1.63, and 2.18 ± 1.77, respectively. Furthermore, patients with declined HOMA-β had higher risk of developing septic shock, MODS, MV, and mortality, even after adjusting age

  3. Introduction and executive summary: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.

    PubMed

    Christian, Michael D; Devereaux, Asha V; Dichter, Jeffrey R; Rubinson, Lewis; Kissoon, Niranjan

    2014-10-01

    Natural disasters, industrial accidents, terrorism attacks, and pandemics all have the capacity to result in large numbers of critically ill or injured patients. This supplement provides suggestions for all of those involved in a disaster or pandemic with multiple critically ill patients, including front-line clinicians, hospital administrators, professional societies, and public health or government officials. The current Task Force included a total of 100 participants from nine countries, comprised of clinicians and experts from a wide variety of disciplines. Comprehensive literature searches were conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert-opinion-based suggestions that are presented in this supplement using a modified Delphi process. The ultimate aim of the supplement is to expand the focus beyond the walls of ICUs to provide recommendations for the management of all critically ill or injured adults and children resulting from a pandemic or disaster wherever that care may be provided. Considerations for the management of critically ill patients include clinical priorities and logistics (supplies, evacuation, and triage) as well as the key enablers (systems planning, business continuity, legal framework, and ethical considerations) that facilitate the provision of this care. The supplement also aims to illustrate how the concepts of mass critical care are integrated across the spectrum of surge events from conventional through contingency to crisis standards of care. PMID:25144202

  4. Multiple-dose pharmacokinetics of intravenously administered cefoperazone and sulbactam when given in combination to infected, seriously ill, elderly patients.

    PubMed Central

    Schwartz, J I; Jauregui, L E; Bachmann, K A; Martin, M E; Reitberg, D P

    1988-01-01

    The pharmacokinetics of cefoperazone and sulbactam in combination were evaluated in six, elderly, seriously ill patients treated with the drug combination for intra-abdominal infections. After giving informed consent, three males and three females aged 63.5 to 77.5 (mean 67.9) years and weighing 54.5 to 86.8 (mean, 67.6) kg were treated with cefoperazone (2.0 g) and sulbactam (1.0 g) infused intravenously every 12 h for at least 5 days. Cefoperazone and sulbactam pharmacokinetics were characterized on both days 1 and 5 of treatment. Eleven serial blood samples were obtained just prior to and following dose 1 on days 1 and 5 of treatment. Mean estimates of cefoperazone maximal concentration in plasma (Cmax), area under the curve of drug concentration in plasma versus time (AUC), half-life (t 1/2), apparent volume of distribution by the area method (Varea), apparent volume of distribution at steady state (Vss), and total body clearance (CL) for day 1 (day 5) were 297.5 237.5) micrograms/ml, 1,247 (1,063) micrograms.h/ml, 7.0 (4.9) h, 16.1 (13.4) liter, 13.1 (14.4) liter, and 28.9 (34.2) ml/min, respectively. Day 1 (day 5) mean values for sulbactam Cmax, AUC, t 1/2, Varea, Vss, and CL were 110.3 (78.0) micrograms/ml, 228 (217) micrograms.h/ml, 3.4 (2.5) h, 26.1 (18.5) liter, 18.9 (15.4) liter, and 97 (94) ml/min, respectively. Both drugs evidenced slower elimination and greater pharmacokinetic variability in these patients compared with values previously reported for normal volunteers. As patients improved during the course of therapy, the only pharmacokinetic parameter significantly changed between days 1 and 5 was a shortened sulbactam t 1/2. Our inability to find substantial evidence of pharmacokinetic normalization may have been related to sample size and study duration. Both drugs were present in potentially therapeutic concentrations for the entire 12-h dosing interval, but without undue accumulation from days 1 to 5. PMID:3395103

  5. Stratification of the severity of critically ill patients with classification trees

    PubMed Central

    2009-01-01

    Background Development of three classification trees (CT) based on the CART (Classification and Regression Trees), CHAID (Chi-Square Automatic Interaction Detection) and C4.5 methodologies for the calculation of probability of hospital mortality; the comparison of the results with the APACHE II, SAPS II and MPM II-24 scores, and with a model based on multiple logistic regression (LR). Methods Retrospective study of 2864 patients. Random partition (70:30) into a Development Set (DS) n = 1808 and Validation Set (VS) n = 808. Their properties of discrimination are compared with the ROC curve (AUC CI 95%), Percent of correct classification (PCC CI 95%); and the calibration with the Calibration Curve and the Standardized Mortality Ratio (SMR CI 95%). Results CTs are produced with a different selection of variables and decision rules: CART (5 variables and 8 decision rules), CHAID (7 variables and 15 rules) and C4.5 (6 variables and 10 rules). The common variables were: inotropic therapy, Glasgow, age, (A-a)O2 gradient and antecedent of chronic illness. In VS: all the models achieved acceptable discrimination with AUC above 0.7. CT: CART (0.75(0.71-0.81)), CHAID (0.76(0.72-0.79)) and C4.5 (0.76(0.73-0.80)). PCC: CART (72(69-75)), CHAID (72(69-75)) and C4.5 (76(73-79)). Calibration (SMR) better in the CT: CART (1.04(0.95-1.31)), CHAID (1.06(0.97-1.15) and C4.5 (1.08(0.98-1.16)). Conclusion With different methodologies of CTs, trees are generated with different selection of variables and decision rules. The CTs are easy to interpret, and they stratify the risk of hospital mortality. The CTs should be taken into account for the classification of the prognosis of critically ill patients. PMID:20003229

  6. Functional Status of Elderly Adults Before and After Interventions for Critical Limb Ischemia

    PubMed Central

    Vogel, Todd R.; Petroski, Gregory F.; Kruse, Robin L.

    2014-01-01

    Objective The impact of interventions for Critical Limb Ischemia (CLI) on functional status in the elderly remains unclear. Open and endovascular procedures were evaluated. Methods Medicare inpatient claims were linked with nursing home assessment data to identify elective admissions for lower extremity procedures for CLI. A functional impairment score (0-28; higher scores indicating greater impairment) based on residents' need for assistance with self-care activities, walking, and locomotion was calculated before and after interventions. Hierarchical modeling determined the effect of the surgery on residents' function, controlling for comorbidity, cognition, and pre-hospital function. Results 352 and 350 patients underwent open and endovascular procedures, respectively (rest pain: 84; ulceration: 351; and gangrene: 267). Hospitalization was associated with a significant worsening in function following both procedures. Disease severity was associated with the amount of initial decline but not with the rate of recovery (p>.35). Residents who received open surgery improved more quickly following hospital discharge (p=.011). Conclusions In the frail elderly, open and endovascular procedures for CLI were associated with similar initial declines in functional status, suggesting that compared with open procedures, less invasive endovascular procedures were not associated with maintaining baseline function. In this select population, endovascular procedures for CLI were not associated with improved functional status over time compared to open. Six months post-hospital, patients who received traditional open bypass had significantly better functional status than those who received endovascular procedures for all CLI diagnoses. Further analysis is required to assist stakeholders in performing procedures most likely to preserve functional status in the frail elderly and nursing home population. PMID:24139567

  7. Extra Physiotherapy in Critical Care (EPICC) Trial Protocol: a randomised controlled trial of intensive versus standard physical rehabilitation therapy in the critically ill

    PubMed Central

    Wright, Stephen E; Watson, Gillian; Baker, Catherine; Stafford, Victoria; Wade, Clare; Chadwick, Thomas J; Mansfield, Leigh; Wilkinson, Jennifer; Shen, Jing; Deverill, Mark; Bonner, Stephen; Hugill, Keith; Howard, Philip; Henderson, Andrea; Roy, Alistair; Furneval, Julie; Baudouin, Simon V

    2015-01-01

    Introduction Patients discharged from Critical Care suffer from excessive longer term morbidity and mortality. Physical and mental health measures of quality of life show a marked and immediate fall after admission to Critical Care with some recovery over time. However, physical function is still significantly reduced at 6 months. The National Institute for Health and Care Excellence clinical guideline on rehabilitation after critical illness, identified the need for high-quality randomised controlled trials to determine the most effective rehabilitation strategy for critically ill patients at risk of critical illness-associated physical morbidity. In response to this, we will conduct a randomised controlled trial, comparing physiotherapy aimed at early and intensive patient mobilisation with routine care. We hypothesise that this intervention will improve physical outcomes and the mental health and functional well-being of survivors of critical illness. Methods and analysis 308 adult patients who have received more than 48 h of non-invasive or invasive ventilation in Critical Care will be recruited to a patient-randomised, parallel group, controlled trial, comparing two intensities of physiotherapy. Participants will be randomised to receive either standard or intensive physiotherapy for the duration of their Critical Care admission. Outcomes will be recorded on Critical Care discharge, at 3 and 6 months following initial recruitment to the study. The primary outcome measure is physical health at 6 months, as measured by the SF-36 Physical Component Summary. Secondary outcomes include assessment of mental health, activities of daily living, delirium and ventilator-free days. We will also include a health economic analysis. Ethics and dissemination The trial has ethical approval from Newcastle and North Tyneside 2 Research Ethics Committee (11/NE/0206). There is a Trial Oversight Committee including an independent chair. The results of the study will be

  8. Cost effectiveness of intensive care in a low resource setting: A prospective cohort of medical critically ill patients

    PubMed Central

    Cubro, Hajrunisa; Somun-Kapetanovic, Rabija; Thiery, Guillaume; Talmor, Daniel; Gajic, Ognjen

    2016-01-01

    AIM: To calculate cost effectiveness of the treatment of critically ill patients in a medical intensive care unit (ICU) of a middle income country with limited access to ICU resources. METHODS: A prospective cohort study and economic evaluation of consecutive patients treated in a recently established medical ICU in Sarajevo, Bosnia and Herzegovina. A cost utility analysis of the intensive care of critically ill patients compared to the hospital ward treatment from the perspective of the health care system was subsequently performed. Incremental cost effectiveness was calculated using estimates of ICU vs non-ICU treatment effectiveness based on a formal systematic review of published studies. Decision analytic modeling was used to compare treatment alternatives. Sensitivity analyses of the key model parameters were performed. RESULTS: Out of 148 patients, seventy patients (47.2%) survived to one year after critical illness with a median quality of life index 0.64 [interquartile range(IQR) 0.49-0.76]. Median number of life years gained per patient was 30 (IQR 16-40) or 18 quality adjusted life years (QALYs) (IQR 7-28). The cost of treatment of critically ill patients varied between 1820 dollar and 20109 dollar per hospital survivor and between 100 dollar and 2514 dollar per QALY saved. Mean factors that influenced costs were: Age, diagnostic category, ICU and hospital length of stay and number and type of diagnostic and therapeutic interventions. The incremental cost effectiveness ratio for ICU treatment was estimated at 3254 dollar per QALY corresponding to 35% of per capita GDP or a Very Cost Effective category according to World Health Organization criteria. CONCLUSION: The ICU treatment of critically ill medical patients in a resource poor country is cost effective and compares favorably with other medical interventions. Public health authorities in low and middle income countries should encourage development of critical care services. PMID:27152258

  9. Outcome of delirium in critically ill patients: systematic review and meta-analysis

    PubMed Central

    Salluh, Jorge I F; Wang, Han; Schneider, Eric B; Nagaraja, Neeraja; Yenokyan, Gayane; Damluji, Abdulla; Serafim, Rodrigo B

    2015-01-01

    Objectives To determine the relation between delirium in critically ill patients and their outcomes in the short term (in the intensive care unit and in hospital) and after discharge from hospital. Design Systematic review and meta-analysis of published studies. Data sources PubMed, Embase, CINAHL, Cochrane Library, and PsychINFO, with no language restrictions, up to 1 January 2015. Eligibility criteria for selection studies Reports were eligible for inclusion if they were prospective observational cohorts or clinical trials of adults in intensive care units who were assessed with a validated delirium screening or rating system, and if the association was measured between delirium and at least one of four clinical endpoints (death during admission, length of stay, duration of mechanical ventilation, and any outcome after hospital discharge). Studies were excluded if they primarily enrolled patients with a neurological disorder or patients admitted to intensive care after cardiac surgery or organ/tissue transplantation, or centered on sedation management or alcohol or substance withdrawal. Data were extracted on characteristics of studies, populations sampled, identification of delirium, and outcomes. Random effects models and meta-regression analyses were used to pool data from individual studies. Results Delirium was identified in 5280 of 16 595 (31.8%) critically ill patients reported in 42 studies. When compared with control patients without delirium, patients with delirium had significantly higher mortality during admission (risk ratio 2.19, 94% confidence interval 1.78 to 2.70; P<0.001) as well as longer durations of mechanical ventilation and lengths of stay in the intensive care unit and in hospital (standard mean differences 1.79 (95% confidence interval 0.31 to 3.27; P<0.001), 1.38 (0.99 to 1.77; P<0.001), and 0.97 (0.61 to 1.33; P<0.001), respectively). Available studies indicated an association between delirium and cognitive impairment after discharge

  10. Cystatin C and beta2-microglobulin: markers of glomerular filtration in critically ill children

    PubMed Central

    Herrero-Morín, José David; Málaga, Serafín; Fernández, Nuria; Rey, Corsino; Diéguez, María Ángeles; Solís, Gonzalo; Concha, Andrés; Medina, Alberto

    2007-01-01

    Introduction Parameters allowing regular evaluation of renal function in a paediatric intensive care unit (PICU) are not optimal. The aim of the present study was to analyse the utility of serum cystatin C and beta2-microglobulin (B2M) in detecting decreased glomerular filtration rate in critically ill children. Methods This was a prospective, observational study set in an eight-bed PICU. Twenty-five children were included. The inverses of serum creatinine, cystatin C, and B2M were correlated with creatinine clearance (CrC) using a 24-hour urine sample and CrC estimation by Schwartz formula (Schwartz). The diagnostic value of serum creatinine, cystatin C, and B2M to identify a glomerular filtration rate under 80 ml/minute per 1.73 m2 was evaluated using receiver operating characteristic (ROC) curve analysis. Results Mean age was 2.9 years (range, 0.1 to 13.9 years). CrC was less than 80 ml/minute per 1.73 m2 in 14 children, and Schwartz was less than 80 ml/minute per 1.73 m2 in 9 children. Correlations between inverse of B2M and CrC (r = 0.477) and between inverse of B2M and Schwartz (r = 0.697) were better than correlations between inverse of cystatin C and CrC (r = 0.390) or Schwartz (r = 0.586) and better than correlations between inverse of creatinine and CrC (r = 0.104) or Schwartz (r = 0.442). The ability of serum cystatin C and B2M to identify a CrC rate and a Schwartz CrC rate under 80 ml/minute per 1.73 m2 was better than that of creatinine (areas under the ROC curve: 0.851 and 0.792 for cystatin C, 0.802 and 0.799 for B2M, and 0.633 and 0.625 for creatinine). Conclusion Serum cystatin C and B2M were confirmed as easy and useful markers, better than serum creatinine, to detect acute kidney injury in critically ill children. PMID:17519026

  11. Low plasma selenium concentrations in critically ill children: the interaction effect between inflammation and selenium deficiency

    PubMed Central

    2014-01-01

    Introduction Low plasma selenium concentrations are frequent in critically ill patients. However, whether this is due to systemic inflammation, a deficient nutritional state or both is still not clear. We aimed to determine the factors associated with low plasma selenium in critically ill children while considering the inflammatory response and nutritional status. Method A prospective study was conducted in 173 children (median age 34 months) with systemic inflammatory response who had plasma selenium concentrations assessed 48 hours after admission and on the 5th day of ICU stay. The normal reference range was 0.58 μmol/L to 1.6 μmol/L. The outcome variable was ‘low plasma selenium’, which was defined as plasma selenium values below the distribution median during this period. The main explanatory variables were age, malnutrition, sepsis, C-reactive protein (CRP), and clinical severity scores. The data were analyzed using a Binomial Generalized Estimating Equations model, which includes the correlation between admission and 5th day responses. Results Malnutrition and CRP were associated with low plasma selenium. The interaction effect between these two variables was significant. When CRP values were less than or equal to 40 mg/L, malnutrition was associated with low plasma selenium levels (odds ratio (OR) = 3.25, 95% confidence interval (CI) 1.39 to 7.63, P = 0.007; OR = 2.98, 95% CI 1.26 to 7.06, P = 0.013; OR = 2.49, 95% CI 1.01 to 6.17, P = 0.049, for CRP = 10, 20 and 40 mg/L, respectively). This effect decreased as CRP concentrations increased and there was loose significance when CRP values were >40 mg/L. Similarly, the effect of CRP on low plasma selenium was significant for well-nourished patients (OR = 1.13; 95% CI 1.06 to 1.22, P <0.001) but not for the malnourished (OR = 1.03; 95% CI 0.99 to 1.08, P = 0.16). Conclusions There is a significant interaction between the magnitude of the inflammatory

  12. [The Bengmark tube in surgical practice and in the critically ill patient].

    PubMed

    Mangiante, G; Marini, P; Fratucello, G B; Casaril, A; Ciola, M; Facci, E; Colucci, G; Carluccio, S; Marchiori, L; Nicoli, N

    2000-01-01

    Enteral nutrition (EN) is increasingly used to minimize the rate of septic complications related to bacterial translocation, due to its effectiveness and low cost. Bengmark's self-propelling auto-positioning feeding tube (SPT) absorbs and uses gut motility for rapid transport to the upper small intestine, thereby allowing uninterrupted EN both in surgical and critically ill patients. We report on our experience with 175 SPTs applied over the period from December 1996 to February 2000, and analyse the safety, compliance, and indications of SPT in surgical and ICU practice. Open study: feasibility of insertion, time and rate of placement, compliance and complications related to the tube or to EN were studied. SPTs were successfully placed in 40 patients before liver resection, in 32 patients before extensive maxillo-facial surgery MFS and prior to colon resections in 10 cases. SPTs were also applied in 56 patients with acute vascular neurological diseases, 22 in pancreatic diseases and in another 15 critically ill patients. 92.5% of SPT's crossed the pylorus, while only 7.5% stopped in the stomach and 3.4% in the duodenum; 89.14% reached the first jejunal loop. The tip of the tube reached its final position within a mean period of 5.2 hours, 8% instantly and all within 24 hours. Enteral nutrition was started immediately after introduction of the tube into the stomach. The compliance was excellent, even in maxillo-facial surgery patients: only 2/76 patients (2.6%) showed poor compliance. There were no cases of aspiration pneumonia or other complications related to SPT. Polymeric nutrition was usually supplied at a starting flow rate of 45 ml/hour and rapidly increasing over the following 48 h. Eleven patients experienced diarrhoea and 6 abdominal distension, leading to a temporary reduction of the EN flow rate. Clogging of the SPT occurred in 13 patients: 7/13 were cleansed with pancreatic enzymes, but 6 had to be replaced. SPT is ideal for intensive EN and is

  13. Critical Illness Outcome Study: An Observational Study on Protocols and Mortality in Intensive Care Units

    PubMed Central

    Ali, Naeem A.; Gutteridge, David; Shahul, Sajid; Checkley, William; Sevransky, Jonathan; Martin, Greg S.

    2014-01-01

    Introduction Many individual Intensive Care Unit (ICU) characteristics have been associated with patient outcomes, including staffing, expertise, continuity and team structure. Separately, many aspects of clinical care in ICUs have been operationalized through the development of complex treatment protocols. The United State Critical Illness and Injury Trials Group-Critical Illness Outcomes Study (USCIITG-CIOS) was designed to determine whether the extent of protocol availability and use in ICUs is associated with hospital survival in a large cohort of United States ICUs. Here, we describe the study protocol and analysis plan approved by the USCIITG-CIOS Steering Committee. Methods USCIITG-CIOS is a prospective, observational, ecological multi-centered “cohort” study of mixed ICUs in the U.S. The data collected include organizational information for the ICU (e.g., protocol availability and utilization, multi-disciplinary staffing assessment) and patient level information (e.g. demographics, acute and chronic medical conditions). The primary outcome is all-cause hospital mortality, with the objective being to determine whether there is an association between protocol number and hospital mortality for ICU patients. USCIITG-CIOS is powered to detect a 3% difference in crude hospital mortality between high and low protocol use ICUs, dichotomized according to protocol number at the median. The analysis will utilize regression modeling to adjust for outcome clustering by ICU, with secondary linear analysis of protocol number and mortality and a variety of a priori planned ancillary studies. There are presently 60 ICUs participating in USCIITG-CIOS to enroll approximately 6,000 study subjects. Conclusions USCIITG-CIOS is a large multicentric study examining the effect of ICU protocol use on patient outcomes. The primary results of this study will inform our understanding of the relationship between protocol availability, use, and patient outcomes in the ICU. Moreover

  14. Fungal Peritonitis: Underestimated Disease in Critically Ill Patients with Liver Cirrhosis and Spontaneous Peritonitis

    PubMed Central

    Lahmer, Tobias; Brandl, Andreas; Rasch, Sebastian; Schmid, Roland M.; Huber, Wolfgang

    2016-01-01

    Introduction Spontaneous peritonitis, especially spontaneous fungal peritonitis (SFP), is an important and potentially fatal complication in patients with endstage liver disaese. We evaluated potential risk factors, microbiological findings, and outcome of patients with SFP compared to spontaneous bacterial peritonitis (SBP) in critically ill patients. Methods Retrospective analyses of critically ill patients with suspected spontaneous peritonitis. Results Out of 205 patients, 20 (10%) had SFP, 28 (14%) had SBP, 48 (24%) had peritonitis without microbiological findings (SP) and 109 (52%) had no-peritonitis (NP). APACHE II and SOFA score were significantly higher in patients with SFP (26; 22–28; p<0.004 and 16; 14–18; p<0.002), SBP (26; 22–28; p<0.004 and 16; 14–18; p<0.002) and SP (24; 18–30; p<0.045 and 14; 10–18; p<0.044) as compared to NP (22; 16–24 and 12; 10–14). CHILD Pugh classification was mainly CHILD C and MELD Score was in patients with SFP (34; 18–40; p<0.001), SBP (32;12–40 p<0.002) and SP (29; 14–40 p<0.003) significantly higher as compared to NP (25;8–40). Nosocomial peritonitis could be significantly more often found in patients with SFP (65%; p<0.023) and SBP (62%, p<0.030) as compared to SP (51 p = 0.243) and NP (45%). Antibiotic pretreatment last 3 month prior peritonitis was significantly more often in patients with SFP (85%; p<0.002), SBP (71%, p<0.033), and SP (56; p<0.040) as compared to NP (33%). Candida albicans (60%; 12/20) was the most common isolated fungus, followed by Candida glabrata (13%) and Candida krusei (13%). Mortality rate was significantly higher in patients with SFP (90%, p<0.001), followed by SBP (75%; p<0.001) and SP (69%; p<0.001) as compared to NP (45%). Conclusion SFP is not a rare complication in end stage liver disease which is associated with increased mortality. Physicians should be aware of SFP in patients with CHILD C liver cirrhosis, elevated MELD score, antibiotic pretreatment and

  15. Waking the dying: must we always attempt to involve critically ill patients in end-of-life decisions?

    PubMed

    Tonelli, Mark R

    2005-02-01

    Many critically ill persons are unable to participate in medical decision making, due, at least in part, to medications administered to provide sedation and analgesia. Such patients may retain the ability to participate to some degree in medical decisions if these medications can be reduced or eliminated. Decisions regarding the withdrawal of support, in particular, highlight the ethical complexities surrounding the participation of the critically ill patient. An appeal to the principle of autonomy would seem to demand that in all such cases attempts must be made to involve the patient; however, under certain circumstances arousing a dying patient to inform them of their imminent demise runs counter to the principle of beneficence in health care. A casuistic approach to this apparent dilemma identifies the ethically relevant aspects of such cases and allows for the development of specific criteria for judging the appropriateness of attempting to involve a critically ill patient directly in decision making. Patient comfort, prognosis, and prior preferences carry significant ethical weight. In cases in which a sedated, critically ill person cannot be aroused without causing significant pain and suffering, has a very poor prognosis, and in which prior unambiguous directives or current family/surrogate consensus exists that withdrawal of support would be preferred by the patient, the author argues that no ethical obligation to attempt to involve the patient in medical decisions exists. PMID:15706007

  16. The epidemiology and prognostic factors of mortality in critically ill children with acute kidney injury in Taiwan.

    PubMed

    Chang, Jei-Wen; Jeng, Mei-Jy; Yang, Ling-Yu; Chen, Tzeng-Ji; Chiang, Shu-Chiung; Soong, Wen-Jue; Wu, Keh-Gong; Lee, Yu-Sheng; Wang, Hsin-Hui; Yang, Chia-Feng; Tsai, Hsin-Lin

    2015-03-01

    The incidence of acute kidney injury (AKI) in critically ill children varies among countries. Here we used claims data from the Taiwanese National Health Insurance program from 2006 to 2010 to investigate the epidemiological features and identify factors that predispose individuals to developing AKI and mortality in critically ill children with AKI. Of 60,338 children in this nationwide cohort, AKI was identified in 850, yielding an average incidence rate of 1.4%. Significant independent risk factors for AKI were the use of extracorporeal membrane oxygenation, mechanical ventilation or vasopressors, intrinsic renal diseases, sepsis, and age more than 1 year. Overall, of the AKI cases, 46.5% were due to sepsis, 36.1% underwent renal replacement therapy, and the mortality rate was 44.2%. Multivariate analysis showed that the use of vasopressors, mechanical ventilation, and hemato-oncological disorders were independent predictors of mortality in AKI patients. Thirty-two of the 474 patients who survived had progression to chronic kidney disease or end-stage renal disease. Thus, although not common, AKI in critically ill children still has a high mortality rate associated with a variety of factors. Long-term close follow-up to prevent progressive chronic kidney disease in survivors of critical illnesses with AKI is mandatory. PMID:25252027

  17. Should we treat fever in critically ill patients? A summary of the current evidence from three randomized controlled trials

    PubMed Central

    Serpa, Ary; Pereira, Victor Galvão Moura; Colombo, Giancarlo; Scarin, Farah Christina de la Cruz; Pessoa, Camila Menezes Souza; Rocha, Leonardo Lima

    2014-01-01

    Fever is a nonspecific response to various types of infectious or non-infectious insult and its significance in disease remains an enigma. Our aim was to summarize the current evidence for the use of antipyretic therapy in critically ill patients. We performed systematic review and meta-analysis of publications from 1966 to 2013. The MEDLINE and CENTRAL databases were searched for studies on antipyresis in critically ill patients. The meta-analysis was limited to: randomized controlled trials; adult human critically ill patients; treatment with antipyretics in one arm versus placebo or non-treatment in another arm; and report of mortality data. The outcomes assessed were overall intensive care unit mortality, changes in temperature, intensive care unit length of stay, and hospital length of stay. Three randomized controlled trials, covering 320 participants, were included. Patients treated with antipyretic agents showed similar intensive care unit mortality (risk ratio 0.91, with 95% confidence interval 0.65-1.28) when compared with controls. The only difference observed was a greater decrease in temperature after 24 hours in patients treated with antipyretics (-1.70±0.40 versus - 0.56±0.25ºC; p=0.014). There is no difference in treating or not the fever in critically ill patients. PMID:25628209

  18. Hospital malnutrition and inflammatory response in critically ill children and adolescents admitted to a tertiary intensive care unit

    Technology Transfer Automated Retrieval System (TEKTRAN)

    Critical illness has a major impact on the nutritional status of both children and adults. A retrospective study was conducted to evaluate the incidence of hospital malnutrition at a pediatric tertiary intensive care unit (PICU). Serum concentrations of IL-6 in subgroups of well-nourished and malnou...

  19. Perceptions and practices regarding delirium, sedation and analgesia in critically ill patients: a narrative review

    PubMed Central

    Shinotsuka, Cassia Righy; Salluh, Jorge Ibrain Figueira

    2013-01-01

    A significant number of landmark studies have been published in the last decade that increase the current knowledge on sedation for critically ill patients. Therefore, many practices that were considered standard of care are now outdated. Oversedation has been shown to be hazardous, and light sedation and no-sedation protocols are associated with better patient outcomes. Delirium is increasingly recognized as a major form of acute brain dysfunction that is associated with higher mortality, longer duration of mechanical ventilation and longer lengths of stay in the intensive care unit and hospital. Despite all the available evidence, translating research into bedside care is a daunting task. International surveys have shown that practices such as sedation interruption and titration are performed only in the minority of cases. Implementing best practices is a major challenge that must also be addressed in the new guidelines. In this review, we summarize the findings of sedation and delirium research over the last years. We also discuss the gap between evidence and clinical practice and highlight ways to implement best practices at the bedside. PMID:23917981

  20. Branched-chain amino acid supplementation: impact on signaling and relevance to critical illness.

    PubMed

    Mattick, John S A; Kamisoglu, Kubra; Ierapetritou, Marianthi G; Androulakis, Ioannis P; Berthiaume, Francois

    2013-01-01

    The changes that occur in mammalian systems following trauma and sepsis, termed systemic inflammatory response syndrome, elicit major changes in carbohydrate, protein, and energy metabolism. When these events persist for too long they result in a severe depletion of lean body mass, multiple organ dysfunction, and eventually death. Nutritional supplementation has been investigated to offset the severe loss of protein, and recent evidence suggests that diets enriched in branched-chain amino acids (BCAAs) may be especially beneficial. BCAAs are metabolized in two major steps that are differentially expressed in muscle and liver. In muscle, BCAAs are reversibly transaminated to the corresponding α-keto acids. For the complete degradation of BCAAs, the α-keto acids must travel to the liver to undergo oxidation. The liver, in contrast to muscle, does not significantly express the branched-chain aminotransferase. Thus, BCAA degradation is under the joint control of both liver and muscle. Recent evidence suggests that in liver, BCAAs may perform signaling functions, more specifically via activation of mTOR (mammalian target of rapamycin) signaling pathway, influencing a wide variety of metabolic and synthetic functions, including protein translation, insulin signaling, and oxidative stress following severe injury and infection. However, understanding of the system-wide effects of BCAAs that integrate both metabolic and signaling aspects is currently lacking. Further investigation in this respect will help rationalize the design and optimization of nutritional supplements containing BCAAs for critically ill patients. PMID:23554299

  1. Microfluidic Leukocyte Isolation for Gene Expression Analysis in Critically Ill Hospitalized Patients

    PubMed Central

    Russom, Aman; Sethu, Palaniappan; Irimia, Daniel; Mindrinos, Michael N.; Calvano, Steve E.; Garcia, Iris; Finnerty, Celeste; Tannahill, Cynthia; Abouhamze, Amer; Wilhelmy, Julie; López, M. Cecilia; Baker, Henry V.; Herndon, David N.; Lowry, Stephen F.; Maier, Ronald V.; Davis, Ronald W.; Moldawer, Lyle L.; Tompkins, Ronald G.; Toner, Mehmet

    2014-01-01

    BACKGROUND Microarray technology is becoming a powerful tool for diagnostic, therapeutic, and prognostic applications. There is at present no consensus regarding the optimal technique to isolate nucleic acids from blood leukocyte populations for subsequent expression analyses. Current collection and processing techniques pose significant challenges in the clinical setting. Here, we report the clinical validation of a novel microfluidic leukocyte nucleic acid isolation technique for gene expression analysis from critically ill, hospitalized patients that can be readily used on small volumes of blood. METHODS We processed whole blood from hospitalized patients after burn injury and severe blunt trauma according to the microfluidic and standard macroscale leukocyte isolation protocol. Side-by-side comparison of RNA quantity, quality, and genome-wide expression patterns was used to clinically validate the microfluidic technique. RESULTS When the microfluidic protocol was used for processing, sufficient amounts of total RNA were obtained for genome-wide expression analysis from 0.5 mL whole blood. We found that the leukocyte expression patterns from samples processed using the 2 protocols were concordant, and there was less variability introduced as a result of harvesting method than there existed between individuals. CONCLUSIONS The novel microfluidic approach achieves leukocyte isolation in <25 min, and the quality of nucleic acids and genome expression analysis is equivalent to or surpasses that obtained from macroscale approaches. Microfluidics can significantly improve the isolation of blood leukocytes for genomic analyses in the clinical setting. PMID:18375483

  2. Heparin induced thrombocytopenia in critically ill: Diagnostic dilemmas and management conundrums

    PubMed Central

    Gupta, Sachin; Tiruvoipati, Ravindranath; Green, Cameron; Botha, John; Tran, Huy

    2015-01-01

    Thrombocytopenia is often noted in critically ill patients. While there are many reasons for thrombocytopenia, the use of heparin and its derivatives is increasingly noted to be associated with thrombocytopenia. Heparin induced thrombocytopenia syndrome (HITS) is a distinct entity that is characterised by the occurrence of thrombocytopenia in conjunction with thrombotic manifestations after exposure to unfractionated heparin or low molecular weight heparin. HITS is an immunologic disorder mediated by antibodies to heparin-platelet factor 4 (PF4) complex. HITS is an uncommon cause of thrombocytopenia. Reported incidence of HITS in patients exposed to heparin varies from 0.2% to up to 5%. HITS is rare in ICU populations, with estimates varying from 0.39%-0.48%. It is a complex problem which may cause diagnostic dilemmas and management conundrum. The diagnosis of HITS centers around detection of antibodies against PF4-heparin complexes. Immunoassays performed by most pathology laboratories detect the presence of antibodies, but do not reveal whether the antibodies are pathological. Platelet activation assays demonstrate the presence of clinically relevant antibodies, but only a minority of laboratories conduct them. Several anticoagulants are used in management of HITS. In this review we discuss the incidence, pathogenesis, diagnosis and management of HITS. PMID:26261772

  3. Femoral shaft fracture osteosynthesis in a critically ill patient under Extracorporeal Membrane Oxygenation (ECMO)

    PubMed Central

    Calvo, Cristobal; Salineros, Matias; Diaz, Rodrigo; Carvajal, Sebastian

    2016-01-01

    Introduction: Extracorporeal Membrane Oxygenation (ECMO) is an invasive procedure used in critically ill patients with catastrophic pulmonary failure or cardiogenic shock in which conventional management has failed. These patients are managed with permanent anticoagulation, with increased bleeding risk. Hemorrhage is the main reported complication. Case: A 25-year-old polytraumatized woman, both lower limbs amputated and a left femoral shaft fracture with catastrophic pulmonary failure (Murray score 4) that required intensive management care with ECMO. During her evolution definitive femoral shaft osteosynthesis with a nail as required and the medical team decided to operate on the patient under ECMO. She recovered with fluctuations in her hematocrit, but was hemodynamically stable. The patient recovered satisfactorily, was weaned from ECMO and commenced her rehabilitation program. At 16 months, she was almost autovalent, and full consolidation was achieved, with no complication of the implants. Discussion: ECMO is a life-saving support, but requires permanent anticoagulation, which implies a high risk of hemorrhages, specially for surgical treatment. This patient underwent an osteosynthesis surgery satisfactorily. Hematoma was the only complication of her intramedullary femoral nail, without compromising hemodynamics. This case shows that patients on ECMO can undergo a major orthopedic surgery in selected cases. PMID:27194108

  4. Clinical comparison of CR and screen film for imaging the critically ill neonate

    NASA Astrophysics Data System (ADS)

    Andriole, Katherine P.; Brasch, Robert C.; Gooding, Charles A.; Gould, Robert G.; Cohen, Pierre A.; Rencken, Ingo R.; Huang, H. K.

    1996-05-01

    A clinical comparison of computed radiography (CR) versus screen-film for imaging the critically-ill neonate is performed, utilizing a modified (hybrid) film cassette containing a CR (standard ST-V) imaging plate, a conventional screen and film, allowing simultaneous acquisition of perfectly matched CR and plain film images. For 100 portable neonatal chest and abdominal projection radiographs, plain film was subjectively compared to CR hardcopy. Three pediatric radiologists graded overall image quality on a scale of one (poor) to five (excellent), as well as visualization of various anatomic structures (i.e., lung parenchyma, pulmonary vasculature, tubes/lines) and pathological findings (i.e., pulmonary interstitial emphysema, pleural effusion, pneumothorax). Results analyzed using a combined kappa statistic of the differences between scores from each matched set, combined over the three readers showed no statistically significant difference in overall image quality between screen- film and CR (p equals 0.19). Similarly, no statistically significant difference was seen between screen-film and CR for anatomic structure visualization and for visualization of pathological findings. These results indicate that the image quality of CR is comparable to plain film, and that CR may be a suitable alternative to screen-film imaging for portable neonatal chest and abdominal examinations.

  5. Baseline acetylcholinesterase activity and serotonin plasma levels are not associated with delirium in critically ill patients

    PubMed Central

    Tomasi, Cristiane Damiani; Salluh, Jorge; Soares, Márcio; Vuolo, Francieli; Zanatta, Francieli; Constantino, Larissa de Souza; Zugno, Alexandra Ioppi; Ritter, Cristiane; Dal-Pizzol, Felipe

    2015-01-01

    Objective The aim of this study was to investigate whether plasma serotonin levels or acetylcholinesterase activities determined upon intensive care unit admission could predict the occurrence of acute brain dysfunction in intensive care unit patients. Methods A prospective cohort study was conducted with a sample of 77 non-consecutive patients observed between May 2009 and September 2010. Delirium was determined using the Confusion Assessment Method for the Intensive Care Unit tool, and the acetylcholinesterase and serotonin measurements were determined from blood samples collected up to a maximum of 24 h after the admission of the patient to the intensive care unit. Results In the present study, 38 (49.6%) patients developed delirium during their intensive care unit stays. Neither serum acetylcholinesterase activity nor serotonin level was independently associated with delirium. No significant correlations of acetylcholinesterase activity or serotonin level with delirium/coma-free days were observed, but in the patients who developed delirium, there was a strong negative correlation between the acetylcholinesterase level and the number of delirium/coma-free days, indicating that higher acetylcholinesterase levels are associated with fewer days alive without delirium or coma. No associations were found between the biomarkers and mortality. Conclusions Neither serum acetylcholinesterase activity nor serotonin level was associated with delirium or acute brain dysfunction in critically ill patients. Sepsis did not modify these relationships. PMID:26340158

  6. Predictors of Poor Outcomes in Critically Ill Adults with Hematologic Malignancy

    PubMed Central

    Cornish, Marion; Butler, Michael B.; Green, Robert S.

    2016-01-01

    Background. Patients with hematologic malignancy (HM) often require intensive care unit (ICU) admission due to organ failure through disease progression or treatment-related complications. Objective. To determine mortality and prognostic variables in adult patients with HM who were admitted to ICU. Methods. Structured chart review of all adult patients (age ≥ 18 years) with HM admitted to ICU of a Canadian tertiary care hospital between 2004 and 2014. Outcome measures included mortality (ICU, 30-day, 60-day, and 12-month). Logistic regression was performed to determine predictors of mortality. Results. Overall, there were 206 cases of HM admitted to the ICU during the study (mean age: 51.3 ± 13.6 years; 60% male). Median stay was 3 days, with 14.1% requiring prolonged ICU admission. ICU mortality was 45.6% and increased to 59.2% at 30 days, 62.6% at 60 days, and 74.3% at 12 months. Predictors of increased ICU mortality included mechanical ventilation requirement and vasopressor therapy requirement, while admission to ICU postoperatively and having myeloma were associated with decreased mortality. Conclusions. Patients admitted to ICU with HM have high mortality (45.6%), which increased to 74.3% at 1 year. Analysis of multiple variables identified critical illness, postsurgical admission, and myeloma as predictors of patient outcomes. PMID:27445571

  7. Cystatin C Falsely Underestimated GFR in a Critically Ill Patient with a New Diagnosis of AIDS

    PubMed Central

    Brown, Caitlin S.; Kashani, Kianoush B.; Clain, Jeremy M.

    2016-01-01

    Cystatin C has been suggested to be a more accurate glomerular filtration rate (GFR) surrogate than creatinine in patients with acquired immunodeficiency syndrome (AIDS) because it is unaffected by skeletal muscle mass and dietary influences. However, little is known about the utility of this marker for monitoring medications in the critically ill. We describe the case of a 64-year-old female with opportunistic infections associated with a new diagnosis of AIDS. During her course, she experienced neurologic, cardiac, and respiratory failure; yet her renal function remained preserved as indicated by an eGFR ≥ 120 mL/min and a urine output > 1 mL/kg/hr without diuresis. The patient was treated with nephrotoxic agents; therefore cystatin C was assessed to determine if cachexia was resulting in a falsely low serum creatinine. Cystatin C measured 1.50 mg/L which corresponded to an eGFR of 36 mL/min. Given the >60 mL/min discrepancy, serial 8-hour urine samples were collected and a GFR > 120 mL/min was confirmed. It is unclear why cystatin C was falsely elevated, but we hypothesize that it relates to the proinflammatory state with AIDS, opportunistic infections, and corticosteroids. More research is needed before routine use of cystatin C in this setting can be recommended. PMID:27293926

  8. High blood glucose level and increased risk of mortality in critically ill patients.

    PubMed

    Dhungel, Sanjib; Bista, Sukirti

    2007-03-01

    102 patients, 38 from ICU and 64 from postoperative ward were evaluated. Out of these, 49 of the patients had random blood glucose level < 100 mg/dl, 46 had in the range 100 to 140 mg/dl and 7 had > 140 mg/dl. The mean random blood glucose level in medical patients was 146 mg/dl with a standard deviation of 20 and that in the post operative patients was 94.3 mg/dl with a standard deviation of 10. There was an overall mortality of 13.7% (14 patients), of which medical patients were 78.6% (11 patients) and surgical patients were 21.4% (3 patients). Amongst the dead, 81.8% had random blood glucose level > 110 mg/dl and all were medical patients. However all 3 deaths (18.2%) in surgical patients had their random blood glucose level < 110 mg/dl. Higher blood glucose level was observed in critically ill medical patients and mortality was higher among patients with random blood glucose level > 110 mg/dl. PMID:17593678

  9. International recommendations for glucose control in adult non diabetic critically ill patients

    PubMed Central

    2010-01-01

    Introduction The purpose of this research is to provide recommendations for the management of glycemic control in critically ill patients. Methods Twenty-one experts issued recommendations related to one of the five pre-defined categories (glucose target, hypoglycemia, carbohydrate intake, monitoring of glycemia, algorithms and protocols), that were scored on a scale to obtain a strong or weak agreement. The GRADE (Grade of Recommendation, Assessment, Development and Evaluation) system was used, with a strong recommendation indicating a clear advantage for an intervention and a weak recommendation indicating that the balance between desirable and undesirable effects of an intervention is not clearly defined. Results A glucose target of less than 10 mmol/L is strongly suggested, using intravenous insulin following a standard protocol, when spontaneous food intake is not possible. Definition of the severe hypoglycemia threshold of 2.2 mmol/L is recommended, regardless of the clinical signs. A general, unique amount of glucose (enteral/parenteral) to administer for any patient cannot be suggested. Glucose measurements should be performed on arterial rather than venous or capillary samples, using central lab or blood gas analysers rather than point-of-care glucose readers. Conclusions Thirty recommendations were obtained with a strong (21) and a weak (9) agreement. Among them, only 15 were graded with a high level of quality of evidence, underlying the necessity to continue clinical studies in order to improve the risk-to-benefit ratio of glucose control. PMID:20840773

  10. Critical Illness in Patients with Multiple Sclerosis: A Matched Case-Control Study

    PubMed Central

    Karamyan, Anush; Dünser, Martin W.; Wiebe, Douglas J.; Pilz, Georg; Wipfler, Peter; Chroust, Vaclav; Novak, Helmut F.; Hauer, Larissa; Trinka, Eugen; Sellner, Johann

    2016-01-01

    Background Over the course of multiple sclerosis (MS) several conditions may arise that require critical care. We aimed to study the reasons for admission and outcome in patients with MS admitted to a neuro-intensive care unit (NICU). Methods We retrospectively searched the electronic charts of a 9-bedded NICU in a tertiary hospital for patients with a diagnosis of multiple sclerosis (MS) from 1993–2015, and matched them to NICU controls without MS based on age and gender. Conditional logistic regression was used to compare admission causes, Charlson’s Comorbidity Index, indicators of disease severity, and survival between MS and non-MS patients. Results We identified 61 MS patients and 181 non-MS controls. Respiratory dysfunction was the most frequent reason for NICU admission among MS patients (34.4%), having infectious context as a rule. In a matched analysis, after adjusting for co-morbidities and immunosuppressive medications, patients with MS were more likely to be admitted to the NICU because of respiratory dysfunction (OR = 7.86, 95% CI 3.02–20.42, p<0.001), non-respiratory infections (OR = 3.71, 95% CI 1.29–10.68, p = 0.02), had a higher rate of multiple NICU admissions (OR = 2.53, 95% CI 1.05–6.05, p = 0.04) than non-MS patients. Mortality after NICU admission at a median follow-up time of 1 year was higher in MS than control patients (adjusted OR = 4.21, 95% CI 1.49–11.85, p = 0.04). Conclusion The most common reason for NICU admission in MS patients was respiratory dysfunction due to infection. Compared to non-MS patients, critically ill MS patients had a higher NICU re-admission rate, and a higher mortality. PMID:27244560

  11. Community-acquired pneumonia and survival of critically ill acute exacerbation of COPD patients in respiratory intensive care units

    PubMed Central

    Lu, Zhiwei; Cheng, Yusheng; Tu, Xiongwen; Chen, Liang; Chen, Hu; Yang, Jian; Wang, Jinyan; Zhang, Liqin

    2016-01-01

    Purpose The aim of this study was to appraise the effect of community-acquired pneumonia (CAP) on inhospital mortality in critically ill acute exacerbation of COPD (AECOPD) patients admitted to a respiratory intensive care unit. Patients and methods A retrospective observational study was performed. Consecutive critically ill AECOPD patients receiving treatment in a respiratory intensive care unit were reviewed from September 1, 2012, to August 31, 2015. Categorical variables were analyzed using chi-square tests, and continuous variables were analyzed by Mann–Whitney U-test. Kaplan–Meier analysis was used to assess the association of CAP with survival of critically ill AECOPD patients for univariate analysis. Cox’s proportional hazards regression model was performed to identify risk factors for multivariate analysis. Results A total of 80 consecutive eligible individuals were reviewed. These included 38 patients with CAP and 42 patients without CAP. Patients with CAP had a higher inhospital rate of mortality than patients without CAP (42% vs 33.3%, P<0.05). Kaplan–Meier survival analysis showed that patients with CAP had a worse survival rate than patients without CAP (P<0.05). Clinical characteristics, including Acute Physiology and Chronic Health Evaluation II (APACHE II) score, C-reactive protein, and CAP, were found to be closely associated with survival of AECOPD individuals. Further multivariate Cox regression analysis confirmed that CAP and APACHE II were independent risk factors for inhospital mortality in critically ill AECOPD patients (CAP: hazard ratio, 5.29; 95% CI, 1.50–18.47, P<0.01 and APACHE II: hazard ratio, 1.20; 95% CI, 1.06–1.37, P<0.01). Conclusion CAP may be an independent risk factor for higher inhospital mortality in critically ill AECOPD patients. PMID:27563239

  12. Oxidative stress is increased in critically ill patients according to antioxidant vitamins intake, independent of severity: a cohort study

    PubMed Central

    Abilés, Jimena; de la Cruz, Antonio Pérez; Castaño, José; Rodríguez-Elvira, Manuel; Aguayo, Eduardo; Moreno-Torres, Rosario; Llopis, Juan; Aranda, Pilar; Argüelles, Sandro; Ayala, Antonio; de la Quintana, Alberto Machado; Planells, Elena Maria

    2006-01-01

    Introduction Critically ill patients suffer from oxidative stress caused by reactive oxygen species (ROS) and reactive nitrogen species (RNS). Although ROS/RNS are constantly produced under normal circumstances, critical illness can drastically increase their production. These patients have reduced plasma and intracellular levels of antioxidants and free electron scavengers or cofactors, and decreased activity of the enzymatic system involved in ROS detoxification. The pro-oxidant/antioxidant balance is of functional relevance during critical illness because it is involved in the pathogenesis of multiple organ failure. In this study the objective was to evaluate the relation between oxidative stress in critically ill patients and antioxidant vitamin intake and severity of illness. Methods Spectrophotometry was used to measure in plasma the total antioxidant capacity and levels of lipid peroxide, carbonyl group, total protein, bilirubin and uric acid at two time points: at intensive care unit (ICU) admission and on day seven. Daily diet records were kept and compliance with recommended dietary allowance (RDA) of antioxidant vitamins (A, C and E) was assessed. Results Between admission and day seven in the ICU, significant increases in lipid peroxide and carbonyl group were associated with decreased antioxidant capacity and greater deterioration in Sequential Organ Failure Assessment score. There was significantly greater worsening in oxidative stress parameters in patients who received antioxidant vitamins at below 66% of RDA than in those who received antioxidant vitamins at above 66% of RDA. An antioxidant vitamin intake from 66% to 100% of RDA reduced the risk for worsening oxidative stress by 94% (ods ratio 0.06, 95% confidence interval 0.010 to 0.39), regardless of change in severity of illness (Sequential Organ Failure Assessment score). Conclusion The critical condition of patients admitted to the ICU is associated with worsening oxidative stress. Intake of

  13. Vacuum-assisted closure device enhances recovery of critically ill patients following emergency surgical procedures

    PubMed Central

    2009-01-01

    Introduction Critically ill surgical patients frequently develop intra-abdominal hypertension (IAH) leading to abdominal compartment syndrome (ACS) with subsequent high mortality. We compared two temporary abdominal closure systems (Bogota bag and vacuum-assisted closure (VAC) device) in intra-abdominal pressure (IAP) control. Methods This prospective study with a historical control included 66 patients admitted to a medical and surgical intensive care unit (ICU) of a tertiary care referral center (Careggi Hospital, Florence, Italy) from January 2006 to April 2009. The control group included patients consecutively treated with the Bogota bag (Jan 2006-Oct 2007), whereas the prospective group was comprised of patients treated with a VAC. All patients underwent abdominal decompressive surgery. Groups were compared based upon their IAP, SOFA score, serial arterial lactates, the duration of having their abdomen open, the need for mechanical ventilation (MV) along with length of ICU and hospital stay and mortality. Data were collected from the time of abdominal decompression until the end of pressure monitoring. Results The Bogota and VAC groups were similar with regards to demography, admission diagnosis, severity of illness, and IAH grading. The VAC system was more effective in controlling IAP (P < 0.01) and normalizing serum lactates (P < 0.001) as compared to the Bogota bag during the first 24 hours after surgical decompression. There was no significant difference between the SOFA scores. When compared to the Bogota, the VAC group had a faster abdominal closure time (4.4 vs 6.6 days, P = 0.025), shorter duration of MV (7.1 vs 9.9 days, P = 0.039), decreased ICU length of stay (LOS) (13.3 vs 19.2 days, P = 0.024) and hospital LOS (28.5 vs 34.9 days; P = 0.019). Mortality rate did not differ significantly between the two groups. Conclusions Patients with abdominal compartment syndrome who were treated with VAC decompression had a faster abdominal closure rate and

  14. Association of Fluid Accumulation with Clinical Outcomes in Critically Ill Children with Severe Sepsis

    PubMed Central

    Chen, Jiao; Li, Xiaozhong; Bai, Zhenjiang; Fang, Fang; Hua, Jun; Li, Ying; Pan, Jian; Wang, Jian; Feng, Xing; Li, Yanhong

    2016-01-01

    Objective To evaluate whether early and acquired daily fluid overload (FO), as well as fluctuations in fluid accumulation, were associated with adverse outcomes in critically ill children with severe sepsis. Methods This study enrolled 202 children in a pediatric intensive care unit (PICU) with severe sepsis. Early fluid overload was defined as ≥5% fluid accumulation occurring in the first 24 hours of PICU admission. The maximum daily fluid accumulation ≥5% occurring during the next 6 days in patients with at least 48 hours of PICU stay was defined as PICU-acquired daily fluid overload. The fluctuation in fluid accumulation was calculated as the difference between the maximum and the minimum daily fluid accumulation obtained during the first 7 days after admission. Results Of the 202 patients, 61 (30.2%) died during PICU stay. Among all patients, 41 (20.3%) experienced early fluid overload, including 9 with a FO ≥10%. Among patients with at least 48 hours of PICU stay (n = 154), 36 (23.4%) developed PICU-acquired daily fluid overload, including 2 with a FO ≥10%. Both early fluid overload (AOR = 1.20; 95% CI 1.08–1.33; P = 0.001; n = 202) and PICU-acquired daily fluid overload (AOR = 5.47 per log increase; 95% CI 1.15–25.96; P = 0.032; n = 154) were independent risk factors associated with mortality after adjusting for age, illness severity, etc. However, fluctuations in fluid accumulation were not associated with mortality after adjustment. Length of PICU stay increased with greater fluctuations in fluid accumulation in all patients with at least 48 hours of PICU stay (FO <5%, 5%-10% vs. ≥10%: 4 [3–8], 7 [4–11] vs. 10 [6–16] days; P <0.001; n = 154) and in survivors (4 [3–8], 7 [5–11] vs. 10 [5–15] days; P <0.001; n = 121). Early fluid overload achieved an area under-the-receiver-operating-characteristic curve of 0.74 (95% CI 0.65–0.82; P <0.001; n = 202) for predicting mortality in patients with severe sepsis, with a sensitivity of 67

  15. The association of the kynurenine pathway of tryptophan metabolism with acute brain dysfunction during critical illness*

    PubMed Central

    Adams Wilson, Jessica R.; Morandi, Alessandro; Girard, Timothy D.; Thompson, Jennifer L.; Boomershine, Chad S.; Shintani, Ayumi K.; Ely, E. Wesley; Pandharipande, Pratik P.

    2013-01-01

    Objectives Plasma tryptophan levels are associated with delirium in critically ill patients. Although tryptophan has been linked to the pathogenesis of other neurocognitive diseases through metabolism to neurotoxins via the kynurenine pathway, a role for kynurenine pathway activity in intensive care unit brain dysfunction (delirium and coma) remains unknown. This study examined the association between kynurenine pathway activity as determined by plasma kynurenine concentrations and kynurenine/tryptophan ratios and presence or absence of acute brain dysfunction (defined as delirium/coma-free days) in intensive care unit patients. Design, Setting, and Patients This was a prospective cohort study that utilized patient data and blood samples from the Maximizing Efficacy of Targeted Sedation and Reducing Neurologic Dysfunction trial, which compared sedation with dexmedetomidine vs. lorazepam in mechanically ventilated patients. Measurements and Main Results Baseline plasma kynurenine and tryptophan concentrations were measured using high-performance liquid chromatography with or without tandem mass spectrometry. Delirium was assessed daily using the Confusion Assessment Method for the Intensive Care Unit. Linear regression examined associations between kynurenine pathway activity and delirium/coma-free days after adjusting for sedative exposure, age, and severity of illness. Among 84 patients studied, median age was 60 yrs and Acute Physiology and Chronic Health Evaluation II score was 28.5. Elevated plasma kynurenine and kynurenine/tryptophan ratio were both independently associated with significantly fewer delirium/coma-free days (i.e., fewer days without acute brain dysfunction). Specifically, patients with plasma kynurenine or kynurenine/tryptophan ratios at the 75th percentile of our population had an average of 1.8 (95% confidence interval 0.6–3.1) and 2.1 (95% confidence interval 1.0–3.2) fewer delirium/coma-free days than those patients with values at the 25

  16. Optimal Management of the Critically Ill: Anaesthesia, Monitoring, Data Capture, and Point-of-Care Technological Practices in Ovine Models of Critical Care

    PubMed Central

    Shekar, Kiran; Tung, John-Paul; Dunster, Kimble R.; Platts, David; Watts, Ryan P.; Gregory, Shaun D.; Simonova, Gabriela; McDonald, Charles; Hayes, Rylan; Bellpart, Judith; Timms, Daniel; Fung, Yoke L.; Toon, Michael; Maybauer, Marc O.; Fraser, John F.

    2014-01-01

    Animal models of critical illness are vital in biomedical research. They provide possibilities for the investigation of pathophysiological processes that may not otherwise be possible in humans. In order to be clinically applicable, the model should simulate the critical care situation realistically, including anaesthesia, monitoring, sampling, utilising appropriate personnel skill mix, and therapeutic interventions. There are limited data documenting the constitution of ideal technologically advanced large animal critical care practices and all the processes of the animal model. In this paper, we describe the procedure of animal preparation, anaesthesia induction and maintenance, physiologic monitoring, data capture, point-of-care technology, and animal aftercare that has been successfully used to study several novel ovine models of critical illness. The relevant investigations are on respiratory failure due to smoke inhalation, transfusion related acute lung injury, endotoxin-induced proteogenomic alterations, haemorrhagic shock, septic shock, brain death, cerebral microcirculation, and artificial heart studies. We have demonstrated the functionality of monitoring practices during anaesthesia required to provide a platform for undertaking systematic investigations in complex ovine models of critical illness. PMID:24783206

  17. Enterovirus D68 Infections Associated with Severe Respiratory Illness in Elderly Patients and Emergence of a Novel Clade in Hong Kong.

    PubMed

    Lau, Susanna K P; Yip, Cyril C Y; Zhao, Pyrear Su-Hui; Chow, Wang-Ngai; To, Kelvin K W; Wu, Alan K L; Yuen, Kwok-Yung; Woo, Patrick C Y

    2016-01-01

    Despite the recent emergence of enterovirus D68 (EV-D68), its clinical impact on adult population is less well defined. To better define the epidemiology of EV-D68, 6,800 nasopharyngeal aspirates (NPAs) from 2010-2014 were subject to EV-D68 detection by RT-PCR and sequencing of 5'UTR and partial VP1. EV-D68 was detected in 30 (0.44%) NPAs from 22 children and 8 adults/elderlies. Sixteen patients (including five elderly) (53%) had pneumonia and 13 (43%) patients were complicated by small airway disease exacerbation. Phylogenetic analysis of VP1, 2C and 3D regions showed four distinct lineages of EV-D68, clade A1, A2, B1 and B3, with adults/elderlies exclusively infected by clade A2. The potentially new clade, B3, has emerged in 2014, while strains closely related to recently emerged B1 strains in the United States were also detected as early as 2011 in Hong Kong. The four lineages possessed distinct aa sequence patterns in BC and DE loops. Amino acid residues 97 and 140, within BC and DE-surface loops of VP1 respectively, were under potential positive selection. EV-D68 infections in Hong Kong usually peak in spring/summer, though with a delayed autumn/winter peak in 2011. This report suggests that EV-D68 may cause severe respiratory illness in adults/elderlies with underlying co-morbidities. PMID:27121085

  18. Enterovirus D68 Infections Associated with Severe Respiratory Illness in Elderly Patients and Emergence of a Novel Clade in Hong Kong

    PubMed Central

    Lau, Susanna K. P.; Yip, Cyril C. Y.; Zhao, Pyrear Su-Hui; Chow, Wang-Ngai; To, Kelvin K. W.; Wu, Alan K. L.; Yuen, Kwok-Yung; Woo, Patrick C. Y.

    2016-01-01

    Despite the recent emergence of enterovirus D68 (EV-D68), its clinical impact on adult population is less well defined. To better define the epidemiology of EV-D68, 6,800 nasopharyngeal aspirates (NPAs) from 2010–2014 were subject to EV-D68 detection by RT-PCR and sequencing of 5′UTR and partial VP1. EV-D68 was detected in 30 (0.44%) NPAs from 22 children and 8 adults/elderlies. Sixteen patients (including five elderly) (53%) had pneumonia and 13 (43%) patients were complicated by small airway disease exacerbation. Phylogenetic analysis of VP1, 2C and 3D regions showed four distinct lineages of EV-D68, clade A1, A2, B1 and B3, with adults/elderlies exclusively infected by clade A2. The potentially new clade, B3, has emerged in 2014, while strains closely related to recently emerged B1 strains in the United States were also detected as early as 2011 in Hong Kong. The four lineages possessed distinct aa sequence patterns in BC and DE loops. Amino acid residues 97 and 140, within BC and DE-surface loops of VP1 respectively, were under potential positive selection. EV-D68 infections in Hong Kong usually peak in spring/summer, though with a delayed autumn/winter peak in 2011. This report suggests that EV-D68 may cause severe respiratory illness in adults/elderlies with underlying co-morbidities. PMID:27121085

  19. Thromboprophylaxis patterns and determinants in critically ill patients: a multicenter audit

    PubMed Central

    2014-01-01

    Introduction Heparin is safe and prevents venous thromboembolism in critical illness. We aimed to determine the guideline concordance for thromboprophylaxis in critically ill patients and its predictors, and to analyze factors associated with the use of low molecular weight heparin (LMWH), as it may be associated with a lower risk of pulmonary embolism and heparin-induced thrombocytopenia without increasing the bleeding risk. Methods We performed a retrospective audit in 28 North American intensive care units (ICUs), including all consecutive medical-surgical patients admitted in November 2011. We documented ICU thromboprophylaxis and reasons for omission. Guideline concordance was determined by adding days in which patients without contraindications received thromboprophylaxis to days in which patients with contraindications did not receive it, divided by the total number of patient-days. We used multilevel logistic regression including time-varying, center and patient-level covariates to determine the predictors of guideline concordance and use of LMWH. Results We enrolled 1,935 patients (62.3 ± 16.7 years, Acute Physiology and Chronic Health Evaluation [APACHE] II score 19.1 ± 8.3). Patients received thromboprophylaxis with unfractionated heparin (UFH) (54.0%) or LMWH (27.6%). Guideline concordance occurred for 95.5% patient-days and was more likely in patients who were sicker (odds ratio (OR) 1.49, 95% confidence interval (CI) 1.17, 1.75 per 10-point increase in APACHE II), heavier (OR 1.32, 95% CI 1.05, 1.65 per 10-m/kg2 increase in body mass index), had cancer (OR 3.22, 95% CI 1.81, 5.72), previous venous thromboembolism (OR 3.94, 95% CI 1.46,10.66), and received mechanical ventilation (OR 1.83, 95% CI 1.32,2.52). Reasons for not receiving thromboprophylaxis were high risk of bleeding (44.5%), current bleeding (16.3%), no reason (12.9%), recent or upcoming invasive procedure (10.2%), nighttime admission or discharge (9.7%), and life

  20. Association of low serum 25-hydroxyvitamin D levels and mortality in the critically ill

    PubMed Central

    Braun, Andrea; Chang, Domingo; Mahadevappa, Karthik; Gibbons, Fiona K.; Liu, Yan; Giovannucci, Edward; Christopher, Kenneth B.

    2012-01-01

    Objective We hypothesized that deficiency in 25-hydroxy vitamin D (25(OH)D) prior to hospital admission would be associated with all cause mortality in the critically ill. Design Multicenter observational study of patients treated in medical and surgical intensive care units. Setting 209 medical and surgical intensive care beds in two teaching hospitals in Boston, Massachusetts Patients 2,399 patients, age ≥ 18 years, in whom 25(OH)D was measured prior to hospitalization between 1998 and 2009. Measurements Pre-admission 25(OH)D was categorized as deficiency in 25(OH)D (≤15ng/mL), insufficiency (16–29ng/mL) and sufficiency (≥30ng/mL). Logistic regression examined death by days 30, 90 and 365 post-ICU admission, in hospital mortality and blood culture positivity. Adjusted odds ratios were estimated by multivariable logistic regression models. Interventions None Key Results Pre-admission 25(OH)D deficiency is predictive for short term and long term mortality. 30 days following ICU admission, patients with 25(OH)D deficiency have an OR for mortality of 1.69(95%CI, 1.28–2.23;P<.0001) relative to patients with 25(OH)D sufficiency. 25(OH)D deficiency remains a significant predictor of mortality at 30 days following ICU admission following multivariable adjustment (adjusted OR 1.69; 95%CI, 1.26–2.26;P<.0001). 30 days following ICU admission, patients with 25(OH)D insufficiency have an OR of 1.32(95%CI, 1.02–1.72; P=0.036) and an adjusted OR of 1.36(95%CI, 1.03–1.79;P=0.029) relative to patients with 25(OH)D sufficiency. Results were similar at 90 and 365 days following ICU admission and for in hospital mortality. In a subgroup analysis of patients who had blood cultures drawn (n=1,160), 25(OH)D deficiency was associated with increased risk of blood culture positivity. Patients with 25(OH)D insufficiency have an OR for blood culture positivity of 1.64(95%CI, 1.05–2.55;P=0.03) relative to patients with 25(OH)D sufficiency which remains significant following

  1. Evaluation of long-term infusion of dexmedetomidine in critically ill patients: A retrospective analysis

    PubMed Central

    Abuhasna, Said; Al Jundi, Amer; Abdelatty, Wael; urRahman, Masood

    2012-01-01

    Background: Dexmedetomidine is an α2-receptor agonist used for sedation in the intensive care unit (ICU). It is currently FDA indicated for short-term use (i.e., less than 24 h). Objectives: To compare the safety and efficacy of dexmedetomidine if given long- term (>24 h) to short-term infusion (up to 24 h) for mechanically ventilated critically ill patients. Materials and Methods: The medical records of 73 patients were evaluated. Primary outcomes were significant changes in blood pressure or heart rate. Secondary outcomes included hospital and intensive care unit (ICU) length of stay (LOS), ventilator time, rate of reintubation, and rate of death. Statistical Analysis: Pair wise comparisons were based on independent student t-test for continuous data and Chi-square test for categorical data. Statistical difference was defined as P value < 0.05. Results: Of the patients evaluated, 50 received dexmedetomidine for more than 24 h and 23 patients received this agent for 24 h. Patients were similar at baseline except for age. Patients who received dexmedetomidine for more than 24 h were similar to the short-infusion arm in terms of the rate of bradycardia (8.6% vs10%; P = 0.22), hypotension episodes (30.4% vs 28%; P= 0.2), requirement of treatment for those episodes (37% vs 42%; P= 0.43), hospital LOS (30 days vs 38 days; P = 0.45), ICU LOS (14 days vs 19 days; P = 0.44), ventilation days (8 days vs 14 days; P =0.58), rate of reintubation (4% vs 10%; P = 0.79) and mortality (P = 0.2). Conclusion: Long-term dexmedetomidine infusion (> 24 h) had similar safety and clinical outcomes in patients receiving this agent for short-term. Due to the retrospective nature of our investigation, more well-designed studies are needed to confirm these findings. PMID:22837894

  2. Higher serum chloride concentrations are associated with acute kidney injury in unselected critically ill patients

    PubMed Central

    2013-01-01

    Background Chloride administration has been found to be harmful to the kidney in critically ill patients. However the association between plasma chloride concentration and renal function has never been investigated. Methods This was a retrospective study conducted in a tertiary 24-bed intensive care unit from September 2010 to November 2012. Data on serum chloride for each patient during their ICU stay were abstracted from electronic database. Cl0 referred to the initial chloride on ICU entry, Clmax, Clmin and Clmean referred to the maximum, minimum and mean chloride values before the onset of AKI, respectively. AKI was defined according to the conventional AKIN criteria. Univariate and multivariable analysis were performed to examine the association of chloride and AKI development. Results A total of 1221 patients were included into analysis during study period. Three hundred and fifty-seven patients (29.2%) developed AKI. Clmax was significantly higher in AKI than in non-AKI group (111.8 ± 8.1 vs 107.9 ±5.4 mmol/l; p < 0.001); Cl0 was not significantly different between AKI and non-AKI patients; Clmean was significantly higher in AKI than non-AKI (104.3 ±5.8 vs 103.4 ± 4.5; p = 0.0047) patients. Clmax remained to be associated with AKI in multivariable analysis (OR: 1.10, 95% CI: 1.08-1.13). Conclusion Chloride overload as represented by Clmean and Clmax is significantly associated with the development of AKI. PMID:24164963

  3. Prophylactic ranitidine treatment in critically ill children – a population pharmacokinetic study

    PubMed Central

    Hawwa, Ahmed F; Westwood, Paul M; Collier, Paul S; Millership, Jeffrey S; Yakkundi, Shirish; Thurley, Gillian; Shields, Mike D; Nunn, Anthony J; Halliday, Henry L; McElnay, James C

    2013-01-01

    Aims To characterize the population pharmacokinetics of ranitidine in critically ill children and to determine the influence of various clinical and demographic factors on its disposition. Methods Data were collected prospectively from 78 paediatric patients (n = 248 plasma samples) who received oral or intravenous ranitidine for prophylaxis against stress ulcers, gastrointestinal bleeding or the treatment of gastro-oesophageal reflux. Plasma samples were analysed using high-performance liquid chromatography, and the data were subjected to population pharmacokinetic analysis using nonlinear mixed-effects modelling. Results A one-compartment model best described the plasma concentration profile, with an exponential structure for interindividual errors and a proportional structure for intra-individual error. After backward stepwise elimination, the final model showed a significant decrease in objective function value (−12.618; P < 0.001) compared with the weight-corrected base model. Final parameter estimates for the population were 32.1 l h−1 for total clearance and 285 l for volume of distribution, both allometrically modelled for a 70 kg adult. Final estimates for absorption rate constant and bioavailability were 1.31 h−1 and 27.5%, respectively. No significant relationship was found between age and weight-corrected ranitidine pharmacokinetic parameters in the final model, with the covariate for cardiac failure or surgery being shown to reduce clearance significantly by a factor of 0.46. Conclusions Currently, ranitidine dose recommendations are based on children's weights. However, our findings suggest that a dosing scheme that takes into consideration both weight and cardiac failure/surgery would be more appropriate in order to avoid administration of higher or more frequent doses than necessary. PMID:23016949

  4. Association of Patient Care with Ventilator-Associated Conditions in Critically Ill Patients: Risk Factor Analysis

    PubMed Central

    Yamada, Tomomi; Ogura, Toru; Nakajima, Ken; Suzuki, Kei

    2016-01-01

    Background Ventilator-associated conditions (VACs), for which new surveillance definitions and methods were issued by the Center for Disease Control and Prevention (CDC), are respiratory complications occurring in conjunction with the use of invasive mechanical ventilation and are related to adverse outcomes in critically ill patients. However, to date, risk factors for VACs have not been adequately established, leading to a need for developing a better understanding of the risks. The objective of this study was to explore care-related risk factors as a process indicator and provide valuable information pertaining to VAC preventive measures. Methods This retrospective, single-center, cohort study was conducted in the intensive-care unit (ICU) of a university hospital in Japan. Patient data were automatically sampled using a computerized medical records system and retrospectively analyzed. Management and care-related, but not host-related, factors were exhaustively analyzed using multivariate analysis for risks of VACs. VAC correlation to mortality was also investigated. Results Of the 3122 patients admitted in the ICU, 303 ventilated patients meeting CDC-specified eligibility criteria were included in the analysis. Thirty-seven VACs (12.2%) were found with a corresponding rate of 12.1 per 1000 ventilator days. Multivariate analysis revealed four variables related to patient care as risk factors for VACs: absence of intensivist participation in management of ventilated patients [adjusted HR (AHR): 7.325, P < 0.001)], using relatively higher driving pressure (AHR: 1.216, P < 0.001), development of edema (AHR: 2.145, P = 0.037), and a larger body weight increase (AHR: 0.058, P = 0.005). Furthermore, this research confirmed mortality differences in patients with VACs and statistically derived risks compared with those without VACs (HR: 2.623, P = 0.008). Conclusion Four risk factors related to patient care were clearly identified to be the key factors for VAC

  5. Clinical review: Helmet and non-invasive mechanical ventilation in critically ill patients

    PubMed Central

    2013-01-01

    Non-invasive mechanical ventilation (NIV) has proved to be an excellent technique in selected critically ill patients with different forms of acute respiratory failure. However, NIV can fail on account of the severity of the disease and technical problems, particularly at the interface. The helmet could be an alternative interface compared to face mask to improve NIV success. We performed a clinical review to investigate the main physiological and clinical studies assessing the efficacy and related issues of NIV delivered with a helmet. A computerized search strategy of MEDLINE/PubMed (January 2000 to May 2012) and EMBASE (January 2000 to May 2012) was conducted limiting the search to retrospective, prospective, nonrandomized and randomized trials. We analyzed 152 studies from which 33 were selected, 12 physiological and 21 clinical (879 patients). The physiological studies showed that NIV with helmet could predispose to CO2 rebreathing and increase the patients' ventilator asynchrony. The main indications for NIV were acute cardiogenic pulmonary edema, hypoxemic acute respiratory failure (community-acquired pneumonia, postoperative and immunocompromised patients) and hypercapnic acute respiratory failure. In 9 of the 21 studies the helmet was compared to a face mask during either continous positive airway pressure or pressure support ventilation. In eight studies oxygenation was similar in the two groups, while the intubation rate was similar in four and lower in three studies for the helmet group compared to face mask group. The outcome was similar in six studies. The tolerance was better with the helmet in six of the studies. Although these data are limited, NIV delivered by helmet could be a safe alternative to the face mask in patients with acute respiratory failure. PMID:23680299

  6. Prevalence and impact of late defecation in the critically ill, thermally injured adult patient.

    PubMed

    Trexler, Scott T; Lundy, Jonathan B; Chung, Kevin K; Nitzschke, Stephanie L; Burns, Christopher J; Shields, Beth A; Cancio, Leopoldo C

    2014-01-01

    The aim of this study was to determine the prevalence of late defecation (absence of laxation for more than 6 days after admission) as an indicator of lower-gastrointestinal (GI) tract dysfunction in burn patients. In addition, the authors wanted to determine whether the addition of polyethylene glycol 3350 to the standard bowel regimen led to improvement in markers of lower-GI function and outcomes. The authors conducted a retrospective chart review of patients admitted to the burn intensive care unit during a 26-month period. Inclusion criteria were 20% or more TBSA burn, requirement for mechanical ventilation, and age over 18 years. Of 83 patients included, the prevalence of late defecation was 36.1% (n = 30). There was no association between late defecation and mortality. Patients with late defecation had more frequent episodes of constipation after first defecation (P =.03), of feeding intolerance (P =.007), and received total parenteral nutrition more frequently (P =.005). The addition of polyethylene glycol to the standard bowel regimen did not affect markers of lower-GI function. Late defecation occurs in more than one third of critically ill burn patients. Late defecation was associated with ongoing lower-GI dysfunction, feeding intolerance, and the use of total parenteral nutrition. The causal relationship between these problems has not been determined. A prospective study at the authors' institution is currently planned to attempt to validate late defecation as a marker of lower-GI tract dysfunction, determine its relationship to various outcomes, and determine risk factors for its development. PMID:23877139

  7. Urinary L-FABP predicts poor outcomes in critically ill patients with early acute kidney injury.

    PubMed

    Parr, Sharidan K; Clark, Amanda J; Bian, Aihua; Shintani, Ayumi K; Wickersham, Nancy E; Ware, Lorraine B; Ikizler, T Alp; Siew, Edward D

    2015-03-01

    Biomarker studies for early detection of acute kidney injury (AKI) have been limited by nonselective testing and uncertainties in using small changes in serum creatinine as a reference standard. Here we examine the ability of urine L-type fatty acid-binding protein (L-FABP), neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18 (IL-18), and kidney injury molecule-1 (KIM-1) to predict injury progression, dialysis, or death within 7 days in critically ill adults with early AKI. Of 152 patients with known baseline creatinine examined, 36 experienced the composite outcome. Urine L-FABP demonstrated an area under the receiver-operating characteristic curve (AUC-ROC) of 0.79 (95% confidence interval 0.70-0.86), which improved to 0.82 (95% confidence interval 0.75-0.90) when added to the clinical model (AUC-ROC of 0.74). Urine NGAL, IL-18, and KIM-1 had AUC-ROCs of 0.65, 0.64, and 0.62, respectively, but did not significantly improve discrimination of the clinical model. The category-free net reclassification index improved with urine L-FABP (total net reclassification index for nonevents 31.0%) and urine NGAL (total net reclassification index for events 33.3%). However, only urine L-FABP significantly improved the integrated discrimination index. Thus, modest early changes in serum creatinine can help target biomarker measurement for determining prognosis with urine L-FABP, providing independent and additive prognostic information when combined with clinical predictors. PMID:25229339

  8. Microbiological Profile of Organisms Causing Bloodstream Infection in Critically Ill Patients

    PubMed Central

    Orsini, Jose; Mainardi, Carlo; Muzylo, Eliza; Karki, Niraj; Cohen, Nina; Sakoulas, George

    2012-01-01

    Background Bloodstream infection (BSI) is the most frequent infection in critically ill patients. As BSI’s among patients in intensive care units (ICU’s) are usually secondary to intravascular catheters, they can be caused by both Gram-positive and Gram-negative microorganisms as well as fungi. Infection with multidrug-resistant (MDR) organisms is becoming more common, making the choice of empirical antimicrobial therapy challenging. The objective of this study is to evaluate the spectrum of microorganisms causing BSI’s in a Medical-Surgical Intensive Care Unit (MSICU) and their antimicrobial resistance patterns. Methods A prospective observational study among all adult patients with clinical signs of sepsis was conducted in a MSICU of an inner-city hospital in New York City between May 1, 2010 and May 30, 2011. Results A total of 722 adult patients with clinical signs of systemic inflammatory response syndrome (SIRS) and/or sepsis were admitted to the MSICU between May 1, 2010 and May 30, 2011. From those patients, 91 (12.6%) had one or more positive blood culture. A 122 isolates were identified: 72 (59%) were Gram-positive bacteria, 38 (31.1%) were Gram-negative organisms, and 12 (9.8%) were fungi. Thirteen (34.2%) Gram-negative organisms and 14 (19.4%) Gram-positive bacteria were classified as MDR. Conclusions Antimicrobial resistance, particularly among Gram-negative organisms, continues to increase at a rapid rate, especially in the ICU’s. Coordinated infection control interventions and antimicrobial stewardship policies are warranted in order to slow the emergence of resistance. PMID:23226169

  9. Liver transplantation for critically Ill patients with secondary sclerosing cholangitis: Outcome and complications.

    PubMed

    Voigtländer, Torsten; Jaeckel, Elmar; Lehner, Frank; Manns, Michael P; Lankisch, Tim O

    2015-10-01

    Secondary sclerosing cholangitis in critically ill patients (SSC-CIP) is a destructive cholangiopathy with a poor prognosis. Liver transplantation (LT) is an established therapeutic option in end-stage liver disease but is insufficiently evaluated in patients with SSC-CIP. Our aim was the retrospective analysis of the outcome and complications of patients with SSC-CIP undergoing LT between 2002 and 2012. Demographic characteristics, laboratory, transplantation, and follow-up data were compared to sex- and age-matched patients undergoing LT because of other reasons. Quality of life (QoL) before and after LT was assessed in a retrospective telephone interview. LT was performed in 21 patients with SSC-CIP. The main causes for intensive care unit admission comprised cardiothoracic surgery interventions (10/21, 48%), polytrauma (6/21, 29%), and pneumonia (3/21, 14%). Median follow-up period after LT was 82 months (interquartile range [IQR], 37-129) for patients with SSC-CIP and 83 months (IQR, 55-104) for control patients. Biopsy-proven rejection episodes in patients with SSC-CIP (4/21, 19%) were similar compared to control patients (12/60, 20%; P = 0.93). Cytomegalovirus infections were equal in both groups (10/21, 48% versus 25/60, 42%; P = 0.64). The 1-, 3-, and 5-year survival rates of patients with SSC-CIP versus control patients were 100% versus 98%, 86% versus 92%, and 76% versus 87%, respectively (P > 0.05). The QoL improved significantly after LT in SSC-CIP. In conclusion, LT is a valid option for patients with SSC-CIP with excellent long-term outcome and improvement of QoL. PMID:26069199

  10. Antibiotics in critically ill patients: a systematic review of the pharmacokinetics of β-lactams

    PubMed Central

    2011-01-01

    Introduction Several reports have shown marked heterogeneity of antibiotic pharmacokinetics (PK) in patients admitted to ICUs, which might potentially affect outcomes. Therefore, the pharmacodynamic (PD) parameter of the efficacy of β-lactam antibiotics, that is, the time that its concentration is above the bacteria minimal inhibitory concentration (T > MIC), cannot be safely extrapolated from data derived from the PK of healthy volunteers. Methods We performed a full review of published studies addressing the PK of intravenous β-lactam antibiotics given to infected ICU patients. Study selection comprised a comprehensive bibliographic search of the PubMed database and bibliographic references in relevant reviews from January 1966 to December 2010. We selected only English-language articles reporting studies addressing β-lactam antibiotics that had been described in at least five previously published studies. Studies of the PK of patients undergoing renal replacement therapy were excluded. Results A total of 57 studies addressing six different β-lactam antibiotics (meropenem, imipenem, piperacillin, cefpirome, cefepime and ceftazidime) were selected. Significant PK heterogeneity was noted, with a broad, more than twofold variation both of volume of distribution and of drug clearance (Cl). The correlation of antibiotic Cl with creatinine clearance was usually reported. Consequently, in ICU patients, β-lactam antibiotic half-life and T > MIC were virtually unpredictable, especially in those patients with normal renal function. A better PD profile was usually obtained by prolonged or even continuous infusion. Tissue penetration was also found to be compromised in critically ill patients with septic shock. Conclusions The PK of β-lactam antibiotics are heterogeneous and largely unpredictable in ICU patients. Consequently, the dosing of antibiotics should be supported by PK concepts, including data derived from studies of the PK of ICU patients and therapeutic drug

  11. Prediction scores do not correlate with clinically adjudicated categories of pulmonary embolism in critically ill patients

    PubMed Central

    Katsios, CM; Donadini, M; Meade, M; Mehta, S; Hall, R; Granton, J; Kutsiogiannis, J; Dodek, P; Heels-Ansdell, D; McIntyre, L; Vlahakis, N; Muscedere, J; Friedrich, J; Fowler, R; Skrobik, Y; Albert, M; Cox, M; Klinger, J; Nates, J; Bersten, A; Doig, C; Zytaruk, N; Crowther, M; Cook, DJ

    2014-01-01

    BACKGROUND: Prediction scores for pretest probability of pulmonary embolism (PE) validated in outpatient settings are occasionally used in the intensive care unit (ICU). OBJECTIVE: To evaluate the correlation of Geneva and Wells scores with adjudicated categories of PE in ICU patients. METHODS: In a randomized trial of thromboprophylaxis, patients with suspected PE were adjudicated as possible, probable or definite PE. Data were then retrospectively abstracted for the Geneva Diagnostic PE score, Wells, Modified Wells and Simplified Wells Diagnostic scores. The chance-corrected agreement between adjudicated categories and each score was calculated. ANOVA was used to compare values across the three adjudicated PE categories. RESULTS: Among 70 patients with suspected PE, agreement was poor between adjudicated categories and Geneva pretest probabilities (kappa 0.01 [95% CI −0.0643 to 0.0941]) or Wells pretest probabilities (kappa −0.03 [95% CI −0.1462 to 0.0914]). Among four possible, 16 probable and 50 definite PEs, there were no significant differences in Geneva scores (possible = 4.0, probable = 4.7, definite = 4.5; P=0.90), Wells scores (possible = 2.8, probable = 4.9, definite = 4.1; P=0.37), Modified Wells (possible = 2.0, probable = 3.4, definite = 2.9; P=0.34) or Simplified Wells (possible = 1.8, probable = 2.8, definite = 2.4; P=0.30). CONCLUSIONS: Pretest probability scores developed outside the ICU do not correlate with adjudicated PE categories in critically ill patients. Research is needed to develop prediction scores for this population. PMID:24083302

  12. Discontinuation of prolonged infusions of dexmedetomidine in critically ill children with heart disease

    PubMed Central

    Burbano, Nelson H.; Otero, Andrea V.; Berry, Donald E.; Orr, Richard A.; Munoz, Ricardo A.

    2013-01-01

    Purpose To describe changes in hemodynamic variables, sedation and pain score after discontinuation of prolonged infusions of dexmedetomidine in a pediatric population of critically ill cardiac patients. Methods Retrospective case series of patients who received continuous infusions of dexmedetomidine for longer than 3 days in a pediatric cardiac intensive care unit from 2008 to 2010. Results Sixty-two patients, age 5.2 months (range 0.3 months – 17 years) and weight 5.1 kg (range 2.2–84 kg), were included. Thirty-nine patients (63%) were <1 year of age. Median duration of dexmedetomidine infusion was 5.8 days (range 4–26 days) and median infusion dose was 0.71 μg/kg/hr (range 0.2–2.1 μg/kg/hr). Median weaning time and dose at discontinuation were 43 hours (range 0–189 hours) and 0.2 μg/kg/hr (range 0.1–1.3 μg/kg/hr). Tachycardia, transient hypertension and agitation were observed in 27%, 35% and 27% of patients. Episodes of tachycardia were more frequent in children >1 year of age (61% vs. 8%, p < .001), patients who received dexmedetomidine for 4 days when compared to those who received 5 days or longer (48% vs. 17%, p = .011) and patients whose infusion was discontinued abruptly (42% vs. 14%, p = .045). Tachyarrhythmias were seen in 9 patients (15%) after discontinuation of the dexmedetomidine infusion. Adequate sedation and analgesia scores at the moment of infusion discontinuation were seen in 90% and 88%, of patients respectively. Conclusions Our study suggests that tachycardia, transient hypertension and agitation are frequently observed in pediatric cardiac intensive care unit patients after discontinuing prolonged dexmedetomidine infusions. PMID:22160200

  13. Critical Illness in Pregnancy: Part II: Common Medical Conditions Complicating Pregnancy and Puerperium.

    PubMed

    Guntupalli, Kalpalatha K; Karnad, Dilip R; Bandi, Venkata; Hall, Nicole; Belfort, Michael

    2015-11-01

    The first of this two-part series on critical illness in pregnancy dealt with obstetric disorders. In Part II, medical conditions that commonly affect pregnant women or worsen during pregnancy are discussed. ARDS occurs more frequently in pregnancy. Strategies commonly used in nonpregnant patients, including permissive hypercapnia, limits for plateau pressure, and prone positioning, may not be acceptable, especially in late pregnancy. Genital tract infections unique to pregnancy include chorioamnionitis, group A streptococcal infection causing toxic shock syndrome, and polymicrobial infection with streptococci, staphylococci, and Clostridium perfringens causing necrotizing vulvitis or fasciitis. Pregnancy predisposes to VTE; D-dimer levels have low specificity in pregnancy. A ventilation-perfusion scan is preferred over CT pulmonary angiography in some situations to reduce radiation to the mother's breasts. Low-molecular-weight or unfractionated heparins form the mainstay of treatment; vitamin K antagonists, oral factor Xa inhibitors, and direct thrombin inhibitors are not recommended in pregnancy. The physiologic hyperdynamic circulation in pregnancy worsens many cardiovascular disorders. It increases risk of pulmonary edema or arrhythmias in mitral stenosis, heart failure in pulmonary hypertension or aortic stenosis, aortic dissection in Marfan syndrome, or valve thrombosis in mechanical heart valves. Common neurologic problems in pregnancy include seizures, altered mental status, visual symptoms, and strokes. Other common conditions discussed are aspiration of gastric contents, OSA, thyroid disorders, diabetic ketoacidosis, and cardiopulmonary arrest in pregnancy. Studies confined to pregnant women are available for only a few of these conditions. We have, therefore, reviewed pregnancy-specific adjustments in the management of these disorders. PMID:26020727

  14. Functional evolution of critically ill patients undergoing an early rehabilitation protocol

    PubMed Central

    Murakami, Fernanda Murata; Yamaguti, Wellington Pereira; Onoue, Mirian Akemi; Mendes, Juliana Mesti; Pedrosa, Renata Santos; Maida, Ana Lígia Vasconcellos; Kondo, Cláudia Seiko; de Salles, Isabel Chateaubriand Diniz; de Brito, Christina May Moran; Rodrigues, Miguel Koite

    2015-01-01

    Objective Evaluation of the functional outcomes of patients undergoing an early rehabilitation protocol for critically ill patients from admission to discharge from the intensive care unit. Methods A retrospective cross-sectional study was conducted that included 463 adult patients with clinical and/or surgical diagnosis undergoing an early rehabilitation protocol. The overall muscle strength was evaluated at admission to the intensive care unit using the Medical Research Council scale. Patients were allocated to one of four intervention plans according to the Medical Research Council score, the suitability of the plan’s parameters, and the increasing scale of the plan expressing improved functional status. Uncooperative patients were allocated to intervention plans based on their functional status. The overall muscle strength and/or functional status were reevaluated upon discharge from the intensive care unit by comparison between the Intervention Plans upon admission (Planinitial) and discharge (Planfinal). Patients were classified into three groups according to the improvement of their functional status or not: responsive 1 (Planfinal > Planinitial), responsive 2 (Planfinal = Planinitial) and unresponsive (Planfinal < Planinitial). Results In total, 432 (93.3%) of 463 patients undergoing the protocol responded positively to the intervention strategy, showing maintenance and/or improvement of the initial functional status. Clinical patients classified as unresponsive were older (74.3 ± 15.1 years of age; p = 0.03) and had longer lengths of intensive care unit (11.6 ± 14.2 days; p = 0.047) and hospital (34.5 ± 34.1 days; p = 0.002) stays. Conclusion The maintenance and/or improvement of the admission functional status were associated with shorter lengths of intensive care unit and hospital stays. The results suggest that the type of diagnosis, clinical or surgical, fails to define the positive response to an early rehabilitation protocol. PMID:26340157

  15. Role of Hematocrit Concentration on Successful Extubation in Critically Ill Patients in the Intensive Care Units

    PubMed Central

    Beigmohammadi, Mohammad Taghi; Hussain Khan, Zahid; Samadi, Shahram; Mahmoodpoor, Ata; Fotouhi, Akbar; Rahimiforoushani, Abbas; Asadi Gharabaghi, Mehrnaz

    2016-01-01

    Background: Hematocrit (Hct) is an important parameter for optimal oxygenation during discontinuation from ventilator, but there is no consensus about its concentration and effectiveness on successful extubation. Objectives: The current study aimed to determine the role of Hct concentration on extubation failure in critically ill patients. Patients and Methods: The current prospective cohort study investigated the effect of age, gender and Hct level on successful extubation of 163 mechanically ventilated patients in Imam Khomeini hospital intensive care units (ICUs), Tehran, Iran. Following successful weaning process, the patients were classified into two groups on the basis of Hct level; 62 with an Hct level of 21% - 27% and the other 101 patients with Hct levels above 27%. The data were analyzed by chi-square test and multiple logistic regressions. A probability value of less than 0.05 was considered significant. Results: There was no significant association between the level of Hct concentration and extubation failure (8.9% vs. 9.2%, P = 0.507). Gender and age were significantly associated with extubation failure (OR = 9.1, P = 0.034, OR = 12.5, P = 0.014, respectively). Although the differences between, before and after extubation of PaO2 and P/F ratio, were of significant values between the two different groups of Hct (P = 0.001, P = 0.004 respectively), they had no effect on the failure of extubation (P= 0.259, P = 0.403, respectively). Conclusions: Although some studies showed association between anemia and extubation failure, the current study could not confirm it. The study showed that males, regardless of the Hct level, had a better extubation success rate than those of females. PMID:27110535

  16. Fluconazole pharmacokinetics in a morbidly obese, critically ill patient receiving continuous venovenous hemofiltration.

    PubMed

    Lopez, Natasha D; Phillips, Kristy M

    2014-09-01

    Current fluconazole dosing strategies can be described using either standardized doses (800 or 400 mg) or as weight-based dosing recommendations (12 mg/kg loading dose followed by 6 mg/kg maintenance dose). The ideal method of fluconazole dosing is still unclear for certain patient populations, such as those receiving renal replacement therapy or the morbidly obese. We describe a 48-year-old man with a body mass index of 84 kg/m(2) who was receiving continuous venovenous hemofiltration (CVVH) and was treated with fluconazole by using a weight-based dose determined by lean body weight, infused at a rate of 200 mg/hour. Blood samples were collected at hour 0 (i.e., ~24 hrs after the loading dose was administered) and at 3.5, 6.8, and 11.3 hours after the start of the 600-mg maintenance dose, infused over 3 hours. Pharmacokinetic parameters calculated were maximum serum concentration 9.64 mg/L, minimum serum concentration 5.98 mg/L, area under the serum concentration-time curve from 0-24 hours (AUC0-24 ) 184.75 mg/L•hour, elimination rate constant 0.0199 hour(-1) , elimination half-life 34.8 hours, and total body clearance 3.25 L/hour. Our data, when combined with previously published literature, do not support using a linear dose-to-AUC approximation to estimate drug dosing needs in the critically ill patient population receiving CVVH. In addition, our results suggest that morbidly obese patients are able to achieve pharmacodynamic goals defined as an AUC:MIC ratio higher than 25 by using a lean body weight for fluconazole dosing calculations. PMID:25074285

  17. Qualitative critical incident study of patients’ experiences leading to emergency hospital admission with advanced respiratory illness

    PubMed Central

    Karasouli, Eleni; Munday, Daniel; Bailey, Cara; Staniszewska, Sophie; Hewison, Alistair; Griffiths, Frances

    2016-01-01

    Objectives The high volume of emergency admissions to hospital is a challenge for health systems internationally. Patients with lung cancer and chronic obstructive pulmonary disease (COPD) are frequently admitted to hospital as emergency cases. While the frequency of emergency admission has been investigated, few studies report patient experiences, particularly in relation to the decision-making process prior to emergency admission. We sought to explore patient and carer experiences and those of their healthcare professionals in the period leading up to emergency admission to hospital. Setting 3 UK hospitals located in different urban and rural settings. Design Qualitative critical incident study. Participants 24 patients with advanced lung cancer and 15 with advanced COPD admitted to hospital as emergencies, 20 of their carers and 50 of the health professionals involved in the patients’ care. Results The analysis of patient, carer and professionals’ interviews revealed a detailed picture of the complex processes involved leading to emergency admission to hospital. 3 phases were apparent in this period: self-management of deteriorating symptoms, negotiated decision-making and letting go. These were dynamic processes, characterised by an often rapidly changing clinical condition, uncertainty and anxiety. Patients considered their options drawing on experience, current and earlier advice. Patients tried to avoid admission, reluctantly accepting it, albeit often with a sense of relief, as anxiety increased with worsening symptoms. Conclusions Patients with advanced respiratory illness, and their carers, try to avoid emergency admission, and use logical and complex decision-making before reluctantly accepting it. Clinicians and policy-makers need to understand this complex process when considering how to reduce emergency hospital admissions rather than focusing on identifying and labelling admissions as ‘inappropriate’. PMID:26916687

  18. Intestinal crosstalk – a new paradigm for understanding the gut as the “motor” of critical illness

    PubMed Central

    Clark, Jessica A; Coopersmith, Craig M

    2007-01-01

    For more than 20 years, the gut has been hypothesized to be the “motor” of multiple organ dysfunction syndrome (MODS). As critical care research has evolved, there have been multiple mechanisms by which the gastrointestinal tract has been proposed to drive systemic inflammation. Many of these disparate mechanisms have proved to be important in the origin and propagation of critical illness. However, this has led to an unusual situation where investigators describing the gut as a “motor” revving the systemic inflammatory response syndrome (SIRS) are frequently describing wholly different processes to support their claim (i.e. increased apoptosis, altered tight junctions, translocation, cytokine production, crosstalk with commensal bacteria, etc). The purpose of this review is to present a unifying theory as to how the gut drives critical illness. Although the gastrointestinal tract is frequently described simply as “the gut,” it is actually made up of a) an epithelium, b) a diverse and robust immune arm, which contains the majority of immune cells in the body, and c) the commensal bacteria, which contain more cells than are present in the entire host organism. We propose that the intestinal epithelium, the intestinal immune system and the intestine’s endogenous bacteria all play vital roles driving MODS, and the complex crosstalk between these three interrelated portions of the gastrointestinal tract are cumulatively what makes the gut a “motor” of critical illness. PMID:17577136

  19. Results of distal revascularization in elderly patients for critical ischemia of the lower limbs.

    PubMed

    Illuminati, G; Calio, F G; Bertagni, A; Piermattei, A; Vietri, F; Martinelli, V

    1999-04-01

    Thirty eight patients over 75 years of age were operated upon of 40 distal arterial revascularizations for critical ischaemia of the lower limbs. Arterial reconstruction was proposed to ambulatory, self sufficient patients, with a patent artery of the leg or the foot in continuity with pedal arch, at arteriography. The revascularized artery was the peroneal in 14 cases, the anterior tibial in 11, the posterior tibial in 9, the dorsalis pedis in 5, and the external plantar artery in 1 case. Postoperative mortality was 2.6%. No postoperative arterial occlusion occurred and no postoperative amputation needed to be performed. The mean follow-up of 37 patients surviving operation was 21 months (ext. 2-52 months). At 36 months interval, patients' survival was 43%, primary patency rate was 57%, and limb salvage rate was 76%, at life-table analysis. Distal revascularization enables a good number of elderly patients in critical ischaemia of the lower limb, to enjoy an active, independent life, with a viable limb. PMID:10352735

  20. Early lactate clearance for predicting active bleeding in critically ill patients with acute upper gastrointestinal bleeding: a retrospective study.

    PubMed

    Wada, Tomoki; Hagiwara, Akiyoshi; Uemura, Tatsuki; Yahagi, Naoki; Kimura, Akio

    2016-08-01

    Not all patients with upper gastrointestinal bleeding (UGIB) require emergency endoscopy. Lactate clearance has been suggested as a parameter for predicting patient outcomes in various critical care settings. This study investigates whether lactate clearance can predict active bleeding in critically ill patients with UGIB. This single-center, retrospective, observational study included critically ill patients with UGIB who met all of the following criteria: admission to the emergency department (ED) from April 2011 to August 2014; had blood samples for lactate evaluation at least twice during the ED stay; and had emergency endoscopy within 6 h of ED presentation. The main outcome was active bleeding detected with emergency endoscopy. Classification and regression tree (CART) analyses were performed using variables associated with active bleeding to derive a prediction rule for active bleeding in critically ill UGIB patients. A total of 154 patients with UGIB were analyzed, and 31.2 % (48/154) had active bleeding. In the univariate analysis, lactate clearance was significantly lower in patients with active bleeding than in those without active bleeding (13 vs. 29 %, P < 0.001). Using the CART analysis, a prediction rule for active bleeding is derived, and includes three variables: lactate clearance; platelet count; and systolic blood pressure at ED presentation. The rule has 97.9 % (95 % CI 90.2-99.6 %) sensitivity with 32.1 % (28.6-32.9 %) specificity. Lactate clearance may be associated with active bleeding in critically ill patients with UGIB, and may be clinically useful as a component of a prediction rule for active bleeding. PMID:26837207

  1. Relationship between hyperglycemia, hormone disturbances, and clinical evolution in severely hyperglycemic post surgery critically ill children: an observational study

    PubMed Central

    2014-01-01

    Background To study hormonal changes associated with severe hyperglycemia in critically ill children and the relationship with prognosis and length of stay in intensive care. Methods Observational study in twenty-nine critically ill children with severe hyperglycemia defined as 2 blood glucose measurements greater than 180 mg/dL. Severity of illness was assessed using pediatric index of mortality (PIM2), pediatric risk of mortality (PRISM) score, and pediatric logistic organ dysfunction (PELOD) scales. Blood glucose, glycosuria, insulin, C-peptide, cortisol, corticotropin, insulinlike growth factor-1, growth hormone, thyrotropin, thyroxine, and treatment with insulin were recorded. β-cell function and insulin sensitivity and resistance were determined on the basis of the homeostatic model assessment (HOMA), using blood glucose and C-peptide levels. Results The initial blood glucose level was 249 mg/dL and fell gradually to 125 mg/dL at 72 hours. Initial β-cell function (49.2%) and insulin sensitivity (13.2%) were low. At the time of diagnosis of hyperglycemia, 50% of the patients presented insulin resistance and β-cell dysfunction, 46% presented isolated insulin resistance, and 4% isolated β-cell dysfunction. β-cell function improved rapidly but insulin resistance persisted. Initial glycemia did not correlate with any other factor, and there was no relationship between glycemia and mortality. Patients who died had higher cortisol and growth hormone levels at diagnosis. Length of stay was correlated by univariate analysis, but not by multivariate analysis, with C-peptide and glycemic control at 24 hours, insulin resistance, and severity of illness scores. Conclusions Critically ill children with severe hyperglycemia initially present decreased β-cell function and insulin sensitivity. Nonsurvivors had higher cortisol and growth hormone levels and developed hyperglycemia later than survivors. PMID:24628829

  2. Interruption pf physcial activity due to illness in the Lifestyle Interventions and Indepencence for Elders Pilot (LIFE-P) trial

    Technology Transfer Automated Retrieval System (TEKTRAN)

    The Lifestyle Interventions and Independence for Elders Pilot (LIFE-P) was a trial to examine the effects of physical activity (PA) compared to a health education control on measures of disability in sedentary older adults. Medical suspensions were examined for the first 12 months of the trial in th...

  3. Obesity and Serious Mental Ill Health: A Critical Review of the Literature

    PubMed Central

    Bradshaw, Tim; Mairs, Hilary

    2014-01-01

    Individuals who experience serious mental ill health such as schizophrenia are more likely to be overweight or obese than others in the general population. This high prevalence of obesity and other associated metabolic disturbances, such as type 2 diabetes and cardiovascular disease, contribute to a reduced life expectancy of up to 25 years. Several reasons have been proposed for high levels of obesity including a shared biological vulnerability between serious mental ill health and abnormal metabolic processes, potentially compounded by unhealthy lifestyles. However, emerging evidence suggests that the most significant cause of weight gain is the metabolic side effects of antipsychotic medication, usual treatment for people with serious mental ill health. In this paper we review the prevalence of obesity in people with serious mental ill health, explore the contribution that antipsychotic medication may make to weight gain and discuss the implications of this data for future research and the practice of mental health and other professionals.

  4. When to start renal replacement therapy in critically ill patients with acute kidney injury: comment on AKIKI and ELAIN.

    PubMed

    Bagshaw, Sean M; Lamontagne, François; Joannidis, Michael; Wald, Ron

    2016-01-01

    The dilemma of whether and when to start renal replacement therapy among critically ill patients with acute kidney injury in the absence of conventional indications has long been a vexing challenge for clinicians. The lack of high-quality evidence has undoubtedly contributed decisional uncertainty and unnecessary practice variation. Recently, two randomized trials (ELAIN and AKIKI) reported specifically on the issue of the timing of initiation of renal replacement therapy in critically ill patients with acute kidney injury. In this commentary, their fundamental differences in trial design, sample size, and widely discrepant findings are considered in context. While both trials are important contributions towards informing practice on this issue, additional evidence from large multicenter randomized trials is needed. PMID:27495159

  5. Why a second look might be worth it: immuno-modulatory therapies in the critically ill patient.

    PubMed

    Siegler, Benedikt H; Brenner, Thorsten; Uhle, Florian; Weiterer, Sebastian; Weigand, Markus A; Hofer, Stefan

    2016-06-01

    Sepsis and septic shock are associated with high mortality rates and remain a serious menace for the critically ill patient. Concurrent activation of pro- and anti-inflammatory pathways and an excessive cytokine release represent initial key features in the deregulation of the humoral and cellular antimicrobial defense. Research of the last decades addressed both the ebullient inflammation as well as the resulting long-term failure of the host immunity. While the reestablishment of an adequate immune-competence is still under investigation, many promising experimental trials to limit the inflammatory response during sepsis were challenged by missing beneficial effects in clinical studies. Nevertheless, due to advanced knowledge about the complex regulation of inflammatory mediators and their overlapping involvement in other potentially life-threatening diseases, further evaluation of these approaches in relevant subgroups could help to identify critically ill patients with potential benefit from anti-inflammatory therapies. PMID:27293871

  6. Why a second look might be worth it: immuno-modulatory therapies in the critically ill patient

    PubMed Central

    Siegler, Benedikt H.; Brenner, Thorsten; Uhle, Florian; Weiterer, Sebastian; Weigand, Markus A.

    2016-01-01

    Sepsis and septic shock are associated with high mortality rates and remain a serious menace for the critically ill patient. Concurrent activation of pro- and anti-inflammatory pathways and an excessive cytokine release represent initial key features in the deregulation of the humoral and cellular antimicrobial defense. Research of the last decades addressed both the ebullient inflammation as well as the resulting long-term failure of the host immunity. While the reestablishment of an adequate immune-competence is still under investigation, many promising experimental trials to limit the inflammatory response during sepsis were challenged by missing beneficial effects in clinical studies. Nevertheless, due to advanced knowledge about the complex regulation of inflammatory mediators and their overlapping involvement in other potentially life-threatening diseases, further evaluation of these approaches in relevant subgroups could help to identify critically ill patients with potential benefit from anti-inflammatory therapies. PMID:27293871

  7. Pseudallescheria boydii with Aspergillus fumigatus and Aspergillus terreus in a Critically Ill Hematopoietic Stem Cell Recipient with ARDS.

    PubMed

    Lahmer, Tobias; Messer, Marlena; Ehmer, Ursula; Eser, Stefan; Beitz, Analena; Fekecs, Lisa; Schmid, Roland M; Huber, Wolfgang

    2016-04-01

    Pseudallescheria boydii is a fungal organism known to affect immunocompromised patients. This organism is known to cause, in severe cases, invasive infection of various organs such as the central nervous, cardiovascular, and respiratory systems. We report an unusual case of pulmonary P. boydii pneumonia in an immunocompromised critically ill patient with a co-infection of Aspergillus fumigatus and Aspergillus terreus with ARDS. This case highlights the importance of a high index of suspicion for superimposed fungal infections in patients who are critically ill and immunocompromised. Uncommon fungal pathogens should be considered in the differential diagnosis of respiratory failure, especially if diagnostic markers such as galactomannan (from BAL and serum) or 1,3-beta-D-glucan are elevated. Further diagnostic interventions are warranted when insufficient clinical improvement is observed to prevent treatment failure and adverse outcomes. PMID:26455910

  8. The effect of pathophysiology on pharmacokinetics in the critically ill patient--concepts appraised by the example of antimicrobial agents.

    PubMed

    Blot, Stijn I; Pea, Federico; Lipman, Jeffrey

    2014-11-20

    Critically ill patients are at high risk for development of life-threatening infection leading to sepsis and multiple organ failure. Adequate antimicrobial therapy is pivotal for optimizing the chances of survival. However, efficient dosing is problematic because pathophysiological changes associated with critical illness impact on pharmacokinetics of mainly hydrophilic antimicrobials. Concentrations of hydrophilic antimicrobials may be increased because of decreased renal clearance due to acute kidney injury. Alternatively, antimicrobial concentrations may be decreased because of increased volume of distribution and augmented renal clearance provoked by systemic inflammatory response syndrome, capillary leak, decreased protein binding and administration of intravenous fluids and inotropes. Often multiple conditions that may influence pharmacokinetics are present at the same time thereby excessively complicating the prediction of adequate concentrations. In general, conditions leading to underdosing are predominant. Yet, since prediction of serum concentrations remains difficult, therapeutic drug monitoring for individual fine-tuning of antimicrobial therapy seems the way forward. PMID:25038549

  9. Relationship between glycated hemoglobin, Intensive Care Unit admission blood sugar and glucose control with ICU mortality in critically ill patients

    PubMed Central

    Mahmoodpoor, Ata; Hamishehkar, Hadi; Shadvar, Kamran; Beigmohammadi, Mohammadtaghi; Iranpour, Afshin; Sanaie, Sarvin

    2016-01-01

    Background and Aims: The association between hyperglycemia and mortality is believed to be influenced by the presence of diabetes mellitus (DM). In this study, we evaluated the effect of preexisting hyperglycemia on the association between acute blood glucose management and mortality in critically ill patients. The primary objective of the study was the relationship between HbA1c and mortality in critically ill patients. Secondary objectives of the study were relationship between Intensive Care Unit (ICU) admission blood glucose and glucose control during ICU stay with mortality in critically ill patients. Materials and Methods: Five hundred patients admitted to two ICUs were enrolled. Blood sugar and hemoglobin A1c (HbA1c) concentrations on ICU admission were measured. Age, sex, history of DM, comorbidities, Acute Physiology and Chronic Health Evaluation II score, sequential organ failure assessment score, hypoglycemic episodes, drug history, mortality, and development of acute kidney injury and liver failure were noted for all patients. Results: Without considering the history of diabetes, nonsurvivors had significantly higher HbA1c values compared to survivors (7.25 ± 1.87 vs. 6.05 ± 1.22, respectively, P < 0.001). Blood glucose levels in ICU admission showed a significant correlation with risk of death (P < 0.006, confidence interval [CI]: 1.004–1.02, relative risk [RR]: 1.01). Logistic regression analysis revealed that HbA1c increased the risk of death; with each increase in HbA1c level, the risk of death doubled. However, this relationship was not statistically significant (P: 0.161, CI: 0.933–1.58, RR: 1.2). Conclusions: Acute hyperglycemia significantly affects mortality in the critically ill patients; this relation is also influenced by chronic hyperglycemia. PMID:27076705

  10. Albumin concentration significantly impacts on free teicoplanin plasma concentrations in non-critically ill patients with chronic bone sepsis.

    PubMed

    Brink, A J; Richards, G A; Lautenbach, E E G; Rapeport, N; Schillack, V; van Niekerk, L; Lipman, J; Roberts, J A

    2015-06-01

    The impact of decreased serum albumin concentrations on free antibiotic concentrations in non-critically ill patients is poorly described. This study aimed to describe the pharmacokinetics of a high-dose regimen of teicoplanin, a highly protein-bound antibiotic, in non-critically ill patients with hypoalbuminaemia. Ten patients with chronic bone sepsis and decreased serum albumin concentrations (<35 g/L) receiving teicoplanin 12 mg/kg 12-hourly intravenously for 48 h followed by 12 mg/kg once daily were enrolled. Surgical debridement was performed on Day 3. Samples of venous blood were collected pre-infusion and post-infusion during the first 4 days of therapy. Total and free teicoplanin concentrations were assayed using validated chromatographic methods. The median serum albumin concentration for the cohort was 18 (IQR 15-24) g/L. After 48 h, the median (IQR) free trough (fC(min)) and total trough (tC(min)) concentrations were 2.90 (2.67-3.47) mg/L and 15.54 (10.28-19.12) mg/L, respectively, although trough concentrations declined thereafter. Clearance of the free concentrations was significantly high relative to the total fraction at 38.6 (IQR 29.9-47.8) L/h and 7.0 (IQR 6.8-9.8) L/h, respectively (P<0.001). Multiple linear regression analysis demonstrated that whereas total teicoplanin concentration did not impact on free concentrations (P=0.174), albumin concentration did (P<0.001). This study confirms the significant impact of hypoalbuminaemia on free concentrations of teicoplanin in non-critically ill patients, similar to that in critically ill patients. Furthermore, the poor correlation with total teicoplanin concentration suggests that therapeutic drug monitoring of free concentrations should be used in these patients. PMID:25819167

  11. Granulocytic myeloid-derived suppressor cells inversely correlate with plasma arginine and overall survival in critically ill patients

    PubMed Central

    Gey, A; Tadie, J-M; Caumont-Prim, A; Hauw-Berlemont, C; Cynober, L; Fagon, J-Y; Terme, M; Diehl, J-L; Delclaux, C; Tartour, E

    2015-01-01

    Critically ill patients display a state of immunosuppression that has been attributed in part to decreased plasma arginine concentrations. However, we and other authors have failed to demonstrate a clinical benefit of L-arginine supplementation. We hypothesize that, in these critically ill patients, these low plasma arginine levels may be secondary to the presence of granulocytic myeloid-derived suppressor cells (gMDSC), which express arginase known to convert arginine into nitric oxide (NO) and citrulline. Indeed, in a series of 28 non-surgical critically ill patients, we showed a dramatic increase in gMDSC compared to healthy subjects (P = 0·0002). A significant inverse correlation was observed between arginine levels and gMDSC (P = 0·01). As expected, gMDSC expressed arginase preferentially in these patients. Patients with high gMDSC levels on admission to the medical intensive care unit (MICU) presented an increased risk of death at day 7 after admission (P = 0·02). In contrast, neither plasma arginine levels, monocytic MDSC levels nor neutrophil levels were associated with overall survival at day 7. No relationship was found between body mass index (BMI) or simplified acute physiology score (SAPS) score, sequential organ failure assessment (SOFA) score or gMDSC levels, eliminating a possible bias concerning the direct prognostic role of these cells. As gMDSC exert their immunosuppressive activity via multiple mechanisms [production of prostaglandin E2 (PGE2), interleukin (IL)-10, arginase, etc.], it may be more relevant to target these cells, rather than simply supplementing with L-arginine to improve immunosuppression and its clinical consequences observed in critically ill patients. PMID:25476957

  12. Intensive care for the cancer patient - unique clinical and ethical challenges and outcome prediction in the critically ill cancer patient.

    PubMed

    Wigmore, Timothy James; Farquhar-Smith, Paul; Lawson, Andrew

    2013-12-01

    With the rising number of cancer cases and increasing survival times, cancer patients with critical illness are increasingly presenting to the intensive care unit. This article considers the unique challenges they pose in terms of oncological-specific disease processes and treatment and reviews current trends in outcome prediction. We also consider the ethical standpoints surrounding the treatment of patients for whom there may be no cure and their subsequent transition to palliative care, should it become necessary. PMID:24267556

  13. Fluconazole dosing predictions in critically-ill patients receiving prolonged intermittent renal replacement therapy: a Monte Carlo simulation approach.

    PubMed

    Gharibian, Katherine N; Mueller, Bruce A

    2016-07-01

    Fluconazole is a renally-eliminated antifungal commonly used to treat Candida species infections. In critically-ill patients receiving prolonged intermittent renal replacement therapy (PIRRT), limited pharmacokinetic (PK) data are available to guide fluconazole dosing. We used previously-published fluconazole clearance data and PK data of critically-ill patients with acute kidney injury to develop a PK model with the goal of determining a therapeutic dosing regimen for critically-ill patients receiving PIRRT. Monte Carlo simulations were performed to create a virtual cohort of patients receiving different fluconazole dosing regimens. Plasma drug concentration-time profiles were evaluated on the probability of attaining a mean 24-hour area under the drug concentration-time curve to minimum inhibitory concentration ratio (AUC24h : MIC) of 100 during the initial 48 hours of antifungal therapy. At the susceptibility breakpoint of Candida albicans (2 mg/L), 93 - 96% of simulated subjects receiving PIRRT attained the pharmacodynamic target with a fluconazole 800-mg loading dose plus 400 mg twice daily (q12h or pre and post PIRRT) regimen. Monte Carlo simulations of a PK model of PIRRT provided a basis for the development of an informed fluconazole dosing recommendation when PK data was limited. This finding should be validated in the clinical setting. PMID:27251341

  14. How to deal with burden of critical illness: A comparison of strategies in different areas of China

    PubMed Central

    Liu, Pengcheng; Jiang, Liwen; Li, Chengyue; Sun, Mei; Rieger, Alexander; Hao, Mo

    2014-01-01

    Objectives: This article aims to introduce, compare and analyze the design and development of Critical Illness Insurance systems in different parts of China under different social and economic conditions, to explain their characteristics and similarities. It may provide references to other countries, especially developing countries, to solve the problem of high medical costs. Methods: According to the methods in Comparative Economics, 3 areas (Taicang in Jiangsu, Zhanjiang in Guangdong, Xunyi in Shanxi) which are in high, medium and low socio-economic condition respectively were chosen in China. Their critical illness insurance systems were analyzed in the study. Results: Each system shares several common points, including coordinating urban and rural medical insurance fund, financing from the basic medical insurance surplus, and exploring payment reform and so on. But in the way of management, Taicang and Zhanjiang cooperate with commercial insurance agencies, but Xunyi chooses autonomous management by government. In Xunyi, multi-channel financing is relatively more dispersed, while funds of Taicang and Zhanjiang are mainly from the basic medical insurance surplus. The specific method of payment is different among these three areas. Conclusion: Because of the differences in economic development, population structure, and sources of funds, each area took their own mode on health policy orientation, financing, payment, coverage, and fund management to design their Critical Illness Insurance systems. This might provide references to other areas in China and other developing countries in the world. PMID:24948999

  15. Acute Kidney Injury Classification for Critically Ill Cirrhotic Patients: A Comparison of the KDIGO, AKIN, and RIFLE Classifications

    PubMed Central

    Pan, Heng-Chih; Chien, Yu-Shan; Jenq, Chang-Chyi; Tsai, Ming-Hung; Fan, Pei-Chun; Chang, Chih-Hsiang; Chang, Ming-Yang; Tian, Ya-Chung; Fang, Ji-Tseng; Yang, Chih-Wei; Chen, Yung-Chang

    2016-01-01

    Critically ill cirrhotic patients have high mortality rates, particularly when they present with acute kidney injury (AKI) on admission. The Kidney Disease: Improving Global Outcomes (KDIGO) group aimed to standardize the definition of AKI and recently published a new AKI classification. However, the efficacy of the KDIGO classification for predicting outcomes of critically ill cirrhotic patients is unclear. We prospectively enrolled 242 cirrhotic patients from a 10-bed specialized hepatogastroenterology intensive care unit (ICU) in a 2000-bed tertiary-care referral hospital. Demographic parameters and clinical variables on day 1 of admission were prospectively recorded. The overall in-hospital mortality rate was 62.8%. Liver diseases were usually attributed to hepatitis B viral infection (26.9%). The major cause of ICU admission was upper gastrointestinal bleeding (38.0%). Our result showed that the KDIGO classification had better discriminatory power than RIFLE and AKIN criteria in predicting in-hospital mortality. Cumulative survival rates at the 6-month after hospital discharge differed significantly between patients with and without AKI on ICU admission day. In summary, we identified that the outcome prediction performance of KDIGO classification is superior to that of AKIN or RIFLE classification in critically ill cirrhotic patients. PMID:26983372

  16. Challenges and Potential Solutions – Individualised Antibiotic Dosing at the Bedside for Critically Ill Patients: a structured review

    PubMed Central

    Roberts, Jason A.; Aziz, Mohd Hafiz Abdul; Lipman, Jeffrey; Mouton, Johan W.; Vinks, Alexander A.; Felton, Timothy W.; Hope, William W.; Farkas, Andras; Neely, Michael N.; Schentag, Jerome J.; Drusano, George; Frey, Otto R.; Theuretzbacher, Ursula; Kuti, Joseph L.

    2014-01-01

    Summary Infections in critically ill patients are associated with persistently poor clinical outcomes. These patients have severely altered and variable antibiotic pharmacokinetics and are infected by less susceptible pathogens. Antibiotic dosing that does not account for these features is likely to result in sub-optimal outcomes. In this paper, we review the patient- and pathogen-related challenges that contribute to inadequate antibiotic dosing and discuss how a process for individualised antibiotic therapy, that increases the accuracy of dosing, can be implemented to further optimise care for the critically ill patient. The process for optimised antibiotic dosing firstly requires determination of the physiological derangements in the patient that can alter antibiotic concentrations including altered fluid status, microvascular failure, serum albumin concentrations as well as altered renal and hepatic function. Secondly, knowledge of the susceptibility of the infecting pathogen should be determined through liaison with the microbiology laboratory. The patient and pathogen challenges can then be solved by combining susceptibility data with measured antibiotic concentration data (where possible) into a clinical dosing software. Such software uses pharmacokinetic-pharmacodynamic (PK/PD) models from critically ill patients to accurately predict the dosing requirements for the individual patient with the aim of optimising antibiotic exposure and maximising effectiveness. PMID:24768475

  17. Serum Levels of TNF Receptor Ligands Are Dysregulated in Sepsis and Predict Mortality in Critically Ill Patients

    PubMed Central

    Roderburg, Christoph; Benz, Fabian; Schüller, Florian; Pombeiro, Ines; Hippe, Hans-Joerg; Frey, Norbert; Trautwein, Christian; Luedde, Tom; Koch, Alexander; Tacke, Frank; Luedde, Mark

    2016-01-01

    Introduction TNF superfamily members, including TNF-related weak inducer of apoptosis (TWEAK) and Glucocorticoid-Induced TNFR-Related Protein Ligand (GITRL) have been described as serum based biomarkers for inflammatory and immune mediated diseases. However, up to now the role of TWEAK and GITRL has not been analyzed in critical illness and sepsis. Methods GITRL and TWEAK serum concentrations were measured in 121 critically ill patients (84 fulfilled with septic disease), in comparison to 50 healthy controls. Results were correlated with clinical data. Results Serum levels of TWEAK and GITRL were strongly decreased in critically ill patients compared with healthy controls. Concentrations of TWEAK (but not GITRL) were further decreased in patients with sepsis and correlated with routinely used markers of inflammation and bacterial infection such as C-reactive protein, procalcitonin and Interleukin-6. Notably, we failed to detect a correlation to other TNFR ligands such as TNF or APRIL. Finally, TWEAK levels of the upper quartile of the cohort were prognostic for mortality during ICU treatment. Conclusion TWEAK and GITRL levels were lower in intensive care unit medical patients. Levels of TWEAK were further decreased in septic patients, and alterations in TWEAK concentrations were linked to an unfavorable outcome. Together with recently published results on other TNFR ligands, these data indicate specific functions of the different TNFR ligands in septic diseases. PMID:27124414

  18. Meanings of Being Critically Ill in a Sound-Intensive ICU Patient Room - A Phenomenological Hermeneutical Study

    PubMed Central

    Johansson, Lotta; Bergbom, Ingegerd; Lindahl, Berit

    2012-01-01

    The aim of this study was to illuminate the meanings of being critically ill in a sound-intensive ICU patient room, as disclosed through patients’ narratives. Patient rooms in ICUs are filled with loud activity and studies have revealed sound levels comparable to those of a busy road above the patient’s head. There is a risk that the sound or noise is disturbing and at worst a major problem for the patient, but there is a lack of knowledge concerning the patients’ own experiences. Thirteen patients were asked to narrate their experiences of the sound environment in ICU patient rooms. The interviews were analyzed using a phenomenological- hermeneutical method inspired by the philosophy of Ricoeur. Six themes emerged from the analysis. Conclusion: The meanings of being a patient in a sound- intensive environment were interpreted as never knowing what to expect next regarding noise, but also of being situated in the middle of an uncontrollable barrage of noise, unable to take cover or disappear. This condition is not to be seen as static; for some patients there is movement and change over time. The meanings indicate that the unpredictable shifts between silence and disturbing sounds stress the critically ill patient and impede sleep and recovery. Our findings indicate the need to reduce disturbing and unexpected sounds and noise around critically ill patients in high-tech environments in order to facilitate wellbeing, sleep and recovery. Nurses have a vital role in developing such an environment. PMID:22977654

  19. How severe is antibiotic pharmacokinetic variability in critically ill patients and what can be done about it?

    PubMed

    Felton, T W; Hope, W W; Roberts, J A

    2014-08-01

    The pharmacokinetics (PK) of antimicrobial agents administered to critically ill patients exhibit marked variability. This variability results from pathophysiological changes that occur in critically ill patients. Changes in volume of distribution, clearance, and tissue penetration all affect the drug concentrations at the site of infection. PK-pharmacodynamic indices (fCmax:MIC; AUC0-24:MIC; fT>MIC; fCmin:MIC) for both antimicrobial effect and suppression of emergence of resistance are described for many antimicrobial drugs. Changing the regimen by which antimicrobial drugs are delivered can help overcome the PK variability and optimise target attainment. This will deliver optimised antimicrobial chemotherapy to individual critically ill patients. Delivery of β-lactams antimicrobial agents by infusions, rather than bolus dosing, is effective at increasing the duration of the dosing interval that the drug concentration is above the MIC. Therapeutic drug monitoring, utilising population PK mathematical models with Bayesian estimation, can also be used to optimise regimens following measurement of plasma drug concentrations. Clinical trials are required to establish if patient outcomes can be improved by implementing these techniques. PMID:24985764

  20. Has Stewart approach improved our ability to diagnose acid-base disorders in critically ill patients?

    PubMed

    Masevicius, Fabio D; Dubin, Arnaldo

    2015-02-01

    conventional methods. Although the introduction of the Stewart approach was a new insight into acid-base physiology, the method has not significantly improved our ability to understand, diagnose, and treat acid-base alterations in critically ill patients. PMID:25685724

  1. New Regimen for Continuous Infusion of Vancomycin in Critically Ill Patients.

    PubMed

    Cristallini, Stefano; Hites, Maya; Kabtouri, Hakim; Roberts, Jason A; Beumier, Marjorie; Cotton, Frederic; Lipman, Jeffrey; Jacobs, Frédérique; Vincent, Jean-Louis; Creteur, Jacques; Taccone, Fabio Silvio

    2016-08-01

    Despite the development of new agents with activity against Gram-positive bacteria, vancomycin remains one of the primary antibiotics for critically ill septic patients. Because sepsis can alter antimicrobial pharmacokinetics, the development of an appropriate dosing strategy to provide adequate concentrations is crucial. The aim of this study was to prospectively validate a new dosing regimen of vancomycin given by continuous infusion (CI) to septic patients. We included all adult septic patients admitted to a mixed intensive care unit (ICU) between January 2012 and May 2013, who were treated with a new vancomycin CI regimen consisting of a loading dose of 35 mg/kg of body weight given as a 4-h infusion, followed by a daily CI dose adapted to creatinine clearance (CrCL), as estimated by the Cockcroft-Gault formula (median dose, 2,112 [1,500 to 2,838] mg). Vancomycin concentrations were measured at the end of the loading dose (T1), at 12 h (T2), at 24 h (T3), and the day after the start of therapy (T4). Vancomycin concentrations of 20 to 30 mg/liter at T2, T3, and T4 were considered adequate. A total of 107 patients (72% male) were included. Median age, weight, and CrCL were 59 (interquartile range [IQR], 48 to 71) years, 75 (IQR, 65 to 85) kg, and 94 (IQR, 56 to 140) ml/min, respectively. Vancomycin concentrations were 44 (IQR, 37 to 49), 25 (IQR, 21 to 32), 22 (IQR, 19 to 28), and 26 (IQR, 22 to 29) mg/liter at T1, T2, T3, and T4, respectively. Concentrations were adequate in 56% (60/107) of patients at T2, in 54% (57/105) at T3, and in 73% (41/56) at T4. This vancomycin regimen permitted rapid attainment of target concentrations in serum for most patients. Concentrations were insufficient in only 16% of patients at 12 h of treatment. PMID:27216073

  2. Septic versus non-septic acute kidney injury in critically ill patients: characteristics and clinical outcomes

    PubMed Central

    Cruz, Marília Galvão; Dantas, João Gabriel Athayde de Oliveira; Levi, Talita Machado; Rocha, Mário de Seixas; de Souza, Sérgio Pinto; Boa-Sorte, Ney; de Moura, Carlos Geraldo Guerreiro; Cruz, Constança Margarida Sampaio

    2014-01-01

    Objective This study aimed to describe and compare the characteristics and clinical outcomes of patients with septic and non-septic acute kidney injury. Methods This study evaluated an open cohort of 117 critically ill patients with acute kidney injury who were consecutively admitted to an intensive care unit, excluding patients with a history of advanced-stage chronic kidney disease, kidney transplantation, hospitalization or death in a period shorter than 24 hours. The presence of sepsis and in-hospital death were the exposure and primary variables in this study, respectively. A confounding analysis was performed using logistic regression. Results No significant differences were found between the mean ages of the groups with septic and non-septic acute kidney injury [65.30±21.27 years versus 66.35±12.82 years, respectively; p=0.75]. In the septic and non-septic acute kidney injury groups, a predominance of females (57.4% versus 52.4%, respectively; p=0.49) and Afro-descendants (81.5% versus 76.2%, respectively; p=0.49) was observed. Compared with the non-septic patients, the patients with sepsis had a higher mean Acute Physiology and Chronic Health Evaluation II score [21.73±7.26 versus 15.75±5.98; p<0.001)] and a higher mean water balance (p=0.001). Arterial hypertension (p=0.01) and heart failure (p<0.001) were more common in the non-septic patients. Septic acute kidney injury was associated with a greater number of patients who required dialysis (p=0.001) and a greater number of deaths (p<0.001); however, renal function recovery was more common in this group (p=0.01). Sepsis (OR: 3.88; 95%CI: 1.51-10.00) and an Acute Physiology and Chronic Health Evaluation II score >18.5 (OR: 9.77; 95%CI: 3.73-25.58) were associated with death in the multivariate analysis. Conclusion Sepsis was an independent predictor of death. Significant differences were found between the characteristics and clinical outcomes of patients with septic versus non-septic acute kidney

  3. Evaluation of a model for glycemic prediction in critically ill surgical patients.

    PubMed

    Pappada, Scott M; Cameron, Brent D; Tulman, David B; Bourey, Raymond E; Borst, Marilyn J; Olorunto, William; Bergese, Sergio D; Evans, David C; Stawicki, Stanislaw P A; Papadimos, Thomas J

    2013-01-01

    We evaluated a neural network model for prediction of glucose in critically ill trauma and post-operative cardiothoracic surgical patients. A prospective, feasibility trial evaluating a continuous glucose-monitoring device was performed. After institutional review board approval, clinical data from all consenting surgical intensive care unit patients were converted to an electronic format using novel software. This data was utilized to develop and train a neural network model for real-time prediction of serum glucose concentration implementing a prediction horizon of 75 minutes. Glycemic data from 19 patients were used to "train" the neural network model. Subsequent real-time simulated testing was performed in 5 patients to whom the neural network model was naive. Performance of the model was evaluated by calculating the mean absolute difference percent (MAD%), Clarke Error Grid Analysis, and calculation of the percent of hypoglycemic (≤70 mg/dL), normoglycemic (>70 and <150 mg/dL), and hyperglycemic (≥150 mg/dL) values accurately predicted by the model; 9,405 data points were analyzed. The models successfully predicted trends in glucose in the 5 test patients. Clark Error Grid Analysis indicated that 100.0% of predictions were clinically acceptable with 87.3% and 12.7% of predicted values falling within regions A and B of the error grid respectively. Overall model error (MAD%) was 9.0% with respect to actual continuous glucose modeling data. Our model successfully predicted 96.7% and 53.6% of the normo- and hyperglycemic values respectively. No hypoglycemic events occurred in these patients. Use of neural network models for real-time prediction of glucose in the surgical intensive care unit setting offers healthcare providers potentially useful information which could facilitate optimization of glycemic control, patient safety, and improved care. Similar models can be implemented across a wider scale of biomedical variables to offer real-time optimization

  4. High dose tigecycline in critically ill patients with severe infections due to multidrug-resistant bacteria

    PubMed Central

    2014-01-01

    Introduction The high incidence of multidrug-resistant (MDR) bacteria among patients admitted to ICUs has determined an increase of tigecycline (TGC) use for the treatment of severe infections. Many concerns have been raised about the efficacy of this molecule and increased dosages have been proposed. Our purpose is to investigate TGC safety and efficacy at higher than standard doses. Methods We conducted a retrospective study of prospectively collected data in the ICU of a teaching hospital in Rome. Data from all patients treated with TGC for a microbiologically confirmed infection were analyzed. The safety profile and efficacy of high dosing regimen use were investigated. Results Over the study period, 54 patients (pts) received TGC at a standard dose (SD group: 50 mg every 12 hours) and 46 at a high dose (HD group: 100 mg every 12 hours). Carbapenem-resistant Acinetobacter.baumannii (blaOXA-58 and blaOXA-23 genes) and Klebsiella pneumoniae (blaKPC-3 gene) were the main isolated pathogens (n = 79). There were no patients requiring TGC discontinuation or dose reduction because of adverse events. In the ventilation-associated pneumonia population (VAP) subgroup (63 patients: 30 received SD and 33 HD), the only independent predictor of clinical cure was the use of high tigecycline dose (odds ratio (OR) 6.25; 95% confidence interval (CI) 1.59 to 24.57; P = 0.009) whilst initial inadequate antimicrobial treatment (IIAT) (OR 0.18; 95% CI 0.05 to 0.68; P = 0.01) and higher Sequential Organ Failure Assessment (SOFA) score (OR 0.66; 95% CI 0.51 to 0.87; P = 0.003) were independently associated with clinical failure. Conclusions TGC was well tolerated at a higher than standard dose in a cohort of critically ill patients with severe infections. In the VAP subgroup the high-dose regimen was associated with better outcomes than conventional administration due to Gram-negative MDR bacteria. PMID:24887101

  5. Physicians’ Decision Making Roles for an Acutely Unstable Critically and Terminally Ill Patient

    PubMed Central

    Uy, Jamie; White, Douglas B.; Mohan, Deepika; Arnold, Robert M.; Barnato, Amber E.

    2013-01-01

    Background There is substantial variation in use of life sustaining technologies in patients near the end of life but little is known about variation in physicians’ initial ICU admission and intubation decision making processes. Objective To describe variation in hospital-based physicians’ communication behaviors and decision making roles for ICU admission and intubation decisions for an acutely unstable critically and terminally ill patient. Methods We conducted a secondary analysis of transcribed simulation encounters from a multi-center observational study of physician decision making. The simulation depicted a 78 year-old man with metastatic gastric cancer and life threatening hypoxia. He has stable underlying preferences against ICU admission and intubation that he or his wife will report if asked. We coded encounters for communication behaviors (providing medical information, eliciting preferences/values, engaging the patient/surrogate in deliberation, and providing treatment recommendations) and used a previously-developed framework to classify subject physicians into four mutually-exclusive decision-making roles: informative (providing medical information only), facilitative (information + eliciting preferences/values + guiding surrogate to apply preferences/values), collaborative (information + eliciting + guiding + making a recommendation) and directive (making an independent treatment decision). Subjects 24 emergency physicians, 37 hospitalists, and 37 intensivists from 3 US academic medical centers. Results Subject physicians average 12.4 (SD 9.0) years since graduation from medical school. 38/98(39%) physicians sent the patient to the ICU, and 9/98(9%) ultimately decided to intubate. Most (93/98 (95%)) provided at least some medical information, but few explained the short-term prognosis with (26/98 (27%)) or without intubation (37/98 (38%)). Many (80/98 (82%)) elicited the patient's intubation preferences, but few (35/98 (36%)) explored the

  6. Use of Methadone for Prevention of Opioid Withdrawal in Critically Ill Children

    PubMed Central

    Jeffries, Sonia A; McGloin, Rumi; Pitfield, Alexander F; Carr, Roxane R

    2012-01-01

    Background Opioids are commonly administered to critically ill children for analgesia and sedation, but many patients experience opioid withdrawal upon discontinuation. The authors’ institution developed a protocol for using methadone to prevent opioid withdrawal in children who have received morphine by continuous IV infusion for 5 days or longer in the pediatric intensive care unit (PICU). Objectives The primary objectives were to determine if opioids were tapered according to the protocol and to determine the conversion ratio for IV morphine to oral methadone that was used. Secondary objectives were to describe the methadone dosage used and the clinical outcomes, to evaluate adjustments to methadone dosing, and to report the incidence of adverse effects. Methods A retrospective analysis of charts was conducted for pediatric patients who had received morphine by continuous IV infusion for 5 days or longer followed by methadone in the PICU between May 2008 and August 2009. Validated scoring systems (the Withdrawal Assessment Tool and the State Behavioral Scale) were used to assess symptoms of withdrawal and degree of sedation, respectively. Results Forty-three patients were included in the study, with median age of 8 months (range 0.25–201 months). For 31 patients (72%), the protocol was not used, and there were no patients for whom the protocol was followed to completion. The median duration of weaning was 10 days (range 0–91 days). The conversion ratio for IV morphine to oral methadone was 1:0.78 for anticipated 5-day weaning and 1:0.98 for anticipated 10-day weaning. During the first 10 days of weaning, 18 patients (42%) experienced withdrawal symptoms. The methadone dose was increased for 11 (26%) of the 43 patients. Patients were sedated for a median of 1 day (range 0–9 days), were comfortable for a median of 6.5 days (range 1–64 days), and were agitated for a median of 2.5 days (range 0–23 days). Naloxone was required for 2 patients. Conclusions

  7. A prospective determination of the incidence of perceived inappropriate care in critically ill patients

    PubMed Central

    Singal, Rohit K; Sibbald, Robert; Morgan, Brenda; Quinlan, Mel; Parry, Neil; Radford, Michael; Martin, Claudio M

    2014-01-01

    BACKGROUND: Health care providers’ perceptions regarding appropriateness in end-of-life treatments have been widely studied. While nurses and physicians believe that rationing and other cost-related practices sometimes occur in the intensive care unit (ICU), they allege that treatment is often excessive. OBJECTIVE: To prospectively determine the incidence and causes of health care providers’ perceptions regarding appropriateness of end-of-life treatments. METHODS: The present prospective study collected data from patients admitted to the medical-surgical trauma ICU of a 30-bed, Canadian teaching hospital over a three-month period. Daily surveys were completed independently by bedside nurses, charge nurses and attending physician. RESULTS: In total, 5224 of 6558 expected surveys (representing 294 patients) were analyzed, yielding a response rate of 79.7%. The incidence of perceived inappropriate care in the present study was 6.5% (19 of 294 patients), with ongoing treatment for >2 days after this determination occurring in 1% (three of 294 patients). However, at least one caregiver perceived inappropriate care at some point in 110 of 294 (37.5%) patients. In these cases, in which processes to address care were not already underway, respondents believed that important issues resulting in provision of inappropriate treatments included patient-family issues and communication before or in the ICU. Caregivers did not know their patients’ wishes 22% (1129 of 5224) of the time. CONCLUSIONS: Although ongoing inappropriate care appeared to be a rare occurrence, the issue was a concern to at least one caregiver in one-third of cases. Public awareness for end-of-life issues, adequate communication, and up-to-date knowledge and practice in determining the wishes of critically ill patients are potential target areas to improve end-of-life care and reduce inappropriate care in the ICU. A daily, prospective survey of multidisciplinary caregivers, such as the survey used in

  8. Use of subjective global assessment and clinical outcomes in critically ill geriatric patients receiving nutrition support.

    PubMed

    Atalay, Betül Gülsen; Yagmur, Cahide; Nursal, Tarik Zafer; Atalay, Hakan; Noyan, Turgut

    2008-01-01

    The objective of this study is to examine the prevalence of malnutrition and evaluate the nutrition status and clinical outcome in hospitalized patients aged 65 years and older receiving enteral-parenteral nutrition. This retrospective study was carried out at Başkent University Hospital, Adana, Turkey. A total of 119 patients older than 65 years were recruited. Patients were classified into 3 groups: protein-energy malnutrition (PEM), moderate PEM, and well nourished according to subjective global assessment (SGA) at admission. All patients were fed by enteral or parenteral route. Acute physiological and chronic health evaluation (APACHE-2) and simplified acute physiology (SAPS 2) scores were recorded in patients followed in the intensive care unit (ICU). Nutrition status was assessed with biochemical (serum albumin, serum prealbumin) parameters. These results were compared with mortality rate and length of hospital stay (LOS). The subjects' mean (+/-SD) age was 73.1 +/- 5.4 years. Using SGA, 5.9% (n = 7) of the patients were classified as severely PEM, 27.7% (n = 33) were classified as moderately PEM, and 66.4% (n = 79) were classified as well nourished. Some 73.1% (n = 87) of the patients were followed in the ICU. Among all patients, 42.9% (n = 51) were fed by a combined enteral-parenteral route, 31.1% (n = 37) by an enteral route, 18.5% (n = 22) by a parenteral route, and 7.6% (n = 9) by an oral route. The average length of stay for the patients was 18.9 +/- 13.7 days. The mortality rate was 44.5% (n = 53). The mortality rate was 43% (n = 34) in well-nourished patients (n = 79), 48.5% (n = 16) in moderately PEM patients (n = 33), and 42.9% (n = 3) in severely PEM patients (n = 7) (P = .86). The authors observed no difference between well-nourished and malnourished patients with regard to the serum protein values on admission, LOS, and mortality rate. In this study, malnutrition as defined by SGA did not influence the mortality rate of critically ill geriatric

  9. Economics of dialysis dependence following renal replacement therapy for critically ill acute kidney injury patients

    PubMed Central

    Ethgen, Olivier; Schneider, Antoine G.; Bagshaw, Sean M.; Bellomo, Rinaldo; Kellum, John A.

    2015-01-01

    dependence among critically ill AKI survivors. PMID:25326472

  10. Multimorbidity in elderly hospitalised patients and risk of Clostridium difficile infection: a retrospective study with the Cumulative Illness Rating Scale (CIRS)

    PubMed Central

    Ticinesi, Andrea; Nouvenne, Antonio; Folesani, Giuseppina; Prati, Beatrice; Morelli, Ilaria; Guida, Loredana; Turroni, Francesca; Ventura, Marco; Lauretani, Fulvio; Maggio, Marcello; Meschi, Tiziana

    2015-01-01

    Objectives To identify the role of chronic comorbidities, considered together in a literature-validated index (Cumulative Illness Rating Scale, CIRS), and antibiotic or proton-pump inhibitor (PPI) treatments as risk factors for hospital-acquired Clostridium difficile infection (CDI) in elderly multimorbid hospitalised patients. Design Retrospective cohort study. Setting Subacute hospital geriatric care ward in Italy. Participants 505 (238 male (M), 268 female (F)) elderly (age ≥65) multimorbid patients. Main outcome measures The relationship between CDI and CIRS Comorbidity Score, number of comorbidities, antibiotic, antifungal and PPI treatments, and length of hospital stay was assessed through age-adjusted and sex-adjusted and multivariate logistic regression models. The CIRS Comorbidity Score was handled after categorisation in quartiles. Results Mean age was 80.7±11.3 years. 43 patients (22 M, 21 F) developed CDI. The prevalence of CDI increased among quartiles of CIRS Comorbidity Score (3.9% first quartile vs 11.1% fourth quartile, age-adjusted and sex-adjusted p=0.03). In the multivariate logistic regression analysis, patients in the highest quartile of CIRS Comorbidity Score (≥17) carried a significantly higher risk of CDI (OR 5.07, 95% CI 1.28 to 20.14, p=0.02) than patients in the lowest quartile (<9). The only other variable significantly associated with CDI was antibiotic therapy (OR 2.62, 95% CI 1.21 to 5.66, p=0.01). PPI treatment was not associated with CDI. Conclusions Multimorbidity, measured through CIRS Comorbidity Score, is independently associated with the risk of CDI in a population of elderly patients with prolonged hospital stay. PMID:26503394

  11. The Impact of Macro-and Micronutrients on Predicting Outcomes of Critically Ill Patients Requiring Continuous Renal Replacement Therapy

    PubMed Central

    Somlaw, Nicha; Lakananurak, Narisorn; Dissayabutra, Thasinas; Phonork, Chayanat; Leelahavanichkul, Asada; Tiranathanagul, Khajohn; Susantithapong