Pharyngeal oxygen administration increases the time to serious desaturation at intubation in acute lung injury: an experimental study

PubMed Central

2010-01-01

Introduction Endotracheal intubation in critically ill patients is associated with severe life-threatening complications in about 20%, mainly due to hypoxemia. We hypothesized that apneic oxygenation via a pharyngeal catheter during the endotracheal intubation procedure would prevent or increase the time to life-threatening hypoxemia and tested this hypothesis in an acute lung injury animal model. Methods Eight anesthetized piglets with collapse-prone lungs induced by lung lavage were ventilated with a fraction of inspired oxygen of 1.0 and a positive end-expiratory pressure of 5 cmH2O. The shunt fraction was calculated after obtaining arterial and mixed venous blood gases. The trachea was extubated, and in randomized order each animal received either 10 L oxygen per minute or no oxygen via a pharyngeal catheter, and the time to desaturation to pulse oximeter saturation (SpO2) 60% was measured. If SpO2 was maintained at over 60%, the experiment ended when 10 minutes had elapsed. Results Without pharyngeal oxygen, the animals desaturated after 103 (88-111) seconds (median and interquartile range), whereas with pharyngeal oxygen five animals had a SpO2 > 60% for the 10-minute experimental period, one animal desaturated after 7 minutes, and two animals desaturated within 90 seconds (P < 0.016, Wilcoxon signed rank test). The time to desaturation was related to shunt fraction (R2 = 0.81, P = 0.002, linear regression); the animals that desaturated within 90 seconds had shunt fractions >40%, whereas the others had shunt fractions <25%. Conclusions In this experimental acute lung injury model, pharyngeal oxygen administration markedly prolonged the time to severe desaturation during apnea, suggesting that this technique might be useful when intubating critically ill patients with acute respiratory failure. PMID:20497538

Board-invited review: Using behavior to predict and identify ill health in animals.

PubMed

Weary, D M; Huzzey, J M; von Keyserlingk, M A G

2009-02-01

We review recent research in one of the oldest and most important applications of ethology: evaluating animal health. Traditionally, such evaluations have been based on subjective assessments of debilitative signs; animals are judged ill when they appear depressed or off feed. Such assessments are prone to error but can be dramatically improved with training using well-defined clinical criteria. The availability of new technology to automatically record behaviors allows for increased use of objective measures; automated measures of feeding behavior and intake are increasingly available in commercial agriculture, and recent work has shown these to be valuable indicators of illness. Research has also identified behaviors indicative of risk of disease or injury. For example, the time spent standing on wet, concrete surfaces can be used to predict susceptibility to hoof injuries in dairy cattle, and time spent nuzzling the udder of the sow can predict the risk of crushing in piglets. One conceptual advance has been to view decreased exploration, feeding, social, sexual, and other behaviors as a coordinated response that helps afflicted individuals recover from illness. We argue that the sickness behaviors most likely to decline are those that provide longer-term fitness benefits (such as play), as animals divert resources to those functions of critical short-term value such as maintaining body temperature. We urge future research assessing the strength of motivation to express sickness behaviors, allowing for quantitative estimates of how sick an animal feels. Finally, we call for new theoretical and empirical work on behaviors that may act to signal health status, including behaviors that have evolved as honest (i.e., reliable) signals of condition for offspring-parent, inter- and intra-sexual, and predator-prey communication.

The experience of critically ill children: A phenomenological study of discomfort and comfort.

PubMed

Carnevale, Franco A; Gaudreault, Josée

2013-01-01

Emerging evidence indicates that critically ill children are particularly at risk for incurring significant psychological harm. Little is known about these children's actual experiences. The aim of the study was to examine children's experience of critical illness. The research question was: What are a critically ill child's sources of discomfort and comfort? Interpretive phenomenology was selected as the study's method. Children's accounts were examined to identify what they considered meaningful, in terms of their experienced discomfort and comfort. Data sources included formal and informal interviews with child-participants, drawings provided by some participants, and field-notes documenting observed non-verbal data. Twelve children were enrolled in the study, ranging from 3 to 17years of age; including four girls and eight boys. Although all participants were able to discuss the discomfort and comfort they experienced, they reported difficulties in remembering part or most of their experience. Some participants characterized their Pediatric Intensive Care Unit stay quite favourably or as "not that bad", while some described their experience unfavourably. Diverse types of discomforts were reported, including fears and worries, hurt and pain, invasive interventions, missing significant people, noise, food or eating problems, boredom, physical symptoms, as well as four additional discomforts reported by individual participants. Several sources of comfort were described, including parents, visitors and friends, hospital staff (principally nurses), stuffed animal/favourite blanket, entertainment and play, food, selected medical interventions, thinking of going home, being able to walk or run, sleep, waking up, gifts, along with two other comforts reported by individual participants. Embodiment and a tension between aloneness and being with were identified as the principal phenomena underlying these children's experiences. The findings complement existing knowledge regarding the psychological impact of critical illness by highlighting how children regard specific phenomena as discomforting or comforting. This sheds light on future directions for practice and research development in pediatric critical care.

Carboxyhemoglobin levels in medical intensive care patients: a retrospective, observational study

PubMed Central

2012-01-01

Introduction Critical illness leads to increased endogenous production of carbon monoxide (CO) due to the induction of the stress-response enzyme, heme oxygenase-1 (HO-1). There is evidence for the cytoprotective and anti-inflammatory effects of CO based on animal studies. In critically ill patients after cardiothoracic surgery, low minimum and high maximum carboxyhemoglobin (COHb) levels were shown to be associated with increased mortality, which suggests that there is an 'optimal range' for HO-1 activity. Our study aimed to test whether this relationship between COHb and outcome exists in non-surgical ICU patients. Methods We conducted a retrospective, observational study in a medical ICU at a university hospital in Vienna, Austria involving 868 critically ill patients. No interventions were undertaken. Arterial COHb was measured on admission and during the course of treatment in the ICU. The association between arterial COHb levels and ICU mortality was evaluated using bivariate tests and a logistic regression model. Results Minimum COHb levels were slightly lower in non-survivors compared to survivors (0.9%, 0.7% to 1.2% versus 1.2%, 0.9% to 1.5%; P = 0.0001), and the average COHb levels were marginally lower in non-survivors compared to survivors (1.5%, 1.2% to 1.8% versus 1.6%, 1.4% to 1.9%, P = 0.003). The multivariate logistic regression analysis revealed that the association between a low minimum COHb level and increased mortality was independent of the severity of illness and the type of organ failure. Conclusions Critically ill patients surviving the admission to a medical ICU had slightly higher minimum and marginally higher average COHb levels when compared to non-survivors. Even though the observed differences are statistically significant, the minute margins would not qualify COHb as a predictive marker for ICU mortality. PMID:22236404

Carboxyhemoglobin levels in medical intensive care patients: a retrospective, observational study.

PubMed

Fazekas, Andreas S; Wewalka, Marlene; Zauner, Christian; Funk, Georg-Christian

2012-01-11

Critical illness leads to increased endogenous production of carbon monoxide (CO) due to the induction of the stress-response enzyme, heme oxygenase-1 (HO-1). There is evidence for the cytoprotective and anti-inflammatory effects of CO based on animal studies. In critically ill patients after cardiothoracic surgery, low minimum and high maximum carboxyhemoglobin (COHb) levels were shown to be associated with increased mortality, which suggests that there is an 'optimal range' for HO-1 activity. Our study aimed to test whether this relationship between COHb and outcome exists in non-surgical ICU patients. We conducted a retrospective, observational study in a medical ICU at a university hospital in Vienna, Austria involving 868 critically ill patients. No interventions were undertaken. Arterial COHb was measured on admission and during the course of treatment in the ICU. The association between arterial COHb levels and ICU mortality was evaluated using bivariate tests and a logistic regression model. Minimum COHb levels were slightly lower in non-survivors compared to survivors (0.9%, 0.7% to 1.2% versus 1.2%, 0.9% to 1.5%; P=0.0001), and the average COHb levels were marginally lower in non-survivors compared to survivors (1.5%, 1.2% to 1.8% versus 1.6%, 1.4% to 1.9%, P=0.003). The multivariate logistic regression analysis revealed that the association between a low minimum COHb level and increased mortality was independent of the severity of illness and the type of organ failure. Critically ill patients surviving the admission to a medical ICU had slightly higher minimum and marginally higher average COHb levels when compared to non-survivors. Even though the observed differences are statistically significant, the minute margins would not qualify COHb as a predictive marker for ICU mortality.

Assessment of adrenocortical reserve capacity and inflammatory parameters in critically ill dogs.

PubMed

Csöndes, Judit; Fábián, Ibolya; Szabó, Bernadett; Máthé, Ákos; Vajdovich, Péter

2017-12-01

Inflammatory markers and adrenocorticotropic hormone (ACTH) stimulation test results may help us recognise critically ill dogs with poor disease outcome. Systemic inflammatory response syndrome (SIRS) criteria, the fast version of the Acute Patient Physiologic and Laboratory Evaluation Score (APPLE fast ), complete blood count, albumin and C-reactive protein (CRP) levels, baseline and stimulated cortisol levels and Δcortisol value were recorded in 50 client-owned dogs admitted to the Small Animal Hospital of the University of Veterinary Medicine Budapest with various inflammatory or neoplastic conditions. Increasing APPLE fast score was associated with a decreasing chance of survival (P = 0.0420). The Δcortisol value was significantly higher in SIRS dogs than in non-SIRS dogs (mean ± SD Δcortisol SIRS : 342.5 ± 273.96; mean ± SD Δcortisol non-SIRS : 175.3 ± 150.35; P = 0.0443). Elevated baseline or stimulated cortisol levels were associated with a higher chance of non-survival (P = 0.0135 and P = 0.0311, respectively). These data indicate that pathologically higher baseline and stimulated cortisol levels represent an exaggerated stress response in critically ill dogs, which is negatively associated with survival.

Anemia of Inflammation: A Review

PubMed Central

Fraenkel, Paula G.

2016-01-01

Impaired iron homeostasis and the suppressive effects of proinflammatory cytokines on erythropoiesis, together with alterations of the erythrocyte membrane that impair its survival, cause the anemia of inflammation. Recent epidemiologic studies have connected inflammatory anemia with critical illness, obesity, aging, and kidney failure, as well as with cancer, chronic infection, and autoimmune disease. The proinflammatory cytokine, interleukin-6, the iron regulatory hormone, hepcidin, and the iron exporter, ferroportin, interact to cause iron sequestration in the setting of inflammation. While severe anemia is associated with adverse outcomes in critical illness, experimental models suggest that iron sequestration is part of a natural defense against pathogens. In animal models and human patients, experimental therapeutic approaches targeting interleukin-6 or the ferroportin-hepcidin axis have shown efficacy in reversing anemia, although these agents have not yet been approved for the treatment of the anemia of inflammation. PMID:28189171

Development of an Immunoassay for the Kidney Specific Protein myo-Inositol Oxygenase, a Potential Biomarker of Acute Kidney Injury

PubMed Central

Gaut, Joseph P.; Crimmins, Dan L.; Ohlendorf, Matt F.; Lockwood, Christina M.; Griest, Terry A.; Brada, Nancy A.; Hoshi, Masato; Sato, Bryan; Hotchkiss, Richard S.; Jain, Sanjay; Ladenson, Jack H.

2014-01-01

Background Acute kidney injury (AKI) affects 45% of critically ill patients resulting in increased morbidity and mortality. The diagnostic standard, serum creatinine (SCr), is non-specific and may not increase until days after injury. There is significant need for a renal specific AKI biomarker detectable early enough that there would be a potential window for therapeutic intervention. In this study, we sought to identify a renal specific biomarker of AKI. Methods Gene expression data was analyzed from normal mouse tissues to identify kidney specific genes, one of which was Miox. Monoclonal antibodies were generated to recombinant myo-inositol oxygenase (MIOX), and an immunoassay was developed to quantify MIOX in plasma. The immunoassay was tested in animals and retrospectively in patients with and without AKI. Results Kidney tissue specificity of MIOX was supported by Western blot. Immunohistochemistry localized MIOX to the proximal renal tubule. Plasma MIOX, undetectable at baseline, increased 24 hours following AKI in mice. Plasma MIOX was increased in critically ill patients with AKI (12.4 ± 4.3 ng/mL, n=42) compared with patients without AKI (0.5 ± 0.3 ng/mL, n=17) and was highest in patients with oliguric AKI (20.2 ± 7.5 ng/mL, n=23). Plasma MIOX increased 54.3 ± 3.8 hours before the increase in SCr. Conclusions MIOX is a renal specific, proximal tubule protein that is increased in plasma of animals and critically ill patients with AKI. MIOX preceded the elevation in SCr by approximately two days in human patients. Large-scale studies are warranted to further investigate MIOX as an AKI biomarker. PMID:24486646

Foodborne illness: new developments concerning an old problem.

PubMed

Kasowski, Eric J; Gackstetter, Gary D; Sharp, Trueman W

2002-08-01

Foodborne illnesses continue to cause substantial morbidity and mortality in the United States, primarily as gastroenteritis but occasionally as other syndromes as well. Most of these illnesses are caused by a variety of widely known infectious agents, principally viruses, and are probably the result of common mistakes in food handling in the home or in restaurants. The epidemiology of foodborne illness is evolving. Major changes in food production, distribution, and consumption have created opportunities for new pathogens to emerge and for old ones to reemerge, and the potential for widespread outbreaks is increasing. Antibiotic resistance in bacterial pathogens resulting from the widespread use of antimicrobial agents in animal husbandry is also an important concern. Clinicians must be aware of the changing epidemiology of foodborne illness to recognize and manage these conditions in the clinical setting. In addition, clinicians are critical in the reporting of recognized or suspected foodborne illness, so that public health authorities are able to investigate, understand, and ultimately better control them. A number of new techniques have been employed, and others under development will improve our ability to recognize and cope with foodborne diseases.

Critical illness polyneuropathy and myopathy: a systematic review

PubMed Central

Zhou, Chunkui; Wu, Limin; Ni, Fengming; Ji, Wei; Wu, Jiang; Zhang, Hongliang

2014-01-01

Critical illness polyneuropathy and critical illness myopathy are frequent complications of severe illness that involve sensorimotor axons and skeletal muscles, respectively. Clinically, they manifest as limb and respiratory muscle weakness. Critical illness polyneuropathy/myopathy in isolation or combination increases intensive care unit morbidity via the inability or difficulty in weaning these patients off mechanical ventilation. Many patients continue to suffer from decreased exercise capacity and compromised quality of life for months to years after the acute event. Substantial progress has been made lately in the understanding of the pathophysiology of critical illness polyneuropathy and myopathy. Clinical and ancillary test results should be carefully interpreted to differentiate critical illness polyneuropathy/myopathy from similar weaknesses in this patient population. The present review is aimed at providing the latest knowledge concerning the pathophysiology of critical illness polyneuropathy/myopathy along with relevant clinical, diagnostic, differentiating, and treatment information for this debilitating neurological disease. PMID:25206749

Proliferation and differentiation of adipose tissue in prolonged lean and obese critically ill patients.

PubMed

Goossens, Chloë; Vander Perre, Sarah; Van den Berghe, Greet; Langouche, Lies

2017-12-01

In prolonged non-obese critically ill patients, preservation of adipose tissue is prioritized over that of the skeletal muscle and coincides with increased adipogenesis. However, we recently demonstrated that in obese critically ill mice, this priority was switched. In the obese, the use of abundantly available adipose tissue-derived energy substrates was preferred and counteracted muscle wasting. These observations suggest that different processes are ongoing in adipose tissue of lean vs. overweight/obese critically ill patients. We hypothesize that to preserve adipose tissue mass during critical illness, adipogenesis is increased in prolonged lean critically ill patients, but not in overweight/obese critically ill patients, who enter the ICU with excess adipose tissue. To test this, we studied markers of adipogenesis in subcutaneous and visceral biopsies of matched lean (n = 24) and overweight/obese (n = 24) prolonged critically ill patients. Secondly, to further unravel the underlying mechanism of critical illness-induced adipogenesis, local production of eicosanoid PPARγ agonists was explored, as well as the adipogenic potential of serum from matched lean (n = 20) and overweight/obese (n = 20) critically ill patients. The number of small adipocytes, PPARγ protein, and CEBPB expression were equally upregulated (p ≤ 0.05) in subcutaneous and visceral adipose tissue biopsies of lean and overweight/obese prolonged critically ill patients. Gene expression of key enzymes involved in eicosanoid production was reduced (COX1, HPGDS, LPGDS, ALOX15, all p ≤ 0.05) or unaltered (COX2, ALOX5) during critical illness, irrespective of obesity. Gene expression of PLA2G2A and ALOX15B was upregulated in lean and overweight/obese patients (p ≤ 0.05), whereas their end products, the PPARγ-activating metabolites 15s-HETE and 9-HODE, were not increased in the adipose tissue. In vitro, serum of lean and overweight/obese prolonged critically ill patients equally stimulated adipocyte proliferation (p ≤ 0.05) and differentiation (lipid accumulation, DLK1, and CEBPB expression, p ≤ 0.05). Contrary to what was hypothesized, adipogenesis increased independently of initial BMI in prolonged critically ill patients. Not the production of local eicosanoid PPARγ agonists but circulating adipogenic factors seem to be involved in critical illness-induced adipogenesis. Importantly, our findings suggest that abundantly available energy substrates from the adipose tissue, rather than excess adipocytes, can play a beneficial role during critical illness.

Persistent inflammation, immunosuppression, and catabolism and the development of chronic critical illness after surgery.

PubMed

Efron, Philip A; Mohr, Alicia M; Bihorac, Azra; Horiguchi, Hiroyuki; Hollen, McKenzie K; Segal, Mark S; Baker, Henry V; Leeuwenburgh, Christiaan; Moldawer, Lyle L; Moore, Frederick A; Brakenridge, Scott C

2018-05-25

As early as the 1990s, chronic critical illness, a distinct syndrome of persistent high-acuity illness requiring management in the ICU, was reported under a variety of descriptive terms including the "neuropathy of critical illness," "myopathy of critical illness," "ICU-acquired weakness," and most recently "post-intensive care unit syndrome." The widespread implementation of targeted shock resuscitation, improved organ support modalities, and evidence-based protocolized ICU care has resulted in significantly decreased in-hospital mortality within surgical ICUs, specifically by reducing early multiple organ failure deaths. However, a new phenotype of multiple organ failure has now emerged with persistent but manageable organ dysfunction, high resource utilization, and discharge to prolonged care facilities. This new multiple organ failure phenotype is now clinically associated with the rapidly increasing incidence of chronic critical illness in critically ill surgery patients. Although the underlying pathophysiology driving chronic critical illness remains incompletely described, the persistent inflammation, immunosuppression, and catabolism syndrome has been proposed as a mechanistic framework in which to explain the increased incidence of chronic critical illness in surgical ICUs. The purpose of this review is to provide a historic perspective of the epidemiologic evolution of multiple organ failure into persistent inflammation, immunosuppression, and catabolism syndrome; describe the mechanism that drives and sustains chronic critical illness, and review the long-term outcomes of surgical patients who develop chronic critical illness. Copyright © 2018 Elsevier Inc. All rights reserved.

Comparison of piperacillin exposure in the lungs of critically ill patients and healthy volunteers.

PubMed

Felton, T W; Ogungbenro, K; Boselli, E; Hope, W W; Rodvold, K A

2018-01-29

Severe infections of the respiratory tracts of critically ill patients are common and associated with excess morbidity and mortality. Piperacillin is commonly used to treat pulmonary infections in critically ill patients. Adequate antibiotic concentration in the epithelial lining fluid (ELF) of the lung is essential for successful treatment of pulmonary infection. To compare piperacillin pharmacokinetics/pharmacodynamics in the serum and ELF of healthy volunteers and critically ill patients. Piperacillin concentrations in the serum and ELF of healthy volunteers and critically ill patients were compared using population methodologies. Median piperacillin exposure was significantly higher in the serum and the ELF of critically ill patients compared with healthy volunteers. The IQR for serum piperacillin exposure in critically ill patients was six times greater than for healthy volunteers. The IQR for piperacillin exposure in the ELF of critically ill patients was four times greater than for healthy volunteers. The median pulmonary piperacillin penetration ratio was 0.31 in healthy volunteers and 0.54 in critically ill patients. Greater variability in serum and ELF piperacillin concentrations is observed in critically ill patients compared with healthy adult subjects and must be considered in the development of dosage regimens. Pulmonary penetration of antimicrobial agents should be studied in critically ill patients, as well as healthy volunteers, during drug development to ensure appropriate dosing of patients with pneumonia. © The Author(s) 2018. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Tracheal Tube Design and Ventilator-Associated Pneumonia.

PubMed

Rouzé, Anahita; Jaillette, Emmanuelle; Poissy, Julien; Préau, Sébastien; Nseir, Saad

2017-10-01

Microaspiration of contaminated oropharyngeal and gastric secretions is the main mechanism for ventilator-associated pneumonia (VAP) in critically ill patients. Improving the performance of tracheal tubes in reducing microaspiration is one potential means to prevent VAP. The aim of this narrative review is to discuss recent findings on the impact of tracheal tube design on VAP prevention. Several randomized controlled studies have reported that subglottic secretion drainage (SSD) is efficient in VAP prevention. Meta-analyses have reported conflicting results regarding the impact of SSD on duration of mechanical ventilation, and one animal study raised concern about SSD-related tracheal lesions. However, this measure appears to be cost-effective. Therefore, SSD should probably be used in all patients with expected duration of mechanical ventilation > 48 h. Three randomized controlled trials have shown that tapered-cuff tracheal tubes are not useful to prevent VAP and should probably not be used in critically ill patients. Further studies are required to confirm the promising effects of continuous control of cuff pressure, polyurethane-cuffed, silver-coated, and low-volume low-pressure tracheal tubes. There is moderate evidence for the use of SSD and strong evidence against the use of tapered-cuff tracheal tubes in critically ill patients for VAP prevention. However, more data on the safety and cost-effectiveness of these measures are needed. Other tracheal tube-related preventive measures require further investigation. Copyright © 2017 by Daedalus Enterprises.

Dependency in Critically Ill Patients

PubMed Central

Yang, Rumei

2016-01-01

By necessity, critically ill patients admitted to intensive care units (ICUs) have a high level of dependency, which is linked to a variety of negative feelings, such as powerlessness. However, the term dependency is not well defined in the critically ill patients. The concept of “dependency” in critically ill patients was analyzed using a meta-synthesis approach. An inductive process described by Deborah Finfgeld-Connett was used to analyze the data. Overarching themes emerged that reflected critically ill patients’ experience and meaning of being in dependency were (a) antecedents: dependency in critically ill patients was a powerless and vulnerable state, triggered by a life-threatening crisis; (b) attributes: the characteristic of losing “self” was featured by dehumanization and disembodiment, which can be alleviated by a “self”-restoring process; and (c) outcomes: living with dependency and coping with dependency. The conceptual model explicated here may provide a framework for understanding dependency in critically ill patients. PMID:28462328

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

Skeletal Muscle Ultrasonography in Nutrition and Functional Outcome Assessment of Critically Ill Children: Experience and Insights From Pediatric Disease and Adult Critical Care Studies [Formula: see text].

PubMed

Ong, Chengsi; Lee, Jan Hau; Leow, Melvin K S; Puthucheary, Zudin A

2017-09-01

Evidence suggests that critically ill children develop muscle wasting, which could affect outcomes. Muscle ultrasound has been used to track muscle wasting and association with outcomes in critically ill adults but not children. This review aims to summarize methodological considerations of muscle ultrasound, structural findings, and possibilities for its application in the assessment of nutrition and functional outcomes in critically ill children. Medline, Embase, and CINAHL databases were searched up until April 2016. Articles describing skeletal muscle ultrasound in children and critically ill adults were analyzed qualitatively for details on techniques and findings. Thickness and cross-sectional area of various upper and lower body muscles have been studied to quantify muscle mass and detect muscle changes. The quadriceps femoris muscle is one of the most commonly measured muscles due to its relation to mobility and is sensitive to changes over time. However, the margin of error for quadriceps thickness is too wide to reliably detect muscle changes in critically ill children. Muscle size and its correlation with strength and function also have not yet been studied in critically ill children. Echogenicity, used to detect compromised muscle structure in neuromuscular disease, may be another property worth studying in critically ill children. Muscle ultrasound may be useful in detecting muscle wasting in critically ill children but has not been shown to be sufficiently reliable in this population. Further study of the reliability and correlation with functional outcomes and nutrition intake is required before muscle ultrasound is routinely employed in critically ill children.

Oral intake evaluation in patients following critical illness: an ICU cohort study.

PubMed

Jarden, Rebecca J; Sutton-Smith, Lynsey; Boulton, Catherine

2018-04-16

Timely and adequate nutrition improves health outcomes for the critically ill patient. Despite clinical guidelines recommending early oral nutrition, survivors of critical illness experience significant nutritional deficits. This cohort study evaluates the oral nutrition intake in intensive care unit (ICU) patients who have experienced recent critical illness. The oral nutrition intake of a convenience sample of ICU patients post-critical illness was observed during a 1-month period. Data pertaining to both the amount of oral nutrition intake and factors impacting optimal oral nutrition intake were collected and analysed. Inadequate oral intake was identified in 62% of the 79 patients assessed (n = 49). This was noted early in the ICU stay, around day 1-2, for most of the patients. A significant proportion (25%) of patients remained in the hospital with poor oral intake that persisted beyond ICU day 5. Unsurprisingly, these were the patients who had longer ICU stays. Critical illness weakness was a factor in the assessment of poor oral intake. To conclude, patients who have experienced critical illness also experience suboptimal oral nutrition. The three key factors that were identified as impacting optimal oral nutrition were early removal of nasogastric tubes, critical illness weakness and poor appetite post-critical illness. Seven key recommendations are made based on this cohort study. These recommendations are related to patient assessment, monitoring, documentation and future guidelines. Future research opportunities are highlighted, including the investigation of strategies to improve the transition of patients' post-critical illness to oral nutrition. © 2018 British Association of Critical Care Nurses.

Healthcare Disparities in Critical Illness

PubMed Central

Soto, Graciela J.; Martin, Greg S.; Gong, Michelle Ng

2013-01-01

Objective To summarize the current literature on racial and gender disparities in critical care and the mechanisms underlying these disparities in the course of acute critical illness. Data Sources MEDLINE search on the published literature addressing racial, ethnic, or gender disparities in acute critical illness such as sepsis, acute lung injury, pneumonia, venous thromboembolism, and cardiac arrest. Study Selection Clinical studies that evaluated general critically ill patient populations in the United States as well as specific critical care conditions were reviewed with a focus on studies evaluating factors and contributors to health disparities. Data Extraction Study findings are presented according to their association with the incidence, clinical presentation, management, and outcomes in acute critical illness. Data Synthesis This review presents potential contributors for racial and gender disparities related to genetic susceptibility, comorbidities, preventive health services, socioeconomic factors, cultural differences, and access to care. The data is organized along the course of acute critical illness. Conclusions The literature to date shows that disparities in critical care are most likely multifactorial involving individual, community, and hospital-level factors at several points in the continuum of acute critical illness. The data presented identify potential targets as interventions to reduce disparities in critical care and future avenues for research. PMID:24121467

Healthcare disparities in critical illness.

PubMed

Soto, Graciela J; Martin, Greg S; Gong, Michelle Ng

2013-12-01

To summarize the current literature on racial and gender disparities in critical care and the mechanisms underlying these disparities in the course of acute critical illness. MEDLINE search on the published literature addressing racial, ethnic, or gender disparities in acute critical illness, such as sepsis, acute lung injury, pneumonia, venous thromboembolism, and cardiac arrest. Clinical studies that evaluated general critically ill patient populations in the United States as well as specific critical care conditions were reviewed with a focus on studies evaluating factors and contributors to health disparities. Study findings are presented according to their association with the prevalence, clinical presentation, management, and outcomes in acute critical illness. This review presents potential contributors for racial and gender disparities related to genetic susceptibility, comorbidities, preventive health services, socioeconomic factors, cultural differences, and access to care. The data are organized along the course of acute critical illness. The literature to date shows that disparities in critical care are most likely multifactorial involving individual, community, and hospital-level factors at several points in the continuum of acute critical illness. The data presented identify potential targets as interventions to reduce disparities in critical care and future avenues for research.

Nitrogen Balance and Protein Requirements for Critically Ill Older Patients.

PubMed

Dickerson, Roland N

2016-04-18

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.

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

Early-life experiences and the development of adult diseases with a focus on mental illness: The Human Birth Theory.

PubMed

Maccari, Stefania; Polese, Daniela; Reynaert, Marie-Line; Amici, Tiziana; Morley-Fletcher, Sara; Fagioli, Francesca

2017-02-07

In mammals, early adverse experiences, including mother-pup interactions, shape the response of an individual to chronic stress or to stress-related diseases during adult life. This has led to the elaboration of the theory of the developmental origins of health and disease, in particular adult diseases such as cardiovascular and metabolic disorders. In addition, in humans, as stated by Massimo Fagioli's Human Birth Theory, birth is healthy and equal for all individuals, so that mental illness develop exclusively in the postnatal period because of the quality of the relationship in the first year of life. Thus, this review focuses on the importance of programming during the early developmental period on the manifestation of adult diseases in both animal models and humans. Considering the obvious differences between animals and humans we cannot systematically move from animal models to humans. Consequently, in the first part of this review, we will discuss how animal models can be used to dissect the influence of adverse events occurring during the prenatal and postnatal periods on the developmental trajectories of the offspring, and in the second part, we will discuss the role of postnatal critical periods on the development of mental diseases in humans. Epigenetic mechanisms that cause reversible modifications in gene expression, driving the development of a pathological phenotype in response to a negative early postnatal environment, may lie at the core of this programming, thereby providing potential new therapeutic targets. The concept of the Human Birth Theory leads to a comprehension of the mental illness as a pathology of the human relationship immediately after birth and during the first year of life. Copyright © 2016 IBRO. Published by Elsevier Ltd. All rights reserved.

Risk of type 2 diabetes mellitus in patients with acute critical illness: a population-based cohort study.

PubMed

Hsu, Chin-Wang; Lin, Chin-Sheng; Chen, Sy-Jou; Lin, Shih-Hua; Lin, Cheng-Li; Kao, Chia-Hung

2016-01-01

This large population-based cohort study evaluated the association between certain critical illnesses and the incidence of newly diagnosed type 2 diabetes mellitus (T2DM) in Taiwan. Data were obtained from the Taiwan National Health Insurance Research Database. According to age, sex, and propensity score-matching, a cohort comprising 9528 patients with critical illness, including septicemia, septic shock, acute myocardial infarction (AMI), and stroke, and a control cohort of 9528 patients with no critical illness were identified. Cox proportional-hazard regression and competing-risk regression models were employed to evaluate the risk of developing T2DM. With the median follow-up periods (interquartile range) of 3.86 (1.64-6.93) and 5.12 (2.51-8.13) years for the patients in the critical illness and control cohorts, respectively, the risk of developing T2DM in the critical illness cohort was significantly higher than in the control cohort (adjusted hazard ratio, aHR = 1.32; 95% confidence interval, CI 1.16-1.50). In the multivariate competing-risk regression models, the aHR of T2DM was 1.58 (95% CI 1.45-1.72) in the critical illness cohort. Moreover, among the patients with these critical illnesses, those with septicemia or septic shock exhibited the highest risk of developing T2DM (aHR = 1.51, 95% CI 1.37-1.67), followed by AMI compared with the control cohort. Our results suggest that patients with certain critical illnesses are associated with a high risk of developing T2DM. Clinicians should be aware of this association and intensively screen for T2DM in patients following diagnosis of critical illness.

Targeted temperature management in the ICU: guidelines from a French expert panel.

PubMed

Cariou, Alain; Payen, Jean-François; Asehnoune, Karim; Audibert, Gerard; Botte, Astrid; Brissaud, Olivier; Debaty, Guillaume; Deltour, Sandrine; Deye, Nicolas; Engrand, Nicolas; Francony, Gilles; Legriel, Stéphane; Levy, Bruno; Meyer, Philippe; Orban, Jean-Christophe; Renolleau, Sylvain; Vigue, Bernard; De Saint Blanquat, Laure; Mathien, Cyrille; Velly, Lionel

2017-12-01

Over the recent period, the use of induced hypothermia has gained an increasing interest for critically ill patients, in particular in brain-injured patients. The term "targeted temperature management" (TTM) has now emerged as the most appropriate when referring to interventions used to reach and maintain a specific level temperature for each individual. TTM may be used to prevent fever, to maintain normothermia, or to lower core temperature. This treatment is widely used in intensive care units, mostly as a primary neuroprotective method. Indications are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of TTM in adult and paediatric critically ill patients developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de Réanimation de Langue Française [SRLF]) and the French Society of Anesthesia and Intensive Care Medicine (Société Francaise d'Anesthésie Réanimation [SFAR]) with the participation of the French Emergency Medicine Association (Société Française de Médecine d'Urgence [SFMU]), the French Group for Pediatric Intensive Care and Emergencies (Groupe Francophone de Réanimation et Urgences Pédiatriques [GFRUP]), the French National Association of Neuro-Anesthesiology and Critical Care (Association Nationale de Neuro-Anesthésie Réanimation Française [ANARLF]), and the French Neurovascular Society (Société Française Neurovasculaire [SFNV]). Fifteen experts and two coordinators agreed to consider questions concerning TTM and its practical implementation in five clinical situations: cardiac arrest, traumatic brain injury, stroke, other brain injuries, and shock. This resulted in 30 recommendations: 3 recommendations were strong (Grade 1), 13 were weak (Grade 2), and 14 were experts' opinions. After two rounds of rating and various amendments, a strong agreement from voting participants was obtained for all 30 (100%) recommendations, which are exposed in the present article.

Nutritional support and the role of the stress response in critically ill children.

PubMed

Joosten, Koen F M; Kerklaan, Dorian; Verbruggen, Sascha C A T

2016-05-01

Nutrition impacts outcome in critically ill children. Based on evolving neuro-endocrine, immunologic and metabolic alterations, three different phases can be proposed during the course of illness. The different phases each demand for tailored macronutrient intakes in critically ill children. Early enteral nutrition is associated with decreased morbidity and mortality, but several misconceptions concerning the provision of enteral nutrition prevent adequate intake. Parenteral nutrition in critically ill children is associated with potential disadvantages, as nosocomial infections, but evidence on the effect on clinical outcome is lacking. Nutrient restriction early during critical illness might be beneficial for short and long-term outcomes by decreasing the incidence of side-effects and possibly by amplifying the acute catabolic stress response and stimulating autophagy and muscle integrity. Higher caloric and protein intake via the enteral route are associated with higher 60-day survival, asking for a more aggressive feeding approach in subsequent phases. Understanding the stress response to critical illness and its phases is essential for nutritional recommendations in critically ill children. Although parenteral nutrient restriction during the acute phase might be beneficial, inclining requirements ask for a more aggressive approach during the stable and recovery phase to enable recovery, growth and catch-up growth.

Increasing glucose load while maintaining normoglycemia does not evoke neuronal damage in prolonged critically ill rabbits.

PubMed

Sonneville, Romain; den Hertog, Heleen M; Derde, Sarah; Güiza, Fabian; Derese, Inge; Van den Berghe, Greet; Vanhorebeek, Ilse

2013-12-01

Preventing severe hyperglycemia with insulin reduced the neuropathological alterations in frontal cortex during critical illness. We investigated the impact of increasing glucose load under normoglycemia on neurons and glial cells. Hyperinflammatory critically ill rabbits were randomized to fasting or combined parenteral nutrition containing progressively increasing amounts of glucose (low, intermediate, high) within the physiological range but with a similar amount of amino acids and lipids. In all groups, normoglycemia was maintained with insulin. On day 7, we studied the neuropathological alterations in frontal cortex neurons, astrocytes and microglia, and MnSOD as marker of oxidative stress. The percentage of damaged neurons was comparable among all critically ill and healthy rabbits. Critical illness induced an overall 1.8-fold increase in astrocyte density and activation status, largely irrespective of the nutritional intake. The percentage of microglia activation in critically ill rabbits was comparable with that in healthy rabbits, irrespective of glucose load. Likewise, MnSOD expression was comparable in critically ill and healthy rabbits without any clear impact of the nutritional interventions. During prolonged critical illness, increasing intravenous glucose infusion while strictly maintaining normoglycemia appeared safe for neuronal integrity and did not substantially affect glial cells in frontal cortex. Copyright © 2013 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

One Health and Cyanobacteria in Freshwater Systems: Animal Illnesses and Deaths Are Sentinel Events for Human Health Risks

PubMed Central

Hilborn, Elizabeth D.; Beasley, Val R.

2015-01-01

Harmful cyanobacterial blooms have adversely impacted human and animal health for thousands of years. Recently, the health impacts of harmful cyanobacteria blooms are becoming more frequently detected and reported. However, reports of human and animal illnesses or deaths associated with harmful cyanobacteria blooms tend to be investigated and reported separately. Consequently, professionals working in human or in animal health do not always communicate findings related to these events with one another. Using the One Health concept of integration and collaboration among health disciplines, we systematically review the existing literature to discover where harmful cyanobacteria-associated animal illnesses and deaths have served as sentinel events to warn of potential human health risks. We find that illnesses or deaths among livestock, dogs and fish are all potentially useful as sentinel events for the presence of harmful cyanobacteria that may impact human health. We also describe ways to enhance the value of reports of cyanobacteria-associated illnesses and deaths in animals to protect human health. Efficient monitoring of environmental and animal health in a One Health collaborative framework can provide vital warnings of cyanobacteria-associated human health risks. PMID:25903764

One health and cyanobacteria in freshwater systems: animal illnesses and deaths are sentinel events for human health risks.

PubMed

Hilborn, Elizabeth D; Beasley, Val R

2015-04-20

Harmful cyanobacterial blooms have adversely impacted human and animal health for thousands of years. Recently, the health impacts of harmful cyanobacteria blooms are becoming more frequently detected and reported. However, reports of human and animal illnesses or deaths associated with harmful cyanobacteria blooms tend to be investigated and reported separately. Consequently, professionals working in human or in animal health do not always communicate findings related to these events with one another. Using the One Health concept of integration and collaboration among health disciplines, we systematically review the existing literature to discover where harmful cyanobacteria-associated animal illnesses and deaths have served as sentinel events to warn of potential human health risks. We find that illnesses or deaths among livestock, dogs and fish are all potentially useful as sentinel events for the presence of harmful cyanobacteria that may impact human health. We also describe ways to enhance the value of reports of cyanobacteria-associated illnesses and deaths in animals to protect human health. Efficient monitoring of environmental and animal health in a One Health collaborative framework can provide vital warnings of cyanobacteria-associated human health risks.

Probiotics, prebiotics, and competitive exclusion for prophylaxis against bacterial disease

USDA-ARS?s Scientific Manuscript database

Bacteria that are pathogenic to animals and human consumers can exist in the gastrointestinal tract of our food animal species. The gastrointestinal tract of food animals can be inhabited by bacteria that cause foodborne illnesses in humans, but that do not cause detectable animal illnesses or a de...

Neutrophils in critical illness.

PubMed

McDonald, Braedon

2018-03-01

During critical illness, dramatic alterations in neutrophil biology are observed including abnormalities of granulopoeisis and lifespan, cell trafficking and antimicrobial effector functions. As a result, neutrophils transition from powerful antimicrobial protectors into dangerous mediators of tissue injury and organ dysfunction. In this article, the role of neutrophils in the pathogenesis of critical illness (sepsis, trauma, burns and others) will be explored, including pathological changes to neutrophil function during critical illness and the utility of monitoring aspects of the neutrophil phenotype as biomarkers for diagnosis and prognostication. Lastly, we review findings from clinical trials of therapies that target the harmful effects of neutrophils, providing a bench-to-bedside perspective on neutrophils in critical illness.

Diagnosis and management of iron-related anemias in critical illness.

PubMed

Pieracci, Fredric M; Barie, Philip S

2006-07-01

To review of the prevalence, pathogenesis, diagnosis, and management of iron (Fe)-related anemias in critical illness. A MEDLINE/PubMed search from 1966 to October 2005 was conducted. References from relevant articles were manually cross-referenced with additional original articles, review articles, correspondence, and chapters from selected textbooks. Both Fe metabolism and erythropoiesis are affected by the inflammatory response that accompanies critical illness. As a result, many critically ill patients develop the anemia of inflammation, which may be compounded by an underlying Fe deficiency. Most commonly available markers of total body Fe detect Fe deficiency unreliably in the setting of inflammation. Among these tests, the serum transferrin receptor assay is relatively accurate in reflecting total body Fe, regardless of inflammation. Treatment options for Fe-related anemias in critical illness include Fe replacement and recombinant human erythropoietin therapy. The decision to implement these therapies is complex and centers on a critical evaluation of ability to affect anemia, morbidity, and mortality in critical illness and on the potential risks of therapy. Fe deficiency anemia and the anemia of inflammation may co-exist in critical illness. Diagnosis of and differentiation between these two anemias involves careful interpretation of multiple markers of total body Fe stores. The utility of treatment with both Fe and recombinant human erythropoietin for these disorders during critical illness requires further investigation.

'Intensive care unit survivorship' - a constructivist grounded theory of surviving critical illness.

PubMed

Kean, Susanne; Salisbury, Lisa G; Rattray, Janice; Walsh, Timothy S; Huby, Guro; Ramsay, Pamela

2017-10-01

To theorise intensive care unit survivorship after a critical illness based on longitudinal qualitative data. Increasingly, patients survive episodes of critical illness. However, the short- and long-term impact of critical illness includes physical, psychological, social and economic challenges long after hospital discharge. An appreciation is emerging that care needs to extend beyond critical illness to enable patients to reclaim their lives postdischarge with the term 'survivorship' being increasingly used in this context. What constitutes critical illness survivorship has, to date, not been theoretically explored. Longitudinal qualitative and constructivist grounded theory. Interviews (n = 46) with 17 participants were conducted at four time points: (1) before discharge from hospital, (2) four to six weeks postdischarge, (3) six months and (4) 12 months postdischarge across two adult intensive care unit setting. Individual face-to-face interviews. Data analysis followed the principles of Charmaz's constructivist grounded theory. 'Intensive care unit survivorship' emerged as the core category and was theorised using concepts such as status passages, liminality and temporality to understand the various transitions participants made postcritical illness. Intensive care unit survivorship describes the unscheduled status passage of falling critically ill and being taken to the threshold of life and the journey to a life postcritical illness. Surviving critical illness goes beyond recovery; surviving means 'moving on' to life postcritical illness. 'Moving on' incorporates a redefinition of self that incorporates any lingering intensive care unit legacies and being in control of one's life again. For healthcare professionals and policymakers, it is important to realise that recovery and transitioning through to survivorship happen within an individual's time frame, not a schedule imposed by the healthcare system. Currently, there are no care pathways or policies in place for critical illness survivors that would support intensive care unit survivors and their families in the transitions to survivorship. © 2016 John Wiley & Sons Ltd.

Mental illness in Disney animated films.

PubMed

Lawson, Andrea; Fouts, Gregory

2004-05-01

To examine the prevalence of verbalizations about mental illness in the animated feature films of The Walt Disney Company (TWDC). We discuss the results within the context of children's repeated exposure to popular animated movies and their learning of labels and stereotypes associated with mental illness. We recommend further research on this topic. We coded 34 animated feature films produced by TWDC for mental illness references (for example, "crazy" or "nuts"). We developed a coding manual to systematize the content analysis, to ensure accuracy of the data, and to ascertain intercoder reliability. Most of the films (that is, 85%) contain verbal references to mental illness, with an average of 4.6 references per film. The references were mainly used to set apart and denigrate the characters to whom they referred. Twenty-one percent of the principal characters were referred to as mentally ill. We discuss the contributions and limitations of the study. The findings have implications for child viewers in terms of their potentially learning prejudicial attitudes and distancing behaviours toward individuals perceived as being mentally ill. To further verify this connection, an assessment of the incidence of Disney film exposure and attitudes toward people with a mental illness, using a sample of school-aged children, is needed.

Indications and contraindications for infusing specific amino acids (leucine, glutamine, arginine, citrulline, and taurine) in critical illness.

PubMed

Ginguay, Antonin; De Bandt, Jean-Pascal; Cynober, Luc

2016-03-01

The review assesses the utility of supplementing parenteral or enteral nutrition of ICU patients with each of five specific amino acids that display pharmacological properties. Specifying indications implies also stating contraindications.Combined supplementation of amino acids with ω3-fatty acids and/or trace elements (immune-enhancing diets) will not be considered in this review because these mixtures do not allow the role of amino acids in the effect (positive or negative) of the mixture to be isolated, and so cannot show whether or not supplementation of a given amino acid is indicated. After decades of unbridled use of glutamine (GLN) supplementation in critically ill patients, recent large trials have brought a note of caution, indicating for example that GLN should not be used in patients with multiple organ failure. Yet these large trials do not change the conclusions of recent meta-analyses. Arginine (ARG), as a single dietary supplement, is probably not harmful in critical illness, in particular in a situation of ARG deficiency syndrome with low nitric oxide production. Citrulline supplementation strongly improves microcirculation in animal models with gut injury, but clinical studies are lacking. Taurine has a potent protective effect against ischemic reperfusion injury. Amino acid-based pharmaconutrition has displayed familiar 'big project' stages: enthusiasm (citrulline and taurine), doubt (GLN), hunt for the guilty (ARG), and backpedalling (leucine). Progress in this field is very slow, and sometimes gives way to retreat, as demonstrated by recent large trials on GLN supplementation.

Documentation and quantitative analysis of local ethnozoological knowledge among traditional healers of Theni district, Tamil Nadu, India.

PubMed

Chellappandian, M; Pandikumar, P; Mutheeswaran, S; Gabriel Paulraj, M; Prabakaran, S; Duraipandiyan, V; Ignacimuthu, S; Al-Dhabi, N A

2014-05-28

This study investigated the use of animals among the traditional healers in Theni district of Tamil Nadu, India. The data regarding the medicinal animals/animal products were documented and their usages were analyzed quantitatively. Based on free list interviews with the traditional healers, we documented the medicinal usage of animals/animal products and calculated the indices such as informant consensus factor (Fic) to determine the consensus over the species for an illness category, as well as the Index Agreement on Remedies (IAR) to determine the extent of potential utilization of each species. In this study, 69 medicinal animals/animal products were documented with the help of standardized questionnaires among the local healers. The results were tabulated and Fic value for each illness category was calculated. Three illness categories viz., jaundice (milk of Capra aegagrus hircus), orthopedics (egg white and meat of Gallus gallus domesticus) and pediatrics (milk of Equus africanus asinus) had got high Fic values. Fifteen illness categories had moderate Fic values. Highly cited animals in these illness categories were: Rusa unicolor (antiemetic), Reticulitermes spp. (diabetes), flesh of Varanus benghalensis (oral ailments), milk (eye ailments, fever) and urine (antidote) of Homo sepians, meat of Trachypithecus johnii (respiratory ailments), various parts of C. aegagrus hircus (blood ailments, coolants, diarrhea, pulmonary and urinary ailments), flesh of Chamaeleon zeyalnica (neural ailments), meat of Passer domesticus (aphrodisiac), curd and dung of Bos primigenius taurus (dermatological ailments), meat of G. domesticus (musculo-skeletal disorders, analgesic), meat of Lissemys punctata (hemorrhoids), and Pherthima posthuma (psychological ailments). Six illness categories had low Fic values. This study indicated that the animals are still being used by the local healers of Theni district, to treat various illnesses. Cross-disciplinary approaches to explore the full potential of animal-derived medicines will help to improve the health of local people. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

The communicative role of companion pets in patient-centered critical care.

PubMed

Yamasaki, Jill

2018-05-01

This study examines a personal pet hospital visitation program dedicated to preserving the human-animal bond during chronic, critical, or terminal illness to understand the novel ways companion pets facilitate meaningful communication between patients, providers, and families in hospital settings. I thematically analyzed data collected through a variety of qualitative methods, including participant observation, informal and semi-structured interviews, and a review of organizational materials. The presence of a patient's personal pet prompted stories and behaviors characterized by (1) compassion, (2) connection, and (3) response between patients, providers, and family members. Personal pet hospital visits facilitate storied conversations, foster healing relationships, and offer alternative ways of knowing that can promote greater understandings of the patient's psychosocial context for more personalized care and improved well-being. Patient-centered critical care requires meaningful consideration of a patient's health, well-being, and comfort. When appropriate, the therapeutic benefits of companion animals and the deep personal bonds between patients and their pets should be acknowledged and provided as part of this care. Copyright © 2017 Elsevier B.V. All rights reserved.

Psychiatric diagnoses and psychoactive medication use among nonsurgical critically ill patients receiving mechanical ventilation.

PubMed

Wunsch, Hannah; Christiansen, Christian F; Johansen, Martin B; Olsen, Morten; Ali, Naeem; Angus, Derek C; Sørensen, Henrik Toft

2014-03-19

The relationship between critical illness and psychiatric illness is unclear. To assess psychiatric diagnoses and medication prescriptions before and after critical illness. Population-based cohort study in Denmark of critically ill patients in 2006-2008 with follow-up through 2009, and 2 matched comparison cohorts from hospitalized patients and from the general population. Critical illness defined as intensive care unit admission with mechanical ventilation. Adjusted prevalence ratios (PRs) of psychiatrist-diagnosed psychiatric illnesses and prescriptions for psychoactive medications in the 5 years before critical illness. For patients with no psychiatric history, quarterly cumulative incidence (risk) and adjusted hazard ratios (HRs) for diagnoses and medications in the following year, using Cox regression. Among 24,179 critically ill patients, 6.2% had 1 or more psychiatric diagnoses in the prior 5 years vs 5.4% for hospitalized patients (adjusted PR, 1.31; 95% CI, 1.22-1.42; P<.001) and 2.4% for the general population (adjusted PR, 2.57; 95% CI, 2.41-2.73; P<.001). Five-year preadmission psychoactive prescription rates were similar to hospitalized patients: 48.7% vs 48.8% (adjusted PR, 0.97; 95% CI, 0.95-0.99; P<.001) but were higher than the general population (33.2%; adjusted PR, 1.40; 95% CI, 1.38-1.42; P<.001). Among the 9912 critical illness survivors with no psychiatric history, the absolute risk of new psychiatric diagnoses was low but higher than hospitalized patients: 0.5% vs 0.2% over the first 3 months (adjusted HR, 3.42; 95% CI, 1.96-5.99; P <.001), and the general population cohort (0.02%; adjusted HR, 21.77; 95% CI, 9.23-51.36; P<.001). Risk of new psychoactive medication prescriptions was also increased in the first 3 months: 12.7% vs 5.0% for the hospital cohort (adjusted HR, 2.45; 95% CI, 2.19-2.74; P<.001) and 0.7% for the general population (adjusted HR, 21.09; 95% CI, 17.92-24.82; P<.001). These differences had largely resolved by 9 to 12 months after discharge. Prior psychiatric diagnoses are more common in critically ill patients than in hospital and general population cohorts. Among survivors of critical illness, new psychiatric diagnoses and psychoactive medication use is increased in the months after discharge. Our data suggest both a possible role of psychiatric disease in predisposing patients to critical illness and an increased but transient risk of new psychiatric diagnoses and treatment after critical illness.

External validation of a prehospital risk score for critical illness.

PubMed

Kievlan, Daniel R; Martin-Gill, Christian; Kahn, Jeremy M; Callaway, Clifton W; Yealy, Donald M; Angus, Derek C; Seymour, Christopher W

2016-08-11

Identification of critically ill patients during prehospital care could facilitate early treatment and aid in the regionalization of critical care. Tools to consistently identify those in the field with or at higher risk of developing critical illness do not exist. We sought to validate a prehospital critical illness risk score that uses objective clinical variables in a contemporary cohort of geographically and temporally distinct prehospital encounters. We linked prehospital encounters at 21 emergency medical services (EMS) agencies to inpatient electronic health records at nine hospitals in southwestern Pennsylvania from 2010 to 2012. The primary outcome was critical illness during hospitalization, defined as an intensive care unit stay with delivery of organ support (mechanical ventilation or vasopressor use). We calculated the prehospital risk score using demographics and first vital signs from eligible EMS encounters, and we tested the association between score variables and critical illness using multivariable logistic regression. Discrimination was assessed using the AUROC curve, and calibration was determined by plotting observed versus expected events across score values. Operating characteristics were calculated at score thresholds. Among 42,550 nontrauma, non-cardiac arrest adult EMS patients, 1926 (4.5 %) developed critical illness during hospitalization. We observed moderate discrimination of the prehospital critical illness risk score (AUROC 0.73, 95 % CI 0.72-0.74) and adequate calibration based on observed versus expected plots. At a score threshold of 2, sensitivity was 0.63 (95 % CI 0.61-0.75), specificity was 0.73 (95 % CI 0.72-0.73), negative predictive value was 0.98 (95 % CI 0.98-0.98), and positive predictive value was 0.10 (95 % CI 0.09-0.10). The risk score performance was greater with alternative definitions of critical illness, including in-hospital mortality (AUROC 0.77, 95 % CI 0.7 -0.78). In an external validation cohort, a prehospital risk score using objective clinical data had moderate discrimination for critical illness during hospitalization.

Exploring how nurses assess, monitor and manage acute pain for adult critically ill patients in the emergency department: protocol for a mixed methods study.

PubMed

Varndell, Wayne; Fry, Margaret; Elliott, Doug

2017-08-01

Many critically ill patients experience moderate to severe acute pain that is frequently undetected and/or undertreated. Acute pain in this patient cohort not only derives from their injury and/or illness, but also as a consequence of delivering care whilst stabilising the patient. Emergency nurses are increasingly responsible for the safety and wellbeing of critically ill patients, which includes assessing, monitoring and managing acute pain. How emergency nurses manage acute pain in critically ill adult patients is unknown. The objective of this study is to explore how emergency nurses manage acute pain in critically ill patients in the Emergency Department. In this paper, we provide a detailed description of the methods and protocol for a multiphase sequential mixed methods study, exploring how emergency nurses assess, monitor and manage acute pain in critically ill adult patients. The objective, method, data collection and analysis of each phase are explained. Justification of each method and data integration is described. Synthesis of findings will generate a comprehensive picture of how emergency nurses' perceive and manage acute pain in critically ill adult patients. The results of this study will form a knowledge base to expand theory and inform research and practice.

Does Critical Illness Change Levofloxacin Pharmacokinetics?

PubMed

Roberts, Jason A; Cotta, Menino Osbert; Cojutti, Piergiorgio; Lugano, Manuela; Della Rocca, Giorgio; Pea, Federico

2015-12-14

Levofloxacin is commonly used in critically ill patients for which existing data suggest nonstandard dosing regimens should be used. The objective of this study was to compare the population pharmacokinetics of levofloxacin in critically ill and in non-critically ill patients. Adult patients with a clinical indication for levofloxacin were eligible for participation in this prospective pharmacokinetic study. Patients were given 500 mg or 750 mg daily by intravenous administration with up to 11 blood samples taken on day 1 or 2 of therapy. Plasma samples were analyzed and population pharmacokinetic analysis was undertaken using Pmetrics. Thirty-five patients (18 critically ill) were included. The mean (standard deviation [SD]) age, weight, and Cockcroft-Gault creatinine clearance for the critically ill and for the non-critically ill patients were 60.3 (16.4) and 72.0 (11.6) years, 78.5 (14.8) and 70.9 (15.8) kg, and 71.9 (65.8) and 68.2 (30.1) ml/min, respectively. A two-compartment linear model best described the data. Increasing creatinine clearance was the only covariate associated with increasing drug clearance. The presence of critical illness did not significantly affect any pharmacokinetic parameter. The mean (SD) parameter estimates were as follows: clearance, 8.66 (3.85) liters/h; volume of the central compartment (Vc), 41.5 (24.5) liters; intercompartmental clearance constants from central to peripheral, 2.58 (3.51) liters/h; and peripheral to central compartments, 0.90 (0.58) liters/h. Monte Carlo dosing simulations demonstrated that achievement of therapeutic exposures was dependent on renal function, pathogen, and MIC. Critical illness appears to have no independent effect on levofloxacin pharmacokinetics that cannot be explained by altered renal function. Copyright © 2016, American Society for Microbiology. All Rights Reserved.

Does Critical Illness Change Levofloxacin Pharmacokinetics?

PubMed Central

Cotta, Menino Osbert; Cojutti, Piergiorgio; Lugano, Manuela; Rocca, Giorgio Della; Pea, Federico

2015-01-01

Levofloxacin is commonly used in critically ill patients for which existing data suggest nonstandard dosing regimens should be used. The objective of this study was to compare the population pharmacokinetics of levofloxacin in critically ill and in non-critically ill patients. Adult patients with a clinical indication for levofloxacin were eligible for participation in this prospective pharmacokinetic study. Patients were given 500 mg or 750 mg daily by intravenous administration with up to 11 blood samples taken on day 1 or 2 of therapy. Plasma samples were analyzed and population pharmacokinetic analysis was undertaken using Pmetrics. Thirty-five patients (18 critically ill) were included. The mean (standard deviation [SD]) age, weight, and Cockcroft-Gault creatinine clearance for the critically ill and for the non-critically ill patients were 60.3 (16.4) and 72.0 (11.6) years, 78.5 (14.8) and 70.9 (15.8) kg, and 71.9 (65.8) and 68.2 (30.1) ml/min, respectively. A two-compartment linear model best described the data. Increasing creatinine clearance was the only covariate associated with increasing drug clearance. The presence of critical illness did not significantly affect any pharmacokinetic parameter. The mean (SD) parameter estimates were as follows: clearance, 8.66 (3.85) liters/h; volume of the central compartment (Vc), 41.5 (24.5) liters; intercompartmental clearance constants from central to peripheral, 2.58 (3.51) liters/h; and peripheral to central compartments, 0.90 (0.58) liters/h. Monte Carlo dosing simulations demonstrated that achievement of therapeutic exposures was dependent on renal function, pathogen, and MIC. Critical illness appears to have no independent effect on levofloxacin pharmacokinetics that cannot be explained by altered renal function. PMID:26666946

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

The optimal blood glucose level for critically ill adult patients.

PubMed

Lv, Shaoning; Ross, Paul; Tori, Kathleen

2017-09-01

Glycaemic control is recognized as one of the important aspects in managing critically ill patients. Both hyperglycaemia and hypoglycaemia independently increase the risk of patient mortality. Hence, the identification of optimal glycaemic control is of paramount importance in the management of critically ill patients. The aim of this literature review is to examine the current status of glycaemic control in critically ill adult patients. This literature review will focus on randomized controlled trials comparing intensive insulin therapy to conventional insulin therapy, with an objective to identify optimal blood glucose level targets for critically ill adult patients. A literature review was conducted to identify large randomized controlled trials for the optimal targeted blood glucose level for critically ill adult patients published since 2000. A total of eight studies fulfilled the selection criteria of this review. With current human and technology resources, the results of the studies support commencing glycaemic control once the blood glucose level of critically ill patients reaches 10 mmol/L and maintaining this level between 8 mmol/L and 10 mmol/L. This literature review provides a recommendation for targeting the optimal blood glucose level for critically ill patients within moderate blood glucose level target range (8-10 mmol/L). The need for uniformed glucometrics for unbiased reporting and further research for optimal blood glucose target is required, especially in light of new technological advancements in closed-loop insulin delivery and monitoring devices. This literature review has revealed a need to call for consensus in the measurement and reporting of glycaemic control using standardized glucometrics. © 2017 British Association of Critical Care Nurses.

Determinants of 1-year survival in critically ill acute leukemia patients: a GRRR-OH study.

PubMed

Tavares, Márcio; Lemiale, Virginie; Mokart, Djamel; Pène, Frédéric; Lengliné, Etienne; Kouatchet, Achille; Mayaux, Julien; Vincent, François; Nyunga, Martine; Bruneel, Fabrice; Rabbat, Antoine; Lebert, Christine; Perez, Pierre; Meert, Anne-Pascale; Benoit, Dominique; Darmon, Michael; Azoulay, Elie

2018-06-01

Acute leukemia (AL) is the most common hematological malignancy requiring intensive care unit (ICU) management. Data on long-term survival are limited. This is a post hoc analysis of the prospective multicenter data from France and Belgium: A Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique [A Research Group on Acute Respiratory Failure in Onco-Hematological Patients (French)] Study, to identify determinants of 1-year survival in critically ill AL patients. A total of 278 patients were admitted in the 17 participating ICUs. Median age was 58 years and 70% had newly diagnosed leukemia. ICU mortality rate was 28.6 and 39.6% of the patients alive at 1 year. Admission for intensive monitoring was independently associated with better 1-year survival by multivariate analysis. Conversely, relapsed/refractory disease, secondary leukemia, mechanical ventilation and renal replacement therapy were independently associated with 1-year mortality. This study confirms the impact of organ dysfunction on long-term survival in ICU patients with AL. Follow-up studies to assess respiratory and renal recovery are warranted.

One Health and Cyanobacteria in Freshwater Systems: Animal Illnesses and Deaths are Sentinel Events for Human Health Risks

EPA Science Inventory

Harmful cyanobacterial blooms have adversely impacted human and animal health for thousands of years. Recently, the health impacts of harmful cyanobacteria blooms are becoming more frequently detected and reported. However, reports of human and animal illnesses or deaths associat...

Continuous hemoadsorption with a cytokine adsorber during sepsis - a review of the literature.

PubMed

Houschyar, Khosrow S; Pyles, Malcolm N; Rein, Susanne; Nietzschmann, Ina; Duscher, Dominik; Maan, Zeshaan N; Weissenberg, Kristian; Philipps, Hubertus M; Strauss, Catharina; Reichelt, Beate; Siemers, Frank

2017-05-29

Sepsis is a well-recognized healthcare issue worldwide, ultimately resulting in significant mortality, morbidity and resource utilization during and after critical illness. In its most severe form, sepsis causes multi-organ dysfunction that produces a state of critical illness characterized by severe immune dysfunction and catabolism. Sepsis induces the activation of complement factor via 3 pathways and the release of inflammatory cytokines such as tumor necrosis factor alpha (TNF-α) and interleukin-1beta (IL-1β), resulting in a systemic inflammatory response. The inflammatory cytokines and nitric oxide release induced by sepsis decrease systemic vascular resistance, resulting in profound hypotension. The combination of hypotension and microvascular occlusion results in tissue ischemia and ultimately leads to multiple organ failure. Several clinical and experimental studies have reported that treatment using adsorption of cytokines is beneficial during endotoxemia and sepsis. This review article analyzes the efficacy of CytoSorb® adsorber in reducing the inflammatory response during sepsis. The CytoSorb® adsorber is known to have excellent adsorption rates for inflammatory cytokines such as IL-1β, IL-6, IL-8, IL-10, and TNF-α. Studies have demonstrated that treatment with cytokine adsorbing columns has beneficial effects on the survival rate and inflammatory responses in animal septic models. Additionally, several cases have been reported in which treatment with cytokine adsorbing columns is very effective in hemodynamic stabilization and in preventing organ failure in critically ill patients. Although further investigations and clinical trials are needed, treatment with cytokine adsorbing columns may play an important role in the treatment of sepsis in the near future.

Large animal model for osteoporosis in humans: the ewe.

PubMed

Oheim, R; Amling, M; Ignatius, A; Pogoda, P

2012-11-12

Osteoporosis is a chronic systemic disease characterised by bone loss and microarchitectural deterioration. Since the underlying regulatory mechanisms are still not fully understood and treatment options are not satisfactorily resolved, massive efforts are underway to further investigate this critical illness. Large animal models are stipulated, e.g. by the Food and Drug Administration, for preclinical prevention and intervention studies related to osteoporosis research; in this context, the ewe has already proven its value for orthopaedic research. Although oestrogen deficiency doubtless influences bone metabolism in sheep, the ovariectomised ewe seems unsuitable as a model for postmenopausal osteoporosis and bone loss induction due to its unreliable impact on bone mass and structure. In contrast, glucocorticoid treatment has a major impact on bone turnover and leads to bone conditions comparable to those found in steroid-treated humans. However, adverse side effects can be dramatic resulting in unacceptable discomfort and illness of the experimental animals. Further improvements are therefore essential to judge this model as ethically appropriate. Additionally, models for osteoporosis induced by surgical interventions of central regulatory mechanisms seem to be attractive, as remarkable bone loss is induced by only one surgical procedure without any further treatment. Taken together, different ewe models for osteoporosis have been successfully established and are invaluable for orthopaedic research. However, the search for a 'perfect' large remodelling animal model - in terms of mimicking the human disease and compatibility of bone loss, and without ethical concerns - is still on-going.

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.

Impact of supplementation with amino acids or their metabolites on muscle wasting in patients with critical illness or other muscle wasting illness: a systematic review.

PubMed

Wandrag, L; Brett, S J; Frost, G; Hickson, M

2015-08-01

Muscle wasting during critical illness impairs recovery. Dietary strategies to minimise wasting include nutritional supplements, particularly essential amino acids. We reviewed the evidence on enteral supplementation with amino acids or their metabolites in the critically ill and in muscle wasting illness with similarities to critical illness, aiming to assess whether this intervention could limit muscle wasting in vulnerable patient groups. Citation databases, including MEDLINE, Web of Knowledge, EMBASE, the meta-register of controlled trials and the Cochrane Collaboration library, were searched for articles from 1950 to 2013. Search terms included 'critical illness', 'muscle wasting', 'amino acid supplementation', 'chronic obstructive pulmonary disease', 'chronic heart failure', 'sarcopenia' and 'disuse atrophy'. Reviews, observational studies, sport nutrition, intravenous supplementation and studies in children were excluded. One hundred and eighty studies were assessed for eligibility and 158 were excluded. Twenty-two studies were graded according to standardised criteria using the GRADE methodology: four in critical care populations, and 18 from other clinically relevant areas. Methodologies, interventions and outcome measures used were highly heterogeneous and meta-analysis was not appropriate. Methodology and quality of studies were too varied to draw any firm conclusion. Dietary manipulation with leucine enriched essential amino acids (EAA), β-hydroxy-β-methylbutyrate and creatine warrant further investigation in critical care; EAA has demonstrated improvements in body composition and nutritional status in other groups with muscle wasting illness. High-quality research is required in critical care before treatment recommendations can be made. © 2014 The British Dietetic Association Ltd.

Probiotics and diarrhoea management in enterally tube fed critically ill patients--what is the evidence?

PubMed

Jack, Leanne; Coyer, Fiona; Courtney, Mary; Venkatesh, Bala

2010-12-01

The aim of this literature review is to identify the role of probiotics in the management of enteral tube feeding (ETF) diarrhoea in critically ill patients. Diarrhoea is a common gastrointestinal problem seen in ETF patients. The incidence of diarrhoea in tube fed patients varies from 2% to 68% across all patients. Despite extensive investigation, the pathogenesis surrounding ETF diarrhoea remains unclear. Evidence to support probiotics to manage ETF diarrhoea in critically ill patients remains sparse. Literature on ETF diarrhoea and probiotics in critically ill, adult patients was reviewed from 1980 to 2010. The Cochrane Library, Pubmed, Science Direct, Medline and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) electronic databases were searched using specific inclusion/exclusion criteria. Key search terms used were: enteral nutrition, diarrhoea, critical illness, probiotics, probiotic species and randomised clinical control trial (RCT). Four RCT papers were identified with two reporting full studies, one reporting a pilot RCT and one conference abstract reporting an RCT pilot study. A trend towards a reduction in diarrhoea incidence was observed in the probiotic groups. However, mortality associated with probiotic use in some severely and critically ill patients must caution the clinician against its use. Evidence to support probiotic use in the management of ETF diarrhoea in critically ill patients remains unclear. This paper argues that probiotics should not be administered to critically ill patients until further research has been conducted to examine the causal relationship between probiotics and mortality, irrespective of the patient's disease state or projected prophylactic benefit of probiotic administration. Copyright © 2010 Elsevier Ltd. All rights reserved.

Setting the vision: applied patient-reported outcomes and smart, connected digital healthcare systems to improve patient-centered outcomes prediction in critical illness.

PubMed

Wysham, Nicholas G; Abernethy, Amy P; Cox, Christopher E

2014-10-01

Prediction models in critical illness are generally limited to short-term mortality and uncommonly include patient-centered outcomes. Current outcome prediction tools are also insensitive to individual context or evolution in healthcare practice, potentially limiting their value over time. Improved prognostication of patient-centered outcomes in critical illness could enhance decision-making quality in the ICU. Patient-reported outcomes have emerged as precise methodological measures of patient-centered variables and have been successfully employed using diverse platforms and technologies, enhancing the value of research in critical illness survivorship and in direct patient care. The learning health system is an emerging ideal characterized by integration of multiple data sources into a smart and interconnected health information technology infrastructure with the goal of rapidly optimizing patient care. We propose a vision of a smart, interconnected learning health system with integrated electronic patient-reported outcomes to optimize patient-centered care, including critical care outcome prediction. A learning health system infrastructure integrating electronic patient-reported outcomes may aid in the management of critical illness-associated conditions and yield tools to improve prognostication of patient-centered outcomes in critical illness.

Long-term sequelae of critical illness: memories and health-related quality of life.

PubMed

Hough, Catherine Lee; Curtis, J Randall

2005-04-01

Impaired health-related quality of life after critical illness has been demonstrated in a number of studies. It is not clear exactly how or why critical illness and intensive care lead to impaired health status, but understanding this association is an important step to improving long-term outcomes of the critically ill. There is growing evidence that neuro-psychological symptoms play a significant role in this impairment and that management of patients in the intensive care unit (ICU) may influence these symptoms. This commentary examines a recent study and places this study in the context of previous studies suggesting that both amnesia and persisting nightmares of the ICU experience are associated with impaired quality of life. Further research is needed if we are effectively to understand, prevent and treat the negative sequelae of critical illness.

Special populations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.

PubMed

Dries, David; Reed, Mary Jane; Kissoon, Niranjan; Christian, Michael D; Dichter, Jeffrey R; Devereaux, Asha V; Upperman, Jeffrey S

2014-10-01

Past disasters have highlighted the need to prepare for subsets of critically ill, medically fragile patients. These special patient populations require focused disaster planning that will address their medical needs throughout the event to prevent clinical deterioration. The suggestions in this article are important for all who are involved in large-scale disasters or pandemics with multiple critically ill or injured patients, including frontline clinicians, hospital administrators, and public health or government officials. Key questions regarding the care of critically ill or injured special populations during disasters or pandemics were identified, and a systematic literature review (1985-2013) was performed. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. The panel did not include pediatrics as a separate special population because pediatrics issues are embedded in each consensus document. Fourteen suggestions were formulated regarding the care of critically ill and injured patients from special populations during pandemics and disasters. The suggestions cover the following areas: defining special populations for mass critical care, special population planning, planning for access to regionalized service for special populations, triage and resource allocation of special populations, therapeutic considerations, and crisis standards of care for special populations. Chronically ill, technologically dependent, and complex critically ill patients present a unique challenge to preparing and implementing mass critical care. There are, however, unique opportunities to engage patients, primary physicians, advocacy groups, and professional organizations to lessen the impact of disaster on these special populations.

Proximal gastric motility in critically ill patients with type 2 diabetes mellitus.

PubMed

Nguyen, Nam Q; Fraser, Robert J; Bryant, Laura K; Chapman, Marianne; Holloway, Richard H

2007-01-14

To investigate the proximal gastric motor response to duodenal nutrients in critically ill patients with long-standing type 2 diabetes mellitus. Proximal gastric motility was assessed (using a barostat) in 10 critically ill patients with type 2 diabetes mellitus (59 +/- 3 years) during two 60-min duodenal infusions of Ensure (1 and 2 kcal/min), in random order, separated by 2 h fasting. Data were compared with 15 non-diabetic critically ill patients (48 +/- 5 years) and 10 healthy volunteers (28 +/- 3 years). Baseline proximal gastric volumes were similar between the three groups. In diabetic patients, proximal gastric relaxation during 1 kcal/min nutrient infusion was similar to non-diabetic patients and healthy controls. In contrast, relaxation during 2 kcal/min infusion was initially reduced in diabetic patients (P < 0.05) but increased to a level similar to healthy humans, unlike non-diabetic patients where relaxation was impaired throughout the infusion. Duodenal nutrient stimulation reduced the fundic wave frequency in a dose-dependent fashion in both the critically ill diabetic patients and healthy subjects, but not in critically ill patients without diabetes. Fundic wave frequency in diabetic patients and healthy subjects was greater than in non-diabetic patients. In patients with diabetes mellitus, proximal gastric motility is less disturbed than non-diabetic patients during critical illness, suggesting that these patients may not be at greater risk of delayed gastric emptying.

Improving risk classification of critical illness with biomarkers: a simulation study

PubMed Central

Seymour, Christopher W.; Cooke, Colin R.; Wang, Zheyu; Kerr, Kathleen F.; Yealy, Donald M.; Angus, Derek C.; Rea, Thomas D.; Kahn, Jeremy M.; Pepe, Margaret S.

2012-01-01

Purpose Optimal triage of patients at risk of critical illness requires accurate risk prediction, yet little data exists on the performance criteria required of a potential biomarker to be clinically useful. Materials and Methods We studied an adult cohort of non-arrest, non-trauma emergency medical services encounters transported to a hospital from 2002–2006. We simulated hypothetical biomarkers increasingly associated with critical illness during hospitalization, and determined the biomarker strength and sample size necessary to improve risk classification beyond a best clinical model. Results Of 57,647 encounters, 3,121 (5.4%) were hospitalized with critical illness and 54,526 (94.6%) without critical illness. The addition of a moderate strength biomarker (odds ratio=3.0 for critical illness) to a clinical model improved discrimination (c-statistic 0.85 vs. 0.8, p<0.01), reclassification (net reclassification improvement=0.15, 95%CI: 0.13,0.18), and increased the proportion of cases in the highest risk categoryby+8.6% (95%CI: 7.5,10.8%). Introducing correlation between the biomarker and physiological variables in the clinical risk score did not modify the results. Statistically significant changes in net reclassification required a sample size of at least 1000 subjects. Conclusions Clinical models for triage of critical illness could be significantly improved by incorporating biomarkers, yet, substantial sample sizes and biomarker strength may be required. PMID:23566734

Sleep Disturbance after Hospitalization and Critical Illness: A Systematic Review.

PubMed

Altman, Marcus T; Knauert, Melissa P; Pisani, Margaret A

2017-09-01

Sleep disturbance during intensive care unit (ICU) admission is common and severe. Sleep disturbance has been observed in survivors of critical illness even after transfer out of the ICU. Not only is sleep important to overall health and well being, but patients after critical illness are also in a physiologically vulnerable state. Understanding how sleep disturbance impacts recovery from critical illness after hospital discharge is therefore clinically meaningful. This Systematic Review aimed to summarize studies that identify the prevalence of and risk factors for sleep disturbance after hospital discharge for critical illness survivors. PubMed (January 4, 2017), MEDLINE (January 4, 2017), and EMBASE (February 1, 2017). Databases were searched for studies of critically ill adult patients after hospital discharge, with sleep disturbance measured as a primary outcome by standardized questionnaire or objective measurement tools. From each relevant study, we extracted prevalence and severity of sleep disturbance at each time point, objective sleep parameters (such as total sleep time, sleep efficiency, and arousal index), and risk factors for sleep disturbance. A total of 22 studies were identified, with assessment tools including subjective questionnaires, polysomnography, and actigraphy. Subjective questionnaire studies reveal a 50-66.7% (within 1 mo), 34-64.3% (>1-3 mo), 22-57% (>3-6 mo), and 10-61% (>6 mo) prevalence of abnormal sleep after hospital discharge after critical illness. Of the studies assessing multiple time points, four of five questionnaire studies and five of five polysomnography studies show improved aspects of sleep over time. Risk factors for poor sleep varied, but prehospital factors (chronic comorbidity, pre-existing sleep abnormality) and in-hospital factors (severity of acute illness, in-hospital sleep disturbance, pain medication use, and ICU acute stress symptoms) may play a role. Sleep disturbance was frequently associated with postdischarge psychological comorbidities and impaired quality of life. Sleep disturbance is common in critically ill patients up to 12 months after hospital discharge. Both subjective and objective studies, however, suggest that sleep disturbance improves over time. More research is needed to understand and optimize sleep in recovery from critical illness.

Serum Neutrophil Gelatinase-associated Lipocalin (NGAL) as a Marker of Acute Kidney Injury in Critically Ill Children with Septic Shock

PubMed Central

Wheeler, Derek S.; Devarajan, Prasad; Ma, Qing; Harmon, Kelli; Monaco, Marie; Cvijanovich, Natalie; Wong, Hector R.

2009-01-01

Objective To validate serum neutrophil gelatinase-associated lipocalin (NGAL) as an early biomarker for acute kidney injury (AKI) in critically ill children with septic shock. Design Observational cohort study. Setting 15 North American pediatric intensive care units (PICU). Patients A total of 143 critically ill children with SIRS or septic shock and 25 healthy controls. Interventions None. Measurements and Main Results Serum NGAL was measured during the first 24 hours of admission to the PICU. AKI was defined as a blood urea nitrogen (BUN) concentration > 100 mg/dL, serum creatinine > 2 mg/dL in the absence of pre-existing renal disease, or the need for dialysis. There was a significant difference in serum NGAL between healthy children (median 80 ng/mL, IQR 55.5-85.5 ng/mL), critically ill children with SIRS (median 107.5 ng/mL, IQR 89-178.5 ng/mL), and critically ill children with septic shock (median 302 ng/mL, IQR 151-570 ng/mL; p<0.001). AKI developed in 22 out of 143 (15.4%) critically ill children. Serum NGAL was significantly increased in critically ill children with AKI (median 355 ng/mL, IQR 166-1322 ng/mL) compared to those without AKI (median 186 ng/mL, IQR 98-365 ng/mL; p=0.009). Conclusions Serum NGAL is a highly sensitive, but nonspecific predictor of AKI in critically ill children with septic shock. Further validation of serum NGAL as a biomarker of AKI in this population is warranted. PMID:18379258

Serum neutrophil gelatinase-associated lipocalin (NGAL) as a marker of acute kidney injury in critically ill children with septic shock.

PubMed

Wheeler, Derek S; Devarajan, Prasad; Ma, Qing; Harmon, Kelli; Monaco, Marie; Cvijanovich, Natalie; Wong, Hector R

2008-04-01

To validate serum neutrophil gelatinase-associated lipocalin (NGAL) as an early biomarker for acute kidney injury in critically ill children with septic shock. Observational cohort study. Fifteen North American pediatric intensive care units (PICUs). A total of 143 critically ill children with systemic inflammatory response syndrome (SIRS) or septic shock and 25 healthy controls. None. Serum NGAL was measured during the first 24 hrs of admission to the PICU. Acute kidney injury was defined as a blood urea nitrogen concentration >100 mg/dL, serum creatinine >2 mg/dL in the absence of preexisting renal disease, or the need for dialysis. There was a significant difference in serum NGAL between healthy children (median 80 ng/mL, interquartile ratio [IQR] 55.5-85.5 ng/mL), critically ill children with SIRS (median 107.5 ng/mL, IQR 89-178.5 ng/mL), and critically ill children with septic shock (median 302 ng/mL, IQR 151-570 ng/mL; p < .001). Acute kidney injury developed in 22 of 143 (15.4%) critically ill children. Serum NGAL was significantly increased in critically ill children with acute kidney injury (median 355 ng/mL, IQR 166-1322 ng/mL) compared with those without acute kidney injury (median 186 ng/mL, IQR 98-365 ng/mL; p = .009). Serum NGAL is a highly sensitive but nonspecific predictor of acute kidney injury in critically ill children with septic shock. Further validation of serum NGAL as a biomarker of acute kidney injury in this population is warranted.

Energy Requirements in Critically Ill Patients.

PubMed

Ndahimana, Didace; Kim, Eun-Kyung

2018-04-01

During the management of critical illness, optimal nutritional support is an important key for achieving positive clinical outcomes. Compared to healthy people, critically ill patients have higher energy expenditure, thereby their energy requirements and risk of malnutrition being increased. Assessing individual nutritional requirement is essential for a successful nutritional support, including the adequate energy supply. Methods to assess energy requirements include indirect calorimetry (IC) which is considered as a reference method, and the predictive equations which are commonly used due to the difficulty of using IC in certain conditions. In this study, a literature review was conducted on the energy metabolic changes in critically ill patients, and the implications for the estimation of energy requirements in this population. In addition, the issue of optimal caloric goal during nutrition support is discussed, as well as the accuracy of selected resting energy expenditure predictive equations, commonly used in critically ill patients.

Transfusion-related immunomodulation: review of the literature and implications for pediatric critical illness.

PubMed

Muszynski, Jennifer A; Spinella, Philip C; Cholette, Jill M; Acker, Jason P; Hall, Mark W; Juffermans, Nicole P; Kelly, Daniel P; Blumberg, Neil; Nicol, Kathleen; Liedel, Jennifer; Doctor, Allan; Remy, Kenneth E; Tucci, Marisa; Lacroix, Jacques; Norris, Philip J

2017-01-01

Transfusion-related immunomodulation (TRIM) in the intensive care unit (ICU) is difficult to define and likely represents a complicated set of physiologic responses to transfusion, including both proinflammatory and immunosuppressive effects. Similarly, the immunologic response to critical illness in both adults and children is highly complex and is characterized by both acute inflammation and acquired immune suppression. How transfusion may contribute to or perpetuate these phenotypes in the ICU is poorly understood, despite the fact that transfusion is common in critically ill patients. Both hyperinflammation and severe immune suppression are associated with poor outcomes from critical illness, underscoring the need to understand potential immunologic consequences of blood product transfusion. In this review we outline the dynamic immunologic response to critical illness, provide clinical evidence in support of immunomodulatory effects of blood product transfusion, review preclinical and translational studies to date of TRIM, and provide insight into future research directions. © 2016 AABB.

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

Systematic review of β blocker, aspirin, and statin in critically ill patients: importance of severity of illness and cardiac troponin.

PubMed

Rothenberg, Florence G; Clay, Michael B; Jamali, Hina; Vandivier-Pletsch, Robin H

2017-04-01

Non-cardiac critically ill patients with type II myocardial infarction (MI) have a high risk of mortality. There are no evidence-based interventions to mitigate this risk. We systematically reviewed the literature regarding the use of medications known to reduce mortality in patients with cardiac troponin (cTn) elevation due to type I MI (β blockers, statin, and aspirin) in studies of critically ill patients without Type I MI. All PubMed publications between 1976-2/19/16 were reviewed. Search terms included: β blocker or aspirin or statin and intensive care unit (ICU) or critically ill or sepsis; 497 primary references were obtained. Inclusion criteria were as follows: (1) study population consisted of critically ill patients in the ICU with non-cardiovascular illnesses, (2) mortality end point, (3) severity of illness (or injury) was measured, and (4) the antiplatelet agent was primarily aspirin. Retrospective investigations, prospective observational studies, meta-analysis, systematic review, and randomized controlled trials were included; case reports were excluded. 25 primary references were obtained. The data were extracted and tabulated using data collection headings as follows: article title, first author/year/reference number, study type/design, population studied, outcome and intervention, and study question addressed. Evidence was not graded as the majority of studies were non-randomized (low-to-moderate quality). 11 studies were found through bibliography reviews for a total of 36 references. In conclusion, β blockers, statins, and aspirin may play a role in reducing mortality in non-cardiac critically ill patients. Benefit appears to be related to severity of illness, for which cTn may be a marker. Copyright © 2017 American Federation for Medical Research.

Consensus recommendations for the management of hyperglycaemia in critically ill patients in the Indian setting.

PubMed

Mukherjee, J J; Chatterjee, P S; Saikia, M; Muruganathan, A; Das, Ashok Kumar

2014-07-01

Hyperglycaemia occurs frequently in critically-ill patients. Not only does it occur among patients with pre-existing diabetes mellitus but elevated blood glucose values during an acute illness can also be seen in previously glucose-tolerant individuals (stress hyperglycaemia). Numerous observational studies have shown an increase in morbidity and mortality in critically ill patients with hyperglycaemia. Interestingly, outcomes in individuals with stress hyperglycaemia are worse than that in critically ill hyperglycaemic patients with pre-existing diabetes. Proper management of hyperglycaemia has been shown to result in improved clinical outcomes. Critically ill patients with hyperglycaemia should primarily be managed with intravenous insulin infusion to allow dynamic adjustment of treatment to suit the rapid changes in blood glucose values in these patients. Currently, there are in existence a fair number of published protocols to administer intensive intravenous insulin therapy that range from the relatively simple to the fairly complex. Different management strategies have been proposed depending upon whether the critically ill hyperglycaemic patient is stationed in the emergency department, the medical intensive care unit (ICU), the surgical ICU or the coronary care unit. Moreover, the ideal target blood glucose value to maintain in this group of patients remains controversial. Keeping these issues in mind, a group of leading experts in the fields of diabetes and critical care extensively reviewed the literature and framed recommendations with special attention to clinical practice in India. The aim was to formulate recommendations which are based on sound evidence and yet are simple and easy to understand and implement across the ICU throughout the country. In the current recommendations, intensive intravenous insulin therapy has been suggested as the preferred mode of managing hyperglycaemia in patients admitted to critical care settings. The current recommendations suggest using a simple and similar protocol for managing hyperglycaemia in critically-ill patients irrespective of their location among the various critical care units in a hospital. Recommendations have also been made for transition from intravenous to subcutaneous administration of insulin when the patient is transferred out of the critical care setting. It is hoped that the current recommendations shall form the basis for the management of hyperglycaemia in critically ill patients across the country.

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

The diagnostic value of troponin in critically ill.

PubMed

Voga, Gorazd

2010-01-01

Troponin T and I are sensitive and specific markers of myocardial necrosis. They are used for the routine diagnosis of acute coronary syndrome. In critically ill patients they are basic diagnostic tool for diagnosis of myocardial necrosis due to myocardial ischemia. Moreover, the increase of troponin I and T is related with adverse outcome in many subgroups of critically ill patients. The new, high sensitivity tests which have been developed recently allow earlier and more accurate diagnosis of acute coronary syndrome. The use of the new tests has not been studied in critically ill patients, but they will probably replace the old tests and will be used on the routine basis.

New insights into the gut as the driver of critical illness and organ failure.

PubMed

Meng, Mei; Klingensmith, Nathan J; Coopersmith, Craig M

2017-04-01

The gut has long been hypothesized to be the 'motor' of multiple organ dysfunction syndrome. This review serves as an update on new data elucidating the role of the gut as the propagator of organ failure in critical illness. Under basal conditions, the gut absorbs nutrients and serves as a barrier that prevents approximately 40 trillion intraluminal microbes and their products from causing host injury. However, in critical illness, gut integrity is disrupted with hyperpermeability and increased epithelial apoptosis, allowing contamination of extraluminal sites that are ordinarily sterile. These alterations in gut integrity are further exacerbated in the setting of preexisting comorbidities. The normally commensal microflora is also altered in critical illness, with increases in microbial virulence and decreases in diversity, which leads to further pathologic responses within the host. All components of the gut are adversely impacted by critical illness. Gut injury can not only propagate local damage, but can also cause distant injury and organ failure. Understanding how the multifaceted components of the gut interact and how these are perturbed in critical illness may play an important role in turning off the 'motor' of multiple organ dysfunction syndrome in the future.

Glutamine and antioxidants: status of their use in critical illness.

PubMed

van Zanten, Arthur R H

2015-03-01

Many studies in critically ill patients have addressed enteral or parenteral supplementation of glutamine and antioxidants to counteract assumed deficiencies and induce immune-modulating effects to reduce infections and improve outcome. Older studies showed marked reductions in mortality, infectious morbidity and length of stay. Recent studies no longer show beneficial effects and in contrast even demonstrated increased mortality. This opiniating review focuses on the latest information and the consequences for the use of glutamine and antioxidants in critically ill patients. Positive effects in systematic reviews and meta-analyses are based on results from older, smaller and mainly single-centre studies. New information has challenged the conditional deficiency hypothesis concerning glutamine in critically ill patients. The recent REDOXS and MetaPlus trials studying the effects of glutamine, selenium and other antioxidants have shown no benefits and increased mortality. Given that the first dictum in medicine is to do no harm, we cannot be confident that immune-modulating nutrient supplementation with glutamine and antioxidants is effective and well tolerated for critically ill patients. Until more data are available, it is probably better not to routinely administer glutamine and antioxidants in nonphysiological doses to mechanically ventilated critically ill patients.

Expert elicitation as a means to attribute 28 enteric pathogens to foodborne, waterborne, animal contact, and person-to-person transmission routes in Canada.

PubMed

Butler, Ainslie J; Thomas, M Kate; Pintar, Katarina D M

2015-04-01

Enteric illness contributes to a significant burden of illness in Canada and globally. Understanding its sources is a critical step in identifying and preventing health risks. Expert elicitation is a powerful tool, used previously, to obtain information about enteric illness source attribution where information is difficult or expensive to obtain. Thirty-one experts estimated transmission of 28 pathogens via major transmission routes (foodborne, waterborne, animal contact, person-to-person, and other) at the point of consumption. The elicitation consisted of a (snowball) recruitment phase; administration of a pre-survey to collect background information, an introductory webinar, an elicitation survey, a 1-day discussion, survey readministration, and a feedback exercise, and surveys were administered online. Experts were prompted to quantify changes in contamination at the point of entry into the kitchen versus point of consumption. Estimates were combined via triangular probability distributions, and medians and 90% credible-interval estimates were produced. Transmission was attributed primarily to food for Bacillus cereus, Clostridium perfringens, Cyclospora cayetanensis, Trichinella spp., all three Vibrio spp. categories explored, and Yersinia enterocolitica. Multisource pathogens (e.g., transmitted commonly through both water and food) such as Campylobacter spp., four Escherichia coli categories, Listeria monocytogenes, Salmonella spp., and Staphylococcus aureus were also estimated as mostly foodborne. Water was the primary pathway for Giardia spp. and Cryptosporidium spp., and person-to-person transmission dominated for six enteric viruses and Shigella spp. Consideration of the point of attribution highlighted the importance of food handling and cross-contamination in the transmission pathway. This study provides source attribution estimates of enteric illness for Canada, considering all possible transmission routes. Further research is necessary to improve our understanding of poorly characterized pathogens such as sapovirus and E. coli subgroups in Canada.

Forging a critical alliance: Addressing the research needs of the United States critical illness and injury community.

PubMed

Cobb, J Perren; Ognibene, Frederick P; Ingbar, David H; Mann, Henry J; Hoyt, David B; Angus, Derek C; Thomas, Alvin V; Danner, Robert L; Suffredini, Anthony F

2009-12-01

Discuss the research needs of the critical illness and injury communities in the United States. Workshop session held during the 5 National Institutes of Health Symposium on the Functional Genomics of Critical Illness and Injury (November 15, 2007). The current clinical research infrastructure misses opportunities for synergy and does not address many important needs. In addition, it remains challenging to rapidly and properly implement system-wide changes based upon reproducible evidence from clinical research. Author presentations, panel discussion, attendee feedback. The critical illness and injury research communities seek better communication and interaction, both of which will improve the breadth and quality of acute care research. Success in meeting these needs should come from cooperative and strategic actions that favor collaboration, standardization of protocols, and strong leadership. An alliance framed on common goals will foster collaboration among experts to better promote clinical trials within the critically ill or injured patient population. The U.S. Critical Illness and Injury Trials Group was funded to create a clinical research framework that can reduce the barriers to investigation using an investigator-initiated, evidence-driven, inclusive approach that has proven successful elsewhere. This alliance will provide an annual venue for systematic review and strategic planning that will include framing the research agenda, raising awareness for the value of acute care research, gathering and promoting best practices, and bolstering the critical care workforce.

Part 1: Pressure ulcer assessment - the development of Critical Care Pressure Ulcer Assessment Tool made Easy (CALCULATE).

PubMed

Richardson, Annette; Barrow, Isabel

2015-11-01

Critically ill patients are at high risk of developing pressure ulcers resulting in serious untoward patient and health care system outcomes. Pressure ulcer prevention is therefore an important patient safety priority and establishing a structured approach to pressure ulcer risk assessment to identify patients at risk is a critical first step. The literature was searched using three electronic databases from 2000 to 2011 to identify papers reporting on pressure ulcer risk factors and assessment in adult critical care. The review and appraisal of papers were conducted by two critical care nurses. Papers underwent detailed review if they met inclusion criteria where they identified pressure ulcer assessment scores, scales or risk factors and related to adult critical care patients Seven papers were reviewed. No single assessment tool was sufficiently validated for critically ill patients and seven key critical care risk factors were identified. These risk factors were: mechanical ventilation, impaired circulation, dialysis, long surgery, low protein and too unstable to turn. The tool Critical Care Pressure Ulcer Assessment Tool made Easy (CALCULATE) was developed utilizing the risk factors from the literature and expert critical care nursing consensus decision-making. In the absence of current consensus, valid assessment scales and limited evidence for the most appropriate pressure ulcer assessment for critically ill patients, this assessment tool offers an easy, appropriate alternative for critically ill patients than existing tools primarily validated for acute care wards. 'CALCULATE' offers an important contribution towards the advancement and development of critical care pressure ulcer risk assessment. Future research is needed to further enhance and inform pressure ulcer risk assessment of the critically ill patients. The identification of critical care risk factors may be an indicative method of assessing pressure ulcer risk in the critically ill patients. © 2015 British Association of Critical Care Nurses.

Linking Human Health and Livestock Health: A “One-Health” Platform for Integrated Analysis of Human Health, Livestock Health, and Economic Welfare in Livestock Dependent Communities

PubMed Central

Thumbi, S. M.; Njenga, M. Kariuki; Marsh, Thomas L.; Noh, Susan; Otiang, Elkanah; Munyua, Peninah; Ochieng, Linus; Ogola, Eric; Yoder, Jonathan; Audi, Allan; Montgomery, Joel M.; Bigogo, Godfrey; Breiman, Robert F.; Palmer, Guy H.; McElwain, Terry F.

2015-01-01

Background For most rural households in sub-Saharan Africa, healthy livestock play a key role in averting the burden associated with zoonotic diseases, and in meeting household nutritional and socio-economic needs. However, there is limited understanding of the complex nutritional, socio-economic, and zoonotic pathways that link livestock health to human health and welfare. Here we describe a platform for integrated human health, animal health and economic welfare analysis designed to address this challenge. We provide baseline epidemiological data on disease syndromes in humans and the animals they keep, and provide examples of relationships between human health, animal health and household socio-economic status. Method We designed a study to obtain syndromic disease data in animals along with economic and behavioral information for 1500 rural households in Western Kenya already participating in a human syndromic disease surveillance study. Data collection started in February 2013, and each household is visited bi-weekly and data on four human syndromes (fever, jaundice, diarrhea and respiratory illness) and nine animal syndromes (death, respiratory, reproductive, musculoskeletal, nervous, urogenital, digestive, udder disorders, and skin disorders in cattle, sheep, goats and chickens) are collected. Additionally, data from a comprehensive socio-economic survey is collected every 3 months in each of the study households. Findings Data from the first year of study showed 93% of the households owned at least one form of livestock (55%, 19%, 41% and 88% own cattle, sheep, goats and chickens respectively). Digestive disorders, mainly diarrhea episodes, were the most common syndromes observed in cattle, goats and sheep, accounting for 56% of all livestock syndromes, followed by respiratory illnesses (18%). In humans, respiratory illnesses accounted for 54% of all illnesses reported, followed by acute febrile illnesses (40%) and diarrhea illnesses (5%). While controlling for household size, the incidence of human illness increased 1.31-fold for every 10 cases of animal illness or death observed (95% CI 1.16–1.49). Access and utilization of animal source foods such as milk and eggs were positively associated with the number of cattle and chickens owned by the household. Additionally, health care seeking was correlated with household incomes and wealth, which were in turn correlated with livestock herd size. Conclusion This study platform provides a unique longitudinal dataset that allows for the determination and quantification of linkages between human and animal health, including the impact of healthy animals on human disease averted, malnutrition, household educational attainment, and income levels. PMID:25798951

Linking human health and livestock health: a "one-health" platform for integrated analysis of human health, livestock health, and economic welfare in livestock dependent communities.

PubMed

Thumbi, S M; Njenga, M Kariuki; Marsh, Thomas L; Noh, Susan; Otiang, Elkanah; Munyua, Peninah; Ochieng, Linus; Ogola, Eric; Yoder, Jonathan; Audi, Allan; Montgomery, Joel M; Bigogo, Godfrey; Breiman, Robert F; Palmer, Guy H; McElwain, Terry F

2015-01-01

For most rural households in sub-Saharan Africa, healthy livestock play a key role in averting the burden associated with zoonotic diseases, and in meeting household nutritional and socio-economic needs. However, there is limited understanding of the complex nutritional, socio-economic, and zoonotic pathways that link livestock health to human health and welfare. Here we describe a platform for integrated human health, animal health and economic welfare analysis designed to address this challenge. We provide baseline epidemiological data on disease syndromes in humans and the animals they keep, and provide examples of relationships between human health, animal health and household socio-economic status. We designed a study to obtain syndromic disease data in animals along with economic and behavioral information for 1500 rural households in Western Kenya already participating in a human syndromic disease surveillance study. Data collection started in February 2013, and each household is visited bi-weekly and data on four human syndromes (fever, jaundice, diarrhea and respiratory illness) and nine animal syndromes (death, respiratory, reproductive, musculoskeletal, nervous, urogenital, digestive, udder disorders, and skin disorders in cattle, sheep, goats and chickens) are collected. Additionally, data from a comprehensive socio-economic survey is collected every 3 months in each of the study households. Data from the first year of study showed 93% of the households owned at least one form of livestock (55%, 19%, 41% and 88% own cattle, sheep, goats and chickens respectively). Digestive disorders, mainly diarrhea episodes, were the most common syndromes observed in cattle, goats and sheep, accounting for 56% of all livestock syndromes, followed by respiratory illnesses (18%). In humans, respiratory illnesses accounted for 54% of all illnesses reported, followed by acute febrile illnesses (40%) and diarrhea illnesses (5%). While controlling for household size, the incidence of human illness increased 1.31-fold for every 10 cases of animal illness or death observed (95% CI 1.16-1.49). Access and utilization of animal source foods such as milk and eggs were positively associated with the number of cattle and chickens owned by the household. Additionally, health care seeking was correlated with household incomes and wealth, which were in turn correlated with livestock herd size. This study platform provides a unique longitudinal dataset that allows for the determination and quantification of linkages between human and animal health, including the impact of healthy animals on human disease averted, malnutrition, household educational attainment, and income levels.

Febrile Illness with Skin Rashes

PubMed Central

2015-01-01

Skin rashes that appear during febrile illnesses are in fact caused by various infectious diseases. Since infectious exanthematous diseases range from mild infections that disappear naturally to severe infectious diseases, focus on and basic knowledge of these diseases is very important. But, these include non-infectious diseases, so that comprehensive knowledge of these other diseases is required. Usually, early diagnostic testing for a febrile illness with a rash is inefficient. For clinical diagnosis of diseases accompanied by skin rash and fever, a complete history must be taken, including recent travel, contact with animals, medications, and exposure to forests and other natural environments. In addition, time of onset of symptoms and the characteristics of the rash itself (morphology, location, distribution) could be helpful in the clinical diagnosis. It is also critical to understand the patient's history of specific underlying diseases. However, diagnostic basic tests could be helpful in diagnosis if they are repeated and the clinical course is monitored. Generally, skin rashes are nonspecific and self-limited. Therefore, it could be clinically meaningful as a characteristic diagnostic finding in a very small subset of specific diseases. PMID:26483989

Patient- and family-centered performance measures focused on actionable processes of care for persistent and chronic critical illness: protocol for a systematic review.

PubMed

Rose, Louise; Istanboulian, Laura; Allum, Laura; Burry, Lisa; Dale, Craig; Hart, Nicholas; Kydonaki, Claire; Ramsay, Pam; Pattison, Natalie; Connolly, Bronwen

2017-04-17

Approximately 5 to 10% of critically ill patients transition from acute critical illness to a state of persistent and in some cases chronic critical illness. These patients have unique and complex needs that require a change in the clinical management plan and overall goals of care to a focus on rehabilitation, symptom relief, discharge planning, and in some cases, end-of-life care. However, existing indicators and measures of care quality, and tools such as checklists, that foster implementation of best practices, may not be sufficiently inclusive in terms of actionable processes of care relevant to these patients. Therefore, the aim of this systematic review is to identify the processes of care, performance measures, quality indicators, and outcomes including reports of patient/family experience described in the current evidence base relevant to patients with persistent or chronic critical illness and their family members. Two authors will independently search from inception to November 2016: MEDLINE, Embase, CINAHL, Web of Science, the Cochrane Library, PROSPERO, the Joanna Briggs Institute and the International Clinical Trials Registry Platform. We will include all study designs except case series/reports of <10 patients describing their study population (aged 18 years and older) using terms such as persistent critical illness, chronic critical illness, and prolonged mechanical ventilation. Two authors will independently perform data extraction and complete risk of bias assessment. Our primary outcome is to determine actionable processes of care and interventions deemed relevant to patients experiencing persistent or chronic critical illness and their family members. Secondary outcomes include (1) performance measures and quality indicators considered relevant to our population of interest and (2) themes related to patient and family experience. We will use our systematic review findings, with data from patient, family member and clinician interviews, and a subsequent consensus building process to inform the development of quality metrics and tools to measure processes of care, outcomes and experience for patients experiencing persistent or chronic critical illness and their family members. PROSPERO CRD42016052715.

Protocol for a longitudinal qualitative study: survivors of childhood critical illness exploring long-term psychosocial well-being and needs—The SCETCH Project

PubMed Central

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

2014-01-01

Introduction Life-threatening critical illness affects over a quarter of a million children and adolescents (0–18 years old) annually in the USA and the UK. Death from critical illness is rare; however, survivors and their families can be exposed to a complex array of negative physical, psychological and social problems. Currently, within the literature, there is a distinct paucity of child and adolescent survivor self-reports, thus limiting our understanding of how survivors perceive this adversity and subsequently cope and grow in the long-term following their critical illness. This study aims to explore and understand psychosocial well-being and needs of critical illness survivors, 6–20 months post paediatric intensive care admission. Methods and analysis A longitudinal, qualitative approach will provide a platform for a holistic and contextualised exploration of outcomes and mechanisms at an individual level. Up to 80 participants, including 20 childhood critical illness survivors and 60 associated family members or health professionals/teachers, will be recruited. Three interviews, 7–9 weeks apart, will be conducted with critical illness survivors, allowing for the exploration of psychosocial well-being over time. A single interview will be conducted with the other participants enabling the exploration of contextual information and how psychosocial well-being may inter-relate between critical illness survivors and themselves. A ‘tool box’ of qualitative methods (semi-structured interviews, draw and tell, photo-elicitation, graphic-elicitation) will be used to collect data. Narrative analysis and pattern matching will be used to identify emergent themes across participants. Ethics and dissemination This study will provide an insight and understanding of participants’ experiences and perspectives of surviving critical illness in the long term with specific relation to their psychosocial well-being. Multiple methods will be used to ensure that the findings are effectively disseminated to service users, clinicians, policy and academic audiences. The study has full ethical approval from the East Midlands Research Ethics Committee and has received National Health Service (NHS) governance clearance. PMID:24435896

GLP-1 secretion is increased by inflammatory stimuli in an IL-6-dependent manner, leading to hyperinsulinemia and blood glucose lowering.

PubMed

Kahles, Florian; Meyer, Christina; Möllmann, Julia; Diebold, Sebastian; Findeisen, Hannes M; Lebherz, Corinna; Trautwein, Christian; Koch, Alexander; Tacke, Frank; Marx, Nikolaus; Lehrke, Michael

2014-10-01

Hypoglycemia and hyperglycemia are both predictors for adverse outcome in critically ill patients. Hyperinsulinemia is induced by inflammatory stimuli as a relevant mechanism for glucose lowering in the critically ill. The incretine hormone GLP-1 was currently found to be induced by endotoxin, leading to insulin secretion and glucose lowering under inflammatory conditions in mice. Here, we describe GLP-1 secretion to be increased by a variety of inflammatory stimuli, including endotoxin, interleukin-1β (IL-1β), and IL-6. Although abrogation of IL-1 signaling proved insufficient to prevent endotoxin-dependent GLP-1 induction, this was abolished in the absence of IL-6 in respective knockout animals. Hence, we found endotoxin-dependent GLP-1 secretion to be mediated by an inflammatory cascade, with IL-6 being necessary and sufficient for GLP-1 induction. Functionally, augmentation of the GLP-1 system by pharmacological inhibition of DPP-4 caused hyperinsulinemia, suppression of glucagon release, and glucose lowering under endotoxic conditions, whereas inhibition of the GLP-1 receptor led to the opposite effect. Furthermore, total GLP-1 plasma levels were profoundly increased in 155 critically ill patients presenting to the intensive care unit (ICU) in comparison with 134 healthy control subjects. In the ICU cohort, GLP-1 plasma levels correlated with markers of inflammation and disease severity. Consequently, GLP-1 provides a novel link between the immune system and the gut with strong relevance for metabolic regulation in context of inflammation. © 2014 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.

Early developments and clinical applications of total parenteral nutrition.

PubMed

Dudrick, Stanley J

2003-01-01

This article recounts the conditions and status of surgical nutrition support in the 1960s and the antecedent basic and clinical investigational work leading to the development of a practical and efficacious method of adequate nourishment entirely by vein in Beagle puppies; describes the subsequent clinical application of the knowledge, techniques, and technology to the first successful long-term total parenteral nutrition (TPN) support of critically ill pediatric and adult patients; and admonishes nutritionists of all backgrounds that some need for parenteral nutrition will likely always exist and that it is incumbent upon everyone to continue endeavors to advance the germinal methodology to perfection. The relevant indications, limitations, hindrances, motivational factors, and studies regarding the development of TPN are reviewed, and the fundamental investigational work culminating in the first successful growth and development of Beagle puppies and a human infant fed entirely by vein are described firsthand. The details of the orderly and logical scientific development of the principles and components of the techniques in animals, infants, and adults are related. Knowledge, techniques, and technologic constituents of the first successful long-term TPN system were developed in the basic biochemical and animal laboratories initially in 6 puppies and subsequently adapted clinically for the efficacious long-term i.v. support of 6 critically ill surgical adult patients and a newborn infant before its widespread clinical application. Long-term TPN was inaugurated successfully as a safe and effective i.v. feeding technique nearly 4 decades ago. However, basic and clinical investigations must continue to be encouraged, supported, and carried out in the quest to perfect the current rudimentary technology, methodology, and outcomes.

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. Copyright © 2013 Elsevier Ltd. All rights reserved.

Toward an Integrated Research Agenda for Critical Illness in Aging

PubMed Central

Milbrandt, Eric B.; Eldadah, Basil; Nayfield, Susan; Hadley, Evan; Angus, Derek C.

2010-01-01

Aging brings an increased predisposition to critical illness. Patients older than 65 years of age account for approximately half of all intensive care unit (ICU) admissions in the United States, a proportion that is expected to increase considerably with the aging of the population. Emerging research suggests that elderly survivors of intensive care suffer significant long-term sequelae, including accelerated age-related functional decline. Existing evidence-based interventions are frequently underused and their efficacy untested in older subjects. Improving ICU outcomes in the elderly will require not only better methods for translating sound science into improved ICU practice but also an enhanced understanding of the underlying molecular, physiological, and pathophysiological interactions of critical illness with the aging process itself. Yet, significant barriers to research for critical illness in aging exist. We review the state of knowledge and identify gaps in knowledge, research opportunities, and barriers to research, with the goal of promoting an integrated research agenda for critical illness in aging. PMID:20558632

Sleep in the Intensive Care Unit

PubMed Central

Friese, Randall S.; Gehlbach, Brian K.; Schwab, Richard J.; Weinhouse, Gerald L.; Jones, Shirley F.

2015-01-01

Sleep is an important physiologic process, and lack of sleep is associated with a host of adverse outcomes. Basic and clinical research has documented the important role circadian rhythm plays in biologic function. Critical illness is a time of extreme vulnerability for patients, and the important role sleep may play in recovery for intensive care unit (ICU) patients is just beginning to be explored. This concise clinical review focuses on the current state of research examining sleep in critical illness. We discuss sleep and circadian rhythm abnormalities that occur in ICU patients and the challenges to measuring alterations in circadian rhythm in critical illness and review methods to measure sleep in the ICU, including polysomnography, actigraphy, and questionnaires. We discuss data on the impact of potentially modifiable disruptors to patient sleep, such as noise, light, and patient care activities, and report on potential methods to improve sleep in the setting of critical illness. Finally, we review the latest literature on sleep disturbances that persist or develop after critical illness. PMID:25594808

[Determination of resting energy expenditure in critically ill children experiencing mechanical ventilation].

PubMed

Dong, Hong-ba; Yang, Yan-wen; Wang, Ying; Hong, Li

2012-11-01

Energy metabolism of critically ill children has its own characteristics, especially for those undergoing mechanical ventilation. We tried to assess the energy expenditure status and evaluate the use of predictive equations in such children. Moreover, the characteristics of the energy metabolism among various situation were explored. Fifty critically ill children undergoing mechanical ventilation were selected in this study. Data produced during the 24 hours of mechanical ventilation were collected for computation of severity of illness. Resting energy expenditure (REE) was determined at 24 hours after mechanical ventilation (MREE). Predictive resting energy expenditure (PREE) was calculated for each subject using age-appropriate equations (Schofield-HTWT, White). The study was approved by the hospital medical ethics committee and obtained parental written informed consent. The pediatric risk of mortality score 3 (PRISM3) and pediatric critical illness score (PCIS) were (7 ± 3) and (82 ± 4), respectively. MREE, Schofield-HTWT equation PREE and White equation PREE were (404.80 ± 178.28), (462.82 ± 160.38) and (427.97 ± 152.30) kcal/d, respectively; 70% were hypometabolic and 10% were hypermetabolic. MREE and PREE which were calculated using Schofield-HTWT equation and White equation, both were higher than MREE (P = 0.029). Correlation analysis was performed between PRISM3 and PCIS with MREE. There were no statistically significant correlation (P > 0.05). The hypometabolic response is apparent in critically ill children with mechanical ventilation; Schofield-HTWT equation and White equation could not predict energy requirements within acceptable clinical accuracy. In critically ill children undergoing mechanical ventilation, the energy expenditure is not correlated with the severity of illness.

RBC Storage Effect on Coagulation, Microparticles and Microchimerism in Critically Ill Patients

DTIC Science & Technology

2015-03-01

Award Number: W81XWH-11-2-0028 TITLE: “RBC Storage Effect on Coagulation, Microparticles and Microchimerism in Critically Ill Patients...27 DEC 2010 - 26 DEC 2015 – 4. TITLE AND SUBTITLE "“RBC Storage Effect on Coagulation, Microparticles and 5a. CONTRACT NUMBER Microchimerism in...15. SUBJECT TERMS RBC storage age; microchimerism; critically ill patients; coagulation; microparticles 16. SECURITY CLASSIFICATION OF: U 17

New insights into the gut as the driver of critical illness and organ failure

PubMed Central

Meng, Mei; Klingensmith, Nathan J.; Coopersmith, Craig M.

2017-01-01

Purpose of review The gut has long been hypothesized to be the “motor” of multiple organ dysfunction syndrome (MODS). This review serves as an update on new data elucidating the role of the gut as the propagator of organ failure in critical illness. Recent findings Under basal conditions, the gut absorbs nutrients and serves as a barrier that prevents approximately 40 trillion intraluminal microbes and their products from causing host injury. However, in critical illness, gut integrity is disrupted with hyperpermeability and increased epithelial apoptosis, allowing contamination of extraluminal sites that are ordinarily sterile. These alterations in gut integrity are further exacerbated in the setting of pre-existing co-morbidities. The normally commensal microflora is also altered in critical illness, with increases in microbial virulence and decreases in diversity, which leads to further pathologic responses within the host. Summary All components of the gut are adversely impacted by critical illness. Gut injury can not only propagate local damage, but can also cause distant injury and organ failure. Understanding how the multifaceted components of the gut interact and how these are perturbed in critical illness may play an important role in turning off the “motor” of MODS in the future. PMID:28092310

Timing of the initiation of parenteral nutrition in critically ill children.

PubMed

Jimenez, Lissette; Mehta, Nilesh M; Duggan, Christopher P

2017-05-01

To review the current literature evaluating clinical outcomes of early and delayed parenteral nutrition initiation among critically ill children. Nutritional management remains an important aspect of care among the critically ill, with enteral nutrition generally preferred. However, inability to advance enteral feeds to caloric goals and contraindications to enteral nutrition often leads to reliance on parenteral nutrition. The timing of parenteral nutrition initiation is varied among critically ill children, and derives from an assessment of nutritional status, energy requirements, and physiologic differences between adults and children, including higher nutrient needs and lower body reserves. A recent randomized control study among critically ill children suggests improved clinical outcomes with avoiding initiation of parenteral nutrition on day 1 of admission to the pediatric ICU. Although there is no consensus on the optimal timing of parenteral nutrition initiation among critically ill children, recent literature does not support the immediate initiation of parenteral nutrition on pediatric ICU admission. A common theme in the reviewed literature highlights the importance of accurate assessment of nutritional status and energy expenditure in deciding when to initiate parenteral nutrition. As with all medical interventions, the initiation of parenteral nutrition should be considered in light of the known benefits of judiciously provided nutritional support with the known risks of artificial, parenteral feeding.

Timing of the initiation of parenteral nutrition in critically ill children

PubMed Central

Jimenez, Lissette; Mehta, Nilesh M.; Duggan, Christopher

2018-01-01

Purpose of Review To review the current literature evaluating clinical outcomes of early and delayed parenteral nutrition initiation among critically ill children. Recent Findings Nutritional management remains an important aspect of care among the critically ill, with enteral nutrition (EN) generally preferred. However, inability to advance enteral feeds to caloric goals and contraindications to EN often leads to reliance on parenteral nutrition (PN). The timing of PN initiation is varied among critically ill children, and derives from an assessment of nutritional status, energy requirements, and physiologic differences between adults and children, including higher nutrient needs and lower body reserves. A recent randomized control study among critically ill children suggests improved clinical outcomes with postponing initiation of PN to 1 week after admission to the pediatric intensive care unit (PICU). Summary Although there is no consensus on the optimal timing of PN initiation among critically ill children, recent literature does not support the immediate initiation of PN on PICU admission. A common theme in the reviewed literature highlights the importance of accurate assessment of nutritional status and energy expenditure in deciding when to initiate PN. As with all medical interventions, the initiation of PN should be considered in light of the known benefits of judiciously provided nutritional support with the known risks of artificial, parenteral feeding. PMID:28376054

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

Gastric residual volume in critically ill patients: a dead marker or still alive?

PubMed

Elke, Gunnar; Felbinger, Thomas W; Heyland, Daren K

2015-02-01

Early enteral nutrition (EN) is consistently recommended as first-line nutrition therapy in critically ill patients since it favorably alters outcome, providing both nutrition and nonnutrition benefits. However, critically ill patients receiving mechanical ventilation are at risk for regurgitation, pulmonary aspiration, and eventually ventilator-associated pneumonia (VAP). EN may increase these risks when gastrointestinal (GI) dysfunction is present. Gastric residual volume (GRV) is considered a surrogate parameter of GI dysfunction during the progression of enteral feeding in the early phase of critical illness and beyond. By monitoring GRV, clinicians may detect patients with delayed gastric emptying earlier and intervene with strategies that minimize or prevent VAP as one of the major risks of EN. The value of periodic GRV measurements with regard to risk reduction of VAP incidence has frequently been questioned in the past years. Increasing the GRV threshold before interrupting gastric feeding results in marginal increases in EN delivery. More recently, a large randomized clinical trial revealed that abandoning GRV monitoring did not negatively affect clinical outcomes (including VAP) in mechanically ventilated patients. The results have revived the discussion on the role of GRV monitoring in critically ill, mechanically ventilated patients receiving early EN. This review summarizes the most recent clinical evidence on the use of GRV monitoring in critically ill patients. Based on the clinical evidence, it discusses the pros and cons and further addresses whether GRV is a dead marker or still alive for the nutrition management of critically ill patients. © 2014 American Society for Parenteral and Enteral Nutrition.

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. © 2016 American Society for Parenteral and Enteral Nutrition.

The epidemiology of chronic critical illness in the United States*.

PubMed

Kahn, Jeremy M; Le, Tri; Angus, Derek C; Cox, Christopher E; Hough, Catherine L; White, Douglas B; Yende, Sachin; Carson, Shannon S

2015-02-01

The epidemiology of chronic critical illness is not well characterized. We sought to determine the prevalence, outcomes, and associated costs of chronic critical illness in the United States. Population-based cohort study using data from the United States Healthcare Costs and Utilization Project from 2004 to 2009. Acute care hospitals in Massachusetts, North Carolina, Nebraska, New York, and Washington. Adult and pediatric patients meeting a consensus-derived definition for chronic critical illness, which included one of six eligible clinical conditions (prolonged acute mechanical ventilation, tracheotomy, stroke, traumatic brain injury, sepsis, or severe wounds) plus at least 8 days in an ICU. None. Out of 3,235,741 admissions to an ICU during the study period, 246,151 (7.6%) met the consensus definition for chronic critical illness. The most common eligibility conditions were prolonged acute mechanical ventilation (72.0% of eligible admissions) and sepsis (63.7% of eligible admissions). Among patients meeting chronic critical illness criteria through sepsis, the infections were community acquired in 48.5% and hospital acquired in 51.5%. In-hospital mortality was 30.9% with little change over the study period. The overall population-based prevalence was 34.4 per 100,000. The prevalence varied substantially with age, peaking at 82.1 per 100,000 individuals 75-79 years old but then declining coincident with a rise in mortality before day 8 in otherwise eligible patients. Extrapolating to the entire United States, for 2009, we estimated a total of 380,001 cases; 107,880 in-hospital deaths and $26 billion in hospital-related costs. Using a consensus-based definition, the prevalence, hospital mortality, and costs of chronic critical illness are substantial. Chronic critical illness is particularly common in the elderly although in very old patients the prevalence declines, in part because of an increase in early mortality among potentially eligible patients.

Chronic restraint stress after injury and shock is associated with persistent anemia despite prolonged elevation in erythropoietin levels.

PubMed

Bible, Letitia E; Pasupuleti, Latha V; Gore, Amy V; Sifri, Ziad C; Kannan, Kolenkode B; Mohr, Alicia M

2015-07-01

Following severe traumatic injury, critically ill patients have a prolonged hypercatacholamine state that is associated with bone marrow (BM) dysfunction and persistent anemia. However, current animal models of injury and shock result in a transient anemia. Daily restraint stress (chronic stress [CS]) has been shown to increase catecholamines. We hypothesize that adding CS following injury or injury and shock in rats will prolong the hypercatecholaminemia and prolong the initial anemia, despite elevated erythropoietin (EPO) levels. Male Sprague-Dawley rats (n = 6-8 per group) underwent lung contusion (LC) or combined LC/hemorrhagic shock (LCHS) followed by 6 days of CS. CS consisted of a 2-hour restraint period interrupted with repositioning and alarms every 30 minutes. At 7 days, urine was assessed for norepinephrine (NE) levels, blood for EPO and hemoglobin (Hgb), and BM for erythroid progenitor growth. Animals undergoing LC or combined LCHS predictably recovered by Day 7; urine NE, EPO, and Hgb levels were normal. The addition of CS to LC and LCHS models was associated with a significant elevation in NE on Day 6. The addition of CS to LC led to a persistent 20% to 25% decrease in the growth of BM hematopoietic progenitor cells. These findings were further exaggerated when CS was added following LCHS, resulting in a 20%q to 40% reduction in BM erythroid progenitor colony growth and a 20% decrease in Hgb when compared with LCHS alone. Exposing injured animals to CS results in prolonged elevation of NE and EPO, which is associated with worsening BM erythroid function and persistent anemia. Chronic restraint stress following injury and shock provides a clinically relevant model to further evaluate persistent injury-associated anemia seen in critically ill trauma patients. Furthermore, alleviating CS after severe injury is a potential therapeutic target to improve BM dysfunction and anemia.

Hospital-acquired Anemia in Critically Ill Dogs and Cats: A Multi-Institutional Study.

PubMed

Lynch, A M; Respess, M; Boll, A E; Bozych, M; McMichael, M; Fletcher, D J; De Laforcade, A M; Rozanski, E A

2016-01-01

Hospital-acquired anemia is commonly described in people but limited information currently is available regarding its prevalence in animals. Assess the prevalence of hospital-acquired anemia in hospitalized critically ill dogs and cats, and examine its relationship with phlebotomy practices, transfusion administration, and survival to discharge. Eight hundred and fifty-one client-owned animals (688 dogs and 163 cats). A multicenter, observational study was conducted in which packed cell volume (PCV) was recorded at the time of admission and on subsequent hospitalization days. Signalment, number of blood samples obtained, underlying disease, whether or not blood products were administered, duration of hospitalization, and survival to discharge were recorded. Admission anemia prevalence was 32%, with overall prevalence during the hospitalization period of 56%. The last recorded PCV was significantly lower than the admission PCV for both dogs (admission PCV, 42% [range, 6-67%]; last recorded PCV, 34% [range, 4-64%], P < .0001) and cats (admission PCV, 31% [range, 6-55%]; last recorded PCV, 26% [range, 10-46%], P < .0001). Patients that developed anemia had significantly more blood samples obtained (nonanemic, 5 blood samples [range, 2-54]; anemic, 7 blood samples [range, 2-49], P < .0001). Hospitalized cats were significantly more likely to develop anemia compared to dogs (P < .0001), but anemic dogs were significantly less likely to survive to discharge (P = .0001). Surgical patients were at higher risk of developing hospital-acquired anemia compared to medical patients (OR, 0.63; 95% CI, 0.4-0.9; P = .01). Hospital-acquired anemia occurred frequently, especially in surgical patients. Additional studies focused on the direct effect of phlebotomy practices on the likelihood of anemia development in hospitalized animals are warranted. Copyright © 2015 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals, Inc. on behalf of the American College of Veterinary Internal Medicine.

Chronic Restraint Stress after Injury and Shock is Associated with Persistent Anemia despite Prolonged Elevation in Erythropoietin Levels

PubMed Central

Bible, Letitia E.; Pasupuleti, Latha V.; Gore, Amy V.; Sifri, Ziad C.; Kannan, Kolenkode B.; Mohr, Alicia M.

2015-01-01

Background Following severe traumatic injury, critically ill patients have a prolonged hypercatacholamine state that is associated with bone marrow (BM) dysfunction and persistent anemia. However, current animal models of injury and shock result in a transient anemia. Daily restraint stress (CS) has been shown to increase catecholamines. We hypothesize that adding CS following injury or injury and shock in rats will prolong the hypercatecholaminemia, and prolong the initial anemia, despite elevated erythropoietin levels. Methods Male Sprague-Dawley Rats (N=6–8/group) underwent lung contusion (LC) or combined lung contusion/hemorrhagic shock (LCHS) followed by six days of chronic stress (CS). CS consisted of a two hour restraint period interrupted with repositioning and alarms every 30 minutes. At seven days, urine was assessed for norepinephrine (NE) levels, blood for erythropoietin (EPO) and hemoglobin (Hgb), and BM for erythroid progenitor growth. Results Animals undergoing LC or combined LCHS predictably recovered by day seven; urine NE, EPO and Hgb levels were normal. The addition of CS to LC and LCHS models was associated with a significant elevation in NE on day six. The addition of CS to LC led to a persistent 20–25% decrease in the growth of BM HPCs. These findings were further exaggerated when CS was added following LCHS, resulting in a 20–40% reduction in BM erythroid progenitor colony growth and a 20% decrease in Hgb when compared to LCHS alone. Conclusions Exposing injured animals to CS results in prolonged elevation of norepinephrine and erythropoietin which is associated with worsening BM erythroid function and persistent anemia. Chronic restraint stress following injury and shock provides a clinically relevant model to further evaluate persistent injury-associated anemia seen in critically ill trauma patients. Furthermore, alleviating chronic stress after severe injury is a potential therapeutic target to improve BM dysfunction and anemia. PMID:26091320

Translational research in immune senescence: Assessing the relevance of current models

PubMed Central

High, Kevin P.; Akbar, Arne N.; Nikolich-Zugich, Janko

2014-01-01

Advancing age is accompanied by profound changes in immune function; some are induced by the loss of critical niches that support development of naïve cells (e.g. thymic involution), others by the intrinsic physiology of long-lived cells attempting to maintain homeostasis, still others by extrinsic effects such as oxidative stress or long-term exposure to antigen due to persistent viral infections. Once compensatory mechanisms can no longer maintain a youthful phenotype the end result is the immune senescent milieu – one characterized by chronic, low grade, systemic inflammation and impaired responses to immune challenge, particularly when encountering new antigens. This state is associated with progression of chronic illnesses like atherosclerosis and dementia, and an increased risk of acute illness, disability and death in older adults. The complex interaction between immune senescence and chronic illness provides an ideal landscape for translational research with the potential to greatly affect human health. However, current animal models and even human investigative strategies for immune senescence have marked limitations, and the reductionist paradigm itself may be poorly suited to meet these challenges. A new paradigm, one that embraces complexity as a core feature of research in older adults is required to address the critical health issues facing the burgeoning senior population, the group that consumes the majority of healthcare resources. In this review, we outline the major advantages and limitations of current models and offer suggestions for how to move forward. PMID:22633440

Monocyte Profiles in Critically Ill Patients With Pseudomonas Aeruginosa Sepsis

ClinicalTrials.gov

2017-02-02

Pseudomonas Infections; Pseudomonas Septicemia; Pseudomonas; Pneumonia; Pseudomonal Bacteraemia; Pseudomonas Urinary Tract Infection; Pseudomonas Gastrointestinal Tract Infection; Sepsis; Sepsis, Severe; Critically Ill

Does artificial nutrition improve outcome of critical illness? An alternative viewpoint!

PubMed

Heyland, Daren K; Wischmeyer, Paul E

2013-08-27

Recent studies challenge the beneficial role of artificial nutrition provided to critically ill patients and point out the limitations of existing studies in this area. We take a differing view of the existing data and refute many of the arguments put forward by previous authors. We review the mechanistic, observational, and experimental data supporting a role for early enteral nutrition in the critically ill patient. We conclude without question that more, high-quality research is needed to better define the role of artificial nutrition in the critical care setting, but until then early and adequate delivery of enteral nutrition is a legitimate, evidence-based treatment recommendation and we see no evidence-based role for restricting enteral nutrition in critically ill patients. The role of early supplemental parenteral nutrition continues to be defined as new data emerge.

Glycated haemoglobin is increased in critically ill patients with stress hyperglycaemia: Implications for risk of diabetes in survivors of critical illness.

PubMed

Du, Yang T; Kar, Palash; Abdelhamid, Yasmine Ali; Horowitz, Michael; Deane, Adam M

2018-01-01

It remains uncertain if stress hyperglycaemia (SH) indicates a long-term predisposition to the development of type 2 diabetes. We conducted a retrospective observational study in critically ill patients and found SH to be associated with an increased HbA1c, which may indicate an increased risk of type 2 diabetes. Copyright © 2017 Elsevier B.V. All rights reserved.

A Capabilities Based Assessment of the United States Air Force Critical Care Air Transport Team

DTIC Science & Technology

2013-09-01

usually consist of a critical care physician, critical care nurse , and respiratory therapist. A Front-end Analysis has found several problems within...critically ill and wounded. This life-saving mission is executed by CCAT teams, which usually consist of a critical care physician, critical care nurse ...ill and wounded. This life-saving mission is executed by CCAT teams, which usually consist of a critical care physician, critical care nurse , and

[Bacterial parotitis in an immunocompromised patient in adult ICU].

PubMed

Vassal, O; Bernet, C; Wallet, F; Friggeri, A; Piriou, V

2013-09-01

Bacterial parotitis is a common childhood disease with a favorable outcome. Staphylococcus aureus is the most frequently involved pathogen. Clinical presentation in adult patients can be misleading, Onset occurs in patients with multiple comorbidities, making diagnosis difficult--particularly in ICU. Different pathogens are found in adults with worse outcomes observed. We report here the case of a critically ill patient and discuss diagnosis and management of bacterial parotitis. Copyright © 2013 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.

Sepsis and Critical Illness Research Center investigators: protocols and standard operating procedures for a prospective cohort study of sepsis in critically ill surgical patients

PubMed Central

Loftus, Tyler J; Mira, Juan C; Ozrazgat-Baslanti, Tezcan; Ghita, Gabriella L; Wang, Zhongkai; Stortz, Julie A; Brumback, Babette A; Bihorac, Azra; Segal, Mark S; Anton, Stephen D; Leeuwenburgh, Christiaan; Mohr, Alicia M; Efron, Philip A; Moldawer, Lyle L; Moore, Frederick A; Brakenridge, Scott C

2017-01-01

Introduction Sepsis is a common, costly and morbid cause of critical illness in trauma and surgical patients. Ongoing advances in sepsis resuscitation and critical care support strategies have led to improved in-hospital mortality. However, these patients now survive to enter state of chronic critical illness (CCI), persistent low-grade organ dysfunction and poor long-term outcomes driven by the persistent inflammation, immunosuppression and catabolism syndrome (PICS). The Sepsis and Critical Illness Research Center (SCIRC) was created to provide a platform by which the prevalence and pathogenesis of CCI and PICS may be understood at a mechanistic level across multiple medical disciplines, leading to the development of novel management strategies and targeted therapies. Methods Here, we describe the design, study cohort and standard operating procedures used in the prospective study of human sepsis at a level 1 trauma centre and tertiary care hospital providing care for over 2600 critically ill patients annually. These procedures include implementation of an automated sepsis surveillance initiative, augmentation of clinical decisions with a computerised sepsis protocol, strategies for direct exportation of quality-filtered data from the electronic medical record to a research database and robust long-term follow-up. Ethics and dissemination This study has been registered at ClinicalTrials.gov, approved by the University of Florida Institutional Review Board and is actively enrolling subjects. Dissemination of results is forthcoming. PMID:28765125

Measuring and Predicting Long-Term Outcomes in Older Survivors of Critical Illness

PubMed Central

Baldwin, Matthew R.

2015-01-01

Older adults (age ≥65 years) now initially survive what were previously fatal critical illnesses, but long-term mortality and disability after critical illness remain high. Most studies show that the majority of deaths among older ICU survivors occur during the first 6 to 12 months after hospital discharge. Recent studies of older ICU survivors have created a new standard for longitudinal critical care outcomes studies with a systematic evaluation of pre-critical illness comorbidities and disability and detailed assessments of physical and cognitive function after hospital discharge. These studies show that after controlling for pre-morbid health, older ICU survivors experience large and persistent declines in cognitive and physical function after critical illness. Long-term health-related quality-of-life studies suggest that some older ICU survivors may accommodate to a degree of physical disability and still report good emotional and social well-being, but these studies are subject to survivorship and proxy-response bias. In order to risk-stratify older ICU survivors for long-term (6–12 month) outcomes, we will need a paradigm shift in the timing and type of predictors measured. Emerging literature suggests that the initial acuity of critical illness will be less important, whereas pre-hospitalization estimates of disability and frailty, and, in particular, measures of comorbidity, frailty, and disability near the time of hospital discharge will be essential in creating reliable long-term risk-prediction models. PMID:24923682

Short- and long-term impact of critical illness on relatives: literature review.

PubMed

Paul, Fiona; Rattray, Janice

2008-05-01

This paper is a report of a literature review undertaken to identify the short- and long-term impact of critical illness on relatives. Patients in intensive care can experience physical and psychological consequences, and their relatives may also experience such effects. Although it is recognized that relatives have specific needs, it is not clear whether these needs are always met and whether further support is required, particularly after intensive care. The following databases were searched for the period 1950-2007: Medline, British Nursing Index and Archive, EMBASE, CINAHL, PsycINFO and EMB Reviews--Cochrane Central Register of Clinical Trials. Search terms focused on adult relatives of critically ill adult patients during and after intensive care. Recurrent topics were categorized to structure the review, i.e. 'relatives needs', 'meeting relatives' needs', 'interventions', 'satisfaction', 'psychological outcomes' and 'coping'. Studies have mainly identified relatives' immediate needs using the Critical Care Family Needs Inventory. There are few studies of interventions to meet relatives' needs and the short- and long-term effects of critical illness on relatives. Despite widespread use of the Critical Care Family Needs Inventory, factors such as local or cultural differences may influence relatives' needs. Relatives may also have unidentified needs, and these needs should be explored. Limited research has been carried out into interventions to meet relatives' needs and the effects of critical illness on their well-being, yet some relatives may experience negative psychological consequences far beyond the acute phase of the illness.

A Combined Early Cognitive and Physical Rehabilitation Program for People Who Are Critically Ill: The Activity and Cognitive Therapy in the Intensive Care Unit (ACT-ICU) Trial

PubMed Central

Jackson, James C.; Girard, Timothy D.; Pandharipande, Pratik P.; Schiro, Elena; Work, Brittany; Pun, Brenda T.; Boehm, Leanne; Gill, Thomas M.; Ely, E. Wesley

2012-01-01

Background In the coming years, the number of survivors of critical illness is expected to increase. These survivors frequently develop newly acquired physical and cognitive impairments. Long-term cognitive impairment is common following critical illness and has dramatic effects on patients' abilities to function autonomously. Neuromuscular weakness affects similar proportions of patients and leads to equally profound life alterations. As knowledge of these short-term and long-term consequences of critical illness has come to light, interventions to prevent and rehabilitate these devastating consequences have been sought. Physical rehabilitation has been shown to improve functional outcomes in people who are critically ill, but subsequent studies of physical rehabilitation after hospital discharge have not. Post-hospital discharge cognitive rehabilitation is feasible in survivors of critical illness and is commonly used in people with other forms of acquired brain injury. The feasibility of early cognitive therapy in people who are critically ill remains unknown. Objective The purpose of this novel protocol trial will be to determine the feasibility of early and sustained cognitive rehabilitation paired with physical rehabilitation in patients who are critically ill from medical and surgical intensive care units. Design This is a randomized controlled trial. Setting The setting for this trial will be medical and surgical intensive care units of a large tertiary care referral center. Patients The participants will be patients who are critically ill with respiratory failure or shock. Intervention Patients will be randomized to groups receiving usual care, physical rehabilitation, or cognitive rehabilitation plus physical rehabilitation. Twice-daily cognitive rehabilitation sessions will be performed with patients who are noncomatose and will consist of orientation, memory, and attention exercises (eg, forward and reverse digit spans, matrix puzzles, letter-number sequences, pattern recognition). Daily physical rehabilitation sessions will advance patients from passive range of motion exercises through ambulation. Patients with cognitive or physical impairment at discharge will undergo a 12-week, in-home cognitive rehabilitation program. Measurements A battery of neurocognitive and functional outcomes will be measured 3 and 12 months after hospital discharge. Conclusions If feasible, these interventions will lay the groundwork for a larger, multicenter trial to determine their efficacy. PMID:22577067

Multidrug-resistant Salmonella Typhimurium in Four Animal Facilities

PubMed Central

Wright, Jennifer G.; Tengelsen, Leslie A.; Smith, Kirk E.; Bender, Jeff B.; Frank, Rodney K.; Grendon, John H.; Rice, Daniel H.; Thiessen, Ann Marie B.; Gilbertson, Catherine Jo; Sivapalasingam, Sumathi; Barrett, Timothy J.; Besser, Thomas E.; Hancock, Dale D.

2005-01-01

In 1999 and 2000, 3 state health departments reported 4 outbreaks of gastrointestinal illness due to Salmonella enterica serotype Typhimurium in employees, clients, and client animals from 3 companion animal veterinary clinics and 1 animal shelter. More than 45 persons and companion animals became ill. Four independent investigations resulted in the testing of 19 human samples and >200 animal samples; 18 persons and 36 animals were culture-positive for S. Typhimurium. One outbreak was due to multidrug-resistant S. Typhimurium R-type ACKSSuT, while the other 3 were due to multidrug-resistant S. Typhimurium R-type ACSSuT DT104. This report documents nosocomial transmission of S. Typhimurium and demonstrates that companion animal facilities may serve as foci of transmission for salmonellae between animals and humans if adequate precautions are not followed. PMID:16102313

Impact of Anemia in Critically Ill Burned Casualties Evacuated From Combat Theater via US Military Critical Care Air Transport Teams.

PubMed

Hamilton, Joshua A; Mora, Alejandra G; Chung, Kevin K; Bebarta, Vikhyat S

2015-08-01

US military Critical Care Air Transport Teams (CCATT) transport critically ill burn patients out of theater. Blood transfusion may incur adverse effects, and studies report lower hemoglobin (Hgb) value may be safe for critically ill patients. There are no studies evaluating the optimal Hgb value for critically ill burn patients prior to CCATT evacuation. The aim of the study was to determine if critically ill burn casualties with an Hgb of 10 g/dL or less, transported via CCATT, have similar clinical outcomes at 30 days as compared with patients with an Hgb of greater than 10 g/dL. We conducted an institutional review board-approved retrospective cohort study involving patients transported via CCATT. We separated our study population into two cohorts based on Hgb levels at the time of theater evacuation: Hgb ≤10 g/dL or Hgb ≥10 g/dL. We compared demographics, injury description, physiologic parameters, and clinical outcomes. Of the 140 subjects enrolled, 29 were Hgb ≤10, and 111 were Hgb ≥10. Both groups were similar in age and percent total body surface area burned. Those Hgb ≤10 had a higher injury severity score (34 ± 19.8 vs. 25 ± 16.9, P = 0.02) and were more likely to have additional trauma (50% vs. 25%, P = 0.04). Modeling revealed no persistent differences in mortality, and other clinical outcomes measured. Critical Care Air Transport Teams transport of critically ill burn patients with an Hgb of 10 g/dL or less had no significant differences in complications or mortality as compared with patients with an Hgb of greater than 10 g/dL. In this study, lower hemoglobin levels did not confer greater risk for worse outcomes.

Proton pump inhibitor medication is associated with colonisation of gut flora in the oropharynx.

PubMed

Tranberg, A; Thorarinsdottir, H R; Holmberg, A; Schött, U; Klarin, B

2018-03-08

The normal body exists in mutualistic balance with a large range of microbiota. The primary goal of this study was to establish whether there is an imbalance in the oropharyngeal flora early after hospital or ICU admittance, and whether flora differs between control, ward and critically ill patients. The secondary goal was to explore whether there are patient characteristics that can be associated with a disturbed oropharyngeal flora. Oropharyngeal cultures were obtained from three different study groups: (1) controls from the community, (2) ward patients and (3) critically ill patients, the two latter within 24 h after admittance. Cultures were obtained from 487 individuals: 77 controls, 193 ward patients and 217 critically ill patients. Abnormal pharyngeal flora was more frequent in critically ill and ward patients compared with controls (62.2% and 10.4% vs. 1.3%, P < 0.001 and P = 0.010, respectively). Colonisation of gut flora in the oropharynx was more frequent in critically ill patients compared with ward patients or controls (26.3% vs. 4.7% and 1.3%, P < 0.001 and P < 0.001, respectively). Proton pump inhibitor medication was the strongest independent factor associated with the presence of gut flora in the oropharynx in both ward and critically ill patients (P = 0.030 and P = 0.044, respectively). This study indicates that abnormal oropharyngeal flora is an early and frequent event in hospitalised patients and more so in the critically ill, compared to controls. Proton pump inhibitor medication is associated with colonisation of gut flora in the oropharynx. © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

Exercise rehabilitation following hospital discharge in survivors of critical illness: an integrative review

PubMed Central

2012-01-01

Although clinical trials have shown benefit from early rehabilitation within the ICU, rehabilitation of patients following critical illness is increasingly acknowledged as an area of clinical importance. However, despite recommendations from published guidelines for rehabilitation to continue following hospital discharge, there is limited evidence to underpin practice during this intermediate stage of recovery. Those patients with ICU-acquired weakness on discharge from the ICU are most likely to benefit from ongoing rehabilitation. Despite this, screening based on strength alone may fail to account for the associated level of physical functioning, which may not correlate with muscle strength, nor address non-physical complications of critical illness. The aim of this review was to consider which patients are likely to require rehabilitation following critical illness and to perform an integrative review of the available evidence of content and nature of exercise rehabilitation programmes for survivors of critical illness following hospital discharge. Literature databases and clinical trials registries were searched using appropriate terms and groups of terms. Inclusion criteria specified the reporting of rehabilitation programmes for patients following critical illness post-hospital discharge. Ten items, including data from published studies and protocols from trial registries, were included. Because of the variability in study methodology and inadequate level of detail of reported exercise prescription, at present there can be no clear recommendations for clinical practice from this review. As this area of clinical practice remains in its relative infancy, further evidence is required both to identify which patients are most likely to benefit and to determine the optimum content and format of exercise rehabilitation programmes for patients following critical illness post-hospital discharge. PMID:22713336

Arginine appearance and nitric oxide synthesis in critically ill infants can be increased with a protein-energy–enriched enteral formula12345

PubMed Central

de Betue, Carlijn TI; Joosten, Koen FM; Deutz, Nicolaas EP; Vreugdenhil, Anita CE; van Waardenburg, Dick A

2013-01-01

Background: Arginine is considered an essential amino acid during critical illness in children, and supplementation of arginine has been proposed to improve arginine availability to facilitate nitric oxide (NO) synthesis. Protein-energy–enriched enteral formulas (PE-formulas) can improve nutrient intake and promote anabolism in critically ill infants. However, the effect of increased protein and energy intake on arginine metabolism is not known. Objective: We investigated the effect of a PE-formula compared with that of a standard infant formula (S-formula) on arginine kinetics in critically ill infants. Design: A 2-h stable-isotope tracer protocol was conducted in 2 groups of critically ill infants with respiratory failure because of viral bronchiolitis, who received either a PE-formula (n = 8) or S-formula (n = 10) in a randomized, blinded, controlled setting. Data were reported as means ± SDs. Results: The intake of a PE-formula in critically ill infants (aged 0.23 ± 0.14 y) resulted in an increased arginine appearance (PE-formula: 248 ± 114 μmol · kg−1 · h−1; S-formula: 130 ± 53 μmol · kg−1 · h−1; P = 0.012) and NO synthesis (PE-formula: 1.92 ± 0.99 μmol · kg−1 · h−1; S-formula: 0.84 ± 0.36 μmol · kg−1 · h−1; P = 0.003), whereas citrulline production and plasma arginine concentrations were unaffected. Conclusion: In critically ill infants with respiratory failure because of viral bronchiolitis, the intake of a PE-formula increases arginine availability by increasing arginine appearance, which leads to increased NO synthesis, independent of plasma arginine concentrations. This trial was registered at www.trialregister.nl as NTR515. PMID:23945723

Feasibility and safety of virtual-reality-based early neurocognitive stimulation in critically ill patients.

PubMed

Turon, Marc; Fernandez-Gonzalo, Sol; Jodar, Mercè; Gomà, Gemma; Montanya, Jaume; Hernando, David; Bailón, Raquel; de Haro, Candelaria; Gomez-Simon, Victor; Lopez-Aguilar, Josefina; Magrans, Rudys; Martinez-Perez, Melcior; Oliva, Joan Carles; Blanch, Lluís

2017-12-01

Growing evidence suggests that critical illness often results in significant long-term neurocognitive impairments in one-third of survivors. Although these neurocognitive impairments are long-lasting and devastating for survivors, rehabilitation rarely occurs during or after critical illness. Our aim is to describe an early neurocognitive stimulation intervention based on virtual reality for patients who are critically ill and to present the results of a proof-of-concept study testing the feasibility, safety, and suitability of this intervention. Twenty critically ill adult patients undergoing or having undergone mechanical ventilation for ≥24 h received daily 20-min neurocognitive stimulation sessions when awake and alert during their ICU stay. The difficulty of the exercises included in the sessions progressively increased over successive sessions. Physiological data were recorded before, during, and after each session. Safety was assessed through heart rate, peripheral oxygen saturation, and respiratory rate. Heart rate variability analysis, an indirect measure of autonomic activity sensitive to cognitive demands, was used to assess the efficacy of the exercises in stimulating attention and working memory. Patients successfully completed the sessions on most days. No sessions were stopped early for safety concerns, and no adverse events occurred. Heart rate variability analysis showed that the exercises stimulated attention and working memory. Critically ill patients considered the sessions enjoyable and relaxing without being overly fatiguing. The results in this proof-of-concept study suggest that a virtual-reality-based neurocognitive intervention is feasible, safe, and tolerable, stimulating cognitive functions and satisfying critically ill patients. Future studies will evaluate the impact of interventions on neurocognitive outcomes. Trial registration Clinical trials.gov identifier: NCT02078206.

Preload assessment and optimization in critically ill patients.

PubMed

Voga, Gorazd

2010-01-01

Preload assessment and optimization is the basic hemodynamic intervention in critically ill. Beside clinical assessment, non-invasive or invasive assessment by measurement of various pressure or volume hemodynamic variables, are helpful for estimation of preload and fluid responsiveness. The use of dynamic variables is useful in particular subgroup of critically ill patients. In patients with inadequate preload, fluid responsiveness and inadequate flow, treatment with crystalloids or colloids is mandatory. When rapid hemodynamic response is necessary colloids are preferred.

Calcium supplementation improves clinical outcome in intensive care unit patients: a propensity score matched analysis of a large clinical database MIMIC-II.

PubMed

Zhang, Zhongheng; Chen, Kun; Ni, Hongying

2015-01-01

Observational studies have linked hypocalcemia with adverse clinical outcome in critically ill patients. However, calcium supplementation has never been formally investigated for its beneficial effect in critically ill patients. To investigate whether calcium supplementation can improve 28-day survival in adult critically ill patients. Secondary analysis of a large clinical database consisting over 30,000 critical ill patients was performed. Multivariable analysis was performed to examine the independent association of calcium supplementation and 28-day morality. Furthermore, propensity score matching technique was employed to investigate the role of calcium supplementation in improving survival. none. Primary outcome was the 28-day mortality. 90-day mortality was used as secondary outcome. A total of 32,551 adult patients, including 28,062 survivors and 4489 non-survivors (28-day mortality rate: 13.8 %) were included. Calcium supplementation was independently associated with improved 28-day mortality after adjusting for confounding variables (hazard ratio: 0.51; 95 % CI 0.47-0.56). Propensity score matching was performed and the after-matching cohort showed well balanced covariates. The results showed that calcium supplementation was associated with improved 28- and 90-day mortality (p < 0.05 for both Log-rank test). In adult critically ill patients, calcium supplementation during their ICU stay improved 28-day survival. This finding supports the use of calcium supplementation in critically ill patients.

The Predictive Prognostic Values of Serum TNF-α in Comparison to SOFA Score Monitoring in Critically Ill Patients

PubMed Central

Yousef, Ayman Abd Al-Maksoud; Suliman, Ghada Abdulmomen

2013-01-01

Background. The use of inflammatory markers to follow up critically ill patients is controversial. The short time frame, the need for frequent and serial measurement of biomarkers, the presence of soluble receptor and their relatively high cost are the major drawbacks. Our study's objective is to compare the prognostic values of serum TNF-α and SOFA score monitoring in critically ill patients. Patients and Methods. A total of ninety patients were included in the study. Forty-five patients developed septic complication (sepsis group). Forty-five patients were critically ill without evidence of infectious organism (SIRS group). Patients' data include clinical status, central venous pressure, and laboratory analysis were measured. A serum level of TNF-α and SOFA score were monitored. Results. Monitoring of TNF-α revealed significant elevation of TNF-α at 3rd and 5th days of ICU admission in both groups. Monitoring of SOFA score revealed significant elevation of SOFA scores in both groups throughout their ICU stay, particularly in nonsurvivors. Positive predictive ability of SOFA score was demonstrated in critically ill patients. Conclusion. Transient significant increase in serum levels of TNF-α were detected in septic patients. Persistent elevation of SOFA score was detected in nonsurvivor septic patients. SOFA score is an independent prognostic value in critically ill patients. PMID:24175285

Sarcopenia and critical illness: a deadly combination in the elderly.

PubMed

Hanna, Joseph S

2015-03-01

Sarcopenia is the age-associated loss of lean skeletal muscle mass. It is the result of multiple physiologic derangements, ultimately resulting in an insidious functional decline. Frailty, the clinical manifestation of sarcopenia and physical infirmity, is associated with significant morbidity and mortality in the elderly population. The underlying pathology results in a disruption of the individual's ability to tolerate internal and external stressors such as injury or illness. This infirmity results in a markedly increased risk of falls and subsequent morbidity and mortality from the resulting traumatic injury, as well as an inability to recover from medical insults, resulting in critical illness. The increasing prevalence of sarcopenia and critical illness in the elderly has resulted in a deadly intersection of disease processes. The lethality of this combination appears to be the result of altered muscle metabolism, decreased mitochondrial energetics needed to survive critical illness, and a chronically activated catabolic state likely mediated by tumor necrosis factor-α. Furthermore, these underlying derangements are independently associated with an increased incidence of critical illness, resulting in a progressive downward spiral. Considerable evidence has been gathered supporting the role of aggressive nutrition support and physical therapy in improving outcomes. Critical care practitioners must consider sarcopenia and the resulting frailty phenotype a comorbid condition so that the targeted interventions can be instituted and research efforts focused. © 2015 American Society for Parenteral and Enteral Nutrition.

Parenteral or Enteral Arginine Supplementation Safety and Efficacy.

PubMed

Rosenthal, Martin D; Carrott, Phillip W; Patel, Jayshil; Kiraly, Laszlo; Martindale, Robert G

2016-12-01

Arginine supplementation has the potential to improve the health of patients. Its use in hospitalized patients has been a controversial topic in the nutrition literature, especially concerning supplementation of septic patients. In this article, we review the relevant literature both for and against the use of arginine in critically ill, surgical, and hospitalized patients. The effect of critical illness on arginine metabolism is reviewed, as is its use in septic and critically ill patients. Although mounting evidence supports immunonutrition, there are only a few studies that suggest that this is safe in patients with severe sepsis. The use of arginine has been shown to benefit a variety of critically ill patients. It should be considered for inclusion in combinations of immunonutrients or commercial formulations for groups in whom its benefit has been reported consistently, such as those who have suffered trauma and those in acute surgical settings. The aims of this review are to discuss the role of arginine in health, the controversy surrounding arginine supplementation of septic patients, and the use of arginine in critically ill patients. © 2016 American Society for Nutrition.

Is refeeding syndrome relevant for critically ill patients?

PubMed

Koekkoek, Wilhelmina A C; Van Zanten, Arthur R H

2018-03-01

To summarize recent relevant studies regarding refeeding syndrome (RFS) in critically ill patients and provide recommendations for clinical practice. Recent knowledge regarding epidemiology of refeeding syndrome among critically ill patients, how to identify ICU patients at risk, and strategies to reduce the potential negative impact on outcome are discussed. RFS is a potentially fatal acute metabolic derangement that ultimately can result in marked morbidity and even mortality. These metabolic derangements in ICU patients differ from otherwise healthy patients with RFS, as there is lack of anabolism. This is because of external stressors inducing a hypercatabolic response among other reasons also reflected by persistent high glucagon despite initiation of feeding. Lack of a proper uniform definition complicates diagnosis and research of RFS. However, refeeding hypophosphatemia is commonly encountered during critical illness. The correlations between risk factors proposed by international guidelines and the occurrence of RFS in ICU patients remains unclear. Therefore, regular phosphate monitoring is recommended. Based on recent trials among critically ill patients, only treatment with supplementation of electrolytes and vitamins seems not sufficient. In addition, caloric restriction for several days and gradual increase of caloric intake over days is recommendable.

Intensive Care and its Discontents: Psychiatric Illness in the Critically Ill.

PubMed

Hashmi, Ali M; Han, Jin Y; Demla, Vishal

2017-09-01

Critically ill patients can develop a host of cognitive and psychiatric complaints during their intensive care unit (ICU) stay, many of which persist for weeks or months following discharge from the ICU and can seriously affect their quality of life, including their ability to return to work. This article describes some common psychiatric problems encountered by clinicians in the ICU, including their assessment and management. A comprehensive approach is needed to decrease patient suffering, improve morbidity and mortality, and ensure that critically ill patients can return to the highest quality of life after an ICU stay. Copyright © 2017 Elsevier Inc. All rights reserved.

Pseudomembranous aspergillar tracheobronchitis in a non-neutropenic critically ill patient in the intensive care unit

PubMed Central

Khalid, Sameen; -Rahman, FNU Asad-ur; Abbass, Aamer; Aldarondo, Sigfredo; Abusaada, Khalid

2017-01-01

ABSTRACT Invasive aspergillosis is an important cause of morbidity and mortality among immunocompromised patients. Prolonged neutropenia is the most common risk factor. It has rarely been reported to occur in non-neutropenic critically ill patients in the intensive care unit setting. Mortality rate in this group has been reported to be as high as 92%. We report a case of tracheobronchial aspergillosis in a non-neutropenic critically ill patient to highlight the fact that critically ill patients admitted in the intensive care unit can develop opportunistic infections such as invasive aspergillosis even in the absence of classic risk factors and prior history of immunosuppression. Early diagnosis and prompt initiation of antifungal therapy may improve the outcome and decrease mortality rate. PMID:28634525

Occupational Risks during a Monkeypox Outbreak, Wisconsin, 2003

PubMed Central

Sotir, Mark J.; Williams, Carl J.; Kazmierczak, James J.; Wegner, Mark V.; Rausch, Darren; Graham, Mary Beth; Foldy, Seth L.; Wolters, Mat; Damon, Inger K.; Karem, Kevin L.; Davis, Jeffrey P.

2007-01-01

We determined factors associated with occupational transmission in Wisconsin during the 2003 outbreak of prairie dog–associated monkeypox virus infections. Our investigation included active contact surveillance, exposure-related interviews, and a veterinary facility cohort study. We identified 19 confirmed, 5 probable, and 3 suspected cases. Rash, headache, sweats, and fever were reported by >80% of patients. Occupationally transmitted infections occurred in 12 veterinary staff, 2 pet store employees, and 2 animal distributors. The following were associated with illness: working directly with animal care (p = 0.002), being involved in prairie dog examination, caring for an animal within 6 feet of an ill prairie dog (p = 0.03), feeding an ill prairie dog (p = 0.002), and using an antihistamine (p = 0.04). Having never handled an ill prairie dog (p = 0.004) was protective. Veterinary staff used personal protective equipment sporadically. Our findings underscore the importance of standard veterinary infection-control guidelines. PMID:17953084

Does RBC Storage Age Effect Inflammation, Immune Function and Susceptibility to Transfusion Associated Microchimerism in Critically Ill Patients? Adverse Effects of RBC Storage in Critically Ill Patients

DTIC Science & Technology

2014-12-01

repository; Microparticles ; Coagulation; Microchimerism 16. SECURITY CLASSIFICATION OF: U 17. LIMITATION OF ABSTRACT 18. NUMBER OF PAGES 11 19a. NAME...inflammation, coagulation, microparticle concentrations and microchimerism. Since the last annual report, preliminary data from the ABLE trial have...function correlate with clinical outcomes. 1b.) To determine if RBC unit storage time affects microparticle concentrations in the critically ill and if

Is the glutamine story over?

PubMed

Smedberg, Marie; Wernerman, Jan

2016-11-10

Glutamine has been launched as a conditionally indispensible amino acid for the critically ill. Supplementation has been recommended in guidelines from international societies. Although data have been presented pointing out that glutamine supplementation may not be for everybody, recommendations for treatments and design of study protocols have included all critically ill patients. Results from more recent studies and meta-analyses indicate that indiscriminate use of glutamine supplementation in critically ill patients may actually cause harm rather than beneficial effects. This viewpoint sorts out arguments of controversy in the glutamine story.

Severe Hemorrhagic Fever in Strain 13/N Guinea Pigs Infected with Lujo Virus

PubMed Central

Bird, Brian H.; Dodd, Kimberly A.; Erickson, Bobbie R.; Albariño, César G.; Chakrabarti, Ayan K.; McMullan, Laura K.; Bergeron, Eric; Ströeher, Ute; Cannon, Deborah; Martin, Brock; Coleman-McCray, JoAnn D.; Nichol, Stuart T.; Spiropoulou, Christina F.

2012-01-01

Lujo virus (LUJV) is a novel member of the Arenaviridae family that was first identified in 2008 after an outbreak of severe hemorrhagic fever (HF). In what was a small but rapidly progressing outbreak, this previously unknown virus was transmitted from the critically ill index patient to 4 attending healthcare workers. Four persons died during this outbreak, for a total case fatality of 80% (4/5). The suspected rodent source of the initial exposure to LUJV remains a mystery. Because of the ease of transmission, high case fatality, and novel nature of LUJV, we sought to establish an animal model of LUJV HF. Initial attempts in mice failed, but infection of inbred strain 13/N guinea pigs resulted in lethal disease. A total of 41 adult strain 13/N guinea pigs were infected with either wild-type LUJV or a full-length recombinant LUJV. Results demonstrated that strain 13/N guinea pigs provide an excellent model of severe and lethal LUJV HF that closely resembles what is known of the human disease. All infected animals experienced consistent weight loss (3–5% per day) and clinical illness characterized by ocular discharge, ruffled fur, hunched posture, and lethargy. Uniform lethality occurred by 11–16 days post-infection. All animals developed disseminated LUJV infection in various organs (liver, spleen, lung, and kidney), and leukopenia, lymphopenia, thrombocytopenia, coagulopathy, and elevated transaminase levels. Serial euthanasia studies revealed a temporal pattern of virus dissemination and increasing severity of disease, primarily targeting the liver, spleen, lungs, and lower gastrointestinal tract. Establishing an animal LUJV model is an important first step towards understanding the high pathogenicity of LUJV and developing vaccines and antiviral therapeutic drugs for this highly transmissible and lethal emerging pathogen. PMID:22953019

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 journey of survival and provide appropriate support. Further empirical research is warranted to explore the deficits identified with the existing literature. PMID:24147805

Management of Chronic Kidney Disease Patients in the Intensive Care Unit: Mixing Acute and Chronic Illness.

PubMed

De Rosa, Silvia; Samoni, Sara; Villa, Gianluca; Ronco, Claudio

2017-01-01

Patients with chronic kidney disease (CKD) are at high risk for developing critical illness and for admission to intensive care units (ICU). 'Critically ill CKD patients' frequently develop an acute worsening of renal function (i.e. acute-on-chronic, AoC) that contributes to long-term kidney dysfunction, potentially leading to end-stage kidney disease (ESKD). An integrated multidisciplinary effort is thus necessary to adequately manage the multi-organ damage of those kidney patients and contemporaneously reduce the progression of kidney dysfunction when they are critically ill. The aim of this review is to describe (1) the pathophysiological mechanisms underlying the development of AoC kidney dysfunction and its role in the progression toward ESKD; (2) the most common clinical presentations of critical illness among CKD/ESKD patients; and (3) the continuum of care for CKD/ESKD patients from maintenance hemodialysis/peritoneal dialysis to acute renal replacement therapy performed in ICU and, vice-versa, for AoC patients who develop ESKD. © 2017 S. Karger AG, Basel.

Approach to critical illness polyneuropathy and myopathy.

PubMed

Pati, S; Goodfellow, J A; Iyadurai, S; Hilton-Jones, D

2008-07-01

A newly acquired neuromuscular cause of weakness has been found in 25-85% of critically ill patients. Three distinct entities have been identified: (1) critical illness polyneuropathy (CIP); (2) acute myopathy of intensive care (itself with three subtypes); and (3) a syndrome with features of both 1 and 2 (called critical illness myopathy and/or neuropathy or CRIMYNE). CIP is primarily a distal axonopathy involving both sensory and motor nerves. Electroneurography and electromyography (ENG-EMG) is the gold standard for diagnosis. CIM is a proximal as well as distal muscle weakness affecting both types of muscle fibres. It is associated with high use of non-depolarising muscle blockers and corticosteroids. Avoidance of systemic inflammatory response syndrome (SIRS) is the most effective way to reduce the likelihood of developing CIP or CIM. Outcome is variable and depends largely on the underlying illness. Detailed history, careful physical examination, review of medication chart and analysis of initial investigations provides invaluable clues towards the diagnosis.

Endoscopic colostomy with percutaneous colopexy: an animal feasibility study.

PubMed

Bustamante-Lopez, Leonardo Alfonso; Sulbaran, Marianny; Nahas, Sergio Carlos; de Moura, Eduardo Guimaraes Horneaux; Nahas, Caio Sergio; Marques, Carlos Frederico; Sakai, Christiano; Cecconello, Ivan; Sakai, Paulo

2017-04-01

Indications for colostomy in colorectal diseases are obstruction of the large bowel, such as in cancer, diverticular disease in the acute phase, post-radiotherapy enteritis, complex perirectal fistulas, anorectal trauma and severe anal incontinence. Some critically ill patients cannot tolerate an exploratory laparotomy, and laparoscopic assisted colostomy also requires general anesthesia. To evaluate the feasibility, safety and efficacy of performing colostomy assisted by colonoscopy and percutaneous colopexy. Five pigs underwent endoscopic assisted colostomy with percutaneous colopexy. Animals were evaluated in post-operative days 1, 2, 5 and 7 for feeding acceptance and colostomy characteristics. On day 7 full colonoscopy was performed on animals followed by exploratory laparotomy. Average procedure time was 27 minutes (21-54 min). Postoperative mobility and feeding of animals were immediate after anesthesia recovery. Position of the colostomy, edges color, appearance of periostomal area, as well as its function was satisfactory in four animals. Retraction of colostomy was present in one pig. The colonoscopy and laparotomy control on the seventh day were considered as normal. A bladder perforation that was successfully repaired through the colostomy incision occurred in one pig. The main limitation of this study is its experimental nature. Endoscopic assisted colostomy with percutaneous colopexy proves to be a safe and effective method with low morbidity for performing colostomy in experimental animals, with possible clinical application in humans.

Sepsis and Critical Illness Research Center investigators: protocols and standard operating procedures for a prospective cohort study of sepsis in critically ill surgical patients.

PubMed

Loftus, Tyler J; Mira, Juan C; Ozrazgat-Baslanti, Tezcan; Ghita, Gabriella L; Wang, Zhongkai; Stortz, Julie A; Brumback, Babette A; Bihorac, Azra; Segal, Mark S; Anton, Stephen D; Leeuwenburgh, Christiaan; Mohr, Alicia M; Efron, Philip A; Moldawer, Lyle L; Moore, Frederick A; Brakenridge, Scott C

2017-08-01

Sepsis is a common, costly and morbid cause of critical illness in trauma and surgical patients. Ongoing advances in sepsis resuscitation and critical care support strategies have led to improved in-hospital mortality. However, these patients now survive to enter state of chronic critical illness (CCI), persistent low-grade organ dysfunction and poor long-term outcomes driven by the persistent inflammation, immunosuppression and catabolism syndrome (PICS). The Sepsis and Critical Illness Research Center (SCIRC) was created to provide a platform by which the prevalence and pathogenesis of CCI and PICS may be understood at a mechanistic level across multiple medical disciplines, leading to the development of novel management strategies and targeted therapies. Here, we describe the design, study cohort and standard operating procedures used in the prospective study of human sepsis at a level 1 trauma centre and tertiary care hospital providing care for over 2600 critically ill patients annually. These procedures include implementation of an automated sepsis surveillance initiative, augmentation of clinical decisions with a computerised sepsis protocol, strategies for direct exportation of quality-filtered data from the electronic medical record to a research database and robust long-term follow-up. This study has been registered at ClinicalTrials.gov, approved by the University of Florida Institutional Review Board and is actively enrolling subjects. Dissemination of results is forthcoming. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Relationship Between Beta Cell Dysfunction and Severity of Disease Among Critically Ill Children: A STROBE-Compliant Prospective Observational Study.

PubMed

Liu, Ping-Ping; Lu, Xiu-Lan; Xiao, Zheng-Hui; Qiu, Jun; Zhu, Yi-Min

2016-05-01

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, gender, myocardial injury, and lung injury. For instance, compared with group I, the multivariate-adjusted odds ratio (95% confidence interval) for developing septic shock was 2.17 (0.59, 8.02), 2.94 (2.18, 6.46), and 2.76 (1.18, 6.46) among patients in group II, III, and IV, respectively.Beta cell dysfunction reflected the severity of disease among critically ill children. Therefore, assessment of beta cell function is critically important to reduce incidence of adverse events in PICU.

The Critical Care Obesity Paradox and Implications for Nutrition Support.

PubMed

Patel, Jayshil J; Rosenthal, Martin D; Miller, Keith R; Codner, Panna; Kiraly, Laszlo; Martindale, Robert G

2016-09-01

Obesity is a leading cause of preventable death worldwide. The prevalence of obesity has been increasing and is associated with an increased risk for other co-morbidities. In the critical care setting, nearly one third of patients are obese. Obese critically ill patients pose significant physical and on-physical challenges to providers, including optimization of nutrition therapy. Intuitively, obese patients would have worse critical care-related outcome. On the contrary, emerging data suggests that critically ill obese patients have improved outcomes, and this phenomenon has been coined "the obesity paradox." The purposes of this review will be to outline the historical views and pathophysiology of obesity and epidemiology of obesity, describe the challenges associated with obesity in the intensive care unit setting, review critical care outcomes in the obese, define the obesity-critical care paradox, and identify the challenges and role of nutrition support in the critically ill obese patient.

Timing of onset and burden of persistent critical illness in Australia and New Zealand: a retrospective, population-based, observational study.

PubMed

Iwashyna, Theodore J; Hodgson, Carol L; Pilcher, David; Bailey, Michael; van Lint, Allison; Chavan, Shaila; Bellomo, Rinaldo

2016-07-01

Critical care physicians recognise persistent critical illness as a specific syndrome, yet few data exist for the timing of the transition from acute to persistent critical illness. Defining the onset of persistent critical illness as the time at which diagnosis and illness severity at intensive care unit (ICU) arrival no longer predict outcome better than do simple pre-ICU patient characteristics, we measured the timing of this onset at a population level in Australia and New Zealand, and the variation therein, and assessed the characteristics, burden of care, and hospital outcomes of patients with persistent critical illness. In this retrospective, population-based, observational study, we used data for ICU admission in Australia and New Zealand from the Australian and New Zealand Intensive Care Society Adult Patient Database. We included all patients older than 16 years of age admitted to a participating ICU. We excluded patients transferred from another hospital and those admitted to an ICU for palliative care or awaiting organ donation. The primary outcome was in-hospital mortality. Using statistical methods in evenly split development and validation samples for risk score development, we examined the ability of characteristics to predict in-hospital mortality. Between Jan, 2000, and Dec, 2014, we studied 1 028 235 critically ill patients from 182 ICUs across Australia and New Zealand. Among patients still in an ICU, admission diagnosis and physiological derangements, which accurately predicted outcome on admission (area under the receiver operating characteristics curve 0·898 [95% CI 0·897-0·899] in the validation cohort), progressively lost their predictive ability and no longer predicted outcome more accurately than did simple antecedent patient characteristics (eg, age, sex, or chronic health status) after 10 days in the ICU, thus empirically defining the onset of persistent critical illness. This transition occurred between day 7 and day 22 across diagnosis-based subgroups and between day 6 and day 15 across risk-of-death-based subgroups. Cases of persistent critical illness accounted for only 51 509 (5·0%) of the 1 028 235 patients admitted to an ICU, but for 1 029 345 (32·8%) of 3 138 432 ICU bed-days and 2 197 108 (14·7%) of 14 961 693 hospital bed-days. Overall, 12 625 (24·5%) of 51 509 patients with persistent critical illness died and only 23 968 (46·5%) of 51 509 were discharged home. Onset of persistent critical illness can be empirically measured at a population level. Patients with this condition consume vast resources, have high mortality, have much less chance of returning home than do typical ICU patients, and require dedicated future research. ICU clinicians should be aware that the risk of in-hospital mortality can change quickly over the first 2 weeks of an ICU course and be sure to incorporate such changes in their decision making and prognostication. None. Copyright © 2016 Elsevier Ltd. All rights reserved.

Haemato-oncology patients' perceptions of health-related quality of life after critical illness: A qualitative phenomenological study.

PubMed

O'Gara, Geraldine; Tuddenham, Simon; Pattison, Natalie

2018-02-01

Haemato-oncology patients often require critical care support due to side-effects of treatment. Discharge can mark the start of an uncertain journey due to the impact of critical illness on health-related quality of life. Qualitatively establishing needs is a priority as current evidence is limited. To qualitatively explore perceptions of haemato-oncology patients' health-related quality of life after critical illness and explore how healthcare professionals can provide long-term support. Nine in-depth interviews were conducted three to eighteen months post-discharge from critical care. Phenomenology was used to gain deeper understanding of the patients' lived experience. A 19-bedded Intensive Care Unit in a specialist cancer centre. Five major themes emerged: Intensive care as a means to an end; Rollercoaster of illness; Reliance on hospital; Having a realistic/sanguine approach; Living in the moment. Haemato-oncology patients who experience critical illness may view it as a small part of a larger treatment pathway, thus health-related quality of life is impacted by this rather than the acute episode. Discharge from the intensive care unit can be seen as a positive end-point, allowing personal growth in areas such as relationships and living life to the full. The contribution of health-care professionals and support of significant others is regarded as critical to the recovery experience. Copyright © 2017 Elsevier Ltd. All rights reserved.

Effects of an Integrative Nursing Intervention on Pain in Critically Ill Patients: A Pilot Clinical Trial.

PubMed

Papathanassoglou, Elizabeth D E; Hadjibalassi, Maria; Miltiadous, Panagiota; Lambrinou, Ekaterini; Papastavrou, Evridiki; Paikousis, Lefkios; Kyprianou, Theodoros

2018-05-01

Pain, a persistent problem in critically ill patients, adversely affects outcomes. Despite recommendations, no evidence-based nonpharmacological approaches for pain treatment in critically ill patients have been developed. To investigate the effects of a multimodal integrative intervention on the incidence of pain and on secondary outcomes: intensity of pain, hemodynamic indices (systolic and mean arterial pressure, heart rate), anxiety, fear, relaxation, optimism, and sleep quality. A randomized, controlled, double-blinded repeated-measures trial with predetermined eligibility criteria was conducted. The intervention included relaxation, guided imagery, moderate pressure massage, and listening to music. The primary outcome was incidence of pain (score on Critical Care Pain Observation Tool > 2). Other outcomes included pain ratings, hemodynamic measurements, self-reported psychological outcomes, and quality of sleep. Repeated-measures models with adjustments (baseline levels, confounders) were used. Among the 60 randomized critically ill adults in the sample, the intervention group experienced significant decreases in the incidence ( P = .003) and ratings of pain ( P < .001). Adjusted models revealed a significant trend for lower incidence ( P = .002) and ratings ( P < .001) of pain, systolic arterial pressure ( P < .001), anxiety ( P = .01), and improved quality of sleep ( P = .02). A multimodal integrative intervention may be effective in decreasing pain and improving pain-related outcomes in critically ill patients. © 2018 American Association of Critical-Care Nurses.

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

PubMed Central

Klingensmith, Nathan J.; Coopersmith, Craig M.

2015-01-01

Synopsis 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

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. Copyright © 2016 Elsevier Inc. All rights reserved.

The role of nutritional support in the physical and functional recovery of critically ill patients: a narrative review.

PubMed

Bear, Danielle E; Wandrag, Liesl; Merriweather, Judith L; Connolly, Bronwen; Hart, Nicholas; Grocott, Michael P W

2017-08-26

The lack of benefit from randomised controlled trials has resulted in significant controversy regarding the role of nutrition during critical illness in terms of long-term recovery and outcome. Although methodological caveats with a failure to adequately appreciate biological mechanisms may explain these disappointing results, it must be acknowledged that nutritional support during early critical illness, when considered alone, may have limited long-term functional impact.This narrative review focuses specifically on recent clinical trials and evaluates the impact of nutrition during critical illness on long-term physical and functional recovery.Specific focus on the trial design and methodological limitations has been considered in detail. Limitations include delivery of caloric and protein targets, patient heterogeneity, short duration of intervention, inappropriate clinical outcomes and a disregard for baseline nutritional status and nutritional intake in the post-ICU period.With survivorship at the forefront of critical care research, it is imperative that nutrition studies carefully consider biological mechanisms and trial design because these factors can strongly influence outcomes, in particular long-term physical and functional outcome. Failure to do so may lead to inconclusive clinical trials and consequent rejection of the potentially beneficial effects of nutrition interventions during critical illness.

Nutrition Considerations in the Pediatric Cardiac Intensive Care Unit Patient.

PubMed

Justice, Lindsey; Buckley, Jason R; Floh, Alejandro; Horsley, Megan; Alten, Jeffrey; Anand, Vijay; Schwartz, Steven M

2018-05-01

Adequate caloric intake plays a vital role in the course of illness and the recovery of critically ill patients. Nutritional status and nutrient delivery during critical illness have been linked to clinical outcomes such as mortality, incidence of infection, and length of stay. However, feeding practices with critically ill pediatric patients after cardiac surgery are variable. The Pediatric Cardiac Intensive Care Society sought to provide an expert review on provision of nutrition to pediatric cardiac intensive care patients, including caloric requirements, practical considerations for providing nutrition, safety of enteral nutrition in controversial populations, feeding considerations with chylothorax, and the benefits of feeding beyond nutrition. This article addresses these areas of concern and controversy.

[Enteral nutrition and the critically ill patient].

PubMed

Planas, M

1999-09-01

Critically ill patients often suffer from malnutrition y loss of muscle weight throughout the whole time they are ill, even when they receive nutritional therapy, due to the tremendous amount of stress they undergo accompanied by a high degree of hypercatabolism. The most recent theories all coincide in the importance of the intestine as the preferred way for nutrients to enter the bodies of these patients because besides fulfilling its function to absorb and digest nutrients, the intestine plays an important role as a barrier to bacteria and their toxins. For these reasons, enteral nutrition should be the first option to consider whenever we must feed a critically ill patient by artificial means.

Changes in zinc status and zinc transporters expression in whole blood of patients with Systemic Inflammatory Response Syndrome (SIRS).

PubMed

Florea, Daniela; Molina-López, Jorge; Hogstrand, Christer; Lengyel, Imre; de la Cruz, Antonio Pérez; Rodríguez-Elvira, Manuel; Planells, Elena

2018-09-01

Critically ill patients develop severe stress, inflammation and a clinical state that may raise the utilization and metabolic replacement of many nutrients and especially zinc, depleting their body reserves. This study was designed to assess the zinc status in critical care patients with systemic inflammatory response syndrome (SIRS), comparing them with a group of healthy people, and studying the association with expression of zinc transporters. This investigation was a prospective, multicentre, comparative, observational and analytic study. Twelve critically ill patients from different hospitals and 12 healthy subjects from Granada, Spain, all with informed consent were recruited. Data on daily nutritional assessment, ICU severity scores, inflammation, clinical and nutritional parameters, plasma and blood cell zinc concentrations, and levels of transcripts for zinc transporters in whole blood were taken at admission and at the seventh day of the ICU stay. Zinc levels on critical ill patient are diminish comparing with the healthy control (HS: 0.94 ± 0.19; CIPF: 0.67 ± 0.16 mg/dL). The 58% of critical ill patients showed zinc plasma deficiency at beginning of study while 50.0% of critical ill after 7 days of ICU stay. ZnT7, ZIP4 and ZIP9 were the zinc transporters with highest expression in whole blood. In general, all zinc transporters were significantly down-regulated (P < 0.05) in the critical ill population at admission in comparison with healthy subjects. Severity scores and inflammation were significantly associated (P < 0.05) with zinc plasma levels, and zinc transporters ZIP3, ZIP4, ZIP8, ZnT6, ZnT7. Expression of 11 out of 24 zinc transporters was analysed, and ZnT1, ZnT4, ZnT5 and ZIP4, which were downregulated by more than 3-fold in whole blood of patients. In summary, in our study an alteration of zinc status was related with the severity-of-illness scores and inflammation in critical ill patients since admission in ICU stay. SIRS caused a general shut-down of expression of zinc transporters in whole blood. That behavior was associated with severity and inflammation of patients at ICU admission regardless zinc status. We conclude that zinc transporters in blood might be useful indicators of severity of systemic inflammation and outcome for critically ill patients. Copyright © 2017 Elsevier GmbH. All rights reserved.

Pathways to Care for Critically Ill or Injured Children: A Cohort Study from First Presentation to Healthcare Services through to Admission to Intensive Care or Death.

PubMed

Hodkinson, Peter; Argent, Andrew; Wallis, Lee; Reid, Steve; Perera, Rafael; Harrison, Sian; Thompson, Matthew; English, Mike; Maconochie, Ian; Ward, Alison

2016-01-01

Critically ill or injured children require prompt identification, rapid referral and quality emergency management. We undertook a study to evaluate the care pathway of critically ill or injured children to identify preventable failures in the care provided. A year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation to healthcare services until paediatric intensive care unit (PICU) admission or emergency department death, using expert panel review of medical records and caregiver interview. Main outcomes were expert assessment of overall quality of care; avoidability of severity of illness and PICU admission or death and the identification of modifiable factors. The study enrolled 282 children, 252 emergency PICU admissions, and 30 deaths. Global quality of care was graded good in 10% of cases, with half having at least one major impact modifiable factor. Key modifiable factors related to access to care and identification of the critically ill, assessment of severity, inadequate resuscitation, and delays in decision making and referral. Children were transferred with median time from first presentation to PICU admission of 12.3 hours. There was potentially avoidable severity of illness in 185 (74%) of children, and death prior to PICU admission was avoidable in 17/30 (56.7%) of children. The study presents a novel methodology, examining quality of care across an entire system, and highlighting the complexity of the pathway and the modifiable events amenable to interventions, that could reduce mortality and morbidity, and optimize utilization of scarce critical care resources; as well as demonstrating the importance of continuity and quality of care.

The impact of transport of critically ill pediatric patients on rural emergency departments in Manitoba.

PubMed

Hansen, Gregory; Beer, Darcy L; Vallance, Jeff K

2017-01-01

Although the interfacility transport (IFT) of critically ill pediatric patients from rural to tertiary health centres may improve outcomes, the impact of IFTs on the rural referring centre is not known. The purpose of this study was to investigate how the IFT of critically ill children affects staffing and functionality of rural emergency departments (EDs) in Manitoba. In 2015, surveys were emailed to the medical directors of all 15 regional EDs within 2 hours' travel time from a tertiary pediatric hospital. The survey consisted of 9 questions that addressed baseline characteristics of the regional EDs and duration of ED staffing changes or closures due to IFT of critically ill pediatric patients. Ten surveys were received (67% response rate); a regional ED catchment population of about 130 000 people was represented. Interfacility transport caused most EDs (60%, with an average catchment population of 15 000) to close or to alter their staffing to a registered nurse only. These temporary changes lasted a cumulative total of 115 hours. Interfacility transport of critically ill pediatric patients resulted in ED closures and staffing changes in rural Manitoba. These findings suggest that long-term sustainable solutions are required to improve access to emergency care.

Bench-to-bedside review: The gut as an endocrine organ in the critically ill

PubMed Central

2010-01-01

In health, hormones secreted from the gastrointestinal tract have an important role in regulating gastrointestinal motility, glucose metabolism and immune function. Recent studies in the critically ill have established that the secretion of a number of these hormones is abnormal, which probably contributes to disordered gastrointestinal and metabolic function. Furthermore, manipulation of endogenous secretion, physiological replacement and supra-physiological treatment (pharmacological dosing) of these hormones are likely to be novel therapeutic targets in this group. Fasting ghrelin concentrations are reduced in the early phase of critical illness, and exogenous ghrelin is a potential therapy that could be used to accelerate gastric emptying and/or stimulate appetite. Motilin agonists, such as erythromycin, are effective gastrokinetic drugs in the critically ill. Cholecystokinin and peptide YY concentrations are elevated in both the fasting and postprandial states, and are likely to contribute to slow gastric emptying. Accordingly, there is a rationale for the therapeutic use of their antagonists. So-called incretin therapies (glucagon-like peptide-1 and glucose-dependent insulinotropic polypeptide) warrant evaluation in the management of hyperglycaemia in the critically ill. Exogenous glucagon-like peptide-2 (or its analogues) may be a potential therapy because of its intestinotropic properties. PMID:20887636

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

Lower urinary tract dysfunction in critical illness polyneuropathy.

PubMed

Reitz, André

2013-01-01

Critical illness polyneuropathy is a frequent complication of critical illness in intensive care units. Reports on autonomic systems like lower urinary tract and bowel functions in patients with CIP are not available in medical literature. This study performed during primary rehabilitation of patients with critical illness polyneuropathy explores if sensory and motor pathways controlling the lower urinary tract function are affected from the disease. Neurourological examinations, urodynamics, electromyography and lower urinary tract imaging were performed in 28 patients with critical illness polyneuropathy. Sacral sensation was impaired in 1 patient (4%). Sacral reflexes were absent in 8 patients (30%). Anal sphincter resting tone was reduced in 3 (12%), anal sphincter voluntary contraction was absent or reduced in 8 patients (30%). Urodynamic findings were detrusor overactivity and detrusor overactivity incontinence in 9 (37.5%), incomplete voiding in 8 (30%), abnormal sphincter activity in 4 (16%), abnormal bladder sensation in 4 (16%) and detrusor acontractility in 2 patients (8.3%). Morphological abnormalities of the lower urinary tract had 10 patients (41.6%). Sensory and motor pathways controlling the lower urinary tract might be affected from CIP. During urodynamics dysfunctions of the storage as well as the voiding phase were found. Morphological lower urinary tract abnormalities were common.

Challenges faced by nurses in managing pain in a critical care setting.

PubMed

Subramanian, Pathmawathi; Allcock, Nick; James, Veronica; Lathlean, Judith

2012-05-01

To explore nurses' challenges in managing pain among ill patients in critical care. Pain can lead to many adverse medical consequences and providing pain relief is central to caring for ill patients. Effective pain management is vital since studies show patients admitted to critical care units still suffer from significant levels of acute pain. The effective delivery of care in clinical areas remains a challenge for nurses involved with care which is dynamic and constantly changing in critically ill. Qualitative prospective exploratory design. This study employed semi structured interviews with nurses, using critical incident technique. Twenty-one nurses were selected from critical care settings from a large acute teaching health care trust in the UK. A critical incident interview guide was constructed from the literature and used to elicit responses. Framework analysis showed that nurses perceived four main challenges in managing pain namely lack of clinical guidelines, lack of structured pain assessment tool, limited autonomy in decision making and the patient's condition itself. Nurses' decision making and pain management can influence the quality of care given to critically ill patients. It is important to overcome the clinical problems that are faced when dealing with pain experience. There is a need for nursing education on pain management. Providing up to date and practical strategies may help to reduce nurses' challenges in managing pain among critically ill patients. Broader autonomy and effective decision making can be seen as beneficial for the nurses besides having a clearer and structured pain management guidelines. © 2011 Blackwell Publishing Ltd.

[Prevalence and prognostic value of non-thyroidal illness syndrome among critically ill children].

PubMed

El-Ella, Sohair Sayed Abu; El-Mekkawy, Muhammad Said; El-Dihemey, Mohamed Abdelrahman

2018-04-05

Alterations in thyroid hormones during critical illness, known as non-thyroidal illness syndrome (NTIS), were suggested to have a prognostic value. However, pediatric data is limited. The aim of this study was to assess prevalence and prognostic value of NTIS among critically ill children. A prospective observational study conducted on 70 critically ill children admitted into pediatric intensive care unit (PICU). Free triiodothyronine (FT3), free thyroxine (FT4), and thyroid stimulating hormone (TSH) were measured within 24hours of PICU admission. Primary outcome was 30-day mortality. NTIS occurred in 62.9% of patients but it took several forms. The most common pattern was low FT3 with normal FT4 and TSH (25.7% of patients). Combined decrease in FT3, FT4, and TSH levels occurred in 7.1% of patients. An unusual finding of elevated TSH was noted in three patients, which might be related to disease severity. Low FT4 was significantly more prevalent among non-survivors compared with survivors (50% versus 19.2%, P=.028). NTIS independently predicted mortality (OR=3.91; 95% CI=1.006-15.19; P=.0491). Concomitant decrease in FT3, FT4, and TSH was the best independent predictor of mortality (OR=16.9; 95% CI=1.40-203.04; P=.026). TSH was negatively correlated with length of PICU stay (r s =-0.35, P=.011). FT3 level was significantly lower among patients who received dopamine infusion compared with those who did not receive it (2.1±0.66 versus 2.76±0.91pg/mL, P=.011). NTIS is common among critically ill children and appears to be associated with mortality and illness severity. Copyright © 2018. Publicado por Elsevier España, S.L.U.

Messy Problems and Lay Audiences: Teaching Critical Thinking within the Finance Curriculum

ERIC Educational Resources Information Center

Carrithers, David; Ling, Teresa; Bean, John C.

2008-01-01

This article investigates the critical thinking difficulties of finance majors when asked to address ill-structured finance problems. The authors build on previous research in which they asked students to analyze an ill-structured investment problem and recommend a course of action. The results revealed numerous critical thinking weaknesses,…

Diaphragm Dysfunction in Critical Illness.

PubMed

Supinski, Gerald S; Morris, Peter E; Dhar, Sanjay; Callahan, Leigh Ann

2018-04-01

The diaphragm is the major muscle of inspiration, and its function is critical for optimal respiration. Diaphragmatic failure has long been recognized as a major contributor to death in a variety of systemic neuromuscular disorders. More recently, it is increasingly apparent that diaphragm dysfunction is present in a high percentage of critically ill patients and is associated with increased morbidity and mortality. In these patients, diaphragm weakness is thought to develop from disuse secondary to ventilator-induced diaphragm inactivity and as a consequence of the effects of systemic inflammation, including sepsis. This form of critical illness-acquired diaphragm dysfunction impairs the ability of the respiratory pump to compensate for an increased respiratory workload due to lung injury and fluid overload, leading to sustained respiratory failure and death. This review examines the presentation, causes, consequences, diagnosis, and treatment of disorders that result in acquired diaphragm dysfunction during critical illness. Copyright © 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

Part II: The Effects of Aromatherapy and Guided Imagery for the Symptom Management of Anxiety, Pain, and Insomnia in Critically Ill Patients: An Integrative Review of Current Literature.

PubMed

Meghani, Naheed; Tracy, Mary Fran; Hadidi, Niloufar Niakosari; Lindquist, Ruth

This review is part II of a 2-part series that presents evidence on the effectiveness of aromatherapy and guided imagery for the symptom management of anxiety, pain, and insomnia in adult critically ill patients. Evidence from this review supports the use of aromatherapy for management of pain, insomnia, and anxiety in critically ill patients. Evidence also supports the use of guided imagery for managing these symptoms in critical care; however, the evidence is sparse, mixed, and weak. More studies with larger samples and stronger designs are needed to further establish efficacy of guided imagery for the management of anxiety, pain, and insomnia of critically ill patients; to accomplish this, standardized evidence-based intervention protocols to ensure comparability and to establish optimal effectiveness are needed. Discussion and recommendations related to the use of these therapies in practice and needs for future research in these areas were generated.

A comparison of critical care research funding and the financial burden of critical illness in the United States.

PubMed

Coopersmith, Craig M; Wunsch, Hannah; Fink, Mitchell P; Linde-Zwirble, Walter T; Olsen, Keith M; Sommers, Marilyn S; Anand, Kanwaljeet J S; Tchorz, Kathryn M; Angus, Derek C; Deutschman, Clifford S

2012-04-01

To estimate federal dollars spent on critical care research, the cost of providing critical care, and to determine whether the percentage of federal research dollars spent on critical care research is commensurate with the financial burden of critical care. The National Institutes of Health Computer Retrieval of Information on Scientific Projects database was queried to identify funded grants whose title or abstract contained a key word potentially related to critical care. Each grant identified was analyzed by two reviewers (three if the analysis was discordant) to subjectively determine whether it was definitely, possibly, or definitely not related to critical care. Hospital and total costs of critical care were estimated from the Premier Database, state discharge data, and Medicare data. To estimate healthcare expenditures associated with caring for critically ill patients, total costs were calculated as the combination of hospitalization costs that included critical illness as well as additional costs in the year after hospital discharge. Of 19,257 grants funded by the National Institutes of Health, 332 (1.7%) were definitely related to critical care and a maximum of 1212 (6.3%) grants were possibly related to critical care. Between 17.4% and 39.0% of total hospital costs were spent on critical care, and a total of between $121 and $263 billion was estimated to be spent on patients who required intensive care. This represents 5.2% to 11.2%, respectively, of total U.S. healthcare spending. The proportion of research dollars spent on critical care is lower than the percentage of healthcare expenditures related to critical illness.

Renal blood flow, fractional excretion of sodium and acute kidney injury: time for a new paradigm?

PubMed

Prowle, John; Bagshaw, Sean M; Bellomo, Rinaldo

2012-12-01

Global renal blood flow is considered pivotal to renal function. Decreased global renal blood flow (decreased perfusion) is further considered the major mechanism of reduced glomerular filtration rate responsible for the development of acute kidney injury (AKI) in critically ill patients. Additionally, urinary biochemical tests are widely taught to allow the differential diagnosis of prerenal (functional) AKI and intrinsic [structural AKI (so-called acute tubular necrosis)]. In this review we will examine recent evidence regarding these two key clinical paradigms. Recent animal experiments and clinical studies in humans using cine-phase contrast magnetic resonance technology are not consistent with the decreased perfusion paradigm. They suggest instead that changes in the intra-renal circulation including modification in efferent arteriolar function and intra-renal shunting are much more likely to be responsible for AKI, especially in sepsis. Similarly, recent human studies indicate the urinary biochemistry has limited diagnostic or prognostic ability and is dissociated form biomarker and microscopic evidence of tubular injury. Intra-renal microcirculatory changes are likely more important than changes in global blood flow in the development of AKI. Urinary biochemistry is not a clinically useful diagnostic or prognostic tool in critically ill patients at risk of or with AKI.

Alkaline phosphatase: a possible treatment for sepsis-associated acute kidney injury in critically ill patients.

PubMed

Peters, Esther; Heemskerk, Suzanne; Masereeuw, Rosalinde; Pickkers, Peter

2014-06-01

Acute kidney injury (AKI) is a common disease in the intensive care unit and accounts for high morbidity and mortality. Sepsis, the predominant cause of AKI in this setting, involves a complex pathogenesis in which renal inflammation and hypoxia are believed to play an important role. A new therapy should be aimed at targeting both these processes, and the enzyme alkaline phosphatase, with its dual mode of action, might be a promising candidate. First, alkaline phosphatase is able to reduce inflammation through dephosphorylation and thereby detoxification of endotoxin (lipopolysaccharide), which is an important mediator of sepsis. Second, adenosine triphosphate, released during cellular stress caused by inflammation and hypoxia, has detrimental effects but can be converted by alkaline phosphatase into adenosine with anti-inflammatory and tissue-protective effects. These postulated beneficial effects of alkaline phosphatase have been confirmed in animal experiments and two phase 2a clinical trials showing that kidney function improved in critically ill patients with sepsis-associated AKI. Because renal inflammation and hypoxia also are observed commonly in AKI induced by other causes, it would be of interest to investigate the therapeutic effect of alkaline phosphatase in these nephropathies as well. Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

How Are Service Dogs for Adults with Post Traumatic Stress Disorder Integrated with Rehabilitation in Denmark? A Case Study

PubMed Central

Glintborg, Chalotte; Hansen, Tia G. B.

2017-01-01

Simple Summary The use of service dogs for adults with mental illnesses has become generally accepted. With reference to a single case study of a client with Post Traumatic Stress (PTSD), this study illustrates some of the potential advantages, but also note an important concern that appears to have gone unnoticed. The provision of service animals/therapy animals for adults with mental illnesses must be sufficiently informed by relevant knowledge and integrated with concurrent rehabilitation efforts. When it is not, it may contradict existing evidence-based treatments or unintentionally worsen conditions such as anxiety. This study argues that integration is possible and greater coordination efforts should be made. Abstract A severe mental illness like Post Traumatic Stress Disorder (PTSD) is known to have psychosocial consequences that can lead to a decreased quality of life. Research in Animal-Assisted Therapy (AAT) has revealed that the presence of a dog can have a positive effect on health, e.g., increase quality of life and lessen depression and anxiety. However, canine companionship is not a catch-all solution. Previous research has revealed methodological limitations that prohibit any clear conclusions, as well as a sparsity of critical reflection in anecdotal reports and case studies, which means that more research is needed to contextualize the findings. There has been an increasing interest in animal-assisted intervention in Denmark in recent years. Previously, authorities could only grant service dogs to adults with physical disabilities, but now this has been extended to adults with mental illnesses. Therefore, it has become important to explore how these service dogs are incorporated into rehabilitation practices in mental health, and how rehabilitation professionals react to the use of service dogs. This paper is a case study of a person who suffers from PTSD. This study examines how the person describes the significance of having a dog during her rehabilitation process, and how this is integrated with existing rehabilitation. The case study has been developed based on a semi-structured interview. A Thematic Content analysis was used to reveal dominant patterns and categories. This study revealed a lack of communication and collaboration between public administration (social service), service dog providers, health rehabilitation services, and providers of psychological treatment. It also revealed limited access for the dog to public services, limited success in incorporating the dog into goal-directed treatment and rehabilitation procedures, a strongly felt emotional support from the dog, and a perceived stigma by having the dog wearing a vest with he words “mentally ill” printed on it. PMID:28441333

Laboratory-based Salmonella surveillance in Fiji, 2004-2005.

PubMed

Dunn, John; Pryor, Jan; Saketa, Salanieta; Delai, Wasale; Buadromo, Eka; Kishore, Kamal; Naidu, Shakila; Greene, Sharon; Varma, Jay; Chiller, Tom

2005-09-01

Although foodborne diseases are an important public health problem worldwide, the burden of foodborne illness is not well described in most Pacific Island Countries and Territories. Laboratory-based surveillance programs can detect trends and outbreaks, estimate burden of illness, and allow subtyping of enteric pathogens (e.g. Salmonella serotyping), which is critical for linking illness to food vehicles and animal reservoirs. To enhance public health capacity in Fiji for foodborne disease surveillance, we developed the Salmonella Surveillance Project (SSP), a collaboration to pilot laboratory-based surveillance for Salmonella. A network of national and international partners was formed including epidemiologists, microbiologists, and environmental health personnel. Ministry of Health personnel were trained in foodborne disease surveillance and outbreak investigation. Three clinical microbiology laboratories from different parts of the country functioned as sentinel sites, reporting all laboratory-confirmed Salmonella infections using a standardized case report form. Non-Typhi Salmonella isolates were collected for serotyping. In 2004-2005, 86 non-Typhi Salmonella and 275 S. Typhi laboratory-confirmed infections were reported. Salmonella enterica serotype I 3,10: r:- and Salmonella enterica serotype Weltevreden were the most commonly isolated non-Typhi serotypes. In Fiji, the SSP utilized international partnerships to facilitate training, and to enhance laboratory capacity and surveillance for salmonellosis. Incorporating laboratory-based foodborne disease reporting into national disease surveillance will enable public health officials to describe the burden of foodborne illness, identify outbreaks, conduct analytic epidemiology studies, and improve food safety.

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.

24-Hour protein, arginine and citrulline metabolism in fed critically ill children – a stable isotope tracer study

PubMed Central

de Betue, Carlijn T.I.; Garcia Casal, Xiomara C.; van Waardenburg, Dick A.; Schexnayder, Stephen M.; Joosten, Koen F.M.; Deutz, Nicolaas E.P.; Engelen, Marielle P.K.J.

2017-01-01

Background & aims The reference method to study protein and arginine metabolism in critically ill children is measuring plasma amino acid appearances with stable isotopes during a short (4–8h) time period and extrapolate results to 24-hour. However, 24-hour measurements may be variable due to critical illness related factors and a circadian rhythm could be present. Since only short duration stable isotope studies in critically ill children have been conducted before, the aim of this study was to investigate 24-hour appearance of specific amino acids representing protein and arginine metabolism, with stable isotope techniques in continuously fed critically ill children. Methods In eight critically ill children, admitted to the pediatric (n=4) or cardiovascular (n=4) intensive care unit, aged 0–10 years, receiving continuous (par)enteral nutrition with protein intake 1.0–3.7 g/kg/day, a 24-hour stable isotope tracer protocol was carried out. L-[ring-2H5]-phenylalanine, L-[3,3-2H2]-tyrosine, L-[5,5,5-2H3]-leucine, L-[guanido-15N2]-arginine and L-[5-13C-3,3,4,4-2H4]-citrulline were infused intravenously and L-[15N]-phenylalanine and L-[1-13C]leucine enterally. Arterial blood was sampled every hour. Results Coefficients of variation, representing intra-individual variability, of the amino acid appearances of phenylalanine, tyrosine, leucine, arginine and citrulline were high, on average 14–19% for intravenous tracers and 23–26% for enteral tracers. No evident circadian rhythm was present. The pattern and overall 24-hour level of whole body protein balance differed per individual. Conclusions In continuously fed stable critically ill children, the amino acid appearances of phenylalanine, tyrosine, leucine, arginine and citrulline show high variability. This should be kept in mind when performing stable isotope studies in this population. There was no apparent circadian rhythm. PMID:28089618

Endothelial Cell-Specific Molecule-1 in Critically Ill Patients With Hematologic Malignancy.

PubMed

Zafrani, Lara; Resche-Rigon, Matthieu; De Freitas Caires, Nathalie; Gaudet, Alexandre; Mathieu, Daniel; Parmentier-Decrucq, Erika; Lemiale, Virginie; Mokart, Djamel; Pène, Frédéric; Kouatchet, Achille; Mayaux, Julien; Vincent, François; N'yunga, Martine; Bruneel, Fabrice; Rabbat, Antoine; Lebert, Christine; Perez, Pierre; Meert, Anne-Pascale; Benoit, Dominique; Darmon, Michael; Azoulay, Elie

2018-03-01

To assess whether serum concentration of endothelial cell-specific molecule-1 (Endocan) at ICU admission is associated with the use of ICU resources and outcomes in critically ill hematology patients. Prospective multicenter cohort study. Seventeen ICUs in France and Belgium. Seven hundred forty-four consecutive critically ill hematology patients; 72 critically ill septic patients without hematologic malignancy; 276 healthy subjects. None. Median total endocan concentrations were 4.46 (2.7-7.8) ng/mL. Endocan concentrations were higher in patients who had received chemotherapy before ICU admission (4.7 [2.8-8.1] ng/mL vs. 3.7 [2.5-6.3] ng/mL [p = 0.002]). In patients with acute respiratory failure, endocan levels were increased in patients with drug-induced pulmonary toxicity compared with other etiologies (p = 0.038). Total endocan levels higher than 4.46 ng/mL were associated with a higher cumulative probability of renal replacement therapy requirement (p = 0.006), a higher requirement of mechanical ventilation (p = 0.01) and a higher requirement of vasopressors throughout ICU stay (p < 0.0001). By multivariate analysis, total endocan levels at admission were independently associated with ICU mortality (odds ratios, 1.39; 95% CI, 1.06-1.83; p = 0.018). The predictive value of endocan peptide fragments of 14 kDa in terms of mortality and life-sustaining therapies requirement was inferior to that of total endocan. Endocan levels were higher in critically ill hematology patients compared with healthy subjects (p < 0.0001) but lower than endocan values in critically ill septic patients without hematologic malignancy (p = 0.005) CONCLUSIONS:: Serum concentrations of endocan at admission are associated with the use of ICU resources and mortality in critically ill hematology patients. Studies to risk-stratify patients in the emergency department or in the hematology wards based on endocan concentrations to identify those likely to benefit from early ICU management are warranted.

Temporal Characteristics of the Sleep EEG Power Spectrum in Critically Ill Children

PubMed Central

Kudchadkar, Sapna R.; Yaster, Myron; Punjabi, Arjun N.; Quan, Stuart F.; Goodwin, James L.; Easley, R. Blaine; Punjabi, Naresh M.

2015-01-01

Study Objectives: Although empirical evidence is limited, critical illness in children is associated with disruption of the normal sleep-wake rhythm. The objective of the current study was to examine the temporal characteristics of the sleep electroencephalogram (EEG) in a sample of children with critical illness. Methods: Limited montage EEG recordings were collected for at least 24 hours from 8 critically ill children on mechanical ventilation for respiratory failure in a pediatric intensive care unit (PICU) of a tertiary-care hospital. Each PICU patient was age- and gender-matched to a healthy subject from the community. Power spectral analysis with the fast Fourier transform (FFT) was used to characterize EEG spectral power and categorized into 4 frequency bands: δ (0.8 to 4.0 Hz), θ (4.1 to 8.0 Hz), α (8.1 to 13.0 Hz), and β1/β2 (13.1 to 20.0 Hz). Results: PICU patients did not manifest the ultradian variability in EEG power spectra including the typical increase in δ-power during the first third of the night that was observed in healthy children. Differences noted included significantly lower mean nighttime δ and θ power in the PICU patients compared to healthy children (p < 0.001). Moreover, in the PICU patients, mean δ and θ power were higher during daytime hours than nighttime hours (p < 0.001). Conclusions: The results presented herein challenge the assumption that children experience restorative sleep during critical illness, highlighting the need for interventional studies to determine whether sleep promotion improves outcomes in critically ill children undergoing active neurocognitive development. Citation: Kudchadkar SR, Yaster M, Punjabi AN, Quan SF, Goodwin JL, Easley RB, Punjabi NM. Temporal characteristics of the sleep EEG power spectrum in critically ill children. J Clin Sleep Med 2015;11(12):1449–1454. PMID:26194730

Advance directives lessen the decisional burden of surrogate decision-making for the chronically critically ill.

PubMed

Hickman, Ronald L; Pinto, Melissa D

2014-03-01

To identify the relationships between advance directive status, demographic characteristics and decisional burden (role stress and depressive symptoms) of surrogate decision-makers (SDMs) of patients with chronic critical illness. Although the prevalence of advance directives among Americans has increased, SDMs are ultimately responsible for complex medical decisions of the chronically critically ill patient. Decisional burden has lasting psychological effects on SDMs. There is insufficient evidence on the influence of advance directives on the decisional burden of surrogate decision-makers of patients with chronic critical illness. The study was a secondary data analysis of cross-sectional data. Data were obtained from 489 surrogate decision-makers of chronically critically ill patients at two academic medical centres in Northeast Ohio, United States, between September 2005-May 2008. Data were collected using demographic forms and questionnaires. A single-item measure of role stress and the Center for Epidemiological Studies Depression (CESD) scale were used to capture the SDM's decisional burden. Descriptive statistics, t-tests, chi-square and path analyses were performed. Surrogate decision-makers who were nonwhite, with low socioeconomic status and low education level were less likely to have advance directive documentation for their chronically critically ill patient. The presence of an advance directive mitigates the decisional burden by directly reducing the SDM's role stress and indirectly lessening the severity of depressive symptoms. Most SDMs of chronically critically ill patients will not have the benefit of knowing the patient's preferences for life-sustaining therapies and consequently be at risk of increased decisional burden. Study results are clinically useful for patient education on the influence of advance directives. Patients may be informed that SDMs without advance directives are at risk of increased decisional burden and will require decisional support to facilitate patient-centred decision-making. © 2013 John Wiley & Sons Ltd.

Hypoglycemia in Critically Ill Children

PubMed Central

Faustino, E Vincent S; Hirshberg, Eliotte L; Bogue, Clifford W

2012-01-01

Background The practice of glycemic control with intravenous insulin in critically ill patients has brought clinical focus on understanding the effects of hypoglycemia, especially in children. Very little is published on the impact of hypoglycemia in this population. We aimed to review the existing literature on hypoglycemia in critically ill neonates and children. Methods We performed a systematic review of the literature up to August 2011 using PubMed, Ovid MEDLINE and ISI Web of Science using the search terms “hypoglycemia or hypoglyc*” and “critical care or intensive care or critical illness”. Articles were limited to “all child (0–18 years old)” and “English”. Results A total of 513 articles were identified and 132 were included for review. Hypoglycemia is a significant concern among pediatric and neonatal intensivists. Its definition is complicated by the use of a biochemical measure (i.e., blood glucose) for a pathophysiologic problem (i.e., neuroglycopenia). Based on associated outcomes, we suggest defining hypoglycemia as <40–45 mg/dl in neonates and <60–65 mg/dl in children. Below the suggested threshold values, hypoglycemia is associated with worse neurological outcomes, increased intensive care unit stay, and increased mortality. Disruptions in carbohydrate metabolism increase the risk of hypoglycemia incritically ill children. Prevention of hypoglycemia, especially in the setting of intravenous insulin use, will be best accomplished by the combination of accurate measuring techniques, frequent or continuous glucose monitoring, and computerized insulin titration protocols. Conclusion Studies on hypoglycemia in critically ill children have focused on spontaneous hypoglycemia. With the current practice of maintaining blood glucose within a narrow range with intravenous insulin, the risk factors and outcomes associated with insulin-induced hypoglycemia should be rigorously studied to prevent hypoglycemia and potentially improve outcomes of critically ill children. PMID:22401322

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 antioxidant vitamins below 66% of RDA and alteration in endogenous levels of substances with antioxidant capacity are related to redox imbalance in critical ill patients. Therefore, intake of antioxidant vitamins should be carefully monitored so that it is as close as possible to RDA. PMID:17040563

Utility of CT-compatible EEG electrodes in critically ill children.

PubMed

Abend, Nicholas S; Dlugos, Dennis J; Zhu, Xiaowei; Schwartz, Erin S

2015-04-01

Electroencephalographic monitoring is being used with increasing frequency in critically ill children who may require frequent and sometimes urgent brain CT scans. Standard metallic disk EEG electrodes commonly produce substantial imaging artifact, and they must be removed and later reapplied when CT scans are indicated. To determine whether conductive plastic electrodes caused artifact that limited CT interpretation. We describe a retrospective cohort of 13 consecutive critically ill children who underwent 17 CT scans with conductive plastic electrodes during 1 year. CT images were evaluated by a pediatric neuroradiologist for artifact presence, type and severity. All CT scans had excellent quality images without artifact that impaired CT interpretation except for one scan in which improper wire placement resulted in artifact. Conductive plastic electrodes do not cause artifact limiting CT scan interpretation and may be used in critically ill children to permit concurrent electroencephalographic monitoring and CT imaging.

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.

Diastolic dysfunction in the critically ill patient.

PubMed

Suárez, J C; López, P; Mancebo, J; Zapata, L

2016-11-01

Left ventricular diastolic dysfunction is a common finding in critically ill patients. It is characterized by a progressive deterioration of the relaxation and the compliance of the left ventricle. Two-dimensional and Doppler echocardiography is a cornerstone in its diagnosis. Acute pulmonary edema associated with hypertensive crisis is the most frequent presentation of diastolic dysfunction critically ill patients. Myocardial ischemia, sepsis and weaning failure from mechanical ventilation also may be associated with diastolic dysfunction. The treatment is based on the reduction of pulmonary congestion and left ventricular filling pressures. Some studies have found a prognostic role of diastolic dysfunction in some diseases such as sepsis. The present review aims to analyze thoroughly the echocardiographic diagnosis and the most frequent scenarios in critically ill patients in whom diastolic dysfunction plays a key role. Copyright © 2016 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

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

Agriculture and food animals as a source of antimicrobial-resistant bacteria

PubMed Central

Economou, Vangelis; Gousia, Panagiota

2015-01-01

One of the major breakthroughs in the history of medicine is undoubtedly the discovery of antibiotics. Their use in animal husbandry and veterinary medicine has resulted in healthier and more productive farm animals, ensuring the welfare and health of both animals and humans. Unfortunately, from the first use of penicillin, the resistance countdown started to tick. Nowadays, the infections caused by antibiotic-resistant bacteria are increasing, and resistance to antibiotics is probably the major public health problem. Antibiotic use in farm animals has been criticized for contributing to the emergence of resistance. The use and misuse of antibiotics in farm animal settings as growth promoters or as nonspecific means of infection prevention and treatment has boosted antibiotic consumption and resistance among bacteria in the animal habitat. This reservoir of resistance can be transmitted directly or indirectly to humans through food consumption and direct or indirect contact. Resistant bacteria can cause serious health effects directly or via the transmission of the antibiotic resistance traits to pathogens, causing illnesses that are difficult to treat and that therefore have higher morbidity and mortality rates. In addition, the selection and proliferation of antibiotic-resistant strains can be disseminated to the environment via animal waste, enhancing the resistance reservoir that exists in the environmental microbiome. In this review, an effort is made to highlight the various factors that contribute to the emergence of antibiotic resistance in farm animals and to provide some insights into possible solutions to this major health issue. PMID:25878509

Discussion of Animal Stem Cells in the Classroom: Engaging Students through the Lens of Veterinary Medicine

ERIC Educational Resources Information Center

Farenga, Stephen J.; Niess, Daniel; Hutchinson, Michael

2015-01-01

Learning about stem cells within the context of treating pet illness or injury is an additional way for teachers to discuss the integration of science, technology, and veterinary medicine. We explain how practitioners in veterinary medicine harvest animal stem cells from adipose (fat) tissue in treating pet illness or injury. Further, we narrate…

Health-promoting conversations-A novel approach to families experiencing critical illness in the ICU environment.

PubMed

Hollman Frisman, Gunilla; Wåhlin, Ingrid; Orvelius, Lotti; Ågren, Susanna

2018-02-01

To identify and describe the outcomes of a nurse-led intervention, "Health-promoting conversations with families," regarding family functioning and well-being in families with a member who was critically ill. Families who have a critically ill family member in an intensive care unit face a demanding situation, threatening the normal functioning of the family. Yet, there is a knowledge gap regarding family members' well-being during and after critical illness. The study used a qualitative inductive-descriptive design. Eight families participated in health-promoting conversations aimed to create a context for change related to the families' identified problems and resources. Fifteen qualitative interviews were conducted with 18 adults who participated in health-promoting conversations about a critical illness in the family. Eight participants were patients (six men, two women) and 10 were family members (two male partners, five female partners, one mother, one daughter, one female grandchild). The interviews were analysed by conventional content analysis. Family members experienced strengthened togetherness, a caring attitude and confirmation through health-promoting conversations. The caring and calming conversations were appreciated despite the reappearance of exhausting feelings. Working through the experience and being confirmed promoted family well-being. Health-promoting conversations were considered to be healing, as the family members take part in sharing each other's feelings, thoughts and experiences with the critical illness. Health-promoting conversations could be a simple and effective nursing intervention for former intensive care patients and their families in any cultural context. © 2017 John Wiley & Sons Ltd.

Citrate Pharmacokinetics in Critically Ill Patients with Acute Kidney Injury

PubMed Central

Zhu, Qiuyu; Liu, Junfeng; Qian, Jing; You, Huaizhou; Gu, Yong; Hao, Chuanming; Jiao, Zheng; Ding, Feng

2013-01-01

Introduction Regional citrate anticoagulation (RCA) is gaining popularity in continous renal replacement therapy (CRRT) for critically ill patients. The risk of citrate toxicity is a primary concern during the prolonged process. The aim of this study was to assess the pharmacokinetics of citrate in critically ill patients with AKI, and used the kinetic parameters to predict the risk of citrate accumulation in this population group undergoing continuous veno-venous hemofiltration (CVVH) with RCA. Methods Critically ill patients with AKI (n = 12) and healthy volunteers (n = 12) were investigated during infusing comparative dosage of citrate. Serial blood samples were taken before, during 120 min and up to 120 min after infusion. Citrate pharmacokinetics were calculated and compared between groups. Then the estimated kinetic parameters were applied to the citrate kinetic equation for validation in other ten patients’ CVVH sessions with citrate anticoagulation. Results Total body clearance of citrate was similar in critically ill patients with AKI and healthy volunteers (648.04±347.00 L/min versus 686.64±353.60 L/min; P = 0.624). Basal and peak citrate concentrations were similar in both groups (p = 0.423 and 0.247, respectively). The predicted citrate curve showed excellent fit to the measurements. Conclusions Citrate clearance is not impaired in critically ill patients with AKI in the absence of severe liver dysfunction. Citrate pharmacokinetic data can provide a basis for the clinical use of predicting the risk of citrate accumulation. Trial Registration ClinicalTrials.gov Identifier NCT00948558 PMID:23824037

Novel, Family-Centered Intervention to Improve Nutrition in Patients Recovering From Critical Illness: A Feasibility Study.

PubMed

Marshall, Andrea P; Lemieux, Margot; Dhaliwal, Rupinder; Seyler, Hilda; MacEachern, Kristen N; Heyland, Daren K

2017-06-01

Critically ill patients are at increased risk of developing malnutrition-related complications because of physiological changes, suboptimal delivery, and reduced intake. Strategies to improve nutrition during critical illness recovery are required to prevent iatrogenic underfeeding and risk of malnutrition. The purpose of this study was to assess the feasibility and acceptability of a novel family-centered intervention to improve nutrition in critically ill patients. A 3-phase, prospective cohort feasibility study was conducted in 4 intensive care units (ICUs) across 2 countries. Intervention feasibility was determined by patient eligibility, recruitment, and retention rates. The acceptability of the intervention was assessed by participant perspectives collected through surveys. Participants included family members of the critically ill patients and ICU and ward healthcare professionals (HCPs). A total of 75 patients and family members, as well as 56 HCPs, were enrolled. The consent rate was 66.4%, and 63 of 75 (84%) of family participants completed the study. Most family members (53/55; 98.1%) would recommend the nutrition education program to others and reported improved ability to ask questions about nutrition (16/20; 80.0%). Family members viewed nutrition care more positively in the ICU. HCPs agreed that families should partner with HCPs to achieve optimal nutrition in the ICU and the wards. Health literacy was identified as a potential barrier to family participation. The intervention was feasible and acceptable to families of critically ill patients and HCPs. Further research to evaluate intervention impact on nutrition intake and patient-centered outcomes is required.

Cytokines in chronically critically ill patients after activity and rest.

PubMed

Winkelman, Chris; Higgins, Patricia A; Chen, Yea Jyh Kathy; Levine, Alan D

2007-04-01

Inflammation, a common problem for patients in the intensive care unit (ICU), frequently is associated with serious and prolonged critical illnesses. To date, no study has examined whether physical activity influences inflammatory factors in critically ill adults. The objectives of this study were to (a) examine the relationships between type and duration of physical activity and serum levels of interleukin 6 (IL-6), a proinflammatory cytokine; IL-10, an anti-inflammatory cytokine; and their ratio and (b) determine if there are associations between cytokines or their ratio and activity or outcomes. This descriptive feasibility study investigated the approaches to measuring levels of physical activity and its relationship to serum levels of IL-6 and IL-10 and the ratio between them in patients with prolonged mechanical ventilation during periods of activity and rest. Measurements included serum IL-6 and IL-10 levels, direct observation and actigraphy, and prospective chart review. Ten critically ill patients who were mechanically ventilated for an average of 10 days in a large, urban, teaching hospital were enrolled. The average ratio of IL-6 to IL-10 improved after an average of 14.7 min of passive physical activity, typically multiple in-bed turns associated with hygiene. IL-6, IL-10, and their ratio were not associated with patient outcomes of weaning success or length of stay. High levels of IL-6 were associated with mortality. Cytokine balance may be improved by low levels of activity among patients with prolonged critical illness. The pattern of cytokines produced after activity may improve patients' recovery from prolonged critical illness and mechanical ventilation.

How Much and What Type of Protein Should a Critically Ill Patient Receive?

PubMed

Ochoa Gautier, Juan B; Martindale, Robert G; Rugeles, Saúl J; Hurt, Ryan T; Taylor, Beth; Heyland, Daren K; McClave, Stephen A

2017-04-01

Protein loss, manifested as loss of muscle mass, is observed universally in all critically ill patients. Depletion of muscle mass is associated with impaired function and poor outcomes. In extreme cases, protein malnutrition is manifested by respiratory failure, lack of wound healing, and immune dysfunction. Protecting muscle loss focused initially on meeting energy requirements. The assumption was that protein was being used (through oxidation) as an energy source. In healthy individuals, small amounts of glucose (approximately 400 calories) protect muscle loss and decrease amino acid oxidation (protein-sparing effect of glucose). Despite expectations of the benefits, the high provision of energy (above basal energy requirements) through the delivery of nonprotein calories has failed to demonstrate a clear benefit at curtailing protein loss. The protein-sparing effect of glucose is not clearly observed during illness. Increasing protein delivery beyond the normal nutrition requirements (0.8 g/k/d) has been investigated as an alternative solution. Over a dozen observational studies in critically ill patients suggest that higher protein delivery is beneficial at protecting muscle mass and associated with improved outcomes (decrease in mortality). Not surprisingly, new Society of Critical Care Medicine/American Society for Parenteral and Enteral Nutrition guidelines and expert recommendations suggest higher protein delivery (>1.2 g/kg/d) for critically ill patients. This article provides an introduction to the concepts that delineate the basic principles of modern medical nutrition therapy as it relates to the goal of achieving an optimal management of protein metabolism during critical care illness, highlighting successes achieved so far but also placing significant challenges limiting our success in perspective.

Temporal Characteristics of the Sleep EEG Power Spectrum in Critically Ill Children.

PubMed

Kudchadkar, Sapna R; Yaster, Myron; Punjabi, Arjun N; Quan, Stuart F; Goodwin, James L; Easley, R Blaine; Punjabi, Naresh M

2015-12-15

Although empirical evidence is limited, critical illness in children is associated with disruption of the normal sleep-wake rhythm. The objective of the current study was to examine the temporal characteristics of the sleep electroencephalogram (EEG) in a sample of children with critical illness. Limited montage EEG recordings were collected for at least 24 hours from 8 critically ill children on mechanical ventilation for respiratory failure in a pediatric intensive care unit (PICU) of a tertiary-care hospital. Each PICU patient was age- and gender-matched to a healthy subject from the community. Power spectral analysis with the fast Fourier transform (FFT) was used to characterize EEG spectral power and categorized into 4 frequency bands: δ (0.8 to 4.0 Hz), θ (4.1 to 8.0 Hz), α (8.1 to 13.0 Hz), and β1/β2 (13.1 to 20.0 Hz). PICU patients did not manifest the ultradian variability in EEG power spectra including the typical increase in δ-power during the first third of the night that was observed in healthy children. Differences noted included significantly lower mean nighttime δ and θ power in the PICU patients compared to healthy children (p < 0.001). Moreover, in the PICU patients, mean δ and θ power were higher during daytime hours than nighttime hours (p < 0.001). The results presented herein challenge the assumption that children experience restorative sleep during critical illness, highlighting the need for interventional studies to determine whether sleep promotion improves outcomes in critically ill children undergoing active neurocognitive development. © 2015 American Academy of Sleep Medicine.

Performance of Predictive Equations Specifically Developed to Estimate Resting Energy Expenditure in Ventilated Critically Ill Children.

PubMed

Jotterand Chaparro, Corinne; Taffé, Patrick; Moullet, Clémence; Laure Depeyre, Jocelyne; Longchamp, David; Perez, Marie-Hélène; Cotting, Jacques

2017-05-01

To determine, based on indirect calorimetry measurements, the biases of predictive equations specifically developed recently for estimating resting energy expenditure (REE) in ventilated critically ill children, or developed for healthy populations but used in critically ill children. A secondary analysis study was performed using our data on REE measured in a previous prospective study on protein and energy needs in pediatric intensive care unit. We included 75 ventilated critically ill children (median age, 21 months) in whom 407 indirect calorimetry measurements were performed. Fifteen predictive equations were used to estimate REE: the equations of White, Meyer, Mehta, Schofield, Henry, the World Health Organization, Fleisch, and Harris-Benedict and the tables of Talbot. Their differential and proportional biases (with 95% CIs) were computed and the bias plotted in graphs. The Bland-Altman method was also used. Most equations underestimated and overestimated REE between 200 and 1000 kcal/day. The equations of Mehta, Schofield, and Henry and the tables of Talbot had a bias ≤10%, but the 95% CI was large and contained values by far beyond ±10% for low REE values. Other specific equations for critically ill children had even wider biases. In ventilated critically ill children, none of the predictive equations tested met the performance criteria for the entire range of REE between 200 and 1000 kcal/day. Even the equations with the smallest bias may entail a risk of underfeeding or overfeeding, especially in the youngest children. Indirect calorimetry measurement must be preferred. Copyright © 2016 Elsevier Inc. All rights reserved.

Protocols and Hospital Mortality in Critically Ill Patients: The United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study.

PubMed

Sevransky, Jonathan E; Checkley, William; Herrera, Phabiola; Pickering, Brian W; Barr, Juliana; Brown, Samuel M; Chang, Steven Y; Chong, David; Kaufman, David; Fremont, Richard D; Girard, Timothy D; Hoag, Jeffrey; Johnson, Steven B; Kerlin, Mehta P; Liebler, Janice; O'Brien, James; O'Keefe, Terence; Park, Pauline K; Pastores, Stephen M; Patil, Namrata; Pietropaoli, Anthony P; Putman, Maryann; Rice, Todd W; Rotello, Leo; Siner, Jonathan; Sajid, Sahul; Murphy, David J; Martin, Greg S

2015-10-01

Clinical protocols may decrease unnecessary variation in care and improve compliance with desirable therapies. We evaluated whether highly protocolized ICUs have superior patient outcomes compared with less highly protocolized ICUs. Observational study in which participating ICUs completed a general assessment and enrolled new patients 1 day each week. A total of 6,179 critically ill patients. Fifty-nine ICUs in the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study. None. The primary exposure was the number of ICU protocols; the primary outcome was hospital mortality. A total of 5,809 participants were followed prospectively, and 5,454 patients in 57 ICUs had complete outcome data. The median number of protocols per ICU was 19 (interquartile range, 15-21.5). In single-variable analyses, there were no differences in ICU and hospital mortality, length of stay, use of mechanical ventilation, vasopressors, or continuous sedation among individuals in ICUs with a high versus low number of protocols. The lack of association was confirmed in adjusted multivariable analysis (p = 0.70). Protocol compliance with two ventilator management protocols was moderate and did not differ between ICUs with high versus low numbers of protocols for lung protective ventilation in acute respiratory distress syndrome (47% vs 52%; p = 0.28) and for spontaneous breathing trials (55% vs 51%; p = 0.27). Clinical protocols are highly prevalent in U.S. ICUs. The presence of a greater number of protocols was not associated with protocol compliance or patient mortality.

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

Experimental psychiatric illness and drug abuse models: from human to animal, an overview.

PubMed

Edwards, Scott; Koob, George F

2012-01-01

Preclinical animal models have supported much of the recent rapid expansion of neuroscience research and have facilitated critical discoveries that undoubtedly benefit patients suffering from psychiatric disorders. This overview serves as an introduction for the following chapters describing both in vivo and in vitro preclinical models of psychiatric disease components and briefly describes models related to drug dependence and affective disorders. Although there are no perfect animal models of any psychiatric disorder, models do exist for many elements of each disease state or stage. In many cases, the development of certain models is essentially restricted to the human clinical laboratory domain for the purpose of maximizing validity, whereas the use of in vitro models may best represent an adjunctive, well-controlled means to model specific signaling mechanisms associated with psychiatric disease states. The data generated by preclinical models are only as valid as the model itself, and the development and refinement of animal models for human psychiatric disorders continues to be an important challenge. Collaborative relationships between basic neuroscience and clinical modeling could greatly benefit the development of new and better models, in addition to facilitating medications development.

Acute kidney injury in critically ill patients with haematological malignancies: results of a multicentre cohort study from the Groupe de Recherche en Réanimation Respiratoire en Onco-Hématologie.

PubMed

Darmon, Michael; Vincent, François; Canet, Emmanuel; Mokart, Djamel; Pène, Frédéric; Kouatchet, Achille; Mayaux, Julien; Nyunga, Martine; Bruneel, Fabrice; Rabbat, Antoine; Lebert, Christine; Perez, Pierre; Renault, Anne; Meert, Anne-Pascale; Benoit, Dominique; Hamidfar, Rebecca; Jourdain, Mercé; Schlemmer, Benoit; Chevret, Sylvie; Lemiale, Virginie; Azoulay, Elie

2015-12-01

Cancer patients are at high risk for acute kidney injury (AKI), which is associated with high morbidity and mortality. We sought to appraise the incidence, risk factors, and outcome of AKI in a large multicentre cohort study of critically ill patients with haematological malignancies. We used a retrospective analysis of a prospectively collected database. The study was carried out in 17 university or university-affiliated centres in France and Belgium between 2010 and 2012. AKI was defined according to the Acute Kidney Injury Network (AKIN) definition. Of the 1011 patients admitted into the intensive care unit (ICU) during the study period, 1009 were included in this study. According to the AKIN definition, 671 patients (66.5%) developed an AKI during their ICU stay, of which 258 patients (38.4%) were AKI stage 1, 75 patients (11.2%) AKI stage 2 and 338 patients (50.4%) AKI stage 3. After adjustment for confounders, main adverse risk factors of AKI were older age, severity [non-renal Sequential Organ Failure Assessment (SOFA)], history of hypertension, tumour lysis syndrome, exposure to nephrotoxic agents and myeloma. Hospital mortality was 44.3% in patients with AKI and 25.4% in patients without AKI (P < 0.0001). After adjustment for confounders, AKI was independently associated with hospital mortality [OR 1.65 (95% CI 1.19-2.29)]. Overall, 271 patients required renal replacement therapy (RRT), of whom 57.2% died during their hospital stay as compared with 31.2% (P < 0.0001) in those not requiring RRT. Two-thirds of critically ill patients with haematological malignancies developed AKI. Hospital mortality in this population of patients developing AKI or requiring RRT is close to that in general ICU population. © The Author 2015. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

Fluid therapy and perfusional considerations during resuscitation in critically ill patients with intra-abdominal hypertension.

PubMed

Regli, Adrian; De Keulenaer, Bart; De Laet, Inneke; Roberts, Derek; Dabrowski, Wojciech; Malbrain, Manu L N G

2015-01-01

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are consistently associated with morbidity and mortality among the critically ill or injured. Thus, avoiding or potentially treating these conditions may improve patient outcomes. With the aim of improving the outcomes for patients with IAH/ACS, the World Society of the Abdominal Compartment Syndrome recently updated its clinical practice guidelines. In this article, we review the association between a positive fluid balance and outcomes among patients with IAH/ACS and how optimisation of fluid administration and systemic/regional perfusion may potentially lead to improved outcomes among this patient population.Evidence consistently associates secondary IAH with a positive fluid balance. However, despite increased research in the area of non-surgical management of patients with IAH and ACS, evidence supporting this approach is limited. Some evidence exists to support implementing goal-directed resuscitation protocols and restrictive fluid therapy protocols in shocked and recovering critically ill patients with IAH. Data from animal experiments and clinical trials has shown that the early use of vasopressors and inotropic agents is likely to be safe and may help reduce excessive fluid administration, especially in patients with IAH. Studies using furosemide and/or renal replacement therapy to achieve a negative fluid balance in patients with IAH are encouraging. The type of fluid to be administered in patients with IAH remains far from resolved. There is currently insufficient evidence to recommend the use of abdominal perfusion pressure as a resuscitation endpoint in patients with IAH. However, it is important to recognise that IAH either abolishes or increases threshold values for pulse pressure variation and stroke volume variation to predict fluid responsiveness, while the presence of IAH may also result in a false negative passive leg raising test.Correct fluid therapy and perfusional support during resuscitation form the cornerstone of medical management in patients with abdominal hypertension. Controlled studies determining whether the above medical interventions may improve outcomes among those with IAH/ACS are urgently required.

Personalised fluid resuscitation in the ICU: still a fluid concept?

PubMed

van Haren, Frank

2017-12-28

The administration of intravenous fluid to critically ill patients is one of the most common, but also one of the most fiercely debated, interventions in intensive care medicine. Even though many thousands of patients have been enrolled in large trials of alternative fluid strategies, consensus remains elusive and practice is widely variable. Critically ill patients are significantly heterogeneous, making a one size fits all approach unlikely to be successful.New data from basic, animal, and clinical research suggest that fluid resuscitation could be associated with significant harm. There are several important limitations and concerns regarding fluid bolus therapy as it is currently being used in clinical practice. These include, but are not limited to: the lack of an agreed definition; limited and short-lived physiological effects; no evidence of an effect on relevant patient outcomes; and the potential to contribute to fluid overload, specifically when fluid responsiveness is not assessed and when targets and safety limits are not used.Fluid administration in critically ill patients requires clinicians to integrate abnormal physiological parameters into a clinical decision-making model that also incorporates the likely diagnosis and the likely risk or benefit in the specific patient's context. Personalised fluid resuscitation requires careful attention to the mnemonic CIT TAIT: context, indication, targets, timing, amount of fluid, infusion strategy, and type of fluid.The research agenda should focus on experimental and clinical studies to: improve our understanding of the physiological effects of fluid infusion, e.g. on the glycocalyx; evaluate new types of fluids; evaluate novel fluid minimisation protocols; study the effects of a no-fluid strategy for selected patients and scenarios; and compare fluid therapy with other interventions. The adaptive platform trial design may provide us with the tools to evaluate these types of interventions in the intrinsically heterogeneous intensive care unit population, accounting for the explicit assumption that treatment effects may be heterogeneous.

Increased morbidity and mortality in domestic animals eating dropped and bitten fruit in Bangladeshi villages: Implications for zoonotic disease transmission

PubMed Central

Openshaw, John J.; Hegde, Sonia; Sazzad, Hossain M. S.; Khan, Salah Uddin; Hossain, M. Jahangir; Epstein, Jonathan H.; Daszak, Peter; Gurley, Emily S.; Luby, Stephen P.

2016-01-01

We used data on feeding practices and domestic animal health gathered from 207 Bangladeshi villages to identify any association between grazing dropped fruit found on the ground or owners directly feeding bat or bird-bitten fruit and animal health. We compared mortality and morbidity in domestic animals using a mixed effects model controlling for village clustering, herd size, and proxy measures of household wealth. Thirty percent of household heads reported that their animals grazed on dropped fruit and 20% reported that they actively fed bitten fruit to their domestic herds. Household heads allowing their cattle to graze on dropped fruit were more likely to report an illness within their herd (adjusted prevalence ratio 1.17, 95% CI 1.02-1.31). Household heads directly feeding goats bitten fruit were more likely to report illness (adjusted prevalence ratio 1.35, 95% CI 1.16-1.57) and deaths (adjusted prevalence ratio 1.64, 95% CI 1.13-2.4). Reporting of illnesses and deaths among goats rose as the frequency of feeding bitten fruit increased. One possible explanation for this finding is the transmission of bat pathogens to domestic animals via bitten fruit consumption. PMID:26668032

Increased Morbidity and Mortality in Domestic Animals Eating Dropped and Bitten Fruit in Bangladeshi Villages: Implications for Zoonotic Disease Transmission.

PubMed

Openshaw, John J; Hegde, Sonia; Sazzad, Hossain M S; Khan, Salah Uddin; Hossain, M Jahangir; Epstein, Jonathan H; Daszak, Peter; Gurley, Emily S; Luby, Stephen P

2016-03-01

We used data on feeding practices and domestic animal health gathered from 207 Bangladeshi villages to identify any association between grazing dropped fruit found on the ground or owners directly feeding bat- or bird-bitten fruit and animal health. We compared mortality and morbidity in domestic animals using a mixed effects model controlling for village clustering, herd size, and proxy measures of household wealth. Thirty percent of household heads reported that their animals grazed on dropped fruit and 20% reported that they actively fed bitten fruit to their domestic herds. Household heads allowing their cattle to graze on dropped fruit were more likely to report an illness within their herd (adjusted prevalence ratio 1.17, 95% CI 1.02-1.31). Household heads directly feeding goats bitten fruit were more likely to report illness (adjusted prevalence ratio 1.35, 95% CI 1.16-1.57) and deaths (adjusted prevalence ratio 1.64, 95% CI 1.13-2.4). Reporting of illnesses and deaths among goats rose as the frequency of feeding bitten fruit increased. One possible explanation for this finding is the transmission of bat pathogens to domestic animals via bitten fruit consumption.

The Effect of an Extended Wilderness Education Experience on Ill-Structured Problem-Solving Skill Development in Emerging Adult Students

ERIC Educational Resources Information Center

Collins, Rachel H.

2014-01-01

In a society that is becoming more dynamic, complex, and diverse, the ability to solve ill-structured problems has become an increasingly critical skill. Emerging adults are at a critical life stage that is an ideal time to develop the skills needed to solve ill-structured problems (ISPs) as they are transitioning to adult roles and starting to…

Glutamine: an obligatory parenteral nutrition substrate in critical care therapy.

PubMed

Stehle, Peter; Kuhn, Katharina S

2015-01-01

Critical illness is characterized by glutamine depletion owing to increased metabolic demand. Glutamine is essential to maintain intestinal integrity and function, sustain immunologic response, and maintain antioxidative balance. Insufficient endogenous availability of glutamine may impair outcome in critically ill patients. Consequently, glutamine has been considered to be a conditionally essential amino acid and a necessary component to complete any parenteral nutrition regimen. Recently, this scientifically sound recommendation has been questioned, primarily based on controversial findings from a large multicentre study published in 2013 that evoked considerable uncertainty among clinicians. The present review was conceived to clarify the most important questions surrounding glutamine supplementation in critical care. This was achieved by addressing the role of glutamine in the pathophysiology of critical illness, summarizing recent clinical studies in patients receiving parenteral nutrition with intravenous glutamine, and describing practical concepts for providing parenteral glutamine in critical care.

Glutamine: An Obligatory Parenteral Nutrition Substrate in Critical Care Therapy

PubMed Central

Stehle, Peter; Kuhn, Katharina S.

2015-01-01

Critical illness is characterized by glutamine depletion owing to increased metabolic demand. Glutamine is essential to maintain intestinal integrity and function, sustain immunologic response, and maintain antioxidative balance. Insufficient endogenous availability of glutamine may impair outcome in critically ill patients. Consequently, glutamine has been considered to be a conditionally essential amino acid and a necessary component to complete any parenteral nutrition regimen. Recently, this scientifically sound recommendation has been questioned, primarily based on controversial findings from a large multicentre study published in 2013 that evoked considerable uncertainty among clinicians. The present review was conceived to clarify the most important questions surrounding glutamine supplementation in critical care. This was achieved by addressing the role of glutamine in the pathophysiology of critical illness, summarizing recent clinical studies in patients receiving parenteral nutrition with intravenous glutamine, and describing practical concepts for providing parenteral glutamine in critical care. PMID:26495301

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

Changes in case-mix and outcomes of critically ill patients in an Australian tertiary intensive care unit.

PubMed

Williams, T A; Ho, K M; Dobb, G J; Finn, J C; Knuiman, M W; Webb, S A R

2010-07-01

Critical care service is expensive and the demand for such service is increasing in many developed countries. This study aimed to assess the changes in characteristics of critically ill patients and their effect on long-term outcome. This cohort study utilised linked data between the intensive care unit database and state-wide morbidity and mortality databases. Logistic and Cox regression was used to examine hospital survival and five-year survival of 22,298 intensive care unit patients, respectively. There was a significant increase in age, severity of illness and Charlson Comorbidity Index of the patients over a 16-year study period. Although hospital mortality and median length of intensive care unit and hospital stay remained unchanged, one- and five-year survival had significantly improved with time, after adjusting for age, gender; severity of illness, organ failure, comorbidity, 'new' cancer and diagnostic group. Stratified analyses showed that the improvement in five-year survival was particularly strong among patients admitted after cardiac surgery (P = 0.001). In conclusion, although critical care service is increasingly being provided to patients with a higher severity of acute and chronic illnesses, long-term survival outcome has improved with time suggesting that critical care service may still be cost-effectiveness despite the changes in case-mix.

Treatment of hypophosphatemia in the intensive care unit: a review

PubMed Central

2010-01-01

Introduction Currently no evidence-based guideline exists for the approach to hypophosphatemia in critically ill patients. Methods We performed a narrative review of the medical literature to identify the incidence, symptoms, and treatment of hypophosphatemia in critically ill patients. Specifically, we searched for answers to the questions whether correction of hypophosphatemia is associated with improved outcome, and whether a certain treatment strategy is superior. Results Incidence: hypophosphatemia is frequently encountered in the intensive care unit; and critically ill patients are at increased risk for developing hypophosphatemia due to the presence of multiple causal factors. Symptoms: hypophosphatemia may lead to a multitude of symptoms, including cardiac and respiratory failure. Treatment: hypophosphatemia is generally corrected when it is symptomatic or severe. However, although multiple studies confirm the efficacy and safety of intravenous phosphate administration, it remains uncertain when and how to correct hypophosphatemia. Outcome: in some studies, hypophosphatemia was associated with higher mortality; a paucity of randomized controlled evidence exists for whether correction of hypophosphatemia improves the outcome in critically ill patients. Conclusions Additional studies addressing the current approach to hypophosphatemia in critically ill patients are required. Studies should focus on the association between hypophosphatemia and morbidity and/or mortality, as well as the effect of correction of this electrolyte disorder. PMID:20682049

Concise Review: Mesenchymal Stem (Stromal) Cells: Biology and Preclinical Evidence for Therapeutic Potential for Organ Dysfunction Following Trauma or Sepsis.

PubMed

Matthay, Michael A; Pati, Shibani; Lee, Jae-Woo

2017-02-01

Several experimental studies have provided evidence that bone-marrow derived mesenchymal stem (stromal) cells (MSC) may be effective in treating critically ill surgical patients who develop traumatic brain injury, acute renal failure, or the acute respiratory distress syndrome. There is also preclinical evidence that MSC may be effective in treating sepsis-induced organ failure, including evidence that MSC have antimicrobial properties. This review considers preclinical studies with direct relevance to organ failure following trauma, sepsis or major infections that apply to critically ill patients. Progress has been made in understanding the mechanisms of benefit, including MSC release of paracrine factors, transfer of mitochondria, and elaboration of exosomes and microvesicles. Regardless of how well they are designed, preclinical studies have limitations in modeling the complexity of clinical syndromes, especially in patients who are critically ill. In order to facilitate translation of the preclinical studies of MSC to critically ill patients, there will need to be more standardization regarding MSC production with a focus on culture methods and cell characterization. Finally, well designed clinical trials will be needed in critically ill patient to assess safety and efficacy. Stem Cells 2017;35:316-324. © 2016 AlphaMed Press.

Effect of calcitriol on in vitro whole blood cytokine production in critically ill dogs.

PubMed

Jaffey, J A; Amorim, J; DeClue, A E

2018-06-01

Hypovitaminosis D has been identified as a predictor of mortality in human beings, dogs, cats and foals. However, the immunomodulatory effects of vitamin D in critically ill dogs has not been evaluated. The aim of this study was to evaluate the effect of calcitriol on cytokine production from whole blood collected from critically ill dogs in vitro. Twelve critically ill dogs admitted to a veterinary intensive care unit (ICU) were enrolled in a prospective cohort study. Whole blood from these dogs was incubated with calcitriol (2×10 -7 M) or ethanol (control) for 24h. Subsequent to this incubation, lipopolysaccharide (LPS)-stimulated whole blood production of tumor necrosis factor (TNF)-α, interleukin (IL)-6 and IL-10 were measured using a canine-specific multiplex assay. Calcitriol significantly increased LPS-stimulated whole blood production of IL-10 and decreased TNF-α production without significantly altering IL-6 production. There was no significant difference in whole blood cytokine production capacity between survivors and non-survivors at the time of discharge from the ICU or 30days after discharge. These data suggests that calcitriol induces an anti-inflammatory phenotype in vitro in whole blood from critically ill dogs. Copyright © 2018 Elsevier Ltd. All rights reserved.

Improving Care of Critically Unwell Patients through Development of a Simulation Programme in a Malawian Hospital

ERIC Educational Resources Information Center

Barnes, Jonathan; Paterson-Brown, Lucy

2017-01-01

Introduction: Malawi is one of the world's poorest countries with very limited healthcare spending and a lack of post-graduate training for healthcare workers, including in critical illness management. Critical illness simulation courses have been shown to be an effective training tool and form a key part of training for healthcare professionals…

Towards a better understanding of Rift Valley fever epidemiology in the south-west of the Indian Ocean

PubMed Central

2013-01-01

Rift Valley fever virus (Phlebovirus, Bunyaviridae) is an arbovirus causing intermittent epizootics and sporadic epidemics primarily in East Africa. Infection causes severe and often fatal illness in young sheep, goats and cattle. Domestic animals and humans can be contaminated by close contact with infectious tissues or through mosquito infectious bites. Rift Valley fever virus was historically restricted to sub-Saharan countries. The probability of Rift Valley fever emerging in virgin areas is likely to be increasing. Its geographical range has extended over the past years. As a recent example, autochthonous cases of Rift Valley fever were recorded in 2007–2008 in Mayotte in the Indian Ocean. It has been proposed that a single infected animal that enters a naive country is sufficient to initiate a major outbreak before Rift Valley fever virus would ever be detected. Unless vaccines are available and widely used to limit its expansion, Rift Valley fever will continue to be a critical issue for human and animal health in the region of the Indian Ocean. PMID:24016237

Hyperactivity in Anorexia Nervosa: Warming Up Not Just Burning-Off Calories

PubMed Central

Carrera, Olaia; Adan, Roger A. H.; Gutierrez, Emilio; Danner, Unna N.; Hoek, Hans W.; van Elburg, Annemarie A.; Kas, Martien J. H.

2012-01-01

Excessive physical activity is a common feature in Anorexia Nervosa (AN) that interferes with the recovery process. Animal models have demonstrated that ambient temperature modulates physical activity in semi-starved animals. The aim of the present study was to assess the effect of ambient temperature on physical activity in AN patients in the acute phase of the illness. Thirty-seven patients with AN wore an accelerometer to measure physical activity within the first week of contacting a specialized eating disorder center. Standardized measures of anxiety, depression and eating disorder psychopathology were assessed. Corresponding daily values for ambient temperature were obtained from local meteorological stations. Ambient temperature was negatively correlated with physical activity (p = −.405) and was the only variable that accounted for a significant portion of the variance in physical activity (p = .034). Consistent with recent research with an analogous animal model of the disorder, our findings suggest that ambient temperature is a critical factor contributing to the expression of excessive physical activity levels in AN. Keeping patients warm may prove to be a beneficial treatment option for this symptom. PMID:22848634

Scene analysis in the natural environment

PubMed Central

Lewicki, Michael S.; Olshausen, Bruno A.; Surlykke, Annemarie; Moss, Cynthia F.

2014-01-01

The problem of scene analysis has been studied in a number of different fields over the past decades. These studies have led to important insights into problems of scene analysis, but not all of these insights are widely appreciated, and there remain critical shortcomings in current approaches that hinder further progress. Here we take the view that scene analysis is a universal problem solved by all animals, and that we can gain new insight by studying the problems that animals face in complex natural environments. In particular, the jumping spider, songbird, echolocating bat, and electric fish, all exhibit behaviors that require robust solutions to scene analysis problems encountered in the natural environment. By examining the behaviors of these seemingly disparate animals, we emerge with a framework for studying scene analysis comprising four essential properties: (1) the ability to solve ill-posed problems, (2) the ability to integrate and store information across time and modality, (3) efficient recovery and representation of 3D scene structure, and (4) the use of optimal motor actions for acquiring information to progress toward behavioral goals. PMID:24744740

Towards a better understanding of Rift Valley fever epidemiology in the south-west of the Indian Ocean.

PubMed

Balenghien, Thomas; Cardinale, Eric; Chevalier, Véronique; Elissa, Nohal; Failloux, Anna-Bella; Jean Jose Nipomichene, Thiery Nirina; Nicolas, Gaelle; Rakotoharinome, Vincent Michel; Roger, Matthieu; Zumbo, Betty

2013-09-09

Rift Valley fever virus (Phlebovirus, Bunyaviridae) is an arbovirus causing intermittent epizootics and sporadic epidemics primarily in East Africa. Infection causes severe and often fatal illness in young sheep, goats and cattle. Domestic animals and humans can be contaminated by close contact with infectious tissues or through mosquito infectious bites. Rift Valley fever virus was historically restricted to sub-Saharan countries. The probability of Rift Valley fever emerging in virgin areas is likely to be increasing. Its geographical range has extended over the past years. As a recent example, autochthonous cases of Rift Valley fever were recorded in 2007-2008 in Mayotte in the Indian Ocean. It has been proposed that a single infected animal that enters a naive country is sufficient to initiate a major outbreak before Rift Valley fever virus would ever be detected. Unless vaccines are available and widely used to limit its expansion, Rift Valley fever will continue to be a critical issue for human and animal health in the region of the Indian Ocean.

Critical care use during the course of serious illness.

PubMed

Iwashyna, Theodore J

2004-11-01

Despite its expense and importance, it is unknown how common critical care use is. We describe longitudinal patterns of critical care use among a nationally representative cohort of elderly patients monitored from the onset of common serious illnesses. A retrospective population-based cohort study of elderly patients in fee-for-service Medicare is used, with 1,108,060 Medicare beneficiaries at least 68 years of age and newly diagnosed with serious illnesses: 1 of 9 malignancies, stroke, congestive heart failure, hip fracture, or myocardial infarction. Medicare inpatient hospital claims from diagnosis until death (65.1%) or fixed-right censoring (more than 4 years) were reviewed. Distinct hospitalizations involving critical care use (intensive care unit or critical care unit) were counted and associated reimbursements were assessed; repeated use was defined as five or more such hospitalizations. Of the cohort, 54.9% used critical care at some time after diagnosis. Older patients were much less likely to ever use critical care (odds ratio, 0.31; comparing patients more than 90 years old with those 68-70 years old), even after adjustment. A total of 31,348 patients (2.8%) were repeated users of critical care; they accounted for 3.6 billion dollars in hospital charges and 1.4 billion dollars in Medicare reimbursement. We conclude that critical care use is common in serious chronic illness and is not associated solely with preterminal hospitalizations. Use is uneven, and a minority of patients who repeatedly use critical care account for disproportionate costs.

Use of a High-Flow Oxygen Delivery System in a Critically Ill Patient with Dementia

DTIC Science & Technology

2008-12-01

February 1, 2007. http://www.fda.gov/ cdrh /safety/ 020107_vapotherm.html. Accessed October 7, 2008. HIGH-FLOW OXYGEN IN A CRITICALLY ILL PATIENT WITH DEMENTIA RESPIRATORY CARE • DECEMBER 2008 VOL 53 NO 12 1743

Critical care medicine training and certification for emergency physicians.

PubMed

Huang, David T; Osborn, Tiffany M; Gunnerson, Kyle J; Gunn, Scott R; Trzeciak, Stephen; Kimball, Edward; Fink, Mitchell P; Angus, Derek C; Dellinger, R Phillip; Rivers, Emanuel P

2005-09-01

Demand for critical care services is increasing. Unless the supply of intensivists increases, critically ill patients will not have access to intensivists. Recent critical care society recommendations include increased graduate medical education support and expansion of the J-1 visa waiver program for foreign medical graduates. This article proposes additional recommendations, based on strengthening the relationship between emergency medicine and critical care medicine. Demand for critical care services is increasing. Unless the supply of intensivists increases, critically ill patients will not have access to intensivists. Recent critical care society recommendations include increased graduate medical education support and expansion of the J-1 visa waiver program for foreign medical graduates. This article proposes additional recommendations, based on strengthening the relationship between emergency medicine (EM) and critical care medicine (CCM). Critical care is a continuum that includes prehospital, emergency department (ED), and intensive care unit (ICU) care teams. Both EM and CCM require expertise in treating life-threatening acute illness, with many critically ill patients often presenting first to the ED. Increased patient volumes and acuity have resulted in longer ED lengths of stay and more critical care delivery in the ED. However, the majority of CCM fellowships do not accept EM residents, and those who successfully complete a fellowship do not have access to a U.S. certification exam in CCM. Despite these barriers, interest in CCM training among EM physicians is increasing. Dual EM/CCM-trained physicians not only will help alleviate the intensivist shortage but also will strengthen critical care delivery in the ED and facilitate coordination at the ED-ICU interface. We therefore propose that all accreditation bodies work cooperatively to create a route to CCM certification for emergency physicians who complete a critical care fellowship.

Communication about chronic critical illness.

PubMed

Nelson, Judith E; Mercado, Alice F; Camhi, Sharon L; Tandon, Nidhi; Wallenstein, Sylvan; August, Gary I; Morrison, R Sean

2007-12-10

Despite poor outcomes, life-sustaining treatments including mechanical ventilation are continued for a large and growing population of patients with chronic critical illness. This may be owing in part to a lack of understanding resulting from inadequate communication between clinicians and patients and families. Our objective was to investigate the informational needs of patients with chronic critical illness and their families and the extent to which these needs are met. In this prospective observational study conducted at 5 adult intensive care units in a large, university-affiliated hospital in New York, New York, 100 patients with chronic critical illness (within 3-7 days of elective tracheotomy for prolonged mechanical ventilation) or surrogates for incapacitated patients were surveyed using an 18-item questionnaire addressing communication about chronic critical illness. Main outcome measures included ratings of importance and reports of whether information was received about questionnaire items. Among 125 consecutive, eligible patients, 100 (80%) were enrolled; questionnaire respondents included 2 patients and 98 surrogates. For all items, more than 78% of respondents rated the information as important for decision making (>98% for 16 of 18 items). Respondents reported receiving no information for a mean (SD) of 9.0 (3.3) of 18 items, with 95% of respondents reporting not receiving information for approximately one-quarter of the items. Of the subjects rating the item as important, 77 of 96 (80%) and 69 of 74 (93%) reported receiving no information about expected functional status at hospital discharge and prognosis for 1-year survival, respectively. Many patients and their families may lack important information for decision making about continuation of treatment in the chronic phase of critical illness. Strategies for effective communication in this clinical context should be investigated and implemented.

Global Variability in Reported Mortality for Critical Illness during the 2009-10 Influenza A(H1N1) Pandemic: A Systematic Review and Meta-Regression to Guide Reporting of Outcomes during Disease Outbreaks.

PubMed

Duggal, Abhijit; Pinto, Ruxandra; Rubenfeld, Gordon; Fowler, Robert A

2016-01-01

To determine how patient, healthcare system and study-specific factors influence reported mortality associated with critical illness during the 2009-2010 Influenza A (H1N1) pandemic. Systematic review with meta-regression of studies reporting on mortality associated with critical illness during the 2009-2010 Influenza A (H1N1) pandemic. Medline, Embase, LiLACs and African Index Medicus to June 2009-March 2016. 226 studies from 50 countries met our inclusion criteria. Mortality associated with H1N1-related critical illness was 31% (95% CI 28-34). Reported mortality was highest in South Asia (61% [95% CI 50-71]) and Sub-Saharan Africa (53% [95% CI 29-75]), in comparison to Western Europe (25% [95% CI 22-30]), North America (25% [95% CI 22-27]) and Australia (15% [95% CI 13-18]) (P<0.0001). High income economies had significantly lower reported mortality compared to upper middle income economies and lower middle income economies respectively (P<0.0001). Mortality for the first wave was non-significantly higher than wave two (P = 0.66). There was substantial variability in reported mortality among the specific subgroups of patients: unselected critically ill adults (27% [95% CI 24-30]), acute respiratory distress syndrome (37% [95% CI 32-44]), acute kidney injury (44% [95% CI 26-64]), and critically ill pregnant patients (10% [95% CI 5-19]). Reported mortality for outbreaks and pandemics may vary substantially depending upon selected patient characteristics, the number of patients described, and the region and economic status of the outbreak location. Outcomes from a relatively small number of patients from specific regions may lead to biased estimates of outcomes on a global scale.

Parenteral Fish Oil Lipid Emulsions in the Critically Ill: a Systematic Review and Meta-analysis

PubMed Central

Manzanares, William; Dhaliwal, Rupinder; Jurewitsch, Brian; Stapleton, Renee D.; Jeejeebhoy, Khursheed N.; Heyland, Daren K.

2015-01-01

Introduction Polyunsaturated series-3 fatty acids (PUFAs n-3) contained in fish oils (FO) posess major anti-inflammatory, anti-oxidant, and immunological properties which could be beneficial during critical illness. We hypothesized that parenteral FO containing emulsions may improve clinical outcomes in the critically ill. Methods We searched computerized databases from 1980 to 2012. We included randomized controlled trials (RCTs) conducted in critically ill adults patients that evaluated FO containing emulsions, either in the context of parenteral nutrition (PN) or enteral nutrition (EN) fed patients. Results A total of 6 RCTs (n=390 patients) were included; the mean methodological score of all trials was 10 (range: 6–13). When the results of these studies were aggregated, FO containing emulsions were associated with with a trend towards a reduction in mortality (risk ratio RR= 0.71, 95% confidence intervals CI 0.49, 1.04, P=0.08, heterogeneity I2=0%) and a tendency to reduce the duration of mechanical ventilation (weighted mean difference in days [WMD] −1.41, 95% CI −3.43, 0.61, P=0.17). However, this strategy had no effect on infections (RR= 0.76, 95% CI 0.42, 1.36, P= 0.35) and intensive care unit (ICU) length of stay (LOS) (WMD −0.46, 95% CI −4.87, 3.95, P=0.84, heterogeneity I2=75%). Conclusion FO containing lipid emulsions may be able to decrease mortality and ventilation days in the critically ill. However, because of the paucity of clinical data, there is inadequate evidence to recommend the routine use of parenteral FO. Large, rigorously designed, RCTs are required to elucidate the efficacy of parenteral FO in the critically ill. PMID:23609773

Venous thromboembolism prophylaxis in the critically ill: a point prevalence survey of current practice in Australian and New Zealand intensive care units.

PubMed

Robertson, Megan S; Nichol, Alistair D; Higgins, Alisa M; Bailey, Michael J; Presneill, Jeffrey J; Cooper, D James; Webb, Steven A; McArthur, Colin; MacIsaac, Christopher M

2010-03-01

Critically ill patients are at high risk of morbidity and mortality caused by venous thromboembolism (VTE). In addition to premorbid predisposing conditions, critically ill patients may be exposed to prolonged immobility, invasive intravascular catheters and frequent operative procedures, and further may have contraindications to pharmaceutical prophylactic measures designed to attenuate VTE risk. There are limited data describing current VTE prophylaxis regimens in Australia and New Zealand. To document current Australian and New Zealand management of VTE prophylaxis in a large mixed cohort of critically ill patients. Prospective, multicentre point prevalence survey endorsed by the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS CTG). 30 public hospital ICUs in Australia and New Zealand surveyed on Wednesday 9 May 2007. For all patients in each ICU on the study day, demographic data, admission diagnosis and information on VTE prophylaxis were prospectively collected. 502 patients were included in the survey, and 431 of these (86%) received VTE prophylaxis. Of these, 64% (276/431) received pharmacological prophylaxis and 80% (345/431) received mechanical prophylaxis, with 44% (190/431) receiving both. Of those receiving pharmacological prophylaxis, unfractionated heparin was used in 74%, and enoxaparin (low molecular weight heparin) in 23%. Contraindications to pharmacological prophylaxis were reported in 122 patients. Overall, pharmacological prophylaxis was administered to 87% of potentially suitable patients. We observed a high prevalence of VTE prophylaxis, with many critically ill patients receiving two or more modalities of prophylaxis. These results show that the potential risk of VTE in critically ill patients is recognised in Australia and New Zealand, and strategies to mitigate this serious complication are widely implemented.

SaMpling Antibiotics in Renal Replacement Therapy (SMARRT): an observational pharmacokinetic study in critically ill patients.

PubMed

Roberts, Jason A; Choi, Gordon Y S; Joynt, Gavin M; Paul, Sanjoy K; Deans, Renae; Peake, Sandra; Cole, Louise; Stephens, Dianne; Bellomo, Rinaldo; Turnidge, John; Wallis, Steven C; Roberts, Michael S; Roberts, Darren M; Lassig-Smith, Melissa; Starr, Therese; Lipman, Jeffrey

2016-03-01

Optimal antibiotic dosing is key to maximising patient survival, and minimising the emergence of bacterial resistance. Evidence-based antibiotic dosing guidelines for critically ill patients receiving RRT are currently not available, as RRT techniques and settings vary greatly between ICUs and even individual patients. We aim to develop a robust, evidence-based antibiotic dosing guideline for critically ill patients receiving various forms of RRT. We further aim to observe whether therapeutic antibiotic concentrations are associated with reduced 28-day mortality. We designed a multi-national, observational pharmacokinetic study in critically ill patients requiring RRT. The study antibiotics will be vancomycin, linezolid, piperacillin/tazobactam and meropenem. Pharmacokinetic sampling of each patient's blood, RRT effluent and urine will take place during two separate dosing intervals. In addition, a comprehensive data set, which includes the patients' demographic and clinical parameters, as well as modality, technique and settings of RRT, will be collected. Pharmacokinetic data will be analysed using a population pharmacokinetic approach to identify covariates associated with changes in pharmacokinetic parameters in critically ill patients with AKI who are undergoing RRT for the five commonly prescribed antibiotics. Using the comprehensive data set collected, the pharmacokinetic profile of the five antibiotics will be constructed, including identification of RRT and other factors indicative of the need for altered antibiotic dosing requirements. This will enable us to develop a dosing guideline for each individual antibiotic that is likely to be relevant to any critically ill patient with acute kidney injury receiving any of the included forms of RRT. Australian New Zealand Clinical Trial Registry ( ACTRN12613000241730 ) registered 28 February 2013.

Protocols and Hospital Mortality in Critically ill Patients: The United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study

PubMed Central

Sevransky, Jonathan E.; Checkley, William; Herrera, Phabiola; Pickering, Brian W.; Barr, Juliana; Brown, Samuel M; Chang, Steven Y; Chong, David; Kaufman, David; Fremont, Richard D; Girard, Timothy D; Hoag, Jeffrey; Johnson, Steven B; Kerlin, Mehta P; Liebler, Janice; O'Brien, James; O'Keefe, Terence; Park, Pauline K; Pastores, Stephen M; Patil, Namrata; Pietropaoli, Anthony P; Putman, Maryann; Rice, Todd W.; Rotello, Leo; Siner, Jonathan; Sajid, Sahul; Murphy, David J; Martin, Greg S

2015-01-01

Objective Clinical protocols may decrease unnecessary variation in care and improve compliance with desirable therapies. We evaluated whether highly protocolized intensive care units have superior patient outcomes compared with less highly protocolized intensive care units. Design Observational study in which participating intensive care units completed a general assessment and enrolled new patients one day each week. Setting and Patients 6179 critically ill patients across 59 intensive care units in the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study Interventions: None Measurements and Main Results The primary exposure was the number of intensive care unit protocols; the primary outcome was hospital mortality. 5809 participants were followed prospectively and 5454 patients in 57 intensive care units had complete outcome data. The median number of protocols per intensive care unit was 19 (IQR 15 to 21.5). In single variable analyses, there were no differences in intensive care unit and hospital mortality, length of stay, use of mechanical ventilation, vasopressors, or continuous sedation among individuals in intensive care units with a high vs. low number of protocols. The lack of association was confirmed in adjusted multivariable analysis (p=0.70). Protocol compliance with two ventilator management protocols was moderate and did not differ between intensive care units with high vs. low numbers of protocols for lung protective ventilation in ARDS (47% vs. 52%; p=0.28) and for spontaneous breathing trials (55% vs. 51%; p=0.27). Conclusions Clinical protocols are highly prevalent in United States intensive care units. The presence of a greater number of protocols was not associated with protocol compliance or patient mortality. PMID:26110488

Communication About Chronic Critical Illness

PubMed Central

Nelson, Judith E.; Mercado, Alice F.; Camhi, Sharon L.; Tandon, Nidhi; Wallenstein, Sylvan; August, Gary I.; Morrison, R. Sean

2008-01-01

Background Despite poor outcomes, life-sustaining treatments including mechanical ventilation are continued for a large and growing population of patients with chronic critical illness. This may be owing in part to a lack of understanding resulting from inadequate communication between clinicians and patients and families. Our objective was to investigate the informational needs of patients with chronic critical illness and their families and the extent to which these needs are met. Methods In this prospective observational study conducted at 5 adult intensive care units in a large, university-affiliated hospital in New York, New York, 100 patients with chronic critical illness (within 3–7 days of elective tracheotomy for prolonged mechanical ventilation) or surrogates for incapacitated patients were surveyed using an 18-item questionnaire addressing communication about chronic critical illness. Main outcome measures included ratings of importance and reports of whether information was received about questionnaire items. Results Among 125 consecutive, eligible patients, 100 (80%) were enrolled; questionnaire respondents included 2 patients and 98 surrogates. For all items, more than 78% of respondents rated the information as important for decision making (>98% for 16 of 18 items). Respondents reported receiving no information for a mean (SD) of 9.0 (3.3) of 18 items, with 95% of respondents reporting not receiving information for approximately one-quarter of the items. Of the subjects rating the item as important, 77 of 96 (80%) and 69 of 74 (93%) reported receiving no information about expected functional status at hospital discharge and prognosis for 1-year survival, respectively. Conclusions Many patients and their families may lack important information for decision making about continuation of treatment in the chronic phase of critical illness. Strategies for effective communication in this clinical context should be investigated and implemented. PMID:18071175

Rectal and Naris Swabs: Practical and Informative Samples for Analyzing the Microbiota of Critically Ill Patients.

PubMed

Bansal, Saumya; Nguyen, Jenny P; Leligdowicz, Aleksandra; Zhang, Yu; Kain, Kevin C; Ricciuto, Daniel R; Coburn, Bryan

2018-06-27

Commensal microbiota are immunomodulatory, and their pathological perturbation can affect the risk and outcomes of infectious and inflammatory diseases. Consequently, the human microbiota is an emerging diagnostic and therapeutic target in critical illness. In this study, we compared four sample types-rectal, naris, and antecubital swabs and stool samples-for 16S rRNA gene microbiota sequencing in intensive care unit (ICU) patients. Stool samples were obtained in only 31% of daily attempts, while swabs were reliably obtained (≥97% of attempts). Swabs were compositionally distinct by anatomical site, and rectal swabs identified within-patient temporal trends in microbiota composition. Rectal swabs from ICU patients demonstrated differences from healthy stool similar to those observed in comparing stool samples from ICU patients to those from the same healthy controls. Rectal swabs are a useful complement to other sample types for analysis of the intestinal microbiota in critical illness, particularly when obtaining stool may not be feasible or practical. IMPORTANCE Perturbation of the microbiome has been correlated with various infectious and inflammatory diseases and is common in critically ill patients. Stool is typically used to sample the microbiota in human observational studies; however, it is often unavailable for collection from critically ill patients, reducing its utility as a sample type to study this population. Our research identified alternatives to stool for sampling the microbiota during critical illness. Rectal and naris swabs were practical alternatives for use in these patients, as they were observed to be more reliably obtained than stool, were suitable for culture-independent analysis, and successfully captured within- and between-patient microbiota differences. Copyright © 2018 Bansal et al.

A pilot study of urinary fibroblast growth factor-2 and epithelial growth factor as potential biomarkers of acute kidney injury in critically ill children

PubMed Central

Wai, Kitman; Soler-García, Ángel A.; Perazzo, Sofia; Mattison, Parnell

2014-01-01

Background Acute kidney injury (AKI) increases the morbidity of critically ill children. Thus, it is necessary to identify better renal biomarkers to follow the outcome of these patients. This prospective case–control study explored the clinical value of a urinary biomarker profile comprised of neutrophil gelatinase lipocalin (uNGAL), fibroblast growth factor-2 (uFGF-2), and epidermal growth factor (uEGF) to follow these patients. Methods Urine samples were collected from 21 healthy children, and 39 critically ill children (mean age 7.5 years±6.97 SD) admitted to a pediatric intensive care unit with sepsis or requiring extra corporeal membrane oxygenation (ECMO). uNGAL, uFGF-2, and uEGF levels were measured using ELISA kits during the first 24 h of admission to PICU, at peak of illness, and upon resolution of the critical illness. Results On admission, the uNGAL and uFGF-2 levels were increased, and the uEGF levels were decreased, in critically ill children with AKI (n=19) compared to those without AKI (n=20), and healthy controls. A biomarker score using the combined cut-off values of uNGAL, uFGF-2, and uEGF (AUC=0.90) showed the highest specificity to identify children with AKI, relative to each biomarker alone. uNGAL and uFGF-2 on admission showed high sensitivity and specificity to predict mortality (AUC=0.82). Conclusions The biomarker profile comprised of uNGAL, uFGF-2, and uEGF increased the specificity to detect AKI in critically ill children, when compared to each biomarker used alone. uNGAL and uFGF-2 may also predict the risk of death. Further validation of these findings in a large sample size is warranted. PMID:23872928

Receiving power through confirmation: the meaning of close relatives for people who have been critically ill.

PubMed

Engström, Asa; Söderberg, Siv

2007-09-01

This paper is a report of a study to elucidate the meaning of close relatives for people who have been critically ill and received care in an intensive care unit. Falling critically ill can bring about a difficult change in life. In previous reports such events are described as frightening experiences, and close relatives are described as an important source of support in this difficult situation. A purposive sample of 10 adults, eight men and two women, narrated how they experienced their close relatives during and after the time they were critically ill. The data were collected in 2004. The interview texts were transcribed and interpreted using a phenomenological hermeneutic approach influenced by the philosophy of Ricoeur. One major theme was identified, experiencing confirmation, with six sub-themes: receiving explanations; a feeling of being understood; a feeling of safety; gaining strength and will-power; having possibilities and realizing their value. Close relatives served as tools for the person who was ill, facilitating better communication and an increased ability to do various things. Simultaneously, feelings of dependence on the close relatives were expressed. There were descriptions of loneliness and fear in the absence of close relatives and, in order to feel safe, the participants wanted their close relatives to stay near them. Close relatives are vital, as they are the ill person's motivation to stay alive and to continue the struggle. Their presence is of great importance for the ill person and must be facilitated by staff.

Descriptive study of enteric zoonoses in Ontario, Canada, from 2010 - 2012.

PubMed

Whitfield, Yvonne; Johnson, Karen; Hobbs, Leigh; Middleton, Dean; Dhar, Badal; Vrbova, Linda

2017-02-21

Contact with animals and their environment has long been recognized as an important source of enteric zoonoses. However, there are limited data available on the burden of illness associated with specific types of animals in Canada. This study describes the overall burden of enteric zoonoses in Ontario, Canada from 2010 to 2012. Confirmed cases of seven enteric zoonotic diseases (campylobacteriosis, cryptosporidiosis, giardiasis, listeriosis, salmonellosis, verotoxin-producing E. coli (VTEC) infection, and yersiniosis) with episode dates from 2010 to 2012 were extracted from the integrated Public Health Information System (iPHIS). Reported exposures were categorized as animal contact, foodborne, waterborne and 'other', with animal contact grouped into nine sub-categories based on the type of animal or transmission setting. Overall incidence rates and proportions by animal exposure categories, age and sex-specific incidence rates and hospitalization and death proportions were calculated and sex proportions compared. Our study found that approximately 26% of the enteric pathogens assessed during the 2010 to 2012 period reported contact with animals and their environments as the mode of transmission. Of enteric disease cases reporting animal contact, farm exposures were reported for 51.3%, dog or cat exposures for 26.3%, and reptile or amphibian exposures for 8.9%. Contact with animals was reported more frequently during the period 2010 to 2012 in comparison to the period 1997 to 2003 when 6% or less of enteric cases were associated with animal contact. Public health professionals, stakeholders associated with animals and their related industries (e.g., pet treats, mobile zoos, abattoirs), and the public should recognize that animal contact is an important source of enteric illnesses in order to take measures to reduce the burden of illness from animal sources.

Recent antiseizure medications in the Intensive Care Unit.

PubMed

Orinx, Cindy; Legros, Benjamin; Gaspard, Nicolas

2017-08-01

Seizures and status epilepticus (SE), both clinical and subclinical, are frequent in critically ill patients. The list of available antiseizure medications (ASMs) is expanding and now includes older and widely used drugs as well as more recent medications with a better safety and pharmacokinetics profile. We review a selection of recent publications about the indications and administration of ASMs in critical care for the prophylaxis and treatment of seizures and SE, focusing on recent ASMs available as intravenous formulation and emphasizing pharmacokinetics and safety issues in relation to several aspects of critical illness. Levetiracetam, lacosamide and more recently brivaracetam, represent interesting alternatives to older ASMs, mostly due to a more favorable safety and pharmacokinetic profile. Low-quality studies suggest that this profile results in better tolerability in treated patients. Ketamine might represent a useful addition in our anesthetic armamentarium for refractory SE, due to its different mechanism of action and cardiovascular properties. Little evidence is available however to support the prophylactic use of ASMs in critically ill patients, except in specific settings (traumatic brain injury and subarachnoid hemorrhage). Head-to-head studies comparing recent and older ASMs in the treatment of acute seizures and SE are ongoing or awaiting publication. Administration of ASMs to critically ill patients needs to be adapted to organ dysfunction, and especially to renal dysfunction for recent drugs. Recent ASMs and could represent better treatment choices in critically ill patients than older ones but this needs to be confirmed in randomized controlled studies. In general, further studies are required to clarify the indications and optimal use of ASMs in the critical care setting.

Unsuspected Critical Illness Among Emergency Department Patients Presenting for Acute Alcohol Intoxication.

PubMed

Klein, Lauren R; Cole, Jon B; Driver, Brian E; Battista, Christopher; Jelinek, Ryan; Martel, Marc L

2018-03-01

Emergency department (ED) visits for acute alcohol intoxication are common, but this population is at risk for decompensation and occult critical illness. The purpose of this study is to describe the incidence and predictors of unsuspected critical illness among patients with acute alcohol intoxication. This was a retrospective observational study of ED patients from 2011 to 2016 with acute alcohol intoxication. The study cohort included patients presenting for alcohol intoxication, whose initial assessment was uncomplicated alcohol intoxication without any other active acute medical or traumatic complaints. The primary outcome was defined as the unanticipated subsequent use of critical care resources during the encounter or admission to an ICU. We investigated potential predictors for this outcome with generalized estimating equations. We identified 31,364 eligible patient encounters (median age 38 years; 71% men; median breath alcohol concentration 234 mg/dL); 325 encounters (1%) used critical care resources. The most common diagnoses per 1,000 ED encounters were acute hypoxic respiratory failure (3.1), alcohol withdrawal (1.7), sepsis or infection (1.1), and intracranial hemorrhage (1.0). Three patients sustained a cardiac arrest. Presence of the following had an increased adjusted odds ratio (aOR) of developing critical illness: hypoglycemia (aOR 9.2), hypotension (aOR 3.8), tachycardia (aOR 1.8), fever (aOR 7.6), hypoxia (aOR 3.8), hypothermia (aOR 4.2), and parenteral sedation (aOR 2.4). The initial blood alcohol concentration aOR was 1.0. Critical care resources were used for 1% of ED patients with alcohol intoxication who were initially assessed by physicians to have low risk. Abnormal vital signs, hypoglycemia, and chemical sedation were associated with increased odds of critical illness. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

9 CFR 117.4 - Test animals.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 9 Animals and Animal Products 1 2012-01-01 2012-01-01 false Test animals. 117.4 Section 117.4... Test animals. (a) All test animals shall be examined for clinical signs of illness, injury, or abnormal behavior prior to the start of a test and throughout the observation period specified in the test protocol...

9 CFR 117.4 - Test animals.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 9 Animals and Animal Products 1 2010-01-01 2010-01-01 false Test animals. 117.4 Section 117.4... Test animals. (a) All test animals shall be examined for clinical signs of illness, injury, or abnormal behavior prior to the start of a test and throughout the observation period specified in the test protocol...

Therapeutic drug monitoring of anti-infective agents in critically ill patients.

PubMed

Jager, Nynke G L; van Hest, Reinier M; Lipman, Jeffrey; Taccone, Fabio S; Roberts, Jason A

2016-07-01

Initial adequate anti-infective therapy is associated with significantly improved clinical outcomes for patients with severe infections. However, in critically ill patients, several pathophysiological and/or iatrogenic factors may affect the pharmacokinetics of anti-infective agents leading to suboptimal drug exposure, in particular during the early phase of therapy. Therapeutic drug monitoring (TDM) may assist to overcome this problem. We discuss the available evidence on the use of TDM in critically ill patient populations for a number of anti-infective agents, including aminoglycosides, β-lactams, glycopeptides, antifungals and antivirals. Also, we present the available evidence on the practices of anti-infective TDM and describe the potential utility of TDM to improve treatment outcome in critically ill patients with severe infections. For aminoglycosides, glycopeptides and voriconazole, beneficial effects of TDM have been established on both drug effectiveness and potential side effects. However, for other drugs, therapeutic ranges need to be further defined to optimize treatment prescription in this setting.

Plasmodium vivax Hospitalizations in a Monoendemic Malaria Region: Severe Vivax Malaria?

PubMed Central

Quispe, Antonio M.; Pozo, Edwar; Guerrero, Edith; Durand, Salomón; Baldeviano, G. Christian; Edgel, Kimberly A.; Graf, Paul C. F.; Lescano, Andres G.

2014-01-01

Severe malaria caused by Plasmodium vivax is no longer considered rare. To describe its clinical features, we performed a retrospective case control study in the subregion of Luciano Castillo Colonna, Piura, Peru, an area with nearly exclusive vivax malaria transmission. Severe cases and the subset of critically ill cases were compared with a random set of uncomplicated malaria cases (1:4). Between 2008 and 2009, 6,502 malaria cases were reported, including 106 hospitalized cases, 81 of which fit the World Health Organization definition for severe malaria. Of these 81 individuals, 28 individuals were critically ill (0.4%, 95% confidence interval = 0.2–0.6%) with severe anemia (57%), shock (25%), lung injury (21%), acute renal failure (14%), or cerebral malaria (11%). Two potentially malaria-related deaths occurred. Compared with uncomplicated cases, individuals critically ill were older (38 versus 26 years old, P < 0.001), but similar in other regards. Severe vivax malaria monoinfection with critical illness is more common than previously thought. PMID:24752683

Plasmodium vivax hospitalizations in a monoendemic malaria region: severe vivax malaria?

PubMed

Quispe, Antonio M; Pozo, Edwar; Guerrero, Edith; Durand, Salomón; Baldeviano, G Christian; Edgel, Kimberly A; Graf, Paul C F; Lescano, Andres G

2014-07-01

Severe malaria caused by Plasmodium vivax is no longer considered rare. To describe its clinical features, we performed a retrospective case control study in the subregion of Luciano Castillo Colonna, Piura, Peru, an area with nearly exclusive vivax malaria transmission. Severe cases and the subset of critically ill cases were compared with a random set of uncomplicated malaria cases (1:4). Between 2008 and 2009, 6,502 malaria cases were reported, including 106 hospitalized cases, 81 of which fit the World Health Organization definition for severe malaria. Of these 81 individuals, 28 individuals were critically ill (0.4%, 95% confidence interval = 0.2-0.6%) with severe anemia (57%), shock (25%), lung injury (21%), acute renal failure (14%), or cerebral malaria (11%). Two potentially malaria-related deaths occurred. Compared with uncomplicated cases, individuals critically ill were older (38 versus 26 years old, P < 0.001), but similar in other regards. Severe vivax malaria monoinfection with critical illness is more common than previously thought. © The American Society of Tropical Medicine and Hygiene.

Trophic or full nutritional support?

PubMed

Arabi, Yaseen M; Al-Dorzi, Hasan M

2018-06-04

Full nutritional support during the acute phase of critical illness has traditionally been recommended to reduce catabolism and prevent malnutrition. Approaches to achieve full nutrition include early initiation of nutritional support, targeting full nutritional requirement as soon as possible and initiation of supplemental parenteral nutrition when enteral nutrition does not reach the target. Existing evidence supports early enteral nutrition over delayed enteral nutrition or early parenteral nutrition. Recent randomized controlled trials have demonstrated that permissive underfeeding or trophic feeding is associated with similar outcomes compared with full feeding in the acute phase of critical illness. In patients with refeeding syndrome, patients with high nutritional risk and patients with shock, early enteral nutrition targeting full nutritional targets may be associated with worse outcomes compared with less aggressive enteral nutrition strategy. A two-phase approach for nutritional support may more appropriately account for the physiologic changes during critical illness than one-phase approach. Further evidence is awaited for the optimal protein amount during critical illness and for feeding patients at high nutritional risk or with acute gastrointestinal injury.

Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients.

PubMed

Gosselink, R; Bott, J; Johnson, M; Dean, E; Nava, S; Norrenberg, M; Schönhofer, B; Stiller, K; van de Leur, H; Vincent, J L

2008-07-01

The Task Force reviewed and discussed the available literature on the effectiveness of physiotherapy for acute and chronic critically ill adult patients. Evidence from randomized controlled trials or meta-analyses was limited and most of the recommendations were level C (evidence from uncontrolled or nonrandomized trials, or from observational studies) and D (expert opinion). However, the following evidence-based targets for physiotherapy were identified: deconditioning, impaired airway clearance, atelectasis, intubation avoidance, and weaning failure. Discrepancies and lack of data on the efficacy of physiotherapy in clinical trials support the need to identify guidelines for physiotherapy assessments, in particular to identify patient characteristics that enable treatments to be prescribed and modified on an individual basis. There is a need to standardize pathways for clinical decision-making and education, to define the professional profile of physiotherapists, and increase the awareness of the benefits of prevention and treatment of immobility and deconditioning for critically ill adult patients.

Proceedings of the 2016 Clinical Nutrition Week Research Workshop-The Optimal Dose of Protein Provided to Critically Ill Patients.

PubMed

Heyland, Daren K; Rooyakers, Olav; Mourtzakis, Marina; Stapleton, Renee D

2017-02-01

Recent literature has created considerable confusion about the optimal amount of protein/amino acids that should be provided to the critically ill patient. In fact, the evidentiary basis that directly tries to answer this question is relatively small. As a clinical nutrition research community, there is an urgent need to develop the optimal methods to assess the impact of exogenous protein/amino acid administration in the intensive care unit setting. That assessment can be conducted at various levels: (1) impact on stress response pathways, (2) impact on muscle synthesis and protein balance, (3) impact on muscle mass and function, and (4) impact on the patient's recovery. The objective of this research workshop was to review current literature relating to protein/amino acid administration for the critically ill patient and clinical outcomes and to discuss the key measurement and methodological features of future studies that should be done to inform the optimal protein/amino acid dose provided to critically ill patients.

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

Evidence to support tooth brushing in critically ill patients.

PubMed

Ames, Nancy J

2011-05-01

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.

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.

[Critical illness polyneuropathy and myopathy].

PubMed

Motomura, Masakatsu

2003-11-01

Critical Illness Polyneuropathy (CIP) and Myopathy (CIM), either singly or in combination, are a common complication of critical illness. Both disorders may lead to severe weakness and require mechanical ventilation. CIP, as initially described by Bolton et al., in 1984, is a sensorimotor polyneuropathy that is often a complication of sepsis and multiorgan failure. In Japan, Horinouchi et al., first reported a case in 1994. CIM has been referred to by a number of different terms (acute quadriplegic myopathy, thick filament myopathy, acute necrotizing myopathy of intensive care, rapidly evolving myopathy with myosin-deficiency fibers) in the literature. A variety of serious problems (e.g., pneumonia, severe asthma, and lung or liver transplantation) and the concomitant use of high-dose intravenous corticosteroids and nondepolarizing neuromuscular blocking agents predispose to CIM. In Japan, Kawada et al., reported a first case as acute quadriplegic myopathy in 2000. There is no specific treatment for CIP and CIM. Minimizing the use of corticosteroids and nondepolarizing neuromuscular blocking agents in a critical illness setting may prove helpful in preventing the occurrence of these disorders. The prognosis is directly related to the age of the patient and the seriousness of the underlying illness.

SCREEN: A simple layperson administered screening algorithm in low resource international settings significantly reduces waiting time for critically ill children in primary healthcare clinics.

PubMed

Hansoti, Bhakti; Jenson, Alexander; Kironji, Antony G; Katz, Joanne; Levin, Scott; Rothman, Richard; Kelen, Gabor D; Wallis, Lee A

2017-01-01

In low resource settings, an inadequate number of trained healthcare workers and high volumes of children presenting to Primary Healthcare Centers (PHC) result in prolonged waiting times and significant delays in identifying and evaluating critically ill children. The Sick Children Require Emergency Evaluation Now (SCREEN) program, a simple six-question screening algorithm administered by lay healthcare workers, was developed in 2014 to rapidly identify critically ill children and to expedite their care at the point of entry into a clinic. We sought to determine the impact of SCREEN on waiting times for critically ill children post real world implementation in Cape Town, South Africa. This is a prospective, observational implementation-effectiveness hybrid study that sought to determine: (1) the impact of SCREEN implementation on waiting times as a primary outcome measure, and (2) the effectiveness of the SCREEN tool in accurately identifying critically ill children when utilised by the QM and adherence by the QM to the SCREEN algorithm as secondary outcome measures. The study was conducted in two phases, Phase I control (pre-SCREEN implementation- three months in 2014) and Phase II (post-SCREEN implementation-two distinct three month periods in 2016). In Phase I, 1600 (92.38%) of 1732 children presenting to 4 clinics, had sufficient data for analysis and comprised the control sample. In Phase II, all 3383 of the children presenting to the 26 clinics during the sampling time frame had sufficient data for analysis. The proportion of critically ill children who saw a professional nurse within 10 minutes increased tenfold from 6.4% to 64% (Phase I to Phase II) with the median time to seeing a professional nurse reduced from 100.3 minutes to 4.9 minutes, (p < .001, respectively). Overall layperson screening compared to Integrated Management of Childhood Illnesses (IMCI) designation by a nurse had a sensitivity of 94.2% and a specificity of 88.1%, despite large variance in adherence to the SCREEN algorithm across clinics. The SCREEN program when implemented in a real-world setting can significantly reduce waiting times for critically ill children in PHCs, however further work is required to improve the implementation of this innovative program.

Monitoring of argatroban and lepirudin anticoagulation in critically ill patients by conventional laboratory parameters and rotational thromboelastometry - a prospectively controlled randomized double-blind clinical trial.

PubMed

Beiderlinden, Martin; Werner, Patrick; Bahlmann, Astrid; Kemper, Johann; Brezina, Tobias; Schäfer, Maximilian; Görlinger, Klaus; Seidel, Holger; Kienbaum, Peter; Treschan, Tanja A

2018-02-09

Argatroban or lepirudin anticoagulation therapy in patients with heparin induced thrombocytopenia (HIT) or HIT suspect is typically monitored using the activated partial thromboplastin time (aPTT). Although aPTT correlates well with plasma levels of argatroban and lepirudin in healthy volunteers, it might not be the method of choice in critically ill patients. However, in-vivo data is lacking for this patient population. Therefore, we studied in vivo whether ROTEM or global clotting times would provide an alternative for monitoring the anticoagulant intensity effects in critically ill patients. This study was part of the double-blind randomized trial "Argatroban versus Lepirudin in critically ill patients (ALicia)", which compared critically ill patients treated with argatroban or lepirudin. Following institutional review board approval and written informed consent, for this sub-study blood of 35 critically ill patients was analysed. Before as well as 12, 24, 48 and 72 h after initiation of argatroban or lepirudin infusion, blood was analysed for aPTT, aPTT ratios, thrombin time (TT), INTEM CT,INTEM CT ratios, EXTEM CT, EXTEM CT ratios and maximum clot firmness (MCF) and correlated with the corresponding plasma concentrations of the direct thrombin inhibitor. To reach a target aPTT of 1.5 to 2 times baseline, median [IQR] plasma concentrations of 0.35 [0.01-1.2] μg/ml argatroban and 0.17 [0.1-0.32] μg/ml lepirudin were required. For both drugs, there was no significant correlation between aPTT and aPTT ratios and plasma concentrations. INTEM CT, INTEM CT ratios, EXTEM CT, EXTEM CT ratios, TT and TT ratios correlated significantly with plasma concentrations of both drugs. Additionally, agreement between argatroban plasma levels and EXTEM CT and EXTEM CT ratios were superior to agreement between argatroban plasma levels and aPTT in the Bland Altman analysis. MCF remained unchanged during therapy with both drugs. In critically ill patients, TT and ROTEM parameters may provide better correlation to argatroban and lepirudin plasma concentrations than aPTT. ClinicalTrials.gov , NCT00798525 , registered on 25 Nov 2008.

24-Hour protein, arginine and citrulline metabolism in fed critically ill children - A stable isotope tracer study.

PubMed

de Betue, Carlijn T I; Garcia Casal, Xiomara C; van Waardenburg, Dick A; Schexnayder, Stephen M; Joosten, Koen F M; Deutz, Nicolaas E P; Engelen, Marielle P K J

2017-06-01

The reference method to study protein and arginine metabolism in critically ill children is measuring plasma amino acid appearances with stable isotopes during a short (4-8 h) time period and extrapolate results to 24-h. However, 24-h measurements may be variable due to critical illness related factors and a circadian rhythm could be present. Since only short duration stable isotope studies in critically ill children have been conducted before, the aim of this study was to investigate 24-h appearance of specific amino acids representing protein and arginine metabolism, with stable isotope techniques in continuously fed critically ill children. In eight critically ill children, admitted to the pediatric (n = 4) or cardiovascular (n = 4) intensive care unit, aged 0-10 years, receiving continuous (par)enteral nutrition with protein intake 1.0-3.7 g/kg/day, a 24-h stable isotope tracer protocol was carried out. L-[ring- 2 H 5 ]-phenylalanine, L-[3,3- 2 H 2 ]-tyrosine, L-[5,5,5- 2 H 3 ]-leucine, L-[guanido- 15 N 2 ]-arginine and L-[5- 13 C-3,3,4,4- 2 H 4 ]-citrulline were infused intravenously and L-[ 15 N]-phenylalanine and L-[1- 13 C]leucine enterally. Arterial blood was sampled every hour. Coefficients of variation, representing intra-individual variability, of the amino acid appearances of phenylalanine, tyrosine, leucine, arginine and citrulline were high, on average 14-19% for intravenous tracers and 23-26% for enteral tracers. No evident circadian rhythm was present. The pattern and overall 24-h level of whole body protein balance differed per individual. In continuously fed stable critically ill children, the amino acid appearances of phenylalanine, tyrosine, leucine, arginine and citrulline show high variability. This should be kept in mind when performing stable isotope studies in this population. There was no apparent circadian rhythm. NCT01511354 on clinicaltrials.gov. Copyright © 2017 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

A mixed-methods systematic review protocol to examine the use of physical restraint with critically ill adults and strategies for minimizing their use.

PubMed

Rose, Louise; Dale, Craig; Smith, Orla M; Burry, Lisa; Enright, Glenn; Fergusson, Dean; Sinha, Samir; Wiesenfeld, Lesley; Sinuff, Tasnim; Mehta, Sangeeta

2016-11-21

Critically ill patients frequently experience severe agitation placing them at risk of harm. Physical restraint is common in intensive care units (ICUs) for clinician concerns about safety. However, physical restraint may not prevent medical device removal and has been associated with negative physical and psychological consequences. While professional society guidelines, legislation, and accreditation standards recommend physical restraint minimization, guidelines for critically ill patients are over a decade old, with recommendations that are non-specific. Our systematic review will synthesize evidence on physical restraint in critically ill adults with the primary objective of identifying effective minimization strategies. Two authors will independently search from inception to July 2016 the following: Ovid MEDLINE, CINAHL, Embase, Web of Science, Cochrane Library, PROSPERO, Joanna Briggs Institute, grey literature, professional society websites, and the International Clinical Trials Registry Platform. We will include quantitative and qualitative study designs, clinical practice guidelines, policy documents, and professional society recommendations relevant to physical restraint of critically ill adults. Authors will independently perform data extraction in duplicate and complete risk of bias and quality assessment using recommended tools. We will assess evidence quality for quantitative studies using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and for qualitative studies using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) guidelines. Outcomes of interest include (1) efficacy/effectiveness of physical restraint minimization strategies; (2) adverse events (unintentional device removal, psychological impact, physical injury) and associated benefits including harm prevention; (3) ICU outcomes (ventilation duration, length of stay, and mortality); (4) prevalence, incidence, patterns of use including patient and treatment characteristics and chemical restraint; (5) barriers and facilitators to minimization; (6) patient, family, and healthcare professional perspectives; (7) professional society-endorsed recommendations; and (8) evidence gaps and research priorities. We will use our systematic review findings to produce updated guidelines on physical restraint use for critically ill adults and to develop a professional society-endorsed position statement. This will foster patient and clinician safety by providing clinicians, administrators, and policy makers with a tool to promote minimal and safe use of physical restraint for critically ill adults. PROSPERO CRD42015027860.

Red blood cell 2,3-diphosphoglycerate concentration and in vivo P50 during early critical illness.

PubMed

Ibrahim, Ezz el din S; McLellan, Stuart A; Walsh, Timothy S

2005-10-01

To measure red blood cell 2,3-diphosphoglycerate (RBC 2,3-DPG) concentrations in early critical illness; to investigate factors associated with high or low RBC 2,3-DPG levels; to calculate in vivo P50 in patients with early critical illness; and to explore the relationship between RBC 2,3-DPG and intensive care mortality. Prospective cohort study. General medical-surgical intensive care unit (ICU) of a major Scottish teaching hospital. One-hundred eleven critically ill patients during the first 24 hrs in the ICU with no history of chronic hematologic disorders or RBC transfusion within 24 hrs and 34 age- and sex-matched healthy reference subjects. None. We measured RBC 2,3-DPG concentration, plasma biochemistry values, and arterial blood gas parameters. On average, RBC 2,3-DPG was lower among critically ill patients than controls (mean [sd], 14.1 [6.3] vs. 16.7 [3.7] mumol/g hemoglobin; p = .004) and had a wider range of values (patients, 3.2-32.5 mumol/g hemoglobin; reference group, 9.1-24.3). Regression analysis indicated a strong independent association between plasma pH and RBC 2,3-DPG (B, 32.15 [95% confidence interval, 19.07-46.22], p < .001) and a weak association with plasma chloride (B, -0.196 [95% confidence interval, -0.39 to -0.01], p = .044) but not with hemoglobin or other measured biochemical parameters. The mean calculated in vivo P50 level was normal (3.8 kPa) but varied widely among patients (range, 2.0-5.5 kPa). RBC 2,3-DPG concentration was similar for ICU survivors and nonsurvivors. RBC 2,3-DPG concentrations vary widely among critically ill patients. Acidosis is associated with lower RBC 2,3-DPG concentrations, but anemia is not associated with a compensatory increase in RBC 2,3-DPG early in critical illness. Lower RBC 2,3-DPG concentrations during the first 24 hrs of intensive care are not associated with higher ICU mortality.

Time to look beyond one-year mortality in critically ill hematological patients?

PubMed

Moors, Ine; Benoit, Dominique D

2014-02-11

The spectacular improvement in long-term prognosis of patients with hematological malignancies since the 1980s, coupled with the subsequent improvement over the past decade in short- and mid-term survival in cases of critical illness, resulted in an increasing referral of such patients to the ICU. A remaining question, however, is how these patients perform in the long term with regard to survival and quality of life. Here we discuss the present multicenter study on survival beyond 1 year in critically ill patients with hematological malignancies. We conclude with suggestions on how we can further improve the long-term outcome of these patients.

Cerebral Microcirculation during Experimental Normovolaemic Anemia

PubMed Central

Bellapart, Judith; Cuthbertson, Kylie; Dunster, Kimble; Diab, Sara; Platts, David G.; Raffel, O. Christopher; Gabrielian, Levon; Barnett, Adrian; Paratz, Jenifer; Boots, Rob; Fraser, John F.

2016-01-01

Anemia is accepted among critically ill patients as an alternative to elective blood transfusion. This practice has been extrapolated to head injury patients with only one study comparing the effects of mild anemia on neurological outcome. There are no studies quantifying microcirculation during anemia. Experimental studies suggest that anemia leads to cerebral hypoxia and increased rates of infarction, but the lack of clinical equipoise, when testing the cerebral effects of transfusion among critically injured patients, supports the need of experimental studies. The aim of this study was to quantify cerebral microcirculation and the potential presence of axonal damage in an experimental model exposed to normovolaemic anemia, with the intention of describing possible limitations within management practices in critically ill patients. Under non-recovered anesthesia, six Merino sheep were instrumented using an intracardiac transeptal catheter to inject coded microspheres into the left atrium to ensure systemic and non-chaotic distribution. Cytometric analyses quantified cerebral microcirculation at specific regions of the brain. Amyloid precursor protein staining was used as an indicator of axonal damage. Animals were exposed to normovolaemic anemia by blood extractions from the indwelling arterial catheter with simultaneous fluid replacement through a venous central catheter. Simultaneous data recording from cerebral tissue oxygenation, intracranial pressure, and cardiac output was monitored. A regression model was used to examine the effects of anemia on microcirculation with a mixed model to control for repeated measures. Homogeneous and normal cerebral microcirculation with no evidence of axonal damage was present in all cerebral regions, with no temporal variability, concluding that acute normovolaemic anemia does not result in short-term effects on cerebral microcirculation in the ovine brain. PMID:26869986

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

[Limited evidence for monitoring and treatment of hypophosphataemia in critically ill patients].

PubMed

Federspiel, Christine; Itenov, Theis S; Thormar, Katrin; Bestle, Morten H

2015-12-07

Hypophosphataemia is a potentially hazardous metabolic disturbance which is common in critically ill patients. The condition is reported to be associated with severe complications and increased mortality. It is unknown, whether hypophosphataemia has a causal effect or reflects the severity of illness. There are no randomized clinical trials to support treatment of hypophosphataemia with intravenous phosphate substitution, which has resulted in large variations in monitoring and treatment of hypophosphataemia in the intensive care unit.

Sepsis Pathophysiology, Chronic Critical Illness, and Persistent Inflammation-Immunosuppression and Catabolism Syndrome.

PubMed

Mira, Juan C; Gentile, Lori F; Mathias, Brittany J; Efron, Philip A; Brakenridge, Scott C; Mohr, Alicia M; Moore, Frederick A; Moldawer, Lyle L

2017-02-01

To provide an appraisal of the evolving paradigms in the pathophysiology of sepsis and propose the evolution of a new phenotype of critically ill patients, its potential underlying mechanism, and its implications for the future of sepsis management and research. Literature search using PubMed, MEDLINE, EMBASE, and Google Scholar. Sepsis remains one of the most debilitating and expensive illnesses, and its prevalence is not declining. What is changing is our definition(s), its clinical course, and how we manage the septic patient. Once thought to be predominantly a syndrome of over exuberant inflammation, sepsis is now recognized as a syndrome of aberrant host protective immunity. Earlier recognition and compliance with treatment bundles has fortunately led to a decline in multiple organ failure and in-hospital mortality. Unfortunately, more and more sepsis patients, especially the aged, are suffering chronic critical illness, rarely fully recover, and often experience an indolent death. Patients with chronic critical illness often exhibit "a persistent inflammation-immunosuppression and catabolism syndrome," and it is proposed here that this state of persisting inflammation, immunosuppression and catabolism contributes to many of these adverse clinical outcomes. The underlying cause of inflammation-immunosuppression and catabolism syndrome is currently unknown, but there is increasing evidence that altered myelopoiesis, reduced effector T-cell function, and expansion of immature myeloid-derived suppressor cells are all contributory. Although newer therapeutic interventions are targeting the inflammatory, the immunosuppressive, and the protein catabolic responses individually, successful treatment of the septic patient with chronic critical illness and persistent inflammation-immunosuppression and catabolism syndrome may require a more complementary approach.

Frailty in the critically ill: a novel concept

PubMed Central

2011-01-01

The concept of frailty has been defined as a multidimensional syndrome characterized by the loss of physical and cognitive reserve that predisposes to the accumulation of deficits and increased vulnerability to adverse events. Frailty is strongly correlated with age, and overlaps with and extends aspects of a patient's disability status (that is, functional limitation) and/or burden of comorbid disease. The frail phenotype has more specifically been characterized by adverse changes to a patient's mobility, muscle mass, nutritional status, strength and endurance. We contend that, in selected circumstances, the critically ill patient may be analogous to the frail geriatric patient. The prevalence of frailty amongst critically ill patients is currently unknown; however, it is probably increasing, based on data showing that the utilization of intensive care unit (ICU) resources by older people is rising. Owing to the theoretical similarities in frailty between geriatric and critically ill patients, this concept may have clinical relevance and may be predictive of outcomes, along with showing important interaction with several factors including illness severity, comorbid disease, and the social and structural environment. We believe studies of frailty in critically ill patients are needed to evaluate how it correlates with outcomes such as survival and quality of life, and how it relates to resource utilization, such as length of mechanical ventilation, ICU stay and duration of hospitalization. We hypothesize that the objective measurement of frailty may provide additional support and reinforcement to clinicians confronted with end-of-life decisions on the appropriateness of ICU support and/or withholding of life-sustaining therapies. PMID:21345259

Clinical review: Critical care in the global context – disparities in burden of illness, access, and economics

PubMed Central

Fowler, Robert A; Adhikari, Neill KJ; Bhagwanjee, Satish

2008-01-01

World health care expenditures exceed US $4 trillion. However, there is marked variation in global health care spending, from upwards of US $7,000 per capita in the US to under US $25 per capita in most of sub-Saharan Africa. In developed countries, care of the critically ill comprises a large proportion of health care spending; however, in developing countries, with a greater burden of both illness and critical illness, there is little infrastructure to provide care for these patients. There is sparse research to inform the needs of critically ill patients, but often basic requirements such as trained personnel, medications, oxygen, diagnostic and therapeutic equipment, reliable power supply, and safe transportation are unavailable. Why should this be a focus of intensivists of the developed world? Nearly all of those dying in developing countries would be our patients without the accident of latitude. Tailored to the needs of the region, the provision of critical care has a role, even in the context of limited preventive and primary care. Internationally and locally driven solutions are needed. We can help by recognizing the '10/90 gap' that is pervasive within global health care and our profession by educating ourselves of needs, contacting and collaborating with colleagues in the developing world, and advocating that our professional societies and funding agencies consider an increasingly global perspective in education and research. PMID:19014409

[Metabolic control in the critically ill patient an update: hyperglycemia, glucose variability hypoglycemia and relative hypoglycemia].

PubMed

Pérez-Calatayud, Ángel Augusto; Guillén-Vidaña, Ariadna; Fraire-Félix, Irving Santiago; Anica-Malagón, Eduardo Daniel; Briones Garduño, Jesús Carlos; Carrillo-Esper, Raúl

Metabolic changes of glucose in critically ill patients increase morbidity and mortality. The appropriate level of blood glucose has not been established so far and should be adjusted for different populations. However concepts such as glucose variability and relative hypoglycemia of critically ill patients are concepts that are changing management methods and achieving closer monitoring. The purpose of this review is to present new data about the management and metabolic control of patients in critical areas. Currently glucose can no longer be regarded as an innocent element in critical patients; both hyperglycemia and hypoglycemia increase morbidity and mortality of patients. Protocols and better instruments for continuous measurement are necessary to achieve the metabolic control of our patients. Copyright © 2016 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. All rights reserved.

Viral pathogen discovery

PubMed Central

Chiu, Charles Y

2015-01-01

Viral pathogen discovery is of critical importance to clinical microbiology, infectious diseases, and public health. Genomic approaches for pathogen discovery, including consensus polymerase chain reaction (PCR), microarrays, and unbiased next-generation sequencing (NGS), have the capacity to comprehensively identify novel microbes present in clinical samples. Although numerous challenges remain to be addressed, including the bioinformatics analysis and interpretation of large datasets, these technologies have been successful in rapidly identifying emerging outbreak threats, screening vaccines and other biological products for microbial contamination, and discovering novel viruses associated with both acute and chronic illnesses. Downstream studies such as genome assembly, epidemiologic screening, and a culture system or animal model of infection are necessary to establish an association of a candidate pathogen with disease. PMID:23725672

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

USDA-ARS?s Scientific Manuscript database

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...

Nutrition of the critically ill patient in field hospitals on operations.

PubMed

Henning, J; Scott, T; Price, S

2008-12-01

Although much of the evidence is inconclusive, most of it is based on small patient groups it is generally supportive of early, enteral feeding of critically ill patients. It has become a standard of care in the UK and as such should be encouraged in deployed operational ITUs.

Caring for a critically ill Amish newborn.

PubMed

Gibson, Elizabeth A

2008-10-01

This article describes a neonatal nurse's personal experience in working with a critically ill newborn and his Amish family in a newborn intensive care unit in Montana. The description includes a cultural experience with an Amish family with application to Madeleine Leininger's theory of culture care diversity and universality.

Critical illness-related corticosteroid insufficiency (CIRCI): a narrative review from a Multispecialty Task Force of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM).

PubMed

Annane, Djillali; Pastores, Stephen M; Arlt, Wiebke; Balk, Robert A; Beishuizen, Albertus; Briegel, Josef; Carcillo, Joseph; Christ-Crain, Mirjam; Cooper, Mark S; Marik, Paul E; Meduri, Gianfranco Umberto; Olsen, Keith M; Rochwerg, Bram; Rodgers, Sophia C; Russell, James A; Van den Berghe, Greet

2017-12-01

To provide a narrative review of the latest concepts and understanding of the pathophysiology of critical illness-related corticosteroid insufficiency (CIRCI). A multispecialty task force of international experts in critical care medicine and endocrinology and members of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM). Medline, Database of Abstracts of Reviews of Effects (DARE), Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews. Three major pathophysiologic events were considered to constitute CIRCI: dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, altered cortisol metabolism, and tissue resistance to glucocorticoids. The dysregulation of the HPA axis is complex, involving multidirectional crosstalk between the CRH/ACTH pathways, autonomic nervous system, vasopressinergic system, and immune system. Recent studies have demonstrated that plasma clearance of cortisol is markedly reduced during critical illness, explained by suppressed expression and activity of the primary cortisol-metabolizing enzymes in the liver and kidney. Despite the elevated cortisol levels during critical illness, tissue resistance to glucocorticoids is believed to occur due to insufficient glucocorticoid alpha-mediated anti-inflammatory activity. Novel insights into the pathophysiology of CIRCI add to the limitations of the current diagnostic tools to identify at-risk patients and may also impact how corticosteroids are used in patients with CIRCI.

Understanding health economic analysis in critical care: insights from recent randomized controlled trials.

PubMed

Sud, Sachin; Cuthbertson, Brian H

2011-10-01

The article reviews the methods of health economic analysis (HEA) in clinical trials of critically ill patients. Emphasis is placed on the usefulness of HEA in the context of positive and 'no effect' studies, with recent examples. The need to control costs and promote effective spending in caring for the critically ill has garnered considerable attention due to the high cost of critical illness. Many clinical trials focus on short-term mortality, ignoring costs and quality of life, and fail to change clinical practice or promote efficient use of resources. Incorporating HEA into clinical trials is a possible solution. Such studies have shown some interventions, although expensive, provide good value, whereas others should be withdrawn from clinical practice. Incorporating HEA into randomized controlled trials (RCTs) requires careful attention to collect all relevant costs. Decision trees, modeling assumptions and methods for collecting costs and measuring outcomes should be planned and published beforehand to minimize bias. Costs and cost-effectiveness are potentially useful outcomes in RCTs of critically ill patients. Future RCTs should incorporate parallel HEA to provide both economic outcomes, which are important to the community, alongside patient-centered outcomes, which are important to individuals.

Interpatient Variability in Dexmedetomidine Response: A Survey of the Literature

PubMed Central

Holliday, Samantha F.; Kane-Gill, Sandra L.; Empey, Philip E.; Buckley, Mitchell S.; Smithburger, Pamela L.

2014-01-01

Fifty-five thousand patients are cared for in the intensive care unit (ICU) daily with sedation utilized to reduce anxiety and agitation while optimizing comfort. The Society of Critical Care Medicine (SCCM) released updated guidelines for management of pain, agitation, and delirium in the ICU and recommended nonbenzodiazepines, such as dexmedetomidine and propofol, as first line sedation agents. Dexmedetomidine, an alpha-2 agonist, offers many benefits yet its use is mired by the inability to consistently achieve sedation goals. Three hypotheses including patient traits/characteristics, pharmacokinetics in critically ill patients, and clinically relevant genetic polymorphisms that could affect dexmedetomidine response are presented. Studies in patient traits have yielded conflicting results regarding the role of race yet suggest that dexmedetomidine may produce more consistent results in less critically ill patients and with home antidepressant use. Pharmacokinetics of critically ill patients are reported as similar to healthy individuals yet wide, unexplained interpatient variability in dexmedetomidine serum levels exist. Genetic polymorphisms in both metabolism and receptor response have been evaluated in few studies, and the results remain inconclusive. To fully understand the role of dexmedetomidine, it is vital to further evaluate what prompts such marked interpatient variability in critically ill patients. PMID:24558330

Protein-energy nutrition in the ICU is the power couple: A hypothesis forming analysis.

PubMed

Oshima, Taku; Deutz, Nicolaas E; Doig, Gordon; Wischmeyer, Paul E; Pichard, Claude

2016-08-01

We hypothesize that an optimal and simultaneous provision of energy and protein is favorable to clinical outcome of the critically ill patients. We conducted a review of the literature, obtained via electronic databases and focused on the metabolic alterations during critical illness, the estimation of energy and protein requirements, as well as the impact of their administration. Critically ill patients undergo severe metabolic stress during which time a great amount of energy and protein is utilized in a variety of reactions essential for survival. Energy provision for critically ill patients has drawn attention given its association with morbidity, survival and long-term recovery, but protein provision is not sufficiently taken into account as a critical component of nutrition support that influences clinical outcome. Measurement of energy expenditure is done by indirect calorimetry, but protein status cannot be measured with a bedside technology at present. Recent studies suggest the importance of optimal and combined provision of energy and protein to optimize clinical outcome. Clinical randomized controlled studies measuring energy and protein targets should confirm this hypothesis and therefore establish energy and protein as a power couple. Copyright © 2015 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Carriage of methicillin-resistant Staphylococcus aureus by healthy companion animals

USDA-ARS?s Scientific Manuscript database

Methicillin-resistant Staphylococcus aureus (MRSA) is a significant human pathogen and has also been associated with wounded or ill companion animals. Healthy animals may also harbor MRSA without presenting any symptoms, but little is known about the prevalence of MRSA among these animals. Therefo...

Measurement of salivary cortisol level for the diagnosis of critical illness-related corticosteroid insufficiency in children.

PubMed

Gunnala, Vishal; Guo, Rong; Minutti, Carla; Durazo-Arvizu, Ramon; Laporte, Cynthia; Mathews, Herbert; Kliethermis, Stephanie; Bhatia, Rahul

2015-05-01

To compare serum total, serum free and salivary cortisol in critically ill children. Prospective observational cohort study. Tertiary pediatric critical care unit at Ronald McDonald Children's Hospital at Loyola University Medical Center. We enrolled 59 patients (4 weeks to 18 years of age) between January 2012 and May 2013. Thirty-four patients were included in the salivary to serum free cortisol correlational analysis. Blood and saliva samples were obtained simultaneously within 24 hours of admission between the hours of 6 AM and 12 PM. Salivary cortisol was tested by liquid chromatography/tandem mass spectrometry, serum free cortisol by liquid chromatography/tandem mass spectrometry followed by equilibrium dialysis, and serum total cortisol by liquid chromatography/tandem mass spectrometry. Salivary and serum free cortisol values from 34 patients had a correlation coefficient (r) of 0.87 (95% CI, 0.75-0.93; p < 0.0001). The total serum and salivary cortisol values had a correlation coefficient (r) of 0.67 (95% CI, 0.42-0.81; p < 0.0001). The total serum and serum free cortisol values had a correlation coefficient (r) of 0.83 (95% CI, 0.69-0.91; p < 0.0001). Serum free and salivary cortisol values correlate in critically ill children. Salivary cortisol can be used as a surrogate for serum free cortisol in critically ill pediatric patients. Salivary cortisol is a cost-effective and less invasive measure of bioavailable cortisol and offers an alternate and accurate method for assessing critical illness-related corticosteroid insufficiency in children.

The burden of surgical diseases on critical care services at a tertiary hospital in sub-Saharan Africa.

PubMed

Tomlinson, Jared; Haac, Bryce; Kadyaudzu, Clement; Samuel, Jonathan C; Campbell, Emilia L P; Lee, Clara N; Charles, Anthony G

2013-01-01

In many developing countries, including those of sub-Saharan Africa, care of the critically ill is poorly developed. We sought to elucidate the characteristics and outcomes of critically ill patients in order to better define the burden of disease and identify strategies for improving care. We conducted a cross sectional observation study of patients admitted to the intensive care unit at Kamuzu Central Hospital in 2010. Demographics, patient characteristics, clinical specialty and outcome data was collected for the 234 patients admitted during the study period. Older age and admission from trauma, general surgery or medical services were associated with increased mortality. The lowest mortality was among obstetrical and gynaecology patients. Use of the ventilator and transfusions were not associated with increased mortality. Patients with head injuries had the highest mortality rate. Rationing of critical care resources, using admitting diagnosis or scoring tools, can maximize access to critical care services in resource-limited settings. Furthermore, improvements of critical care services will be central to future efforts to reduce surgical morbidity and mortality and improving outcomes in all critically ill patients.

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. Copyright 2010 Elsevier Inc. All rights reserved.

Bugs or drugs: are probiotics safe for use in the critically ill?

PubMed

Urben, Lindsay M; Wiedmar, Jennifer; Boettcher, Erica; Cavallazzi, Rodrigo; Martindale, Robert G; McClave, Stephen A

2014-01-01

Probiotics are living microorganisms which have demonstrated many benefits in prevention, mitigation, and treatment of various disease states in critically ill populations. These diseases include antibiotic-associated diarrhea, Clostridium difficile diarrhea, ventilator-associated pneumonia, clearance of vancomycin-resistant enterococci from the GI tract, pancreatitis, liver transplant, major abdominal surgery, and trauma. However, their use has been severely limited due to a variety of factors including a general naïveté within the physician community, lack of regulation, and safety concerns. This article focuses on uses for probiotics in prevention and treatment, addresses current concerns regarding their use as well as proposing a protocol for safe use of probiotics in the critically ill patient.

Physician Reimbursement for Critical Care Services Integrating Palliative Care for Patients Who Are Critically Ill

PubMed Central

Nelson, Judith E.; Weissman, David E.; Hays, Ross M.; Mosenthal, Anne C.; Mulkerin, Colleen; Puntillo, Kathleen A.; Ray, Daniel E.; Bassett, Rick; Boss, Renee D.; Brasel, Karen J.; Campbell, Margaret L.; Cortez, Therese B.; Curtis, J. Randall

2012-01-01

Patients with advanced illness often spend time in an ICU, while nearly one-third of patients with advanced cancer who receive Medicare die in hospitals, often with failed ICU care. For most, death occurs following the withdrawal or withholding of life-sustaining treatments. The integration of palliative care is essential for high-quality critical care. Although palliative care specialists are becoming increasingly available, intensivists and other physicians are also expected to provide basic palliative care, including symptom treatment and communication about goals of care. Patients who are critically ill are often unable to make decisions about their care. In these situations, physicians must meet with family members or other surrogates to determine appropriate medical treatments. These meetings require clinical expertise to ensure that patient values are explored for medical decision making about therapeutic options, including palliative care. Meetings with families take time. Issues related to the disease process, prognosis, and treatment plan are complex, and decisions about the use or limitation of intensive care therapies have life-or-death implications. Inadequate reimbursement for physician services may be a barrier to the optimal delivery of high-quality palliative care, including effective communication. Appropriate documentation of time spent integrating palliative and critical care for patients who are critically ill can be consistent with the Current Procedural Terminology codes (99291 and 99292) for critical care services. The purpose of this article is to help intensivists and other providers understand the circumstances in which integration of palliative and critical care meets the definition of critical care services for billing purposes. PMID:22396564

Extra Physiotherapy in Critical Care (EPICC) Trial Protocol: a randomised controlled trial of intensive versus standard physical rehabilitation therapy in the critically ill.

PubMed

Thomas, Kirsty; 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

2015-05-25

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. 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. 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 submitted for publication in peer-reviewed journals and presented at national and international scientific meetings. ISRCTN20436833. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Antimicrobial resistance in Salmonella that caused foodborne disease outbreaks: United States, 2003–2012

PubMed Central

BROWN, A. C.; GRASS, J. E.; RICHARDSON, L. C.; NISLER, A. L.; BICKNESE, A. S.; GOULD, L. H.

2016-01-01

SUMMARY Although most non-typhoidal Salmonella illnesses are self-limiting, antimicrobial treatment is critical for invasive infections. To describe resistance in Salmonella that caused foodborne outbreaks in the United States, we linked outbreaks submitted to the Foodborne Disease Outbreak Surveillance System to isolate susceptibility data in the National Antimicrobial Resistance Monitoring System. Resistant outbreaks were defined as those linked to one or more isolates with resistance to at least one antimicrobial drug. Multidrug resistant (MDR) outbreaks had at least one isolate resistant to three or more antimicrobial classes. Twenty-one per cent (37/176) of linked outbreaks were resistant. In outbreaks attributed to a single food group, 73% (16/22) of resistant outbreaks and 46% (31/68) of non-resistant outbreaks were attributed to foods from land animals (P < 0.05). MDR Salmonella with clinically important resistance caused 29% (14/48) of outbreaks from land animals and 8% (3/40) of outbreaks from plant products (P < 0.01). In our study, resistant Salmonella infections were more common in outbreaks attributed to foods from land animals than outbreaks from foods from plants or aquatic animals. Antimicrobial susceptibility data on isolates from foodborne Salmonella outbreaks can help determine which foods are associated with resistant infections. PMID:27919296

Antimicrobial resistance in Salmonella that caused foodborne disease outbreaks: United States, 2003-2012.

PubMed

Brown, A C; Grass, J E; Richardson, L C; Nisler, A L; Bicknese, A S; Gould, L H

2017-03-01

Although most non-typhoidal Salmonella illnesses are self-limiting, antimicrobial treatment is critical for invasive infections. To describe resistance in Salmonella that caused foodborne outbreaks in the United States, we linked outbreaks submitted to the Foodborne Disease Outbreak Surveillance System to isolate susceptibility data in the National Antimicrobial Resistance Monitoring System. Resistant outbreaks were defined as those linked to one or more isolates with resistance to at least one antimicrobial drug. Multidrug resistant (MDR) outbreaks had at least one isolate resistant to three or more antimicrobial classes. Twenty-one per cent (37/176) of linked outbreaks were resistant. In outbreaks attributed to a single food group, 73% (16/22) of resistant outbreaks and 46% (31/68) of non-resistant outbreaks were attributed to foods from land animals (P < 0·05). MDR Salmonella with clinically important resistance caused 29% (14/48) of outbreaks from land animals and 8% (3/40) of outbreaks from plant products (P < 0·01). In our study, resistant Salmonella infections were more common in outbreaks attributed to foods from land animals than outbreaks from foods from plants or aquatic animals. Antimicrobial susceptibility data on isolates from foodborne Salmonella outbreaks can help determine which foods are associated with resistant infections.

Animal models of yellow fever and their application in clinical research.

PubMed

Julander, Justin G

2016-06-01

Yellow fever virus (YFV) is an arbovirus that causes significant human morbidity and mortality. This virus has been studied intensively over the past century, although there are still no treatment options for those who become infected. Periodic and unpredictable yellow fever (YF) outbreaks in Africa and South America continue to occur and underscore the ongoing need to further understand this viral disease and to develop additional countermeasures to prevent or treat cases of illness. The use of animal models of YF is critical to accomplishing this goal. There are several animal models of YF that replicate various aspects of clinical disease and have provided insight into pathogenic mechanisms of the virus. These typically include mice, hamsters and non-human primates (NHP). The utilities and shortcomings of the available animal models of YF are discussed. Information on recent discoveries that have been made in the field of YFV research is also included as well as important future directions in further ameliorating the morbidity and mortality that occur as a result of YFV infection. It is anticipated that these model systems will help facilitate further improvements in the understanding of this virus and in furthering countermeasures to prevent or treat infections. Copyright © 2016 Elsevier B.V. All rights reserved.

Development and Validation of a Printed Information Brochure for Families of Chronically Critically Ill Patients

PubMed Central

Carson, Shannon S.; Vu, Maihan; Danis, Marion; Camhi, Sharon L.; Scheunemann, Leslie P.; Cox, Christopher E.; Hanson, Laura C.; Nelson, Judith E.

2012-01-01

Objective Families and other surrogate decision-makers for chronically critically ill patients often lack information about patient prognosis or options for care. This study describes an approach to develop and validate a printed information brochure about chronic critical illness aimed at improving comprehension of the disease process and outcomes for patients’ families and other surrogate decision-makers. Design Investigators reviewed existing literature to identify key domains of informational needs. Content of these domains was incorporated in a draft brochure that included graphics and a glossary of terms. Clinical sensibility, balance, and emotional sensitivity of the draft brochure were tested in a series of evaluations by cohorts of experienced clinicians (n=49) and clinical content experts (n=8), with revisions after each review. Cognitive testing of the brochure was performed through interviews of 10 representative family members of chronically critically ill patients with quantitative and qualitative analysis of responses. Measurements and Main Results Clinical sensibility and balance were rated in the two most favorable categories on a 5-point scale by more than two thirds of clinicians and content experts. After review, family members described the brochure as clear and readable and recommended that the brochure be delivered to family members by clinicians, followed by a discussion of its contents. They indicated that the glossary was useful and recommended supplementation by additional lists of local resources. After reading the brochure, their prognostic estimates became more consistent with actual outcomes. Conclusions We have developed and validated a printed information brochure that may improve family comprehension of chronic critical illness and its outcomes. The structured process that is described can serve as a template for the development of other information aids for use with seriously ill populations. PMID:21926610

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…

The Effects of Head Trauma and Brain Injury on Neuroendocrinologic Function

DTIC Science & Technology

1984-07-13

V., Lee, L.A., and Kelly, M. Apparent hypogonadism caused by critical illness: The " Hypogonadal Sick" syndrome. Submitted for publication. 2...Abstracts *Woolf, P.D., Hamill, R.W., McDonald, J.V., Lee, L.A., and Kelly, M. Apparent hypogonadism caused by critical illness: The " Hypogonadal Sick

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

Update: Assessment of gastric pH in the critically ill.

PubMed

Neill, K M; Rice, K T; Ahern, H L

1998-04-27

The purpose of this manuscript is to update a review of the measurement of intraluminal gastric pH in the critically ill. Intraluminal gastric pH is readily measured by aspirates tested with litmus paper or a nasogastric tube with an antimony or glass electrode tip. Significant variations of intragastric pH have been shown in different stomach locations. Significant variations in the accuracy of pH readings have also been demonstrated. Prophylactic therapy in the critically ill is aimed at maintaining a gastric pH greater than 4.0 by drug therapy that 1) neutralizes acid, 2) interrupts the signal to produce acid, 3) reduces the amount of acid produced, or 4) enhances the mucosal barrier of the stomach lining. The critically ill patients at risk of respiratory failure or coagulopathy are the patients most at risk of gastrointestinal bleeding and are, therefore, the ones most likely to benefit from prophylactic therapy. Multiple pH readings are more reliable indicators of gastric pH than are individual readings. Continuous prophylaxis is more effective than intermittent.

Protein nutrition and exercise survival kit for critically ill.

PubMed

Weijs, Peter J M

2017-08-01

Protein delivery as well as exercise of critically ill in clinical practice is still a highly debated issue. Here we discuss only the most recent updates in the literature concerning protein nutrition and exercise of the critically ill. By lack of randomized controlled trial (RCTs) in protein nutrition we discuss four post-hoc analyses of nutrition studies and one experimental study in mice. Studies mainly confirm some insights that protein and energy effects are separate and that the trajectory of the patient in the ICU might change these effects. Exercise has been studied much more extensively with RCTs in the last year, although also here the differences between patient groups and timing of intervention might play their roles. Overall the effects of protein nutrition and exercise appear to be beneficial. However, studies into the differential effects of protein nutrition and/or exercise, and optimization of their combined use, have not been performed yet and are on the research agenda. Optimal protein nutrition, optimal exercise intervention as well as the optimal combination of nutrition, and exercise may help to improve long-term physical performance outcome in the critically ill patients.

Stress Induced Hyperglycemia and the Subsequent Risk of Type 2 Diabetes in Survivors of Critical Illness

PubMed Central

Plummer, Mark P.; Finnis, Mark E.; Phillips, Liza K.; Kar, Palash; Bihari, Shailesh; Biradar, Vishwanath; Moodie, Stewart; Horowitz, Michael; Shaw, Jonathan E.; Deane, Adam M.

2016-01-01

Objective Stress induced hyperglycemia occurs in critically ill patients who have normal glucose tolerance following resolution of their acute illness. The objective was to evaluate the association between stress induced hyperglycemia and incident diabetes in survivors of critical illness. Design Retrospective cohort study. Setting All adult patients surviving admission to a public hospital intensive care unit (ICU) in South Australia between 2004 and 2011. Patients Stress induced hyperglycemia was defined as a blood glucose ≥ 11.1 mmol/L (200 mg/dL) within 24 hours of ICU admission. Prevalent diabetes was identified through ICD-10 coding or prior registration with the Australian National Diabetes Service Scheme (NDSS). Incident diabetes was identified as NDSS registration beyond 30 days after hospital discharge until July 2015. The predicted risk of developing diabetes was described as sub-hazard ratios using competing risk regression. Survival was assessed using Cox proportional hazards regression. Main Results Stress induced hyperglycemia was identified in 2,883 (17%) of 17,074 patients without diabetes. The incidence of type 2 diabetes following critical illness was 4.8% (821 of 17,074). The risk of diabetes in patients with stress induced hyperglycemia was approximately double that of those without (HR 1.91 (95% CI 1.62, 2.26), p<0.001) and was sustained regardless of age or severity of illness. Conclusions Stress induced hyperglycemia identifies patients at subsequent risk of incident diabetes. PMID:27824898

Conversations About Goals and Values Are Feasible and Acceptable in Long-Term Acute Care Hospitals: A Pilot Study.

PubMed

Lamas, Daniela J; Owens, Robert L; Nace, R Nicholas; Massaro, Anthony F; Pertsch, Nathan J; Moore, Susan T; Bernacki, Rachelle E; Block, Susan D

2017-07-01

The chronically critically ill have survived acute critical illness but require prolonged mechanical ventilation. These patients are frequently transferred from acute care to long-term acute care hospitals (LTACHs) for prolonged recovery, yet many suffer setbacks requiring readmission to acute care. The patient's relatively improved condition while at the LTACH might be an opportunity for communication regarding care goals; however, there have been no prior studies of the feasibility of such conversations in the LTACH. To determine the feasibility, acceptability, and potential usefulness of conversations about serious illness with chronic critical illness patients or their surrogate decision makers after LTACH admission. We adapted an existing conversation guide for use in chronically critically ill (defined by tracheotomy for prolonged ventilation) LTACH patients or their surrogates to explore views about quality of life, understanding of medical conditions, expectations, and planning for setbacks. These conversations were conducted by one interviewer and summarized for the patients' clinicians. We surveyed patients, surrogates, and clinicians to assess acceptability. A total of 70 subjects were approached and 50 (71%) were enrolled, including 30 patients and 20 surrogates. The median duration of the conversation was 14 minutes 45 seconds [IQR 12:46, 19]. The presence of ongoing mechanical ventilation did not lead to longer conversations; in fact, conversations with patients were shorter than those with surrogates. The majority of subjects (81%) described the conversation as worthwhile. The majority of clinicians (73%) reported that the conversation offered a new and significant understanding of the patient's preferences if a setback were to occur. Conversations about serious illness care goals can be accomplished in a relatively short period of time, are acceptable to chronically critically ill patients and their surrogate decision makers in the LTACH, and are perceived as worthwhile by patients, surrogates, and clinicians.

 Liver transplantation in the critically ill: donation after cardiac death compared to donation after brain death grafts.

PubMed

Taner, C Burcin; Bulatao, Ilynn G; Arasi, Lisa C; Perry, Dana K; Willingham, Darrin L; Sibulesky, Lena; Rosser, Barry G; Canabal, Juan M; Nguyen, Justin H; Kramer, David J

2012-01-01

 Patients with end stage liver disease may become critically ill prior to LT requiring admission to the intensive care unit (ICU). The high acuity patients may be thought too ill to transplant; however, often LT is the only therapeutic option. Choosing the correct liver allograft for these patients is often difficult and it is imperative that the allograft work immediately. Donation after cardiac death (DCD) donors provide an important source of livers, however, DCD graft allocation remains a controversial topic, in critically ill patients. Between January 2003-December 2008, 1215 LTs were performed: 85 patients at the time of LT were in the ICU. Twelve patients received DCD grafts and 73 received donation after brain dead (DBD) grafts. After retransplant cases and multiorgan transplants were excluded, 8 recipients of DCD grafts and 42 recipients of DBD grafts were included in this study. Post-transplant outcomes of DCD and DBD liver grafts were compared. While there were differences in graft and survival between DCD and DBD groups at 4 month and 1 year time points, the differences did not reach statistical significance. The graft and patient survival rates were similar among the groups at 3-year time point. There is need for other large liver transplant programs to report their outcomes using liver grafts from DCD and DBD donors. We believe that the experience of the surgical, medical and critical care team is important for successfully using DCD grafts for critically ill patients.

Designing drug regimens for special intensive care unit populations

PubMed Central

Erstad, Brian L

2015-01-01

This review is intended to help clinicians design drug regimens for special populations of critically ill patients with extremes of body size, habitus and composition that make drug choice or dosing particularly challenging due to the lack of high-level evidence on which to make well-informed clinical decisions. The data sources included a literature search of MEDLINE and EMBASE with reviews of reference lists of retrieved articles. Abstracts of original research investigations and review papers were reviewed for their relevance to drug choice or dosing in the following special critically ill populations: patients with more severe forms of bodyweight or height, patients with amputations or missing limbs, pregnant patients, and patients undergoing extracorporeal membrane oxygenation or plasma exchange. Relevant papers were retrieved and evaluated, and their associated reference lists were reviewed for citations that may have been missed through the electronic search strategy. Relevant original research investigations and review papers that could be used to formulate general principles for drug choice or dosing in special populations of critically ill patients were extracted. Randomized studies with clinically relevant endpoints were not available for performing quantitative analyses. Critically ill patients with changes in body size, habitus and composition require special consideration when designing medication regimens, but there is a paucity of literature on which to make drug-specific, high-level evidence-based recommendations. Based on the evidence that is available, general recommendations are provided for drug choice or dosing in special critically ill populations. PMID:25938029

The experience of sleep deprivation in intensive care patients: findings from a larger hermeneutic phenomenological study.

PubMed

Tembo, Agness C; Parker, Vicki; Higgins, Isabel

2013-12-01

Sleep deprivation in critically ill patients has been well documented for more than 30 years. Despite the large body of literature, sleep deprivation remains a significant concern in critically ill patients in intensive care unit (ICU). This paper discusses sleep deprivation in critically ill patients as one of the main findings from a study that explored the lived experiences of critically ill patients in ICU with daily sedation interruption (DSI). Twelve participants aged between 20 and 76 years with an ICU stay ranging from three to 36 days were recruited from a 16 bed ICU in a large regional referral hospital in New South Wales (NSW), Australia. Participants were intubated, mechanically ventilated and subjected to daily sedation interruption during their critical illness in ICU. In-depth face to face interviews with the participants were conducted at two weeks after discharge from ICU. A second interview was conducted with eight participants six to eleven months later. Interviews were audio taped and transcribed. Data were analysed thematically. "Longing for sleep" and "being tormented by nightmares" capture the experiences and concerns of some of the participants. The findings suggest a need for models of care that seek to support restful sleep and prevent or alleviate sleep deprivation and nightmares. These models of care need to promote both quality and quantity of sleep in and beyond ICU and identify patients suffering from sleep deprivation to make appropriate referrals for treatment and support. Copyright © 2013 Elsevier Ltd. All rights reserved.

Global Variability in Reported Mortality for Critical Illness during the 2009-10 Influenza A(H1N1) Pandemic: A Systematic Review and Meta-Regression to Guide Reporting of Outcomes during Disease Outbreaks

PubMed Central

Pinto, Ruxandra; Rubenfeld, Gordon; Fowler, Robert A.

2016-01-01

Purpose To determine how patient, healthcare system and study-specific factors influence reported mortality associated with critical illness during the 2009–2010 Influenza A (H1N1) pandemic. Methods Systematic review with meta-regression of studies reporting on mortality associated with critical illness during the 2009–2010 Influenza A (H1N1) pandemic. Data Sources Medline, Embase, LiLACs and African Index Medicus to June 2009-March 2016. Results 226 studies from 50 countries met our inclusion criteria. Mortality associated with H1N1-related critical illness was 31% (95% CI 28–34). Reported mortality was highest in South Asia (61% [95% CI 50–71]) and Sub-Saharan Africa (53% [95% CI 29–75]), in comparison to Western Europe (25% [95% CI 22–30]), North America (25% [95% CI 22–27]) and Australia (15% [95% CI 13–18]) (P<0.0001). High income economies had significantly lower reported mortality compared to upper middle income economies and lower middle income economies respectively (P<0.0001). Mortality for the first wave was non-significantly higher than wave two (P = 0.66). There was substantial variability in reported mortality among the specific subgroups of patients: unselected critically ill adults (27% [95% CI 24–30]), acute respiratory distress syndrome (37% [95% CI 32–44]), acute kidney injury (44% [95% CI 26–64]), and critically ill pregnant patients (10% [95% CI 5–19]). Conclusion Reported mortality for outbreaks and pandemics may vary substantially depending upon selected patient characteristics, the number of patients described, and the region and economic status of the outbreak location. Outcomes from a relatively small number of patients from specific regions may lead to biased estimates of outcomes on a global scale. PMID:27170999

Advances in Biomarkers in Critical Ill Polytrauma Patients.

PubMed

Papurica, Marius; Rogobete, Alexandru F; Sandesc, Dorel; Dumache, Raluca; Cradigati, Carmen A; Sarandan, Mirela; Nartita, Radu; Popovici, Sonia E; Bedreag, Ovidiu H

2016-01-01

The complexity of the cases of critically ill polytrauma patients is given by both the primary, as well as the secondary, post-traumatic injuries. The severe injuries of organ systems, the major biochemical and physiological disequilibrium, and the molecular chaos lead to a high rate of morbidity and mortality in this type of patient. The 'gold goal' in the intensive therapy of such patients resides in the continuous evaluation and monitoring of their clinical status. Moreover, optimizing the therapy based on the expression of certain biomarkers with high specificity and sensitivity is extremely important because of the clinical course of the critically ill polytrauma patient. In this paper we wish to summarize the recent studies of biomarkers useful for the intensive care unit (ICU) physician. For this study the available literature on specific databases such as PubMed and Scopus was thoroughly analyzed. Each article was carefully reviewed and useful information for this study extracted. The keywords used to select the relevant articles were "sepsis biomarker", "traumatic brain injury biomarker" "spinal cord injury biomarker", "inflammation biomarker", "microRNAs biomarker", "trauma biomarker", and "critically ill patients". For this study to be carried out 556 original type articles were analyzed, as well as case reports and reviews. For this review, 89 articles with relevant topics for the present paper were selected. The critically ill polytrauma patient, because of the clinical complexity the case presents with, needs a series of evaluations and specific monitoring. Recent studies show a series of either tissue-specific or circulating biomarkers that are useful in the clinical status evaluation of these patients. The biomarkers existing today, with regard to the critically ill polytrauma patient, can bring a significant contribution to increasing the survival rate, by adapting the therapy according to their expressions. Nevertheless, the necessity remains to research new non-invasive diagnostic methods that present with higher specificity and selectivity.

Instrumental Activities of Daily Living after Critical Illness: A Systematic Review.

PubMed

Hopkins, Ramona O; Suchyta, Mary R; Kamdar, Biren B; Darowski, Emily; Jackson, James C; Needham, Dale M

2017-08-01

Poor functional status is common after critical illness, and can adversely impact the abilities of intensive care unit (ICU) survivors to live independently. Instrumental activities of daily living (IADL), which encompass complex tasks necessary for independent living, are a particularly important component of post-ICU functional outcome. To conduct a systematic review of studies evaluating IADLs in survivors of critical illness. We searched PubMed, CINAHL, Cochrane Library, SCOPUS, and Web of Science for all relevant English-language studies published through December 31, 2016. Additional articles were identified from personal files and reference lists of eligible studies. Two trained researchers independently reviewed titles and abstracts, and potentially eligible full text studies. Eligible studies included those enrolling adult ICU survivors with IADL assessments, using a validated instrument. We excluded studies involving specific ICU patient populations, specialty ICUs, those enrolling fewer than 10 patients, and those that were not peer-reviewed. Variables related to IADLs were reported using the Patient Reported Outcomes Measurement Information System (PROMIS). Thirty of 991 articles from our literature search met inclusion criteria, and 23 additional articles were identified from review of reference lists and personal files. Sixteen studies (30%) published between 1999 and 2016 met eligibility criteria and were included in the review. Study definitions of impairment in IADLs were highly variable, as were reported rates of pre-ICU IADL dependencies (7-85% of patients). Eleven studies (69%) found that survivors of critical illness had new or worsening IADL dependencies. In three of four longitudinal studies, survivors with IADL dependencies decreased over the follow-up period. Across multiple studies, no risk factors were consistently associated with IADL dependency. Survivors of critical illness commonly experience new or worsening IADL dependency that may improve over time. As part of ongoing efforts to understand and improve functional status in ICU survivors, future research must focus on risk factors for IADL dependencies and interventions to improve these cognitive and physical dependencies after critical illness.

Deciding in the dark: advance directives and continuation of treatment in chronic critical illness.

PubMed

Camhi, Sharon L; Mercado, Alice F; Morrison, R Sean; Du, Qingling; Platt, David M; August, Gary I; Nelson, Judith E

2009-03-01

Chronic critical illness is a devastating syndrome for which treatment offers limited clinical benefit but imposes heavy burdens on patients, families, clinicians, and the health care system. We studied the availability of advance directives and appropriate surrogates to guide decisions about life-sustaining treatment for the chronically critically ill and the extent and timing of treatment limitation. Prospective cohort study. Respiratory Care Unit (RCU) in a large, tertiary, urban, university-affiliated, hospital. Two hundred three chronically critically ill adults transferred to RCU after tracheotomy for failure to wean from mechanical ventilation in the intensive care unit. None. We interviewed RCU caregivers and reviewed patient records to identify proxy appointments, living wills, or oral statements of treatment preferences, resuscitation directives, and withholding/withdrawal of mechanical ventilation, nutrition, hydration, renal replacement and vasopressors. Forty-three of 203 patients (21.2%) appointed a proxy and 33 (16.2%) expressed preferences in advance directives. Do not resuscitate directives were given for 71 patients (35.0%). Treatment was limited for 39 patients (19.2%). Variables significantly associated with treatment limitation were proxy appointment prior to study entry (time of tracheotomy/RCU transfer) (odds ratio = 6.7, 95% confidence interval [CI], 2.3-20.0, p = 0.0006) and palliative care consultation in the RCU (OR = 40.9, 95% CI, 13.1-127.4, p < 0.0001). Median (interquartile range) time to first treatment limitation was 39 (31.0-45.0) days after hospital admission and 13 (8.0-29.0) days after RCU admission. For patients dying after treatment limitation, median time from first limitation to death ranged from 3 days for mechanical ventilation and hydration to 7 days for renal replacement. Most chronically critically ill patients fail to designate a surrogate decision-maker or express preferences regarding life-sustaining treatments. Despite burdensome symptoms and poor outcomes, limitation of such treatments was rare and occurred late, when patients were near death. Opportunities exist to improve communication and decision-making in chronic critical illness.

Vitamin D levels in critically ill patients with acute kidney injury: a protocol for a prospective cohort study (VID-AKI)

PubMed Central

Cameron, Lynda Katherine; Lei, Katie; Smith, Samantha; Doyle, Nanci Leigh; Doyle, James F; Flynn, Kate; Purchase, Nicola; Smith, John; Chan, Kathryn; Kamara, Farida; Kidane, Nardos Ghebremedhin; Forni, Lui G; Harrington, Dominic; Hampson, Geeta; Ostermann, Marlies

2017-01-01

Introduction Acute kidney injury (AKI) affects more than 50% of critically ill patients. The formation of calcitriol, the active vitamin D metabolite, from the main inactive circulating form, 25-hydroxyvitamin D (25(OH)D), occurs primarily in the proximal renal tubules. This results in a theoretical basis for reduction in levels of calcitriol over the course of an AKI. Vitamin D deficiency is highly prevalent in critically ill adults, and has been associated with increased rates of sepsis, longer hospital stays and increased mortality. The primary objective of this study is to perform serial measurements of 25(OH)D and calcitriol (1,25(OH)2D), as well as parathyroid hormone (PTH) and fibroblast growth factor 23 (FGF23) levels, in critically ill adult patients with and without AKI, and to determine whether patients with AKI have significantly lower vitamin D metabolite concentrations. The secondary objectives are to describe dynamic changes in vitamin D metabolites, PTH and FGF23 during critical illness; to compare vitamin D metabolite concentrations in patients with AKI with and without renal replacement therapy; and to investigate whether there is an association between vitamin D status and outcomes. Methods and analysis 230 general adult intensive care patients will be recruited. The AKI arm will include 115 critically ill patients with AKI Kidney Disease Improving Global Outcome stage II or stage III. The comparison group will include 115 patients who require cardiovascular or respiratory support, but who do not have AKI. Serial measurements of vitamin D metabolites and associated hormones will be taken on prespecified days. Patients will be recruited from two large teaching Trusts in England. Data will be analysed using standard statistical methods. Ethics and dissemination Ethical approval was obtained. Upon completion, the study team will submit the study report for publication in a peer-reviewed scientific journal and for conference presentation. Trial registration number NCT02869919; Pre-results. PMID:28706103

Stenotrophomonas, Mycobacterium, and Streptomyces in home dust and air: associations with moldiness and other home/family characteristics.

PubMed

Kettleson, E; Kumar, S; Reponen, T; Vesper, S; Méheust, D; Grinshpun, S A; Adhikari, A

2013-10-01

Respiratory illnesses have been linked to children's exposures to water-damaged homes. Therefore, understanding the microbiome in water-damaged homes is critical to preventing these illnesses. Few studies have quantified bacterial contamination, especially specific species, in water-damaged homes. We collected air and dust samples in twenty-one low-mold homes and twenty-one high-mold homes. The concentrations of three bacteria/genera, Stenotrophomonas maltophilia, Streptomyces sp., and Mycobacterium sp., were measured in air and dust samples using quantitative PCR (QPCR). The concentrations of the bacteria measured in the air samples were not associated with any specific home characteristic based on multiple regression models. However, higher concentrations of S. maltophilia in the dust samples were associated with water damage, that is, with higher floor surface moisture and higher concentrations of moisture-related mold species. The concentrations of Streptomyces and Mycobacterium sp. had similar patterns and may be partially determined by human and animal occupants and outdoor sources of these bacteria. © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Critical illness in children with influenza A/pH1N1 2009 infection in Canada.

PubMed

Jouvet, Philippe; Hutchison, Jamie; Pinto, Ruxandra; Menon, Kusum; Rodin, Rachel; Choong, Karen; Kesselman, Murray; Veroukis, Stasa; André Dugas, Marc; Santschi, Miriam; Guerguerian, Anne-Marie; Withington, Davinia; Alsaati, Basem; Joffe, Ari R; Drews, Tanya; Skippen, Peter; Rolland, Elizabeth; Kumar, Anand; Fowler, Robert

2010-09-01

To describe characteristics, treatment, and outcomes of critically ill children with influenza A/pandemic influenza A virus (pH1N1) infection in Canada. An observational study of critically ill children with influenza A/pH1N1 infection in pediatric intensive care units (PICUs). Nine Canadian PICUs. A total of 57 patients admitted to PICUs between April 16, 2009 and August 15, 2009. None. Characteristics of critically ill children with influenza A/pH1N1 infection were recorded. Confirmed intensive care unit cases were compared with a national surveillance database containing all hospitalized pediatric patients with influenza A/pH1N1 infection. Risk factors were assessed with a Cox proportional hazard model. The PICU cohort and national surveillance data were compared, using chi-square tests. Fifty-seven children were admitted to the PICU for community-acquired influenza A/pH1N1 infection. One or more chronic comorbid illnesses were observed in 70.2% of patients, and 24.6% of patients were aboriginal. Mechanical ventilation was used in 68% of children, 20 children (35.1%) had acute lung injury on the first day of admission, and the median duration of ventilation was 6 days (range, 0-67 days). The PICU mortality rate was 7% (4 of 57 patients). When compared with nonintensive care unit hospitalized children, PICU children were more likely to have a chronic medical condition (relative risk, 1.73); aboriginal ethnicity was not a risk factor of intensive care unit admission. During the first outbreak of influenza A/pH1N1 infection, when the population was naïve to this novel virus, severe illness was common among children with underlying chronic conditions and aboriginal children. Influenza A/pH1N1-related critical illness in children was associated with severe hypoxemic respiratory failure and prolonged mechanical ventilation. However, this higher rate and severity of respiratory illness did not result in an increased mortality when compared with seasonal influenza.

The effect of glutamine therapy on outcomes in critically ill patients: a meta-analysis of randomized controlled trials

PubMed Central

2014-01-01

Introduction Glutamine supplementation is supposed to reduce mortality and nosocomial infections in critically ill patients. However, the recently published reducing deaths due to oxidative stress (REDOX) trials did not provide evidence supporting this. This study investigated the impact of glutamine-supplemented nutrition on the outcomes of critically ill patients using a meta-analysis. Methods We searched for and gathered data from the Cochrane Central Register of Controlled Trials, MEDLINE, Elsevier, Web of Science and ClinicalTrials.gov databases reporting the effects of glutamine supplementation on outcomes in critically ill patients. We produced subgroup analyses of the trials according to specific patient populations, modes of nutrition and glutamine dosages. Results Among 823 related articles, eighteen Randomized Controlled Trials (RCTs) met all inclusion criteria. Mortality events among 3,383 patients were reported in 17 RCTs. Mortality showed no significant difference between glutamine group and control group. In the high dosage subgroup (above 0.5 g/kg/d), the mortality rate in the glutamine group was significantly higher than that of the control group (relative risk (RR) 1.18; 95% confidence interval (CI), 1.02 to 1.38; P = 0.03). In 15 trials, which included a total of 2,862 patients, glutamine supplementation reportedly affected the incidence of nosocomial infections in the critically ill patients observed. The incidence of nosocomial infections in the glutamine group was significantly lower than that of the control group (RR 0.85; 95% CI, 0.74 to 0.97; P = 0.02). In the surgical ICU subgroup, glutamine supplementation statistically reduced the rate of nosocomial infections (RR 0.70; 95% CI, 0.52 to 0.94; P = 0.04). In the parental nutrition subgroup, glutamine supplementation statistically reduced the rate of nosocomial infections (RR 0.83; 95% CI, 0.70 to 0.98; P = 0.03). The length of hospital stay was reported in 14 trials, in which a total of 2,777 patients were enrolled; however, the patient length of stay was not affected by glutamine supplementation. Conclusions Glutamine supplementation conferred no overall mortality and length of hospital stay benefit in critically ill patients. However, this therapy reduced nosocomial infections among critically ill patients, which differed according to patient populations, modes of nutrition and glutamine dosages. PMID:24401636

Animal models of hospital-acquired pneumonia: current practices and future perspectives

PubMed Central

Bielen, Kenny; ’S Jongers, Bart; Malhotra-Kumar, Surbhi; Jorens, Philippe G.; Goossens, Herman

2017-01-01

Lower respiratory tract infections are amongst the leading causes of mortality and morbidity worldwide. Especially in hospital settings and more particularly in critically ill ventilated patients, nosocomial pneumonia is one of the most serious infectious complications frequently caused by opportunistic pathogens. Pseudomonas aeruginosa is one of the most important causes of ventilator-associated pneumonia as well as the major cause of chronic pneumonia in cystic fibrosis patients. Animal models of pneumonia allow us to investigate distinct types of pneumonia at various disease stages, studies that are not possible in patients. Different animal models of pneumonia such as one-hit acute pneumonia models, ventilator-associated pneumonia models and biofilm pneumonia models associated with cystic fibrosis have been extensively studied and have considerably aided our understanding of disease pathogenesis and testing and developing new treatment strategies. The present review aims to guide investigators in choosing appropriate animal pneumonia models by describing and comparing the relevant characteristics of each model using P. aeruginosa as a model etiology for hospital-acquired pneumonia. Key to establishing and studying these animal models of infection are well-defined end-points that allow precise monitoring and characterization of disease development that could ultimately aid in translating these findings to patient populations in order to guide therapy. In this respect, and discussed here, is the development of humanized animal models of bacterial pneumonia that could offer unique advantages to study bacterial virulence factor expression and host cytokine production for translational purposes. PMID:28462212

Farm Fairs and Petting Zoos: A Review of Animal Contact as a Source of Zoonotic Enteric Disease.

PubMed

Conrad, Cheyenne C; Stanford, Kim; Narvaez-Bravo, Claudia; Callaway, Todd; McAllister, Tim

2017-02-01

Many public venues such as farms, fairs, and petting zoos encourage animal contact for both educational and entertainment purposes. However, healthy farm animals, including cattle, small ruminants, and poultry, can be reservoirs for enteric zoonotic pathogens, with human infections resulting in nausea, vomiting, diarrhea, and, in some cases, severe complications that can lead to death. As animals shed these organisms in their feces, contamination of themselves and their surroundings is unavoidable. The majority of North Americans reside in urban and suburban settings, and the general public often possess limited knowledge of agricultural practices and minimal contact with farm animals. Furthermore, there is a lack of understanding of zoonotic pathogens, particularly how these pathogens are spread and the human behaviors that may increase the risk of infection. Human risk behaviors include hand-to-mouth contact immediately after physical contact with animals and their environments, a practice that facilitates the ingestion of pathogens. It is often young children who become ill due to their under-developed immune systems and poorer hygienic practices compared with adults, such as more frequent hand-to-mouth behaviors, and infrequent or improper hand washing. These illnesses are often preventable, simply through adequate hygiene and hand washing. Our objective was to use a structured approach to review the main causal organisms responsible for human illnesses acquired in petting zoo and open farm environments, Shiga toxin-producing Escherichia coli, nontyphoidal Salmonella, Campylobacter, and Cryptosporidium. Notable outbreaks involving direct contact with farm animals and farm, fair, or petting zoo environments are discussed and recommendations for how public venues can increase safety and hand hygiene compliance among visitors are proposed. The most effective protective measures against enteric illnesses include education of the public, increasing overall awareness of the risks and the importance of hand hygiene, as well as access to hand-washing facilities.

Cellular Therapies in Trauma and Critical Care Medicine: Forging New Frontiers

PubMed Central

Pati, Shibani; Pilia, Marcello; Grimsley, Juanita M.; Karanikas, Alexia T.; Oyeniyi, Blessing; Holcomb, John B.; Cap, Andrew P.; Rasmussen, Todd E.

2015-01-01

ABSTRACT Trauma is a leading cause of death in both military and civilian populations worldwide. Although medical advances have improved the overall morbidity and mortality often associated with trauma, additional research and innovative advancements in therapeutic interventions are needed to optimize patient outcomes. Cell-based therapies present a novel opportunity to improve trauma and critical care at both the acute and chronic phases that often follow injury. Although this field is still in its infancy, animal and human studies suggest that stem cells may hold great promise for the treatment of brain and spinal cord injuries, organ injuries, and extremity injuries such as those caused by orthopedic trauma, burns, and critical limb ischemia. However, barriers in the translation of cell therapies that include regulatory obstacles, challenges in manufacturing and clinical trial design, and a lack of funding are critical areas in need of development. In 2015, the Department of Defense Combat Casualty Care Research Program held a joint military–civilian meeting as part of its effort to inform the research community about this field and allow for effective planning and programmatic decisions regarding research and development. The objective of this article is to provide a “state of the science” review regarding cellular therapies in trauma and critical care, and to provide a foundation from which the potential of this emerging field can be harnessed to mitigate outcomes in critically ill trauma patients. PMID:26428845

Cellular Therapies in Trauma and Critical Care Medicine: Forging New Frontiers.

PubMed

Pati, Shibani; Pilia, Marcello; Grimsley, Juanita M; Karanikas, Alexia T; Oyeniyi, Blessing; Holcomb, John B; Cap, Andrew P; Rasmussen, Todd E

2015-12-01

Trauma is a leading cause of death in both military and civilian populations worldwide. Although medical advances have improved the overall morbidity and mortality often associated with trauma, additional research and innovative advancements in therapeutic interventions are needed to optimize patient outcomes. Cell-based therapies present a novel opportunity to improve trauma and critical care at both the acute and chronic phases that often follow injury. Although this field is still in its infancy, animal and human studies suggest that stem cells may hold great promise for the treatment of brain and spinal cord injuries, organ injuries, and extremity injuries such as those caused by orthopedic trauma, burns, and critical limb ischemia. However, barriers in the translation of cell therapies that include regulatory obstacles, challenges in manufacturing and clinical trial design, and a lack of funding are critical areas in need of development. In 2015, the Department of Defense Combat Casualty Care Research Program held a joint military-civilian meeting as part of its effort to inform the research community about this field and allow for effective planning and programmatic decisions regarding research and development. The objective of this article is to provide a "state of the science" review regarding cellular therapies in trauma and critical care, and to provide a foundation from which the potential of this emerging field can be harnessed to mitigate outcomes in critically ill trauma patients.

Gastrointestinal microbial ecology and the safety of our food supply as related to Salmonella.

PubMed

Callaway, T R; Edrington, T S; Anderson, R C; Byrd, J A; Nisbet, D J

2008-04-01

Salmonella causes an estimated 1.3 million human foodborne illnesses and more than 500 deaths each year in the United States, representing an annual estimated cost to the economy of approximately $2.4 billion. Salmonella enterica comprises more than 2,500 serotypes. With this genetic and environmental diversity, serotypes are adapted to live in a variety of hosts, which may or may not manifest with clinical illness. Thus, Salmonella presents a multifaceted threat to food production and safety. Salmonella have been isolated from all food animals and can cause morbidity and mortality in swine, cattle, sheep, and poultry. The link between human salmonellosis and host animals is most clear in poultry. During the early part of the 20th century, a successful campaign was waged to eliminate fowl typhoid caused by Salmonella Gallinarum/Pullorum. Microbial ecology is much like macroecology; environmental niches are filled by adapted and specialized species. Elimination of S. Gallinarum cleared a niche in the on-farm and intestinal microbial ecology that was quickly exploited by Salmonella Enteritidis and other serotypes that live in other hosts, such as rodents. In the years since, human salmonellosis cases linked to poultry have increased to the point that uncooked chicken and eggs are regarded as toxic in the zeitgeist. Salmonellosis caused by poultry products have increased significantly in the past 5 yr, leading to a USDA Food Safety and Inspection Service "Salmonella Attack Plan" that aims to reduce the incidence of Salmonella in chickens below the current 19%. The prevalence of Salmonella in swine and cattle is lower, but still poses a threat to food safety and production efficiency. Thus, approaches to reducing Salmonella in animals must take into consideration that the microbial ecology of the animal is a critical factor that should be accounted for when designing intervention strategies. Use of competitive exclusion, sodium chlorate, vaccination, and bacteriophage are all strategies that can reduce Salmonella in the live animal, but it is vital to understand how they function so that we do not invoke the law of unintended consequences.

The impact of advanced technology on critical care. Dilemmas in the making.

PubMed

Aarons, D E

1998-12-01

Advanced technology has enhanced our ability to diagnose and treat critically ill patients, thereby assisting in prolonging life for many. However, its high cost has been prohibitive, and it may impose more burdens than benefits on some patients. Although technological advances have accelerated social change, many have also fuelled legal and ethical concerns. Consequently, the rationale for the use of advanced technology in the care of critically ill patients should be clear and ethically justified.

Recovery after critical illness: putting the puzzle together-a consensus of 29.

PubMed

Azoulay, Elie; Vincent, Jean-Louis; Angus, Derek C; Arabi, Yaseen M; Brochard, Laurent; Brett, Stephen J; Citerio, Giuseppe; Cook, Deborah J; Curtis, Jared Randall; Dos Santos, Claudia C; Ely, E Wesley; Hall, Jesse; Halpern, Scott D; Hart, Nicholas; Hopkins, Ramona O; Iwashyna, Theodore J; Jaber, Samir; Latronico, Nicola; Mehta, Sangeeta; Needham, Dale M; Nelson, Judith; Puntillo, Kathleen; Quintel, Michael; Rowan, Kathy; Rubenfeld, Gordon; Van den Berghe, Greet; Van der Hoeven, Johannes; Wunsch, Hannah; Herridge, Margaret

2017-12-05

In this review, we seek to highlight how critical illness and critical care affect longer-term outcomes, to underline the contribution of ICU delirium to cognitive dysfunction several months after ICU discharge, to give new insights into ICU acquired weakness, to emphasize the importance of value-based healthcare, and to delineate the elements of family-centered care. This consensus of 29 also provides a perspective and a research agenda about post-ICU recovery.

2009 H1N1 influenza and experience in three critical care units.

PubMed

Teke, Turgut; Coskun, Ramazan; Sungur, Murat; Guven, Muhammed; Bekci, Taha T; Maden, Emin; Alp, Emine; Doganay, Mehmet; Erayman, Ibrahim; Uzun, Kursat

2011-04-07

We describe futures of ICU admission, demographic characteristics, treatment and outcome for critically ill patients with laboratory-confirmed and suspected infection with the H1N1 virus admitted to the three different critical care departments in Turkey. Retrospective study of critically ill patients with 2009 influenza A(H1N1) at ICU. Demographic data, symptoms, comorbid conditions, and clinical outcomes were collected using a case report form. Critical illness occurred in 61 patients admitted to an ICU with confirmed (n=45) or probable and suspected 2009 influenza A(H1N1). Patients were young (mean, 41.5 years), were female (54%). Fifty-six patients, required mechanical ventilation (14 invasive, 27 noninvasive, 15 both) during the course of ICU. On admission, mean APACHE II score was 18.7±6.3 and median PaO(2)/FIO(2) was 127.9±70.4. 31 patients (50.8%) was die. There were no significant differences in baseline PaO(2)/FIO(2 )and ventilation strategies between survivors and nonsurvivors. Patients who survived were more likely to have NIMV use at the time of admission to the ICU. Critical illness from 2009 influenza A(H1N1) in ICU predominantly affects young patients with little major comorbidity and had a high case-fatality rate. NIMV could be used in 2009 influenza A (H1N1) infection-related hypoxemic respiratory failure.

The meaning of social support for the critically ill patient.

PubMed

Hupcey, J E

2001-08-01

Social support has been shown to be important for the critically ill patient. However, what constitutes adequate support for these patients has not been investigated. Thus, the purpose of this qualitative study was to investigate patients' perceptions of their need for and adequacy of the social support received while they were critically ill. Thirty adult patients who were critical during some point of their stay in the intensive care unit (ICU) stay were interviewed, once stable. Interviews were tape-recorded and began with an open-ended question regarding the ICU experience. This was followed by open-ended focused questions regarding social support, such as 'Who were your greatest sources of social support while you were critically ill?' 'What did they do that was supportive or unsupportive?' Data were analyzed according to Miles and Huberman (1994). The categories that emerged were need for social support based on patient perceptions (not number of visitors), quality of support (based on perceptions of positive and negative behaviors of supporters) and lack of support. This study found that quality of support was more important than the actual number of visitors. Patients with few visitors may have felt supported, while those with numerous visitors felt unsupported. Patients who felt unsupported also were more critical of the staff and the care they received. Nurses need to individually assess patients regarding their need for support, and assist family/friends to meet these needs.

Critical behavior in a stochastic model of vector mediated epidemics

NASA Astrophysics Data System (ADS)

Alfinito, E.; Beccaria, M.; Macorini, G.

2016-06-01

The extreme vulnerability of humans to new and old pathogens is constantly highlighted by unbound outbreaks of epidemics. This vulnerability is both direct, producing illness in humans (dengue, malaria), and also indirect, affecting its supplies (bird and swine flu, Pierce disease, and olive quick decline syndrome). In most cases, the pathogens responsible for an illness spread through vectors. In general, disease evolution may be an uncontrollable propagation or a transient outbreak with limited diffusion. This depends on the physiological parameters of hosts and vectors (susceptibility to the illness, virulence, chronicity of the disease, lifetime of the vectors, etc.). In this perspective and with these motivations, we analyzed a stochastic lattice model able to capture the critical behavior of such epidemics over a limited time horizon and with a finite amount of resources. The model exhibits a critical line of transition that separates spreading and non-spreading phases. The critical line is studied with new analytical methods and direct simulations. Critical exponents are found to be the same as those of dynamical percolation.

Critical behavior in a stochastic model of vector mediated epidemics.

PubMed

Alfinito, E; Beccaria, M; Macorini, G

2016-06-06

The extreme vulnerability of humans to new and old pathogens is constantly highlighted by unbound outbreaks of epidemics. This vulnerability is both direct, producing illness in humans (dengue, malaria), and also indirect, affecting its supplies (bird and swine flu, Pierce disease, and olive quick decline syndrome). In most cases, the pathogens responsible for an illness spread through vectors. In general, disease evolution may be an uncontrollable propagation or a transient outbreak with limited diffusion. This depends on the physiological parameters of hosts and vectors (susceptibility to the illness, virulence, chronicity of the disease, lifetime of the vectors, etc.). In this perspective and with these motivations, we analyzed a stochastic lattice model able to capture the critical behavior of such epidemics over a limited time horizon and with a finite amount of resources. The model exhibits a critical line of transition that separates spreading and non-spreading phases. The critical line is studied with new analytical methods and direct simulations. Critical exponents are found to be the same as those of dynamical percolation.

Seroepidemiological Studies of Crimean-Congo Hemorrhagic Fever Virus in Domestic and Wild Animals

PubMed Central

Spengler, Jessica R.; Bergeron, Éric; Rollin, Pierre E.

2016-01-01

Crimean-Congo hemorrhagic fever (CCHF) is a widely distributed, tick-borne viral disease. Humans are the only species known to develop illness after CCHF virus (CCHFV) infection, characterized by a nonspecific febrile illness that can progress to severe, often fatal, hemorrhagic disease. A variety of animals may serve as asymptomatic reservoirs of CCHFV in an endemic cycle of transmission. Seroepidemiological studies have been instrumental in elucidating CCHFV reservoirs and in determining endemic foci of viral transmission. Herein, we review over 50 years of CCHFV seroepidemiological studies in domestic and wild animals. This review highlights the role of livestock in the maintenance and transmission of CCHFV, and provides a detailed summary of seroepidemiological studies of wild animal species, reflecting their relative roles in CCHFV ecology. PMID:26741652

Seroepidemiological Studies of Crimean-Congo Hemorrhagic Fever Virus in Domestic and Wild Animals

DOE Office of Scientific and Technical Information (OSTI.GOV)

Spengler, Jessica R.; Bergeron, Eric; Rollin, Pierre E.

Crimean-Congo hemorrhagic fever (CCHF) is a widely distributed, tick-borne viral disease. Humans are the only species known to develop illness after CCHF virus (CCHFV) infection, characterized by a nonspecific febrile illness that can progress to severe, often fatal, hemorrhagic disease. A variety of animals may serve as asymptomatic reservoirs of CCHFV in an endemic cycle of transmission. Seroepidemiological studies have been instrumental in elucidating CCHFV reservoirs and in determining endemic foci of viral transmission. Herein, we review over 50 years of CCHFV seroepidemiological studies in domestic and wild animals. Furthermore, this review highlights the role of livestock in the maintenancemore » and transmission of CCHFV, and provides a detailed summary of seroepidemiological studies of wild animal species, reflecting their relative roles in CCHFV ecology.« less

Seroepidemiological Studies of Crimean-Congo Hemorrhagic Fever Virus in Domestic and Wild Animals.

PubMed

Spengler, Jessica R; Bergeron, Éric; Rollin, Pierre E

2016-01-01

Crimean-Congo hemorrhagic fever (CCHF) is a widely distributed, tick-borne viral disease. Humans are the only species known to develop illness after CCHF virus (CCHFV) infection, characterized by a nonspecific febrile illness that can progress to severe, often fatal, hemorrhagic disease. A variety of animals may serve as asymptomatic reservoirs of CCHFV in an endemic cycle of transmission. Seroepidemiological studies have been instrumental in elucidating CCHFV reservoirs and in determining endemic foci of viral transmission. Herein, we review over 50 years of CCHFV seroepidemiological studies in domestic and wild animals. This review highlights the role of livestock in the maintenance and transmission of CCHFV, and provides a detailed summary of seroepidemiological studies of wild animal species, reflecting their relative roles in CCHFV ecology.

Seroepidemiological Studies of Crimean-Congo Hemorrhagic Fever Virus in Domestic and Wild Animals

DOE PAGES

Spengler, Jessica R.; Bergeron, Eric; Rollin, Pierre E.; ...

2016-01-07

Crimean-Congo hemorrhagic fever (CCHF) is a widely distributed, tick-borne viral disease. Humans are the only species known to develop illness after CCHF virus (CCHFV) infection, characterized by a nonspecific febrile illness that can progress to severe, often fatal, hemorrhagic disease. A variety of animals may serve as asymptomatic reservoirs of CCHFV in an endemic cycle of transmission. Seroepidemiological studies have been instrumental in elucidating CCHFV reservoirs and in determining endemic foci of viral transmission. Herein, we review over 50 years of CCHFV seroepidemiological studies in domestic and wild animals. Furthermore, this review highlights the role of livestock in the maintenancemore » and transmission of CCHFV, and provides a detailed summary of seroepidemiological studies of wild animal species, reflecting their relative roles in CCHFV ecology.« less

Uncertainty in Antibiotic Dosing in Critically Ill Neonate and Pediatric Patients: Can Microsampling Provide the Answers?

PubMed

Dorofaeff, Tavey; Bandini, Rossella M; Lipman, Jeffrey; Ballot, Daynia E; Roberts, Jason A; Parker, Suzanne L

2016-09-01

With a decreasing supply of antibiotics that are effective against the pathogens that cause sepsis, it is critical that we learn to use currently available antibiotics optimally. Pharmacokinetic studies provide an evidence base from which we can optimize antibiotic dosing. However, these studies are challenging in critically ill neonate and pediatric patients due to the small blood volumes and associated risks and burden to the patient from taking blood. We investigate whether microsampling, that is, obtaining a biologic sample of low volume (<50 μL), can improve opportunities to conduct pharmacokinetic studies. We performed a literature search to find relevant articles using the following search terms: sepsis, critically ill, severe infection, intensive care AND antibiotic, pharmacokinetic, p(a)ediatric, neonate. For microsampling, we performed a search using antibiotics AND dried blood spots OR dried plasma spots OR volumetric absorptive microsampling OR solid-phase microextraction OR capillary microsampling OR microsampling. Databases searched include Web of Knowledge, PubMed, and EMbase. Of the 32 antibiotic pharmacokinetic studies performed on critically ill neonate or pediatric patients in this review, most of the authors identified changes to the pharmacokinetic properties in their patient group and recommended either further investigations into this patient population or therapeutic drug monitoring to ensure antibiotic doses are suitable. There remain considerable gaps in knowledge regarding the pharmacokinetic properties of antibiotics in critically ill pediatric patients. Implementing microsampling in an antibiotic pharmacokinetic study is contingent on the properties of the antibiotic, the pathophysiology of the patient (and how this can affect the microsample), and the location of the patient. A validation of the sampling technique is required before implementation. Current antibiotic regimens for critically ill neonate and pediatric patients are frequently suboptimal due to a poor understanding of altered pharmacokinetic properties. An assessment of the suitability of microsampling for pharmacokinetic studies in neonate and pediatric patients is recommended before wider use. The method of sampling, as well as the method of bioanalysis, also requires validation to ensure the data obtained reflect the true result. Copyright © 2016 Elsevier HS Journals, Inc. All rights reserved.

Life after critical illness: an overview.

PubMed

Rattray, Janice

2014-03-01

To illustrate the potential physical and psychological problems faced by patients after an episode of critical illness, highlight some of the interventions that have been tested and identify areas for future research. Recovery from critical illness is an international problem and as an issue is likely to increase. For some, recovery from critical illness is prolonged, subject to physical and psychological problems that may negatively impact upon health-related quality of life. The literature accessed for this review includes the work of a number of key researchers in the field of critical care research. These were identified from a number of sources include (1) personal knowledge of the research field accumulated over the last decade and (2) using the search engine 'The Knowledge Network Scotland'. Fatigue and weakness are significant problems for critical care survivors and are common in patients who have been in ICU for more than one week. Psychological problems include anxiety, depression, post-traumatic stress, delirium and cognitive impairment. Prevalence of these problems is difficult to establish for a number of methodological reasons that include the use of self-report questionnaires, the number of different questionnaires used and the variation in administration and timing. Certain subgroups of ICU survivors especially those at the more severe end of the illness severity spectrum are more at risk and this has been demonstrated for both physical and psychological problems. Findings from international studies of a range of potential interventions are presented. However, establishing effectiveness for most of these still has to be empirically demonstrated. What seems clear is the need for a co-ordinated, multidisciplinary, designated recovery and rehabilitation pathway that begins as soon as the patient is admitted into an intensive care unit. © 2013 John Wiley & Sons Ltd.

Diagnosing delirium in critically ill children: Validity and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit*

PubMed Central

Smith, Heidi A. B.; Boyd, Jenny; Fuchs, D. Catherine; Melvin, Kelly; Berry, Pamela; Shintani, Ayumi; Eden, Svetlana K.; Terrell, Michelle K.; Boswell, Tonya; Wolfram, Karen; Sopfe, Jenna; Barr, Frederick E.; Pandharipande, Pratik P.; Ely, E. Wesley

2013-01-01

Objective To validate a diagnostic instrument for pediatric delirium in critically ill children, both ventilated and nonventilated, that uses standardized, developmentally appropriate measurements. Design and Setting A prospective observational cohort study investigating the Pediatric Confusion Assessment Method for Intensive Care Unit (pCAM-ICU) patients in the pediatric medical, surgical, and cardiac intensive care unit of a university-based medical center. Patients A total of 68 pediatric critically ill patients, at least 5 years of age, were enrolled from July 1, 2008, to March 30, 2009. Interventions None. Measurements Criterion validity including sensitivity and specificity and interrater reliability were determined using daily delirium assessments with the pCAM-ICU by two critical care clinicians compared with delirium diagnosis by pediatric psychiatrists using Diagnostic and Statistical Manual, 4th Edition, Text Revision criteria. Results A total of 146 paired assessments were completed among 68 enrolled patients with a mean age of 12.2 yrs. Compared with the reference standard for diagnosing delirium, the pCAM-ICU demonstrated a sensitivity of 83% (95% confidence interval, 66–93%), a specificity of 99% (95% confidence interval, 95–100%), and a high interrater reliability (κ = 0.96; 95% confidence interval, 0.74–1.0). Conclusions The pCAM-ICU is a highly valid reliable instrument for the diagnosis of pediatric delirium in critically ill children chronologically and developmentally at least 5 yrs of age. Use of the pCAM-ICU may expedite diagnosis and consultation with neuropsychiatry specialists for treatment of pediatric delirium. In addition, the pCAM-ICU may provide a means for delirium monitoring in future epidemiologic and interventional studies in critically ill children. (Crit Care Med 2011; 39:150–157) PMID:20959783

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.

Diagnosing delirium in critically ill children: Validity and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit.

PubMed

Smith, Heidi A B; Boyd, Jenny; Fuchs, D Catherine; Melvin, Kelly; Berry, Pamela; Shintani, Ayumi; Eden, Svetlana K; Terrell, Michelle K; Boswell, Tonya; Wolfram, Karen; Sopfe, Jenna; Barr, Frederick E; Pandharipande, Pratik P; Ely, E Wesley

2011-01-01

To validate a diagnostic instrument for pediatric delirium in critically ill children, both ventilated and nonventilated, that uses standardized, developmentally appropriate measurements. A prospective observational cohort study investigating the Pediatric Confusion Assessment Method for Intensive Care Unit (pCAM-ICU) patients in the pediatric medical, surgical, and cardiac intensive care unit of a university-based medical center. A total of 68 pediatric critically ill patients, at least 5 years of age, were enrolled from July 1, 2008, to March 30, 2009. None. Criterion validity including sensitivity and specificity and interrater reliability were determined using daily delirium assessments with the pCAM-ICU by two critical care clinicians compared with delirium diagnosis by pediatric psychiatrists using Diagnostic and Statistical Manual, 4th Edition, Text Revision criteria. A total of 146 paired assessments were completed among 68 enrolled patients with a mean age of 12.2 yrs. Compared with the reference standard for diagnosing delirium, the pCAM-ICU demonstrated a sensitivity of 83% (95% confidence interval, 66-93%), a specificity of 99% (95% confidence interval, 95-100%), and a high interrater reliability (κ = 0.96; 95% confidence interval, 0.74-1.0). The pCAM-ICU is a highly valid reliable instrument for the diagnosis of pediatric delirium in critically ill children chronologically and developmentally at least 5 yrs of age. Use of the pCAM-ICU may expedite diagnosis and consultation with neuropsychiatry specialists for treatment of pediatric delirium. In addition, the pCAM-ICU may provide a means for delirium monitoring in future epidemiologic and interventional studies in critically ill children.

Clinical problems of sloths (Bradypus sp. and Choloepus sp.) in captivity.

PubMed

Diniz, L S; Oliveira, P M

1999-03-01

A 20-yr retrospective study of disease prevalence was carried out for 51 sloths (34 Bradypus sp. and 17 Choloepus sp.) at the São Paulo Zoo. A total of 81 clinical disorders were detected, including nutritional (45.7%), digestive (12.3%), and respiratory (12.3%) problems and injuries (6.1%). A definitive diagnosis was not possible in 8.6% of the cases. The incidence of disease varied according to seasonal climate (winter, 32.5%; spring, 24%; summer, 22.9%; autumn, 20.5%), time in captivity (96.4% of diseases occurred within the first 6 mo and 3.6% occurred thereafter), and type of enclosure (quarantine cage, 96.4%; exhibition enclosure, 3.6%). Both young animals (86.7%) and adults (3.2%) were affected. Parasites were identified by fecal examination in 45.4% of animals with clinical illness (Ascaris sp., 80%; Coccidia sp., 20%). Bacteria such as Salmonella enteritidis, Escherichia coli, and Citrobacter freundii were isolated from feces and/or organs. The first 6 mo in captivity are critical for these animals. Proper management and early identification of medical conditions in captivity have implications for sloth population in the wild.

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…

Unexplained Deaths and Critical Illnesses of Suspected Infectious Cause, Taiwan, 2000–2005

PubMed Central

Wei, Kuo-Chen; Jiang, Donald Dah-Shyong; Chiu, Chan-Hsian; Chang, Shan-Chwen

2008-01-01

We report 5 years’ surveillance data from the Taiwan Centers for Disease Control on unexplained deaths and critical illnesses suspected of being caused by infection. A total of 130 cases were reported; the incidence rate was 0.12 per 100,000 person-years; and infectious causes were identified for 81 cases (62%). PMID:18826839

Albumin administration in the acutely ill: what is new and where next?

PubMed

Vincent, Jean-Louis; Russell, James A; Jacob, Matthias; Martin, Greg; Guidet, Bertrand; Wernerman, Jan; Ferrer, Ricard; Roca, Ricard Ferrer; McCluskey, Stuart A; Gattinoni, Luciano

2014-07-16

Albumin solutions have been used worldwide for the treatment of critically ill patients since they became commercially available in the 1940s. However, their use has become the subject of criticism and debate in more recent years. Importantly, all fluid solutions have potential benefits and drawbacks. Large multicenter randomized studies have provided valuable data regarding the safety of albumin solutions, and have begun to clarify which groups of patients are most likely to benefit from their use. However, many questions remain related to where exactly albumin fits within our fluid choices. Here, we briefly summarize some of the physiology and history of albumin use in intensive care before offering some evidence-based guidance for albumin use in critically ill patients.

Albumin administration in the acutely ill: what is new and where next?

PubMed Central

2014-01-01

Albumin solutions have been used worldwide for the treatment of critically ill patients since they became commercially available in the 1940s. However, their use has become the subject of criticism and debate in more recent years. Importantly, all fluid solutions have potential benefits and drawbacks. Large multicenter randomized studies have provided valuable data regarding the safety of albumin solutions, and have begun to clarify which groups of patients are most likely to benefit from their use. However, many questions remain related to where exactly albumin fits within our fluid choices. Here, we briefly summarize some of the physiology and history of albumin use in intensive care before offering some evidence-based guidance for albumin use in critically ill patients. PMID:25042164

Electrographic status epilepticus in children with critical illness: Epidemiology and outcome.

PubMed

Abend, Nicholas S

2015-08-01

Electrographic seizures and electrographic status epilepticus are common in children with critical illness with acute encephalopathy, leading to increasing use of continuous EEG monitoring. Many children with electrographic status epilepticus have no associated clinical signs, so EEG monitoring is required for seizure identification. Further, there is increasing evidence that high seizure burdens, often classified as electrographic status epilepticus, are associated with worse outcomes. This review discusses the incidence of electrographic status epilepticus, risk factors for electrographic status epilepticus, and associations between electrographic status epilepticus and outcomes, and it summarizes recent guidelines and consensus statements addressing EEG monitoring in children with critical illness. This article is part of a Special Issue entitled "Status Epilepticus". Copyright © 2015 Elsevier Inc. All rights reserved.

Outbreak of Campylobacteriosis Associated with Raccoon Contact at a Wildlife Rehabilitation Centre, Minnesota, 2013.

PubMed

Saunders, S; Smith, K; Schott, R; Dobbins, G; Scheftel, J

2017-05-01

Campylobacteriosis is an enteric illness caused by bacteria of the genus Campylobacter. There are approximately 900 culture-confirmed cases of campylobacteriosis reported annually to the Minnesota Department of Health (MDH). Case patients are interviewed about risk factors, including foods eaten, recreational and drinking water exposures and animal contact. In September 2013, MDH identified two Campylobacter jejuni cases who reported working at the same wildlife rehabilitation centre before illness onset. This report describes the investigation, which used a case-control study design, and identified 16 additional ill persons, for a total of 18 ill persons. Both cases and controls reported working with a variety of animals, including squirrels, chipmunks, mice, raccoons, opossums, rabbits, songbirds, waterfowl and reptiles. In univariate analyses, contact with a number of different animal species was significantly associated with illness, including raccoons (odds ratio [OR], 11.1; P < 0.001), chipmunks (OR, 3.65; P = 0.01), opossums (OR, 4.38; P = 0.005), mice (OR, 4.18; P = 0.01) and rabbits (OR, 4.36; P = 0.003). In a multivariate model, contact with raccoons was the only exposure independently associated with illness (adjusted OR, 12.2; P = 0.01). Bacterial culture and subtyping of the outbreak strain of C. jejuni from raccoon faecal samples further implicated raccoons as the source of the outbreak. Not all of the cases reported handling raccoons, suggesting that environmental contamination contributed to transmission. MDH worked with the wildlife rehabilitation centre's management to strengthen biosecurity and infection control protocols. © 2016 Blackwell Verlag GmbH.

Extended infusion of beta-lactam antibiotics: optimizing therapy in critically-ill patients in the era of antimicrobial resistance.

PubMed

Rizk, Nesrine A; Kanafani, Zeina A; Tabaja, Hussam Z; Kanj, Souha S

2017-07-01

Beta-lactams are at the cornerstone of therapy in critical care settings, but their clinical efficacy is challenged by the rise in bacterial resistance. Infections with multi-drug resistant organisms are frequent in intensive care units, posing significant therapeutic challenges. The problem is compounded by a dearth in the development of new antibiotics. In addition, critically-ill patients have unique physiologic characteristics that alter the drugs pharmacokinetics and pharmacodynamics. Areas covered: The prolonged infusion of antibiotics (extended infusion [EI] and continuous infusion [CI]) has been the focus of research in the last decade. As beta-lactams have time-dependent killing characteristics that are altered in critically-ill patients, prolonged infusion is an attractive approach to maximize their drug delivery and efficacy. Several studies have compared traditional dosing to EI/CI of beta-lactams with regard to clinical efficacy. Clinical data are primarily composed of retrospective studies and some randomized controlled trials. Several reports show promising results. Expert commentary: Reviewing the currently available evidence, we conclude that EI/CI is probably beneficial in the treatment of critically-ill patients in whom an organism has been identified, particularly those with respiratory infections. Further studies are needed to evaluate the efficacy of EI/CI in the management of infections with resistant organisms.

Clinical review: optimizing enteral nutrition for critically ill patients - a simple data-driven formula

PubMed Central

2011-01-01

In modern critical care, the paradigm of 'therapeutic nutrition' is replacing traditional 'supportive nutrition'. Standard enteral formulas meet basic macro- and micronutrient needs; therapeutic enteral formulas meet these basic needs and also contain specific pharmaconutrients that may attenuate hyperinflammatory responses, enhance the immune responses to infection, or improve gastrointestinal tolerance. Choosing the right enteral feeding formula may positively affect a patient's outcome; targeted use of therapeutic formulas can reduce the incidence of infectious complications, shorten lengths of stay in the ICU and in the hospital, and lower risk for mortality. In this paper, we review principles of how to feed (enteral, parenteral, or both) and when to feed (early versus delayed start) patients who are critically ill. We discuss what to feed these patients in the context of specific pharmaconutrients in specialized feeding formulations, that is, arginine, glutamine, antioxidants, certain ω-3 and ω-6 fatty acids, hydrolyzed proteins, and medium-chain triglycerides. We summarize current expert guidelines for nutrition in patients with critical illness, and we present specific clinical evidence on the use of enteral formulas supplemented with anti-inflammatory or immune-modulating nutrients, and gastrointestinal tolerance-promoting nutritional formulas. Finally, we introduce an algorithm to help bedside clinicians make data-driven feeding decisions for patients with critical illness. PMID:22136305

Comparison of 2 intravenous insulin protocols: Glycemia variability in critically ill patients.

PubMed

Gómez-Garrido, Marta; Rodilla-Fiz, Ana M; Girón-Lacasa, María; Rodríguez-Rubio, Laura; Martínez-Blázquez, Anselmo; Martínez-López, Fernando; Pardo-Ibáñez, María Dolores; Núñez-Marín, Juan M

2017-05-01

Glycemic variability is an independent predictor of mortality in critically ill patients. The objective of this study was to compare two intravenous insulin protocols in critically ill patients regarding the glycemic variability. This was a retrospective observational study performed by reviewing clinical records of patients from a Critical Care Unit for 4 consecutive months. First, a simpler Scale-Based Intravenous Insulin Protocol (SBIIP) was reviewed and later it was compared for the same months of the following year with a Sliding Scale-Based Intravenous Insulin Protocol (SSBIIP). All adult patients admitted to the unit during the referred months were included. Patients in whom the protocol was not adequately followed were excluded. A total of 557 patients were reviewed, of whom they had needed intravenous insulin 73 in the first group and 52 in the second group. Four and two patients were excluded in each group respectively. Glycemic variability for both day 1 (DS1) and total stay (DST) was lower in SSBIIP patients compared to SBIIP patients: SD1 34.88 vs 18.16 and SDT 36.45 vs 23.65 (P<.001). A glycemic management protocol in critically ill patients based on sliding scales decreases glycemic variability. Copyright © 2017 SEEN. Publicado por Elsevier España, S.L.U. All rights reserved.

[Evaluation and treatment of the critically ill cirrhotic patient].

PubMed

Fernández, Javier; Aracil, Carles; Solà, Elsa; Soriano, Germán; Cinta Cardona, Maria; Coll, Susanna; Genescà, Joan; Hombrados, Manoli; Morillas, Rosa; Martín-Llahí, Marta; Pardo, Albert; Sánchez, Jordi; Vargas, Victor; Xiol, Xavier; Ginès, Pere

2016-11-01

Cirrhotic patients often develop severe complications requiring ICU admission. Grade III-IV hepatic encephalopathy, septic shock, acute-on-chronic liver failure and variceal bleeding are clinical decompensations that need a specific therapeutic approach in cirrhosis. The increased effectiveness of the treatments currently used in this setting and the spread of liver transplantation programs have substantially improved the prognosis of critically ill cirrhotic patients, which has facilitated their admission to critical care units. However, gastroenterologists and intensivists have limited knowledge of the pathogenesis, diagnosis and treatment of these complications and of the prognostic evaluation of critically ill cirrhotic patients. Cirrhotic patients present alterations in systemic and splanchnic hemodynamics, coagulation and immune dysfunction what further increase the complexity of the treatment, the risk of developing new complications and mortality in comparison with the general population. These differential characteristics have important diagnostic and therapeutic implications that must be known by general intensivists. In this context, the Catalan Society of Gastroenterology and Hepatology requested a group of experts to draft a position paper on the assessment and treatment of critically ill cirrhotic patients. This article describes the recommendations agreed upon at the consensus meetings and their main conclusions. Copyright © 2015 Elsevier España, S.L.U. y AEEH y AEG. All rights reserved.

Safety Hazards During Intrahospital Transport: A Prospective Observational Study.

PubMed

Bergman, Lina M; Pettersson, Monica E; Chaboyer, Wendy P; Carlström, Eric D; Ringdal, Mona L

2017-10-01

To identify, classify, and describe safety hazards during the process of intrahospital transport of critically ill patients. A prospective observational study. Data from participant observations of the intrahospital transport process were collected over a period of 3 months. The study was undertaken at two ICUs in one university hospital. Critically ill patients transported within the hospital by critical care nurses, unlicensed nurses, and physicians. None. Content analysis was performed using deductive and inductive approaches. We detected a total of 365 safety hazards (median, 7; interquartile range, 4-10) during 51 intrahospital transports of critically ill patients, 80% of whom were mechanically ventilated. The majority of detected safety hazards were assessed as increasing the risk of harm, compromising patient safety (n = 204). Using the System Engineering Initiative for Patient Safety, we identified safety hazards related to the work system, as follows: team (n = 61), tasks (n = 83), tools and technologies (n = 124), environment (n = 48), and organization (n = 49). Inductive analysis provided an in-depth description of those safety hazards, contributing factors, and process-related outcomes. Findings suggest that intrahospital transport is a hazardous process for critically ill patients. We have identified several factors that may contribute to transport-related adverse events, which will provide the opportunity for the redesign of systems to enhance patient safety.

The Impact of Chronic Illness on Psychosocial Stages of Human Development.

ERIC Educational Resources Information Center

Lapham, E. Virginia, Ed.; Shevlin, Kathleen M., Ed.

This book addresses critical issues regarding the impact of chronic illness and disability on human development. It was written for health care professionals who help chronically ill and disabled persons deal with the psychological and social as well as the biological aspects of their illness or disability. An expanded version of Erik Erikson's…

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.

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

Therapeutic drug monitoring of antitubercular agents for disseminated Mycobacterium tuberculosis during intermittent haemodialysis and continuous venovenous haemofiltration.

PubMed

Sin, J H; Elshaboury, R H; Hurtado, R M; Letourneau, A R; Gandhi, R G

2018-04-01

There is a lack of data regarding therapeutic drug monitoring (TDM) of antitubercular agents in the setting of continuous venovenous haemofiltration (CVVH). We describe TDM results of numerous antitubercular agents in a critically ill patient during CVVH and haemodialysis. A 49-year-old man was initiated on treatment for disseminated Mycobacterium tuberculosis. During hospital admission, the patient developed critical illness and required renal replacement therapy. TDM results and pharmacokinetic calculations showed adequate serum concentrations of rifampin, ethambutol and amikacin during CVVH and of rifampin, pyrazinamide, ethambutol and levofloxacin during intermittent haemodialysis. The presence of critical illness and renal replacement therapy can induce pharmacokinetic changes that may warrant vigilant TDM to ensure optimal therapy. To our knowledge, this is the first report to describe TDM for several antitubercular agents during CVVH in a critically patient with disseminated M. tuberculosis. © 2017 John Wiley & Sons Ltd.

Integration of Palliative Care in Chronic Critical Illness Management

PubMed Central

Nelson, Judith E; Hope, Aluko A

2016-01-01

Palliative care is an essential component of comprehensive care for all patients with chronic critical illness, including those receiving restorative or life-sustaining therapies. Core elements include alleviation of symptom distress, communication about care goals, alignment of treatment with the patient’s values and preferences, transitional planning, and family support. Here we address strategies for assessment and management of symptoms, including pain, dyspnea, and depression, and for assisting patients to communicate while endotracheally intubated. We also discuss approaches to optimize communication among clinicians, patients, and families about care goals. Challenges for supporting families and planning for transitions between care settings are identified, while the value of interdisciplinary input is emphasized. We review “consultative” and “integrative” models for integrating palliative care and restorative critical care. Finally, we highlight key ethical issues that arise in the care of chronically critically ill patients and their families. PMID:22663973

Refeeding in the ICU: an adult and pediatric problem.

PubMed

Byrnes, Matthew C; Stangenes, Jessica

2011-03-01

To describe the etiology and complications of the refeeding syndrome. Complications of the refeeding syndrome can include electrolyte abnormalities, heart failure, respiratory failure, and death. This syndrome is of particular importance to critically ill patients, who can be moved from the starved state to the fed state rapidly via enteral or parenteral nutrition. There are a variety of risk factors for the development of the refeeding syndrome. All of these risk factors are tied together by starvation physiology. Case reports and case series continue to be reported, suggesting that this entity continues to exist in critically ill patients. Initiation of enteral nutrition to patients with starvation physiology should be gradual and careful monitoring of electrolytes and organ function is critical during the early stages of refeeding. The refeeding syndrome remains a significant issue in critically ill patients. Knowledge of the risk factors and the clinical signs of the refeeding syndrome is important to optimize outcomes.

Fluid therapy in critically ill patients: perspectives from the right heart.

PubMed

Elbers, Paul; Rodrigus, Tim; Nossent, Esther; Malbrain, Manu L N G; Vonk-Noordegraaf, Anton

2015-01-01

As right heart function can affect outcome in the critically ill patient, a thorough understanding of factors determining right heart performance in health and disease is pivotal for the critical care physician. This review focuses on fluid therapy, which remains controversial in the setting of impending or overt right heart failure. In this context, we will attempt to elucidate which patients are likely to benefit from fluid administration and for which patients fluid therapy would likely be harmful. Following a general discussion of right heart function and failure, we specifically focus on important causes of right heart failure in the critically ill, i.e. sepsis induced myocardial dysfunction, the acute respiratory distress syndrome, acute pulmonary embolism and the effects of positive pressure ventilation. It is argued that fluid therapy should always be cautiously administered with the right heart in mind, which calls for close multimodal monitoring.

Malaysia's social policies on mental health: a critical theory.

PubMed

Mubarak, A Rahamuthulla

2003-01-01

This article aims to review the social policies on mental health and mental illness in Malaysia. Using critical theory, major policy issues pertaining to mental health and mental illness such as mental health legislation, prevalence rates and quality of services available to the people with mental health problems are discussed in detail. Implications of these issues on persons with mental health problems are critically evaluated. The paper highlights that the other countries in ASEAN region also require similar review by policy literature.

The Burden of Surgical Diseases on Critical Care Services at a Tertiary Referral Hospital in Sub-Saharan Africa

PubMed Central

Tomlinson, Jared; Haac, Bryce; Kadyaudzu, Clement; Samuel, Jonathan C; Campbell, Emilia LP; Lee, Clara; Charles, Anthony G

2013-01-01

In many developing countries including those of sub-Saharan Africa care of the critically ill is poorly developed. We therefore sought to elucidate the characteristics and outcomes of critically ill patients to better define the burden of disease and identify strategies for improving care. We conducted a cross sectional observation study of patients admitted to the intensive care unit at Kamuzu Central Hospital in 2010. Demographic, patient characteristics, clinical specialty and outcome data was collected. There were 234 patients admitted during the study period. Older age and admission from trauma, general surgery or medical services were associated with increased mortality. The lowest mortality was among obstetrical and gynecologic patients. Use of the ventilator and transfusions were not associated with increased mortality. Head injured patients had the highest mortality rate among all diagnoses. Rationing of critical care resources using admitting diagnosis or scoring tools can maximize access to critical care services in resource-limited settings. Furthermore, improvements on critical care services will be central to future efforts at reducing surgical morbidity and mortality and improving outcomes in all critically ill patients. PMID:23492923

Children's and young people's experiences of a parent's critical illness and admission to the intensive care unit: A qualitative meta-synthesis.

PubMed

MacEachnie, Lise H; Larsen, Hanne B; Egerod, Ingrid

2018-04-27

Little is known about how children and young people experience and manage the critical illness of a parent and a parent's admission to the intensive care unit (ICU). The aim of this study was to search and interpret the existing literature describing children's and young people's experiences of a parent's illness trajectory in the ICU. A qualitative meta-synthesis was conducted based on a systematic literature search of online databases. Four main themes were identified and synthesised to describe the integrated experiences of children and young people: (a) the parent-child bond, (b) the unfamiliar environment, (c) the impact of the illness and (d) the experience of being overseen as close family members. Experiencing a parent's critical illness and admittance to the ICU is overwhelming. The bond between the parent and child is exposed by the separation from the ill parent. To comprehend and manage the experience, children and young people seek information depending on their individual capacities. They express a need to be close to their ill parent and to be seen and approached as close members of the family. However, children experience being overseen in their needs for support during their parent's ICU illness with the risk of being left in loneliness, sadness and lack of understanding of the parent's illness. Children and young people as relatives need to be acknowledged as close members of the family, when facing the illness trajectory of a parent, who is admitted to the ICU. They need to be seen as close family members and to be approached in their needs for support in order to promote their well-being during a family illness crisis. Early supportive interventions tailored to include children of the intensive care patient are recommended. © 2018 John Wiley & Sons Ltd.

Clinical and critical care concerns in severely ill obese patient

PubMed Central

Bajwa, Sukhminder Jit Singh; Sehgal, Vishal; Bajwa, Sukhwinder Kaur

2012-01-01

The incidence of obesity has acquired an epidemic proportion throughout the globe. As a result, increasing number of obese patients is being presented to critical care units for various indications. The attending intensivist has to face numerous challenges during management of such patients. Almost all the organ systems are affected by the impact of obesity either directly or indirectly. The degree of obesity and its prolong duration are the main factors which determine the harmful effect of obesity on human body. The present article reviews few of the important clinical and critical care concerns in critically ill obese patients. PMID:23087857

Muslim women's narratives about bodily change and care during critical illness: a qualitative study.

PubMed

Zeilani, Ruqayya; Seymour, Jane E

2012-03-01

To explore experiences of Jordanian Muslim women in relation to bodily change during critical illness. A longitudinal narrative approach was used. A purposive sample of 16 Jordanian women who had spent a minimum of 48 hr in intensive care participated in one to three interviews over a 6-month period. Three main categories emerged from the analysis: the dependent body reflects changes in the women's bodily strength and performance, as they moved from being care providers into those in need of care; this was associated with experiences of a sense of paralysis, shame, and burden. The social body reflects the essential contribution that family help or nurses' support (as a proxy for family) made to women's adjustment to bodily change and their ability to make sense of their illness. The cultural body reflects the effect of cultural norms and Islamic beliefs on the women's interpretation of their experiences and relates to the women's understandings of bodily modesty. This study illustrates, by in-depth focus on Muslim women's narratives, the complex interrelationship between religious beliefs, cultural norms, and the experiences and meanings of bodily changes during critical illness. This article provides insights into vital aspects of Muslim women's needs and preferences for nursing care. It highlights the importance of including an assessment of culture and spiritual aspects when nursing critically ill patients. © 2011 Sigma Theta Tau International.

Diarrhoea risk factors in enterally tube fed critically ill patients: a retrospective audit.

PubMed

Jack, Leanne; Coyer, Fiona; Courtney, Mary; Venkatesh, Bala

2010-12-01

Diarrhoea in the enterally tube fed (ETF) intensive care unit (ICU) patient is a multi-factorial problem. Diarrhoeal aetiologies in this patient cohort remain debatable; however, the consequences of diarrhoea have been well established and include electrolyte imbalance, dehydration, bacterial translocation, peri anal wound contamination and sleep deprivation. This study examined the incidence of diarrhoea and explored factors contributing to the development of diarrhoea in the ETF, critically ill, adult patient. After institutional ethical review and approval, a single centre medical chart audit was undertaken to examine the incidence of diarrhoea in ETF, critically ill patients. Retrospective, non-probability sequential sampling was used of all emergency admission adult ICU patients who met the inclusion/exclusion criteria. Fifty patients were audited. Faecal frequency, consistency and quantity were considered important criteria in defining ETF diarrhoea. The incidence of diarrhoea was 78%. Total patient diarrhoea days (r=0.422; p=0.02) and total diarrhoea frequency (r=0.313; p=0.027) increased when the patient was ETF for longer periods of time. Increased severity of illness, peripheral oxygen saturation (Sp02), glucose control, albumin and white cell count were found to be statistically significant factors for the development of diarrhoea. Diarrhoea in ETF critically ill patients is multi-factorial. The early identification of diarrhoea risk factors and the development of a diarrhoea risk management algorithm is recommended. Copyright © 2010. Published by Elsevier Ltd.

Oxidative Stress and Lung Ischemia-Reperfusion Injury

PubMed Central

Ferrari, Renata Salatti; Andrade, Cristiano Feijó

2015-01-01

Ischemia-reperfusion (IR) injury is directly related to the formation of reactive oxygen species (ROS), endothelial cell injury, increased vascular permeability, and the activation of neutrophils and platelets, cytokines, and the complement system. Several studies have confirmed the destructiveness of the toxic oxygen metabolites produced and their role in the pathophysiology of different processes, such as oxygen poisoning, inflammation, and ischemic injury. Due to the different degrees of tissue damage resulting from the process of ischemia and subsequent reperfusion, several studies in animal models have focused on the prevention of IR injury and methods of lung protection. Lung IR injury has clinical relevance in the setting of lung transplantation and cardiopulmonary bypass, for which the consequences of IR injury may be devastating in critically ill patients. PMID:26161240

Influenza A (H1N1pdm09)-Related Critical Illness and Mortality in Mexico and Canada, 2014.

PubMed

Dominguez-Cherit, Guillermo; De la Torre, Alethse; Rishu, Asgar; Pinto, Ruxandra; Ñamendys-Silva, Silvio A; Camacho-Ortiz, Adrián; Silva-Medina, Marco Antonio; Hernández-Cárdenas, Carmen; Martínez-Franco, Michel; Quesada-Sánchez, Alejandro; López-Gallegos, Guadalupe Celia; Mosqueda-Gómez, Juan L; Rivera-Martinez, Norma E; Campos-Calderón, Fernando; Rivero-Sigarroa, Eduardo; Hernández-Gilsoul, Thierry; Espinosa-Pérez, Lourdes; Macías, Alejandro E; Lue-Martínez, Dolores M; Buelna-Cano, Christian; Ramírez-García Luna, Ana-Sofía; Cruz-Ruiz, Nestor G; Poblano-Morales, Manuel; Molinar-Ramos, Fernando; Hernandez-Torre, Martin; León-Gutiérrez, Marco Antonio; Rosaldo-Abundis, Oscar; Baltazar-Torres, José Ángel; Stelfox, Henry T; Light, Bruce; Jouvet, Philippe; Reynolds, Steve; Hall, Richard; Shindo, Nikki; Daneman, Nick; Fowler, Robert A

2016-10-01

The 2009-2010 influenza A (H1N1pdm09) pandemic caused substantial morbidity and mortality among young patients; however, mortality estimates have been confounded by regional differences in eligibility criteria and inclusion of selected populations. In 2013-2014, H1N1pdm09 became North America's dominant seasonal influenza strain. Our objective was to compare the baseline characteristics, resources, and treatments with outcomes among critically ill patients with influenza A (H1N1pdm09) in Mexican and Canadian hospitals in 2014 using consistent eligibility criteria. Observational study and a survey of available healthcare setting resources. Twenty-one hospitals, 13 in Mexico and eight in Canada. Critically ill patients with confirmed H1N1pdm09 during 2013-2014 influenza season. None. The main outcome measures were 90-day mortality and independent predictors of mortality. Among 165 adult patients with H1N1pdm09-related critical illness between September 2013 and March 2014, mean age was 48.3 years, 64% were males, and nearly all influenza was community acquired. Patients were severely hypoxic (median PaO2-to-FIO2 ratio, 83 mm Hg), 97% received mechanical ventilation, with mean positive end-expiratory pressure of 14 cm H2O at the onset of critical illness and 26.7% received rescue oxygenation therapy with prone ventilation, extracorporeal life support, high-frequency oscillatory ventilation, or inhaled nitric oxide. At 90 days, mortality was 34.6% (13.9% in Canada vs 50.5% in Mexico, p < 0.0001). Independent predictors of mortality included lower presenting PaO2-to-FIO2 ratio (odds ratio, 0.89 per 10-point increase [95% CI, 0.80-0.99]), age (odds ratio, 1.49 per 10 yr increment [95% CI, 1.10-2.02]), and requiring critical care in Mexico (odds ratio, 7.76 [95% CI, 2.02-27.35]). ICUs in Canada generally had more beds, ventilators, healthcare personnel, and rescue oxygenation therapies. Influenza A (H1N1pdm09)-related critical illness still predominantly affects relatively young to middle-aged patients and is associated with severe hypoxemic respiratory failure. The local critical care system and available resources may be influential determinants of patient outcome.

CAREGIVERS OF THE CHRONICALLY CRITICALLY ILL AFTER DISCHARGE FROM THE INTENSIVE CARE UNIT: SIX MONTHS’ EXPERIENCE

PubMed Central

Choi, JiYeon; Donahoe, Michael P.; Zullo, Thomas G.; Hoffman, Leslie A.

2011-01-01

Background Chronically critically ill patients typically undergo an extended recovery after discharge from the intensive care unit, making involvement of family caregivers essential. Prior studies provide limited detail about specific ways this experience affects caregivers. Objectives To (1) describe lifestyle restrictions and distress among caregivers of chronically critically ill patients 1 and 6 months after discharge and (2) explore how caregivers’ lifestyle restrictions and distress differ according to patients’ and caregivers’ characteristics. Methods Sixty-nine chronically critically ill patients and their family caregivers completed follow-up at 1 and 6 months after discharge from the intensive care unit. Data were collected from medical records and survey via telephone or mail. Results Caregivers’ perceived lifestyle restrictions (Changes in Role Function) decreased from 1 month (mean [SD], 23.0 [8.3]) to 6 months (19.4 [8.6]) after discharge (P = .003), although patients’ problem behaviors and caregivers’ distress (8.9 [9.3] vs 7.9 [9.6], respectively; P = .32) did not change. Change in caregivers’ lifestyle restrictions differed by patients’ disposition (P = .02) and functional status (Health Assessment Questionnaire; P = .007). Caregiver’s lifestyle restrictions remained high when patients never returned home or never recovered their preadmission functional status. Caregivers reported the most restrictions in social life and personal recreation. Patients’ negative emotions and pain caused the most caregiver distress. Conclusions Caregivers of chronically critically ill patients perceived fewer lifestyle restrictions over time but reported no change in patients’ problem behaviors or distress. Lifestyle restrictions and distress remained high when patients never returned home or regained their preadmission functional status. PMID:21196567

Caregivers of the chronically critically ill after discharge from the intensive care unit: six months' experience.

PubMed

Choi, JiYeon; Donahoe, Michael P; Zullo, Thomas G; Hoffman, Leslie A

2011-01-01

Chronically critically ill patients typically undergo an extended recovery after discharge from the intensive care unit, making involvement of family caregivers essential. Prior studies provide limited detail about specific ways this experience affects caregivers. To (1) describe lifestyle restrictions and distress among caregivers of chronically critically ill patients 1 and 6 months after discharge and (2) explore how caregivers' lifestyle restrictions and distress differ according to patients' and caregivers' characteristics. Sixty-nine chronically critically ill patients and their family caregivers completed follow-up at 1 and 6 months after discharge from the intensive care unit. Data were collected from medical records and survey via telephone or mail. Caregivers' perceived lifestyle restrictions (Changes in Role Function) decreased from 1 month (mean [SD], 23.0 [8.3]) to 6 months (19.4 [8.6]) after discharge (P = .003), although patients' problem behaviors and caregivers' distress (8.9 [9.3] vs 7.9 [9.6], respectively; P = .32) did not change. Change in caregivers' lifestyle restrictions differed by patients' disposition (P = .02) and functional status (Health Assessment Questionnaire; P = .007). Caregiver's lifestyle restrictions remained high when patients never returned home or never recovered their preadmission functional status. Caregivers reported the most restrictions in social life and personal recreation. Patients' negative emotions and pain caused the most caregiver distress. Caregivers of chronically critically ill patients perceived fewer lifestyle restrictions over time but reported no change in patients' problem behaviors or distress. Lifestyle restrictions and distress remained high when patients never returned home or regained their preadmission functional status.

Pediatric Critical Care Telemedicine Program: A Single Institution Review.

PubMed

Hernandez, Maria; Hojman, Nayla; Sadorra, Candace; Dharmar, Madan; Nesbitt, Thomas S; Litman, Rebecca; Marcin, James P

2016-01-01

Rural and community emergency departments (EDs) often receive and treat critically ill children despite limited access to pediatric expertise. Increasingly, pediatric critical care programs at children's hospitals are using telemedicine to provide consultations to these EDs with the goal of increasing the quality of care. We conducted a retrospective review of a pediatric critical care telemedicine program at a single university children's hospital. Between the years 2000 and 2014, we reviewed all telemedicine consultations provided to children in rural and community EDs, classified the visits using a comprehensive evidence-based set of chief complaints, and reported the consultations' impact on patient disposition. We also reviewed the total number of pediatric ED visits to calculate the relative frequency with which telemedicine consultations were provided. During the study period, there were 308 consultations provided to acutely ill and/or injured children for a variety of chief complaints, most commonly for respiratory illnesses, acute injury, and neurological conditions. Since inception, the number of consultations has been increasing, as has the number of participating EDs (n = 18). Telemedicine consultations were conducted on 8.6% of seriously ill children, the majority of which resulted in admission to the receiving hospital (n = 150, 49%), with a minority of patients requiring transport to the university children's hospital (n = 103, 33%). This single institutional, university children's hospital-based review demonstrates that a pediatric critical care telemedicine program used to provide consultations to seriously ill children in rural and community EDs is feasible, sustainable, and used relatively infrequently, most typically for the sickest pediatric patients.

Transcutaneous oxygen tension monitoring in critically ill patients receiving packed red blood cells.

PubMed

Schlager, Oliver; Gschwandtner, Michael E; Willfort-Ehringer, Andrea; Kurz, Martin; Mueller, Markus; Koppensteiner, Renate; Heinz, Gottfried

2014-12-01

Whether transfusions of packed red blood cells (PRBCs) affect tissue oxygenation in stable critically ill patients is still matter of discussion. The microvascular capacity for tissue oxygenation can be determined noninvasively by measuring transcutaneous oxygen tension (tcpO2). The aim of this study was to assess tissue oxygenation by measuring tcpO2 in stable critically ill patients receiving PRBC transfusions. Nineteen stable critically ill patients, who received 2 units of PRBC, were prospectively included into this pilot study. Transcutaneous oxygen tension was measured continuously during PRBC transfusions using Clark's electrodes. In addition, whole blood viscosity and global hemodynamics were determined. Reliable measurement signals during continuous tcpO2 monitoring were observed in 17 of 19 included patients. Transcutaneous oxygen tension was related to the global oxygen consumption (r=-0.78; P=.003), the arterio-venous oxygen content difference (r=-0.65; P=.005), and the extraction rate (r=-0.71; P=.02). The transfusion-induced increase of the hemoglobin concentration was paralleled by an increase of the whole blood viscosity (P<.001). Microvascular tissue oxygenation by means of tcpO2 was not affected by PRBC transfusions (P=.46). Packed red blood cell transfusions resulted in an increase of global oxygen delivery (P=.02) and central venous oxygen saturation (P=.01), whereas oxygen consumption remained unchanged (P=.72). In stable critically ill patients, microvascular tissue oxygenation can be continuously monitored by Clark's tcpO2 electrodes. According to continuous tcpO2 measurements, the microvascular tissue oxygenation is not affected by PRBC transfusions. Copyright © 2014 Elsevier Inc. All rights reserved.

Physiological and management implications of obesity in critical illness.

PubMed

Shashaty, Michael G S; Stapleton, Renee D

2014-10-01

Obesity is highly prevalent in the United States and is becoming increasingly common worldwide. The anatomic and physiological changes that occur in obese individuals may have an impact across the spectrum of critical illness. Obese patients may be more susceptible to hypoxemia and hypercapnia. During mechanical ventilation, elevated end-expiratory pressures may be required to improve lung compliance and to prevent ventilation-perfusion mismatch due to distal airway collapse. Several studies have shown an increased risk of organ dysfunction such as the acute respiratory distress syndrome and acute kidney injury in obese patients. Predisposition to ventricular hypertrophy and increases in blood volume should be considered in fluid management decisions. Obese patients have accelerated muscle losses in critical illness, making nutrition essential, although the optimal predictive equation to estimate nutritional needs or formulation for obese patients is not well established. Many common intensive care unit medications are not well studied in obese patients, necessitating understanding of pharmacokinetic concepts and consultation with pharmacists. Obesity is associated with higher risk of deep venous thrombosis and catheter-associated bloodstream infections, likely related to greater average catheter dwell times. Logistical issues such as blood pressure cuff sizing, ultrasound assistance for procedures, diminished quality of some imaging modalities, and capabilities of hospital equipment such as beds and lifts are important considerations. Despite the physiological alterations and logistical challenges involved, it is not clear whether obesity has an effect on mortality or long-term outcomes from critical illness. Effects may vary by type of critical illness, obesity severity, and obesity-associated comorbidities.

Opening the Door: The Experience of Chronic Critical Illness in a Long-Term Acute Care Hospital.

PubMed

Lamas, Daniela J; Owens, Robert L; Nace, R Nicholas; Massaro, Anthony F; Pertsch, Nathan J; Gass, Jonathon; Bernacki, Rachelle E; Block, Susan D

2017-04-01

Chronically critically ill patients have recurrent infections, organ dysfunction, and at least half die within 1 year. They are frequently cared for in long-term acute care hospitals, yet little is known about their experience in this setting. Our objective was to explore the understanding and expectations and goals of these patients and surrogates. We conducted semi-structured interviews with chronically critically ill long-term acute care hospital patients or surrogates. Conversations were recorded, transcribed, and analyzed. One long-term acute care hospital. Chronically critically ill patients, defined by tracheotomy for prolonged mechanical ventilation, or surrogates. Semi-structured conversation about quality of life, expectations, and planning for setbacks. A total of 50 subjects (30 patients and 20 surrogates) were enrolled. Thematic analyses demonstrated: 1) poor quality of life for patients; 2) surrogate stress and anxiety; 3) optimistic health expectations; 4) poor planning for medical setbacks; and 5) disruptive care transitions. Nearly 80% of patient and their surrogate decision makers identified going home as a goal; 38% were at home at 1 year. Our study describes the experience of chronically critically ill patients and surrogates in an long-term acute care hospital and the feasibility of patient-focused research in this setting. Our findings indicate overly optimistic expectations about return home and unmet palliative care needs, suggesting the need for integration of palliative care within the long-term acute care hospital. Further research is also needed to more fully understand the challenges of this growing population of ICU survivors.

Evaluation of a multi-center randomised clinical trial on prophylactic transfusion of fresh frozen plasma: implications for future trials.

PubMed

Müller, M C A; de Haan, R J; Vroom, M B; Juffermans, N P

2014-10-01

Prophylactic use of fresh frozen plasma (FFP) in critically ill patients with a coagulopathy is common. However, a lack of evidence of efficacy has resulted in a call for trials on the benefit of FFP in these patients. To date, conducting a trial on this subject has not been successful. Recently, a multi-center randomised trial was stopped prematurely due to slow inclusion. To assess clinicians' opinions regarding a trial on prophylactic administration of FFP in coagulopathic critically ill patients who need to undergo an intervention. A survey among 55 intensivists who all participated in a randomised trial on the risks and benefits of FFP in critically ill patients. Response rate was 84%. Majority of respondents indicated that international normalised ratio (INR) should be assessed before insertion of a central venous catheter (CVC) (61%), chest tube (89%) or tracheostomy (91%). Reasons to withhold transfusion of FFP to non-bleeding critically ill patients are risk of transfusion-related acute lung injury (TRALI) (46%), fluid overload (39%) and allergic reaction (24%). Although, the majority of respondents expressed the opinion that the trial was clinically relevant, 56% indicated that ≥1 patient subgroups should have been excluded from participation. Intensivists express the need for more evidence on the prophylactic use of FFP in coagulopathic critically ill patients. However, lack of knowledge about FFP and personal beliefs about the preferable transfusion strategy among clinicians, resulted in premature termination of a clinical trial on this topic. © 2014 British Blood Transfusion Society.

Cone Beam X-Ray Luminescence Tomography Imaging Based on KA-FEM Method for Small Animals.

PubMed

Chen, Dongmei; Meng, Fanzhen; Zhao, Fengjun; Xu, Cao

2016-01-01

Cone beam X-ray luminescence tomography can realize fast X-ray luminescence tomography imaging with relatively low scanning time compared with narrow beam X-ray luminescence tomography. However, cone beam X-ray luminescence tomography suffers from an ill-posed reconstruction problem. First, the feasibility of experiments with different penetration and multispectra in small animal has been tested using nanophosphor material. Then, the hybrid reconstruction algorithm with KA-FEM method has been applied in cone beam X-ray luminescence tomography for small animals to overcome the ill-posed reconstruction problem, whose advantage and property have been demonstrated in fluorescence tomography imaging. The in vivo mouse experiment proved the feasibility of the proposed method.

Immunonutrition in Critical Illness: What Is the Role?

PubMed

McCarthy, Mary S; Martindale, Robert G

2018-06-01

Acute illness-associated malnutrition leads to muscle wasting, delayed wound healing, failure to wean from ventilator support, and possibly higher rates of infection and longer hospital stays unless appropriate metabolic support is provided in the form of nutrition therapy. Agreement is still lacking about the value of individual immune-modulating substrates for specific patient populations. However, it has long been agreed that there are 3 primary targets for these substrates: 1) mucosal barrier function, 2) cellular defense function, and 3) local and systemic inflammation. These targets guide the multitude of interventions necessary to stabilize and treat the hypercatabolic intensive care unit patient, including specialized nutrition therapy. The paradigm shift that occurred 30 years ago created a unique role for nutrition as an agent to support host defense mechanisms and prevent infectious complications in the critically ill patient. This overview of immunonutrition will discuss the evidence for its role in critical illness today. © 2018 American Society for Parenteral and Enteral Nutrition.

Outbreak of E. coli O157:H7 Infections Associated with Exposure to Animal Manure in a Rural Community - Arizona and Utah, June-July 2017.

PubMed

Luna, Sarah; Krishnasamy, Vikram; Saw, Louise; Smith, Lori; Wagner, Jennifer; Weigand, Jenna; Tewell, Mackenzie; Kellis, Marilee; Penev, Roumen; McCullough, Laine; Eason, Jeffrey; McCaffrey, Keegan; Burnett, Cindy; Oakeson, Kelly; Dimond, Melissa; Nakashima, Allyn; Barlow, Deidre; Scherzer, Anna; Sarino, Melanie; Schroeder, Morgan; Hassan, Rashida; Basler, Colin; Wise, Matthew; Gieraltowski, Laura

2018-06-15

On June 26, 2017, a hospital in southern Utah notified the Utah Department of Health of Shiga toxin-producing Escherichia coli (STEC) O157:H7 infections in two children from a small community on the Arizona-Utah border. Both children developed hemolytic uremic syndrome, characterized by hemolytic anemia, acute kidney failure, and thrombocytopenia and died within a few days of illness onset. Over the next few days, several more STEC-associated illnesses were reported in residents of the community. A joint investigation by local and state health agencies from Arizona and Utah and CDC was initiated to identify the outbreak source and prevent additional cases; a total of 12 cases were identified, including the two children who died. Investigators initially explored multiple potential sources of illness; epidemiologic and environmental information revealed cow manure contact as the likely initial cause of the outbreak, which was followed by subsequent person-to-person transmission. One of the outbreak strains was isolated from bull and horse manure collected from a yard near a community household with two ill children. Local health agencies made recommendations to the public related to both animal contact and hand hygiene to reduce the risk for STEC transmission. Animal or animal manure contact should be considered a potential source of STEC O157:H7 during outbreaks in communities where ruminants are kept near the home.

En Route Use of Analgesics in Nonintubated, Critically Ill Patients Transported by U.S. Air Force Critical Care Air Transport Teams.

PubMed

Mora, Alejandra G; Ganem, Victoria J; Ervin, Alicia T; Maddry, Joseph K; Bebarta, Vikhyat S

2016-05-01

U.S. Critical Care Air Transport Teams (CCATTs) evacuate critically ill patients with acute pain in the combat setting. Limited data have been reported on analgesic administration en route, and no study has reported analgesic use by CCATTs. Our objective was to describe analgesics used by CCATTs for nonintubated, critically ill patients during evacuation from a combat setting. We conducted an institutional review board-approved, retrospective review of CCATT records. We included nonintubated, critically ill patients who were administered analgesics in flight and were evacuated out of theater (2007-2012). Demographics, injury description, analgesics and anesthetics, and predefined clinical adverse events were recorded. Data were presented as mean ± standard deviation or percentage (%). Of 1,128 records, we analyzed 381 subjects with the following characteristics: age 26 ± 7.0 years; 98% male; and 97% trauma (70% blast, 17% penetrating, 11% blunt, and 3% burn). The injury severity score was 19 ± 9. Fifty-one percent received morphine, 39% hydromorphone, 15% fentanyl, and 5% ketamine. Routes of delivery were 63% patient-controlled analgesia (PCA), 32% bolus intravenous (IV) administration, 24% epidural delivery, 21% continuous IV infusions, and 9% oral opioids. Patients that were administered local anesthetics (nerve block or epidural delivery) with IV opioids received a lower total dose of opioids than those who received opioids alone. No differences were associated between analgesics and frequency of complications in flight or postflight. About half of nonintubated, critically ill subjects evacuated out of combat by CCATT received morphine and more than half had a PCA. In our study, ketamine was not frequently used and pain scores were rarely recorded. However, we detected an opioid-sparing effect associated with local anesthetics (regional nerve blocks and epidural delivery). Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.

The role of health information technology on critical care services in Thailand.

PubMed

Wacharasint, Petch

2014-01-01

Health information technology (IT) has become an important part of current medical practice, especially in critical care services. One significant advance is the use of telemedicine which was initiated in Thailand nearly two decades ago. Telemedicine is also used in the intensive care unit or what has been termed the "Tele-ICU". It has evolved as an alternate paradigm linking the intensivist and critical care specialists to critically ill patients in remote areas. In this article, the author has reviewed the evidence of health IT on critical care services in Thailand, focusing on telemedicine, as well as the concept of the 'Tele-ICU' and its challenges. These factors may assist intensivists to reach more critically ill patients in remote areas.

Evaluation of CHROMagar Acinetobacter for Detection of Enteric Carriage of Multidrug-Resistant Acinetobacter baumannii in Samples from Critically Ill Patients▿

PubMed Central

Gordon, N. C.; Wareham, D. W.

2009-01-01

CHROMagar Acinetobacter was used to screen stool and perineal swabs for enteric carriage of multidrug-resistant Acinetobacter baumannii in samples from critically ill patients. Results were compared with a molecular assay resulting in sensitivity and specificity of culture compared to PCR of 91.7% and 89.6%, respectively. PMID:19439546

Alternative to Blood Replacement in the Critically Ill.

PubMed

Tolich, Deborah J; McCoy, Kelly

2017-09-01

This article reviews treatments and strategies that can be used to reduce, or as adjuncts to, blood transfusion to manage blood volumes in patients who are critically ill. Areas addressed include iatrogenic anemia, fluid management, pharmaceutical agents, hemostatic agents, hemoglobin-based oxygen carriers, and management of patients for whom blood is not an option. Copyright © 2017 Elsevier Inc. All rights reserved.

The incidence of ocular candidiasis and evaluation of routine opthalmic examination in critically ill patients with candidaemia.

PubMed

Gluck, S; Headdon, W G; Tang, Dws; Bastian, I B; Goggin, M J; Deane, A M

2015-11-01

Despite a paucity of data regarding both the incidence of ocular candidiasis and the utility of ophthalmic examination in critically ill patients, routine ophthalmic examination is recommended for critically ill patients with candidaemia. The objectives were to estimate the incidence of ocular candidiasis and evaluate whether ophthalmic examination influenced subsequent management of these patients. We conducted a ten-year retrospective observational study. Data were extracted for all ICU patients who were blood culture positive for fungal infection. Risk factors for candidaemia and eye involvement were quantified and details regarding ophthalmic examination were reviewed. Candida species were cultured in 93 patients. Risk factors for ocular candidiasis were present in 57% of patients. Forty-one percent of patients died prior to ophthalmology examination and 2% of patients were discharged before candidaemia was identified. During examination, signs of ocular candidiasis were only present in one (2.9%) patient, who had a risk factor for ocular candidiasis. Based on these findings, the duration of antifungal treatment for this patient was increased. Ocular candidiasis occurs rarely in critically ill patients with candidaemia, but because treatment regimens may be altered when diagnosed, routine ophthalmic examination is still indicated.

DALI: Defining Antibiotic Levels in Intensive care unit patients: a multi-centre point of prevalence study to determine whether contemporary antibiotic dosing for critically ill patients is therapeutic.

PubMed

Roberts, Jason A; De Waele, Jan J; Dimopoulos, George; Koulenti, Despoina; Martin, Claude; Montravers, Philippe; Rello, Jordi; Rhodes, Andrew; Starr, Therese; Wallis, Steven C; Lipman, Jeffrey

2012-07-06

The clinical effects of varying pharmacokinetic exposures of antibiotics (antibacterials and antifungals) on outcome in infected critically ill patients are poorly described. A large-scale multi-centre study (DALI Study) is currently underway describing the clinical outcomes of patients achieving pre-defined antibiotic exposures. This report describes the protocol. DALI will recruit over 500 patients administered a wide range of either beta-lactam or glycopeptide antibiotics or triazole or echinocandin antifungals in a pharmacokinetic point-prevalence study. It is anticipated that over 60 European intensive care units (ICUs) will participate. The primary aim will be to determine whether contemporary antibiotic dosing for critically ill patients achieves plasma concentrations associated with maximal activity. Secondary aims will compare antibiotic pharmacokinetic exposures with patient outcome and will describe the population pharmacokinetics of the antibiotics included. Various subgroup analyses will be conducted to determine patient groups that may be at risk of very low or very high concentrations of antibiotics. The DALI study should inform clinicians of the potential clinical advantages of achieving certain antibiotic pharmacokinetic exposures in infected critically ill patients.

Oxygen in the critically ill: friend or foe?

PubMed

Damiani, Elisa; Donati, Abele; Girardis, Massimo

2018-04-01

To examine the potential harmful effects of hyperoxia and summarize the results of most recent clinical studies evaluating oxygen therapy in critically ill patients. Excessive oxygen supplementation may have detrimental pulmonary and systemic effects because of enhanced oxidative stress and inflammation. Hyperoxia-induced lung injury includes altered surfactant protein composition, reduced mucociliary clearance and histological damage, resulting in atelectasis, reduced lung compliance and increased risk of infections. Hyperoxemia causes vasoconstriction, reduction in coronary blood flow and cardiac output and may alter microvascular perfusion. Observational studies showed a close relationship between hyperoxemia and increased mortality in several subsets of critically ill patients. In absence of hypoxemia, the routine use of oxygen therapy in patients with myocardial infarction, stroke, traumatic brain injury, cardiac arrest and sepsis, showed no benefit but rather it seems to be harmful. In patients admitted to intensive care unit, a conservative oxygen therapy aimed to maintain arterial oxygenation within physiological range has been proved to be well tolerated and may improve outcome. Liberal O2 use and unnecessary hyperoxia may be detrimental in critically ill patients. The current evidence supports the use of a conservative strategy in O2 therapy to avoid patient exposure to unnecessary hyperoxemia.

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

PubMed

Scherer, Jennifer S; Holley, Jean L

2016-02-05

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. Copyright © 2016 by the American Society of Nephrology.

A prospective randomised trial of probiotics in critically ill patients.

PubMed

McNaught, Clare E; Woodcock, Nicholas P; Anderson, Alexander D G; MacFie, John

2005-04-01

Probiotics exert a beneficial effect on the host through modulation of gastrointestinal microflora. The aim of this study was to investigate the effect of the probiotic Lactobacillus plantarum 299v on gut barrier function and the systemic inflammatory response in critically ill patients. One hundred and three critically ill patients were randomised to receive an oral preparation containing L. plantarum 299v (ProViva) in addition to conventional therapy (treatment group, n = 52) or conventional therapy alone (control group, n = 51). Serial outcome measures included gastric colonisation, intestinal permeability (lactulose/rhamnose dual-sugar probe technique), endotoxin exposure (IgM EndoCAb), C-reactive protein and Interleukin 6 levels. L. plantarum had no identifiable effect on gastric colonisation, intestinal permeability, endotoxin exposure or serum CRP levels. There were no differences between the groups in terms of septic morbidity or mortality. On day 15 serum IL-6 levels were significantly lower in the treatment group compared to controls. The enteral administration of L. plantarum 299v to critically ill patients was associated with a late attenuation of the systemic inflammatory response. This was not accompanied by any significant changes in the intestinal microflora, intestinal permeability, endotoxin exposure, septic morbidity or mortality.

Higher Plasma Pyridoxal Phosphate Is Associated with Increased Antioxidant Enzyme Activities in Critically Ill Surgical Patients

PubMed Central

Cheng, Chien-Hsiang; Huang, Shih-Chien; Chiang, Ting-Yu; Wong, Yueching

2013-01-01

Critically ill patients experience severe stress, inflammation and clinical conditions which may increase the utilization and metabolic turnover of vitamin B-6 and may further increase their oxidative stress and compromise their antioxidant capacity. This study was conducted to examine the relationship between vitamin B-6 status (plasma and erythrocyte PLP) oxidative stress, and antioxidant capacities in critically ill surgical patients. Thirty-seven patients in surgical intensive care unit of Taichung Veterans General Hospital, Taiwan, were enrolled. The levels of plasma and erythrocyte PLP, serum malondialdehyde, total antioxidant capacity, and antioxidant enzyme activities (i.e., superoxide dismutase (SOD), glutathione S-transferase, and glutathione peroxidase) were determined on the 1st and 7th days of admission. Plasma PLP was positively associated with the mean SOD activity level on day 1 (r = 0.42, P < 0.05), day 7 (r = 0.37, P < 0.05), and on changes (Δ (day 7 − day 1)) (r = 0.56, P < 0.01) after adjusting for age, gender, and plasma C-reactive protein concentration. Higher plasma PLP could be an important contributing factor in the elevation of antioxidant enzyme activity in critically ill surgical patients. PMID:23819116

Parenteral nutrition in the critically ill.

PubMed

Gunst, Jan; Van den Berghe, Greet

2017-04-01

Feeding guidelines have recommended early, full nutritional support in critically ill patients to prevent hypercatabolism and muscle weakness. Early enteral nutrition was suggested to be superior to early parenteral nutrition. When enteral nutrition fails to meet nutritional target, it was recommended to administer supplemental parenteral nutrition, albeit with a varying starting point. Sufficient amounts of amino acids were recommended, with addition of glutamine in subgroups. Recently, several large randomized controlled trials (RCTs) have yielded important new insights. This review summarizes recent evidence with regard to the indication, timing, and dosing of parenteral nutrition in critically ill patients. One large RCT revealed no difference between early enteral nutrition and early parenteral nutrition. Two large multicenter RCTs showed harm by early supplementation of insufficient enteral nutrition with parenteral nutrition, which could be explained by feeding-induced suppression of autophagy. Several RCTs found either no benefit or harm with a higher amino acid or caloric intake, as well as harm by administration of glutamine. Although unanswered questions remain, current evidence supports accepting low macronutrient intake during the acute phase of critical illness and does not support use of early parenteral nutrition. The timing when parenteral nutrition can be initiated safely and effectively is unclear.

Characteristics of Resting Metabolic Rate in Critically Ill, Mechanically Ventilated Adults With Cystic Fibrosis.

PubMed

Frankenfield, David C; Ashcraft, Christine M; Drasher, Tammy L; Reid, Elizabeth K; Vender, Robert L

2017-05-01

Critically ill patients with cystic fibrosis may be especially sensitive to the negative consequences of overfeeding and underfeeding, yet there is almost no information available about the energy needs of these patients. The purpose of this study was to characterize the metabolic rate of critically ill adult patients with cystic fibrosis requiring mechanical ventilation. This was an observational study in which the resting metabolic rate, oxygen consumption, and carbon dioxide production of adult patients with cystic fibrosis requiring critical care, sedation, and mechanical ventilation were measured with indirect calorimetry. This group was compared with a cohort of adult critical care patients without cystic fibrosis. Twelve patients with cystic fibrosis were identified and measured. These were compared with a control group of 25 critically ill patients. Both groups were underweight (body mass index, 17.4 ± 4.0 kg/m 2 in cystic fibrosis and 18.4 ± 2.3 kg/m 2 in control). Adjusting for differences in age, sex, height, and weight, there was no difference in resting metabolic rate between the cystic fibrosis and control groups (1702 ± 193 vs 1642 ± 194 kcal/d, P = .388). Measured resting metabolic rate matched predicted values 58% of the time in cystic fibrosis and 60% of the time in control. The resting metabolic rate of sedated adult patients with cystic fibrosis being assisted with mechanical ventilation is not different from that of adult critical care patients without cystic fibrosis. In both these underweight groups, accurate prediction of resting metabolic rate is difficult to obtain.

PSYCHIATRIC DISORDERS AND LEUKOCYTE TELOMERE LENGTH: UNDERLYING MECHANISMS LINKING MENTAL ILLNESS WITH CELLULAR AGING

PubMed Central

Lindqvist, Daniel; Epel, Elissa S.; Mellon, Synthia H.; Penninx, Brenda W.; Révész, Dóra; Verhoeven, Josine E.; Reus, Victor I.; Lin, Jue; Mahan, Laura; Hough, Christina M.; Rosser, Rebecca; Bersani, F. Saverio; Blackburn, Elizabeth H.; Wolkowitz, Owen M.

2015-01-01

Many psychiatric illnesses are associated with early mortality and with an increased risk of developing physical diseases that are more typically seen in the elderly. Moreover, certain psychiatric illnesses may be associated with accelerated cellular aging, evidenced by shortened leukocyte telomere length (LTL), which could underlie this association. Shortened LTL reflects a cell’s mitotic history and cumulative exposure to inflammation and oxidation as well as the availability of telomerase, a telomere-lengthening enzyme. Critically short telomeres can cause cells to undergo senescence, apoptosis or genomic instability, and shorter LTL correlates with poorer health and predicts mortality. Emerging data suggest that LTL may be reduced in certain psychiatric illnesses, perhaps in proportion to exposure to the psychiatric illnesses, although conflicting data exist. Telomerase has been less well characterized in psychiatric illnesses, but a role in depression and in antidepressant and neurotrophic effects has been suggested by preclinical and clinical studies. In this article, studies on LTL and telomerase activity in psychiatric illnesses are critically reviewed, potential mediators are discussed, and future directions are suggested. A deeper understanding of cellular aging in psychiatric illnesses could lead to re-conceptualizing them as systemic illnesses with manifestations inside and outside the brain and could identify new treatment targets. PMID:25999120

Art Education and Disability Studies Perspectives on Mental Illness Discourses

ERIC Educational Resources Information Center

Derby, John K.

2009-01-01

This dissertation critically examines mental illness discourses through the intersecting disciplinary lenses of art education and disability studies. Research from multiple disciplines is compared and theorized to uncover the ways in which discourses, or language systems, have oppressively constructed and represented "mental illness." To establish…

Administrative Segregation for Mentally Ill Inmates

ERIC Educational Resources Information Center

O'Keefe, Maureen L.

2007-01-01

Largely the result of prison officials needing to safely and efficiently manage a volatile inmate population, administrative segregation or supermax facilities are criticized as violating basic human needs, particularly for mentally ill inmates. The present study compared Colorado offenders with mental illness (OMIs) to nonOMIs in segregated and…

Development of an intensive care unit resource assessment survey for the care of critically ill patients in resource-limited settings.

PubMed

Leligdowicz, Aleksandra; Bhagwanjee, Satish; Diaz, Janet V; Xiong, Wei; Marshall, John C; Fowler, Robert A; Adhikari, Neill Kj

2017-04-01

Capacity to provide critical care in resource-limited settings is poorly understood because of lack of data about resources available to manage critically ill patients. Our objective was to develop a survey to address this issue. We developed and piloted a cross-sectional self-administered survey in 9 resource-limited countries. The survey consisted of 8 domains; specific items within domains were modified from previously developed survey tools. We distributed the survey by e-mail to a convenience sample of health care providers responsible for providing care to critically ill patients. We assessed clinical sensibility and test-retest reliability. Nine of 15 health care providers responded to the survey on 2 separate occasions, separated by 2 to 4 weeks. Clinical sensibility was high (3.9-4.9/5 on assessment tool). Test-retest reliability for questions related to resource availability was acceptable (intraclass correlation coefficient, 0.94; 95% confidence interval, 0.75-0.99; mean (SD) of weighted κ values = 0.67 [0.19]). The mean (SD) time for survey completion survey was 21 (16) minutes. A reliable cross-sectional survey of available resources to manage critically ill patients can be feasibly administered to health care providers in resource-limited settings. The survey will inform future research focusing on access to critical care where it is poorly described but urgently needed. Copyright © 2016 Elsevier Inc. All rights reserved.

Clinical chronobiology: a timely consideration in critical care medicine.

PubMed

McKenna, Helen; van der Horst, Gijsbertus T J; Reiss, Irwin; Martin, Daniel

2018-05-11

A fundamental aspect of human physiology is its cyclical nature over a 24-h period, a feature conserved across most life on Earth. Organisms compartmentalise processes with respect to time in order to promote survival, in a manner that mirrors the rotation of the planet and accompanying diurnal cycles of light and darkness. The influence of circadian rhythms can no longer be overlooked in clinical settings; this review provides intensivists with an up-to-date understanding of the burgeoning field of chronobiology, and suggests ways to incorporate these concepts into daily practice to improve patient outcomes. We outline the function of molecular clocks in remote tissues, which adjust cellular and global physiological function according to the time of day, and the potential clinical advantages to keeping in time with them. We highlight the consequences of "chronopathology", when this harmony is lost, and the risk factors for this condition in critically ill patients. We introduce the concept of "chronofitness" as a new target in the treatment of critical illness: preserving the internal synchronisation of clocks in different tissues, as well as external synchronisation with the environment. We describe methods for monitoring circadian rhythms in a clinical setting, and how this technology may be used for identifying optimal time windows for interventions, or to alert the physician to a critical deterioration of circadian rhythmicity. We suggest a chronobiological approach to critical illness, involving multicomponent strategies to promote chronofitness (chronobundles), and further investment in the development of personalised, time-based treatment for critically ill patients.

How Are Service Dogs for Adults with Post Traumatic Stress Disorder Integrated with Rehabilitation in Denmark? A Case Study.

PubMed

Glintborg, Chalotte; Hansen, Tia G B

2017-04-25

A severe mental illness like Post Traumatic Stress Disorder (PTSD) is known to have psychosocial consequences that can lead to a decreased quality of life. Research in Animal-Assisted Therapy (AAT) has revealed that the presence of a dog can have a positive effect on health, e.g., increase quality of life and lessen depression and anxiety. However, canine companionship is not a catch-all solution. Previous research has revealed methodological limitations that prohibit any clear conclusions, as well as a sparsity of critical reflection in anecdotal reports and case studies, which means that more research is needed to contextualize the findings. There has been an increasing interest in animal-assisted intervention in Denmark in recent years. Previously, authorities could only grant service dogs to adults with physical disabilities, but now this has been extended to adults with mental illnesses. Therefore, it has become important to explore how these service dogs are incorporated into rehabilitation practices in mental health, and how rehabilitation professionals react to the use of service dogs. This paper is a case study of a person who suffers from PTSD. This study examines how the person describes the significance of having a dog during her rehabilitation process, and how this is integrated with existing rehabilitation. The case study has been developed based on a semi-structured interview. A Thematic Content analysis was used to reveal dominant patterns and categories. This study revealed a lack of communication and collaboration between public administration (social service), service dog providers, health rehabilitation services, and providers of psychological treatment. It also revealed limited access for the dog to public services, limited success in incorporating the dog into goal-directed treatment and rehabilitation procedures, a strongly felt emotional support from the dog, and a perceived stigma by having the dog wearing a vest with he words "mentally ill" printed on it.

Feeding the critically ill obese patient: a systematic review protocol.

PubMed

Secombe, Paul; Harley, Simon; Chapman, Marianne; Aromataris, Edoardo

2015-10-01

The objective of this review is to identify effective enteral nutritional regimens targeting protein and calorie delivery for the critically ill obese patient on morbidity and mortality.More specifically, the review question is:In the critically ill obese patient, what is the optimal enteral protein and calorie target that improves mortality and morbidity? The World Health Organization (WHO) defines obesity as abnormal or excessive fat accumulation that may impair health, or, empirically, as a body mass index (BMI) ≥ 30 kg/m. Twenty-eight percent of the Australian population is obese with the prevalence rising to 44% in rural areas, and there is evidence that rates of obesity are increasing. The prevalence of obese patients in intensive care largely mirrors that of the general population. There is concern, however, that this may also be rising. A recently published multi-center nutritional study of critically ill patients reported a mean BMI of 29 in their sample, suggesting that just under 50% of their intensive care population is obese. It is inevitable, therefore, that the intensivist will care for the critically ill obese patient.Managing the critically ill obese patient is challenging, not least due to the co-morbid diseases frequently associated with obesity, including diabetes mellitus, cardiovascular disease, dyslipidaemia, sleep disordered breathing and respiratory insufficiency, hepatic steatohepatitis, chronic kidney disease and hypertension. There is also evidence that metabolic processes differ in the obese patient, particularly those with underlying insulin resistance, itself a marker of the metabolic syndrome, which may predispose to futile cycling, altered fuel utilization and protein catabolism. These issues are compounded by altered drug pharmacokinetics, and the additional logistical issues associated with prophylactic, therapeutic and diagnostic interventions.It is entirely plausible that the altered metabolic processes observed in the obese intensify and compound the metabolic changes that occur during critical illness. The early phases of critical illness are characterized by an increase in energy expenditure, resulting in a catabolic state driven by the stress response. Activation of the stress response involves up-regulation of the sympathetic nervous system and the release of pituitary hormones resulting in altered cortisol metabolism and elevated levels of endogenous catecholamines. These produce a range of metabolic disturbances including stress hyperglycemia, arising from both peripheral resistance to the effects of anabolic factors (predominantly insulin) and increased hepatic gluconeogenesis. Proteolysis is accelerated, releasing amino acids that are thought to be important in supporting tissue repair, immune defense and the synthesis of acute phase reactants. There is also altered mobilization of fuel stores, futile cycling, and evidence of altered lipoprotein metabolism. In the short term this is likely to be an adaptive response, but with time and ongoing inflammation this becomes maladaptive with a concomitant risk of protein-calorie malnutrition, immunosuppression and wasting of functional muscle tissue resulting from protein catabolism, and this is further compounded by disuse atrophy. Muscle atrophy and intensive care unit (ICU) acquired weakness is complex and poorly understood, but it is postulated that the provision of calories and sufficient protein to avoid a negative nitrogen balance mitigates this process. Avoiding lean muscle mass loss in the obese intuitively has substantial implications, given the larger mass that is required to be mobilized during their rehabilitation phase.There is, in addition, evolving evidence that hormones derived from both the gut and adipose tissue are also involved in the response to stress and critical illness, and that adipose tissue in particular is not a benign tissue bed, but rather should be considered an endocrine organ. Some of these hormones are thought to be pro-inflammatory and some anti-inflammatory; however both the net result and clinical significance of these are yet to be fully elucidated.The provision of adequate nutrition has become an integral component of supportive ICU care, but is complex. There is ongoing debate within critical care literature regarding the optimal route of delivery, the target dose, and the macronutrient components (proportion of protein and non-protein calories) of nutritional support. A number of studies have associated caloric deficit with morbidity and mortality, with the resultant assumption that prescribing sufficient calories to match energy expenditure will reduce morbidity and mortality, although the evidence base underpinning this assumption is limited to observational studies and small, randomized trials.There is research available that suggests hyper-caloric feeding or hyper-alimentation, particularly of carbohydrates, may result in increased morbidity including hyperglycemia, liver steatosis, respiratory insufficiency with prolonged duration of mechanical ventilation, re-feeding syndrome and immune suppression. But the results from studies of hypo-caloric and eucaloric feeding regimens in critically ill patients are conflicting, independent of the added metabolic complexities observed in the critically ill obese patient.Notwithstanding the debate regarding the dose and components of nutritional therapy, there is consensus that nutrition should be provided, preferably via the enteral route, and preferably initiated early in the ICU admission. The enteral route is preferred for a variety of reasons, not the least of which is cost. In addition there is evidence to suggest the enteral route is associated with the maintenance of gut integrity, a reduction in bacterial translocation and infection rates, a reduction in the incidence of stress ulceration, attenuation of oxidative stress, release of incretins and other entero-hormones, and modulation of systemic immune responses. Yet there is evidence that the initiation of enteral nutritional support for the obese critically ill patient is delayed, and that when delivered is at sub-optimal levels. The reasons for this remain obscure, but may be associated with the false assumption that every obese patient has nutritional reserves due to their adipose tissues, and can therefore withstand longer periods with no, or reduced nutritional support. In fact obesity does not necessarily protect from malnutrition, particularly protein and micronutrient malnutrition. It has been suggested by some authors that the malnutrition status of critically ill patients is a stronger predictor of mortality than BMI, and that once malnutrition status is controlled for, the apparent protective effects of obesity observed in several epidemiological studies dissipate. This would be consistent with the large body of evidence that associates malnutrition (BMI < 20 kg/m) with increased mortality, and has led some authors to postulate that the weight-mortality relationship is U-shaped. This has proven difficult to demonstrate, however, due to recognized confounding influences such as chronic co-morbidities, baseline nutritional status and the nature of the presenting critical illness.This has led to interest in nutritional regimens targeting alternative calorie and protein goals to protect the obese critically ill patient from complications arising from critical illness, and particularly protein catabolism. However, of the three major nutritional organizations, the American Society of Parenteral and Enteral Nutrition (ASPEN) is the only professional organization to make specific recommendations about providing enteral nutritional support to the critically ill obese patient, recommending a regimen targeting a hypo-caloric, high-protein goal. It is thought that this regimen, in which 60-70% of caloric requirements are provided promotes steady weight loss, while providing sufficient protein to achieve a neutral, or slightly positive, nitrogen balance, mitigating lean muscle mass loss, and allowing for wound healing. Targeting weight loss is proposed to improve insulin sensitivity, improve nursing care and reduce the risk of co-morbidities, although how this occurs and whether it can occur over the relatively short time frame of an intensive care admission (days to weeks) remains unclear. Despite these recommendations observational data of international nutritional practice suggest that ICU patients are fed uniformly low levels of calories and protein across BMI groups.Supporting the critically ill obese patient will become an increasingly important skill in the intensivist's armamentarium, and enteral nutritional therapy forms a cornerstone of this support. Yet, neither the optimal total caloric goal nor the macronutrient components of a feeding regimen for the critically ill obese patient is evident. Although the suggestion that altering the macronutrient goals for this vulnerable group of patients appears to have a sound physiological basis, the level of evidence supporting this remains unclear, and there are no systematic reviews on this topic. The aim of this systematic review is to evaluate existing literature to determine the best available evidence describing a nutritional strategy that targets energy and protein delivery to reduce morbidity and mortality for the obese patient who is critically ill.

Critical care of tropical disease in low income countries: Report from the Task Force on Tropical Diseases by the World Federation of Societies of Intensive and Critical Care Medicine.

PubMed

Baker, Tim; Khalid, Karima; Acicbe, Ozlem; McGloughlin, Steve; Amin, Pravin

2017-12-01

Tropical disease results in a great burden of critical illness. The same life-saving and supportive therapies to maintain vital organ functions that comprise critical care are required by these patients as for all other diseases. In low income countries, the little available data points towards high mortality rates and big challenges in the provision of critical care. Improving critical care in low income countries requires a focus on hospital design, training, triage, monitoring & treatment modifications, the basic principles of critical care, hygiene and the involvement of multi-disciplinary teams. As a large proportion of critical illness from tropical disease is in low income countries, the impact and reductions in mortality rates of improved critical care in such settings could be substantial. Copyright © 2017. Published by Elsevier Inc.

Improving Communication About Serious Illness

ClinicalTrials.gov

2017-01-07

Critical Illness; Chronic Disease; Terminal Care; Palliative Care; Communication; Advance Care Planning; Neoplasm Metastasis; Lung Neoplasms; Pulmonary Disease, Chronic Obstructive; Heart Failure; End Stage Liver Disease; Kidney Failure, Chronic

Aromatase Blockade Is Associated With Increased Mortality in Acute Illness in Male Mice.

PubMed

Connerney, Jeannette J; Spratt, Daniel I

2017-09-01

The increase in circulating estrogen levels with acute illness in humans is accompanied by increased aromatase expression in adipose tissue and increased peripheral aromatization of estrogens to androgens. Animal studies indicate that estrogen may be beneficial in acute illness. We hypothesized that blockade of aromatase in acute illness would decrease survival. Prospective sham controlled. Maine Medical Center Research Institute animal facility. Six- to 8-week-old male black 6 mice. Mice underwent cecal ligation and puncture (CLP) to induce acute illness and were administered letrozole to block aromatase or saline. Mice undergoing sham surgery with or without letrozole served as controls. Adipose and cardiovascular tissue was harvested for preliminary evaluation of aromatase expression. Survival was the main outcome measurement. Evidence for aromatase expression in tissue samples was assessed using western blot and/or immunohistochemistry. With aromatase blockade, survival in CLP mice was decreased ( P = 0.04). The presence of aromatase in adipose tissue was observed by western blot in CLP but not control mice. Similarly, the presence of aromatase was observed in cardiac tissue of CLP but not in control mice. The decreased survival during sepsis with aromatase blockade suggests that this response to acute illness may be important both physiologically and clinically. The preliminary observation of aromatase expression in adipose and cardiovascular tissue during acute illness in this mouse model indicates that this model has parallels to human physiology and may be useful for further studying the aromatase response to acute illness.

[Clinical study on sepsis in 2 pediatric intensive care units in Beijing].

PubMed

2012-03-01

To investigate the incidence, mortality, causes and risk factors of sepsis in children in pediatric intensive care units (PICU) in Beijing through large sample prospective clinical research. From 1st November 2008 to 31st December 2009, all patients aged from 29 days to 18 years admitted to PICU of the two children's hospitals in Beijing were surveyed. Patients who met the conditions of Chinese pediatric critical illness score (PCIS) < 90 or American guidelines for PICU admission were defined as critically ill cases. According to the definitions of sepsis of 2005 international pediatric sepsis consensus conference and 2006 Chinese Medical Association meeting, sepsis, sever sepsis, and septic shock cases were selected from these critically ill patients. The qualified subjects were surveyed by questionnaire until discharge or death the data were analyzed by SPSS. A total of 1531 of PICU admissions were enrolled within a 14-month period, of whom 1250 met the criteria of critically ill case; 486 developed sepsis, of whom 55 died. The morbidity of sepsis for all in critically ill patients in PICU was 38.9% (486/1250) and the mortality was 11.3% (55/486). The morbidity of sepsis, severe sepsis and septic shock in these PICU was 25.5% (319/1250), 10.3% (129/1250), 3.0% (38/1250) and the mortality was 2.2% (7/319), 23.3% (30/129), and 47.4% (18/38), respectively. The proportion of less than 3 years old was 75.5% (367/486). Respiratory system diseases (71.8%), such as pneumonia (63.6%), were the underlying primary infectious diseases of sepsis. Bacterial etiology accounted for 64.1% of the cases with sepsis with definite etiological test results. The proportion of gram-positive bacteria and gram-negative bacteria were 46.1% and 53.9%, respectively. PCIS and disease severity were negatively correlated (r = -0.583, P < 0.01). Multiple stepwise logistic regression analysis showed that depressed PCIS and use of mechanical ventilation were the risk factors for death. Average medical costs per patient in PICU with severe sepsis and septic shock were 2.3 times and 1.3 times higher than those of critically ill patients. Sepsis with the characteristics of high morbidity, mortality and cost was one of the critical illnesses in PICU in two pediatric hospitals in Beijing. Patients younger than 3 years were more susceptible to develop sepsis. Main infectious cause was pneumonia and bacteria was the main pathogen bacterial pneumonia. Risk factors for death were depressed PCIS and use of mechanical ventilation.

Critically ill patients with 2009 influenza A(H1N1) infection in Canada.

PubMed

Kumar, Anand; Zarychanski, Ryan; Pinto, Ruxandra; Cook, Deborah J; Marshall, John; Lacroix, Jacques; Stelfox, Tom; Bagshaw, Sean; Choong, Karen; Lamontagne, Francois; Turgeon, Alexis F; Lapinsky, Stephen; Ahern, Stéphane P; Smith, Orla; Siddiqui, Faisal; Jouvet, Philippe; Khwaja, Kosar; McIntyre, Lauralyn; Menon, Kusum; Hutchison, Jamie; Hornstein, David; Joffe, Ari; Lauzier, Francois; Singh, Jeffrey; Karachi, Tim; Wiebe, Kim; Olafson, Kendiss; Ramsey, Clare; Sharma, Sat; Dodek, Peter; Meade, Maureen; Hall, Richard; Fowler, Robert A

2009-11-04

Between March and July 2009, the largest number of confirmed cases of 2009 influenza A(H1N1) infection occurred in North America. To describe characteristics, treatment, and outcomes of critically ill patients in Canada with 2009 influenza A(H1N1) infection. A prospective observational study of 168 critically ill patients with 2009 influenza A(H1N1) infection in 38 adult and pediatric intensive care units (ICUs) in Canada between April 16 and August 12, 2009. The primary outcome measures were 28-day and 90-day mortality. Secondary outcomes included frequency and duration of mechanical ventilation and duration of ICU stay. Critical illness occurred in 215 patients with confirmed (n = 162), probable (n = 6), or suspected (n = 47) community-acquired 2009 influenza A(H1N1) infection. Among the 168 patients with confirmed or probable 2009 influenza A(H1N1), the mean (SD) age was 32.3 (21.4) years; 113 were female (67.3%) and 50 were children (29.8%). Overall mortality among critically ill patients at 28 days was 14.3% (95% confidence interval, 9.5%-20.7%). There were 43 patients who were aboriginal Canadians (25.6%). The median time from symptom onset to hospital admission was 4 days (interquartile range [IQR], 2-7 days) and from hospitalization to ICU admission was 1 day (IQR, 0-2 days). Shock and nonpulmonary acute organ dysfunction was common (Sequential Organ Failure Assessment mean [SD] score of 6.8 [3.6] on day 1). Neuraminidase inhibitors were administered to 152 patients (90.5%). All patients were severely hypoxemic (mean [SD] ratio of Pao(2) to fraction of inspired oxygen [Fio(2)] of 147 [128] mm Hg) at ICU admission. Mechanical ventilation was received by 136 patients (81.0%). The median duration of ventilation was 12 days (IQR, 6-20 days) and ICU stay was 12 days (IQR, 5-20 days). Lung rescue therapies included neuromuscular blockade (28% of patients), inhaled nitric oxide (13.7%), high-frequency oscillatory ventilation (11.9%), extracorporeal membrane oxygenation (4.2%), and prone positioning ventilation (3.0%). Overall mortality among critically ill patients at 90 days was 17.3% (95% confidence interval, 12.0%-24.0%; n = 29). Critical illness due to 2009 influenza A(H1N1) in Canada occurred rapidly after hospital admission, often in young adults, and was associated with severe hypoxemia, multisystem organ failure, a requirement for prolonged mechanical ventilation, and the frequent use of rescue therapies.

Treatment and prevention of pediatric heat-related illnesses at mass gatherings and special events.

PubMed

Bernardo, Lisa Marie; Crane, Patricia A; Veenema, Tener Goodwin

2006-01-01

Pediatric heat-related illnesses are likely to occur during mass gatherings and special events. Because critical care nurses may be called upon to provide care during such events, education in the recognition, treatment, and prevention of these illnesses is essential. This article describes the pathophysiology of heat-related illnesses and their recognition and treatment at mass gatherings and special events. Interventions to prevent heat-related illnesses at these events are discussed.

Employment Outcomes after Critical Illness: An Analysis of the BRAIN-ICU Cohort

PubMed Central

Norman, Brett C.; Jackson, James C.; Graves, John A.; Girard, Timothy D.; Pandharipande, Pratik P.; Brummel, Nathan E.; Wang, Li; Thompson, Jennifer L.; Chandrasekhar, Rameela; Ely, E. Wesley

2016-01-01

Objective To characterize survivors’ employment status after critical illness and to determine if duration of delirium during hospitalization and residual cognitive function are each independently associated with decreased employment. Design Prospective cohort investigation with baseline and in-hospital clinical data and follow up at 3 and 12 months. Setting Medical and surgical intensive care units (ICUs) at two tertiary-care hospitals. Patients Previously employed patients from the BRAIN-ICU study who survived a critical illness due to respiratory failure or shock and were evaluated for global cognition and employment status at 3- and 12-month follow-up. Measurements We used multivariable logistic regression to evaluate independent associations between employment at both 3 and 12 months and global cognitive function at the same time point, and delirium during the hospital stay. Main Results At 3-month follow-up, 113 of the total survival cohort of 448 (25%) were identified as being employed at study enrollment. Of these, 94 survived to 12-month follow-up. At 3 and 12months follow-up, 62% and 49% had a decrease in employment, 57% and 49% of whom, respectively, were newly unemployed. After adjustment for physical health status, depressive symptoms, marital status, level of education, and severity of illness, we did not find significant predictors of employment status at 3 months, but better cognition at 12 months was marginally associated with lower odds of employment reduction at 12 months, OR 0.49, p=0.07). Conclusions Reduction in employment after critical illness was present in the majority of our ICU surivors, approximately half of which was new unemployment. In this potentially underpowered pilot study, delirium at either 3 or 12 months was not a predictor yet cognitive function at 12 months was a predictor of subsequent employment status. Further research is needed into the potential relationship between the impact of critical illness on cognitive function and employment status. PMID:27171492

Employment Outcomes After Critical Illness: An Analysis of the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors Cohort.

PubMed

Norman, Brett C; Jackson, James C; Graves, John A; Girard, Timothy D; Pandharipande, Pratik P; Brummel, Nathan E; Wang, Li; Thompson, Jennifer L; Chandrasekhar, Rameela; Ely, E Wesley

2016-11-01

To characterize survivors' employment status after critical illness and to determine if duration of delirium during hospitalization and residual cognitive function are each independently associated with decreased employment. Prospective cohort investigation with baseline and in-hospital clinical data and follow-up at 3 and 12 months. Medical and surgical ICUs at two tertiary-care hospitals. Previously employed patients from the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors study who survived a critical illness due to respiratory failure or shock were evaluated for global cognition and employment status at 3- and 12-month follow-up. We used multivariable logistic regression to evaluate independent associations between employment at both 3 and 12 months and global cognitive function at the same time point, and delirium during the hospital stay. At 3-month follow-up, 113 of the total survival cohort of 448 (25%) were identified as being employed at study enrollment. Of these, 94 survived to 12-month follow-up. At 3- and 12-month follow-up, 62% and 49% had a decrease in employment, 57% and 49% of whom, respectively, were newly unemployed. After adjustment for physical health status, depressive symptoms, marital status, level of education, and severity of illness, we did not find significant predictors of employment status at 3 months, but better cognition at 12 months was marginally associated with lower odds of employment reduction at 12 months (odds ratio, 0.49; p = 0.07). Reduction in employment after critical illness was present in the majority of our ICU survivors, approximately half of which was new unemployment. Cognitive function at 12 months was a predictor of subsequent employment status. Further research is needed into the potential relationship between the impact of critical illness on cognitive function and employment status.

Doubt and belief in physicians' ability to prognosticate during critical illness: The perspective of surrogate decision makers

PubMed Central

Zier, Lucas S.; Burack, Jeffrey H.; Micco, Guy; Chipman, Anne K.; Frank, James A.; Luce, John M.; White, Douglas B.

2009-01-01

Objectives: Although discussing a prognosis is a duty of physicians caring for critically ill patients, little is known about surrogate decision-makers' beliefs about physicians' ability to prognosticate. We sought to determine: 1) surrogates' beliefs about whether physicians can accurately prognosticate for critically ill patients; and 2) how individuals use prognostic information in their role as surrogate decision-makers. Design, Setting, and Patients: Multicenter study in intensive care units of a public hospital, a tertiary care hospital, and a veterans' hospital. We conducted semistructured interviews with 50 surrogate decision-makers of critically ill patients. We analyzed the interview transcripts using grounded theory methods to inductively develop a framework to describe surrogates' beliefs about physicians' ability to prognosticate. Validation methods included triangulation by multidisciplinary analysis and member checking. Measurements and Main Results: Overall, 88% (44 of 50) of surrogates expressed doubt about physicians' ability to prognosticate for critically ill patients. Four distinct themes emerged that explained surrogates' doubts about prognostic accuracy: a belief that God could alter the course of the illness, a belief that predicting the future is inherently uncertain, prior experiences where physicians' prognostications were inaccurate, and experiences with prognostication during the patient's intensive care unit stay. Participants also identified several factors that led to belief in physicians' prognostications, such as receiving similar prognostic estimates from multiple physicians and prior experiences with accurate prognostication. Surrogates' doubts about prognostic accuracy did not prevent them from wanting prognostic information. Instead, most surrogate decision-makers view physicians' prognostications as rough estimates that are valuable in informing decisions, but are not determinative. Surrogates identified the act of prognostic disclosure as a key step in preparing emotionally and practically for the possibility that a patient may not survive. Conclusions: Although many surrogate decision-makers harbor some doubt about the accuracy of physicians' prognostications, they highly value discussions about prognosis and use the information for multiple purposes. (Crit Care Med 2008; 36: 2341–2347) PMID:18596630

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.

Social Work Faculty and Mental Illness Stigma

ERIC Educational Resources Information Center

Watson, Amy C.; Fulambarker, Anjali; Kondrat, David C.; Holley, Lynn C.; Kranke, Derrick; Wilkins, Brittany T.; Stromwall, Layne K.; Eack, Shaun M.

2017-01-01

Stigma is a significant barrier to recovery and full community inclusion for people with mental illnesses. Social work educators can play critical roles in addressing this stigma, yet little is known about their attitudes. Social work educators were surveyed about their general attitudes about people with mental illnesses, attitudes about practice…

Does RBC Storage Age Effect Inflammation, Immune Function and Susceptibility to Transfusion Associated Microchimerism in Critically Ill Patients? Adverse Effects of RBC Storage in Critically Ill Patients

DTIC Science & Technology

2013-12-01

PROGRAM ELEMENT NUMBER 6. AUTHOR(S) Philip Spinella, M.D. 5d. PROJECT NUMBER Philip J. Norris , M.D.; Avani Shah, MPH 5e. TASK NUMBER Email...dysfunction syndrome , serious thrombotic events and nosocomial infections, and ICU and hospital length of stay. Prospective clinical studies investigating

Diabetes, insulin, and development of acute lung injury

PubMed Central

Honiden, Shyoko; Gong, Michelle N.

2009-01-01

Objectives Recently, many studies have investigated the immunomodulatory effects of insulin and glucose control in critical illness. This review examines evidence regarding the relationship between diabetes and the development of acute lung injury/acute respiratory distress syndrome (ALI/ARDS), reviews studies of lung injury related to glycemic and nonglycemic metabolic features of diabetes, and examines the effect of diabetic therapies. Data Sources and Study Selection A MEDLINE/PubMed search from inception to August 1, 2008, was conducted using the search terms acute lung injury, acute respiratory distress syndrome, hyperglycemia, diabetes mellitus, insulin, hydroxymethylglutaryl-CoA reductase inhibitors (statins), angiotensin-converting enzyme inhibitor, and peroxisome proliferator-activated receptors, including combinations of these terms. Bibliographies of retrieved articles were manually reviewed. Data Extraction and Synthesis Available studies were critically reviewed, and data were extracted with special attention to the human and animal studies that explored a) diabetes and ALI; b) hyperglycemia and ALI; c) metabolic nonhyperglycemic features of diabetes and ALI; and d) diabetic therapies and ALI. Conclusions Clinical and experimental data indicate that diabetes is protective against the development of ALI/ARDS. The pathways involved are complex and likely include effects of hyperglycemia on the inflammatory response, metabolic abnormalities in diabetes, and the interactions of therapeutic agents given to diabetic patients. Multidisciplinary, multifaceted studies, involving both animal models and clinical and molecular epidemiology techniques, are essential. PMID:19531947

Managing social awkwardness when caring for morbidly obese patients in intensive care: A focused ethnography.

PubMed

Hales, Caz; de Vries, Kay; Coombs, Maureen

2016-06-01

Critically ill morbidly obese patients pose considerable healthcare delivery and resource utilisation challenges in the intensive care setting. These are resultant from specific physiological responses to critical illness in this population and the nature of the interventional therapies used in the intensive care environment. An additional challenge arises for this population when considering the social stigma that is attached to being obese. Intensive care staff therefore not only attend to the physical and care needs of the critically ill morbidly obese patient but also navigate, both personally and professionally, the social terrain of stigma when providing care. To explore the culture and influences on doctors and nurses within the intensive care setting when caring for critically ill morbidly obese patients. A focused ethnographic approach was adopted to elicit the 'situated' experiences of caring for critically ill morbidly obese patients from the perspectives of intensive care staff. Participant observation of care practices and interviews with intensive care staff were undertaken over a four month period. Analysis was conducted using constant comparison technique to compare incidents applicable to each theme. An 18 bedded tertiary intensive care unit in New Zealand. Sixty-seven intensive care nurses and 13 intensive care doctors involved with the care and management of seven critically ill patients with a body mass index ≥40kg/m(2). Interactions between intensive care staff and morbidly obese patients were challenging due to the social stigma surrounding obesity. Social awkwardness and managing socially awkward moments were evident when caring for morbidly obese patients. Intensive care staff used strategies of face-work and mutual pretence to alleviate feelings of discomfort when engaged in aspects of care and caring. This was a strategy used to prevent embarrassment and distress for both the patients and staff. This study has brought new understandings about intensive care situations where social awkwardness occurs in the context of obesity and care practices, and of the performances and behaviours of staff in managing the social awkwardness of fat-stigma during care situations. Copyright © 2016. Published by Elsevier Ltd.

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 information is needed on safety profile of probiotics in immunocompromised state of the critically ill in view of rare reports of fungemia and sepsis and a trend toward possible increase in nosocomial infection. At present, despite theoretical potential benefits, available evidence is not conclusive to recommend probiotics for routine use in the critically ill.

Supplemental parenteral nutrition in critically ill patients: a study protocol for a phase II randomised controlled trial.

PubMed

Ridley, Emma J; Davies, Andrew R; Parke, Rachael; Bailey, Michael; McArthur, Colin; Gillanders, Lyn; Cooper, David J; McGuinness, Shay

2015-12-24

Nutrition is one of the fundamentals of care provided to critically ill adults. The volume of enteral nutrition received, however, is often much less than prescribed due to multiple functional and process issues. To deliver the prescribed volume and correct the energy deficit associated with enteral nutrition alone, parenteral nutrition can be used in combination (termed "supplemental parenteral nutrition"), but benefits of this method have not been firmly established. A multi-centre, randomised, clinical trial is currently underway to determine if prescribed energy requirements can be provided to critically ill patients by using a supplemental parenteral nutrition strategy in the critically ill. This prospective, multi-centre, randomised, stratified, parallel-group, controlled, phase II trial aims to determine whether a supplemental parenteral nutrition strategy will reliably and safely increase energy intake when compared to usual care. The study will be conducted for 100 critically ill adults with at least one organ system failure and evidence of insufficient enteral intake from six intensive care units in Australia and New Zealand. Enrolled patients will be allocated to either a supplemental parenteral nutrition strategy for 7 days post randomisation or to usual care with enteral nutrition. The primary outcome will be the average energy amount delivered from nutrition therapy over the first 7 days of the study period. Secondary outcomes include protein delivery for 7 days post randomisation; total energy and protein delivery, antibiotic use and organ failure rates (up to 28 days); duration of ventilation, length of intensive care unit and hospital stay. At both intensive care unit and hospital discharge strength and health-related quality of life assessments will be undertaken. Study participants will be followed up for health-related quality of life, resource utilisation and survival at 90 and 180 days post randomisation (unless death occurs first). This trial aims to determine if provision of a supplemental parenteral nutrition strategy to critically ill adults will increase energy intake compared to usual care in Australia and New Zealand. Trial outcomes will guide development of a subsequent larger randomised controlled trial. NCT01847534 (First registered 5 February 2013, last updated 14 October 2015).

Children visiting family and friends on adult intensive care units: the nurses' perspective.

PubMed

Clarke, C M

2000-02-01

Recent surveys show that children are still restricted from visiting their critically ill family and friends on many adult intensive care units throughout the country. The purpose of this small-scale exploratory pilot study was to examine and describe the experiences and perceptions of trained nurses towards children visiting within this setting. The aim of the study was to gain greater insight and understanding into the reason why, despite evidence to support the benefits to children of visiting their critically ill family and friends, they remain discouraged and restricted. It is hoped that the study will act as an initial enquiry to generate themes and further research questions. A qualitative research approach was adopted and in-depth focused interviews used as a method of data collection. The participants of the study were trained nurses working on an adult intensive care unit in a district general hospital in England. A total of 12 individual interviews were conducted which were audiotaped in full and analysed using a method of thematic content analysis. The value of the research is to promote family-centred care within an adult intensive care environment to meet the neglected needs of the well children of the critically ill person. The findings suggest that the participants in the study attempted to offer valuable support to children visiting their critically ill family and friends, but, despite an open visiting policy, children rarely visited within this setting. The desire of the well parent to protect and shield the child from the crisis of critical illness was perceived by the participants to be the main reason why they did not visit. To provide family-centred care within an adult intensive care setting has many implications for practice and several of these important issues are discussed. These include the educational and training needs of nursing staff and the importance of adopting a collaborative team approach to providing care for the critically ill person and their family. The need to generate research and literature from within the United Kingdom's health care system has also been identified and recommendations for further studies are proposed.

Critical behavior in a stochastic model of vector mediated epidemics

PubMed Central

Alfinito, E.; Beccaria, M.; Macorini, G.

2016-01-01

The extreme vulnerability of humans to new and old pathogens is constantly highlighted by unbound outbreaks of epidemics. This vulnerability is both direct, producing illness in humans (dengue, malaria), and also indirect, affecting its supplies (bird and swine flu, Pierce disease, and olive quick decline syndrome). In most cases, the pathogens responsible for an illness spread through vectors. In general, disease evolution may be an uncontrollable propagation or a transient outbreak with limited diffusion. This depends on the physiological parameters of hosts and vectors (susceptibility to the illness, virulence, chronicity of the disease, lifetime of the vectors, etc.). In this perspective and with these motivations, we analyzed a stochastic lattice model able to capture the critical behavior of such epidemics over a limited time horizon and with a finite amount of resources. The model exhibits a critical line of transition that separates spreading and non-spreading phases. The critical line is studied with new analytical methods and direct simulations. Critical exponents are found to be the same as those of dynamical percolation. PMID:27264105

Decision making in critically ill patients with hematologic malignancy.

PubMed Central

Crawford, S. W.

1991-01-01

Hematologic neoplasms that were previously considered fatal are now potentially curable with techniques such as bone marrow transplantation. Such therapies also carry significant morbidity and mortality. With the increasing application of these therapies, a growing number of physicians are using medical decision making regarding critical care for these patients. The process by which ethical decisions are reached for these critically ill patients may be baffling because of several factors: rapidly evolving treatments, uncertain probabilities of the cure of the malignant disorder, the relatively young age of many of these patients, and the poor prognosis with critical illness. I discuss a process to reach acceptable decisions, providing a case example of the application of the process. This process is derived from the ethical principles that drive decision making in general medicine and attempts to maximize patients' autonomy. It involves a consideration of accurate information regarding the disease process and the prognosis, a clear delineation of the goals of the medical care, and communication with patients. Appropriate, ethical, and consistent decisions regarding the critical care of patients with hematologic malignancy can be reached when these considerations are addressed. PMID:1815387

Progress on core outcome sets for critical care research.

PubMed

Blackwood, Bronagh; Marshall, John; Rose, Louise

2015-10-01

Appropriate selection and definition of outcome measures are essential for clinical trials to be maximally informative. Core outcome sets (an agreed, standardized collection of outcomes measured and reported in all trials for a specific clinical area) were developed due to established inconsistencies in trial outcome selection. This review discusses the rationale for, and methods of, core outcome set development, as well as current initiatives in critical care. Recent systematic reviews of reported outcomes and measurement instruments relevant to the critically ill highlight inconsistencies in outcome selection, definition, and measurement, thus establishing the need for core outcome sets. Current critical care initiatives include development of core outcome sets for trials aimed at reducing mechanical ventilation duration; rehabilitation following critical illness; long-term outcomes in acute respiratory failure; and epidemic and pandemic studies of severe acute respiratory infection. Development and utilization of core outcome sets for studies relevant to the critically ill is in its infancy compared to other specialties. Notwithstanding, core outcome set development frameworks and guidelines are available, several sets are in various stages of development, and there is strong support from international investigator-led collaborations including the International Forum for Acute Care Trialists.

Interhospital Transport of Critically Ill Children to PICUs in the United Kingdom and Republic of Ireland: Analysis of an International Dataset.

PubMed

Ramnarayan, Padmanabhan; Dimitriades, Konstantinos; Freeburn, Lynsey; Kashyap, Aravind; Dixon, Michaela; Barry, Peter W; Claydon-Smith, Kathryn; Wardhaugh, Allan; Lamming, Caroline R; Draper, Elizabeth S

2018-06-01

International data on characteristics and outcomes of children transported from general hospitals to PICUs are scarce. We aimed to 1) describe the development of a common transport dataset in the United Kingdom and Ireland and 2) analyze transport data from a recent 2-year period. Retrospective analysis of prospectively collected data. Specialist pediatric critical care transport teams and PICUs in the United Kingdom and Ireland. Critically ill children less than 16 years old transported by pediatric critical care transport teams to PICUs in the United Kingdom and Ireland. None. A common transport dataset was developed as part of the Paediatric Intensive Care Audit Network, and standardized data were collected from all PICUs and pediatric critical care transport teams from 2012. Anonymized data on transports (and linked PICU admissions) from a 2-year period (2014-2015) were analyzed to describe patient and transport characteristics, and in uni- and multivariate analyses, to study the association between key transport factors and PICU mortality. A total of 8,167 records were analyzed. Transported children were severely ill (median predicted mortality risk 4.4%) with around half being infants (4,226/8,167; 51.7%) and nearly half presenting with respiratory illnesses (3,619/8,167; 44.3%). The majority of transports were led by physicians (78.4%; consultants: 3,059/8,167, fellows: 3,344/8,167). The median time for a pediatric critical care transport team to arrive at the patient's bedside from referral was 85 minutes (interquartile range, 58-135 min). Adverse events occurred in 369 transports (4.5%). There were considerable variations in how transports were organized and delivered across pediatric critical care transport teams. In multivariate analyses, consultant team leader and transport from an intensive care area were associated with PICU mortality (p = 0.006). Variations exist in United Kingdom and Ireland services for critically ill children needing interhospital transport. Future studies should assess the impact of these variations on long-term patient outcomes taking into account treatment provided prior to transport.

Balancing the Risks and Benefits of Oxygen Therapy in Critically III Adults

PubMed Central

Mutlu, Gökhan M.

2013-01-01

Oxygen therapy is an integral part of the treatment of critically ill patients. Maintenance of adequate oxygen delivery to vital organs often requires the administration of supplemental oxygen, sometimes at high concentrations. Although oxygen therapy is lifesaving, it may be associated with deleterious effects when administered for prolonged periods at high concentrations. Here, we review the recent advances in our understanding of the molecular responses to hypoxia and high levels of oxygen and review the current guidelines for oxygen therapy in critically ill patients. PMID:23546490

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

'Doing good by proxy': human-animal kinship and the 'donation' of canine blood.

PubMed

Ashall, Vanessa; Hobson-West, Pru

2017-07-01

This article demonstrates the relevance of animals to medical sociology by arguing that pet owners' accounts of veterinary decision-making can highlight key sociological themes which are important to both human and animal health. Based on semi-structured interviews, the article argues that interspecies 'kinship' allows for the extension of sociological claims regarding altruism, self-interest and mutuality from human blood donation to companion animal blood 'donation'. Furthermore, this study extends sociological understanding of the human-animal bond by showing how the dog's status as kin meant they were expected to donate blood, and that the act of donation itself represents an important opportunity for family 'display'. However, owners who do not or cannot donate blood themselves describe pet blood donation as an opportunity to lessen associated feelings of guilt or obligation through 'doing good by proxy'. These findings raise critical sociological and ethical questions concerning the risks and benefits of donation, and for how we understand third-party decision making. Finally, the article argues for the close entanglement of human and animal health, and concludes that sociologists of health and medicine should explore the radical possibility that decision-making in healthcare more generally might be influenced by experiences at the veterinary clinic, and vice versa. (A Virtual Abstract of this paper can be viewed at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA). © 2017 The Authors. Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for SHIL.

The Emerging Field of Quantitative Blood Metabolomics for Biomarker Discovery in Critical Illnesses

PubMed Central

Serkova, Natalie J.; Standiford, Theodore J.

2011-01-01

Metabolomics, a science of systems biology, is the global assessment of endogenous metabolites within a biologic system and represents a “snapshot” reading of gene function, enzyme activity, and the physiological landscape. Metabolite detection, either individual or grouped as a metabolomic profile, is usually performed in cells, tissues, or biofluids by either nuclear magnetic resonance spectroscopy or mass spectrometry followed by sophisticated multivariate data analysis. Because loss of metabolic homeostasis is common in critical illness, the metabolome could have many applications, including biomarker and drug target identification. Metabolomics could also significantly advance our understanding of the complex pathophysiology of acute illnesses, such as sepsis and acute lung injury/acute respiratory distress syndrome. Despite this potential, the clinical community is largely unfamiliar with the field of metabolomics, including the methodologies involved, technical challenges, and, most importantly, clinical uses. Although there is evidence of successful preclinical applications, the clinical usefulness and application of metabolomics in critical illness is just beginning to emerge, the advancement of which hinges on linking metabolite data to known and validated clinically relevant indices. In addition, other important aspects, such as patient selection, sample collection, and processing, as well as the needed multivariate data analysis, have to be taken into consideration before this innovative approach to biomarker discovery can become a reliable tool in the intensive care unit. The purpose of this review is to begin to familiarize clinicians with the field of metabolomics and its application for biomarker discovery in critical illnesses such as sepsis. PMID:21680948

Acute exacerbations of chronic obstructive pulmonary disease: diagnosis, management, and prevention in critically ill patients.

PubMed

Dixit, Deepali; Bridgeman, Mary Barna; Andrews, Liza Barbarello; Narayanan, Navaneeth; Radbel, Jared; Parikh, Amay; Sunderram, Jag

2015-06-01

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death and is a substantial source of disability in the United States. Moderate-to-severe acute exacerbations of COPD (AECOPD) can progress to respiratory failure, necessitating ventilator assistance in patients in the intensive care unit (ICU). Patients in the ICU with AECOPD requiring ventilator support have higher morbidity and mortality rates as well as costs compared with hospitalized patients not in the ICU. The mainstay of management for patients with AECOPD in the ICU includes ventilator support (noninvasive or invasive), rapid-acting inhaled bronchodilators, systemic corticosteroids, and antibiotics. However, evidence supporting these interventions for the treatment of AECOPD in critically ill patients admitted to the ICU is scant. Corticosteroids have gained widespread acceptance in the management of patients with AECOPD necessitating ventilator assistance, despite their lack of evaluation in clinical trials as well as controversies surrounding optimal dosage regimens and duration of treatment. Recent studies evaluating the safety and efficacy of corticosteroids have found that higher doses are associated with increased adverse effects, which therefore support lower dosing strategies, particularly for patients admitted to the ICU for COPD exacerbations. This review highlights recent findings from the current body of evidence on nonpharmacologic and pharmacologic treatment and prevention of AECOPD in critically ill patients. In addition, the administration of bronchodilators using novel delivery devices in the ventilated patient and the conflicting evidence surrounding antibiotic use in AECOPD in the critically ill is explored. Further clinical trials, however, are warranted to clarify the optimal pharmacotherapy management for AECOPD, particularly in critically ill patients admitted to the ICU. © 2015 Pharmacotherapy Publications, Inc.

Acute and long-term dysphagia in critically ill patients with severe sepsis: results of a prospective controlled observational study.

PubMed

Zielske, Joerg; Bohne, Silvia; Brunkhorst, Frank M; Axer, Hubertus; Guntinas-Lichius, Orlando

2014-11-01

Dysphagia is a major risk factor for morbidity and mortality in critically ill patients treated in intensive care units (ICUs). Structured otorhinolaryngological data on dysphagia in ICU survivors with severe sepsis are missing. In a prospective study, 30 ICU patients with severe sepsis and thirty without sepsis as control group were examined using bedside fiberoptic endoscopic evaluation of swallowing after 14 days in the ICU (T1) and 4 months after onset of critical illness (T2). Swallowing dysfunction was assessed using the Penetration-Aspiration Scale (PAS). The Functional Oral Intake Scale was applied to evaluate the diet needed. Primary endpoint was the burden of dysphagia defined as PAS score >5. At T1, 19 of 30 severe sepsis patients showed aspiration with a PAS score >5, compared to 7 of 30 in critically ill patients without severe sepsis (p = 0.002). Severe sepsis and tracheostomy were independent risk factors for severe dysphagia with aspiration (PAS > 5) at T1 (p = 0.042 and 0.006, respectively). 4-month mortality (T2) was 57 % in severe sepsis patients compared to 20 % in patients without severe sepsis (p = 0.006). At T2, more severe sepsis survivors were tracheostomy-dependent and needed more often tube or parenteral feeding (p = 0.014 and p = 0.040, respectively). Multivariate analysis revealed tracheostomy at T1 as independent risk factor for severe dysphagia at T2 (p = 0.030). Severe sepsis appears to be a relevant risk factor for long-term dysphagia. An otorhinolaryngological evaluation of dysphagia at ICU discharge is mandatory for survivors of severe critical illness to plan specific swallowing rehabilitation programs.

Physical complications in acute lung injury survivors: a two-year longitudinal prospective study.

PubMed

Fan, Eddy; Dowdy, David W; Colantuoni, Elizabeth; Mendez-Tellez, Pedro A; Sevransky, Jonathan E; Shanholtz, Carl; Himmelfarb, Cheryl R Dennison; Desai, Sanjay V; Ciesla, Nancy; Herridge, Margaret S; Pronovost, Peter J; Needham, Dale M

2014-04-01

Survivors of severe critical illness frequently develop substantial and persistent physical complications, including muscle weakness, impaired physical function, and decreased health-related quality of life. Our objective was to determine the longitudinal epidemiology of muscle weakness, physical function, and health-related quality of life and their associations with critical illness and ICU exposures. A multisite prospective study with longitudinal follow-up at 3, 6, 12, and 24 months after acute lung injury. Thirteen ICUs from four academic teaching hospitals. Two hundred twenty-two survivors of acute lung injury. None. At each time point, patients underwent standardized clinical evaluations of extremity, hand grip, and respiratory muscle strength; anthropometrics (height, weight, mid-arm circumference, and triceps skin fold thickness); 6-minute walk distance, and the Medical Outcomes Short-Form 36 health-related quality of life survey. During their hospitalization, survivors also had detailed daily evaluation of critical illness and related treatment variables. Over one third of survivors had objective evidence of muscle weakness at hospital discharge, with most improving within 12 months. This weakness was associated with substantial impairments in physical function and health-related quality of life that persisted at 24 months. The duration of bed rest during critical illness was consistently associated with weakness throughout 24-month follow-up. The cumulative dose of systematic corticosteroids and use of neuromuscular blockers in the ICU were not associated with weakness. Muscle weakness is common after acute lung injury, usually recovering within 12 months. This weakness is associated with substantial impairments in physical function and health-related quality of life that continue beyond 24 months. These results provide valuable prognostic information regarding physical recovery after acute lung injury. Evidence-based methods to reduce the duration of bed rest during critical illness may be important for improving these long-term impairments.

Temporary Decompression in Critically Ill Patients: Retrospective Comparison of Ileostomy and Colostomy.

PubMed

Lin, Zhi-Liang; Yu, Wen-Kui; Shi, Jia-Liang; Chen, Qi-Yi; Tan, Shan-Jun; Li, Ning

2014-05-01

In critically ill patients, gastrointestinal function plays an important role in multiple organ dysfunction syndrome. Patients suffering from acute lower gastrointestinal dysfunction need to be performed a temporary fecal diversion after the failure of conservative treatment. This study aims to determine which type of fecal diversion is associated with better clinical outcomes in critically ill patients. Data of critically ill patients requiring surgical decompression following acute lower gastrointestinal dysfunction between January 2008 and June 2013 were retrospectively analyzed. Comparison was made between ileostomy group and colostomy group regarding the stoma-related complications and the recovery after stoma creation. 63 patients consisted of temporary ileostomy group (n = 35) and temporary colostomy group (n = 28) were included in this study. First bowel movement and length of enteral nutrition intolerance after fecal diversion were both significantly shorter in the ileostomy group than in the colostomy group (1.70 ± 0.95 vs. 3.04 ± 1.40; p < 0.001 and 3.96 ± 2.84 vs. 8.12 ± 7.05; p = 0.009). In comparison of the complication rates, we found a significantly higher incidence of dermatitis (31.43% vs. 7.14%; p = 0.017), hypokalemia (25.71 vs. 3.57; p = 0.017) and hypocalcemia (28.57 vs. 7.14; p = 0.031), and slightly lower incidence of stoma prolapse (0% vs. 10.71%; p = 0.082) in the ileostomy group than in the colostomy group. Both procedures provide an effective defunctioning of the distant gastrointestinal tract with a low complication incidence. We prefer a temporary ileostomy to temporary colostomy for acute lower gastrointestinal dysfunction in critically ill patients.

Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial.

PubMed

Brummel, N E; Girard, T D; Ely, E W; Pandharipande, P P; Morandi, A; Hughes, C G; Graves, A J; Shintani, A; Murphy, E; Work, B; Pun, B T; Boehm, L; Gill, T M; Dittus, R S; Jackson, J C

2014-03-01

Cognitive impairment after critical illness is common and debilitating. We developed a cognitive therapy program for critically ill patients and assessed the feasibility and safety of administering combined cognitive and physical therapy early during a critical illness. We randomized 87 medical and surgical ICU patients with respiratory failure and/or shock in a 1:1:2 manner to three groups: usual care, early once-daily physical therapy, or early once-daily physical therapy plus a novel, progressive, twice-daily cognitive therapy protocol. Cognitive therapy included orientation, memory, attention, and problem-solving exercises, and other activities. We assessed feasibility outcomes of the early cognitive plus physical therapy intervention. At 3 months, we also assessed cognitive, functional, and health-related quality of life outcomes. Data are presented as median (interquartile range) or frequency (%). Early cognitive therapy was a delivered to 41/43 (95%) of cognitive plus physical therapy patients on 100% (92-100%) of study days beginning 1.0 (1.0-1.0) day following enrollment. Physical therapy was received by 17/22 (77%) of usual care patients, by 21/22 (95%) of physical therapy only patients, and 42/43 (98%) of cognitive plus physical therapy patients on 17% (10-26%), 67% (46-87%), and 75% (59-88%) of study days, respectively. Cognitive, functional, and health-related quality of life outcomes did not differ between groups at 3-month follow-up. This pilot study demonstrates that early rehabilitation can be extended beyond physical therapy to include cognitive therapy. Future work to determine optimal patient selection, intensity of treatment, and benefits of cognitive therapy in the critically ill is needed.

Early initiated feeding versus early reached target enteral nutrition in critically ill children: An observational study in paediatric intensive care units in Turkey.

PubMed

Baǧci, Soyhan; Keleş, Elif; Girgin, Feyza; Yıldızdaş, Dinçer R; Horoz, Özden Ö; Yalındağ, Nilüfer; Tanyıldız, Murat; Bayrakçi, Benan; Kalkan, Gökhan; Akyıldız, Başak N; Köker, Alper; Köroğlu, Tolga; Anıl, Ayşe B; Zengin, Neslihan; Dinleyici, Ener Ç; Kıral, Eylem; Dursun, Oğuz; Yavuz, Süleyman Tolga; Bartmann, Peter; Müller, Andreas

2018-05-01

Although early enteral nutrition (EN) is strongly associated with lower mortality in critically ill children, there is no consensus on the definition of early EN. The aim of this study was to evaluate our current practice supplying EN and to identify factors that affect both the initiation of feeding within 24 h after paediatric intensive care unit (PICU) admission and the adequate supply of EN in the first 48 h after PICU admission in critically ill children. We conducted a prospective, multicentre, observational study in nine PICUs in Turkey. Any kind of tube feeding commenced within 24 h of PICU admission was considered early initiated feeding (EIF). Patients who received more than 25% of the estimated energy requirement via enteral feeding within 48 h of PICU admission were considered to have early reached target EN (ERTEN). Feeding was initiated in 47.4% of patients within 24 h after PICU admission. In many patients, initiation of feeding seems to have been delayed without an evidence-based reason. ERTEN was achieved in 43 (45.3%) of 95 patients. Patients with EIF were significantly more likely to reach ERTEN. ERTEN was an independent significant predictor of mortality (P < 0.001), along with reached target enteral caloric intake on day 2 associated with decreased mortality. There is a substantial variability among clinicians' perceptions regarding indications for delay to initiate enteral feeding in critically ill children, especially after the first 6 h of PICU admission. ERTEN, but not EIF, is associated with a significantly lower mortality rate in critically ill children. © 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).

Impressions of Early Mobilization of Critically Ill Children-Clinician, Patient, and Family Perspectives.

PubMed

Zheng, Katina; Sarti, Aimee; Boles, Sama; Cameron, Saoirse; Carlisi, Robert; Clark, Heather; Khawaji, Adeeb; Awladthani, Saif; Al-Harbi, Samah; Choong, Karen

2018-04-11

To understand patient, family caregiver, and clinician impressions of early mobilization, the perceived barriers and facilitators to its implementation, and the use of in-bed cycling as a method of mobilization. A qualitative study, conducted as part of the Early Exercise in Critically ill Youth and Children, a preliminary Evaluation (wEECYCLE) Pilot randomized controlled trial. McMaster Children's Hospital PICU, Hamilton, ON, Canada. Clinicians (i.e., physicians, nurses, and physiotherapists), family caregivers, and capable patients age greater than or equal to 8 years old who were enrolled in a clinical trial of early mobilization in critically ill children (wEECYCLE). Semistructured, face-to-face interviews using a customized interview guide for clinicians, caregivers, and patients respectively, conducted after exposure to the early mobilization intervention. Thirty-seven participants were interviewed (19 family caregivers, four patients, and 14 clinicians). Family caregivers and clinicians described similar interrelated themes representing barriers to mobilization, namely low prioritization of mobilization by the medical team, safety concerns, the lack of physiotherapy resources, and low patient motivation. Key facilitators were family trust in the healthcare team, team engagement, an a priori belief that physical activity is important, and participation in research. Increased familiarity and specific features such as the virtual reality component and ability to execute passive and or active mobilization helped to engage critically ill children in in-bed cycling. Clinicians, patients, and families were highly supportive of mobilization in critically ill children; however, concerns were identified with respect to how and when to execute this practice. Understanding key stakeholder perspectives enables the development of strategies to facilitate the implementation of early mobilization and in-bed cycling, not just in the context of a clinical trial but also within the culture of practice in a PICU.

Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial

PubMed Central

Brummel, N.E.; Girard, T.D.; Ely, E.W.; Pandharipande, P.P.; Morandi, A.; Hughes, C.G.; Graves, A.J.; Shintani, A.K.; Murphy, E.; Work, B.; Pun, B.T.; Boehm, L.; Gill, T.M.; Dittus, R.S.; Jackson, J.C.

2013-01-01

PURPOSE Cognitive impairment after critical illness is common and debilitating. We developed a cognitive therapy program for critically ill patients and assessed the feasibility and safety of administering combined cognitive and physical therapy early during a critical illness. METHODS We randomized 87 medical and surgical ICU patients with respiratory failure and/or shock in a 1:1:2 manner to three groups: usual care, early once-daily physical therapy, or early once-daily physical therapy plus a novel, progressive, twice-daily cognitive therapy protocol. Cognitive therapy included orientation, memory, attention, and problem solving exercises, and other activities. We assessed feasibility outcomes of the early cognitive plus physical therapy intervention. At 3-months, we also assessed cognitive, functional and health-related quality of life outcomes. Data are presented as median [interquartile range] or frequency (%). RESULTS Early cognitive therapy was a delivered to 41/43 (95%) of cognitive plus physical therapy patients on 100% [92–100%] of study days beginning 1.0 [1.0–1.0] day following enrollment. Physical therapy was received by 17/22 (77%) of usual care patients, by 21/22 (95%) of physical therapy only patients and 42/43 (98%) of cognitive plus physical therapy patients on 17% [10–26%], 67% [46–87%] and 75% [59–88%] of study days, respectively. Cognitive, functional and health-related quality of life outcomes did not differ between groups at 3-month follow-up. CONCLUSIONS This pilot study demonstrates that early rehabilitation can be extended beyond physical therapy to include cognitive therapy. Future work to determine optimal patient selection, intensity of treatment and benefits of cognitive therapy in the critically ill is needed. PMID:24257969

Understanding Response Rates to Surveys About Family Members' Psychological Symptoms After Patients' Critical Illness.

PubMed

Long, Ann C; Downey, Lois; Engelberg, Ruth A; Nielsen, Elizabeth; Ciechanowski, Paul; Curtis, J Randall

2017-07-01

Achieving adequate response rates from family members of critically ill patients can be challenging, especially when assessing psychological symptoms. To identify factors associated with completion of surveys about psychological symptoms among family members of critically ill patients. Using data from a randomized trial of an intervention to improve communication between clinicians and families of critically ill patients, we examined patient-level and family-level predictors of the return of usable surveys at baseline, three months, and six months (n = 181, 171, and 155, respectively). Family-level predictors included baseline symptoms of psychological distress, decisional independence preference, and attachment style. We hypothesized that family with fewer symptoms of psychological distress, a preference for less decisional independence, and secure attachment style would be more likely to return questionnaires. We identified several predictors of the return of usable questionnaires. Better self-assessed family member health status was associated with a higher likelihood and stronger agreement with a support-seeking attachment style with a lower likelihood, of obtaining usable baseline surveys. At three months, family-level predictors of return of usable surveys included having usable baseline surveys, status as the patient's legal next of kin, and stronger agreement with a secure attachment style. The only predictor of receipt of surveys at six months was the presence of usable surveys at three months. We identified several predictors of the receipt of surveys assessing psychological symptoms in family of critically ill patients, including family member health status and attachment style. Using these characteristics to inform follow-up mailings and reminders may enhance response rates. Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Variability in protein binding of teicoplanin and achievement of therapeutic drug monitoring targets in critically ill patients: lessons from the DALI Study.

PubMed

Roberts, J A; Stove, V; De Waele, J J; Sipinkoski, B; McWhinney, B; Ungerer, J P J; Akova, M; Bassetti, M; Dimopoulos, G; Kaukonen, K-M; Koulenti, D; Martin, C; Montravers, P; Rello, J; Rhodes, A; Starr, T; Wallis, S C; Lipman, J

2014-05-01

The aims of this study were to describe the variability in protein binding of teicoplanin in critically ill patients as well as the number of patients achieving therapeutic target concentrations. This report is part of the multinational pharmacokinetic DALI Study. Patients were sampled on a single day, with blood samples taken both at the midpoint and the end of the dosing interval. Total and unbound teicoplanin concentrations were assayed using validated chromatographic methods. The lower therapeutic range of teicoplanin was defined as total trough concentrations from 10 to 20 mg/L and the higher range as 10-30 mg/L. Thirteen critically ill patients were available for analysis. The following are the median (interquartile range) total and free concentrations (mg/L): midpoint, total 13.6 (11.2-26.0) and free 1.5 (0.7-2.5); trough, total 11.9 (10.2-22.7) and free 1.8 (0.6-2.6). The percentage free teicoplanin for the mid-dose and trough time points was 6.9% (4.5-15.6%) and 8.2% (5.5-16.4%), respectively. The correlation between total and free antibiotic concentrations was moderate for both the midpoint (ρ = 0.79, P = 0.0021) and trough (ρ = 0.63, P = 0.027). Only 42% and 58% of patients were in the lower and higher therapeutic ranges, respectively. In conclusion, use of standard dosing for teicoplanin leads to inappropriate concentrations in a high proportion of critically ill patients. Variability in teicoplanin protein binding is very high, placing significant doubt on the validity of total concentrations for therapeutic drug monitoring in critically ill patients. Copyright © 2014 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.

Hypocaloric vs Normocaloric Nutrition in Critically Ill Patients: A Prospective Randomized Pilot Trial.

PubMed

Petros, Sirak; Horbach, Monika; Seidel, Frank; Weidhase, Lorenz

2016-02-01

Optimal nutrition of critically ill patients is still a matter of debate. This pilot trial aimed to compare the impact of normocaloric vs hypocaloric feeding in critically ill patients in the first 7 days in the intensive care unit (ICU). The primary end point was the rate of nosocomial infections during the ICU stay. Critically ill patients requiring artificial nutrition for at least 72 hours were included within 24 hours of ICU admission and randomized into a normocaloric group (receiving 100% of their daily energy expenditure) and a hypocaloric group (receiving 50% of their daily energy expenditure). One hundred patients were included (54 in the normocaloric group and 46 in the hypocaloric group). There were 66 male and 34 female patients with a mean age of 65.8 ± 11.6 years. The mean daily caloric supply was 19.7 ± 5.7 kcal/kg for the normocaloric group and 11.3 ± 3.1 kcal/kg for the hypocaloric group (P = .0001). Insulin demand was significantly higher and gastrointestinal intolerance more frequent in the normocaloric group than in the hypocaloric group. Nosocomial infections were detected more frequently in the hypocaloric group than in the normocaloric group (26.1% vs 11.1%, respectively). The ICU mortality rate was 22.2% in the normocaloric group and 21.7% in the hypocaloric group (not significant). The hospital mortality rate was 31.5% in the normocaloric group and 37.0% in the hypocaloric group (P = .67). Hypocaloric feeding in the first 7 days in critically ill patients was associated with more nosocomial infections but less insulin demand and less gastrointestinal intolerance compared with normocaloric feeding. DRKS00000104 (German Clinical Trials Register). © 2014 American Society for Parenteral and Enteral Nutrition.

Reduced nocturnal ACTH-driven cortisol secretion during critical illness

PubMed Central

Boonen, Eva; Meersseman, Philippe; Vervenne, Hilke; Meyfroidt, Geert; Guïza, Fabian; Wouters, Pieter J.; Veldhuis, Johannes D.

2014-01-01

Recently, during critical illness, cortisol metabolism was found to be reduced. We hypothesize that such reduced cortisol breakdown may suppress pulsatile ACTH and cortisol secretion via feedback inhibition. To test this hypothesis, nocturnal ACTH and cortisol secretory profiles were constructed by deconvolution analysis from plasma concentration time series in 40 matched critically ill patients and eight healthy controls, excluding diseases or drugs that affect the hypothalamic-pituitary-adrenal axis. Blood was sampled every 10 min between 2100 and 0600 to quantify plasma concentrations of ACTH and (free) cortisol. Approximate entropy, an estimation of process irregularity, cross-approximate entropy, a measure of ACTH-cortisol asynchrony, and ACTH-cortisol dose-response relationships were calculated. Total and free plasma cortisol concentrations were higher at all times in patients than in controls (all P < 0.04). Pulsatile cortisol secretion was 54% lower in patients than in controls (P = 0.005), explained by reduced cortisol burst mass (P = 0.03), whereas cortisol pulse frequency (P = 0.35) and nonpulsatile cortisol secretion (P = 0.80) were unaltered. Pulsatile ACTH secretion was 31% lower in patients than in controls (P = 0.03), again explained by a lower ACTH burst mass (P = 0.02), whereas ACTH pulse frequency (P = 0.50) and nonpulsatile ACTH secretion (P = 0.80) were unchanged. ACTH-cortisol dose response estimates were similar in patients and controls. ACTH and cortisol approximate entropy were higher in patients (P ≤ 0.03), as was ACTH-cortisol cross-approximate entropy (P ≤ 0.001). We conclude that hypercortisolism during critical illness coincided with suppressed pulsatile ACTH and cortisol secretion and a normal ACTH-cortisol dose response. Increased irregularity and asynchrony of the ACTH and cortisol time series supported non-ACTH-dependent mechanisms driving hypercortisolism during critical illness. PMID:24569590

Safety and feasibility of an exercise prescription approach to rehabilitation across the continuum of care for survivors of critical illness.

PubMed

Berney, Sue; Haines, Kimberley; Skinner, Elizabeth H; Denehy, Linda

2012-12-01

Survivors of critical illness can experience long-standing functional limitations that negatively affect their health-related quality of life. To date, no model of rehabilitation has demonstrated sustained improvements in physical function for survivors of critical illness beyond hospital discharge. The aims of this study were: (1) to describe a model of rehabilitation for survivors of critical illness, (2) to compare the model to local standard care, and (3) to report the safety and feasibility of the program. This was a cohort study. As part of a larger randomized controlled trial, 74 participants were randomly assigned, 5 days following admission to the intensive care unit (ICU), to a protocolized rehabilitation program that commenced in the ICU and continued on the acute care ward and for a further 8 weeks following hospital discharge as an outpatient program. Exercise training was prescribed based on quantitative outcome measures to achieve a physiological training response. During acute hospitalization, 60% of exercise sessions were able to be delivered. The most frequently occurring barriers to exercise were patient safety and patient refusal due to fatigue. Point prevalence data showed patients were mobilized more often and for longer periods compared with standard care. Outpatient classes were poorly attended, with only 41% of the patients completing more than 70% of outpatient classes. No adverse events occurred. Limitations included patient heterogeneity and delayed commencement of exercise in the ICU due to issues of consent and recruitment. Exercise training that commences in the ICU and continues through to an outpatient program is safe and feasible for survivors of critical illness. Models of care that maximize patient participation across the continuum of care warrant further investigation.

Validation of a New Small-Volume Sodium Citrate Collection Tube for Coagulation Testing in Critically Ill Patients with Coagulopathy.

PubMed

Adam, Elisabeth H; Zacharowski, Kai; Hintereder, Gudrun; Raimann, Florian; Meybohm, Patrick

2018-06-01

Blood loss due to phlebotomy leads to hospital-acquired anemia and more frequent blood transfusions that may be associated with increased risk of morbidity and mortality in critically ill patients. Multiple blood conservation strategies have been proposed in the context of patient blood management to minimize blood loss. Here, we evaluated a new small-volume sodium citrate collection tube for coagulation testing in critically ill patients. In 46 critically adult ill patients admitted to an interdisciplinary intensive care unit, we prospectively compared small-volume (1.8 mL) sodium citrate tubes with the conventional (3 mL) sodium citrate tubes. The main inclusion criterium was a proven coagulopathy (Quick < 60% and/or aPTT > 40 second) due to anticoagulation therapy or perioperative coagulopathy. In total, 92 coagulation analyses were obtained. Linear correlation analysis detected a positive relationship for 7 coagulation parameters (Prothrombin Time, r = 0.987; INR, r = 0.985; activated Partial Thromboplastin Time, r = 0.967; Thrombin Clotting Time, r = 0.969; Fibrinogen, r = 0.986; Antithrombin, r = 0.988; DDimer, r = 0.969). Bland-Altman analyses revealed an absolute mean of differences of almost zero. Ninety-five percent of data were within two standard deviations of the mean difference suggesting interchangeability. As systematic deviations between measured parameters of the two tubes were very unlikely, test results of small-volume (1.8 mL) sodium citrate tubes were equal to conventional (3 mL) sodium citrate tubes and can be considered interchangeable. Small-volume sodium citrate tubes reduced unnecessary diagnostic-related blood loss by about 40% and, therefore, should be the new standard of care for routine coagulation analysis in critically ill patients.

High glucose intake and glycaemic level in critically ill neonates with inherited metabolic disorders of intoxication.

PubMed

Grimaud, Marion; de Lonlay, Pascale; Dupic, Laurent; Arnoux, Jean-Baptiste; Brassier, Anais; Hubert, Philippe; Lesage, Fabrice; Oualha, Mehdi

2016-06-01

To investigate glycaemic levels in critically ill neonates with inherited metabolic disorders of intoxication. Thirty-nine neonates with a median age of 7 days (0-24) were retrospectively included (urea cycle disorders (n = 18), maple syrup disease (n = 13), organic acidemias (n = 8)). Twenty-seven neonates were intubated, 21 were haemodialysed and 6 died. During the first 3 days, median total and peak blood glucose (BG) levels were 7.1 mmol/L (0.9-50) and 10 mmol/L (5.1-50), respectively. The median glucose intake rate was 11 mg/kg/min (2.7-15.9). Fifteen and 23 neonates exhibited severe hyperglycaemia (≥2 BG levels >12 mmol/L) and mild hyperglycaemia (≥2 BG levels >7 and ≤12 mmol/L), respectively. Glycaemic levels and number of hyperglycaemic neonates decreased over the first 3 days (p < 0.001) while total glucose intake rate was stable (p = 0.11). Enteral route of glucose intake was associated with a lower number of hyperglycaemic neonates (p = 0.04) and glycaemic level (p = 0.02). Hyperglycaemia is common in critically ill neonates receiving high glucose intake with inherited metabolic disorders of intoxication. Physicians should decrease the rate of total glucose intake and begin enteral feeding as quickly as possible in cases of persistent hyperglycaemia. • The risk of hyperglycaemia in the acute phase of critical illness is high. What is New: • Hyperglycaemia is common in the initial management of critically ill neonates with inherited metabolic disorders of intoxication receiving high glucose intake.

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

Corticosteroid therapy in critical illness due to seasonal and pandemic influenza

PubMed Central

Yale, Philippe; Adhikari, Neill KJ; Masse, Vincent; Fowler, Robert A; Xiong, Wei; McGeer, Allison; Cann, Darlene; Rudnick, Wallis; Green, Karen; Meade, Maureen O; Valiquette, Louis; Lamontagne, François

2015-01-01

BACKGROUND: Survey data suggest that Canadian intensivists administer corticosteroids to critically ill patients primarily in response to airway obstruction, perceived risk for adrenal insufficiency and hemodynamic instability. OBJECTIVE: To describe variables independently associated with systemic corticosteroid therapy during an influenza outbreak. METHODS: The present analysis was retrospective cohort study involving critically ill patients with influenza in two Canadian cities. Hospital records were reviewed for critically ill patients treated in the intensive care units (ICUs) of eight hospitals in Canada during the 2008 to 2009 and 2009 to 2010 influenza outbreaks. Abstracted data included demographic information, symptoms at disease onset, chronic comorbidities and baseline illness severity scores. Corticosteroid use data were extracted for every ICU day and expressed as hydrocortisone dose equivalent in mg. Multivariable regression models were constructed to identify variables independently associated with corticosteroid therapy in the ICU. RESULTS: The study cohort included 90 patients with a mean (± SD) age of 55.0±17.3 years and Acute Physiology and Chronic Health Evaluation II score of 19.8±8.3. Patients in 2009 to 2010 were younger with more severe lung injury but similar exposure to corticosteroids. Overall, 54% of patients received corticosteroids at a mean daily dose of 343±330 mg of hydrocortisone for 8.5±4.8 days. Variables independently associated with corticosteroid therapy in the ICU were history of airway obstruction (OR 4.8 [95% CI 1.6 to 14.9]) and hemodynamic instability (OR 4.6 [95% CI 1.2 to 17.8]). CONCLUSION: Observational data revealed that hemodynamic instability and airway obstruction were associated with corticosteroid therapy in the critical care setting, similar to a recent survey of stated practice. Efforts to determine the effects of corticosteroids in the ICU for these specific clinical situations are warranted. PMID:26436911

Corticosteroid therapy in critical illness due to seasonal and pandemic influenza.

PubMed

Yale, Philippe; Adhikari, Neill K J; Masse, Vincent; Fowler, Robert A; Xiong, Wei; McGeer, Allison; Cann, Darlene; Rudnick, Wallis; Green, Karen; Meade, Maureen O; Valiquette, Louis; Lamontagne, François

2015-01-01

Survey data suggest that Canadian intensivists administer corticosteroids to critically ill patients primarily in response to airway obstruction, perceived risk for adrenal insufficiency and hemodynamic instability. To describe variables independently associated with systemic corticosteroid therapy during an influenza outbreak. The present analysis was retrospective cohort study involving critically ill patients with influenza in two Canadian cities. Hospital records were reviewed for critically ill patients treated in the intensive care units (ICUs) of eight hospitals in Canada during the 2008 to 2009 and 2009 to 2010 influenza outbreaks. Abstracted data included demographic information, symptoms at disease onset, chronic comorbidities and baseline illness severity scores. Corticosteroid use data were extracted for every ICU day and expressed as hydrocortisone dose equivalent in mg. Multivariable regression models were constructed to identify variables independently associated with corticosteroid therapy in the ICU. The study cohort included 90 patients with a mean (± SD) age of 55.0 ± 17.3 years and Acute Physiology and Chronic Health Evaluation II score of 19.8 ± 8.3. Patients in 2009 to 2010 were younger with more severe lung injury but similar exposure to corticosteroids. Overall, 54% of patients received corticosteroids at a mean daily dose of 343 ± 330 mg of hydrocortisone for 8.5 ± 4.8 days. Variables independently associated with corticosteroid therapy in the ICU were history of airway obstruction (OR 4.8 [95% CI 1.6 to 14.9]) and hemodynamic instability (OR 4.6 [95% CI 1.2 to 17.8]). Observational data revealed that hemodynamic instability and airway obstruction were associated with corticosteroid therapy in the critical care setting, similar to a recent survey of stated practice. Efforts to determine the effects of corticosteroids in the ICU for these specific clinical situations are warranted.

Long-Term Survival and Quality of Life After Transfusion-Associated Pulmonary Edema in Critically III Medical Patients

PubMed Central

Kojicic, Marija; Reriani, Martin K.; Fernández Pérez, Evans R.; Thakur, Lokendra; Kashyap, Rahul; Van Buskirk, Camille M.; Gajic, Ognjen

2010-01-01

Background: Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) commonly complicate transfusion in critically ill patients. Prior outcome studies of TACO and TRALI have focused on short-term morbidity and mortality, but the long-term survival and quality of life (QOL) of these patients remain unknown. Methods: In a nested case-control study, we compared survival and QOL between critically ill medical patients who developed pulmonary edema after transfusion (TRALI or TACO) and medical critically ill transfused controls, matched by age, gender, and admission diagnostic group. QOL in survivors was assessed with a 36-item short form health survey 1 year after initial hospitalization. Results: Hospital, 1-year, and 2-year mortality among the 74 TRALI cases and 74 matched controls were 43.2% vs 24.3% (P = .020), 63.8% vs 46.4% (P = .037) and 74.3% vs 54.3% (P = .031), whereas among the 51 TACO cases and 51 matched controls these values were 7.8% vs 11.8% (P = .727), 38.0% vs 28.0% (P = .371), and 44.9% vs 38.8% (P = .512). When adjusted for age and baseline severity of illness in a Cox proportional hazard analysis, the development of TRALI remained associated with decreased survival (hazard ratio 1.86; 95% CI, 1.19-2.93; P = .006). Both TRALI (P = .006, P = .03) and TACO (P = .03, P = .049) were associated with prolonged ICU and hospital lengths of stay. Conclusions: In critically ill medical patients, development of TRALI, but not TACO, is independently associated with decreased long-term survival. PMID:19837827

Lipopolysaccharide-binding protein, lipopolysaccharide, and soluble CD14 in sepsis of critically ill neonates and children.

PubMed

Pavcnik-Arnol, Maja; Hojker, Sergej; Derganc, Metka

2007-06-01

To compare the diagnostic accuracy of lipopolysaccharide-binding protein (LBP) for sepsis in critically ill neonates and children with the two markers participating in the same inflammatory pathway, lipopolysaccharide and soluble CD14. Prospective, observational study in a multidisciplinary neonatal and pediatric intensive care unit. 47 critically ill neonates and 49 critically ill children with systemic inflammatory response syndrome (SIRS) and suspected sepsis, classified into two groups: those with and those without sepsis. Serum LBP, lipopolysaccharide, soluble CD14, C-reactive protein, and procalcitonin were measured on 2 consecutive days. The area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and predictive values were evaluated. AUC for LBP on the first day of suspected infection was 0.97 in neonates aged under 48 h, 0.93 in neonates over 48 h and 0.82 in children. AUCs for lipopolysaccharide and soluble CD14 were 0.77 and 0.74 in neonates under 48 h, 0.53 and 0.76 in neonates over 48 h, and 0.72 and 0.53 in children. AUCs for procalcitonin and C-reactive protein were 0.65 and 0.89 in neonates under 48 h, 0.65 and 0.91 in neonates over 48 h, and 0.76 and 0.69 in children. In critically ill neonates and children LBP concentration on the first day of suspected sepsis is a better marker of sepsis than lipopolysaccharide, soluble CD14, procalcitonin, and in neonates younger than 48 h and children, also a better marker than C-reactive protein. Lipopolysaccharide and soluble CD14 are not suitable markers for the differentiation of infectious and noninfectious SIRS.

Differences in pharmacokinetics and pharmacodynamics of colistimethate sodium (CMS) and colistin between three different CMS dosage regimens in a critically ill patient infected by a multidrug-resistant Acinetobacter baumannii.

PubMed

Luque, Sònia; Grau, Santiago; Valle, Marta; Sorlí, Luisa; Horcajada, Juan Pablo; Segura, Concha; Alvarez-Lerma, Francisco

2013-08-01

Use of colistin has re-emerged for the treatment of infections caused by multidrug-resistant (MDR) Gram-negative bacteria, but information on its pharmacokinetics and pharmacodynamics is limited, especially in critically ill patients. Recent data from pharmacokinetic/pharmacodynamic (PK/PD) population studies have suggested that this population could benefit from administration of higher than standard doses of colistimethate sodium (CMS), but the relationship between administration of incremental doses of CMS and corresponding PK/PD parameters as well as its efficacy and toxicity have not yet been investigated in a clinical setting. The objective was to study the PK/PD differences of CMS and colistin between three different CMS dosage regimens in the same critically ill patient. A critically ill patient with nosocomial pneumonia caused by a MDR Acinetobacter baumannii received incremental doses of CMS. During administration of the different CMS dosage regimens, CMS and colistin plasma concentrations were determined and PK/PD indexes were calculated. With administration of the highest CMS dose once daily (720 mg every 24h), the peak plasma concentration of CMS and colistin increased to 40.51 mg/L and 1.81 mg/L, respectively, and the AUC0-24/MIC of colistin was 184.41. This dosage regimen was efficacious, and no nephrotoxicity or neurotoxicity was observed. In conclusion, a higher and extended-interval CMS dosage made it possible to increase the exposure of CMS and colistin in a critically ill patient infected by a MDR A. baumannii and allowed a clinical and microbiological optimal response to be achieved without evidence of toxicity. Copyright © 2013 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.

Evaluation of a Device Combining an Inferior Vena Cava Filter and a Central Venous Catheter for Preventing Pulmonary Embolism Among Critically Ill Trauma Patients.

PubMed

Tapson, Victor F; Hazelton, Joshua P; Myers, John; Robertson, Claudia; Gilani, Ramyar; Dunn, Julie A; Bukur, Marko; Croce, Martin A; Peick, Ann; West, Sonlee; Lottenberg, Lawrence; Doucet, Jay; Miller, Preston R; Crookes, Bruce; Gandhi, Rajesh R; Croft, Chasen A; Manasia, Anthony; Hoey, Brian A; Lieberman, Howard; Guillamondegui, Oscar D; Novack, Victor; Piazza, Gregory; Goldhaber, Samuel Z

2017-09-01

To evaluate efficacy and safety of a novel device that combines an inferior vena cava (IVC) filter and central venous catheter (CVC) for prevention of pulmonary embolism (PE) in critically ill patients. In a multicenter, prospective, single-arm clinical trial, the device was inserted at the bedside without fluoroscopy and subsequently retrieved before transfer from the intensive care unit (ICU). The primary efficacy endpoint was freedom from clinically significant PE or fatal PE 72 hours after device removal or discharge, whichever occurred first. Secondary endpoints were incidence of acute proximal deep venous thrombosis (DVT), catheter-related thrombosis, catheter-related bloodstream infections, major bleeding events, and clinically significant thrombus (occupying > 25% of volume of filter) detected by cavography before retrieval. The device was placed in 163 critically ill patients with contraindications to anticoagulation; 151 (93%) were critically ill trauma patients, 129 (85%) had head or spine trauma, and 102 (79%) had intracranial bleeding. The primary efficacy endpoint was achieved for all 163 (100%) patients (95% confidence interval [CI], 97.8%-100%, P < .01). Diagnosis of new or worsening acute proximal DVT was time dependent with 11 (7%) occurring during the first 7 days. There were no (0%) catheter-related bloodstream infections. There were 5 (3.1%) major bleeding events. Significant thrombus in the IVC filter occurred in 14 (8.6%) patients. Prophylactic anticoagulation was not initiated for a mean of 5.5 days ± 4.3 after ICU admission. This novel device prevented clinically significant and fatal PE among critically ill trauma patients with low risk of complications. Copyright © 2017 SIR. Published by Elsevier Inc. All rights reserved.

Comparison of measured versus predicted energy requirements in critically ill cancer patients.

PubMed

Pirat, Arash; Tucker, Anne M; Taylor, Kim A; Jinnah, Rashida; Finch, Clarence G; Canada, Todd D; Nates, Joseph L

2009-04-01

Accurate determination of caloric requirements is essential to avoid feeding-associated complications in critically ill patients. In critically ill cancer patients we compared the measured and estimated resting energy expenditures. All patients admitted to the oncology intensive care unit between March 2004 and July 2005 were considered for inclusion. For those patients enrolled (n = 34) we measured resting energy expenditure via indirect calorimetry, and estimated resting energy expenditure in 2 ways: clinically estimated resting energy expenditure; and the Harris-Benedict basal energy expenditure equation. Clinically estimated resting energy expenditure was associated with underfeeding, appropriate feeding, and overfeeding in approximately 15%, 15%, and 71% of the patients, respectively. The Harris-Benedict basal energy expenditure was associated with underfeeding, appropriate feeding, and overfeeding in approximately 29%, 41%, and 29% of the patients, respectively. The mean measured resting energy expenditure (1,623 +/- 384 kcal/d) was similar to the mean Harris-Benedict basal energy expenditure without the addition of stress or activity factors (1,613 +/- 382 kcal/d, P = .87), and both were significantly lower than the mean clinically estimated resting energy expenditure (1,862 +/- 330 kcal/d, P < or = .003 for both). There was a significant correlation only between mean measured resting energy expenditure and mean Harris-Benedict basal energy expenditure (P < .001), but the correlation coefficient between those values was low (r = 0.587). Underfeeding and overfeeding were common in our critically ill cancer patients when resting energy expenditure was estimated rather than measured. Indirect calorimetry is the method of choice for determining caloric need in critically ill cancer patients, but if indirect calorimetry is not available or feasible, the Harris-Benedict equation without added stress and activity factors is more accurate than the clinically estimated resting energy expenditure.

Performance of the PEdiatric Logistic Organ Dysfunction-2 score in critically ill children requiring plasma transfusions.

PubMed

Karam, Oliver; Demaret, Pierre; Duhamel, Alain; Shefler, Alison; Spinella, Philip C; Stanworth, Simon J; Tucci, Marisa; Leteurtre, Stéphane

2016-12-01

Organ dysfunction scores, based on physiological parameters, have been created to describe organ failure. In a general pediatric intensive care unit (PICU) population, the PEdiatric Logistic Organ Dysfunction-2 score (PELOD-2) score had both a good discrimination and calibration, allowing to describe the clinical outcome of critically ill children throughout their stay. This score is increasingly used in clinical trials in specific subpopulation. Our objective was to assess the performance of the PELOD-2 score in a subpopulation of critically ill children requiring plasma transfusions. This was an ancillary study of a prospective observational study on plasma transfusions over a 6-week period, in 101 PICUs in 21 countries. All critically ill children who received at least one plasma transfusion during the observation period were included. PELOD-2 scores were measured on days 1, 2, 5, 8, and 12 after plasma transfusion. Performance of the score was assessed by the determination of the discrimination (area under the ROC curve: AUC) and the calibration (Hosmer-Lemeshow test). Four hundred and forty-three patients were enrolled in the study (median age and weight: 1 year and 9.1 kg, respectively). Observed mortality rate was 26.9 % (119/443). For PELOD-2 on day 1, the AUC was 0.76 (95 % CI 0.71-0.81) and the Hosmer-Lemeshow test was p = 0.76. The serial evaluation of the changes in the daily PELOD-2 scores from day 1 demonstrated a significant association with death, adjusted for the PELOD-2 score on day 1. In a subpopulation of critically ill children requiring plasma transfusion, the PELOD-2 score has a lower but acceptable discrimination than in an entire population. This score should therefore be used cautiously in this specific subpopulation.

Pyridoxal-5'-phosphate deficiency is associated with hyperhomocysteinemia regardless of antioxidant, thiamine, riboflavin, cobalamine, and folate status in critically ill patients.

PubMed

Molina-López, Jorge; Florea, Daniela; Quintero-Osso, Bartolomé; de la Cruz, Antonio Pérez; Rodríguez-Elvira, Manuel; Del Pozo, Elena Planells

2016-06-01

Critically ill patients develop severe stress, inflammation and a clinical state that may raise the utilization and metabolic replacement of pyridoxal-5'-phosphate decreasing their body reserves. This study was designed to assess the nutritional pyridoxal-5'-phosphate status in critical care patients with systemic inflammatory response syndrome, comparing them with a group of healthy people, and studying it's association with factors involved in the pyridoxine and other B vitamins metabolism, as the total antioxidant capacity and Hcy as cardiovascular risk biomarker. Prospective, multicentre, comparative, observational and analytic study. One hundred and three critically ill patients from different hospitals, and eighty four healthy subjects from Granada, Spain, all with informed consent. Data from daily nutritional assessment, ICU severity scores, clinical and nutritional parameters, antioxidant status and homocysteine levels was taken at admission and at the seventh day of the ICU stay. Thiamine, riboflavin, pyridoxine and folate status proved deficient in a large number of patients, being significantly lower in comparison with control group, and significantly decreased at 7th day of ICU stay. Higher homocysteine was observed in patients compared with control group (p < 0.05) where 31.5 and 26.8 percent of subjects presented hyperhomocysteinemia at initial and final of study, respectively. Antioxidant status was lower than control group in two periods analysed, and decreased at 7th day of ICU stay (p < 0.05) being associated with PLP deficiency. PLP deficiency was also correlated with hyperhomocysteinemia at two times measured (r. -0.73, p < 0.001; r. -0.69, p < 0.001, respectively), showing at day 7 an odds ratio of 6.62 in our multivariate model. Critically ill patients with SIRS show deficient B vitamin and low antioxidant statuses. Despite association found between PLP deficiency and low antioxidant status in critically ill patients, PLP deficiency was only associated with hyperhomocysteinemia regardless of antioxidant, riboflavin, cobalamine, and folate statuses in critically ill patients with SIRS at seventh day of ICU stay. PLP deficient patients presented about six times more risk of cardiovascular disease than non deficients. Copyright © 2015 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Pediatric neurocritical care.

PubMed

Murphy, Sarah

2012-01-01

Pediatric neurocritical care is an emerging multidisciplinary field of medicine and a new frontier in pediatric critical care and pediatric neurology. Central to pediatric neurocritical care is the goal of improving outcomes in critically ill pediatric patients with neurological illness or injury and limiting secondary brain injury through optimal critical care delivery and the support of brain function. There is a pressing need for evidence based guidelines in pediatric neurocritical care, notably in pediatric traumatic brain injury and pediatric stroke. These diseases have distinct clinical and pathophysiological features that distinguish them from their adult counterparts and prevent the direct translation of the adult experience to pediatric patients. Increased attention is also being paid to the broader application of neuromonitoring and neuroprotective strategies in the pediatric intensive care unit, in both primary neurological and primary non-neurological disease states. Although much can be learned from the adult experience, there are important differences in the critically ill pediatric population and in the circumstances that surround the emergence of neurocritical care in pediatrics.

Early Physical Rehabilitation in the ICU: A Review for the Neurohospitalist

PubMed Central

Mendez-Tellez, Pedro A.; Nusr, Rasha; Feldman, Dorianne; Needham, Dale M.

2012-01-01

Advances in critical care have resulted in improved intensive care unit (ICU) mortality. However, improved ICU survival has resulted in a growing number of ICU survivors living with long-term sequelae of critical illness, such as impaired physical function and quality of life (QOL). In addition to critical illness, prolonged bed rest and immobility may lead to severe physical deconditioning and loss of muscle mass and muscle weakness. ICU-acquired weakness is associated with increased duration of mechanical ventilation and weaning, longer ICU and hospital stay, and increased mortality. These physical impairments may last for years after ICU discharge. Early Physical Medicine and Rehabilitation (PM&R) interventions in the ICU may attenuate or prevent the weakness and physical impairments occurring during critical illness. This article reviews the evidence regarding safety, feasibility, barriers, and benefits of early PM&R interventions in ICU patients and discusses the limited existing data on early PM&R in the neurological ICU and future directions for early PM&R in the ICU. PMID:23983871

[The development of a portable life support device for transporting pre-hospital critically ill patients].

PubMed

Song, Zhen-xing; Wu, Tai-hu; Meng, Xing-ju; Lu, Heng-zhi; Zheng, Jie-wen; Wang, Hai-tao

2012-06-01

To describe a portable life support device for transportation of pre-hospital patients with critical illness. The characteristics and requirements for urgent management during transportation of critically ill patients to a hospital were analyzed. With adoption of the original equipment, with the aid of staple of the art soft ware, the overall structure, its installation, fixation, freedom from interference, operational function were studied, and the whole system of life support and resuscitation was designed. The system was composed by different modules, including mechanical ventilation, transfusion, aspiration, critical care, oxygen supply and power supply parts. The system could be fastened quickly to a stretcher to form portable intensive care unit (ICU), and it could be carried by different size vehicles to provide nonstop treatment by using power supply of the vehicle, thus raising the efficiency of urgent care. With characteristics of its small size, lightweight and portable, the device is particularly suitable for narrow space and extreme environment.

Ensuring relational competency in critical care: Importance of nursing students' communication skills.

PubMed

Sánchez Expósito, Judit; Leal Costa, César; Díaz Agea, José Luis; Carrillo Izquierdo, María Dolores; Jiménez Rodríguez, Diana

2018-02-01

The aim of this study was to analyse the communication skills of students in interactions with simulated critically-ill patients using a new assessment tool to study the relationships between communication skills, teamwork and clinical skills and to analyse the psychometric properties of the tool. A cross-sectional study was conducted to assess the communications skills of 52 students with critically-ill patients through the use of a new measurement tool to score video recordings of simulated clinical scenarios. The 52 students obtained low scores on their skills in communicating with patients. The reliability of the measuring instrument showed good inter-observer agreement (ICC between 0.71 and 0.90) and the validity yielded a positive correlation (p<0.01). The results provide evidence that nursing students lack skills when communicating with critically ill patients in simulated scenarios. The measuring instrument used is therefore deemed valid and reliable for assessing nursing students through a clinical simulation. Copyright © 2017 Elsevier Ltd. All rights reserved.

Sudden Advanced Illness: An Emerging Concept Among Palliative Care and Surgical Critical Care Physicians.

PubMed

Barnett, Michael D; Williams, Beverly R; Tucker, Rodney O

2016-05-01

End-of-life discussions in critically-ill patients with acute surgical conditions may be rushed and occur earlier during hospitalization. This study explores the concept of sudden advanced illness (SAI) and its relevance to patients requiring Palliative and Surgical Critical Care. Semi-structured interviews were completed with 16 physicians, querying each about (1) definitional components, (2) illustrative cases, and (3) comfort with SAI. Analysis was done by grounded theory. SAI was characterized as unforeseen, emerging abruptly and producing devastating injury, often in healthy, younger patients. There is (1) prognostic uncertainty, (2) loss of capacity, and (3) unprepared surrogate decision-making. Cases are emotionally-charged and often personal. The emerging concept of SAI is important for understanding how Palliative Care can enhance care for this subset of patients. © The Author(s) 2014.

Activity in the chronically critically ill.

PubMed

Winkelman, Chris; Higgins, Patricia A; Chen, Yea-Jyh Kathy

2005-01-01

Although therapeutic activity prevents functional decline and reduces mortality, little is known about typical levels of activity among intensive care unit (ICU) patients. This report of a preliminary study describes typical therapeutic activity and compares the use of two measures of activity in a small sample of chronically critically ill adults. Type, frequency, and duration of therapeutic activity were measured simultaneously with direct observation and actigraphy. The only consistent activity documented was turning (frequency: 3 turns/8 hours; duration: mean average of 11 minutes). Analysis demonstrated acceptable agreement between the two measures of activity for both frequency and duration of therapeutic but not for type of activity. Congruence between measures for duration of activity was also supported. This study provides information for investigators and practitioners who are interested in measuring or implementing therapeutic activity in selected critically ill adults.

Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: neurocritical patient.

PubMed

Acosta Escribano, J; Herrero Meseguer, I; Conejero García-Quijada, R

2011-11-01

Neurocritical patients require specialized nutritional support due to their intense catabolism and prolonged fasting. The preferred route of nutrient administration is the gastrointestinal route, especially the gastric route. Alternatives are the transpyloric route or mixed enteral-parenteral nutrition if an effective nutritional volume of more than 60% cannot be obtained. Total calorie intake ranges from 20-30 kcal/kg/day, depending on the period of the clinical course, with protein intake higher than 20% of total calories (hyperproteic diet). Nutritional support should be initiated early. The incidence of gastrointestinal complications is generally higher to other critically-ill patients, the most frequent complication being an increase in gastric residual volume. As in other critically-ill patients, glycemia should be closely monitored and maintained below 150 mg/dL.

The use of pre- and probiotics to improve food safety in the live animal

USDA-ARS?s Scientific Manuscript database

Too many foodborne illnesses happen around the world and are linked to the consumption of meat or contact with animals or their feces. Strategies to reduce these pathogen levels in food animals include the use of probiotics, prebiotics, and competitive exclusion cultures. These products all utiliz...

Critical Care

MedlinePlus

Critical care helps people with life-threatening injuries and illnesses. It might treat problems such as complications from surgery, ... attention by a team of specially-trained health care providers. Critical care usually takes place in an ...

Fluid overload in the ICU: evaluation and management.

PubMed

Claure-Del Granado, Rolando; Mehta, Ravindra L

2016-08-02

Fluid overload is frequently found in acute kidney injury patients in critical care units. Recent studies have shown the relationship of fluid overload with adverse outcomes; hence, manage and optimization of fluid balance becomes a central component of the management of critically ill patients. In critically ill patients, in order to restore cardiac output, systemic blood pressure and renal perfusion an adequate fluid resuscitation is essential. Achieving an appropriate level of volume management requires knowledge of the underlying pathophysiology, evaluation of volume status, and selection of appropriate solution for volume repletion, and maintenance and modulation of the tissue perfusion. Numerous recent studies have established a correlation between fluid overload and mortality in critically ill patients. Fluid overload recognition and assessment requires an accurate documentation of intakes and outputs; yet, there is a wide difference in how it is evaluated, reviewed and utilized. Accurate volume status evaluation is essential for appropriate therapy since errors of volume evaluation can result in either in lack of essential treatment or unnecessary fluid administration, and both scenarios are associated with increased mortality. There are several methods to evaluate fluid status; however, most of the tests currently used are fairly inaccurate. Diuretics, especially loop diuretics, remain a valid therapeutic alternative. Fluid overload refractory to medical therapy requires the application of extracorporeal therapies. In critically ill patients, fluid overload is related to increased mortality and also lead to several complications like pulmonary edema, cardiac failure, delayed wound healing, tissue breakdown, and impaired bowel function. Therefore, the evaluation of volume status is crucial in the early management of critically ill patients. Diuretics are frequently used as an initial therapy; however, due to their limited effectiveness the use of continuous renal replacement techniques are often required for fluid overload treatment. Successful fluid overload treatment depends on precise assessment of individual volume status, understanding the principles of fluid management with ultrafiltration, and clear treatment goals.

Developing a Research Agenda for Integrating Palliative Care into Critical Care and Pulmonary Practice To Improve Patient and Family Outcomes

PubMed Central

Reinke, Lynn F.; Cox, Christopher; Kross, Erin K.; Benzo, Roberto P.; Curtis, J. Randall

2017-01-01

Abstract Background: Palliative care is a medical specialty and philosophy of care that focuses on reducing suffering among patients with serious illness and their family members, regardless of disease diagnosis or prognosis. As critical illness or moderate to severe pulmonary disease confers significant disease-related symptom burdens, palliative care and palliative care specialists can aid in reducing symptom burden and improving quality of life among these patients and their family members. Objective: The objective of this article is to review the existing gaps in evidence for palliative care in pulmonary disease and critical illness and to use an interdisciplinary working group convened by the National Institutes of Health and the National Palliative Care Research Center to develop a research agenda to address these gaps. Methods: We completed a narrative review of the literature concerning the integration of palliative care into pulmonary and/or critical care. The review was based on recent systematic reviews on these topics as well as a summary of relevant articles identified through hand search. We used this review to identify gaps in current knowledge and develop a research agenda for the future. Results: We identified key areas of need and knowledge gaps that should be addressed to improve palliative care for patients with pulmonary and critical illness. These areas include developing and validating patient- and family-centered outcomes, identifying the key components of palliative care that are effective and cost-effective, developing and evaluating different models of palliative care delivery, and determining the effectiveness and cost-effectiveness of palliative care interventions. Conclusions: The goal of this research agenda is to encourage researchers, clinicians, healthcare systems, and research funders to identify research that can address these gaps and improve the lives of patients with pulmonary and critical illness and their family members. PMID:28379812

Sedation and Analgesia in Transportation of Acutely and Critically Ill Patients.

PubMed

Johnston, Dawn; Franklin, Kevin; Rigby, Paul; Bergman, Karen; Davidson, Scott B

2016-06-01

Transportation of acutely or critically ill patients is a challenge for health care providers. Among the difficulties that providers face is the balance between adequate sedation and analgesia for the transportation event and maintaining acceptable respiratory and physiologic parameters of the patient. This article describes common challenges in providing sedation and analgesia during various phases of transport. Copyright © 2016 Elsevier Inc. All rights reserved.

RBC Storage Effect on Coagulation, Microparticles and Microchimerism in Critically Ill Patients

DTIC Science & Technology

2014-01-01

Effect on Coagulation, Microparticles and Microchimerism in Critically Ill Patients.” PRINCIPAL INVESTIGATOR: Phillip Norris , MD CONTRACTING...NUMBER 6. AUTHOR(S) Philip J. Norris , MD 5d. PROJECT NUMBER Philip Spinella, MD 5e. TASK NUMBER Avani Shah, MPH 5f. WORK UNIT NUMBER 7...severity of multiple organ dysfunction syndrome , serious thrombotic events and nosocomial infections, and ICU and hospital length of stay

Immunologic alterations and the pathogenesis of organ failure in the ICU.

PubMed

Opal, Steven M

2011-10-01

Rapid and marked alterations of innate and adaptive immunity typify the host response to systemic infection and acute inflammatory states. Immune dysfunction contributes to the development of organ failure in most patients with critical illness. The molecular mechanisms by which microbial pathogens and tissue injury activate myeloid cells and prime cellular and humoral immunity are increasingly understood. An early and effective immune response to microbial invasion is essential to mount an effective antimicrobial response. However, unchecked and nonresolving inflammation can induce diffuse vasodilation, increased capillary permeability, microvascular damage, coagulation activation, and organ dysfunction. Control of the inflammatory response to limit tissue damage, yet retain the antimicrobial responses in critically ill patients with severe infection, has been sought for decades. Anti-inflammatory approaches might be beneficial in some patients but detrimental in others. It is now clear that a state of sepsis-induced immune suppression can follow the immune activation phase of sepsis. In carefully selected patients, a better therapeutic strategy might be to provide immunoadjuvants to reconstitute immune function in intensive care unit (ICU) patients. Proresolving agents are also in development to terminate acute inflammatory reactions without immune suppression. This brief review summarizes the current understanding of the fundamental immune alterations in critical illness that lead to organ failure in critical illness. © Thieme Medical Publishers.

Meal Disturbance Effect on Control of Blood Glucose Level for Critically-ill Patients using In-silico Works

NASA Astrophysics Data System (ADS)

Yusof, N. F. M.; Som, A. M.; Ali, S. A.; Azman, N. H.

2018-05-01

This study was conducted to determine the effect of meal disturbance on blood glucose level of the critically ill patients and to simulate the control algorithm previously developed using in-silico works. The study is significant so as to reduce the mortality rate of critically ill patients who usually encounter hyperglycaemia or/and hypoglycaemia while in treatment. The meal intake is believed to affect the blood glucose regulation and causes the hyperglycaemia to occur. Critically ill patients receive their meal through parenteral and enteral nutrition. Furthermore, by using in-silico works, time consumed and resources needed for clinical evaluation of the patients can be reduced. Hovorka model was employed in which the simulation study was carried out using MATLAB on the virtual patient and it was being compared with actual patient in which the data were provided by Institut Jantung Negara (IJN). Based on the simulation, the disturbance on enteral glucose supplied had affected the blood glucose level of the patient; however, it remained unchanged for the parental glucose. To reduce the occurrence of hypoglycaemia and hyperglycaemia, the patient was injected with 30 g/hr and 10 g/hr of enteral glucose, respectively. In conclusion, the disturbance of meal received can be controlled through in-silico works.

Microbial cell preparation in enteral feeding in critically ill patients: A randomized, double-blind, placebo-controlled clinical trial.

PubMed

Malik, Ausama A; Rajandram, Retnagowri; Tah, Pei Chien; Hakumat-Rai, Vineya-Rai; Chin, Kin-Fah

2016-04-01

Gut failure is a common condition in critically ill patients in the intensive care unit (ICU). Enteral feeding is usually the first line of choice for nutrition support in critically ill patients. However, enteral feeding has its own set of complications such as alterations in gut transit time and composition of gut eco-culture. The primary aim of this study was to investigate the effect of microbial cell preparation on the return of gut function, white blood cell count, C-reactive protein levels, number of days on mechanical ventilation, and length of stay in ICU. A consecutive cohort of 60 patients admitted to the ICU in University Malaya Medical Centre requiring enteral feeding were prospectively randomized to receive either treatment (n = 30) or placebo (n = 30). Patients receiving enteral feeding supplemented with a course of treatment achieved a faster return of gut function and required shorter duration of mechanical ventilation and shorter length of stay in the ICU. However, inflammatory markers did not show any significant change in the pretreatment and posttreatment groups. Overall, it can be concluded that microbial cell preparation enhances gut function and the overall clinical outcome of critically ill patients receiving enteral feeding in the ICU. Copyright © 2015 Elsevier Inc. All rights reserved.

Pharmacological interventions for stress ulcer prophylaxis in critically ill patients: a mixed treatment comparison network meta-analysis and a recursive cumulative meta-analysis.

PubMed

Sridharan, Kannan; Sivaramakrishnan, Gowri; Gnanaraj, Jerome

2018-02-01

Proton pump inhibitors (PPI), histamine-2 receptor antagonists (H2RA), sucralfate and antacids are the commonly administered agents for stress ulcer prophylaxis (SUP) in critically ill patients. The authors of this paper have conducted a network meta-analysis to compare the efficacy of these agents in SUP. Electronic databases were searched for randomized controlled trials, cohort studies and conference abstracts for studies comparing a SUP agent in critically ill patients to another active SUP agent or placebo. Overt, occult and clinically significant upper gastro-intestinal (UGI) bleeding, all-cause mortality, pneumonia, gastric colonization and ICU length of stay were considered as the outcome measures. A random effects model was used to generate pooled estimates. A total of 53 studies (4258 participants) were included. The pooled estimates were in favor of PPI and sucralfate for the overt UGI bleeding. PPI and H2RA bolus were associated with increased risk of gastric colonization and pneumonia. SUP in critically ill patients was not associated with any benefit with regard to clinically significant bleeding episodes. However, PPI and sucralfate significantly reduces overt UGI bleeding. On the contrary, PPI and H2RA bolus are associated with an increased risk of gastric colonization and pneumonia.

Surrogate decision makers' perspectives on preventable breakdowns in care among critically ill patients: A qualitative study.

PubMed

Fisher, Kimberly A; Ahmad, Sumera; Jackson, Madeline; Mazor, Kathleen M

2016-10-01

To describe surrogate decision makers' (SDMs) perspectives on preventable breakdowns in care among critically ill patients. We screened 70 SDMs of critically ill patients for those who identified a preventable breakdown in care, defined as an event where the SDM believes something "went wrong", that could have been prevented, and resulted in harm. In-depth interviews were conducted with SDMs who identified an eligible event. 32 of 70 participants (46%) identified at least one preventable breakdown in care, with a total of 75 discrete events. Types of breakdowns involved medical care (n=52), communication (n=59), and both (n=40). Four additional breakdowns were related to problems with SDM bedside access to the patient. Adverse consequences of breakdowns included physical harm, need for additional medical care, emotional distress, pain, suffering, loss of trust, life disruption, impaired decision making, and financial expense. 28 of 32 SDMs raised their concerns with clinicians, yet only 25% were satisfactorily addressed. SDMs of critically ill patients frequently identify preventable breakdowns in care which result in harm. An in-depth understanding of the types of events SDMs find problematic and the associated harms is an important step towards improving the safety and patient-centeredness of healthcare. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Personalized physiological medicine.

PubMed

Ince, Can

2017-12-28

This paper introduces the concept of personalized physiological medicine that is specifically directed at the needs of the critically ill patient. This differs from the conventional view of personalized medicine, characterized by biomarkers and gene profiling, instead focusing on time-variant changes in the pathophysiology and regulation of various organ systems and their cellular and subcellular constituents. I propose that personalized physiological medicine is composed of four pillars relevant to the critically ill patient. Pillar 1 is defined by the frailty and fitness of the patient and their physiological reserve to cope with the stress of critical illness and therapy. Pillar 2 involves monitoring of the key physiological variables of the different organ systems and their response to disease and therapy. Pillar 3 concerns the evaluation of the success of resuscitation by assessment of the hemodynamic coherence between the systemic and microcirculation and parenchyma of the organ systems. Finally, pillar 4 is defined by the integration of the physiological and clinical data into a time-learning adaptive model of the patient to provide feedback about the function of organ systems and to guide and assess the response to disease and therapy. I discuss each pillar and describe the challenges to research and development that will allow the realization of personalized physiological medicine to be practiced at the bedside for critically ill patients.

Population pharmacokinetics of phenytoin in critically ill children.

PubMed

Hennig, Stefanie; Norris, Ross; Tu, Quyen; van Breda, Karin; Riney, Kate; Foster, Kelly; Lister, Bruce; Charles, Bruce

2015-03-01

The objective was to study the population pharmacokinetics of bound and unbound phenytoin in critically ill children, including influences on the protein binding profile. A population pharmacokinetic approach was used to analyze paired protein-unbound and total phenytoin plasma concentrations (n = 146 each) from 32 critically ill children (0.08-17 years of age) who were admitted to a pediatric hospital, primarily intensive care unit. The pharmacokinetics of unbound and bound phenytoin and the influence of possible influential covariates were modeled and evaluated using visual predictive checks and bootstrapping. The pharmacokinetics of protein-unbound phenytoin was described satisfactorily by a 1-compartment model with first-order absorption in conjunction with a linear partition coefficient parameter to describe the binding of phenytoin to albumin. The partitioning coefficient describing protein binding and distribution to bound phenytoin was estimated to be 8.22. Nonlinear elimination of unbound phenytoin was not supported in this patient group. Weight, allometrically scaled for clearance and volume of distribution for the unbound and bound compartments, and albumin concentration significantly influenced the partition coefficient for protein binding of phenytoin. The population model can be applied to estimate the fraction of unbound phenytoin in critically ill children given an individual's albumin concentration. © 2014, The American College of Clinical Pharmacology.

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

Safety of intravenous lacosamide in critically ill children.

PubMed

Welsh, Sarah S; Lin, Nan; Topjian, Alexis A; Abend, Nicholas S

2017-11-01

Acute seizures are common in critically ill children. These patients would benefit from intravenous anti-seizure medications with few adverse effects. We reviewed the usage and effects of intravenous lacosamide in critically ill children with seizures or status epilepticus. This retrospective series included consecutive patients who received at least one dose of intravenous lacosamide from April 2011 to February 2016 in the pediatric intensive care unit of a quaternary care children's hospital, including patients with new lacosamide initiation and continuation of outpatient oral lacosamide. Dosing and prescribing practices were reviewed. Adverse effects were defined by predefined criteria, and most were evaluated during the full admission. We identified 51 intensive care unit admissions (47 unique patients) with intravenous lacosamide administration. Lacosamide was utilized as a third or fourth-line anti-seizure medication for acute seizures or status epilepticus in the lacosamide-naïve cohort. One patient experienced bradycardia and one patient experienced a rash that were considered potentially related to lacosamide. No other adverse effects were identified, including no evidence of PR interval prolongation. Lacosamide was well tolerated in critically ill children. Further study is warranted to evaluate the effectiveness of earlier lacosamide use for pediatric status epilepticus and acute seizures. Copyright © 2017 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

Persistent inflammation and recovery after intensive care: A systematic review.

PubMed

Griffith, David M; Vale, Matthew E; Campbell, Christine; Lewis, Steff; Walsh, Timothy S

2016-06-01

Physical weakness is common after critical illness; however, it is not clear how best to treat it. Inflammation characterizes critical illness, is associated with loss of muscle mass during critical illness, and potentially modifies post-intensive care unit (ICU) recovery. We sought to identify published reports on the prevalence of systemic inflammation after critical illness and its association with physical recovery. This is a systematic review of the literature from MEDLINE, EMBASE, CINAHL, CPCI-SSH, and CPCI-S from January 1982 to December 2011. From 7433 references, 207 full-text articles were reviewed, 57 were eligible, and 22 were included. Inflammation was present in most patients at ICU discharge according to C-reactive protein concentration (range, 70%-100%), procalcitonin (range, 89%-100%), tumor necrosis factor α (100%), and systemic inflammatory response syndrome criteria (range, 92%-95%). Fewer patients had elevated myeloperoxidase concentrations (range, 0%-56%). At hospital discharge, 9 (90%) of 10 chronic obstructive pulmonary disease patients had elevated C-reactive protein. No studies tested the association between inflammation and physical recovery. Inflammation is present in most patients at ICU discharge, but little is known or has been investigated about persistent inflammation after this time point. No studies have explored the relationship between persistent inflammation and physical recovery. Further research is proposed. Copyright © 2016 Elsevier Inc. All rights reserved.

Fiberoptic endoscopic evaluation of swallowing in intensive care unit patients

PubMed Central

Hafner, Gert; Neuhuber, Andreas; Hirtenfelder, Sylvia; Schmedler, Brigitte

2007-01-01

Aspiration in critically ill patients frequently causes severe co-morbidity. We evaluated a diagnostic protocol using routine FEES in critically ill patients at risk to develop aspiration following extubation. We instructed intensive care unit physicians on specific risk factors for and clinical signs of aspiration following extubation in critically ill patients and offered bedside FEES for such patients. Over a 45-month period, we were called to perform 913 endoscopic examinations in 553 patients. Silent aspiration or aspiration with acute symptoms (cough or gag reflex as the bolus passed into the trachea) was detected in 69.3% of all patients. Prolonged non-oral feeding via a naso-gastric tube was initiated in 49.7% of all patients. In 13.2% of patients, a percutaneous endoscopic gastrostomy was initiated as a result of FEES findings, and in 6.3% an additional tracheotomy to prevent aspiration had to be initiated. In 59 out of 258 patients (22.9%), tracheotomies were closed, and 30.7% of all 553 patients could be managed with the immediate onset of an oral diet and compensatory treatment procedures. Additional radiological examinations were not required. FEES in critically ill patients allows for a rapid evaluation of deglutition and for the immediate initiation of symptom-related rehabilitation or for an early resumption of oral feeding. PMID:17968575

A descriptive study of reportable gastrointestinal illnesses in Ontario, Canada, from 2007 to 2009.

PubMed

Vrbova, Linda; Johnson, Karen; Whitfield, Yvonne; Middleton, Dean

2012-11-12

Gastrointestinal illnesses (GI) continue to pose a substantial burden in terms of morbidity and economic impact in Canada. We describe the epidemiology of reportable GI in Ontario by characterizing the incidence of each reportable GI, as well as associated demographics, clinical outcomes, seasonality, risk settings, and likely sources of infection. Reports on laboratory confirmed cases of amebiasis, botulism, campylobacteriosis, cryptosporidiosis, cyclosporiasis, giardiasis, hepatitis A, listeriosis, paratyphoid fever, salmonellosis, shigellosis, typhoid fever, illness due to verotoxin-producing Escherichia coli (VTEC-illness), and yersiniosis, from January 1, 2007 to December 31, 2009 were obtained from Ontario's passive reportable disease surveillance system. Cases were classified by history of relevant travel, association with outbreaks, and likely source of infection, obtained through follow-up of reported cases by local health authorities. There were 29,897 GI reported by health authorities in Ontario from 2007 to 2009. The most frequently reported diseases were campylobacteriosis (10,916 cases or 36.5% of all GI illnesses) and salmonellosis (7,514 cases, 25.1%). Overall, 26.9% of GI cases reported travel outside of Ontario during the relevant incubation period. Children four years of age and younger had the highest incidence rate for most GI, and significantly more (54.8%, p<0.001) cases occurred among males than females. The most commonly reported sources of infections were food (54.2%), animals (19.8%), and contact with ill persons (16.9%). Private homes (45.5%) and food premises (29.7%) were the most commonly reported exposure settings. Domestic cases of campylobacteriosis, cryptosporidiosis, giardiasis, salmonellosis, and VTEC-illness showed seasonal patterns with incidence peaking in the summer months. Reportable GI continues to be a burden in Ontario. Since more than one in four GI cases experienced in Ontario were acquired outside of the province, international travel is an important risk factor for most GI. Because private homes are the most commonly reported risk settings and the main suspect sources of infection are food, animal contact and ill persons, these findings support the continued need for public health food safety programs, public education on safe handling of food and animals, and proper hand hygiene practices.

A descriptive study of reportable gastrointestinal illnesses in Ontario, Canada, from 2007 to 2009

PubMed Central

2012-01-01

Background Gastrointestinal illnesses (GI) continue to pose a substantial burden in terms of morbidity and economic impact in Canada. We describe the epidemiology of reportable GI in Ontario by characterizing the incidence of each reportable GI, as well as associated demographics, clinical outcomes, seasonality, risk settings, and likely sources of infection. Methods Reports on laboratory confirmed cases of amebiasis, botulism, campylobacteriosis, cryptosporidiosis, cyclosporiasis, giardiasis, hepatitis A, listeriosis, paratyphoid fever, salmonellosis, shigellosis, typhoid fever, illness due to verotoxin-producing Escherichia coli (VTEC-illness), and yersiniosis, from January 1, 2007 to December 31, 2009 were obtained from Ontario’s passive reportable disease surveillance system. Cases were classified by history of relevant travel, association with outbreaks, and likely source of infection, obtained through follow-up of reported cases by local health authorities. Results There were 29,897 GI reported by health authorities in Ontario from 2007 to 2009. The most frequently reported diseases were campylobacteriosis (10,916 cases or 36.5% of all GI illnesses) and salmonellosis (7,514 cases, 25.1%). Overall, 26.9% of GI cases reported travel outside of Ontario during the relevant incubation period. Children four years of age and younger had the highest incidence rate for most GI, and significantly more (54.8%, p<0.001) cases occurred among males than females. The most commonly reported sources of infections were food (54.2%), animals (19.8%), and contact with ill persons (16.9%). Private homes (45.5%) and food premises (29.7%) were the most commonly reported exposure settings. Domestic cases of campylobacteriosis, cryptosporidiosis, giardiasis, salmonellosis, and VTEC-illness showed seasonal patterns with incidence peaking in the summer months. Conclusions Reportable GI continues to be a burden in Ontario. Since more than one in four GI cases experienced in Ontario were acquired outside of the province, international travel is an important risk factor for most GI. Because private homes are the most commonly reported risk settings and the main suspect sources of infection are food, animal contact and ill persons, these findings support the continued need for public health food safety programs, public education on safe handling of food and animals, and proper hand hygiene practices. PMID:23145487

Enteral nutrition therapy for critically ill adult patients; critical review and algorithm creation.

PubMed

Araújo-Junqueira, L; De-Souza, Daurea A

2012-01-01

Undernutrition directly affects critically ill patient's clinical outcome and mortality rates. Interdisciplinar algorithm creation aiming to optimize the enteral nutrition therapy for critically ill adult patients. Pubmed, SciELO, Scholar Google, Web of Science, Scopus, with research of these key words: protocols, enteral nutrition, nutritional support, critical care, undernutrition, fasting. Intensive Care Unit, Hospital de Clínicas, Federal University of Uberlándia, MG, Brazil. Were established in the algorithm a following sequential steps: After a clinical-surgical diagnosis, including the assessment of hemodynamic stability, were requested passage of a feeding tube in post-pyloric position and a drainage tube in gastric position. After hemodynamic stability it should be done the nutritional status diagnosis, calculated nutritional requirements, as well as chosen formulation of enteral feeding. Unless contraindicated, aiming to increase tolerance was started infusion with small volumes (15 ml/h) of a semi-elemental diet, normocaloric, hypolipidic (also hyperproteic, with addition of glutamine). To ensure infusion of the diet, as well as the progressive increase of infusion rates, the patient was monitored for moderate or severe intestinal intolerance. The schedule and infusion rates were respected and diet was not routinely suspended for procedures and diagnostic tests, unless indicated by the medical team. For nutrition therapy success it is essential routine monitoring and extensive interaction between the professionals involved. Nutritional conducts should be reevaluated and improved, seeking complete and specialized care to the critically ill patients. Adherence to new practices is challenging, though instruments such as protocols and algorithms help making information more accessible and comprehensible.

An exploration of how film portrays psychopathology: the animated documentary film Waltz with Bashir, the depiction of PTSD and cultural perceptions.

PubMed

Hankir, Ahmed; Agius, Mark

2012-09-01

With the inauguration of the UK's first ever Medical Film festival MedFest in 2011 there has been resurgence in the interest of the association between psychiatry and film. The festival in 2012 was titled "HealthScreen": Understanding Illness through Film and its aim, according to the founder Dr Kamran Ahmed, was, 'To stimulate debate of the social, political and ethical implications of portrayals of health and illness on our screens' (1). Waltz with Bashir is a 2008 Israeli animated documentary film written and directed by Ari Folman. It portrays the protagonist (Folman) in search of his lost memories of his experience as a soldier in the 1982 Lebanon War and his attempt to both decipher them and reconcile himself with them. 2012 marks the 30th year commemoration of the Sabra and Shatilla tragedies. Waltz with Bashir vividly depicts the massacres of Palestinians in the Sabra and Shatilla refugee camps in Beirut through the lens of an ex-IDF serviceman and the harrowing effects that PTSD has on him. Waltz with Bashir was nominated for an Academy Award for Best Foreign Language Film however despite the popularity of the film and much critical acclaim it is officially banned in Lebanon. The authors are mindful of the devastating effects that the atrocities have had on the mental health of all those who were involved, the Lebanese, Palestinians and also the Israelis. The purpose of this presentation is to explore how the film Waltz with Bashir portrays PTSD and how it has influenced cultural perceptions.

Viral hemorrhagic fever in the tropics: Report from the task force on tropical diseases by the World Federation of Societies of Intensive and Critical Care Medicine.

PubMed

Hidalgo, Jorge; Richards, Guy A; Jiménez, Juan Ignacio Silesky; Baker, Tim; Amin, Pravin

2017-12-01

Viral hemorrhagic fevers (VHFs) are a group of illnesses caused by four families of viruses namely Arenaviruses, Filoviruses, Bunyaviruses, and Flaviviruses. Humans are not the natural reservoir for any of these organisms and acquire the disease through vectors from animal reservoirs. In some conditions human to human transmission is possible increasing the risk to healthy individuals in the vicinity, more so to Health Care Workers (HCW). The pathogenesis of VHF, though poorly understood, varies according to the viruses involved. The resultant microvascular damage leads to increased vascular permeability, organ dysfunction and even death. The management is generally supportive but antiviral agents are of benefit in certain circumstances. Copyright © 2017 Elsevier Inc. All rights reserved.

Shiga toxin-producing Escherichia coli in swine: the public health perspective

PubMed Central

Tseng, Marion; Fratamico, Pina M.; Manning, Shannon D.; Funk, Julie A.

2014-01-01

Shiga toxin-producing Escherichia coli (STEC) strains are food-borne pathogens that are an important public health concern. STEC infection is associated with severe clinical diseases in human beings, including hemorrhagic colitis (HC) and hemolytic uremic syndrome (HUS), which can lead to kidney failure and death. Cattle are the most important STEC reservoir. However, a number of STEC outbreaks and HUS cases have been attributed to pork products. In swine, STEC strains are known to be associated with edema disease. Nevertheless, the relationship between STEC of swine origin and human illness has yet to be determined. This review critically summarizes epidemiologic and biological studies of swine STEC. Several epidemiologic studies conducted in multiple regions of the world have demonstrated that domestic swine can carry and shed STEC. Moreover, animal studies have demonstrated that swine are susceptible to STEC O157:H7 infection and can shed the bacterium for 2 months. A limited number of molecular epidemiologic studies, however, have provided conflicting evidence regarding the relationship between swine STEC and human illness. The role that swine play in STEC transmission to people and the contribution to human disease frequency requires further evaluation. PMID:24397985

In vitro meat: A future animal-free harvest.

PubMed

Bhat, Zuhaib Fayaz; Kumar, Sunil; Bhat, Hina Fayaz

2017-03-04

In vitro meat production is a novel idea of producing meat without involving animals with the help of tissue engineering techniques. This biofabrication of complex living products by using various bioengineering techniques is a potential solution to reduce the ill effects of current meat production systems and can dramatically transform traditional animal-based agriculture by inventing "animal-free" meat and meat products. Nutrition-related diseases, food-borne illnesses, resource use and pollution, and use of farm animals are some serious consequences associated with conventional meat production methods. This new way of animal-free meat production may offer health and environmental advantages by reducing environmental pollution and resource use associated with current meat production systems and will also ensure sustainable production of designer, chemically safe, and disease-free meat as the conditions in an in vitro meat production system are controllable and manipulatable. Theoretically, this system is believed to be efficient enough to supply the global demand for meat; however, establishment of a sustainable in vitro meat production would face considerably greater technical challenges and a great deal of research is still needed to establish this animal-free meat culturing system on an industrial scale.

History of technology in the intensive care unit.

PubMed

Puri, Nitin; Puri, Vinod; Dellinger, R P

2009-01-01

Critical care medicine is a young specialty and since its inception has been heavily reliant upon technology. Invasive monitoring has its humble beginnings in the continuous monitoring of heart rate and rhythm. From the development of right heart catheterization to the adaption of the echocardiogram for use in shock, intensivists have used technology to monitor hemodynamics. The care of the critically ill has been buoyed by investigators who sought to offer renal replacement therapy to unstable patients and worked to improve the monitoring of oxygen saturation. The evolution of mechanical ventilation for the critically ill embodies innumerable technological advances. More recently, critical care has insisted upon rigorous testing and cost-benefit analysis of technological advances.

Ethical and methodological issues in qualitative studies involving people with severe and persistent mental illness such as schizophrenia and other psychotic conditions: a critical review.

PubMed

Carlsson, Ing-Marie; Blomqvist, Marjut; Jormfeldt, Henrika

2017-01-01

Undertaking research studies in the field of mental health is essential in mental health nursing. Qualitative research methodologies enable human experiences to become visible and recognize the importance of lived experiences. This paper argues that involving people with schizophrenia in research is critical to promote their health and well-being. The quality of qualitative research needs scrutinizing according to methodological issues such as trustworthiness and ethical standards that are a fundamental part of qualitative research and nursing curricula. The aim of this study was to critically review recent qualitative studies involving people with severe and persistent mental illness such as schizophrenia and other psychotic conditions, regarding descriptions of ethical and methodological issues in data collection and analysis. A search for relevant papers was conducted in three electronic databases, in December 2016. Fifteen qualitative interview studies were included and reviewed regarding methodological issues related to ethics, and data collection and analysis. The results revealed insufficient descriptions of methodology regarding ethical considerations and issues related to recruitment and sampling in qualitative interview studies with individuals with severe mental illness, putting trustworthiness at risk despite detailed descriptions of data analysis. Knowledge from the perspective of individuals with their own experience of mental illness is essential. Issues regarding sampling and trustworthiness in qualitative studies involving people with severe mental illness are vital to counteract the stigmatization of mental illness.

Ethical and methodological issues in qualitative studies involving people with severe and persistent mental illness such as schizophrenia and other psychotic conditions: a critical review

PubMed Central

Carlsson, Ing-Marie; Blomqvist, Marjut; Jormfeldt, Henrika

2017-01-01

ABSTRACT Undertaking research studies in the field of mental health is essential in mental health nursing. Qualitative research methodologies enable human experiences to become visible and recognize the importance of lived experiences. This paper argues that involving people with schizophrenia in research is critical to promote their health and well-being. The quality of qualitative research needs scrutinizing according to methodological issues such as trustworthiness and ethical standards that are a fundamental part of qualitative research and nursing curricula. The aim of this study was to critically review recent qualitative studies involving people with severe and persistent mental illness such as schizophrenia and other psychotic conditions, regarding descriptions of ethical and methodological issues in data collection and analysis. A search for relevant papers was conducted in three electronic databases, in December 2016. Fifteen qualitative interview studies were included and reviewed regarding methodological issues related to ethics, and data collection and analysis. The results revealed insufficient descriptions of methodology regarding ethical considerations and issues related to recruitment and sampling in qualitative interview studies with individuals with severe mental illness, putting trustworthiness at risk despite detailed descriptions of data analysis. Knowledge from the perspective of individuals with their own experience of mental illness is essential. Issues regarding sampling and trustworthiness in qualitative studies involving people with severe mental illness are vital to counteract the stigmatization of mental illness. PMID:28901217

Postmortem Brain: An Underutilized Substrate for Studying Severe Mental Illness

PubMed Central

McCullumsmith, Robert E; Hammond, John H; Shan, Dan; Meador-Woodruff, James H

2014-01-01

We propose that postmortem tissue is an underutilized substrate that may be used to translate genetic and/or preclinical studies, particularly for neuropsychiatric illnesses with complex etiologies. Postmortem brain tissues from subjects with schizophrenia have been extensively studied, and thus serve as a useful vehicle for illustrating the challenges associated with this biological substrate. Schizophrenia is likely caused by a combination of genetic risk and environmental factors that combine to create a disease phenotype that is typically not apparent until late adolescence. The complexity of this illness creates challenges for hypothesis testing aimed at understanding the pathophysiology of the illness, as postmortem brain tissues collected from individuals with schizophrenia reflect neuroplastic changes from a lifetime of severe mental illness, as well as treatment with antipsychotic medications. While there are significant challenges with studying postmortem brain, such as the postmortem interval, it confers a translational element that is difficult to recapitulate in animal models. On the other hand, data derived from animal models typically provide specific mechanistic and behavioral measures that cannot be generated using human subjects. Convergence of these two approaches has led to important insights for understanding molecular deficits and their causes in this illness. In this review, we discuss the problem of schizophrenia, review the common challenges related to postmortem studies, discuss the application of biochemical approaches to this substrate, and present examples of postmortem schizophrenia studies that illustrate the role of the postmortem approach for generating important new leads for understanding the pathophysiology of severe mental illness. PMID:24091486

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

Development of an animal model of nephrocalcinosis via selective dietary sodium and chloride depletion

PubMed Central

Tuchman, Shamir; Asico, Laureano D.; Escano, Crisanto; Bobb, Daniel A.; Ray, Patricio E.

2013-01-01

Background Nephrocalcinosis (NC) is an important clinical problem seen in critically ill pre-term neonates treated with loop diuretics. No reliable animal models are available to study the pathogenesis of NC in preterm infants. The purpose of this study was to develop a reproducible and clinically relevant animal model of NC for these patients, and to explore the impact of extracellular fluid (ECF) volume contraction induced by sodium and chloride depletion in this process. Methods Three-week old weanling Sprague-Dawley rats were fed diets deficient in either chloride or sodium and chloride. A sub-group of rats from each dietary group was injected daily with furosemide (40 mg/kg; i.p.). Results Rats fed a control diet, with or without furosemide, or a chloride depleted diet alone, did not develop NC. In contrast, 50% of the rats injected with furosemide and fed the chloride depleted diet developed NC. Moreover, 94% of the rats fed the combined sodium/chloride depleted diet developed NC, independently of furosemide use. NC was associated with the development of severe ECF volume contraction, hypochloremic, hypokalemic metabolic alkalosis, increased phosphaturia, and growth retardation. Conclusion Severe ECF volume contraction induced by chronic sodium and chloride depletion appears to play an important role in the pathogenesis of NC. PMID:23174703

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

PubMed

Frantzeskaki, Frantzeska; Diakaki, Chryssi; Rizos, Michalis; Theodorakopoulou, Maria; Papadopoulos, Panagiotis; Antonopoulou, Anastasia; Nikitas, Nikitas; Lignos, Michail; Brountzos, Elias; Velegraki, Aristea; Paramythiotou, Elisabeth; Panagyotides, John; Armaganidis, Apostolos; Dimopoulos, George

2014-07-15

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. We describe the case of a 28-year-old Greek man with yeast central nervous system infection. 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.

Arteriovenous carboxyhemoglobin difference in critical illness: fiction or fact?

PubMed

Westphal, Martin; Eletr, Dina; Bone, Hans Georg; Ertmer, Christian; Weber, Thomas Peter; Aken, Hugo Van; Booke, Michael

2002-12-06

It is still unclear whether the paradoxical arteriovenous carboxyhemoglobin (COHb) difference found in critical illness is due to increased COHb production by the lung, or whether this gradient is caused by technical artifacts using spectrophotometry. In healthy and matched endotoxemic sheep, blood gases were analyzed with a standard ABL 625 and the updated version, an ABL 725. The latter one was accurately calibrated for COHb wavelengths (SAT 100) to eliminate the FCOHb dependency on oxygen tension. All endotoxemic sheep exhibited a hypotensive-hyperdynamic circulation and a pulmonary hypertension. Interestingly, arteriovenous COHb difference occurred in both healthy and endotoxemic sheep (P<0.001 each). Arterial and central venous COHb concentrations determined with the ABL 625 were significantly lower than those measured with the ABL 725 (P<0.001 each). We conclude that (a) arteriovenous COHb difference per se does not reflect critical illness and (b) measurements with an ABL 625 underestimate COHb concentrations.

Profound metabolic acidosis and oxoprolinuria in an adult.

PubMed

Hodgman, Michael J; Horn, James F; Stork, Christine M; Marraffa, Jeanna M; Holland, Michael G; Cantor, Richard; Carmel, Patti M

2007-09-01

Profound metabolic acidosis in critically ill adults sometimes remains unexplained despite extensive evaluation. A 58-year-old female presented in a confused state to the emergency department; she had been confused for several days. Laboratory evaluation revealed a high anion gap metabolic acidosis and modestly elevated acetaminophen level. Lactic acid was only modestly elevated. There was no evidence of ketoacids, salicylate, methanol, or ethylene glycol. A urine sample submitted on day 1 of hospitalization revealed a markedly elevated level of 5-oxoproline. Originally described in children with an inherited defect of glutathione synthetase, 5-oxoproline is an unusual cause of metabolic acidosis. More recently this disturbance has been recognized in critically ill adults without a recognized inherited metabolic disorder. In most of these cases there has been the concomitant use of acetaminophen. Any causal relationship between acetaminophen and this disturbance is speculative. In critically ill adults with unexplained metabolic acidosis, 5-Oxoproline should be considered in the differential.

Hypophosphatemia in critically ill patients.

PubMed

Suzuki, Satoshi; Egi, Moritoki; Schneider, Antoine G; Bellomo, Rinaldo; Hart, Graeme K; Hegarty, Colin

2013-08-01

The aim of this study was to assess the association of phosphate concentration with key clinical outcomes in a heterogeneous cohort of critically ill patients. This was a retrospective observational study at a general intensive care unit (ICU) of an Australian university teaching hospital enrolling 2730 adult critically ill patients. We studied 10504 phosphate measurements with a mean value of 1.17 mmol/L (measurements every 28.8 hours on average). Hyperphosphatemia (inorganic phosphate [iP] concentration > 1.4 mmol/L) occurred in 45% and hypophosphatemia (iP ≤ 0.6 mmol/L) in 20%. Among patients without any episodes of hyperphosphatemia, patients with at least 1 episode of hypophosphatemia had a higher ICU mortality than those without hypophosphatemia (P = .004). In addition, ICU nonsurvivors had lower minimum phosphate concentrations than did survivors (P = .009). Similar results were seen for hospital mortality. However, on multivariable logistic regression analysis, hypophosphatemia was not independently associated with ICU mortality (adjusted odds ratio, 0.86 [95% confidence interval, 0.66-1.10]; P = .24) and hospital mortality (odds ratio, 0.89 [0.73-1.07]; P = .21). Even when different cutoff points were used for hypophosphatemia (iP ≤ 0.5, 0.4, 0.3, or 0.2 mmol/L), hypophosphatemia was not an independent risk factor for ICU and hospital morality. In addition, timing of onset and duration of hypophosphatemia were not independent risk factor for ICU and hospital mortality. Hypophosphatemia behaves like a general marker of illness severity and not as an independent predictor of ICU or in-hospital mortality in critically ill patients. Copyright © 2013 Elsevier Inc. All rights reserved.

Quantitative Microbial Risk Assessment of Freshwater Impacted by Animal Fecal Material

EPA Science Inventory

We evaluated the potential for human illness from a hypothetical recreational exposure to freshwater impacted by land-applied, agricultural animal fecal material. The hypothetical exposure scenario included the following characteristics: 1) fresh cattle manure, pig slurry, or ch...

CE: critical care recovery center: an innovative collaborative care model for ICU survivors.

PubMed

Khan, Babar A; Lasiter, Sue; Boustani, Malaz A

2015-03-01

Five million Americans require admission to ICUs annually owing to life-threatening illnesses. Recent medical advances have resulted in higher survival rates for critically ill patients, who often have significant cognitive, physical, and psychological sequelae, known as postintensive care syndrome (PICS). This growing population threatens to overwhelm the current U.S. health care system, which lacks established clinical models for managing their care. Novel innovative models are urgently needed. To this end, the pulmonary/critical care and geriatrics divisions at the Indiana University School of Medicine joined forces to develop and implement a collaborative care model, the Critical Care Recovery Center (CCRC). Its mission is to maximize the cognitive, physical, and psychological recovery of ICU survivors. Developed around the principles of implementation and complexity science, the CCRC opened in 2011 as a clinical center with a secondary research focus. Care is provided through a pre-CCRC patient and caregiver needs assessment, an initial diagnostic workup visit, and a follow-up visit that includes a family conference. With its sole focus on the prevention and treatment of PICS, the CCRC represents an innovative prototype aimed at modifying post-critical illness morbidities and improving the ICU survivor's quality of life.

Animal-Based Remedies as Complementary Medicines in the Semi-Arid Region of Northeastern Brazil

PubMed Central

Alves, Rômulo R. N.; Barbosa, José A. A.; Santos, Silene L. D. X.; Souto, Wedson M. S.; Barboza, Raynner R. D.

2011-01-01

Animals (and their derived products) are essential ingredients in the preparation of many traditional remedies. Despite its prevalence in traditional medical practices worldwide, research on medicinal animals has often been neglected in comparison to medicinal plant research. This work documents the medicinal animals used by a rural community in the semi-arid region, inserted in Caatinga Biome, where 66 respondents provided information on animal species used as medicine, body parts used to prepare the remedies and illnesses to which the remedies were prescribed. We calculated the informant consensus factor to determine the consensus over which species are effective for particular ailments, as well as the species use value to determine the extent of utilization of each species. We recorded the use of 51 animal species as medicines, whose products were recommended for the treatment of 68 illnesses. The informant consensus in the use of many specific remedies is fairly high, giving an additional validity to this folk medicine. Eight species not previously reported as having medicinal use were recorded. The local medicinal fauna is largely based on wild animals, including some endangered species. Given a high proportion of medicinal animals observed in the study area, it is logical to conclude that any conservation strategy should include access to modern health care. PMID:19729490

Effectiveness of haloperidol prophylaxis in critically ill patients with a high risk of delirium: a systematic review.

PubMed

Santos, Eduardo; Cardoso, Daniela; Neves, Hugo; Cunha, Madalena; Rodrigues, Manuel; Apóstolo, João

2017-05-01

Delirium is associated with increased intensive care unit and hospital length of stay, prolonged duration of mechanical ventilation, unplanned removal of tubes and catheters, and increased morbidity and mortality. Prophylactic treatment with low-dose haloperidol may have beneficial effects for critically ill patients with a high risk of delirium. To identify the effectiveness of haloperidol prophylaxis in critically ill patients with a high risk for delirium. Patients with a predicted high risk of delirium, aged 18 years or over, and in intensive care units. Patients with a history of concurrent antipsychotic medication use were excluded. Haloperidol prophylaxis for preventing delirium. Experimental and epidemiological study designs. Primary outcome is the incidence of delirium. Secondary outcomes are duration of mechanical ventilation, incidence of re-intubation, incidence of unplanned/accidental removal of tubes/lines and catheters, intensive care unit and hospital length of stay, and re-admissions to both settings. An initial search of MEDLINE and CINAHL was undertaken, followed by a second search for published and unpublished studies from January 1967 to September 2015 in major healthcare-related electronic databases. Studies in English, Spanish and Portuguese were included. Two independent reviewers assessed the methodological quality of five studies using the standardized critical appraisal instrument from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. There was general agreement among the reviewers to exclude one relevant study due to methodological quality. Data were extracted using the JBI data extraction form for experimental studies and included details about the interventions, populations, study methods and outcomes of significance to the review questions. Significant differences were found between participants, interventions, outcome measures (clinical heterogeneity) and designs (methodological heterogeneity). For these reasons, we were unable to perform a meta-analysis. Therefore, the results have been described in a narrative format. Five studies met the inclusion criteria. One of these studies was excluded due to poor methodological quality. The remaining four original studies (total of 1142 patients) were included in this review. Three studies were randomized controlled trials and one was a cohort study.Two studies confirmed the effectiveness of haloperidol prophylaxis in critically ill patients with a high risk of delirium. These studies showed that short-term prophylactic administration of low-dose intravenous haloperidol significantly decreased the incidence of delirium in elderly patients admitted to intensive care units after non-cardiac surgery and in general intensive care unit patients with a high risk of delirium.However, the two remaining studies showed contradictory results in mechanically ventilated critically ill adults, revealing that the administration of haloperidol reduced delirium prevalence, delayed its occurrence, and/or shorten its duration. The evidence related to the effectiveness of haloperidol prophylaxis in critically ill patients with a high risk of delirium is contradictory. However, balancing the benefits and low side effects associated with haloperidol prophylaxis, this preventive intervention may be useful to reduce the incidence of delirium in critically ill adults in intensive care units.

Reinforcement Learning Using a Continuous Time Actor-Critic Framework with Spiking Neurons

PubMed Central

Frémaux, Nicolas; Sprekeler, Henning; Gerstner, Wulfram

2013-01-01

Animals repeat rewarded behaviors, but the physiological basis of reward-based learning has only been partially elucidated. On one hand, experimental evidence shows that the neuromodulator dopamine carries information about rewards and affects synaptic plasticity. On the other hand, the theory of reinforcement learning provides a framework for reward-based learning. Recent models of reward-modulated spike-timing-dependent plasticity have made first steps towards bridging the gap between the two approaches, but faced two problems. First, reinforcement learning is typically formulated in a discrete framework, ill-adapted to the description of natural situations. Second, biologically plausible models of reward-modulated spike-timing-dependent plasticity require precise calculation of the reward prediction error, yet it remains to be shown how this can be computed by neurons. Here we propose a solution to these problems by extending the continuous temporal difference (TD) learning of Doya (2000) to the case of spiking neurons in an actor-critic network operating in continuous time, and with continuous state and action representations. In our model, the critic learns to predict expected future rewards in real time. Its activity, together with actual rewards, conditions the delivery of a neuromodulatory TD signal to itself and to the actor, which is responsible for action choice. In simulations, we show that such an architecture can solve a Morris water-maze-like navigation task, in a number of trials consistent with reported animal performance. We also use our model to solve the acrobot and the cartpole problems, two complex motor control tasks. Our model provides a plausible way of computing reward prediction error in the brain. Moreover, the analytically derived learning rule is consistent with experimental evidence for dopamine-modulated spike-timing-dependent plasticity. PMID:23592970

Reinforcement learning using a continuous time actor-critic framework with spiking neurons.

PubMed

Frémaux, Nicolas; Sprekeler, Henning; Gerstner, Wulfram

2013-04-01

Animals repeat rewarded behaviors, but the physiological basis of reward-based learning has only been partially elucidated. On one hand, experimental evidence shows that the neuromodulator dopamine carries information about rewards and affects synaptic plasticity. On the other hand, the theory of reinforcement learning provides a framework for reward-based learning. Recent models of reward-modulated spike-timing-dependent plasticity have made first steps towards bridging the gap between the two approaches, but faced two problems. First, reinforcement learning is typically formulated in a discrete framework, ill-adapted to the description of natural situations. Second, biologically plausible models of reward-modulated spike-timing-dependent plasticity require precise calculation of the reward prediction error, yet it remains to be shown how this can be computed by neurons. Here we propose a solution to these problems by extending the continuous temporal difference (TD) learning of Doya (2000) to the case of spiking neurons in an actor-critic network operating in continuous time, and with continuous state and action representations. In our model, the critic learns to predict expected future rewards in real time. Its activity, together with actual rewards, conditions the delivery of a neuromodulatory TD signal to itself and to the actor, which is responsible for action choice. In simulations, we show that such an architecture can solve a Morris water-maze-like navigation task, in a number of trials consistent with reported animal performance. We also use our model to solve the acrobot and the cartpole problems, two complex motor control tasks. Our model provides a plausible way of computing reward prediction error in the brain. Moreover, the analytically derived learning rule is consistent with experimental evidence for dopamine-modulated spike-timing-dependent plasticity.

GLUCOCORTICOID TREATMENT—EFFECT ON ADRENAL MEDULLARY CATECHOLAMINE PRODUCTION

PubMed Central

Sharara-Chami, Rana I.; Joachim, Maria; Pacak, Karel; Majzoub, Joseph A.

2016-01-01

Glucocorticoid and epinephrine are important stress hormones secreted from the adrenal gland during critical illness. Adrenal glucocorticoid stimulates phenylethanolamine N-methyltransferase (PNMT) to convert norepinephrine to epinephrine in the adrenal medulla. Glucocorticoid is sometimes used in catecholamine-resistant septic shock in critically ill patients. By suppressing adrenal glucocorticoid production, glucocorticoid therapy might also reduce the secretion of epinephrine during stress. To investigate this, we used a mouse model subjected to glucocorticoid therapy under basal conditions (experiment 1) and during stress (experiment 2). In experiment 1, pellets containing 0% to 8% dexamethasone were implanted subcutaneously in mice for 4 weeks. In experiment 2, animals received 14 days of intraperitoneal injections of normal saline, low- or high-dose dexamethasone, followed by 2 h of restraint. We found that in experiment 1, adrenal corticosterone did not differ with dexamethasone treatment. Phenylethanolamine N-methyltransferase messenger RNA levels and adrenal catecholamines were highest in the 8% dexamethasone group. Compared with experiment 1, restrained control mice in experiment 2 had high adrenal corticosterone, which decreased with dexamethasone. Phenylethanolamine N-methyltransferase messenger RNA content doubled with restraint but decreased with dexamethasone treatment. As in experiment 1, adrenal catecholamine content increased significantly with dexamethasone treatment. We conclude that without stress, when adrenocorticotropic hormone is low, high doses of exogenous dexamethasone stimulate PNMT and catecholamine synthesis, likely independently of adrenal corticosterone concentration. After stress, adrenocorticotropic hormone levels are elevated, and exogenous dexamethasone suppresses endogenous corticosterone and PNMT production. Nonetheless, catecholamines increase, possibly due to direct neural stimulation, which may override the hormonal regulation of epinephrine synthesis during stress. PMID:19503019

Current clinical nutrition practices in critically ill patients in Latin America: a multinational observational study.

PubMed

Vallejo, Karin Papapietro; Martínez, Carolina Méndez; Matos Adames, Alfredo A; Fuchs-Tarlovsky, Vanessa; Nogales, Guillermo Carlos Contreras; Paz, Roger Enrique Riofrio; Perman, Mario Ignacio; Correia, Maria Isabel Toulson Davisson; Waitzberg, Dan Linetzky

2017-08-25

Malnutrition in critically ill adults in the intensive care unit (ICU) is associated with a significantly elevated risk of mortality. Adequate nutrition therapy is crucial to optimise outcomes. Currently, there is a paucity of such data in Latin America. Our aims were to characterise current clinical nutrition practices in the ICU setting in Latin America and evaluate whether current practices meet caloric and protein requirements in critically ill patients receiving nutrition therapy. We conducted a cross-sectional, retrospective, observational study in eight Latin American countries (Argentina, Brazil, Chile, Colombia, Ecuador, Mexico, Panama, and Peru). Eligible patients were critically ill adults hospitalised in the ICU and receiving enteral nutrition (EN) and/or parenteral nutrition (PN) on the Screening Day and the previous day (day -1). Caloric and protein balance on day -1, nutritional status, and prescribed nutrition therapy were recorded. Multivariable logistic regression analysis was performed to identify independent predictors of reaching daily caloric and protein targets. The analysis included 1053 patients from 116 hospitals. Evaluation of nutritional status showed that 74.1% of patients had suspected/moderate or severe malnutrition according to the Subjective Global Assessment. Prescribed nutrition therapy included EN alone (79.9%), PN alone (9.4%), and EN + PN (10.7%). Caloric intake met >90% of the daily target in 59.7% of patients on day -1; a caloric deficit was present in 40.3%, with a mean (±SD) daily caloric deficit of -688.8 ± 455.2 kcal. Multivariable logistic regression analysis showed that combined administration of EN + PN was associated with a statistically significant increase in the probability of meeting >90% of daily caloric and protein targets compared with EN alone (odds ratio, 1.56; 95% confidence interval, 1.02-2.39; p = 0.038). In the ICU setting in Latin America, malnutrition was highly prevalent and caloric intake failed to meet targeted energy delivery in 40% of critically ill adults receiving nutrition therapy. Supplemental administration of PN was associated with improved energy and protein delivery; however, PN use was low. Collectively, these findings suggest an opportunity for more effective utilisation of supplemental PN in critically ill adults who fail to receive adequate nutrition from EN alone.

Inactivation of F.tularensis Utah-112 on food and food contact surfaces by ultraviolet light

USDA-ARS?s Scientific Manuscript database

Francisella tularensis is the causative agent of tularemia, a plague-like illness that affects animals and humans, and has caused large illness pandemics in the last century. It has also been used as a biological warfare agent, and tularemia can be contracted through consumption of contaminated food...

An introduction to on-farm strategies to control foodborne pathogens

USDA-ARS?s Scientific Manuscript database

Foodborne illnesses affect more than 48 million Americans each year. The economic impact of these foodborne illnesses caused by bacteria associated with food animals ranges from $10 to 40 billion (USD) per year, and effects across the EU are similar in scale. Because of the large drain on the GDP,...

Accuracy of subcutaneous continuous glucose monitoring in critically ill adults: improved sensor performance with enhanced calibrations.

PubMed

Leelarathna, Lalantha; English, Shane W; Thabit, Hood; Caldwell, Karen; Allen, Janet M; Kumareswaran, Kavita; Wilinska, Malgorzata E; Nodale, Marianna; Haidar, Ahmad; Evans, Mark L; Burnstein, Rowan; Hovorka, Roman

2014-02-01

Accurate real-time continuous glucose measurements may improve glucose control in the critical care unit. We evaluated the accuracy of the FreeStyle(®) Navigator(®) (Abbott Diabetes Care, Alameda, CA) subcutaneous continuous glucose monitoring (CGM) device in critically ill adults using two methods of calibration. In a randomized trial, paired CGM and reference glucose (hourly arterial blood glucose [ABG]) were collected over a 48-h period from 24 adults with critical illness (mean±SD age, 60±14 years; mean±SD body mass index, 29.6±9.3 kg/m(2); mean±SD Acute Physiology and Chronic Health Evaluation score, 12±4 [range, 6-19]) and hyperglycemia. In 12 subjects, the CGM device was calibrated at variable intervals of 1-6 h using ABG. In the other 12 subjects, the sensor was calibrated according to the manufacturer's instructions (1, 2, 10, and 24 h) using arterial blood and the built-in point-of-care glucometer. In total, 1,060 CGM-ABG pairs were analyzed over the glucose range from 4.3 to 18.8 mmol/L. Using enhanced calibration median (interquartile range) every 169 (122-213) min, the absolute relative deviation was lower (7.0% [3.5, 13.0] vs. 12.8% [6.3, 21.8], P<0.001), and the percentage of points in the Clarke error grid Zone A was higher (87.8% vs. 70.2%). Accuracy of the Navigator CGM device during critical illness was comparable to that observed in non-critical care settings. Further significant improvements in accuracy may be obtained by frequent calibrations with ABG measurements.

Prognostic value of severity by various visceral proteins in critically ill patients with SIRS during 7 days of stay.

PubMed

Bouharras-El Idrissi, Hicham; Molina-López, Jorge; Herrera-Quintana, Lourdes; Domínguez-García, Álvaro; Lobo-Támer, Gabriela; Pérez-Moreno, Irene; Pérez-de la Cruz, Antonio; Planells-Del Pozo, Elena

2016-11-29

Critically ill patients typically develop a catabolic stress state as a result of a systemic inflammatory response (SIRS) that alters clinical-nutritional biomarkers, increasing energy demands and nutritional requirements. To evaluate the status of albumin, prealbumin and transferrin in critically ill patients and the association between these clinical-nutritional parameters with the severity during a seven day stay in intensive care unit (ICU). Multicenter, prospective, observational and analytical follow-up study. A total of 115 subjects in critical condition were included in this study. Clinical and nutritional parameters and severity were monitored at admission and at the seventh day of the ICU stay. A significant decrease in APACHE II and SOFA (p < 0.05) throughout the evolution of critically ill patients in ICU. In general, patients showed an alteration of most of the parameters analyzed. The status of albumin, prealbumin and transferrin were below reference levels both at admission and the 7th day in ICU. A high percentage of patients presented an unbalanced status of albumin (71.3%), prealbumin (84.3%) and transferrin (69.0%). At admission, 27% to 47% of patients with altered protein parameters had APACHE II above 18. The number of patients with altered protein parameters and APACHE II below 18 were significantly higher than severe ones throughout the ICU stay (p < 0.01). Regarding the multivariate analysis, low prealbumin status was the best predictor of severity critical (p < 0.05) both at admission and 7th day of the ICU stay. The results of the present study support the idea of including low prealbumin status as a severity predictor in APACHE II scale, due to the association found between severity and poor status of prealbumin.

Accuracy of Subcutaneous Continuous Glucose Monitoring in Critically Ill Adults: Improved Sensor Performance with Enhanced Calibrations

PubMed Central

Leelarathna, Lalantha; English, Shane W.; Thabit, Hood; Caldwell, Karen; Allen, Janet M.; Kumareswaran, Kavita; Wilinska, Malgorzata E.; Nodale, Marianna; Haidar, Ahmad; Evans, Mark L.; Burnstein, Rowan

2014-01-01

Abstract Objective: Accurate real-time continuous glucose measurements may improve glucose control in the critical care unit. We evaluated the accuracy of the FreeStyle® Navigator® (Abbott Diabetes Care, Alameda, CA) subcutaneous continuous glucose monitoring (CGM) device in critically ill adults using two methods of calibration. Subjects and Methods: In a randomized trial, paired CGM and reference glucose (hourly arterial blood glucose [ABG]) were collected over a 48-h period from 24 adults with critical illness (mean±SD age, 60±14 years; mean±SD body mass index, 29.6±9.3 kg/m2; mean±SD Acute Physiology and Chronic Health Evaluation score, 12±4 [range, 6–19]) and hyperglycemia. In 12 subjects, the CGM device was calibrated at variable intervals of 1–6 h using ABG. In the other 12 subjects, the sensor was calibrated according to the manufacturer's instructions (1, 2, 10, and 24 h) using arterial blood and the built-in point-of-care glucometer. Results: In total, 1,060 CGM–ABG pairs were analyzed over the glucose range from 4.3 to 18.8 mmol/L. Using enhanced calibration median (interquartile range) every 169 (122–213) min, the absolute relative deviation was lower (7.0% [3.5, 13.0] vs. 12.8% [6.3, 21.8], P<0.001), and the percentage of points in the Clarke error grid Zone A was higher (87.8% vs. 70.2%). Conclusions: Accuracy of the Navigator CGM device during critical illness was comparable to that observed in non–critical care settings. Further significant improvements in accuracy may be obtained by frequent calibrations with ABG measurements. PMID:24180327

Research Domain Criteria versus DSM V: How does this debate affect attempts to model corticostriatal dysfunction in animals?

PubMed

Young, Jared W; Winstanley, Catharine A; Brady, Anne Marie; Hall, Frank Scott

2017-05-01

For decades, the nosology of mental illness has been based largely upon the descriptions in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM). A recent challenge to the DSM approach to psychiatric nosology from the National Institute on Mental Health (USA) defines Research Domain Criteria (RDoC) as an alternative. For RDoC, psychiatric illnesses are not defined as discrete categories, but instead as specific behavioral dysfunctions irrespective of DSM diagnostic categories. This approach was driven by two primary weaknesses noted in the DSM: (1) the same symptoms occur in very different disease states; and (2) DSM criteria lack grounding in the underlying biological causes of mental illness. RDoC intends to ground psychiatric nosology in those underlying mechanisms. This review addresses the suitability of RDoC vs. DSM from the view of modeling mental illness in animals. A consideration of all types of psychiatric dysfunction is beyond the scope of this review, which will focus on models of conditions associated with frontostriatal dysfunction. Copyright © 2016. Published by Elsevier Ltd.

[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. Copyright © 2015 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.

Policing ‘Vancouver’s Mental Health Crisis’: A Critical Discourse Analysis

PubMed Central

Boyd, Jade; Kerr, Thomas

2016-01-01

In Canada and other western nations there has been an unprecedented expansion of criminal justice systems and a well documented increase of contact between people with mental illness and the police. Canadian police, especially in Vancouver, British Columbia, have been increasingly at the forefront of discourse and regulation specific to mental health. Drawing on critical discourse analysis, this paper explores this claim through a case study of four Vancouver Police Department (VPD) policy reports on “Vancouver’s mental health crisis” from 2008–2013, which include recommendations for action. Analyzed is the VPD’s role in framing issues of mental health in one urban space. This study is the first analysis to critically examine the VPD reports on mental health in Vancouver, B.C. The reports reproduce negative discourses about deinstitutionalization, mental illness and dangerousness that may contribute to further stigma and discrimination of persons with mental illness. Policing reports are widely drawn upon, thus critical analyses are particularly significant for policy makers and public health professionals in and outside of Canada. PMID:28496294

Utility of transthoracic echocardiography (TTE) in assessing fluid responsiveness in critically ill patients - a challenge for the bedside sonographer.

PubMed

Mielnicki, Wojciech; Dyla, Agnieszka; Zawada, Tomasz

2016-12-05

Transthoracic echocardiography (TTE) has become one of the most important diagnostic tools in the treatment of critically ill patients. It allows clinicians to recognise potentially reversible life-threatening situations and is also very effective in the monitoring of the fluid status of patients, slowly substituting invasive methods in the intensive care unit. Hemodynamic assessment is based on a few static and dynamic parameters. Dynamic parameters change during the respiratory cycle in mechanical ventilation and the level of this change directly corresponds to fluid responsiveness. Most of the parameters cannot be used in spontaneously breathing patients. For these patients the most important test is passive leg raising, which is a good substitute for fluid bolus. Although TTE is very useful in the critical care setting, we should not forget the important limitations, not only technical ones but also caused by the critical illness itself. Unfortunately, this method does not allow continuous monitoring and every change in the patient's condition requires repeated examination.

An Australian Brain Bank: a critical investment with a high return!

PubMed Central

Garrick, T.; Dedova, I.; Hunt, C.; Miller, R.; Sundqvist, N.; Harper, C.

2012-01-01

Research into neuropsychiatric disorders, including alcohol-related problems, is limited in part by the lack of appropriate animal models. However, the development of new technologies in pathology and molecular biology means that many more questions can be addressed using appropriately stored human brain tissues. The New South Wales Tissue Resource Centre (TRC) in the University of Sydney (Australia) is a human brain bank that can provide tissues to the neuroscience research community studying alcohol-related brain disorders, schizophrenia, depression and bipolar disorders. Carefully standardised operational protocols and integrated information systems means that the TRC can provide high quality, accurately characterised, tissues for research. A recent initiative, the pre-mortem donor program called “Using our Brains”, encourages individuals without neuropsychiatric illness to register as control donors, a critical group for all research. Community support for this program is strong with over 2,000 people registering their interest. Discussed herein are the protocols pertaining to this multifaceted facility and the benefits of investment, both scientific and financial, to neuroscience researchers and the community at large. PMID:18543078

An Australian Brain Bank: a critical investment with a high return!

PubMed

Sheedy, D; Garrick, T; Dedova, I; Hunt, C; Miller, R; Sundqvist, N; Harper, C

2008-09-01

Research into neuropsychiatric disorders, including alcohol-related problems, is limited in part by the lack of appropriate animal models. However, the development of new technologies in pathology and molecular biology means that many more questions can be addressed using appropriately stored human brain tissues. The New South Wales Tissue Resource Centre (TRC) in the University of Sydney (Australia) is a human brain bank that can provide tissues to the neuroscience research community studying alcohol-related brain disorders, schizophrenia, depression and bipolar disorders. Carefully standardised operational protocols and integrated information systems means that the TRC can provide high quality, accurately characterised, tissues for research. A recent initiative, the pre-mortem donor program called "Using our Brains", encourages individuals without neuropsychiatric illness to register as control donors, a critical group for all research. Community support for this program is strong with over 2,000 people registering their interest. Discussed herein are the protocols pertaining to this multifaceted facility and the benefits of investment, both scientific and financial, to neuroscience researchers and the community at large.

The Impact of Neonatal Illness on Nutritional Requirements—One Size Does Not Fit All

PubMed Central

Ramel, Sara E.; Brown, Laura D.

2015-01-01

Sick neonates are at high risk for growth failure and poorer neurodevelopment than their healthy counterparts. The etiology of postnatal growth failure in sick infants is likely multi-factorial and includes undernutrition due to the difficulty of feeding them during their illness and instability. Illness also itself induces fundamental changes in cellular metabolism that appear to significantly alter nutritional demand and nutrient handling. Inflammation and physiologic stress play a large role in inducing the catabolic state characteristic of the critically ill newborn infant. Inflammatory and stress responses are critical short-term adaptations to promote survival, but are not conducive to promoting long-term growth and development. Conditions such as sepsis, surgery, necrotizing enterocolitis, chronic lung disease and intrauterine growth restriction and their treatments are characterized by altered energy, protein and micronutrient metabolism that result in nutritional requirements that are different from those of the healthy, growing term or preterm infant. PMID:25722954

The ethical dimension in published animal research in critical care: the dark side of our moon.

PubMed

Huet, Olivier; de Haan, Judy B

2014-03-13

The replacement, refinement, and reduction (3Rs) guidelines are the cornerstone of animal welfare practice for medical research. Nowadays, no animal research can be performed without being approved by an animal ethics committee. Therefore, we should expect that any published article would respect and promote the highest standard of animal welfare. However, in the previous issue of Critical Care, Bara and Joffe reported an unexpected finding: animal welfare is extremely poorly reported in critical care research publications involving animal models.This may have a significant negative impact on the reliability of the results and on future funding for our research.The ability of septic shock animal models to translate into clinical studies has been a challenge. Therefore, every means to improve the quality of these models should be pursued. Animal welfare issues should be seen as an additional benefit to achieve this goal. It is therefore critical to draw conclusions from this study to improve the standard of animal welfare in critical care research. This has already been achieved in other fields of research, and we should follow their example.

Metabolic and endocrine effects of sedative agents.

PubMed

Mistraletti, Giovanni; Donatelli, Francesco; Carli, Franco

2005-08-01

To bring to the attention of the clinician the metabolic effects of most common sedatives and analgesics used in critically ill patients. Most patients admitted to the intensive care unit require sedation and analgesia to reduce anxiety, agitation, and delirium and provide pain relief. Inappropriate sedation and analgesia techniques can cause harm to the already compromised patient if they do not take into account the metabolic effect they produce. Metabolically critical illness can be divided in two phases, and acute and a prolonged one. Whereas the acute or hypermetabolic phase is characterized by elevated circulating concentration of catabolic hormones and substrate utilization to provide energy to vital organs, the prolonged or catabolic phase of critical illness is marked by reduced endocrine stimulation and severe loss of body cell mass. The most common analgesic and sedative agents used in the intensive care unit, if used in small or moderate doses, do not interfere significantly with the metabolic milieu; however, prolonged infusions, and in high doses, without adequate monitoring of level of sedation and quality of analgesia, can precipitate morbid events. Further research is needed in the metabolic aspects of analgesia and sedation in the intensive care unit, particularly if a multimodal pharmacologic strategy is used whereby multiple interventions aim at minimizing the risk of overdosing and contributing to attenuation of the stress response associated with critical illness.

Fluid and electrolyte disturbances in critically ill patients.

PubMed

Lee, Jay Wook

2010-12-01

Disturbances in fluid and electrolytes are among the most common clinical problems encountered in the intensive care unit (ICU). Recent studies have reported that fluid and electrolyte imbalances are associated with increased morbidity and mortality among critically ill patients. To provide optimal care, health care providers should be familiar with the principles and practice of fluid and electrolyte physiology and pathophysiology. Fluid resuscitation should be aimed at restoration of normal hemodynamics and tissue perfusion. Early goal-directed therapy has been shown to be effective in patients with severe sepsis or septic shock. On the other hand, liberal fluid administration is associated with adverse outcomes such as prolonged stay in the ICU, higher cost of care, and increased mortality. Development of hyponatremia in critically ill patients is associated with disturbances in the renal mechanism of urinary dilution. Removal of nonosmotic stimuli for vasopressin secretion, judicious use of hypertonic saline, and close monitoring of plasma and urine electrolytes are essential components of therapy. Hypernatremia is associated with cellular dehydration and central nervous system damage. Water deficit should be corrected with hypotonic fluid, and ongoing water loss should be taken into account. Cardiac manifestations should be identified and treated before initiating stepwise diagnostic evaluation of dyskalemias. Divalent ion deficiencies such as hypocalcemia, hypomagnesemia and hypophosphatemia should be identified and corrected, since they are associated with increased adverse events among critically ill patients.

Inferior vena cava collapsibility detects fluid responsiveness among spontaneously breathing critically-ill patients.

PubMed

Corl, Keith A; George, Naomi R; Romanoff, Justin; Levinson, Andrew T; Chheng, Darin B; Merchant, Roland C; Levy, Mitchell M; Napoli, Anthony M

2017-10-01

Measurement of inferior vena cava collapsibility (cIVC) by point-of-care ultrasound (POCUS) has been proposed as a viable, non-invasive means of assessing fluid responsiveness. We aimed to determine the ability of cIVC to identify patients who will respond to additional intravenous fluid (IVF) administration among spontaneously breathing critically-ill patients. Prospective observational trial of spontaneously breathing critically-ill patients. cIVC was obtained 3cm caudal from the right atrium and IVC junction using POCUS. Fluid responsiveness was defined as a≥10% increase in cardiac index following a 500ml IVF bolus; measured using bioreactance (NICOM™, Cheetah Medical). cIVC was compared with fluid responsiveness and a cIVC optimal value was identified. Of the 124 participants, 49% were fluid responders. cIVC was able to detect fluid responsiveness: AUC=0.84 [0.76, 0.91]. The optimum cutoff point for cIVC was identified as 25% (LR+ 4.56 [2.72, 7.66], LR- 0.16 [0.08, 0.31]). A cIVC of 25% produced a lower misclassification rate (16.1%) for determining fluid responsiveness than the previous suggested cutoff values of 40% (34.7%). IVC collapsibility, as measured by POCUS, performs well in distinguishing fluid responders from non-responders, and may be used to guide IVF resuscitation among spontaneously breathing critically-ill patients. Copyright © 2017 Elsevier Inc. All rights reserved.

Hypophosphatemia in Critically Ill Children: Risk Factors, Outcome and Mechanism.

PubMed

Shah, Satish Kumar; Irshad, Mohammad; Gupta, Nandita; Kabra, Sushil Kumar; Lodha, Rakesh

2016-11-01

To determine the prevalence of hypophosphatemia in critically ill children and its association with clinical outcomes; to determine risk factors and mechanism of hypophosphatemia. Levels of serum phosphate, phosphate intake, renal phosphate handling indices and blood gases were measured on days 1, 3, 7 and 10 of pediatric intensive care unit (PICU) stay. Hypophosphatemia was defined as any serum phosphorus <3.8 mg/dl for children younger than 2 y and <3.5 mg/dl for children 2 y or older. Renal phosphate loss was assessed using the ratio of tubular maximum reabsorption of phosphate (TmP) to glomerular filtration rate (GFR) [TmP/GFR]. Prevalence of hypophosphatemia was 71.6 % (95 % CI: 64.6-78.6). On adjusted analysis, hypophosphatemia was associated with prolonged PICU length of stay (PICU LOS > 6 d) (adjusted OR: 3.0 [95 % CI: 1.4-6.7; p = 0.005]) but not associated with increased mortality. Renal phosphate threshold was significantly lower on all the days in hypophosphatemic group compared to that of non-hypophosphatemic group. No statistically significant difference in the amount of phosphate intake was seen in both the groups. Hypophosphatemia is highly prevalent in critically ill children and is associated with prolonged PICU LOS. Increased phosphate loss in urine is one of the mechanism responsible for hypophosphatemia in critically ill children.

How to deal with burden of critical illness: A comparison of strategies in different areas of China.

PubMed

Liu, Pengcheng; Jiang, Liwen; Li, Chengyue; Sun, Mei; Rieger, Alexander; Hao, Mo

2014-05-01

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. 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. 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. 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.

Nutritional care after critical illness: a qualitative study of patients' experiences.

PubMed

Merriweather, J L; Salisbury, L G; Walsh, T S; Smith, P

2016-04-01

The present qualitative study aimed to explore the factors influencing nutritional recovery in patients after critical illness and to develop a model of care to improve current management of nutrition for this patient group. Patients were recruited into the study on discharge from a general intensive care unit (ICU) of a large teaching hospital in central Scotland. Semi-structured interviews were carried out after discharge from the ICU, weekly for the duration of their ward stay, and at 3 months post ICU discharge. Observations of ward practice were undertaken thrice weekly for the duration of the ward stay. Seventeen patients were recruited into the study and, using a grounded theory approach, 'inter-related system breakdowns during the nutritional recovery process' emerged as the overarching core category that influenced patients' experiences of eating after critical illness. This encompassed the categories, 'experiencing a dysfunctional body', 'experiencing socio-cultural changes in relation to eating' and 'encountering nutritional care delivery failures'. The findings from the present study provide a unique contribution to knowledge by offering important insights into patients' experiences of eating after critical illness. The study has identified numerous nutritional problems and raises questions about the efficacy of current nutritional management in this patient group. Adopting a more individualised approach to nutritional care could ameliorate the nutritional issues experienced by post ICU patients. This will be evaluated in future work. © 2014 The British Dietetic Association Ltd.

Thromboprophylaxis using combined intermittent pneumatic compression and pharmacologic prophylaxis versus pharmacologic prophylaxis alone in critically ill patients: study protocol for a randomized controlled trial.

PubMed

Arabi, Yaseen M; Alsolamy, Sami; Al-Dawood, Abdulaziz; Al-Omari, Awad; Al-Hameed, Fahad; Burns, Karen E A; Almaani, Mohammed; Lababidi, Hani; Al Bshabshe, Ali; Mehta, Sangeeta; Al-Aithan, Abdulsalam M; Mandourah, Yasser; Almekhlafi, Ghaleb; Finfer, Simon; Abdukahil, Sheryl Ann I; Afesh, Lara Y; Dbsawy, Maamoun; Sadat, Musharaf

2016-08-03

Venous thromboembolism (VTE) remains a common problem in critically ill patients. Pharmacologic prophylaxis is currently the standard of care based on high-level evidence from randomized controlled trials. However, limited evidence exists regarding the effectiveness of intermittent pneumatic compression (IPC) devices. The Pneumatic compREssion for preventing VENous Thromboembolism (PREVENT trial) aims to determine whether the adjunct use of IPC with pharmacologic prophylaxis compared to pharmacologic prophylaxis alone in critically ill patients reduces the risk of VTE. The PREVENT trial is a multicenter randomized controlled trial, which will recruit 2000 critically ill patients from over 20 hospitals in three countries. The primary outcome is the incidence of proximal lower extremity deep vein thrombosis (DVT) within 28 days after randomization. Radiologists interpreting the scans are blinded to intervention allocation, whereas the patients and caregivers are unblinded. The trial has 80 % power to detect a 3 % absolute risk reduction in proximal DVT from 7 to 4 %. The first patient was enrolled in July 2014. As of May 2015, a total of 650 patients have been enrolled from 13 centers in Saudi Arabia, Canada and Australia. The first interim analysis is anticipated in July 2016. We expect to complete recruitment by 2018. Clinicaltrials.gov: NCT02040103 (registered on 3 November 2013). Current controlled trials: ISRCTN44653506 (registered on 30 October 2013).

Blood conservation strategies to reduce the need for red blood cell transfusion in critically ill patients

PubMed Central

Tinmouth, Alan T.; McIntyre, Lauralynn A.; Fowler, Robert A.

2008-01-01

Anemia commonly affects critically ill patients. The causes are multifactorial and include acute blood loss, blood loss from diagnostic testing and blunted red blood cell production. Blood transfusions are frequently given to patients in intensive care units to treat low hemoglobin levels due to either acute blood loss or subacute anemia associated with critical illness. Although blood transfusion is a life-saving therapy, evidence suggests that it may be associated with an increased risk of morbidity and mortality. A number of blood conservation strategies exist that may mitigate anemia in hospital patients and limit the need for transfusion. These strategies include the use of hemostatic agents, hemoglobin substitutes and blood salvage techniques, the reduction of blood loss associated with diagnostic testing, the use of erythropoietin and the use of restrictive blood transfusion triggers. Strategies to reduce blood loss associated with diagnostic testing and the use of hemostatic agents and erythropoietin result in higher hemoglobin levels, but they have not been shown to reduce the need for blood transfusions or to improve clinical outcomes. Lowering the hemoglobin threshold at which blood is transfused will reduce the need for transfusions and is not associated with increased morbidity or mortality among most critically ill patients without active cardiac disease. Further research is needed to determine the potential roles for other blood conservation strategies. PMID:18166731

Oral health and care in the intensive care unit: state of the science.

PubMed

Munro, Cindy L; Grap, Mary Jo

2004-01-01

Oral health is influenced by oral microbial flora, which are concentrated in dental plaque. Dental plaque provides a microhabitat for organisms and an opportunity for adherence of the organisms to either the tooth surface or other microorganisms. In critically ill patients, potential pathogens can be cultured from the oral cavity. These microorganisms in the mouth can translocate and colonize the lung, resulting in ventilator-associated pneumonia. The importance of oral care in the intensive care unit has been noted in the literature, but little research is available on mechanical or pharmacological approaches to reducing oral microbial flora via oral care in critically ill adults. Most research in oral care has been directed toward patients' comfort; the microbiological and physiological effects of tooth brushing in the intensive care unit have not been reported. Although 2 studies indicated reductions in rates of ventilator-associated pneumonia in cardiac surgery patients who received chlorhexidine before intubation and postoperatively, the effects of chlorhexidine in reducing ventilator-associated pneumonia in other populations of critically ill patients or its effect when treatment with the agent initiated after intubation have not been reported. In addition, no evaluation of the effectiveness of pharmacological and mechanical interventions relative to each other or in combination has been published. Additional studies are needed to develop and test best practices for oral care in critically ill patients.

Association of spirochetal infection with Morgellons disease.

PubMed

Middelveen, Marianne J; Burugu, Divya; Poruri, Akhila; Burke, Jennie; Mayne, Peter J; Sapi, Eva; Kahn, Douglas G; Stricker, Raphael B

2013-01-01

Morgellons disease (MD) is an emerging multisystem illness characterized by skin lesions with unusual filaments embedded in or projecting from epithelial tissue. Filament formation results from abnormal keratin and collagen expression by epithelial-based keratinocytes and fibroblasts. Recent research comparing MD to bovine digital dermatitis, an animal infectious disease with similar skin features, provided clues that spirochetal infection could play an important role in the human disease as it does in the animal illness. Based on histological staining, immunofluorescent staining, electron microscopic imaging and polymerase chain reaction, we report the detection of Borrelia spirochetes in dermatological tissue of  four randomly-selected MD patients. The association of MD with spirochetal infection provides evidence that this infection may be a significant factor in the illness and refutes claims that MD lesions are self-inflicted and that people suffering from this disorder are delusional. Molecular characterization of the Borrelia spirochetes found in MD patients is warranted.

Association of spirochetal infection with Morgellons disease

PubMed Central

Stricker, Raphael B

2013-01-01

Morgellons disease (MD) is an emerging multisystem illness characterized by skin lesions with unusual filaments embedded in or projecting from epithelial tissue. Filament formation results from abnormal keratin and collagen expression by epithelial-based keratinocytes and fibroblasts. Recent research comparing MD to bovine digital dermatitis, an animal infectious disease with similar skin features, provided clues that spirochetal infection could play an important role in the human disease as it does in the animal illness. Based on histological staining, immunofluorescent staining, electron microscopic imaging and polymerase chain reaction, we report the detection of Borrelia spirochetes in dermatological tissue of  four randomly-selected MD patients. The association of MD with spirochetal infection provides evidence that this infection may be a significant factor in the illness and refutes claims that MD lesions are self-inflicted and that people suffering from this disorder are delusional. Molecular characterization of the Borrelia spirochetes found in MD patients is warranted. PMID:24715950

Diagnostic approach in leptospirosis patients

NASA Astrophysics Data System (ADS)

Sembiring, E.

2018-03-01

Leptospirosis is as a worldwide zoonotic disease, spread by pathogenic species of the bacterial genus Leptospira that occurs most commonly in tropical and subtropical regions which are one of endemic diseases in some places in Indonesia. The leptospira serovars are naturally carried in the renal tubules of rodents, wild and domestic animals. Human can be infected either through direct contact with urine of infected animals or indirect contact through with contaminated water and soil. Clinical manifestation is highly variable. The most cases are with a mild flu-like illness which may mimic many other diseases. Weil’s disease is the name given to severe illness and is characterized by a severe febrile illness with bleeding, jaundice and renal failure with high mortality rate. Leptospirosis has been frequently underdiagnosed and underreported. The diagnosis of leptospirosis is difficult to confirm and laboratory test is rarely available even in endemic areas.

Spectrum of illness among returned Australian travellers from Bali, Indonesia: a 5-year retrospective observational study.

PubMed

Sohail, Asma; McGuinness, Sarah L; Lightowler, Rachel; Leder, Karin; Jomon, Bismi; Bain, Christopher A; Peleg, Anton Y

2018-06-05

Bali, Indonesia presents significant infectious and non-infectious health risks for Australian travellers. Understanding this spectrum of illnesses has the potential to assist clinicians in evaluating unwell returning travellers and guide provision of pre-travel advice. To describe the spectrum of illnesses seen in returned travellers from Bali. Using a novel text mining approach, we performed a retrospective, observational study of all adult emergency department (ED) presentations to a metropolitan health service in Melbourne, from 2011-2015. Outcome measures included demographic, clinical and laboratory features of travel-related illnesses. A total of 464 patients met inclusion criteria. Gastroenteritis (119/464, 26%), systemic febrile illness (88/464, 19%) and respiratory tract infection (51/464, 11%) were the most common diagnoses. Dengue was the most common laboratory-confirmed diagnosis (25/464, 5%). No cases of malaria were identified. Common non-infectious presentations included traumatic injury (47/464, 10%) and animal bites requiring rabies post-exposure prophylaxis (29/464, 6%). 110 patients (24%) were admitted to hospital; those presenting with systemic febrile illness were more likely to be admitted compared to those presenting with other illnesses (OR 3.42, CI 2.02-5.75, p<0.001). This is the first study to use a text mining approach to identify and describe ED presentations related to diseases acquired in Bali by Australian travellers. While infections are important causes of illness, trauma and animal bites account for a significant number of hospital presentations. Our findings contribute to knowledge on the health risks for travellers to Bali, and will assist clinicians in relevant pre- and post-travel evaluations. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Induction of Bim and Bid gene expression during accelerated apoptosis in severe sepsis.

PubMed

Weber, Stefan U; Schewe, Jens-Christian; Lehmann, Lutz E; Müller, Stefan; Book, Malte; Klaschik, Sven; Hoeft, Andreas; Stüber, Frank

2008-01-01

In transgenic animal models of sepsis, members of the Bcl-2 family of proteins regulate lymphocyte apoptosis and survival of sepsis. This study investigates the gene regulation of pro-apoptotic and anti-apoptotic members of the Bcl-2 family of proteins in patients with early stage severe sepsis. In this prospective case-control study, patients were recruited from three intensive care units (ICUs) in a university hospital. Sixteen patients were enrolled when they fulfilled the criteria of severe sepsis. Ten critically ill but non-septic patients and 11 healthy volunteers served as controls. Blood samples were immediately obtained at inclusion. To confirm the presence of accelerated apoptosis in the patient groups, caspase-3 activation and phosphatidylserine externalisation in CD4+, CD8+ and CD19+ lymphocyte subsets were assessed using flow cytometry. Specific mRNAs of Bcl-2 family members were quantified from whole blood by real-time PCR. To test for statistical significance, Kruskal-Wallis testing with Dunn's multiple comparison test for post hoc analysis was performed. In all lymphocyte populations caspase-3 (p < 0.05) was activated, which was reflected in an increased phosphatidylserine externalisation (p < 0.05). Accordingly, lymphocyte counts were decreased in early severe sepsis. In CD4+ T-cells (p < 0.05) and B-cells (p < 0.001) the Bcl-2 protein was decreased in severe sepsis. Gene expression of the BH3-only Bim was massively upregulated as compared with critically ill patients (p < 0.001) and 51.6-fold as compared with healthy controls (p < 0.05). Bid was increased 12.9-fold compared with critically ill patients (p < 0.001). In the group of mitochondrial apoptosis inducers, Bak was upregulated 5.6-fold, while the expression of Bax showed no significant variations. By contrast, the pro-survival members Bcl-2 and Bcl-xl were both downregulated in severe sepsis (p < 0.001 and p < 0.05, respectively). In early severe sepsis a gene expression pattern with induction of the pro-apoptotic Bcl-2 family members Bim, Bid and Bak and a downregulation of the anti-apoptotic Bcl-2 and Bcl-xl proteins was observed in peripheral blood. This constellation may affect cellular susceptibility to apoptosis and complex immune dysfunction in sepsis.

From psychiatric disorders to animal models: a bidirectional and dimensional approach

PubMed Central

Donaldson, Zoe. R.; Hen, René

2014-01-01

Psychiatric genetics research is bidirectional in nature, with human and animal studies becoming more closely integrated as techniques for genetic manipulations allow for more subtle exploration of disease phenotypes. This synergy, however, highlights the importance of considering the way in which we approach the genotype-phenotype relationship. In particular, the nosological divide of psychiatric illness, while clinically relevant, is not directly translatable in animal models. For instance, mice will never fully re-capitulate the broad criteria for many psychiatric disorders; nor will they have guilty ruminations, suicidal thoughts, or rapid speech. Instead, animal models have been and continue to provide a means to explore dimensions of psychiatric disorders in order to identify neural circuits and mechanisms underlying disease-relevant phenotypes. Thus, the genetic investigation of psychiatric illness will yield the greatest insights if efforts continue to identify and utilize biologically valid phenotypes across species. In this review we discuss the progress to date and the future efforts that will enhance translation between human and animal studies, including the identification of intermediate phenotypes that can be studied across species, as well as the importance of refined modeling of human disease-associated genetic variation in mice and other animal models. PMID:24650688

Fluid composition and acute kidney injury.

PubMed

Zampieri, Fernando G; Libório, Alexandre B; Cavalcanti, Alexandre B

2016-12-01

To describe recent advances in the understanding of the role of fluid composition in renal outcomes in critically ill patients. The debate on fluid composition is now focused in a pragmatic discussion on fluid electrolyte composition. The resurgence of this debate was propelled by several observational studies that suggested that balanced (i.e., low chloride) solutions were associated with less acute kidney injury in critically ill patients. Nevertheless, a cluster randomized trial failed to show any benefit of balanced solutions. This trial, however, may have failed to detect an effect because of low global illness severity and little fluid infused. If balanced solutions are to be associated with less acute kidney injury, it will probably be in high risk, aggressively resuscitated patients. Additionally, the causal loop involving unbalanced solution infusion, induction of hyperchloremia and acute kidney injury is yet to be closed. Other factors, such as buffer type, speed of infusion and temperature, among others, may also be important. Recent evidence suggests that crystalloid fluid composition matters and can influence renal outcomes in critically ill patients. Further studies should assess the impact and cost-efficiency of balanced solutions in the context of high-risk scenarios.

Plasma granulocyte colony-stimulating factor and granulocyte-macrophage colony-stimulating factor levels in critical illness including sepsis and septic shock: relation to disease severity, multiple organ dysfunction, and mortality.

PubMed

Presneill, J J; Waring, P M; Layton, J E; Maher, D W; Cebon, J; Harley, N S; Wilson, J W; Cade, J F

2000-07-01

To define the circulating levels of granulocyte colony-stimulating factor (G-CSF) and granulocyte-macrophage colony-stimulating factor (GM-CSF) during critical illness and to determine their relationship to the severity of illness as measured by the Acute Physiology and Chronic Health Evaluation (APACHE) II score, the development of multiple organ dysfunction, or mortality. Prospective cohort study. University hospital intensive care unit. A total of 82 critically ill adult patients in four clinically defined groups, namely septic shock (n = 29), sepsis without shock (n = 17), shock without sepsis (n = 22), and nonseptic, nonshock controls (n = 14). None. During day 1 of septic shock, peak plasma levels of G-CSF, interleukin (IL)-6, and leukemia inhibitory factor (LIF), but not GM-CSF, were greater than in sepsis or shock alone (p < .001), and were correlated among themselves (rs = 0.44-0.77; p < .02) and with the APACHE II score (rs = 0.25-0.40; p = .03 to .18). G-CSF, IL-6, and UF, and sepsis, shock, septic shock, and APACHE II scores were strongly associated with organ dysfunction or 5-day mortality by univariate analysis. However, multiple logistic regression analysis showed that only septic shock remained significantly associated with organ dysfunction and only APACHE II scores and shock with 5-day mortality. Similarly, peak G-CSF, IL-6, and LIF were poorly predictive of 30-day mortality. Plasma levels of G-CSF, IL-6, and LIF are greatly elevated in critical illness, including septic shock, and are correlated with one another and with the severity of illness. However, they are not independently predictive of mortality, or the development of multiple organ dysfunction. GM-CSF was rarely elevated, suggesting different roles for G-CSF and GM-CSF in human septic shock.

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

PubMed

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

2015-12-01

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. 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. 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. 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). 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.

When the family member is a nurse: the role and needs of nurse family members during critical illness of a loved one.

PubMed

Salmond, Susan W

2011-02-01

The aim of this study was to explore the experience of being a nurse family member of a relative hospitalised for a critical illness. This paper will describe how nurse family members viewed the challenges of the illness experience and the strategies used to manage the challenges and cope with their loved one's critical illness. A qualitative approach using open-ended, focused exploratory interviews was used. Theoretical sampling was used to obtain a total of 22 participants. The knowledge base of the nurse filtered the experience for the nurse family member and their nurse role identity infused each component of the experience. Nurse family members identified their primary role as maintaining guard to protect the patient and family. To accomplish this, six challenges were identified: masking heightened emotional turmoil; assuming the in-charge role; assessing and monitoring; seeking information and meaning; advocating; and, "letting go to assume family and self roles". Strategies to facilitate meeting these challenges are described. In order to provide family-centered care, the critical care nurse must recognise the unique needs of the "nurse family member." By empathising with the emotional experience, allowing the "in-charge" nurse family member to be part of the team, facilitating ongoing observation and monitoring by the nurse family member, seeking out and clarifying information for the nurse family member and partnering to advocate for the patient, the critical care nurse builds a relationship of trust that allows the nurse family member to assume their family role. Copyright © 2010 Elsevier Ltd. All rights reserved.

Care of the Critically Ill Burn Patient. An Overview from the Perspective of Optimizing Palliative Care.

PubMed

Ray, Daniel E; Karlekar, Mohana B; Crouse, Donnelle L; Campbell, Margaret; Curtis, J Randall; Edwards, Jeffrey; Frontera, Jennifer; Lustbader, Dana R; Mosenthal, Anne C; Mulkerin, Colleen; Puntillo, Kathleen A; Weissman, David E; Boss, Renee D; Brasel, Karen J; Nelson, Judith E

2017-07-01

Burn specialists have long recognized the need for and have role modeled a comprehensive approach incorporating relief of distress as part of care during critical illness. More recently, palliative care specialists have become part of the healthcare team in many U.S. hospitals, especially larger academic institutions that are more likely to have designated burn centers. No current literature describes the intersection of palliative care and burn care or integration of primary and specialist palliative care in this unique context. This Perspective gives an overview of burn care; focuses on pain and other symptoms in burn intensive care unit settings; addresses special needs of critically ill burned patients, their families, and clinicians for high-quality palliative care; and highlights potential benefits of integrating primary and specialist palliative care in burn critical care. MEDLINE and the Cumulative Index to Nursing and Allied Health Literature were searched, and an e-mail survey was used to obtain information from U.S. Burn Fellowship Program directors about palliative medicine training. The Improving Palliative Care in the Intensive Care Unit Project Advisory Board synthesized published evidence with their own research and clinical experience in preparing this article. Mortality and severe morbidity for critically ill burned patients remains high. American Burn Association guidelines lay the foundation for a robust system of palliative care delivery, embedding palliative care principles and processes in intensive care by burn providers. Understanding basic burn care, challenges for symptom management and communication, and the culture of the particular burn unit, can optimize quality and integration of primary and specialist palliative care in this distinctive setting.

Indications and Effects of Plasma Transfusions in Critically Ill Children.

PubMed

Karam, Oliver; Demaret, Pierre; Shefler, Alison; Leteurtre, Stéphane; Spinella, Philip C; Stanworth, Simon J; Tucci, Marisa

2015-06-15

Plasma transfusions are frequently prescribed for critically ill children, although their indications lack a strong evidence base. Plasma transfusions are largely driven by physician conceptions of need, and these are poorly documented in pediatric intensive care patients. To identify patient characteristics and to characterize indications leading to plasma transfusions in critically ill children, and to assess the effect of plasma transfusions on coagulation tests. Point-prevalence study in 101 pediatric intensive care units in 21 countries, on 6 predefined weeks. All critically ill children admitted to a participating unit were included if they received at least one plasma transfusion. During the 6 study weeks, 13,192 children were eligible. Among these, 443 (3.4%) received at least one plasma transfusion and were included. The primary indications for plasma transfusion were critical bleeding in 22.3%, minor bleeding in 21.2%, planned surgery or procedure in 11.7%, and high risk of postoperative bleeding in 10.6%. No bleeding or planned procedures were reported in 34.1%. Before plasma transfusion, the median international normalized ratio (INR) and activated partial thromboplastin time (aPTT) values were 1.5 and 48, respectively. After plasma transfusion, the median INR and aPTT changes were -0.2 and -5, respectively. Plasma transfusion significantly improved INR only in patients with a baseline INR greater than 2.5. One-third of transfused patients were not bleeding and had no planned procedure. In addition, in most patients, coagulation tests are not sensitive to increases in coagulation factors resulting from plasma transfusion. Studies assessing appropriate plasma transfusion strategies are urgently needed.