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Sample records for critically ill elderly

  1. 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.

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

    PubMed Central

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

    2016-01-01

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

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

    PubMed Central

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

    2013-01-01

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

  4. 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

  5. The Liver in Critical Illness.

    PubMed

    Damm, Tessa W; Kramer, David J

    2016-07-01

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

  6. The critically ill immunosuppressed patient

    SciTech Connect

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

    1987-01-01

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

  7. Critical illness and changes in sensory perception.

    PubMed

    Schiffman, Susan S

    2007-08-01

    Impairments of sensory perception that occur during a period of critical care can seriously impact on health and nutritional status, activities of daily living, independence, quality of life and the possibility of recovery. It is emphasized from the outset that sensory losses in critically-ill patients may or may not be related to their current medical condition. The present paper provides an overview of all five senses (vision, hearing, taste, smell and touch) and describes the factors that contribute to sensory losses in critically-ill patients, including medications, medical conditions and treatments and the process of aging itself. Cancer and stroke are two critical illnesses in which profound sensory decrements often occur. Many sensory complaints in patients with cancer are related to alteration in sensory signals caused by damage to the sensory receptors. However, some complaints, such as taste aversions in patients with cancer, are not related to altered sensory physiology per se but to learned aversions that arise during the noxious effects of radiotherapy and chemotherapy. The paper also reviews a study in which the sensory performance (of all five senses) was compared in three groups of elderly subjects: (1) patients who had undergone coronary artery bypass surgery; (2) patients with cardiovascular conditions but with no history of surgery; (3) healthy non-medicated age-matched controls. Performance of patients who had undergone coronary artery bypass surgery was worse than that for the other two groups, with taste and smell losses greater than for the other senses. The study demonstrates that critical illness (e.g. coronary artery bypass surgery) can exacerbate sensory losses in an older cohort.

  8. [Nutrition in the critically ill].

    PubMed

    Weimann, A; Andrä, J; Sablotzki, A

    2011-11-01

    The prognostic impact of inadequate energy and protein supply in malnourished intensive care patients has been recently reemphasized. Consent exists about the beneficial effects of early enteral nutrition in the critically ill. However, gastrointestinal intolerance of the critically ill may be a major problem for the feasibility of enteral nutrition bearing additional risks. In case adequate enteral nutrition cannot be realized, there is controversy about the appropriate time to start total parenteral or combined enteral / parenteral nutrition. Due to potential adverse effects immune-enhancing substrates have to be cautiously administered. For standardization implementation of a guideline based nutritional protocol is recommended. The review refers to the recent guidelines of the European Society for Clinical Nutrition and Metabolism (2009), the American Society for Parenteral and Enteral Nutrition (ASPEN) (2009) and the German Sepsis Society (DSG) (2010).

  9. Nutritional interventions in critical illness.

    PubMed

    Powell-Tuck, Jeremy

    2007-02-01

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

  10. Probiotics in critically ill children

    PubMed Central

    Singhi, Sunit C.; Kumar, Suresh

    2016-01-01

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

  11. Probiotics in critically ill children.

    PubMed

    Singhi, Sunit C; Kumar, Suresh

    2016-01-01

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

  12. Sperm retrieval during critical illness.

    PubMed

    Powner, David J; Rumohr, Jon A; Lipshultz, Larry I

    2010-06-01

    Objective of this study is to review technical methods to retrieve sperm from critically ill/injured patients after an appropriate family request, possible harmful effects on sperm production/function by ICU medications or concurrent illnesses, and ethical considerations for hospitals and care providers in providing this resource. Design used for this study includes: literature review, PubMed 1998-2009, and authors' files. There are no interventions. In conclusion, although successful and unsuccessful pregnancies following sperm removal from critically-ill patients are reported, no firm probability predictions for either result are known. Acute and chronic diseases that effect the hypothalamic-pituitary-gonadal axis and multiple medications common to the ICU may reduce sperm production or function. Retrieval methods before and after cardio-respiratory death differ and often require intracytoplasmic sperm injection or other in vitro fertilization techniques to achieve a subsequent pregnancy. The proactive development of a collaborative policy/procedure to identify appropriate roles for the hospital, its employees, and affiliated critical care and urology physicians is strongly recommended.

  13. Fluid therapy in critical illness

    PubMed Central

    2014-01-01

    Major surgery and critical illnesses such as sepsis and trauma all disturb normal physiological fluid handling. Intravenous fluid therapy for resuscitation and fluid maintenance is a central part of medical care during these conditions, yet the evidence base supporting practice in this area lacks answers to a number of important questions. Recent research developments include a refinement of our knowledge of the endothelial barrier structure and function and a focus on the potential harm that may be associated with intravenous fluid therapy. Here, we briefly describe the contemporary view of fluid physiology and how this may be disrupted by pathological processes. The important themes in critical illness fluid research are discussed, with a particular focus on two emerging ideas: firstly, that individualising fluid treatment to the patient, their underlying disease state and the phase of that illness may be key to improving clinical outcomes using fluid interventions and, secondly, that fluids should be considered to be drugs, with specific indications and contraindications, dose ranges and potential toxicities. PMID:25276346

  14. OMEGA-3 FATTY ACIDS IN CRITICAL ILLNESS

    PubMed Central

    Martin, Julie M.; Stapleton, Renee D.

    2015-01-01

    Supplementation of enteral nutritional formulas and parenteral nutrition lipid emulsions with omega-3 fatty acids is a recent area of research in patients with critical illness. It is hypothesized that omega-3 fatty acids may help reduce inflammation in critically ill patients, particularly those with sepsis and acute lung injury. The objective of this article is to review the data on supplementing omega-3 fatty acids during critical illness; enteral and parenteral supplementation are reviewed separately. The results of the research available to date are contradictory for both enteral and parenteral omega-3 fatty acid administration. Supplementation with omega-3 fatty acids may influence the acute inflammatory response in critically ill patients, but more research is needed before definitive recommendations about the routine use of omega-3 fatty acids in caring for critically ill patients can be made. PMID:20796218

  15. [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.

  16. Hypomagnesemia in Critically Ill Sepsis Patients

    PubMed Central

    Velissaris, Dimitrios; Karamouzos, Vassilios; Pierrakos, Charalampos; Aretha, Diamanto; Karanikolas, Menelaos

    2015-01-01

    Magnesium (Mg), also known as “the forgotten electrolyte”, is the fourth most abundant cation overall and the second most abundant intracellular cation in the body. Mg deficiency has been implicated in the pathophysiology of many diseases. This article is a review of the literature regarding Mg abnormalities with emphasis on the implications of hypomagnesemia in critical illness and on treatment options for hypomagnesemia in critically ill patients with sepsis. Hypomagnesemia is common in critically ill patients, and there is strong, consistent clinical evidence, largely from observational studies, showing that hypomagnesemia is significantly associated with increased need for mechanical ventilation, prolonged ICU stay and increased mortality. Although the mechanism linking hypomagnesemia with poor clinical outcomes is not known, experimental data suggest mechanisms contributing to such outcomes. However, at the present time, there is no clear evidence that magnesium supplementation improves outcomes in critically ill patients with hypomagnesemia. Large, well-designed clinical trials are needed to evaluate the role of magnesium therapy for improving outcomes in critically ill patients with sepsis. PMID:26566403

  17. The Role of Plasmapheresis in Critical Illness

    PubMed Central

    Nguyen, Trung C.; Kiss, Joseph E.; Goldman, Jordana R.; Carcillo, Joseph A.

    2012-01-01

    Synopsis In this chapter, we will review the current recommendations from the American Society for Apheresis regarding the use of plasmapheresis in many of the diseases that intensivists commonly encounter in critically ill patients. Recent experience indicates that therapeutic plasma exchange (TPE) may be useful in a wide spectrum of illnesses characterized by microvascular thrombosis, the presence of auto-antibodies, immune activation with dysregulation of immune response, and in some infections. PMID:22713617

  18. Vitamin D Deficiency in Pediatric Critical Illness

    PubMed Central

    Hebbar, Kiran B.; Wittkamp, Michael; Alvarez, Jessica A.; McCracken, Courtney E.; Tangpricha, Vin

    2014-01-01

    Introduction The potential role for vitamin D in infection has been well described in adults. The objective of our study was to determine the prevalence of vitamin D insufficiency and to evaluate the relationship between vitamin D status and markers of innate immunity and infection in critically ill children. Hypothesis Vitamin D deficiency was highly prevalent in children with critical illness and correlated with the severity of illness and dysfunction in innate immunity. Methods We performed a prospective clinical observational study with both case and control groups in the pediatric intensive care unit (PICU). Vitamin D status was defined as vitamin D sufficient (25-hydroxyvitamin D (25(OH)D≥ 20 ng/mL), vitamin D insufficient (25(OH)D 10 to 20 ng/mL), and vitamin D deficient (25(OH)D <10 ng/mL). Vitamin D status, severity of illness scores, and cathelicidin, and other clinical data were collected. Results Sixty-one PICU patients and 46 control patients were enrolled. Over 60% of the PICU cases were found to be vitamin D insufficient while less than 1/3 of the controls were insufficient (p < 0.0001). No significant correlation was seen between plasma 25(OH)D and any severity of illness scores. Cases with asthma had a significantly lower median level 25(OH)D (16.9 ng/mL) than cases without asthma (18.7 ng/mL). Over 50% of patients hospitalized during the fall and winter were considered vitamin D deficient or insufficient whereas in the sunnier seasons (spring and summer) the prevalence of vitamin D deficiency/insufficiency decreased to about 30% (p = 0.003). Conclusions The overall finding of profound vitamin D deficiency in the pediatric critical care population is an important finding. Significant seasonal differences were noted even in the critically ill. Certain diseases like asthma in critically ill children merit further study. PMID:25580380

  19. Bedside echocardiography in critically ill patients

    PubMed Central

    Casaroto, Eduardo; Mohovic, Tatiana; Pinto, Lilian Moreira; de Lara, Tais Rodrigues

    2015-01-01

    ABSTRACT The echocardiography has become a vital tool in the diagnosis of critically ill patients. The use of echocardiography by intensivists has been increasing since the 1990’s. This tool has become a common procedure for the cardiovascular assessment of critically ill patients, especially because it is non-invasive and can be applied in fast and guided manner at the bedside. Physicians with basic training in echocardiography, both from intensive care unit or emergency department, can assess the left ventricle function properly with good accuracy compared with assessment made by cardiologists. The change of treatment approach based on echocardiographic findings is commonly seen after examination of unstable patient. This brief review focuses on growing importance of echocardiography as an useful tool for management of critically ill patients in the intensive care setting along with the cardiac output assessment using this resource. PMID:26761560

  20. Bedside echocardiography in critically ill patients.

    PubMed

    Casaroto, Eduardo; Mohovic, Tatiana; Pinto, Lilian Moreira; Lara, Tais Rodrigues de

    2015-01-01

    The echocardiography has become a vital tool in the diagnosis of critically ill patients. The use of echocardiography by intensivists has been increasing since the 1990's. This tool has become a common procedure for the cardiovascular assessment of critically ill patients, especially because it is non-invasive and can be applied in fast and guided manner at the bedside. Physicians with basic training in echocardiography, both from intensive care unit or emergency department, can assess the left ventricle function properly with good accuracy compared with assessment made by cardiologists. The change of treatment approach based on echocardiographic findings is commonly seen after examination of unstable patient. This brief review focuses on growing importance of echocardiography as an useful tool for management of critically ill patients in the intensive care setting along with the cardiac output assessment using this resource. PMID:26761560

  1. Measurement of sleep in critically ill patients.

    PubMed

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

    2000-01-01

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

  2. Psychoneuroimmunology in critically ill patients.

    PubMed

    DeKeyser, Freda

    2003-02-01

    Psychoneuroimmunology is the study of the interactions among behavior, neural, and endocrine functions and the immune system. The purpose of this review is to briefly summarize the evidence concerning interactions among behavior, the neuroendocrine system, and the immune system, and to show how this evidence relates to critical care patients. It has been shown that the immune function of many patients in the intensive care unit is suppressed as a result of trauma, sepsis, or profound physiologic and psychological stress. Three of the most common stressors among patients in the intensive care unit are pain, sleep deprivation, and fear or anxiety. Findings have shown each of these stressors to be associated with decreased immune functioning. Nurses have an important responsibility to protect their patients from infection and promote their ability to heal. Several actions are suggested that can help the nurse achieve these goals. It is hoped that nurses would keep these interactions in mind while caring for their patients in the intensive care unit.

  3. 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

  4. The interfacility transport of critically ill newborns.

    PubMed

    Whyte, Hilary Ea; Jefferies, Ann L

    2015-01-01

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

  5. Critical Illness Hyperglycemia in Pediatric Cardiac Surgery

    PubMed Central

    Ulate, Kalia P; Raj, Shekhar; Rotta, Alexandre T

    2012-01-01

    Critical illness hyperglycemia (CIH) is common in pediatric and adult intensive care units (ICUs). Children undergoing surgical repair or palliation of congenital cardiac defects are particularly at risk for CIH and its occurrence has been associated with increased morbidity and mortality in this population. Strict glycemic control through the use of intensive insulin therapy (IIT) has been shown to improve outcomes in some adult and pediatric studies, yet these findings have sparked controversy. The practice of strict glycemic control has been slow in extending to pediatric ICUs because of the documented increase in the incidence of hypoglycemia in patients treated with IIT. Protocol driven approaches with more liberal glycemic targets have been successfully validated in general and cardiac critical care pediatric patients with low rates of hypoglycemia. It is unknown whether a therapeutic benefit is obtained by keeping patients in this more liberal glycemic control target. Definitive randomized controlled trials of IIT utilizing these targets in critically ill children are ongoing. PMID:22401320

  6. [Representations of illness among the elderly in Mexico City].

    PubMed

    Campos-Navarro, Roberto; Torrez, Diana; Arganis-Juarez, Elia Nora

    2002-01-01

    To examine the principle sociocultural characteristics of the illness experience in a group of senior citizens diagnosed with hypertension, diabetes, and arthritis, a total of 50 subjects over 60 years old were selected to answer an open-ended questionnaire. Using intentional non-probabilistic sampling, 25% of the sample were randomly selected, and semi-structured interviews were conducted. All individuals in the study are covered by social security institutions and receive medical care at a clinic located in southeastern Mexico City. Explanations for antecedents, causes, symptoms, and treatment of the illness relate to the individual social context. Although these seniors provided folk explanations for the causes of their illnesses, they treat themselves with a combination of biomedical and herbal resources. The authors conclude that it is necessary to analyze how the elderly live with chronic illness in order to propose effective measures to improve their quality of life and provision of health care services.

  7. Clinical Conundrums in Management of Hypothyroidism in Critically Ill Geriatric Patients

    PubMed Central

    Sehgal, Vishal; Bajwa, Sukhminder Jit Singh; Sehgal, Rinku; Bajaj, Anurag

    2014-01-01

    Context: Articles in various international and national bibliographic indices were extensively searched with an emphasis on thyroid and hypothyroid disorders, hypothyroidism in elderly hospitalized patients, hypothyroidism in critically ill geriatric population, thyroxine in elderly hypothyroid, drug interactions and thyroid hormones, and thyroid functions in elderly. Evidence acquisition: Entrez (including PubMed), NIH.gov, Medscape.com, WebMD.com, MedHelp.org, Search Medica, MD consult, yahoo.com, and google.com were searched. Manual search was performed on various textbooks of medicine, critical care, pharmacology, and endocrinology. Results: Thyroid function tests in elderly hospitalized patients must be interpreted with circumspection. The elderly are often exposed to high iodide content and critical care settings. This may occur because of either decreased iodine excretion or very high intake of iodine. This is especially true for elderly population with underlying acute or chronic kidney diseases or both. Amiodarone, with a very high iodine content, is also often used in this set of population. Moreover, other medications including iodinated contrast are often used in the critical care settings. These may affect different steps of thyroid hormone metabolism, and thereby complicate the interpretation of thyroid function tests. Conclusions: The current review is aimed at analyzing and managing various clinical aspects of hypothyroidism in hospitalized elderly, and critically ill geriatric patients. PMID:24719636

  8. Nutrition in critical illness: a current conundrum

    PubMed Central

    Hoffer, L. John; Bistrian, Bruce R.

    2016-01-01

    Critically ill people are unable to eat. What’s the best way to feed them? Nutrition authorities have long recommended providing generous amounts of protein and calories to critically ill patients, either intravenously or through feeding tubes, in order to counteract the catabolic state associated with this condition. In practice, however, patients in modern intensive care units are substantially underfed. Several large randomized clinical trials were recently carried out to determine the clinical implications of this situation. Contradicting decades of physiological, clinical, and observational data, the results of these trials have been claimed to justify the current practice of systematic underfeeding in the intensive care unit. This article explains and suggests how to resolve this conundrum. PMID:27803805

  9. Insulin infusion therapy in critically ill patients.

    PubMed

    Boutin, Jean-Marie; Gauthier, Lyne

    2014-04-01

    While dysglycemia (hyperglycemia, hypoglycemia and glucose variability) is clearly associated with increased mortality in critically ill patients, target range of blood glucose control remains controversial. Standardized insulin infusion protocols constitute the basis of treatment of these patients. The choice of protocol and its implementation is a great challenge. In this article, we review the published data to help define the essential elements that compose a good protocol and apply the right conditions to make it safe and effective. PMID:24690510

  10. 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

  11. Nutritional assessment in the critically ill.

    PubMed

    Manning, E M; Shenkin, A

    1995-07-01

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

  12. Epigenetics in Critical Illness: A New Frontier

    PubMed Central

    Graves, Brian T.; Munro, Cindy L.

    2013-01-01

    Epigenetics is the study of alterations in the function of genes that do not involve changes in the DNA sequence. Within the critical care literature, it is a relatively new and exciting avenue of research in describing pathology, clinical course, and developing targeted therapies to improve outcomes. In this paper, we highlight current research relative to critical care that is focused within the major epigenetic mechanisms of DNA methylation, histone modification, microRNA regulation, and composite epigenetic scoring. Within this emerging body of research it is quite clear that the novel therapies of the future will require clinicians to understand and navigate an even more complex and multivariate relationship between genetic, epigenetic, and biochemical mechanisms in conjunction with clinical presentation and course in order to significantly improve outcomes within the acute and critically ill population. PMID:23936643

  13. Critical illness polyneuropathy: a case report.

    PubMed

    Celik, Canan; Ucan, Halil; Alemdaroglu, Ebru; Oktay, Fugen

    2011-01-01

    Critical illness polyneuropathy (CIP) is defined as a common complication of critically ilness patients who were admitted to the intensive care unit due to sepsis, multiple trauma and/or multi-organ failure. We aimed to present a patient who was diagnosed as CIP. He was admitted to our outpatient clinic due to weakness and pain in his lower extremities. He had been followed in an intensive care unit due to suicid five months ago. There were symmetrically and predominantly muscle weakness, sensory impairment, absence of deep tendon reflexes in his lower extremities. Electrophysiological evaluation demonstrated motor and sensory axonal distal polyneuropathy predominantly in lower extremities. At follow up, he had high fever, and elevated acute phase responses. Therefore source of infection was investigated and was suspected to a diagnosis of infective endocarditis. He was discharged to be hospitalized in cardiology clinic. With this case, we think that physiatrists should take into consideration a diagnosis of critical illness polyneuropathy in patients with symmetric motor weakness. In CIP, muscle weakness, sensory loss, neuropathic pain, and autonomic problems lengthened the rehabilitation period. Due to a diagnosis of infective endocarditis in our case, we point out that source of infection should be carefully investigated if there is acute phase responses in CIP patients even if during rehabilitation period.

  14. Gut Motility Issues in Critical Illness.

    PubMed

    Taylor, Robert W

    2016-04-01

    Acute gastrointestinal injury (AGI) is common in critical illness and negatively affects outcome. A variety of definitions have been used to describe AGI, which has led to clinical confusion and hampered comparison of research studies across institutions. An international working group of the European Society of Intensive Care Medicine was convened to standardize definitions for AGI and provide current evidence-based understanding of its pathophysiology and management. This disorder is associated with a wide variety of signs and symptoms and may be difficult to detect, therefore a high index of suspicion is warranted.

  15. Hypocaloric support in the critically ill.

    PubMed

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

    1999-06-01

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

  16. Blood Glucose Measurements in Critically Ill Patients

    PubMed Central

    Van Herpe, Tom; Mesotten, Dieter

    2012-01-01

    Studies on tight glycemic control by intensive insulin therapy abruptly changed the climate of limited interest in the problem of hyperglycemia in critically ill patients and reopened the discussion on accuracy and reliability of glucose sensor devices. This article describes important components of blood glucose measurements and their interferences with the focus on the intensive care unit setting. Typical methodologies, organized from analytical accuracy to clinical accuracy, to assess imprecision and bias of a glucose sensor are also discussed. Finally, a list of recommendations and requirements to be considered when evaluating (time-discrete) glucose sensor devices is given. PMID:22401319

  17. Reversing oliguria in critically ill patients.

    PubMed

    DePriest, J

    1997-09-01

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

  18. Management of Infections in Critically Ill Patients

    PubMed Central

    Hranjec, Tjasa

    2014-01-01

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

  19. Thyroid function in critically ill patients.

    PubMed

    Fliers, Eric; Bianco, Antonio C; Langouche, Lies; Boelen, Anita

    2015-10-01

    Patients in the intensive care unit (ICU) typically present with decreased concentrations of plasma tri-iodothyronine, low thyroxine, and normal range or slightly decreased concentration of thyroid-stimulating hormone. This ensemble of changes is collectively known as non-thyroidal illness syndrome (NTIS). The extent of NTIS is associated with prognosis, but no proof exists for causality of this association. Initially, NTIS is a consequence of the acute phase response to systemic illness and macronutrient restriction, which might be beneficial. Pathogenesis of NTIS in long-term critical illness is more complex and includes suppression of hypothalamic thyrotropin-releasing hormone, accounting for persistently reduced secretion of thyroid-stimulating hormone despite low plasma thyroid hormone. In some cases distinguishing between NTIS and severe hypothyroidism, which is a rare primary cause for admission to the ICU, can be difficult. Infusion of hypothalamic-releasing factors can reactivate the thyroid axis in patients with NTIS, inducing an anabolic response. Whether this approach has a clinical benefit in terms of outcome is unknown. In this Series paper, we discuss diagnostic aspects, pathogenesis, and implications of NTIS as well as its distinction from severe, primary thyroid disorders in patients in the ICU.

  20. [Invasive candidiasis in critically ill adult patient].

    PubMed

    Tobar A, Eduardo; Silva O, Francisco; Olivares C, Roberto; Gaete G, Pablo; Luppi N, Mario

    2011-02-01

    Invasive infections by Candida strains are a relevant pathology in critically ill patients. Candida should be considered where a high risk of infection is present for a critical early diagnosis. Despite the incorporation of new drugs in the therapeutic armamentarium over the last decade, mortality remains high. The key in improving clinical outcomes of these patients are the use of early effective therapies that offer coverage against different strains of Candida: C. albicans and non-albicans. Recent international guidelines suggest empiric therapy with echinocandins in suspected invasive candidiasis in this patient population. This group of drugs adequately documented clinical efficacy and safe use in these patients. The emergence of new echinocandins could improve access to these drugs by reducing their cost.

  1. Antibiotic dose optimization in critically ill patients.

    PubMed

    Cotta, M O; Roberts, J A; Lipman, J

    2015-12-01

    The judicious use of existing antibiotics is essential for preserving their activity against infections. In the era of multi-drug resistance, this is of particular importance in clinical areas characterized by high antibiotic use, such as the ICU. Antibiotic dose optimization in critically ill patients requires sound knowledge not only of the altered physiology in serious infections - including severe sepsis, septic shock and ventilator-associated pneumonia - but also of the pathogen-drug exposure relationship (i.e. pharmacokinetic/pharmacodynamic index). An important consideration is the fact that extreme shifts in organ function, such as those seen in hyperdynamic patients or those with multiple organ dysfunction syndrome, can have an impact upon drug exposure, and constant vigilance is required when reviewing antibiotic dosing regimens in the critically ill. The use of continuous renal replacement therapy and extracorporeal membrane oxygenation remain important interventions in these patients; however, both of these treatments can have a profound effect on antibiotic exposure. We suggest placing emphasis on the use of therapeutic drug monitoring and dose individualization when optimizing therapy in these settings.

  2. Anesthesia of the critically ill equine patient.

    PubMed

    Cornick-Seahorn, Janyce

    2004-04-01

    There is a plethora of information regarding anesthetic management of horses; however, controlled studies of the critically ill equine patient are few. These patients should be managed like any equine anesthetic candidate but much more stringently:I. Preoperative evaluation and appropriate therapy may represent the difference between life and death during the intraoperative and recovery periods. 2. The anesthetic induction and maintenance protocol should be based on the individual situation of the veterinary facility and personnel("comfort zone"). 3. Appropriate monitoring and intraoperative supportive measures are essential. 4. The anesthetic period is a significant perturbation to homeostasis. Even if the horse seems to have done well (ie, as indicated by the cardiopulmonary values), a problem-free anesthetic period does not guarantee a successful recovery, and close monitoring should continue until the horse is ambulatory. 5. Critically ill patients are often in a negative energy balance. Supportive measures to ensure an adequate caloric intake, such as enteral or parenteral nutrition, facilitate healing and return of homeostasis.

  3. Nitric oxide production in critically ill patients.

    PubMed Central

    Wong, H R; Carcillo, J A; Burckart, G; Kaplan, S S

    1996-01-01

    OBJECTIVE: To measure serum nitrite and nitrate levels in critically ill children as indicators of endogenous nitric oxide (NO) production. HYPOTHESIS: Endogenous NO production is increased in children with conditions characterised by immune stimulation. DESIGN: Prospective descriptive study in a multidisciplinary paediatric intensive care unit. PATIENTS: 137 consecutive critically ill children with a variety of clinical conditions. INTERVENTIONS: Using a rapid microtitre plate technique, daily serum nitrite and nitrate levels were measured from serum samples that remained in the clinical laboratory after daily routine phlebotomy. Clinical and laboratory information was also gathered daily for each patient. RESULTS: The maximum serum nitrite plus nitrate levels (microM) reached by children with infection (41.8 (SD 18.1)), sepsis syndrome (85.1 (39.9)), shock without sepsis (36.4 (19.1)), transplantation alone (61.0 (43.4)), transplantation with sepsis (200.7 (150.5)), or rejection (161.7 (70.4)), were higher than in controls (18.1 (9.3)). In the absence of exogenous NO donors, levels greater than 80 microM were reached only in children with the sepsis syndrome, organ transplantation, or acute rejection. CONCLUSIONS: Increased endogenous NO production occurs in children with clinical conditions associated with immune stimulation. Further investigation is warranted to determine the value of this simple and rapid test as a clinically useful diagnostic tool and therapeutic monitor in the evaluation of children at risk for the sepsis syndrome or acute allograft rejection. PMID:8758122

  4. Lung Ultrasound in the Critically Ill Neonate

    PubMed Central

    Lichtenstein, Daniel A; Mauriat, Philippe

    2012-01-01

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

  5. Lung Ultrasound in the Critically Ill Neonate.

    PubMed

    Lichtenstein, Daniel A; Mauriat, Philippe

    2012-08-01

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

  6. Rhabdomyolysis in Critically Ill Surgical Patients

    PubMed Central

    Kuzmanovska, Biljana; Cvetkovska, Emilija; Kuzmanovski, Igor; Jankulovski, Nikola; Shosholcheva, Mirjana; Kartalov, Andrijan; Spirovska, Tatjana

    2016-01-01

    Introduction: Rhabdomyolysis is a syndrome of injury of skeletal muscles associated with myoglobinuria, muscle weakness, electrolyte imbalance and often, acute kidney injury as severe complication. The aim: of this study is to detect the incidence of rhabdomyolysis in critically ill patients in the surgical intensive care unit (ICU), and to raise awareness of this medical condition and its treatment among the clinicians. Material and methods: A retrospective review of all surgical and trauma patients admitted to surgical ICU of the University Surgical Clinic “Mother Teresa” in Skopje, Macedonia, from January 1st till December 31st 2015 was performed. Patients medical records were screened for available serum creatine kinase (CK) with levels > 200 U/l, presence of myoglobin in the serum in levels > 80 ng/ml, or if they had a clinical diagnosis of rhabdomyolysis by an attending doctor. Descriptive statistical methods were used to analyze the collected data. Results: Out of totally 1084 patients hospitalized in the ICU, 93 were diagnosed with rhabdomyolysis during the course of one year. 82(88%) patients were trauma patients, while 11(12%) were surgical non trauma patients. 7(7.5%) patients diagnosed with rhabdomyolysis developed acute kidney injury (AKI) that required dialysis. Average values of serum myoglobin levels were 230 ng/ml, with highest values of > 5000 ng/ml. Patients who developed AKI had serum myoglobin levels above 2000 ng/ml. Average values of serum CK levels were 400 U/l, with highest value of 21600 U/l. Patients who developed AKI had serum CK levels above 3000 U/l. Conclusion: Regular monitoring and early detection of elevated serum CK and myoglobin levels in critically ill surgical and trauma patients is recommended in order to recognize and treat rhabdomyolysis in timely manner and thus prevent development of AKI. PMID:27703296

  7. Nutritional support in critically ill patients.

    PubMed Central

    Grant, J P

    1994-01-01

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

  8. Nutritional Assessment in Critically Ill Patients

    PubMed Central

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

    2016-01-01

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

  9. 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

  10. Infections in critically ill burn patients.

    PubMed

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

    2016-04-01

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

  11. Infections in critically ill burn patients.

    PubMed

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

    2016-04-01

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

  12. Monitoring the critically ill surgical patient.

    PubMed Central

    Holliday, R L; Doris, P J

    1979-01-01

    Critically ill surgical patients account for approximately half the patients in an active multidisciplinary critical care unit. Hypovolemia and sepsis are common in such patients and affect a number of organ systems. Monitoring these systems provides therapeutically relevant information that may decrease morbidity and improve patient survival. Circulatory hemodynamics may be assessed by direct measurement of the arterial blood pressure, central venous and pulmonary artery pressure monitoring and cardiac output determination; the data thus obtained are valuable in guiding fluid replacement in the hypovolemic individual. The respiratory status may be assessed by bedside spirometry and measurement of arterial blood gas tensions to gauge pulmonary function and the need for assisted ventilation. Renal dysfunction is common in such patients; careful analysis of both urine and blood may identify prerenal as opposed to renal and postrenal factors. Monitoring of the gastrointestinal tract, especially for hemorrhage, is important. Finally, careful attention to nutritional status and provision of adequate protein and energy intake by mouth or by vein is a vital component of the optimal care of these patients. PMID:115566

  13. 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

  14. Lung ultrasound in the critically ill

    PubMed Central

    2014-01-01

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

  15. Lung ultrasound in the critically ill.

    PubMed

    Lichtenstein, Daniel A

    2014-01-01

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

  16. Nerve excitability changes in critical illness polyneuropathy.

    PubMed

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

    2006-09-01

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

  17. Ebola virus disease and critical illness.

    PubMed

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

    2016-01-01

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

  18. Nutritional therapy in critically ill and injured patients.

    PubMed

    Latifi, Rifat

    2011-06-01

    Nutritional support of critically ill or injured patients has undergone significant advances in the last few decades. These advances are the direct result of the growing scientific progress and increased knowledge of the biology and biochemistry of key metabolic and nutrient changes induced by injury, sepsis, and other critical illnesses, both in adults and children. As this knowledge has increased, the science of nutritional support has become more disease based and disorder based. This article discusses protein and nitrogen metabolism in critically ill patients, immunomodulation, and the key nutrients involved in an immune-enhancing diet.

  19. [Scoring system for early detection of critical illness can fail].

    PubMed

    Kamstrup Christiansen, Lærke; Andreasen, Jo Bønding; Frederiksen, Christian Alcaraz; Juhl-Olsen, Peter; Sloth, Erik

    2013-02-18

    A 57-year old male underwent elective aortic valve replacement. The immediate post-operative course was uneventful and the patient was discharged with the lowest possible score on a newly implemented scale for early detection of critical illness. The following day he was readmitted with dyspnoea. The critical illness score was still low despite ultrasonic demonstration of a large pericardial effusion requiring drainage. We are concerned that the widely adopted critical illness scale is not sufficiently sensitive for cardiac surgery patients and advocate the use of point-of-care ultrasound.

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

    PubMed

    Bittinger, M; Messmann, H

    2013-05-01

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

  1. The pharmacologic approach to the critically ill patient

    SciTech Connect

    Chernow, B. )

    1988-01-01

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

  2. Prospective determination of plasma imipenem concentrations in critically ill children.

    PubMed

    Giannoni, Eric; Moreillon, Philippe; Cotting, Jacques; Moessinger, Adrien; Bille, Jacques; Décosterd, Laurent; Zanetti, Giorgio; Majcherczyk, Paul; Bugnon, Denis

    2006-07-01

    Plasma imipenem concentrations were measured in 19 critically ill children (median age, 0.8 year; range, 0.02 to 12.9 years). Wide interindividual variations (2 to 4x at peak and >10x at trough concentrations) resulted in unpredictable plasma levels in several children. To avoid subtherapeutic drug levels, we recommend treatment with at least 100 mg/kg of body weight/day of imipenem-cilastatin for critically ill children requiring such therapy.

  3. 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.

  4. Generalized periodic discharges in the critically ill

    PubMed Central

    Claassen, Jan; Abou Khaled, Karine; Jirsch, Jeffrey; Alschuler, Daniel M.; Wittman, John; Emerson, Ronald G.; Hirsch, Lawrence J.

    2012-01-01

    Objective: Generalized periodic discharges are increasingly recognized on continuous EEG monitoring, but their relationship to seizures and prognosis remains unclear. Methods: All adults with generalized periodic discharges from 1996 to 2006 were matched 1:1 to controls by age, etiology, and level of consciousness. Overall, 200 patients with generalized periodic discharges were matched to 200 controls. Results: Mean age was 66 years (range 18–96); 56% were comatose. Presenting illnesses included acute brain injury (44%), acute systemic illness (38%), cardiac arrest (15%), and epilepsy (3%). A total of 46% of patients with generalized periodic discharges had a seizure during their hospital stay (almost half were focal), vs 34% of controls (p = 0.014). Convulsive seizures were seen in a third of both groups. A total of 27% of patients with generalized periodic discharges had nonconvulsive seizures, vs 8% of controls (p < 0.001); 22% of patients with generalized periodic discharges had nonconvulsive status epilepticus, vs 7% of controls (p < 0.001). In both groups, approximately half died or were in a vegetative state, one-third had severe disability, and one-fifth had moderate to no disability. Excluding cardiac arrest patients, generalized periodic discharges were associated with increased mortality on univariate analysis (36.8% vs 26.9%; p = 0.049). Multivariate predictors of worse outcome were cardiac arrest, coma, nonconvulsive status epilepticus, and sepsis, but not generalized periodic discharges. Conclusion: Generalized periodic discharges were strongly associated with nonconvulsive seizures and nonconvulsive status epilepticus. While nonconvulsive status epilepticus was independently associated with worse outcome, generalized periodic discharges were not after matching for age, etiology, and level of consciousness. PMID:23035068

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

    PubMed

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

    2016-09-01

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

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

    PubMed

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

    2012-05-01

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

  7. Waking up the gut in critically ill patients.

    PubMed

    Meier, Juris J

    2010-01-01

    Multiorgan failure frequently develops in critically ill patients. While therapeutic efforts in such patients are often focused on the lungs, on the cardiovascular system as well as on the kidneys, it is important to also consider the functional alterations in gut motility and hormone secretion. Given the central regulatory functions of many gut hormones, such as glucagon-like peptide 1, glucagon-like peptide 2, ghrelin and others, exogenous supplementation of some of these factors may be beneficial under conditions of critical illness. From a pragmatic point of view, the most feasible way towards a restoration of gut hormone secretion in critically ill patients is to provide enteral nutritional supply as soon as possible.

  8. Assessment and treatment of hyperglycemia in critically ill patients

    PubMed Central

    Viana, Marina Verçoza; Moraes, Rafael Barberena; Fabbrin, Amanda Rodrigues; Santos, Manoella Freitas; Gerchman, Fernando

    2014-01-01

    Hyperglycemia is a commonly encountered issue in critically ill patients in the intensive care setting. The presence of hyperglycemia is associated with increased morbidity and mortality, regardless of the reason for admission (e.g., acute myocardial infarction, status post-cardiovascular surgery, stroke, sepsis). However, the pathophysiology and, in particular, the treatment of hyperglycemia in the critically ill patient remain controversial. In clinical practice, several aspects must be taken into account in the management of these patients, including blood glucose targets, history of diabetes mellitus, the route of nutrition (enteral or parenteral), and available monitoring equipment, which substantially increases the workload of providers involved in the patients' care. This review describes the epidemiology, pathophysiology, management, and monitoring of hyperglycemia in the critically ill adult patient. PMID:24770692

  9. [Assessment and treatment of hyperglycemia in critically ill patients].

    PubMed

    Viana, Marina Verçoza; Moraes, Rafael Barberena; Fabbrin, Amanda Rodrigues; Santos, Manoella Freitas; Gerchman, Fernando

    2014-01-01

    Hyperglycemia is a commonly encountered issue in critically ill patients in the intensive care setting. The presence of hyperglycemia is associated with increased morbidity and mortality, regardless of the reason for admission (e.g., acute myocardial infarction, status post-cardiovascular surgery, stroke, sepsis). However, the pathophysiology and, in particular, the treatment of hyperglycemia in the critically ill patient remain controversial. In clinical practice, several aspects must be taken into account in the management of these patients, including blood glucose targets, history of diabetes mellitus, the route of nutrition (enteral or parenteral), and available monitoring equipment, which substantially increases the workload of providers involved in the patients' care. This review describes the epidemiology, pathophysiology, management, and monitoring of hyperglycemia in the critically ill adult patient.

  10. Antioxidant Vitamins and Trace Elements in Critical Illness.

    PubMed

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

    2016-08-01

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

  11. Fish Oil in Critical Illness: Mechanisms and Clinical Applications

    PubMed Central

    Stapleton, Renee D.; Martin, Julie M.; Mayer, Konstantin

    2015-01-01

    SYNOPSIS Fish oil is rich in omega-3 fatty acids which have been shown to be beneficial in multiple disease states that involve an inflammatory process. It is now hypothesized that omega-3 fatty acids may decrease the inflammatory response and be beneficial in critical illness. After a review of the mechanisms of omega-3 fatty acids in inflammation, research using enteral nutrition formulas and parenteral nutrition lipid emulsions fortified with fish oil are examined. The results of this research to date are inconclusive for both enteral and parenteral omega-3 fatty acid administration. More research is required before definitive recommendations can be made on fish oil supplementation in critical illness. PMID:20643303

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

    PubMed

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

    2015-12-01

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

  13. Transthoracic echocardiography in obstetric anaesthesia and obstetric critical illness.

    PubMed

    Dennis, A T

    2011-04-01

    Transthoracic echocardiography (TTE) is a powerful non-invasive diagnostic, monitoring and measurement device in medicine. In addition to cardiologists, many other specialised groups, including emergency and critical care physicians and cardiac anaesthetists, have recognised its ability to provide high quality information and utilise TTE in the care of their patients. In obstetric anaesthesia and management of obstetric critical illness, the favourable characteristics of pregnant women facilitate TTE examination. These include anterior and left lateral displacement of the heart, frequent employment of the left lateral tilted position to avoid aortocaval compression, spontaneous ventilation and wide acceptance of ultrasound technology by women. Of relevance to obstetric anaesthetists is that maternal morbidity and mortality due to cardiovascular disease is significant worldwide. This makes TTE an appropriate, important and applicable device in pregnant women. Clinician-performed TTE enables differentiation between the life-threatening causes of hypotension. In the critically ill woman this improves diagnostic accuracy and allows treatment interventions to be instituted and monitored at the point of patient care. This article outlines the application of TTE in the specialty of obstetric anaesthesia and in the management of obstetric critical illness. It describes the importance of TTE education, quality assurance and outcome recording. It also discusses how barriers to the routine implementation of TTE in obstetric anaesthesia and management of obstetric critical illness can be overcome. PMID:21315578

  14. Nutritional support in critically ill patients with cancer.

    PubMed

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

    2001-07-01

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

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

    PubMed Central

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

    2015-01-01

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

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

    PubMed

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

    2015-10-12

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

  17. Thrombo-prophylaxis in acutely ill medical and critically ill patients.

    PubMed

    Saigal, Saurabh; Sharma, Jai Prakash; Joshi, Rajnish; Singh, Dinesh Kumar

    2014-06-01

    Thrombo-prophylaxis has been shown to reduce the incidence of pulmonary embolism (PE) and mortality in surgical patients. The purpose of this review is to find out the evidence-based clinical practice criteria of deep vein thrombosis (DVT) prophylaxis in acutely ill medical and critically ill patients. English-language randomized controlled trials, systematic reviews, and meta-analysis were included if they provided clinical outcomes and evaluated therapy with low-dose heparin or related agents compared with placebo, no treatment, or other active prophylaxis in the critically ill and medically ill population. For the same, we searched MEDLINE, PUBMED, Cochrane Library, and Google Scholar. In acutely ill medical patients on the basis of meta-analysis by Lederle et al. (40 trials) and LIFENOX study, heparin prophylaxis had no significant effect on mortality. The prophylaxis may have reduced PE in acutely ill medical patients, but led to more bleeding events, thus resulting in no net benefit. In critically ill patients, results of meta-analysis by Alhazzani et al. and PROTECT Trial indicate that any heparin prophylaxis compared with placebo reduces the rate of DVT and PE, but not symptomatic DVT. Major bleeding risk and mortality rates were similar. On the basis of MAGELLAN trial and EINSTEIN program, rivaroxaban offers a single-drug approach to the short-term and continued treatment of venous thrombosis. Aspirin has been used as antiplatelet agent, but when the data from two trials the ASPIRE and WARFASA study were pooled, there was a 32% reduction in the rate of recurrence of venous thrombo-embolism and a 34% reduction in the rate of major vascular events.

  18. United States Critical Illness and Injury Trials Group.

    PubMed

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

    2013-03-01

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

  19. Pulmonary penetration of piperacillin and tazobactam in critically ill patients

    PubMed Central

    Felton, TW; McCalman, K; Malagon, I; Isalska, B; Whalley, S; Goodwin, J; Bentley, AM; Hope, WW

    2014-01-01

    Pulmonary infections in critically ill patients are common and associated with high morbidity and mortality. Piperacillin-tazobactam is a frequently used therapy in critically ill patients with pulmonary infection. Antibiotic concentrations in the lung reflect target site antibiotic concentrations in patients with pneumonia. The aim of this study was to assess the plasma and intra-pulmonary pharmacokinetics (PK) of piperacillin-tazobactam in critically ill patients administered standard piperacillin-tazobactam regimens. A population PK model was developed to describe plasma and intra-pulmonary piperacillin and tazobactam concentrations. The probability of piperacillin exposures reaching pharmacodynamic endpoints and the impact of pulmonary permeability on piperacillin and tazobactam pulmonary penetration was explored. The median piperacillin and tazobactam pulmonary penetration ratio was 49.3% and 121.2%, respectively. Pulmonary piperacillin and tazobactam concentration were unpredictable and negatively correlated to pulmonary permeability. Current piperacillin-tazobactam regimens may be insufficient to treat pneumonia caused by piperacillin-tazobactam susceptible organisms in some critically ill patients. PMID:24926779

  20. Management of pain, agitation, and delirium in critically ill patients.

    PubMed

    Pandharipande, Pratik P; Patel, Mayur B; Barr, Juliana

    2014-01-01

    Pain, agitation, and delirium (PAD) are common in critically ill patients. Consequently, analgesic and sedative medications are frequently administered to critically ill patients to treat PAD, to improve synchrony with mechanical ventilation, and to decrease the physiological stress response. However, prolonged, continuous deep sedation of intensive care unit (ICU) patients is associated with numerous adverse outcomes, including longer durations of mechanical ventilation, prolonged ICU stays, acute brain dysfunction, and an increased risk of death. The 2013 ICU PAD Guidelines were developed to provide a clear, evidence-based road map for clinicians to better manage PAD in critically ill patients. Significant knowledge gaps in these areas still remain, but if widely adopted, the PAD Guidelines can help bridge these gaps and will be transformative in terms of their impact on ICU care. Strong evidence indicates that linking PAD management strategies with ventilator weaning, early mobility, and sleep hygiene in ICU patients will result in significant synergistic benefits to patient care and reductions in costs. An interdisciplinary team-based approach, using proven process improvement strategies, and ICU patient and family activation and engagement, will help ensure successful implementation of the ICU PAD Care Bundle in ICUs. This paper highlights the major recommendations of the 2013 ICU PAD Guidelines. We hope this review will help ICU physicians and other health care providers advance the management of PAD in critically ill patients, and improve patients' clinical outcomes.

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

    PubMed

    Aitken, Leanne M; Marshall, Andrea P

    2015-02-01

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

  2. Assessment of pain and agitation in critically ill infants.

    PubMed

    Ramelet, A S

    1999-09-01

    Critically ill infants are subjected to many painful experiences that, if inadequately treated, can have severe physiological and psychological consequences. Optimal management of pain relies on the adequacy of nurses' assessment; this, however, is complicated by another common condition, agitation. A multidimensional assessment is therefore necessary to adequately identify pain and agitation. The aim of this descriptive study was to identify the cues that nurses caring for critically ill infants use to assess pain and agitation. A questionnaire, developed from the literature, was distributed to all registered nurses (85) working in the neonatal and paediatric intensive care units of an Australian teaching hospital. Questionnaires were completed by 41 nurses (a 57 per cent response rate). Results revealed that, except for diagnosis, there were no significant differences between the cues participants used to assess pain and those to assess agitation. Nurses used numerous cues from various sources: most importantly, their own judgement (99 per cent); the parents' judgement (90 per cent); the infant's environment; documentation (78 per cent), and the infant's cues (70 per cent). These findings demonstrate the relevance of the nurse's role in assessment of pain and agitation in critically ill infants. Nurses used cues specific to the critically ill rather than the less sick infant. Results of this study also show the difficulty of differentiating between pain and agitation. Further research on ways of distinguishing between the construct of pain and agitation needs to be undertaken.

  3. Social Dimensions of Mental Illness among Rural Elderly Populations.

    ERIC Educational Resources Information Center

    Hendricks, Jon; Turner, Howard B.

    1988-01-01

    Conducted statewide poll (N=743) in Kentucky to examine rural mental health. Results indicated that while physical health tended to be poorer among rural populations, when health was held constant there was inverse relationship between age and depression. Findings suggest that rural elderly are no more likely to be depressed than urban…

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

    ERIC Educational Resources Information Center

    Proctor, Enola K.; And Others

    1996-01-01

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

  5. Treating nonthyroidal illness syndrome in the critically ill patient: still a matter of controversy.

    PubMed

    Bello, G; Paliani, G; Annetta, M G; Pontecorvi, A; Antonelli, M

    2009-08-01

    The nonthyroidal illness syndrome (NTIS) is a clinical condition of abnormal thyroid function tests observed in patients with acute or chronic systemic illnesses. The laboratory parameters of NTIS usually include low serum levels of triiodothyronine, with normal or low levels of thyroxine and normal or low levels of thyroid-stimulating hormone. It is still a matter of controversy whether the NTIS represents a protective adaptation of the organism to a stressful event or a maladaptive response to illness that needs correction. Multiple studies have investigated the effect of thyroid hormone replacement therapy in certain clinical situations, such as caloric restriction, cardiac disease, acute renal failure, brain-dead potential donors, and burn patients. Treating patients with NTIS seems not to be harmful, but there is no persuasive evidence that it is beneficial. The administration of hypothalamic releasing factors in patients with NTIS appears to be safe and effective in improving metabolism and restoring the anterior pituitary pulsatile secretion in the chronic phase of critical illness. However, also this promising strategy needs to be explored further. Anyhow, an extremely prudent approach is needed if treatment is given. Much of the data appearing in the literature on the treatment of NTIS encourage further randomized controlled trials on large number of patients. At present, however, we believe that there is no indication for treating thyroid hormone abnormalities in critically ill patients until convincing proof of efficacy and safety is provided.

  6. Psychiatric complications in the critically ill cardiac patient.

    PubMed Central

    Sanders, K M; Cassem, E H

    1993-01-01

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

  7. Sedation in Critically Ill Children with Respiratory Failure

    PubMed Central

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

    2016-01-01

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

  8. Rare case of severe cholangiopathy following critical illness

    PubMed Central

    Patel, Kamal Vijaykant; Zaman, Sameer; Chang, Fuju; Wilkinson, Mark

    2014-01-01

    Secondary sclerosing cholangitis is a rare condition caused by disorders directly damaging the biliary tree. We present a case of a 34-year-old man with no pre-existing hepatobiliary disease who developed significant cholestasis and subsequent cholangitis while in the intensive care unit for multiorgan failure secondary to H1N1 influenza A (swine flu). After discharge from the intensive care unit, jaundice, fevers, abdominal pain, pruritus and ongoing cholestasis persisted, consistent with recurrent cholangitis. Secondary sclerosing cholangitis was confirmed by liver biopsy and endoscopic retrograde cholangiopancreatography. This is a case of the recently described syndrome of secondary sclerosing cholangitis following critical illness, with associated severe hypoxic and ischaemic injury. He subsequently developed recognised complications of sclerosing cholangitis, including fat-soluble vitamin deficiencies, recurrent cholangitis and liver fibrosis. To the best of our knowledge, this is the first reported case of secondary sclerosing cholangitis following critical illness in the UK. PMID:25270153

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

    PubMed

    Watson, Paula L

    2007-01-01

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

  10. Sedation in Critically Ill Children with Respiratory Failure

    PubMed Central

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

    2016-01-01

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

  11. Hyperglycemia and acute kidney injury in critically ill children

    PubMed Central

    Gordillo, Roberto; Ahluwalia, Tania; Woroniecki, Robert

    2016-01-01

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

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

    PubMed

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

    2010-01-01

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

  13. Gastroesophageal Reflux in Critically Ill Children: A Review

    PubMed Central

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

    2013-01-01

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

  14. Extreme Dysbiosis of the Microbiome in Critical Illness.

    PubMed

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

    2016-01-01

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

  15. Extreme Dysbiosis of the Microbiome in Critical Illness

    PubMed Central

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

    2016-01-01

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

  16. Extreme Dysbiosis of the Microbiome in Critical Illness

    PubMed Central

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

    2016-01-01

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

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

    PubMed

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

    2015-01-01

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

  18. "Eat your lunch!" - controversies in the nutrition of the acutely, non-critically ill medical inpatient.

    PubMed

    Schuetz, Philipp

    2015-01-01

    There is no doubt about the strong association of malnutrition and adverse medical outcomes including mortality, morbidity and quality of life. Particularly in the elderly and frail medical inpatient population, loss of appetite due to the acute illness further aggravates nutritional status. In fact, this relationship between acute disease and eating behaviour / nutritional status may well be bidirectional, with not only illness affecting nutritional status, but also dietary factors influencing the course of illness. Whether loss of appetite associated with acute illness is indeed a protective physiological response or a therapeutic target needing early corrective nutritional therapy is a matter of current debate and can only be resolved within a large and well-designed randomised controlled trial comparing early nutritional therapy with "appetite-guided" nutrition in this patient population. Apart from in critical care, where various large trials have recently been published, there is an important lack of high quality data from large randomised trials in unselected acutely ill medical inpatients to support the early use of nutritional therapy, to shed light on the optimal type, caloric amount and timing of nutritional therapy and to answer ultimately the question as to which patient population will in fact benefit from nutritional interventions. Currently, the EFFORT trial is enrolling patients and aims to fill these literature gaps. The aim of this review is to discuss the current evidence regarding nutritional therapy in acutely ill medical inpatients, and to recommend whether or not, based on today's available evidence, physician should indeed encourage their malnourished patients to "…finish their lunch". PMID:25906253

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

    PubMed

    Cotogni, Paolo; Pittiruti, Mauro

    2014-11-01

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

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

    PubMed Central

    Cotogni, Paolo; Pittiruti, Mauro

    2014-01-01

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

  1. A special population. The elderly deinstitutionalized chronically mentally ill patient.

    PubMed

    Talbott, J A

    1983-01-01

    Deinstitutionalization began with some noble sentiments: to treat and care for the mentally ill in settings that were closer to their homes, families, and neighborhoods; to treat people in more therapeutic and less restrictive settings; and to provide the array of services and settings in the community rather than in far distant institutions. However, few of these intentions have been realized. It is up to us to point out the discrimination, the inequity, indeed the insanity of our current practices and non-system.

  2. Critical illness in systemic lupus erythematosus and the antiphospholipid syndrome

    PubMed Central

    Williams, F; Chinn, S; Hughes, G; Leach, R

    2002-01-01

    Objectives: To investigate the causes, course, and outcome of critical illness requiring emergency admission to the intensive care unit (ICU) in patients with systemic lupus erythematosus (SLE) or the antiphospholipid syndrome (APS), or both. Methods: Critically ill patients with SLE or APS, or both, admitted to a London teaching hospital ICU over a 15 year period were studied. Demographic, diagnostic, physiological, laboratory, and survival data were analysed. Kaplan-Meier survival curves were constructed by age, time from first diagnosis of SLE, and time from first ICU admission. The log rank test and a backwards stepwise Cox regression were used to identify factors associated with reduced survival. Results: Sixty one patients with SLE alone (39%) and/or APS (61%) required 76 emergency admissions to the ICU. Patients had high severity of illness scores (median APACHE II 22 (range 8–45)) and multiorgan dysfunction. The primary diagnoses for patients admitted were infection in 31/76 (41%), renal disease in 16/76 (21%), cardiovascular disease in 12/76 (16%), and coagulopathies in 11/76 (14%). The commonest secondary diagnosis was renal dysfunction (49%). Factors associated with an increased risk of death were cyclophosphamide before admission, low white cell count, and high severity of illness score. Before adjustment for these factors renal disease had a strong adverse effect on long term survival (analysis by age at diagnosis p=0.005, analysis by time since first ICU admission, p=0.07). After adjustment, infection at admission to ICU was associated with an increased ICU mortality (p=0.02) and was the cause of death in 13/17 patients who died in the ICU. Similarly, after adjustment, APS was associated with reduced ICU survival (p=0.1) and reduced long term (p=0.03) survival. Seventeen patients (28%) died in the ICU, and 31 patients (51%) had died by the last follow up. Median time from ICU admission to death was four years. Overall five year survival from the

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

    PubMed

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

    2010-03-01

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

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

    PubMed

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

    2010-03-01

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

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

    PubMed Central

    Zheng, Xin; Woo, Benjamin K P

    2016-01-01

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

  6. Thromboprophylaxis in critically ill children in Spain and Portugal

    PubMed Central

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

    2015-01-01

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

  7. Enteral nutrition in the hemodynamically unstable critically ill patient.

    PubMed

    Flordelís Lasierra, J L; Pérez-Vela, J L; Montejo González, J C

    2015-01-01

    The benefit of enteral nutrition in critically ill patients has been demonstrated by several studies, especially when it is started early, in the first 24-48h of stay in the Intensive Care Unit, and this practice is currently advised by the main clinical guidelines. The start of enteral nutrition is controversial in patients with hemodynamic failure, since it may trigger intestinal ischemia. However, there are data from experimental studies in animals, as well as from observational studies in humans that allow for hypotheses regarding its beneficial effect and safety. Interventional clinical trials are needed to confirm these findings.

  8. Bone turnover in prolonged critical illness: effect of vitamin D.

    PubMed

    Van den Berghe, Greet; Van Roosbroeck, David; Vanhove, Philippe; Wouters, Pieter J; De Pourcq, Lutgart; Bouillon, Roger

    2003-10-01

    In prolonged critical illness, increased bone resorption and osteoblast dysfunction have been reported facing low 25 hydroxy vitamin D [25(OH)D] concentrations. The current study investigates the extent to which lack of nutritional vitamin D and time in intensive care contribute to bone loss in the critically ill. Prolonged critically ill patients (n = 22) were compared with matched controls and then randomized to daily vitamin D supplement of either +/- 200 IU (low dose) or +/- 500 IU (high dose). At intensive care admission, serum concentrations of 25(OH)D, 1,25 dihydroxyvitamin D(3), vitamin D-binding protein, ionized calcium, IL-1, and soluble IL-6-receptor were low, and PTH was normal. Circulating type-I collagen propeptides were high, alkaline phosphatase was normal, and osteocalcin was low. Bone resorption markers [(carboxy terminal cross-linked telopeptide of type I collagen (betaCTX), pyridinoline, deoxypyridinoline (DPD)] were 6-fold increased. Serum C-reactive protein (CRP) was 40-fold, IL-6 400-fold, TNFalpha levels 5-fold, and osteoprotegerin concentrations 3-fold higher than in controls. Soluble receptor activator of nuclear factor kappaB ligand was undetectable. High-dose vitamin D only slightly increased circulating 25 hydroxy vitamin D (P < 0.05), but 1,25 dihydroxyvitamin D(3) was unaltered. High-dose vitamin D slightly increased serum osteocalcin (P < 0.05) and decreased carboxy terminal propeptide type-I collagen (P < 0.05) but did not affect other bone turnover markers. Bone-specific alkaline phosphatase, urinary pyridinoline and DPD, and serum betaCTX markedly increased with time (P < 0.01). Circulating CRP and IL-6 decreased with time, whereas TNFalpha and IL-1 remained unaltered. The fall in CRP and IL-6 was more pronounced with the high- than low-dose vitamin D (P < 0.05). Except for a mirroring of betaCTX rise by a fall in osteoprotegerin, cytokines were unrelated to the progressively aggravating bone resorption. In conclusion, prolonged

  9. Nutrition intervention in the critically ill cardiothoracic patient.

    PubMed

    Cresci, Gail; Hummell, A Christine; Raheem, Sulieman Abdal; Cole, Denise

    2012-06-01

    Despite acute myocardial infarction and cardiac surgery accounting for 2 of the most common reasons patients are admitted to the intensive care unit, little attention and investigation have been directed specifically for these patients. This patient population therefore deserves special attention as they are often malnourished but require emergent interventions, making nutrition intervention challenging. This article reviews current medical interventions implemented in critically ill cardiothoracic patients and discusses evidence-based nutrition therapy, including enteral and parenteral feeding, glycemic control, and antioxidant provision. PMID:22516943

  10. Clinical monitoring of systemic hemodynamics in critically ill newborns.

    PubMed

    de Boode, Willem-Pieter

    2010-03-01

    Circulatory failure is a major cause of mortality and morbidity in critically ill newborn infants. Since objective measurement of systemic blood flow remains very challenging, neonatal hemodynamics is usually assessed by the interpretation of various clinical and biochemical parameters. An overview is given about the predictive value of the most used indicators of circulatory failure, which are blood pressure, heart rate, urine output, capillary refill time, serum lactate concentration, central-peripheral temperature difference, pH, standard base excess, central venous oxygen saturation and colour.

  11. Biomarkers in critical illness: have we made progress?

    PubMed Central

    Honore, Patrick M; Jacobs, Rita; Hendrickx, Inne; De Waele, Elisabeth; Van Gorp, Viola; Joannes-Boyau, Olivier; De Regt, Jouke; Boer, Willem; Spapen, Herbert D

    2016-01-01

    Biomarkers have emerged as exemplary key players in translational medicine. Many have been assessed for timely recognition, early treatment, and adequate follow-up for a variety of pathologies. Biomarker sensitivity has improved considerably over the last years but specificity remains poor, in particular when two “marker-sensitive” conditions overlap in one patient. Biomarker research holds an enormous potential for diagnostic and prognostic purposes in postoperative and critically ill patients who present varying degrees of inflammation, infection, and concomitant (sub)acute organ dysfunction or failure. Despite a remarkable progress in development and testing, biomarkers are not yet ready for routine use at the bedside. PMID:27799811

  12. Coagulation and complement system in critically ill patients.

    PubMed

    Helling, H; Stephan, B; Pindur, G

    2015-01-01

    Activation of coagulation and inflammatory response including the complement system play a major role in the pathogenesis of critical illness. However, only limited data are available addressing the relationship of both pathways and its assessment of a predictive value for the clinical outcome in intense care medicine. Therefore, parameters of the coagulation and complement system were studied in patients with septicaemia and multiple trauma regarded as being exemplary for critical illness. 34 patients (mean age: 51.38 years (±16.57), 15 females, 19 males) were investigated at day 1 of admittance to the intensive care unit (ICU). Leukocytes, complement factors C3a and C5a were significantly (p <  0.0500) higher in sepsis than in trauma, whereas platelet count and plasma fibrinogen were significantly lower in multiple trauma. Activation markers of coagulation were elevated in both groups, however, thrombin-antithrombin-complex was significantly higher in multiple trauma. DIC scores of 5 were not exceeded in any of the two groups. Analysing the influences on mortality (11/34; 32.35% ), which was not different in both groups, non-survivors were significantly older, had significantly higher multiple organ failure (MOF) scores, lactate, abnormal prothrombin times and lower C1-inhibitor activities, even more pronounced in early deaths, than survivors. In septic non-survivors protein C was significantly lower than in trauma. We conclude from these data that activation of the complement system as part of the inflammatory response is a significant mechanism in septicaemia, whereas loss and consumption of blood components including parts of the coagulation and complement system is more characteristic for multiple trauma. Protein C in case of severe reduction might be of special concern for surviving in sepsis. Activation of haemostasis was occurring in both diseases, however, overt DIC was not confirmed in this study to be a leading mechanism in critically ill patients

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

    PubMed

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

    2016-08-01

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

  14. Endocrine and metabolic considerations in critically ill patients 4

    PubMed Central

    Fliers, Eric; Bianco, Antonio C; Langouche, Lies; Boelen, Anita

    2016-01-01

    Patients in the intensive care unit (ICU) typically present with decreased concentrations of plasma tri-iodothyronine, low thyroxine, and normal range or slightly decreased concentration of thyroid-stimulating hormone. This ensemble of changes is collectively known as non-thyroidal illness syndrome (NTIS). The extent of NTIS is associated with prognosis, but no proof exists for causality of this association. Initially, NTIS is a consequence of the acute phase response to systemic illness and macronutrient restriction, which might be beneficial. Pathogenesis of NTIS in long-term critical illness is more complex and includes suppression of hypothalamic thyrotropin-releasing hormone, accounting for persistently reduced secretion of thyroid-stimulating hormone despite low plasma thyroid hormone. In some cases distinguishing between NTIS and severe hypothyroidism, which is a rare primary cause for admission to the ICU, can be difficult. Infusion of hypothalamic-releasing factors can reactivate the thyroid axis in patients with NTIS, inducing an anabolic response. Whether this approach has a clinical benefit in terms of outcome is unknown. In this Series paper, we discuss diagnostic aspects, pathogenesis, and implications of NTIS as well as its distinction from severe, primary thyroid disorders in patients in the ICU. PMID:26071885

  15. Update in the management of critically ill burned patients.

    PubMed

    Lorente, J A; Amaya-Villar, R

    2016-01-01

    The management of critically ill burn patients is challenging. These patients have to be managed in specialized centers, where the expertise of physicians and nursing personnel guarantees the best treatment. Mortality of burn patients has improved over the past decades due to a better understanding of burn shock pathophysiology, optimal surgical management, infection control and nutritional support. Indeed, a more aggressive resuscitation, early excision and grafting, the judicious use of topical antibiotics, and the provision of an adequate calorie and protein intake are key to attain best survival results. General advances in critical care have also to be implemented, including protective ventilation, glycemic control, selective decontamination of the digestive tract, and implementation of sedation protocols.

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

    PubMed

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

    2016-07-01

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

  17. Dangers of growth hormone therapy in critically ill patients.

    PubMed

    Ruokonen, E; Takala, J

    2000-07-01

    Prolonged stay of patients is the major challenge for modern intensive care because of its effects on morbidity and resource utilization. Severe trauma or infection are associated with the catabolic response, characterized by increased protein turnover and negative nitrogen balance. Severe catabolism leads to end-organ dysfunction and muscular weakness prolonging the need for mechanical ventilation. Catabolism cannot be prevented with standard parenteral or enteral nutritional formulas. In order to prevent the complications of catabolism in intensive care patients, recombinant growth hormone (rhGH) has been applied during two decades as an experimental therapy for patients requiring parenteral nutrition and for those with respiratory failure. Administration of rhGH has resulted in positive nitrogen balance, and studies in mechanically ventilated patients suggest that it may shorten the need for ventilatory support. In contrast to the results of these relatively small studies, a recent multinational randomized controlled trial revealed that the administration of rhGH (with doses 10-20 times higher than those used for replacement therapy) increases the mortality of critically ill patients. This excessive mortality in patients treated with rhGH was related to infections and development of multiple organ failure. Administration of high doses of rhGH to critically ill patients cannot thus be recommended.

  18. Ethical challenges of treating the critically ill pregnant patient.

    PubMed

    van Bogaert, Louis-Jacques; Dhai, A

    2008-10-01

    Most ethical issues in obstetrics, both in the critical care and non-emergency situations, hinge around the maternal-fetal relationship. With access to the necessary information and support, most women strive to improve their chance of having healthy babies. However, there could be situations where their interests do not correspond with fetal interests, thereby giving rise to conflict situations. At the centre of the debate about a possible conflict is the notion of the fetus as a patient. A pregnant woman's autonomy and informed refusal should be respected. Where she is not competent to make an informed decision, proxy consent should be obtained or the doctrine of substituted judgement be applied. A decision to withhold or withdraw treatment in the intensive care unit (ICU) should only occur once a definitive diagnosis of terminal illness is made. Standards for the management of the human-immunodeficiency-virus-positive woman in the obstetric ICU situtation should be no different from standards employed to manage a critically ill pregnant patient in ICU with a chronic medical disease.

  19. Agreement between two plasma bicarbonate assays in critically ill patients.

    PubMed

    Story, D A; Poustie, S

    2000-08-01

    Previous studies have suggested that measurement of plasma bicarbonate concentration using the Henderson-Hasselbalch equation may be unreliable, particularly in critically ill patients. We examined the agreement between two plasma bicarbonate concentration assays in critically ill patients. Data were collected from records of routine daily blood samples. Paired samples were taken at the same time from arterial lines. A Bland-Altman analysis was used to compare two bicarbonate assays in clinical use. The first used the Henderson-Hasselbalch equation for blood-gas machine calculations. The second used a spectrophotometric enzymatic technique. Comparing the enzymatic method to the calculated method (enzymatic minus calculated) the bias was -1.6 mmol/l (95% CI: -1.2 to -2.0 mmol/l). The limits of agreement were -5.85 mmol/l to 2.65 mmol/l. This study found poor agreement between the two bicarbonate assays. This poor agreement is clinically important but the causes are unclear. We suggest further investigation of the reliability of bicarbonate assays.

  20. Microcirculatory dysfunction and tissue oxygenation in critical illness.

    PubMed

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

    2015-11-01

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

  1. Glycemic control in non-diabetic critically ill patients

    PubMed Central

    Farrokhi, Farnoosh; Smiley, Dawn; Umpierrez, Guillermo E.

    2013-01-01

    Hyperglycemia is a common and costly health care problem in hospitalized patients. In hospital hyperglycemia is defined as any glucose value >7.8 mmol/l (140 mg/dl). Hyperglycemia is present in 40% of critically ill patients and in up to 80% of patients after cardiac surgery, with ~ 80% of ICU patients with hyperglycemia having no history of diabetes prior to admission. The risk of hospital complications relates to the severity of hyperglycemia, with a higher risk observed in patients without a history of diabetes compared to those with known diabetes. Improvement in glycemic control reduces hospital complications and mortality; however, the ideal glycemic target has not been determined. A target glucose level between 7.8 and 10.0 mmol/l (140 and 180 mg/dl) is recommended for the majority of ICU patients. This review aims to present updated recommendations for the inpatient management of hyperglycemia in critically ill patients with and without a history of diabetes. PMID:21925080

  2. Predictive equations for energy needs for the critically ill.

    PubMed

    Walker, Renee N; Heuberger, Roschelle A

    2009-04-01

    Nutrition may affect clinical outcomes in critically ill patients, and providing either more or fewer calories than the patient needs can adversely affect outcomes. Calorie need fluctuates substantially over the course of critical illness, and nutrition delivery is often influenced by: the risk of refeeding syndrome; a hypocaloric feeding regimen; lack of feeding access; intolerance of feeding; and feeding-delay for procedures. Lean body mass is the strongest determinant of resting energy expenditure, but age, sex, medications, and metabolic stress also influence the calorie requirement. Indirect calorimetry is the accepted standard for determining calorie requirement, but is unavailable or unaffordable in many centers. Moreover, indirect calorimetry is not infallible and care must be taken when interpreting the results. In the absence of calorimetry, clinicians use equations and clinical judgment to estimate calorie need. We reviewed 7 equations (American College of Chest Physicians, Harris-Benedict, Ireton-Jones 1992 and 1997, Penn State 1998 and 2003, Swinamer 1990) and their prediction accuracy. Understanding an equation's reference population and using the equation with similar patients are essential for the equation to perform similarly. Prediction accuracy among equations is rarely within 10% of the measured energy expenditure; however, in the absence of indirect calorimetry, a prediction equation is the best alternative.

  3. Factors associated with vancomycin nephrotoxicity in the critically ill.

    PubMed

    Hanrahan, T P; Kotapati, C; Roberts, M J; Rowland, J; Lipman, J; Roberts, J A; Udy, A

    2015-09-01

    Vancomycin is a glycopeptide antibiotic commonly used in the management of methicillin-resistant Staphylococcus aureus infection. The recent increase in prevalence of methicillin-resistant Staphylococcus aureus with reduced susceptibility to vancomycin has prompted experts to advocate for higher target trough serum concentrations. This study aimed to evaluate the potential consequences of more aggressive vancomycin therapy, by examining the association between higher serum concentrations and acute kidney injury (AKI) in a population of critically ill patients. We collected data for all patients who received vancomycin over a five-year period and evaluated the prevalence of new-onset AKI using the Risk, Injury, Failure, Loss and End-stage (RIFLE) kidney disease criteria. One-hundred and fifty-nine patients provided complete data, with 8.8% manifesting new onset AKI while receiving vancomycin. The median age was 57 (44 to 68) years, while the median trough serum concentration was 16 (10 to 19) mg/l. Multivariate logistic regression analysis identified mean trough concentration (OR=1.174, P=0.024), APACHE II score (OR=1.141, P=0.012) and simultaneous aminoglycoside prescription (OR=18.896, P=0.002) as significant predictors of AKI. These data suggest higher trough vancomycin serum concentrations are associated with greater odds of AKI in the critically ill.

  4. Estimating Kidney Function in the Critically Ill Patients

    PubMed Central

    Seller-Pérez, Gemma; Herrera-Gutiérrez, Manuel E.; Maynar-Moliner, Javier; Sánchez-Izquierdo-Riera, José A.; do Pico, José Luis

    2013-01-01

    Glomerular filtration rate (GFR) is an accepted measure for assessment of kidney function. For the critically ill patient, creatinine clearance is the method of reference for the estimation of the GFR, although this is often not measured but estimated by equations (i.e., Cockroft-Gault or MDRD) not well suited for the critically ill patient. Functional evaluation of the kidney rests in serum creatinine (Crs) that is subjected to multiple external factors, especially relevant overhydration and loss of muscle mass. The laboratory method used introduces variations in Crs, an important fact considering that small increases in Crs have serious repercussion on the prognosis of patients. Efforts directed to stratify the risk of acute kidney injury (AKI) have crystallized in the RIFLE or AKIN systems, based in sequential changes in Crs or urine flow. These systems have provided a common definition of AKI and, due to their sensitivity, have meant a considerable advantage for the clinical practice but, on the other side, have introduced an uncertainty in clinical research because of potentially overestimating AKI incidence. Another significant drawback is the unavoidable period of time needed before a patient is classified, and this is perhaps the problem to be overcome in the near future. PMID:23862059

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

    PubMed Central

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

    2016-01-01

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

  6. Liver dysfunction associated with artificial nutrition in critically ill patients

    PubMed Central

    Grau, Teodoro; Bonet, Alfonso; Rubio, Mercedes; Mateo, Dolores; Farré, Mercé; Acosta, José Antonio; Blesa, Antonio; Montejo, Juan Carlos; de Lorenzo, Abelardo García; Mesejo, Alfonso

    2007-01-01

    Introduction Liver dysfunction associated with artificial nutrition in critically ill patients is a complication that seems to be frequent, but it has not been assessed previously in a large cohort of critically ill patients. Methods We conducted a prospective cohort study of incidence in 40 intensive care units. Different liver dysfunction patterns were defined: (a) cholestasis: alkaline phosphatase of more than 280 IU/l, gamma-glutamyl-transferase of more than 50 IU/l, or bilirubin of more than 1.2 mg/dl; (b) liver necrosis: aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l, plus bilirubin of more than 1.2 mg/dl or international normalized ratio of more than 1.4; and (c) mixed pattern: alkaline phosphatase of more than 280 IU/l or gamma-glutamyl-transferase of more than 50 IU/l, plus aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l. Results Seven hundred and twenty-five of 3,409 patients received artificial nutrition: 303 received total parenteral nutrition (TPN) and 422 received enteral nutrition (EN). Twenty-three percent of patients developed liver dysfunction: 30% in the TPN group and 18% in the EN group. The univariate analysis showed an association between liver dysfunction and TPN (p < 0.001), Multiple Organ Dysfunction Score on admission (p < 0.001), sepsis (p < 0.001), early use of artificial nutrition (p < 0.03), and malnutrition (p < 0.01). In the multivariate analysis, liver dysfunction was associated with TPN (p < 0.001), sepsis (p < 0.02), early use of artificial nutrition (p < 0.03), and calculated energy requirements of more than 25 kcal/kg per day (p < 0.05). Conclusion TPN, sepsis, and excessive calculated energy requirements appear as risk factors for developing liver dysfunction. Septic critically ill patients should not be fed with excessive caloric amounts, particularly when TPN is employed. Administering artificial nutrition in the first 24 hours

  7. Outcomes of critically ill cancer patients with Acinetobacter baumannii infection

    PubMed Central

    Ñamendys-Silva, Silvio A; Correa-García, Paulina; García-Guillén, Francisco J; González-Herrera, María O; Pérez-Alonso, Américo; Texcocano-Becerra, Julia; Herrera-Gómez, Angel; Cornejo-Juárez, Patricia; Meneses-García, Abelardo

    2015-01-01

    AIM: To describe the intensive care unit (ICU) outcomes of critically ill cancer patients with Acinetobacter baumannii (AB) infection. METHODS: This was an observational study that included 23 consecutive cancer patients who acquired AB infections during their stay at ICU of the National Cancer Institute of Mexico (INCan), located in Mexico City. Data collection took place between January 2011, and December 2012. Patients who had AB infections before ICU admission, and infections that occurred during the first 2 d of ICU stay were excluded. Data were obtained by reviewing the electronic health record of each patient. This investigation was approved by the Scientific and Ethics Committees at INCan. Because of its observational nature, informed consent of the patients was not required. RESULTS: Throughout the study period, a total of 494 critically ill patients with cancer were admitted to the ICU of the INCan, 23 (4.6%) of whom developed AB infections. Sixteen (60.9%) of these patients had hematologic malignancies. Most frequent reasons for ICU admission were severe sepsis or septic shock (56.2%) and postoperative care (21.7%). The respiratory tract was the most frequent site of AB infection (91.3%). The most common organ dysfunction observed in our group of patients were the respiratory (100%), cardiovascular (100%), hepatic (73.9%) and renal dysfunction (65.2%). The ICU mortality of patients with 3 or less organ system dysfunctions was 11.7% (2/17) compared with 66.6% (4/6) for the group of patients with 4 or more organ system dysfunctions (P = 0.021). Multivariate analysis identified blood lactate levels (BLL) as the only variable independently associated with in-ICU death (OR = 2.59, 95%CI: 1.04-6.43, P = 0.040). ICU and hospital mortality rates were 26.1% and 43.5%, respectively. CONCLUSION: The mortality rate in critically ill patients with both HM, and AB infections who are admitted to the ICU is high. The variable most associated with increased mortality was

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

    PubMed

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

    2015-03-17

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

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

    PubMed Central

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

    2015-01-01

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

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

    PubMed

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

    2015-03-01

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

  11. From Data Patterns to Mechanistic Models in Acute Critical Illness

    PubMed Central

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

    2014-01-01

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

  12. [Recommendations for artificial nutritional support in critically ill patients].

    PubMed

    de Luis, Daniel; Aller, Rocío; Culebras, Jesús

    2006-07-01

    The development of artificial nutritional support has been increased in the last years. Access routes and composition of formulas have been improved. Critic patients is a group of great controversy in this topic area. Enteral nutrition is better than parenteral nutrition in patients with inflammatory bowel disease, acute pancreatitis, burn and septic with a A level of evidence. Enteral nutrition is better than parenteral nutrition in patients with short bowel disease, chronic hepatopathy, surgery ot digestive tract in patients with cancer disease, patients with HIV infection and patients with politraumatism. Parenteral nutrition is better than enteral nutrition in patients with haematopoyetic transplantation with a B level of evidence. Some nutrients have been shown a beneficial effect in artificial nutritional support such as (diets low in fat and high in complex carbohydrates) (level A), diets with inmunonutrients in patients with surgery of digestive tract cancer (level B), diet enhanced with w3 fatty acids in patients with acute respiratory distress syndrome (level C), and patients with HIV infection (level B), diets enriched with glutamin in patients with politraumatism and haematopoyetic transplantation (level B). Specific diets have not been shown beneficial effects in some pathologies (short bowel syndrome, acute pancreatitis, renal insufficiency treated with dialysis, and respiratory insufficiency). Diets with arginine are contraindicated in septic critically ill patients (level A). In conclusion, artificial nutritional support in critic patients is a controversy topic area with a high level of change in knowledgments with new improvements in access route, diets and designs of interventional trials.

  13. Challenges for the endocrine laboratory in critical illness.

    PubMed

    Clark, P M S; Gordon, K

    2011-10-01

    The endocrine laboratory must provide accurate and timely results for the critically ill patient. A number of pathophysiological factors affect assay systems for adrenal, thyroid and gonadal function tests. The effects are primarily on estimates of 'free hormone' concentration through abnormal binding protein concentrations and the effects of drugs and metabolites on hormone-protein binding. The limitations of the principal analytical techniques (immunoassay and chromatography-mass spectrometry) include drug effects, endogenous antibody interference and ion suppression. These effects are not always easily identified. Analytical specificity and standardisation result in differences in bias between assays and thus a requirement for assay specific decision limits and reference ranges. Good communication between clinician and laboratory is needed to minimise these effects. Developments in mass spectrometry should lead to greater sensitivity and wider applicability of the technique. International efforts to develop higher order reference materials and reference method procedures should lead to greater comparability of results.

  14. [Tissue oxygen saturation in the critically ill patient].

    PubMed

    Gruartmoner, G; Mesquida, J; Baigorri, F

    2014-05-01

    Hemodynamic resuscitation seeks to correct global macrocirculatory parameters of pressure and flow. However, current evidence has shown that despite the normalization of these global parameters, microcirculatory and regional perfusion alterations can persist, and these alterations have been independently associated with a poorer patient prognosis. This in turn has lead to growing interest in new technologies for exploring regional circulation and microcirculation. Near infra-red spectroscopy allows us to monitor tissue oxygen saturation, and has been proposed as a noninvasive, continuous and easy-to-obtain measure of regional circulation. The present review aims to summarize the existing evidence on near infra-red spectroscopy and its potential clinical role in the resuscitation of critically ill patients in shock.

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

    PubMed

    Schulman, Rifka C; Mechanick, Jeffrey I

    2013-01-01

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

  16. Metabolic response to the stress of critical illness.

    PubMed

    Preiser, J-C; Ichai, C; Orban, J-C; Groeneveld, A B J

    2014-12-01

    The metabolic response to stress is part of the adaptive response to survive critical illness. Several mechanisms are well preserved during evolution, including the stimulation of the sympathetic nervous system, the release of pituitary hormones, a peripheral resistance to the effects of these and other anabolic factors, triggered to increase the provision of energy substrates to the vital tissues. The pathways of energy production are altered and alternative substrates are used as a result of the loss of control of energy substrate utilization by their availability. The clinical consequences of the metabolic response to stress include sequential changes in energy expenditure, stress hyperglycaemia, changes in body composition, and psychological and behavioural problems. The loss of muscle proteins and function is a major long-term consequence of stress metabolism. Specific therapeutic interventions, including hormone supplementation, enhanced protein intake, and early mobilization, are investigated. This review aims to summarize the pathophysiological mechanisms, the clinical consequences, and therapeutic implications of the metabolic response to stress.

  17. Echocardiographic Hemodynamic Monitoring in the Critically Ill Patient

    PubMed Central

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

    2011-01-01

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

  18. Cost-of-illness studies: a guide to critical evaluation.

    PubMed

    Larg, Allison; Moss, John R

    2011-08-01

    Cost-of-illness (COI) studies aim to assess the economic burden of health problems on the population overall, and they are conducted for an ever widening range of health conditions and geographical settings. While they attract much interest from public health advocates and healthcare policy makers, inconsistencies in the way in which they are conducted and a lack of transparency in reporting have made interpretation difficult, and have ostensibly limited their usefulness. Yet there is surprisingly little in the literature to assist the non-expert in critically evaluating these studies. This article aims to provide non-expert readers with a straightforward guide to understanding and evaluating traditional COI studies. The intention is to equip a general audience with an understanding of the most important issues that influence the validity of a COI study, and the ability to recognize the most common limitations in such work.

  19. Powered intraosseous device (EZ-IO) for critically ill patients.

    PubMed

    Oksan, Derinoz; Ayfer, Keles

    2013-07-01

    We reviewed the charts of 25 patients who underwent powered intraosseous line insertion between July 1, 2008 and August 31, 2010 to determine its users, indications, procedural details, success rates, and complications. Intraosseous (IO) line was inserted in the anteromedial aspect of the proximal tibia in all patients. The first attempt was successful in 80%, and the median duration for insertion of the IO line was 4 hours. Extravasation was the most common complication. Ninety-six percent of the physicians had undergone prior training in IO insertion. Because of its high success and short procedure time, IO access should be the first alternative to failed vascular access in critically ill children. Training in IO should be extended to all who care for pediatric patients in inpatient as well as in prehospital and emergency department settings.

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

    PubMed

    Kotake, Yoshifumi

    2016-01-01

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

  1. Scoring Systems in Assessing Survival of Critically Ill ICU Patients

    PubMed Central

    Sekulic, Ana D.; Trpkovic, Sladjana V.; Pavlovic, Aleksandar P.; Marinkovic, Olivera M.; Ilic, Aleksandra N.

    2015-01-01

    Background The aim of this study was to determine which of the most commonly used scoring systems for evaluation of critically ill patients in the ICU is the best and simplest to use in our hospital. Material/Methods This prospective study included 60 critically ill patients. After admittance to the ICU, APACHE II, SAPS II, and MPM II0 were calculated. During further treatment in the ICU, SOFA and MPM II were calculated at 24 h, 48 h, and 72 h and 7 days after admittance using laboratory and radiological measures. Results In comparison with survivors, non-survivors were older (p<0.01) and spent significantly more days on mechanical ventilation (p<0.01). ARDS was significantly more common in patients who survived compared to those who did not (chi-square=7.02, p<0.01), which is not the case with sepsis (chi-square=0.388, p=0.53). AUROC SAPS II was 0.690, and is only slightly higher than the other 2 AUROC incipient scoring systems, MPM II and APACHE II (0.654 and 0.623). The APACHE II has the highest specificity (81.8%) and MPM II the highest sensitivity (85.2%). MPM II7day AUROC (1.0) shows the best discrimination between patients who survived and those who did not. MPM II48 (0.836), SOFA72 (0.821) and MPM II72 (0.817) also had good discrimination scores. Conclusions APACHE II and SAPS II measured on admission to the ICU were significant predictors of complications. MPM II7day has the best discriminatory power, followed by SOFA7day and MPM II48. MPM II7day has the best calibration followed by SOFA7day and APACHE II. PMID:26336861

  2. Care-related pain in critically ill mechanically ventilated patients.

    PubMed

    Ayasrah, S

    2016-07-01

    Despite advances in pain management, critically ill patients continue to have unacceptably high rates of uncontrolled pain. Using the Behavioural Pain Scale and physiological indicators of pain, this study examines pain levels in mechanically ventilated patients prior to and during routine nursing procedures. A prospective descriptive design was used to assess and describe care-related pain associated with nociceptive procedures (repositioning, endotracheal suctioning, and vascular punctures) and non-nociceptive procedures (mouth care, eye care and dressing change). A sample of 247 mechanically ventilated Jordanian patients was recruited from intensive care units in a military hospital. The overall mean procedural pain score of 6.34 (standard deviation [SD] 2.36) was significantly higher than the mean preprocedural pain score of 3.43 (SD 0.67, t[246]=20.82, P<0.001). The highest mean procedural pain scores were observed during repositioning (9.25, SD 1.29). Few patients received analgesics and/or sedatives in the hour prior to the procedures. The mean Ramsay Scale score was 2.49 (SD 0.95), indicating that patients were either anxious or responsive to command only. The mean physiological indicators of pain increased during repositioning and endotracheal suctioning and decreased during the rest of the procedures. Mechanically ventilated patients experience pain prior to and during routine nursing procedures. Harmless and comfort procedures are actually painful. When caring for nonverbal critically ill patients, clinicians need to consider care-related pain associated with their interventions. Relying on changes in vital signs as a primary indicator of pain can be misleading. PMID:27456175

  3. Low but Sufficient Anidulafungin Exposure in Critically Ill Patients

    PubMed Central

    van Wanrooy, Marjolijn J. P.; Rodgers, Michael G. G.; Uges, Donald R. A.; Arends, Jan P.; Zijlstra, Jan G.; van der Werf, Tjip S.; Kosterink, Jos G. W.

    2014-01-01

    The efficacy of anidulafungin is driven by the area under the concentration-time curve (AUC)/MIC ratio. Patients in intensive care may be at risk for underexposure. In critically ill patients with an invasive Candida infection, the anidulafungin exposure and a possible correlation with disease severity or plasma protein levels were explored. Concentration-time curves were therefore obtained at steady state. Anidulafungin concentrations were measured with a validated liquid chromatography-tandem mass spectrometry (LC-MS/MS) method. The MIC values of the Candida species were determined with the Etest. The target AUC/MIC ratio was based on European Committee on Antimicrobial Susceptibility Testing (EUCAST) data. Twenty patients were included. The patients received a maintenance dose of 100 mg once daily after a loading dose of 200 mg on the first day. The mean (±standard deviation) AUC, maximum concentration of drug in plasma (Cmax), and minimum concentration of drug in plasma (Cmin) were 69.8 ± 24.1 mg · h/liter, 4.7 ± 1.4 mg/liter, and 2.2 ± 0.8 mg/liter, respectively. The MIC values of all cultured Candida species were below the EUCAST MIC breakpoints. The exposure to anidulafungin in relation to the MIC that was determined appeared sufficient in all patients. The anidulafungin exposure was low in our critically ill patients. However, combined with the low MICs of the isolated Candida strains, the lower exposure observed in comparison to the exposure in the general patient population resulted in favorable AUC/MIC ratios, based on EUCAST data. No correlation was observed between anidulafungin exposure and disease severity or plasma protein concentrations. In patients with less-susceptible Candida albicans or glabrata strains, we recommend considering determining the anidulafungin exposure to ensure adequate exposure. (This trial has been registered at ClinicalTrials.gov under registration no. NCT01047267.) PMID:24165173

  4. Colistin: how should it be dosed for the critically ill?

    PubMed

    Landersdorfer, Cornelia B; Nation, Roger L

    2015-02-01

    Colistin, an "old" polymyxin antibiotic, is increasingly being used as last-line treatment against infections caused by multidrug-resistant gram-negative bacteria. It is administered in patients, parenterally or by inhalation, as its inactive prodrug colistin methanesulfonate (CMS). Scientifically based recommendations on how to optimally dose colistin in critically ill patients have become available over the last decade and are extremely important as colistin has a narrow therapeutic window. A dosing algorithm has been developed to achieve desired plasma colistin concentrations in critically ill patients. This includes the necessary dose adjustments for patients with impaired kidney function and those on renal replacement therapy. Due to the slow conversion of CMS to colistin, a loading dose is needed to generate effective concentrations within a reasonable time period. Therapeutic drug monitoring is warranted, where available; because of the observed high interpatient variability in plasma colistin concentrations. Combination therapy should be considered when the infecting pathogen has a colistin minimum inhibitory concentration above 1 mg/L, as increasing the dose may not be feasible due to the risk for nephrotoxicity. Inhalation of CMS achieves considerably higher colistin concentrations in lung fluids than is possible with intravenous administration, with negligible plasma exposure. Similarly, for central nervous system infections, dosing CMS directly into the cerebrospinal fluid generates significantly higher colistin concentrations at the infection site compared with what can be achieved with systemic administration. While questions remain to be addressed via ongoing research, this article reviews the significant advances that have been made toward optimizing the clinical use of colistin.

  5. [Social representations and living conditions of the mentally ill and mentally retarded elderly in nursing homes.].

    PubMed

    Dorvil, H; Benoit, M

    1999-01-01

    The aging of the population in Québec as in the rest of the western world, brings to the fore people who until now were greatly marginalized. This is the case of mentally ill and mentally retarded elderly who until recently, lived their aging in the shadow of psychiatric institutions. Have these people now found with deinstitutionalization, the possibility of growing old within society ? This article analyses the conditions of integration and support networks, in sum a collective responsability of these aging people in nursing homes.

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

    PubMed Central

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

    2013-01-01

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

  7. [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.

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

    PubMed

    Honiden, Shyoko; Inzucchi, Silvio E

    2015-12-01

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

  9. Mechanical Signaling in the Pathophysiology of Critical Illness Myopathy

    PubMed Central

    Kalamgi, Rebeca C.; Larsson, Lars

    2016-01-01

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

  10. Modified critical care and treatment space considerations for mass casualty critical illness and injury.

    PubMed

    Hotchkin, David L; Rubinson, Lewis

    2008-01-01

    Mass critical care events are increasingly likely, yet the resource challenges to augment everyday, unrestricted critical care for a surge of disaster victims are insurmountable for nearly all communities. In light of these limitations, an expert panel defined a circumscribed set of key critical care interventions that they believed could be offered to many additional people and yet would also continue to offer substantial life-sustaining benefits for nonmoribund critically ill and injured people. They proposed Emergency Mass Critical Care, which is based on the set of key interventions and includes recommendations for necessary surge medical equipment, treatment space characteristics, and staffing competencies for mass critical care response. To date, Emergency Mass Critical Care is untested, and the real benefits of implementation remain uncertain. Nonetheless, Emergency Mass Critical Care currently remains the only comprehensive construct for mass critical care preparedness and response. This paper reviews current concepts to provide life-sustaining care for hundreds or thousands of people outside of traditional critical care sites. PMID:18173861

  11. Nicotine withdrawal and agitation in ventilated critically ill patients

    PubMed Central

    2010-01-01

    Introduction Smoking is highly addictive, and nicotine abstinence is associated with withdrawal syndrome in hospitalized patients. In this study, we aimed to evaluate the impact of sudden nicotine abstinence on the development of agitation and delirium, and on morbidities and outcomes in critically ill patients who required respiratory support, either noninvasive ventilation or intubation, and mechanical ventilation. Methods We conducted a prospective, observational study in two intensive care units (ICUs). The 144 consecutive patients admitted to ICUs and requiring mechanical ventilation for >48 hours were included. Smoking status was assessed at ICU admission by using the Fagerström Test of Nicotine Dependence (FTND). Agitation, with the Sedation-Agitation Scale (SAS), and delirium, with the Intensive Care Delirium Screening Checklist (ICDSC), were tested twice daily during the ICU stay. Agitation and delirium were defined by SAS >4 and ICDSC >4, respectively. Nosocomial complications and outcomes were evaluated. Results Smokers (n = 44) were younger and more frequently male and were more likely to have a history of alcoholism and to have septic shock as the reason for ICU admission than were nonsmokers. The incidence of agitation, but not delirium, increased significantly in the smoker group (64% versus 32%; P = 0.0005). Nicotine abstinence was associated with higher incidences of self-removal of tubes and catheters, and with more interventions, including the need for supplemental sedatives, analgesics, neuroleptics, and physical restraints. Sedation-free days, ventilator-free days, length of stay, and mortality in ICUs did not differ between groups. Multivariate analysis identified active smoking (OR, 3.13; 95% CI, 1.45-6.74; P = 0.003) as an independent risk factor for agitation. Based on a subgroup of 56 patients, analysis of 28 pairs of patients (smokers and nonsmokers in a 1:1 ratio) matched for age, gender, and alcoholism status found similar results

  12. [The Technology Acceptance Model and Its Application in a Telehealth Program for the Elderly With Chronic Illnesses].

    PubMed

    Chang, Chi-Ping

    2015-06-01

    Many technology developments hold the potential to improve the quality of life of people and make life easier and more comfortable. New technologies have been well accepted by most people. Information sharing in particular is a major catalyst of change in our current technology-based society. Technology has widely innovated life and drastically changed lifestyles. The Technology Acceptance Model (TAM), a model developed to address the rapid advances in computer technology, is used to explain and predict user acceptance of new information technology. In the past, businesses have used the TAM as an assessment tool to predict user acceptance when introducing new technology products. They have also used external factors in the model to influence user perceptions and beliefs and to ensure the successful spread of new technologies. Informatization plays a critical role in healthcare services. Due to the rapid aging of populations and upward trends in the incidence of chronic illness, requirements for long-term care have increased in both quality and quantity. Therefore, there has been an increased emphasis on integrating healthcare and information technology. However, most elderly are significantly less adept at technology use than the general population. Therefore, we reexamined the effect that the essential concepts in a TAM exerted on technology acceptance. In the present study, the technology acceptance experience with regard to telehealth of the elderly was used as an example to explain how the revised technology acceptance model (TAM 2) may be effectively applied to enhance the understanding of technology care among nurses. The results may serve as a reference for future research on healthcare-technology use in long-term care or in elderly populations.

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

    PubMed

    Forssén, Annika S K; Carlstedt, Gunilla

    2008-01-01

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

  14. Ultrasound-guided percutaneous tracheostomy in critically ill obese patients

    PubMed Central

    2012-01-01

    Introduction The purpose of this study was to evaluate the feasibility of ultrasound (US)-guided percutaneous tracheostomy (PCT) and the incidence of complications in critically ill, obese patients. Methods Fifty consecutive patients were included in a prospective study in two surgical and critical care medicine departments. Obesity was defined as a body mass index (BMI) of at least 30 kg/m2. The feasibility of PCT and the incidence of complications were compared in obese patients (n = 26) and non-obese patients (n = 24). Results are expressed as the median (25th-75th percentile) or number (percentage). Results The median BMIs were 34 kg/m2 (32-38) in the obese patient group and 25 kg/m2 (24-28) in the non-obese group (p < 0.001). The median times for tracheostomy were 10 min (8-14) in non-obese patients and 9 min (5-10) in obese-patients (p = 0.1). The overall complication rate was similar in obese and non-obese patient groups (35% vs. 33%, p = 0.92). Most complications were minor (hypotension, desaturation, tracheal cuff puncture and minor bleeding), with no differences between obese and non-obese groups. Bronchoscopic inspection revealed two cases of granuloma (8%) in obese patients. One non-obese patient developed a peristomal skin infection, which was treated with intravenous antibiotics. Ultrasound-guided PCT was possible in all enrolled patients and there were no surgical conversions or deaths. Conclusions This study demonstrated that US-guided PCT is feasible in obese patients with a low complication rate. Obesity may not constitute a contra-indication for US-guided PCT. A US examination provides information on cervical anatomy and hence modifies and guides choice of the PCT puncture site. Trial registration ClinicalTrials.gov: NCT01502657. PMID:22390815

  15. Population Pharmacokinetics of Fosfomycin in Critically Ill Patients

    PubMed Central

    Parker, Suzanne L.; Frantzeskaki, Frantzeska; Wallis, Steven C.; Diakaki, Chryssa; Giamarellou, Helen; Koulenti, Despoina; Karaiskos, Ilias; Lipman, Jeffrey; Dimopoulos, George

    2015-01-01

    This study describes the population pharmacokinetics of fosfomycin in critically ill patients. In this observational study, serial blood samples were taken over several dosing intervals of intravenous fosfomycin treatment. Blood samples were analyzed using a validated liquid chromatography-tandem mass spectrometry technique. A population pharmacokinetic analysis was performed using nonlinear mixed-effects modeling. Five hundred fifteen blood samples were collected over one to six dosing intervals from 12 patients. The mean (standard deviation) age was 62 (17) years, 67% of patients were male, and creatinine clearance (CLCR) ranged from 30 to 300 ml/min. A two-compartment model with between-subject variability on clearance and volume of distribution of the central compartment (Vc) described the data adequately. Calculated CLCR was supported as a covariate on fosfomycin clearance. The mean parameter estimates for clearance on the first day were 2.06 liters/h, Vc of 27.2 liters, intercompartmental clearance of 19.8 liters/h, and volume of the peripheral compartment of 22.3 liters. We found significant pharmacokinetic variability for fosfomycin in this heterogeneous patient sample, which may be explained somewhat by the observed variations in renal function. PMID:26239990

  16. RISK FACTORS FOR CANDIDEMIA IN CRITICALLY ILL INFANTS

    PubMed Central

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

    2007-01-01

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

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

    PubMed

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

    2016-01-01

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

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

    NASA Astrophysics Data System (ADS)

    Burykin, Anton; Buchman, Timothy

    2008-03-01

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

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

    PubMed Central

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

    2016-01-01

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

  20. Principles of pulmonary artery catheterization in the critically ill.

    PubMed

    Summerhill, Eleanor M; Baram, Michael

    2005-01-01

    The pulmonary artery catheter (PAC) may be helpful in determining the etiology of shock, lactic acidosis, pulmonary edema, oliguric renal failure, pulmonary hypertension, and a number of cardiac abnormalities. In addition, it may also be useful in guiding fluid and vasoactive therapy. However, although hemodynamic data from the pulmonary artery catheter (PAC) is widely used diagnostically and therapeutically in the care of critically ill patients, the use of the catheter has not been shown to provide outcomes benefit. In fact, there is some evidence to suggest that placement of the PAC may actually be detrimental. The reasons for this are unclear, but it has been shown that both physicians and nurses frequently misinterpret waveforms and other data obtained from the PAC. Presently, there are a number of ongoing randomized, controlled trials investigating the use of the PAC in specific clinical situations and/or patient populations as well as using specific treatment strategies. In the meantime, if any benefit is to be achieved, it is imperative that clinicians have a thorough understanding of the indications, contraindications, complications, and pitfalls of data interpretation prior to using the catheter. These are reviewed in this article. PMID:16078042

  1. The immunocompromised oncohematological critically ill patient: considerations in severe infections

    PubMed Central

    Lagunes, Leonel; Morales-Codina, Marc

    2016-01-01

    Sepsis and septic shock remain a major cause of mortality among critically ill patient. This is particularly relevant among cancer patients as highlighted by different series showing that up to one in five patients admitted to intensive care units (ICU) with sepsis have cancer, and also, sepsis is a leading reason for ICU admission in patients with cancer. The classic predictors of mortality among these patients (such as cancer lineage, neutropenia degree, or bone marrow transplantation history) have changed during the last decades, and they should no longer be used to rule out ICU admission. Instead, a newer approach to these patients should be performed taking into account organ failure assessment and prior performance status. When a doubt exists about the criteria for ICU admission, not only a trial of ICU management should be proposed to assert that no patients are withhold of the opportunity for recovering from the acute condition, but also an early admission, to prevent more derangement, and thus impact on mortality. PMID:27713885

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

    PubMed Central

    Cowan, Robert M; Trzeciak, Stephen

    2005-01-01

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

  3. Pharmacokinetic Changes and Dosing Modification of Aminoglycosides in Critically Ill Obese Patients: A Literature Review

    PubMed Central

    Velissaris, Dimitrios; Karamouzos, Vasilios; Marangos, Markos; Pierrakos, Charalampos; Karanikolas, Menelaos

    2014-01-01

    The objective of the paper is to review the literature and provide recommendations for use of aminoglycoside antibiotics in critically ill obese patients. Literature search in PubMed for all articles on the use of aminoglycosides in critically ill obese patients was conducted, and all articles related to pharmacokinetics in obesity were reviewed. Bibliographies of all searched manuscripts were also reviewed in an attempt to find additional references. Although aminoglycoside pharmacokinetics have been described in detail, data on aminoglycoside use and appropriate dose modification in critically ill obese patients are very limited. Knowledge on aminoglycoside pharmacokinetics and use in critically ill obese patients is incomplete. Pathophysiologic changes in obesity can result in sub- or supra-therapeutic aminoglycoside plasma concentrations, especially in the presence of sepsis. Rigorous clinical studies are needed to establish aminoglycoside dosing guidelines in critically ill obese patients with sepsis. PMID:24883145

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

    PubMed

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

    1992-02-01

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

  5. Alteration of the sublingual microvascular glycocalyx in critically ill patients.

    PubMed

    Donati, Abele; Damiani, Elisa; Domizi, Roberta; Romano, Rocco; Adrario, Erica; Pelaia, Paolo; Ince, Can; Singer, Mervyn

    2013-11-01

    Glycocalyx degradation may contribute to microvascular dysfunction and tissue hypoperfusion during systemic inflammation and sepsis. In this observational study we evaluated the alteration of the sublingual microvascular glycocalyx in 16 healthy volunteers and 50 critically ill patients. Sidestream Dark Field images of the sublingual microcirculation were automatically analyzed by dedicated software. The Perfused Boundary Region (PBR) was calculated as the dimensions of the permeable part of the glycocalyx allowing the penetration of circulating red blood cells, providing an index of glycocalyx damage. The PBR was increased in ICU patients compared to healthy controls (2.7 [2.59-2.88] vs. 2.46 [2.37-2.59]μm, p<0.0001) and tended to be higher in the 32 septic patients compared to non-septics (2.77 [2.62-2.93] vs. 2.67 [2.55-2.75]μm, p=0.05), suggesting more severe glycocalyx alterations. A PBR of 2.76 showed the best discriminative ability towards the presence of sepsis (sensitivity: 50%, specificity: 83%; area under the receiver operating characteristic curve: 0.67, 95% CI 0.52-0.82, p=0.05). A weak positive correlation was found between PBR and heart rate (r=0.3, p=0.03). In 17 septic patients, a correlation was found between PBR and number of rolling leukocytes in post-capillary venules (RL/venule) (r=0.55, p=0.02), confirming that glycocalyx shedding enhances leukocyte-endothelium interaction.

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

    PubMed Central

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

    2013-01-01

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

  7. Critical illness induces alternative activation of M2 macrophages in adipose tissue

    PubMed Central

    2011-01-01

    Introduction We recently reported macrophage accumulation in adipose tissue of critically ill patients. Classically activated macrophage accumulation in adipose tissue is a known feature of obesity, where it is linked with increasing insulin resistance. However, the characteristics of adipose tissue macrophage accumulation in critical illness remain unknown. Methods We studied macrophage markers with immunostaining and gene expression in visceral and subcutaneous adipose tissue from healthy control subjects (n = 20) and non-surviving prolonged critically ill patients (n = 61). For comparison, also subcutaneous in vivo adipose tissue biopsies were studied from 15 prolonged critically ill patients. Results Subcutaneous and visceral adipose tissue biopsies from non-surviving prolonged critically ill patients displayed a large increase in macrophage staining. This staining corresponded with elevated gene expression of "alternatively activated" M2 macrophage markers arginase-1, IL-10 and CD163 and low levels of the "classically activated" M1 macrophage markers tumor necrosis factor (TNF)-α and inducible nitric-oxide synthase (iNOS). Immunostaining for CD163 confirmed positive M2 macrophage staining in both visceral and subcutaneous adipose tissue biopsies from critically ill patients. Surprisingly, circulating levels and tissue gene expression of the alternative M2 activators IL-4 and IL-13 were low and not different from controls. In contrast, adipose tissue protein levels of peroxisome proliferator-activated receptor-γ (PPARγ), a nuclear receptor required for M2 differentiation and acting downstream of IL-4, was markedly elevated in illness. In subcutaneous abdominal adipose tissue biopsies from surviving critically ill patients, we could confirm positive macrophage staining with CD68 and CD163. We also could confirm elevated arginase-1 gene expression and elevated PPARγ protein levels. Conclusions Unlike obesity, critical illness evokes adipose tissue

  8. Adipose tissue alterations in critical illness: a paradox as to patient outcomes.

    PubMed

    Wade, Charles E

    2013-09-20

    Adipocyte morphological changes in critically ill patients have been reported, potentially providing beneficial effects. Marques and colleagues reported that these morphological adipocyte changes, as well as accumulation of M2 phenotype macrophages, occur irrespective of nutritional status in the critically ill. The present study provides insight into the alterations that occur, although further studies are needed to fully understand the role that adipose tissue plays in the critically injured.

  9. Ethacrynic Acid Continuous Infusions in Critically Ill Pediatric Patients

    PubMed Central

    Miller, Jamie L.; Schaefer, Jared; Tam, Matthew; Harrison, Donald L.; Johnson, Peter N.

    2014-01-01

    OBJECTIVES The purpose of this study was to describe dosage regimens and treatment outcomes in critically ill children receiving ethacrynic acid continuous infusions (CI). METHODS This retrospective cross-sectional study evaluated patients less than 18 years of age who received ethacrynic acid CI with a duration exceeding 12 hours, from January 1, 2007, through January 31, 2012. The primary objective was to determine the mean/median doses of ethacrynic acid CI. Secondary objectives were to assess surrogate efficacy markers (e.g., urine output [UOP], fluid balance) and the number of patients with electrolyte abnormalities or metabolic alkalosis. Descriptive statistics were used. A series of repeated measures analyses of variance were conducted to assess differences in surrogate efficacy markers and in adverse events that occurred pre-, mid-, and posttherapy. RESULTS Nine patients were included. The mean ± SD initial and maximum doses (mg/kg/hr) were 0.13 ± 0.07 (median 0.1; range, 0.08–0.3) and 0.17 ± 0.08 (median, 0.16; range 0.09–0.3), respectively. The median UOP (mL/kg/hr) pre-, mid-, and postinfusions (interquartile range [IQR]) were 2.4 (1.8–3.2), 4.2 (3.5–6), and 4 (3.4–5.3), respectively. The median fluid balance (mL; IQR) was 189 (90–526), −258 (−411.7 to 249) and −113.5 (−212.5 to 80.2), respectively. There were statistically significant differences in UOP and fluid balance pre- versus mid-therapy (0.014) and pre- versus posttherapy (p=0.010). No significant differences were noted with magnesium and potassium. Five children (55.6%) developed metabolic alkalosis. CONCLUSIONS This study provides preliminary evidence for ethacrynic acid CI in children. The median initial dose and maximum dose in this cohort were 0.13 mg/kg/hr and 0.17 mg/kg/hr, respectively. Larger prospective studies are needed to confirm these findings. PMID:24782692

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

    PubMed

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

    2010-11-01

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

  11. 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

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

    PubMed

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

    2012-01-01

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

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

    MedlinePlus

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

  14. Head-of-bed elevation in critically ill patients: a review.

    PubMed

    Metheny, Norma A; Frantz, Rita A

    2013-06-01

    Clinicians are confused by conflicting guidelines about the use of head-of-bed elevation to prevent aspiration and pressure ulcers in critically ill patients. Research-based information in support of guidelines for head-of-bed elevation to prevent either condition is limited. However, positioning of the head of the bed has been studied more extensively for the prevention of aspiration than for the prevention of pressure ulcers, especially in critically ill patients. More research on pressure ulcers has been conducted in healthy persons or residents of nursing homes than in critically ill patients. Thus, the optimal elevation for the head of the bed to balance the risks for aspiration and pressure ulcers in critically ill patients who are receiving mechanical ventilation and tube feedings is unknown. Currently available information provides some indications of how to position patients; however, randomized controlled trials where both outcomes are evaluated simultaneously at various head-of-bed positions are needed.

  15. Psychiatric Morbidity in Pediatric Critical Illness Survivors: A Comprehensive Review of the Literature

    PubMed Central

    Davydow, Dimitry S.; Richardson, Laura P.; Zatzick, Douglas F.; Katon, Wayne J.

    2010-01-01

    Objective To review the prevalence of psychiatric syndromes in pediatric critical illness survivors as well as to summarize data on vulnerabilities and pediatric intensive care unit (PICU) exposures that may increase risk of developing these syndromes. Data Sources Medline (1966–2009), the Cochrane Library (2009, Issue 3), and PsycInfo (1967–2009) as of August 9, 2009. Study Selection Case-control, cross-sectional, prospective cohort and retrospective cohort studies, as well as randomized-controlled trials. Main Exposures Hospitalization for the treatment of a critical illness. Main Outcome Measures Assessments of psychiatric symptoms/disorders at least once after discharge. Results Seventeen studies were eligible. The most commonly assessed psychiatric disorders were posttraumatic stress disorder (PTSD) and major depression. The point prevalence of clinically significant PTSD symptoms ranged from 10%–28% (5 studies). The point prevalence of clinically significant depressive symptoms ranged from 7%–13% (3 studies). Pre-illness psychiatric and/or developmental problems and parental psychopathology were associated with vulnerability to psychiatric morbidity. Neither a child’s age nor gender consistently increased vulnerability to post-illness psychopathology. Exposure to increased severity of medical illness and PICU service-delivery characteristics (e.g., invasive procedures) were predictors of psychiatric illness in some, but not all, studies. Early post-illness psychiatric symptoms were predictors of later psychiatric morbidity. Conclusions Psychiatric morbidity appears to be a substantial problem for pediatric critical illness survivors. Future research should include more in-depth assessment of post-critical illness depressive, anxiety and psychotic symptoms, validate existing psychiatric instruments, and clarify how vulnerability factors, PICU service-delivery characteristics and severity of critical illnesses are associated with subsequent

  16. Fresh Approach for Critically Ill Patients with Time-sensitive Needs.

    PubMed

    2016-07-01

    To meet the needs of critically ill patients with time-sensitive needs, the University of Maryland Medical Center (UMMC) created the Critical Care Resuscitation Unit (CCRU), a six-bed, short-stay ICU designed to accelerate care to resource-heavy patients who require immediate evaluation and treatment. The CCRU is modeled after UMMC's trauma resuscitation unit, but with resources and staff geared toward non-trauma, critically ill patients, many of whom require life-saving care. The unit is largely staffed by emergency providers who have undergone additional training in critical care. In place at UMMC since July 2013, the CCRU has enabled UMMC to accommodate many more incoming critically ill patients than it has in the past. In its first year of operation, critically ill transfer patients increased more than 64%. Investigators also observed reduced hospital length of stay for these patients, and they noted trends toward lower mortality. Before the creation of the CCRU, developers say that care of critically ill patients often was delayed because there was no space available in an appropriate ICU. Patients admitted to the CCRU present with a wide range of complex critical care needs that require immediate attention, such as ruptured blood vessels, aortic dissections, strokes requiring neuro interventional radiologic procedures, and aneurysmal bleeds. Developers have streamlined the transfer process so that appropriate care can commence even before patients arrive in the CCRU. PMID:27439226

  17. A critical appraisal of point-of-care coagulation testing in critically ill patients.

    PubMed

    Levi, M; Hunt, B J

    2015-11-01

    Derangement of the coagulation system is a common phenomenon in critically ill patients, who may present with severe bleeding and/or conditions associated with a prothrombotic state. Monitoring of this coagulopathy can be performed with conventional coagulation assays; however, point-of-care tests have become increasingly attractive, because not only do they yield a more rapid result than clinical laboratory testing, but they may also provide a more complete picture of the condition of the hemostatic system. There are many potential areas of study and applications of point-of-care hemostatic testing in critical care, including patients who present with massive blood loss, patients with a hypercoagulable state (such as in disseminated intravascular coagulation), and monitoring of antiplatelet treatment for acute arterial thrombosis, mostly acute coronary syndromes. However, the limitations of near-patient hemostatic testing has not been fully appreciated, and are discussed here. The currently available evidence indicates that point-of-care tests may be applied to guide appropriate blood product transfusion and the use of hemostatic agents to correct the hemostatic defect or to ameliorate antithrombotic treatment. Disappointingly, however, only in cardiac surgery is there adequate evidence to show that application of near-patient thromboelastography leads to an improvement in clinically relevant outcomes, such as reductions in bleeding-related morbidity and mortality, and cost-effectiveness. More research is required to validate the utility and cost-effectiveness of near-patient hemostatic testing in other areas, especially in traumatic bleeding and postpartum hemorrhage.

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

    PubMed

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

    2013-01-01

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

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

    PubMed

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

    2013-01-01

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

  20. Critical life events and the onset of illness.

    PubMed

    Justice, B

    1994-01-01

    What can we conclude from these studies? One fact seems certain: there is no simple connection between life events and illness. Whether we get sick from an infection or a negative life experience depends on more than a germ or stress. All disease is multifactorial, and the resources that help protect us have much to do with our sense of support and control over our lives. What happens in our endocrine system and to our immune response is a function of what is going on inside our heads and hearts--the meanings we give to events and the feelings we have about them. Skeptics have long doubted these tenets. However, emerging evidence increasingly dispels these doubts and has replaced them with a biopsychosocial model based on psychoneuroimmunology (PNI). Indeed, Cousins described PNI as "the new science of medicine." To date, more than a dozen academic medical centers in the United States have PNI research programs and the list is growing. With expanded scientific study of the mind-body connection, people in general will come to recognize that whether they become ill is not always a matter of chance, but to a considerable extent something under their own control.

  1. 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.

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

    PubMed

    Salem, Yasser; Elokda, Ahmed

    2014-01-01

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

  3. Circulating MicroRNA-150 Serum Levels Predict Survival in Patients with Critical Illness and Sepsis

    PubMed Central

    Vargas Cardenas, David; Vucur, Mihael; Scholten, David; Frey, Norbert; Koch, Alexander; Trautwein, Christian; Tacke, Frank; Luedde, Tom

    2013-01-01

    Background and Aims Down-regulation of miR-150 was recently linked to inflammation and bacterial infection. Furthermore, reduced serum levels of miR-150 were reported from a small cohort of patients with sepsis. We thus aimed at evaluating the diagnostic and prognostic value of miR-150 serum levels in patients with critically illness and sepsis. Methods miR-150 serum levels were analyzed in a cohort of 223 critically ill patients of which 138 fulfilled sepsis criteria and compared to 76 healthy controls. Results were correlated with clinical data and extensive sets of routine and experimental biomarkers. Results Measurements of miR-150 serum concentrations revealed only slightly reduced miR-150 serum levels in critically ill patients compared to healthy controls. Furthermore miR-150 levels did not significantly differ in critically ill patients with our without sepsis, indicating that miR-150 serum levels are not suitable for diagnostic establishment of sepsis. However, serum levels of miR-150 correlated with hepatic or renal dysfunction. Low miR-150 serum levels were associated with an unfavorable prognosis of patients, since low miR-150 serum levels predicted mortality with high diagnostic accuracy compared with established clinical scores and biomarkers. Conclusion Reduced miR-150 serum concentrations are associated with an unfavorable outcome in patients with critical illness, independent of the presence of sepsis. Besides a possible pathogenic role of miR-150 in critical illness, our study indicates a potential use of circulating miRNAs as a prognostic rather than diagnostic marker in critically ill patients. PMID:23372743

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

    PubMed Central

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

    2015-01-01

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

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

    ERIC Educational Resources Information Center

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

    2012-01-01

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

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

    ERIC Educational Resources Information Center

    Angeli, Charoula; Valanides, Nicos

    2009-01-01

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

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

    PubMed Central

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

    2016-01-01

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

  8. Neuromuscular disorders and sleep in critically ill patients.

    PubMed

    Irfan, Muna; Selim, Bernardo; Rabinstein, Alejandro A; St Louis, Erik K

    2015-07-01

    Sleep-disordered breathing (SDB) is a frequent presenting manifestation of neuromuscular disorders and can lead to significant morbidity and mortality. If not recognized and addressed early in the clinical course, SDB can lead to clinical deterioration with respiratory failure. The pathophysiologic basis of SDB in neuromuscular disorders, clinical features encountered in specific neuromuscular diseases, and diagnostic and management strategies for SDB in neuromuscular patients in the critical care setting are reviewed. Noninvasive positive pressure ventilation has been a crucial advance in critical care management, improving sleep quality and often preventing or delaying mechanical ventilation and improving survival in neuromuscular patients.

  9. Neuromuscular Disorders and Sleep in Critically Ill Patients

    PubMed Central

    Irfan, Muna; Selim, Bernardo; Rabinstein, Alejandro A.

    2016-01-01

    Synopsis Sleep-disordered breathing (SDB) is a frequent presenting manifestation of neuromuscular disorders and can lead to significant morbidity and mortality. If not promptly recognized and addressed early in the clinical course, SDB can lead to clinical deterioration with respiratory failure. In this article, we review the pathophysiologic basis of SDB in neuromuscular disorders, clinical features encountered in specific neuromuscular diseases, and diagnostic and management strategies for SDB in neuromuscular patients in the critical care setting. Non-invasive positive pressure ventilation (NIPV) has been a crucial advance in critical care management, improving sleep quality and often preventing or delaying mechanical ventilation and improving survival in neuromuscular patients. PMID:26118919

  10. Testing nasogastric tube positioning in the critically ill: exploring the evidence.

    PubMed

    May, Sarah

    Nutritional support in the critically ill is commonly delivered via a nasogastric tube. Correct positioning in the stomach must first be confirmed as inadvertent feeding into the lungs carries a high risk of mortality. The National Patient Safety Agency (2005) recommends the method of pH testing nasogastric tube aspirates to verify tube position. This article critically analyses the research supporting this method, and questions its reliability in critically ill patients whose gastric pH may well be altered due to prophylactic stress ulcer medications and continuous feeding regimens. There is a lack of quality research testing this method in the critically ill population. The theory-practice gap is addressed, and preliminary research behind use of techniques such as capnography and capnometry is also examined.

  11. 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

  12. The influence of frailty syndrome on acceptance of illness in elderly patients with chronic obstructive pulmonary disease

    PubMed Central

    Uchmanowicz, Izabella; Jankowska-Polanska, Beata; Chabowski, Mariusz; Uchmanowicz, Bartosz; Fal, Andrzej M

    2016-01-01

    COPD is one of the most debilitating diseases. Frailty syndrome and advanced age may decrease the acceptance of illness, quality of life, and worsen health conditions in these patients, as well as lead to an increase in health care expenses. The aim of the study was to assess how the level of frailty affects the acceptance of illness in elderly patients with COPD. We also aimed to evaluate the associations between sociodemographic and clinical factors and the level of acceptance of illness, anxiety, and frailty in this group of patients. The study included 102 COPD patients with a mean age of 63.2 (standard deviation =6.5) years and grades I (3%), II (37%), III (52%), and IV (8%) by Global Initiative for Chronic Obstructive Lung Disease. The Polish versions of the Acceptance of Illness Scale and Tilburg frailty indicator were used. Frailty syndrome was found in 77 (75.5%) patients, with an average score of 7.42 (standard deviation =2.24). Coexisting diseases such as hypertension (46.07%), coronary artery disease (32.35%), heart failure (28.43%), diabetes (18.63%), and heart arrhythmia (9.8%) were found among the subjects. The overall level of acceptance of illness was 20.6 (standard deviation =7.62). A lower level of acceptance of illness was associated with a higher level of frailty, especially in the physical and social domain. Elderly patients with severe COPD are more prone to frailty and decreased acceptance of their disease in comparison to patients with other chronic diseases. Assessment and management of frailty in the care of older COPD patients are likely to improve risk stratification significantly and help personalize management, leading to better patient outcomes. PMID:27729781

  13. Sleep of Critically Ill Children in the Pediatric Intensive Care Unit: A Systematic Review

    PubMed Central

    Kudchadkar, Sapna; Aljohani, Othman; Punjabi, Naresh M.

    2013-01-01

    Summary Critically ill children in the Pediatric Intensive Care Unit (PICU) are exposed to multiple physical, environmental and pharmacologic factors which increase the propensity for sleep disruption and loss and may, in turn, play a role in short-term recovery from critical illness and long-term neurocognitive outcomes. Mechanically ventilated children receive sedative and analgesic medications, often at high doses and for long durations, to improve comfort and synchrony with mechanical ventilation. Sedatives and analgesics can decrease slow wave sleep and rapid eye movement sleep. Paradoxically, sedative medications doses are often increased in critically ill children to improve the subjective assessment of sedation and sleep, leading to further agitation and deterioration of sleep quality. The heterogeneity in age and critical illness encountered in the PICU pose several challenges to research on sleep in this setting. The present article reviews the available evidence on sleep in critically ill children admitted to the PICU, with an emphasis on subjective and objective methods of sleep assessment used and special populations studied, including mechanically ventilated children and children with severe burns. PMID:23702219

  14. Overview of the endocrine response to critical illness: how to measure it and when to treat.

    PubMed

    Hassan-Smith, Zaki; Cooper, Mark S

    2011-10-01

    The assessment and manipulation of the endocrine system in patients with critical illness is one of the most complex and controversial areas in endocrinology. Severe acute illness causes dramatic changes in most endocrine systems. This can lead to considerable difficulty in recognising pre-existing endocrine disorders in severely ill patients. Critical care itself might also induce types of endocrine dysfunction not seen outside the critical care unit. It is important to clarify whether or not such endocrine dysfunction occurs. Where it does occur it is also important to determine whether endocrine intervention is useful in improving outcome. There is also the issue of whether endocrine manipulation in critically ill patients without endocrine dysfunction could benefit from endocrine intervention, e.g. to improve haemodynamics or reverse a catabolic state. This review will discuss some of these contentious issues. It will highlight how endocrine assessment of a patient with critical illness differs from that in other types of patient. It will emphasise the added need to place the biochemical assessment and its interpretation in the context of the patients underlying condition.

  15. 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

  16. Regulation and prognostic relevance of symmetric dimethylarginine serum concentrations in critical illness and sepsis.

    PubMed

    Koch, Alexander; Weiskirchen, Ralf; Bruensing, Jan; Dückers, Hanna; Buendgens, Lukas; Kunze, Julian; Matthes, Michael; Luedde, Tom; Trautwein, Christian; Tacke, Frank

    2013-01-01

    In systemic inflammation and sepsis, endothelial activation and microvascular dysfunction are characteristic features that promote multiorgan failure. As symmetric dimethylarginine (SDMA) impacts vascular tension and integrity via modulating nitric oxide (NO) pathways, we investigated circulating SDMA in critical illness and sepsis. 247 critically ill patients (160 with sepsis, 87 without sepsis) were studied prospectively upon admission to the medical intensive care unit (ICU) and on day 7, in comparison to 84 healthy controls. SDMA serum levels were significantly elevated in critically ill patients at admission to ICU compared to controls and remained stably elevated during the first week of ICU treatment. The highest SDMA levels were found in patients with sepsis. SDMA levels closely correlated with disease severity scores, biomarkers of inflammation, and organ failure (renal, hepatic, and circulatory). We identified SDMA serum concentrations at admission as an independent prognostic biomarker in critically ill patients not only for short-term mortality at the ICU but also for unfavourable long-term survival. Thus, the significant increase of circulating SDMA in critically ill patients indicates a potential pathogenic involvement in endothelial dysfunction during sepsis and may be useful for mortality risk stratification at the ICU.

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

    PubMed

    Miller, Jerad P; Choban, Patricia Smith

    2006-12-01

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

  18. Hypothalamic-pituitary hormones during critical illness: a dynamic neuroendocrine response.

    PubMed

    Langouche, Lies; Van den Berghe, Greet

    2014-01-01

    Independent of the underlying condition, critical illness is characterized by a uniform dysregulation of the hypothalamic-pituitary-peripheral axes. In most axes a clear biphasic pattern can be distinguished. The acute phase of critical illness is characterized by low peripheral effector hormone levels such as T3, IGF-1 and testosterone, despite an actively secreting pituitary. The adrenal axis with high cortisol levels in the presence of low ACTH levels is a noteworthy exception. In the prolonged phase of critical illness, low peripheral effector hormone levels coincide with a uniform suppression of the neuroendocrine axes, predominantly of hypothalamic origin. The severity of the alterations in the different neuroendocrine axes is associated with a high risk of morbidity and mortality, but it remains unknown whether the observed changes are cause or consequence of adverse outcome. Several studies have identified therapeutic potential of hypothalamic releasing factors, but clinical outcome remains to be investigated with sufficiently powered randomized controlled trials.

  19. 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

  20. Feeding critically ill patients the right 'whey': thinking outside of the box. A personal view.

    PubMed

    Marik, Paul E

    2015-12-01

    Atrophy of skeletal muscle mass is an almost universal problem in survivors of critical illness and is associated with significant short- and long-term morbidity. Contrary to common practice, the provision of protein/amino acids as a continuous infusion significantly limits protein synthesis whereas intermittent feeding maximally stimulates skeletal muscle synthesis. Furthermore, whey-based protein (high in leucine) increases muscle synthesis compared to soy or casein-based protein. In addition to its adverse effects on skeletal muscle synthesis, continuous feeding is unphysiological and has adverse effects on glucose and lipid metabolism and gastrointestinal function. I propose that critically ill patients' be fed intermittently with a whey-based formula and that such an approach is likely to be associated with better glycemic control, less hepatic steatosis and greater preservation of muscle mass. This paper provides the scientific basis for my approach to intermittent feeding of critically ill patients.

  1. Catecholamine use is associated with enterocyte damage in critically ill patients.

    PubMed

    Piton, Gaël; Cypriani, Benoit; Regnard, Jacques; Patry, Cyrille; Puyraveau, Marc; Capellier, Gilles

    2015-05-01

    Small bowel damage is frequent but underdiagnosed among critically ill patients with shock. High catecholamine doses may have a deleterious effect on mesenteric blood flow. Plasma intestinal fatty acid-binding protein (I-FABP) concentration is a marker of enterocyte damage, whereas plasma citrulline concentration is a marker of functional enterocyte mass. We hypothesized that high doses of catecholamines in critically ill patients may be associated with enterocyte damage. This study aimed to determine the link between catecholamine use and dose with enterocyte damage. This is a prospective observational study performed in a large regional university teaching hospital. Critically ill patients requiring epinephrine and/or norepinephrine at admission to a medical intensive care unit (ICU) were included, as well as controls not receiving catecholamines. We evaluated at admission plasma I-FABP and citrulline concentrations, abdominal perfusion pressure (APP), and variables relating to prognosis and treatment. Patients were categorized according to the quartiles of catecholamine dose at ICU admission. Sixty critically ill patients receiving catecholamines and 27 not receiving catecholamines were included. Plasma I-FABP was higher among patients receiving catecholamine than in controls. Among patients receiving catecholamines, a dose of 0.48 γ kg min or more at ICU admission was associated with a higher I-FABP concentration. A Sepsis-related Organ Failure Assessment score higher than 11 and plasma I-FABP more than 524 pg mL at ICU admission were independently associated with 28-day mortality (odds ratio, 4.0 [1.24-12.95] and odds ratio, 4.90 [1.44-16.6], respectively). Catecholamine use is associated with I-FABP elevation in critically ill patients. Critically ill patients receiving more than 0.48 γ kg min of epinephrine and/or norepinephrine at ICU admission have high I-FABP concentrations. This suggests that enterocyte damage reflects the severity of shock, and an

  2. Glutamine supplementation in the critically ill: friend or foe?

    PubMed

    Oudemans-van Straaten, Heleen M; van Zanten, Arthur R H

    2014-05-19

    In the previous issue of Critical Care, Mori and colleagues demonstrate that glutamine supplementation in mechanically ventilated patients as part of parenteral nutrition increases plasma glutamine concentration and glutamine utilization, but does not mitigate protein degradation and even increases de novo glutamine production. Studies suggest that protein degradation is regulated by the degree of inflammation. Immune cells utilize large amounts of glutamine and derive their glutamine requirements from muscle protein degradation. We hypothesize that the effects of glutamine supplementation depend on the degree of inflammation. Infusing large amounts of exogenous glutamine into patients with inflammatory conditions like sepsis and multiple organ failure may not only enhance immune competence, but may potentially augment the inflammatory response and thereby negatively influence outcome.

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

    PubMed

    Hipp, Dustin M; Ely, E Wesley

    2012-01-01

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

  4. Failure of lorazepam to treat alprazolam withdrawal in a critically ill patient.

    PubMed

    Sachdev, Gaurav; Gesin, Gail; Christmas, A Britton; Sing, Ronald F

    2014-02-01

    Management of sedation in the critical care unit is an ongoing challenge. Benzodiazepines have been commonly used as sedatives in critically ill patients. The pharmacokinetic and pharmacodynamic properties that make benzodiazepines effective and safe in critical care sedation include rapid onset of action and decreased respiratory depression. Alprazolam is a commonly used benzodiazepine that is prescribed for anxiety and panic disorders. It is frequently prescribed in the outpatient setting. Its use has been reported to result in a relatively high rate of dependence and subsequent withdrawal symptoms. Symptoms of alprazolam withdrawal can be difficult to recognize and treat in the critical care setting. In addition, other benzodiazepines may also be ineffective in treating alprazolam withdrawal. We present a case of alprazolam withdrawal in a critically ill trauma patient who failed treatment with lorazepam and haloperidol. Subsequent replacement with alprazolam resulted in significant improvement in the patient's medication use and clinical status.

  5. 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".

  6. The future is now: software-guided intensive insulin therapy in the critically ill.

    PubMed

    Rattan, Rishi; Nasraway, Stanley A

    2013-03-01

    Since the development of intensive insulin therapy for the critically ill adult, tight glycemic control (TGC) has become increasingly complicated to apply and achieve. Software-guided (SG) algorithms for insulin dosing represent a new method to achieve euglycemia in critical illness. We provide an overview of the state of SG TGC with an eye to the future. The current milieu is disorganized, with little research that incorporates newer variables of dysglycemia, such as glycemic variability. To develop and implement better algorithms, scientists, programmers, and clinicians need to standardize measurements and variables.

  7. The Future Is Now: Software-Guided Intensive Insulin Therapy in the Critically Ill

    PubMed Central

    Rattan, Rishi; Nasraway, Stanley A.

    2013-01-01

    Since the development of intensive insulin therapy for the critically ill adult, tight glycemic control (TGC) has become increasingly complicated to apply and achieve. Software-guided (SG) algorithms for insulin dosing represent a new method to achieve euglycemia in critical illness. We provide an overview of the state of SG TGC with an eye to the future. The current milieu is disorganized, with little research that incorporates newer variables of dysglycemia, such as glycemic variability. To develop and implement better algorithms, scientists, programmers, and clinicians need to standardize measurements and variables. PMID:23567013

  8. Early sedation use in critically ill mechanically ventilated patients: when less is really more.

    PubMed

    Lee, Christie M; Mehta, Sangeeta

    2014-01-01

    Over the last 10 years, there has been an explosion of literature surrounding sedation management for critically ill patients. The clinical target has moved away from an unconscious and immobile patient toward a goal of light or no sedation and early mobility. The move away from terms such as 'sedation' toward more patient-centered and symptom-based control of pain, anxiety, and agitation makes the management of critically ill patients more individualized and dynamic. Over-sedation has been associated with negative ICU outcomes, including longer durations of mechanical ventilation and lengths of stay, but few studies have been able to associate deep sedation with increased mortality. PMID:25673278

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

    PubMed

    Moors, Ine; Benoit, Dominique D

    2014-01-01

    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. PMID:24517551

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

    PubMed

    Pattanshetty, Renu B; Gaude, Gajanan S

    2011-04-01

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

  11. [Corticosteroid insufficiency in the critically ill. Pathomechanisms and recommendations for diagnosis and treatment].

    PubMed

    Briegel, J; Vogeser, M; Keh, D; Marik, P

    2009-02-01

    Critically ill patients with severe systemic inflammation can develop critical illness-related corticosteroid insufficiency (CIRCI), which is associated with a poor outcome. A task force of the American College of Critical Care Medicine compiled recommendations for diagnosis and treatment of this clinical entity thereby focusing on patients with septic shock and acute respiratory distress syndrome (ARDS). The results of large scale multi-centre trials gave partially conflicting results arguing against the broad use of corticosteroids in stress doses. However, the task force recommended treatment with stress-dose corticosteroids in patients with septic shock who respond poorly to fluid resuscitation and vasopressor therapy and in patients with early ARDS (<14 days after onset). The dose of corticosteroids should be reduced in a step-wise manner. Corticosteroids at stress doses are currently under investigation in other target populations of critically ill patients potentially suffering from CIRCI. Preliminary data suggest that patients with vasodilatory shock after cardiac surgery and patients with liver cirrhosis and sepsis can benefit from corticosteroids. Critical illness-related corticosteroid insufficiency can also occur in patients with trauma, traumatic brain injury, acute pancreatitis and burn injuries, but data from clinical trials on these target groups are insufficient at present. The therapeutic use of corticosteroids in stress doses reduces the incidence of post-traumatic stress disorder (PTSD) after intensive care treatment.

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

    PubMed Central

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

    2016-01-01

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

  13. [Maintenance of intestinal barrier function in patients with chronic critical illness].

    PubMed

    Wu, Xiuwen; Ren, Jianan; Li, Jieshou

    2016-07-01

    The syndrome known as chronic critical illness (CCI) is defined as that critically ill patients survive their initial acute illness but go on to experience persistent organ failures necessitating prolonged intensive care. Intestinal barrier is the physical barrier that separates the internal and external environments and prevents the invasion of pathogenic antigens. Due to its pathogenesis, many CCI patients have injured intestinal barrier. Gut is the motor organ of stress responses, and gut-associated infections may initiate multiple organ dysfunction. In this way, it is important to maintain intestinal barrier of such patients. Apart from treatment for underlying diseases, resuscitation aiming at improving tissue perfusion, appropriate nutritional support, protection of normal intestinal flora, and provision of probiotics can maintain intestinal barrier of CCI patients. The maintenance and support of barrier function requires attention. PMID:27452748

  14. [Recommendations for nutritional assessment and specialized nutritional support of critically ill patients].

    PubMed

    Ortiz Leyba, C; Montejo Gonzalez, J C; Jiménez Jiménez, F Javier; Lopez Martinez, J; García de Lorenzo y Mateos, A; Grau Carmona, T; Acosta Escribano, J; Mesejo Arizmendi, A; Fernandez Ortega, F; Ordoñez Gonzalez, F J; Bonet Saris, A; Blesa Malpica, A

    2005-06-01

    Due to the characteristics of critically ill patients, elaborating recommendations on nutritional support for these patients is difficult. Usually the time of onset of nutritional support or its features are not well established, so that its application is based on experts' opinion. In the present document, recommendations formulated by the Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Medicine and Coronary Units (SEMICYUC) are presented. Recommendations are based on the literature analysis and further discussion by the working group members in order to define, consensually, the more relevant issues of metabolic and nutritional support of patients in a critical condition. Several clinical situations have been considered which are developed in the following articles of this publication. The present recommendations aim at providing a guideline for the less experienced clinicians when considering the metabolic and nutritional issues of critically ill patients.

  15. 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. PMID:24807079

  16. 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.

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

    PubMed Central

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

    2016-01-01

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

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

    PubMed

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

    2016-01-01

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

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

    PubMed

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

    2015-12-01

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

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

    Technology Transfer Automated Retrieval System (TEKTRAN)

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

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

    PubMed

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

    2015-10-01

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

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

    PubMed

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

    2016-01-01

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

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

    Technology Transfer Automated Retrieval System (TEKTRAN)

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

  4. Stress hyperglycemia in pediatric critical illness: the intensive care unit adds to the stress!

    PubMed

    Srinivasan, Vijay

    2012-01-01

    Stress hyperglycemia (SH) commonly occurs during critical illness in children. The historical view that SH is beneficial has been questioned in light of evidence that demonstrates the association of SH with worse outcomes. In addition to intrinsic changes in glucose metabolism and development of insulin resistance, specific intensive care unit (ICU) practices may influence the development of SH during critical illness. Mechanical ventilation, vasoactive infusions, renal replacement therapies, cardiopulmonary bypass and extracorporeal life support, therapeutic hypothermia, prolonged immobility, nutrition support practices, and the use of medications are all known to mediate development of SH in critical illness. Tight glucose control (TGC) to manage SH has emerged as a promising therapy to improve outcomes in critically ill adults, but results have been inconclusive. Large variations in ICU practices across studies likely resulted in inconsistent results. Future studies of TGC need to take into account the impact of commonly used ICU practices and, ideally, standardize protocols in an attempt to improve the accuracy of conclusions from such studies.

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

    PubMed

    Rattan, Rishi; Nasraway, Stanley A

    2013-07-12

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

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

    PubMed Central

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

    2016-01-01

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

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

    PubMed

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

    2015-10-01

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

  8. 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…

  9. Association of nucleated red blood cells with mortality in critically ill dogs.

    PubMed

    Müller, M; Dörfelt, R; Hamacher, L; Wess, G

    2014-11-22

    The occurrence of nucleated red blood cells (NRBC) in the peripheral blood of critically ill human patients is associated with increased mortality. In dogs, the presence of NRBCs in peripheral blood has been used as a sensitive and specific marker of complications and outcome associated with heatstroke. However, no study has investigated their prevalence in critically ill dogs. Thus, the aim of this study was to determine the prevalence of NRBCs in the peripheral blood, and to evaluate their occurrence as a prognostic factor in critically ill dogs. One hundred and one dogs were prospectively included; the presence of NRBCs was studied on a daily basis from the time of admission until day 3 in the intensive care unit (or less if discharged or death occurred earlier). Dogs fulfilled at least two systemic inflammatory response syndrome (SIRS) criteria and suffered from various diseases. Survival was defined as being alive 28 days postdischarge from hospital. In 42 dogs, NRBCs were detected at least once; 59 patients were NRBC negative. Mortality was significantly higher in NRBC-positive than NRBC-negative patients (54.8 v 30.5 per cent) (P=0.014). However, this association was not present when anaemic dogs were excluded from the analysis. Detection of NRBCs in the peripheral blood may be an indicator for regenerative anaemia and may have potential for use as a prognostic tool or in addition to established scoring systems in critically ill dogs.

  10. 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…

  11. Pharmacological and Mechanical Thromboprophylaxis in Critically Ill Patients: a Network Meta-Analysis of 12 Trials

    PubMed Central

    2016-01-01

    Thromboprophylaxis for venous thromboembolism is widely used in critically ill patients. However, only limited evidence exists regarding the efficacy and safety of the various thromboprophylaxis techniques, especially mechanical thromboprophylaxis. Therefore, we performed meta-analysis of randomized controlled trials (RCTs) that compared the overall incidence of deep vein thrombosis (DVT) for between unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), and intermittent pneumatic compression (IPC) in critically ill patients. A Bayesian random effects model for multiple treatment comparisons was constructed. The primary outcome measure was the overall incidence of DVT at the longest follow-up. The secondary outcome measure was the incidence of major bleeding, as defined by the original trials. Our analysis included 8,622 patients from 12 RCTs. The incidence of DVT was significantly lower in patients treated with UFH (OR, 0.45; 95% CrI, 0.22–0.83) or LMWH (OR, 0.38; 95% CrI, 0.18–0.72) than in patients in the control group. IPC was associated with a reduced incidence of DVT compared to the control group, but the effect was not statistically significant (OR, 0.50; 95% CrI, 0.20–1.23). The risk of DVT was similar for patients treated with UFH and LMWH (OR, 1.16; 95% CrI, 0.68–2.11). The risk of major bleeding was similar between the treatment groups in medical critically ill patients and also in critically ill patients with a high risk of bleeding. In critically ill patients, the efficacy of mechanical thromboprophylaxis in reducing the risk of DVT is not as robust as those of pharmacological thromboprophylaxis. PMID:27709864

  12. Clinical and temporal patterns of severe pneumonia causing critical illness during Hajj

    PubMed Central

    2012-01-01

    Background Pneumonia is a leading cause of hospitalization during Hajj and susceptibility and transmission may be exacerbated by extreme spatial and temporal crowding. We describe the number and temporal onset, co–morbidities, and outcomes of severe pneumonia causing critical illness among pilgrims. Method A cohort study of all critically ill Hajj patients, of over 40 nationalities, admitted to 15 hospitals in 2 cities in 2009 and 2010. Demographic, clinical, and laboratory data, and variables necessary for calculation of the Acute Physiology and Chronic Health Evaluation IV scores were collected. Results There were 452 patients (64.6% male) who developed critical illness. Pneumonia was the primary cause of critical illness in 123 (27.2%) of all intensive care unit (ICU) admissions during Hajj. Pneumonia was community (Hajj)–acquired in 66.7%, aspiration–related in 25.2%, nosocomial in 3.3%, and tuberculous in 4.9%. Pneumonia occurred most commonly in the second week of Hajj, 95 (77.2%) occurred between days 5–15 of Hajj, corresponding to the period of most extreme pilgrim density. Mechanical ventilation was performed in 69.1%. Median duration of ICU stay was 4 (interquartile range [IQR] 1–8) days and duration of ventilation 4 (IQR 3–6) days. Commonest preexisting co–morbidities included smoking (22.8%), diabetes (32.5%), and COPD (17.1%). Short–term mortality (during the 3–week period of Hajj) was 19.5%. Conclusion Pneumonia is a major cause of critical illness during Hajj and occurs amidst substantial crowding and pilgrim density. Increased efforts at prevention for at risk pilgrim prior to Hajj and further attention to spatial and physical crowding during Hajj may attenuate this risk. PMID:22591189

  13. Hsp72 Is a Novel Biomarker to Predict Acute Kidney Injury in Critically Ill Patients

    PubMed Central

    Morales-Buenrostro, Luis E.; Salas-Nolasco, Omar I.; Barrera-Chimal, Jonatan; Casas-Aparicio, Gustavo; Irizar-Santana, Sergio; Pérez-Villalva, Rosalba; Bobadilla, Norma A.

    2014-01-01

    Background and Objectives Acute kidney injury (AKI) complicates the course of disease in critically ill patients. Efforts to change its clinical course have failed because of the fail in the early detection. This study was designed to assess whether heat shock protein (Hsp72) is an early and sensitive biomarker of acute kidney injury (AKI) compared with kidney injury molecule (Kim-1), neutrophil gelatinase-associated lipocalin (NGAL), and interleukin-18 (IL-18) biomarkers. Methods A total of 56 critically ill patients fulfilled the inclusion criteria. From these patients, 17 developed AKI and 20 were selected as controls. In AKI patients, Kim-1, IL-18, NGAL, and Hsp72 were measured from 3 days before and until 2 days after the AKI diagnosis and in no-AKI patients at 1, 5 and 10 days after admission. Biomarker sensitivity and specificity were determined. To validate the results obtained with ROC curves for Hsp72, a new set of critically ill patients was included, 10 with AKI and 12 with no-AKI patients. Results Urinary Hsp72 levels rose since 3 days before the AKI diagnosis in critically ill patients; this early increase was not seen with any other tested biomarkers. Kim-1, IL-18, NGAL, and Hsp72 significantly increased from 2 days before AKI and remained elevated during the AKI diagnosis. The best sensitivity/specificity was observed in Kim-1 and Hsp72: 83/95% and 100/90%, respectively, whereas 1 day before the AKI diagnosis, the values were 100/100% and 100/90%, respectively. The sensibility, specificity and accuracy in the validation test for Hsp72 were 100%, 83.3% and 90.9%, respectively. Conclusions The biomarker Hsp72 is enough sensitive and specific to predict AKI in critically ill patients up to 3 days before the diagnosis. PMID:25313566

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

    PubMed

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

    2015-03-01

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

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

    PubMed

    Verceles, Avelino C; Hager, Erin R

    2015-09-01

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

  16. 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

  17. Neuromuscular electrical stimulation in critically ill patients in the intensive care unit: a systematic review

    PubMed Central

    Ferreira, Lucas Lima; Vanderlei, Luiz Carlos Marques; Valenti, Vitor Engrácia

    2014-01-01

    Objective To analyze the outcomes enabled by the neuromuscular electric stimulation in critically ill patients in intensive care unit assisted. Methods A systematic review of the literature by means of clinical trials published between 2002 and 2012 in the databases LILACS, SciELO, MEDLINE and PEDro using the descriptors “intensive care unit”, “physical therapy”, “physiotherapy”, “electric stimulation” and “randomized controlled trials”. Results We included four trials. The sample size varied between 8 to 33 individuals of both genders, with ages ranging between 52 and 79 years, undergoing invasive mechanical ventilation. Of the articles analyzed, three showed significant benefits of neuromuscular electrical stimulation in critically ill patients, such as improvement in peripheral muscle strength, exercise capacity, functionality, or loss of thickness of the muscle layer. Conclusion The application of neuromuscular electrical stimulation promotes a beneficial response in critically patients in intensive care. PMID:25295458

  18. 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.

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

    PubMed Central

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

    2016-01-01

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

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

    PubMed Central

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

    2013-01-01

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

  1. Research on caregiving in Chinese families living with mental illness: a critical review.

    PubMed

    Hsiao, Chiu-Yueh; Van Riper, Marcia

    2010-02-01

    Much of the existing research on caregiving in families of individuals with mental illness has been conducted in Western societies. Therefore, the purpose of this review was to critically examine research on caregiving in families of individuals with mental illness living in Taiwan, Hong Kong, and Mainland China. A search using computerized databases, public search engines, and references from retrieved articles revealed 37 studies published from 1990 to 2009. Four studies were theory driven at an individual level, and one study was guided by a family-level framework. Thirty-two articles were quantitative studies, and 5 were qualitative studies. All but 5 of 37 studies were cross-sectional. Findings suggest that misconceptions about mental illness, behavior disturbances, inadequate social support, and the limited value placed on caregiving contribute to maladaptation. Future research should include longitudinal studies guided by culturally appropriate family frameworks and studies using mixed methods.

  2. Helping at the bedside: spouses' preferences for helping critically ill patients.

    PubMed

    Eldredge, Deborah

    2004-10-01

    Spouses of patients in intensive care units (ICU) need to be close and helpful to ill partners. According to adult attachment theory, emotional responses may be related to preferences for closeness and helpfulness, and according to control theory optimism also may influence spouses' emotional responses. Spouses' goals and helping behaviors were assessed in 88 spouses of ICU patients. Using a repeated-measures design, the relationships of closeness, helpfulness, and optimism to emotional outcomes were assessed. Preferences for closeness and helpfulness were strongly related, and together with optimism, predicted spouses' mood at some point of the illness trajectory. Spouses who were over-involved with partners' care requirements were at greater risk for emotional distress. Results suggest that closeness and helpfulness are integrated concepts, and that attachment dimensions of a relationship and optimism are useful for understanding spouses' emotional responses to critical illness.

  3. 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

  4. Creating connections to life during life-threatening illness: Creative activity experienced by elderly people and occupational therapists

    PubMed Central

    la Cour, Karen; Josephsson, Staffan; Luborsky, Mark

    2014-01-01

    Objective The aim of this study was to discover and characterize components of engagement in creative activity as occupational therapy for elderly people dealing with life-threatening illness, from the perspective of both clients and therapists. Despite a long tradition of use in clinical interventions, key questions remain little addressed concerning how and why people seek these activities and the kinds of benefits that may result. Method Qualitative interviews were conducted with 8 clients and 7 therapists participating in creative workshops using crafts at a nursing home in Sweden. Analysis of the interviews was conducted using a constant comparative method. Findings Engaging in creative activity served as a medium that enabled creation of connections to wider culture and daily life that counters consequences of terminal illness, such as isolation. Creating connections to life was depicted as the core category, carried out in reference to three subcategories: (1) a generous receptive environment identified as the foundation for engaging in creative activity; (2) unfolding creations—an evolving process; (3) reaching beyond for possible meaning horizons. Conclusion The findings suggest that the domain of creative activity can enable the creation of connections to daily life and enlarge the experience of self as an active person, in the face of uncertain life-threatening illness. Ultimately, the features that participants specify can be used to refine and substantiate the use of creative activities in intervention and general healthcare. PMID:16389735

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

    PubMed

    Redeker, Nancy S

    2008-01-01

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

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

    PubMed

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

    2016-10-01

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

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

    PubMed Central

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

    2015-01-01

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

  8. Quality indicators on the use of antimicrobials in critically ill patients.

    PubMed

    Vera, P; Palomar, M; Álvarez-Lerma, F

    2014-12-01

    Quality indicators have been applied to many areas of health care in recent years, including intensive care. However, they have not been specifically developed and validated for antimicrobial use in critically ill patients. Antimicrobials play a key role in intensive care units not only in the prognosis of each individual patient, but also in the development of resistance and changes in the flora in this setting. Evaluating the use of these agents is complex in the intensive care unit, however, because the indications vary greatly and antimicrobial treatment is often changed during admission. We designed and developed specific quality indicators regarding the use of antimicrobials in critically ill patients admitted to the intensive care unit. These indicators are proposed as a tool for application in intensive care units to detect problems in the use of antimicrobials. Future trials are needed, however, to validate these indicators in a large population over time.

  9. 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.

  10. Organ dysfunction in critically ill cancer patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

    PubMed Central

    ÑAMENDYS-SILVA, SILVIO A.; CORREA-GARCÍA, PAULINA; GARCÍA-GUILLÉN, FRANCISCO J.; LÓPEZ-BASAVE, HORACIO N.; MONTALVO-ESQUIVEL, GONZALO; TEXCOCANO-BECERRA, JULIA; HERRERA-GÓMEZ, ÁNGEL; MENESES-GARCÍA, ABELARDO

    2015-01-01

    The aim of the present study was to observe the incidence of organ dysfunction and the intensive care unit (ICU) outcomes of critically ill cancer patients during the cytoreductive surgery with hyperthermic intraperitoneal chemotherapy post-operative period. The present study included 25 critically ill cancer patients admitted to the ICU of the National Cancer Institute (Mexico City, Mexico) between January 2007 and February 2013. The incidence of organ dysfunction was 68% and patients exhibiting ≤1 organ system dysfunction during ICU admittance remained in hospital for a significantly shorter period compared with patients who exhibited ≥2 organ system dysfunctions (12.4±10.7 vs. 24.1±12.8 days; P=0.025). Therefore, the present study demonstrated that a high incidence of organ dysfunction was associated with a longer ICU hospital stay. PMID:25789059

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

    PubMed Central

    Prieto, Marta Botrán; Cid, Jesús López-Herce

    2011-01-01

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

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

    PubMed Central

    2013-01-01

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

  13. Use of Bioelectrical Impedance Analysis for the Assessment of Nutritional Status in Critically Ill Patients

    PubMed Central

    Lee, Yoojin; Kwon, Oran; Shin, Cheung Soo

    2015-01-01

    Malnutrition is common in the critically ill patients and known to cause a variety of negative clinical outcomes. However, various conventional methods for nutrition assessment have several limitations. We hypothesized that body composition data, as measured using bioelectrical impedance analysis (BIA), may have a significant role in evaluating nutritional status and predicting clinical outcomes in critically ill patients. We gathered clinical, biochemical, and BIA data from 66 critically ill patients admitted to an intensive care unit. Patients were divided into three nutritional status groups according to their serum albumin level and total lymphocyte counts. The BIA results, conventional indicators of nutrition status, and clinical outcomes were compared and analyzed retrospectively. Results showed that the BIA indices including phase angle (PhA), extracellular water (ECW), and ECW/total body water (TBW) were significantly associated with the severity of nutritional status. Particularly, PhA, an indicator of the health of the cell membrane, was higher in the well-nourished patient group, whereas the edema index (ECW/TBW) was higher in the severely malnourished patient group. PhA was positively associated with albumin and ECW/TBW was negatively associated with serum albumin, hemoglobin, and duration of mechanical ventilation. In non-survivors, PhA was significantly lower and both ECW/TBW and %TBW/fat free mass were higher than in survivors. In conclusion, several BIA indexes including PhA and ECW/TBW may be useful for nutritional assessment and represent significant prognostic factors in the care of critically ill patients. PMID:25713790

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

    PubMed Central

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

    2015-01-01

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

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

    PubMed Central

    2011-01-01

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

  16. The significance of tubular and glomerular proteinuria in critically ill patients with severe acute kidney injury

    PubMed Central

    Lim, Christopher Thiam Seong; Tan, Han Khim; Lau, Yeow Kok

    2014-01-01

    Objective: Critically ill patients with acute kidney injury (AKI) frequently need acute renal replacement therapy (aRRT). We evaluated an inexpensive, rapid quantitative and qualitative analysis of proteinuria on the course of AKI patients requiring aRRT in intensive care. Method: This was a prospective, observational study of critically ill patients with severe established AKI or Acute on Chronic Kidney Injury (AoCKI) requiring aRRT. Urine samples were analyzed using Sodium-Dodecyl-Sulphate-Polyacryamide Gel Electrophoresis (SDS-PAGE). Results: A total of 30 critically ill patients were studied. Those who died have higher APACHE II (29 ± 6 vs. 20 ± 5, p<0.001), multi-organ failure (0.7 ± 0.5 vs. 0.2 ± 0.4, p < 0.02) and Tubular/Glomerular ratio (114 ± 60 vs. 75± 37, p < 0.05).The renal non-recoverers have higher baseline creatinine (415 ± 328 vs. 125± 19 umol/l, p < 0.01), urinary Dipstick value (1.8±0.8 vs. 0.5±0, p <0.05) and Glomerular score (3.0 ± 1.8 vs. 0.6 ± 0.2, p < 0.02).Heavy tubular proteinuria also predicts a longer duration of interim dialysis support and mortality whereas glomerular proteinuria correlates with development of chronicity and End Stage Renal Disease (ESRD). Conclusions: The dominant presence of tubular proteinuria is associated with poor survival in patients who have high APACHE II score and multi-organ failure. It also correlates with a longer duration of dialysis support in survivals. Renal Non-recoverers had heavy dominant presence of glomerular proteinuria. SDS-PAGE proteinuria analysis offers a reliable and inexpensive method to prognosticate proteinuria in this group of critically ill patients. PMID:25674105

  17. Laser Doppler flowmetry and cardiac output in critically ill surgical patients.

    PubMed

    Eyer, S; Borgos, J; Strate, R G

    1987-08-01

    Laser Doppler flowmetry (LDF) accurately measures cutaneous microcirculatory blood flow. We compared change in LDF flow to change in thermodilution cardiac output in ten critically ill surgical patients. A subset analysis of three patients with low cardiac output (cardiac index less than 2 L/min X m2) showed no correlation. We conclude that, under these study conditions, LDF microcirculatory flow did not reflect macrocirculatory flow. We conjecture that overcoming cutaneous vasoregulation with thermal vasodilation may obviate these results.

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

    PubMed

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

    2015-01-01

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

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

    PubMed

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

    2016-05-01

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

  20. Coefficient of glucose variation is independently associated with mortality in critically ill patients receiving intravenous insulin

    PubMed Central

    2014-01-01

    Introduction Both patient- and context-specific factors may explain the conflicting evidence regarding glucose control in critically ill patients. Blood glucose variability appears to correlate with mortality, but this variability may be an indicator of disease severity, rather than an independent predictor of mortality. We assessed blood glucose coefficient of variation as an independent predictor of mortality in the critically ill. Methods We used eProtocol-Insulin, an electronic protocol for managing intravenous insulin with explicit rules, high clinician compliance, and reproducibility. We studied critically ill patients from eight hospitals, excluding patients with diabetic ketoacidosis and patients supported with eProtocol-insulin for < 24 hours or with < 10 glucose measurements. Our primary clinical outcome was 30-day all-cause mortality. We performed multivariable logistic regression, with covariates of age, gender, glucose coefficient of variation (standard deviation/mean), Charlson comorbidity score, acute physiology score, presence of diabetes, and occurrence of hypoglycemia < 60 mg/dL. Results We studied 6101 critically ill adults. Coefficient of variation was independently associated with 30-day mortality (odds ratio 1.23 for every 10% increase, P < 0.001), even after adjustment for hypoglycemia, age, disease severity, and comorbidities. The association was higher in non-diabetics (OR = 1.37, P < 0.001) than in diabetics (OR 1.15, P = 0.001). Conclusions Blood glucose variability is associated with mortality and is independent of hypoglycemia, disease severity, and comorbidities. Future studies should evaluate blood glucose variability. PMID:24886864

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

    PubMed

    Ashok Kumar, Prashanth; Anand, Usha

    2016-07-01

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

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

    PubMed

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

    2016-08-01

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

  3. Indirect calorimetry: a guide for optimizing nutritional support in the critically ill child.

    PubMed

    Sion-Sarid, Racheli; Cohen, Jonathan; Houri, Zion; Singer, Pierre

    2013-09-01

    The metabolic response of critically ill children is characterized by an increase in resting energy expenditure and metabolism, and energy needs of the critically ill child are dynamic, changing from a hypermetabolic to hypometabolic state through the continuum of the intensive care unit (ICU) stay. It therefore appears essential to have a precise evaluation of energy needs in these patients in order to avoid underfeeding and overfeeding, loss of critical lean body mass, and worsening of any existing nutrient deficiencies. However, there are no clear definitions regarding either the exact requirements or the ideal method for determining metabolic needs. In clinical practice, energy needs are determined either by using predictive equations or by actual measurement using indirect calorimetry. Although many equations exist for predicting resting energy expenditure, their accuracy is not clear. In addition, very few clinical trials have been performed so that no firm evidence-based recommendations are available regarding optimal nutritional management of critically ill children and infants. Most studies have come to the same conclusion (i.e., current predictive equations do not accurately predict required energy needs in the pediatric ICU population and predictive equations are unreliable compared with indirect calorimetry). The recent American Society for Parenteral and Enteral Nutrition clinical guidelines for nutrition support of the critically ill child suggest that indirect calorimetry measurements be obtained when possible in pediatric patients with suspected metabolic alterations or malnutrition, according to a list of criteria that may lead to metabolic instability, thus making standardized predictive equations even less reliable. Although the standard use of indirect calorimetry is limited due to equipment availability, staffing, and cost, the accuracy of the commercially available devices continues to improve and the measurements have become more reliable and

  4. Changes in arginine metabolism during sepsis and critical illness in children.

    PubMed

    de Betue, Carlijn T I; Deutz, Nicolaas E P

    2013-01-01

    Arginine is an important amino acid during disease and healing because of functions in the immune system and as precursor of nitric oxide (NO). In critically ill adults and children, plasma arginine and citrulline concentrations are substantially decreased, indicating an arginine-deficient state. Arginine availability is reduced because of increased arginine disposal in combination with reduced de novo arginine synthesis. The latter is most likely caused by reduced citrulline availability. As a result, NO synthesis may be impaired, which might compromise microcirculation. These metabolic changes seem to be dependent on the severity of inflammation. Arginine or citrulline supplementation in severe inflammation might therefore be beneficial. Possibly, the use of protein-energy-enriched formulas may be a first step to improve arginine availability and NO synthesis. In critically ill children, arginine metabolism and supplementation is however a virtually unexplored field. Since pediatric sepsis is a significant health problem, which differs in epidemiology and pathophysiology from sepsis in adults, and because of the scarcity of data in this population, studies focused on pathophysiological mechanisms and possible interventions in arginine metabolism in pediatric critical illness are warranted.

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

    PubMed

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

    2016-08-01

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

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

    PubMed Central

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

    2011-01-01

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

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

    PubMed Central

    2010-01-01

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

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

    PubMed

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

    2014-06-01

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

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

    PubMed

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

    2016-08-01

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

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

    PubMed Central

    Bajwa, Sukhminder Jit Singh; Jindal, Ravi

    2012-01-01

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

  11. Intracardiac Origin of Heart Rate Variability, Pacemaker Funny Current and their Possible Association with Critical Illness

    PubMed Central

    Papaioannou, Vasilios E; Verkerk, Arie O; Amin, Ahmed S; de Bakker, Jaques MT

    2013-01-01

    Heart rate variability (HRV) is an indirect estimator of autonomic modulation of heart rate and is considered a risk marker in critical illness, particularly in heart failure and severe sepsis. A reduced HRV has been found in critically ill patients and has been associated with neuro-autonomic uncoupling or decreased baroreflex sensitivity. However, results from human and animal experimental studies indicate that intracardiac mechanisms might also be responsible for interbeat fluctuations. These studies have demonstrated that different membrane channel proteins and especially the so-called ‘funny’ current (If), an hyperpolarization-activated, inward current that drives diastolic depolarization resulting in spontaneous activity in cardiac pacemaker cells, are altered during critical illness. Furthermore, membrane channels kinetics seem to have significant impact upon HRV, whose early decrease might reflect a cellular metabolic stress. In this review article we present research findings regarding intracardiac origin of HRV, at the cellular level and in both isolated sinoatrial node and whole ex vivo heart preparations. In addition, we will review results from various experimental studies that support the interrelation between If and HRV during endotoxemia. We suggest that reduced HRV during sepsis could also be associated with altered pacemaker cell membrane properties, due to ionic current remodeling. PMID:22920474

  12. Symposium on Age Differentiation in Depressive Illness. Depression in the Elderly

    ERIC Educational Resources Information Center

    Epstein, Leon J.

    1976-01-01

    It is important that the clinician who treats older patients be aware that depression is the psychiatric symptom often encountered in the elderly and that it is as distressing in this age group as it is in younger persons. It often is reversible with prompt and appropriate treatment. (Author)

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

    PubMed Central

    Maharaj, R.

    2012-01-01

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

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

    PubMed

    Trigo, Paula; Fischer, Gregory W

    2012-01-01

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

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

    PubMed Central

    Trigo, Paula; Fischer, Gregory W

    2012-01-01

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

  16. Severe febrile respiratory illnesses as a cause of mass critical care.

    PubMed

    Sandrock, Christian E

    2008-01-01

    Febrile respiratory illnesses with respiratory failure are one of the most common reasons for admission to the intensive care unit. Most causes of febrile respiratory illness are bacterial and viral agents of community-acquired pneumonia. However, a small number of rare and highly contagious agents can initially present as febrile respiratory illnesses, which can lead to an epidemic that can greatly impact the health care system. This impact includes sustained mass critical care, with potential scarcity of critical resources (eg, positive-pressure ventilators), spread of disease to health care workers, sustained spread within the community, and extensive morbidity and mortality. The main agents of febrile respiratory illness that would lead to an epidemic include influenza, the coronavirus that causes severe acute respiratory syndrome, smallpox, viral hemorrhagic fever, plague, tularemia, and anthrax. Recognition of these agents occurs largely based on epidemiological clues, and management consists of antibiotics, antivirals, supportive care, and positive-pressure ventilation. Acute respiratory failure and acute respiratory distress syndrome occur with these agents, so a lung-protective (low tidal volume) ventilation strategy is indicated. Additional respiratory care measures, such as nebulized medications, bronchoscopy, humidified oxygen, and airway suctioning, potentiate aerosolization of the virus or bacteria and increase the risk of transmission to health care workers and patients. Thus, appropriate personal protective equipment, including an N95 mask or powered air-purifying respirator, is indicated. A basic understanding of the epidemiology, clinical findings, diagnosis, and treatment of these agents will provide a foundation for early isolation, evaluation, infection control, and public health involvement and response in cases of a febrile respiratory illness that causes respiratory failure. PMID:18173859

  17. Hippocampal neurogenesis as a target for the treatment of mental illness: A critical evaluation

    PubMed Central

    DeCarolis, Nathan A.; Eisch, Amelia J.

    2010-01-01

    Summary Over one-quarter of adult Americans are diagnosed with a mental illness like Major Depressive Disorder (MDD), Post-Traumatic Stress Disorder (PTSD), schizophrenia, and Alzheimer’s Disease. In addition to the exceptional personal burden these disorders exert on patients and their families, they also have enormous cost to society. Although existing pharmacological and psychosocial treatments alleviate symptoms in many patients, the comorbidity, severity, and intractable nature of mental disorders strongly underscore the need for novel strategies. As the hippocampus is a site of structural and functional pathology in most mental illnesses, a hippocampal-based treatment approach has been proposed to counteract the cognitive deficits and mood dysregulation that are hallmarks of psychiatric disorders. In particular, preclinical and clinical research suggests that hippocampal neurogenesis, the generation of new neurons in the adult dentate gyrus, may be harnessed to treat mental illness. There are obvious applications and allures of this approach; for example, perhaps stimulating hippocampal neurogenesis would reverse the overt and noncontroversial hippocampal atrophy and functional deficits observed in Alzheimer’s Disease and schizophrenia, or the more controversial hippocampal deficits seen in MDD and PTSD. However, critical examination suggests that neurogenesis may only correlate with mental illness and treatment, suggesting targeting neurogenesis alone is not a sufficient treatment strategy. Here we review the classic and causative links between adult hippocampal neurogenesis and mental disorders, and provide a critical evaluation of how (and if) our basic knowledge of new neurons in the adult hippocampus might eventually help combat or even prevent mental illness. PMID:20060007

  18. Critically ill patients in emergency department may be characterized by low amplitude and high variability of amplitude of pulse photoplethysmography

    PubMed Central

    2013-01-01

    Background The aim of the present pilot study was to determine if pulse photoplethysmography amplitude (PPGA) could be used as an indicator of critical illness and as a predictor of higher need of care in emergency department patients. Methods This was a prospective observational study. We collected vital signs and one minute of pulse photoplethysmograph signal from 251 consecutive patients admitted to a university hospital emergency department. The patients were divided in two groups regarding to the modified Early Warning Score (mEWS): > 3 (critically ill) and ≤ 3 (non-critically ill). Photoplethysmography characteristics were compared between the groups. Results Sufficient data for analysis was acquired from 212 patients (84.5%). Patients in critically ill group more frequently required intubation and invasive hemodynamic monitoring in the ED and received more intravenous fluids. Mean pulse photoplethysmography amplitude (PPGA) was significantly lower in critically ill patients (median 1.105 [95% CI of mean 0.9946-2.302] vs. 2.476 [95% CI of mean 2.239-2.714], P = 0.0257). Higher variability of PPGA significantly correlated with higher amount of fluids received in the ED (r = 0.1501, p = 0.0296). Conclusions This pilot study revealed differences in PPGA characteristics between critically ill and non-critically ill patients. Further studies are needed to determine if these easily available parameters could help increase accuracy in triage when used in addition to routine monitoring of vital signs. PMID:23799988

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

    PubMed Central

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

    2014-01-01

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

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

    PubMed Central

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

    2015-01-01

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

  1. Light and the outcome of the critically ill: an observational cohort study

    PubMed Central

    2012-01-01

    Introduction Light before and during acute illness has been associated with both benefit and harm in animal models and small human studies. Our objective was to determine the associations of light duration (photoperiod) and intensity (insolation) before and during critical illness with hospital mortality in ICU patients. Based on the 'winter immunoenhancement' theory, we tested the hypothesis that a shorter photoperiod before critical illness is associated with improved survival. Methods We analyzed data from 11,439 patients admitted to 8 ICUs at the University of Pittsburgh Medical Center between June 30, 1999 and July 31, 2004. Daily photoperiod and insolation prior to and after ICU admission were estimated for each patient by using data provided by the United States Naval Observatory and National Aeronautics and Space Administration and direct measurement of light gradient from outside to bedside for each ICU room. Our primary outcome was hospital mortality. The association between light and risk of death was analyzed using multivariate analyses, adjusting for potential confounders, including severity of illness, case mix, and ICU type. Results The cohort had an average APACHE III of 52.9 and a hospital mortality of 10.7%. In total, 128 ICU beds were analyzed; 108 (84%) had windows. Pre-illness photoperiod ranged from 259 to 421 hours in the prior month. A shorter photoperiod was associated with a reduced risk of death: for each 1-hour decrease, the adjusted OR was 0.997 (0.994 to 0.999, p = 0.03). In the ICU, there was near complete (99.6%) degradation of natural light from outside to the ICU bed. Thus, light exposure once in the ICU approached zero; the 24-hour insolation was 0.005 ± 0.003 kWh/m2 with little diurnal variation. There was no association between ICU photoperiod or insolation and mortality. Conclusions Consistent with the winter immunoenhancement theory, a shorter photoperiod in the month before critical illness is associated with a reduced risk

  2. [Medical-social support to the immobile ill elderly living in a mega polis].

    PubMed

    Tolchenov, B A; Kutuzova, N V

    2009-01-01

    The article describes the working experience of the medical-social support department of the municipal clinic. The work is based on the cooperation with the department of social security. The article focuses on the reasons of decreasing the function ability of such people and age-related features of immobile elderly people. The effective functioning of the medical-social support department is being analyzed.

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

    ERIC Educational Resources Information Center

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

    2013-01-01

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

  4. Ethical dilemmas for house staff physicians. The care of critically ill and dying patients.

    PubMed

    Winkenwerder, W

    1985-12-27

    Winkenwerder describes a disagreement about proper management of a critically ill patient that arose during his tenure as a house staff physician. Despite the attending physician's consideration of the family's wishes and the best interests of the patient, the resident was uneasy with the decision to continue life-prolonging treatment and the role he was to play in implementing such procedures. The author argues that ethical decisions within the group of physicians caring for a patient, especially one who is terminally ill, are not always resolved to everyone's satisfaction. What then are the rights and duties of residents to refuse further participation in care? Winkenwerder suggests dealing with conflicts through recognizing value differences, increasing formal ethics teaching, using consultants, and maximizing communication among members of patient care teams.

  5. Severe vitamin C deficiency in a critically ill adult: a case report.

    PubMed

    Doll, S; Ricou, B

    2013-08-01

    Scurvy, a severe form of vitamin C deficiency, killed scores of people until its cause and treatment were firmly established at the end of the eighteenth century. Since then, cases have surged periodically around the world, mostly in developing countries and during times of war and famine. In developed countries, scurvy is still endemic and evidence is growing that vitamin C deficiency might affect up to 30 percent of the population. Low socio-economic status, alcoholism, severe psychiatric illness leading to poor nutrition and critical illness are significant risk factors. We hereby report the case of a patient admitted in a Swiss intensive care unit of a tertiary teaching hospital and presenting with clinical signs and symptoms of severe vitamin C deficiency. PMID:23549202

  6. Emotional responses of family members of a critically ill patient: a hermeneutic analysis.

    PubMed

    Johansson, Ingrid

    2014-01-01

    This study used an exploratory design with a hermeneutic approach. The aim was to increase the understanding of the emotional responses of family members during the patient's critical care. Interviews from the main researcher's previous study about relatives of patients in an intensive care unit (ICU) were used. Two of these interviews were chosen, one with the mother and one with the father of an adult young patient, who became critically ill and admitted to a general ICU in south-west Sweden. The present study identified six feelings describing the emotional responses of the family members. The family members experienced feelings of uncertainty, feelings of abandonment, feelings of desertion from the loved one, feelings of being close to the deathbed, feelings of being in a no-man's-land and feelings of attachment. The experienced feelings described in this article can contribute to expanding healthcare professionals understanding of the family members' emotional responses during the patient's critical care.

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

    PubMed Central

    2011-01-01

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

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

    PubMed Central

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

    2015-01-01

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

  9. [Review of functional impairment associated with acute illness in the elderly].

    PubMed

    Osuna-Pozo, Carmen María; Ortiz-Alonso, Javier; Vidán, Maite; Ferreira, Guillermo; Serra-Rexach, José Antonio

    2014-01-01

    Hospitalization is a risk for elderly population, with a high probability of having adverse events. The most important one is functional impairment, due to its high prevalence and the serious impact it has on the quality of life. The main risk factors for functional decline associated with hospitalization are, age, immobility, cognitive impairment, and functional status prior to admission. It is necessary to detect patients at risk in order to implement the necessary actions to prevent this deterioration, with physical exercise and multidisciplinary geriatric care being the most important.

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

    PubMed

    Gélinas, Céline

    2016-06-01

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

  11. Intensity of Renal Support in Critically Ill Patients with Acute Kidney Injury

    PubMed Central

    2008-01-01

    BACKGROUND The optimal intensity of renal-replacement therapy in critically ill patients with acute kidney injury is controversial. METHODS We randomly assigned critically ill patients with acute kidney injury and failure of at least one nonrenal organ or sepsis to receive intensive or less intensive renal-replacement therapy. The primary end point was death from any cause by day 60. In both study groups, hemodynamically stable patients underwent intermittent hemodialysis, and hemodynamically unstable patients underwent continuous venovenous hemodiafiltration or sustained low-efficiency dialysis. Patients receiving the intensive treatment strategy underwent intermittent hemodialysis and sustained low-efficiency dialysis six times per week and continuous venovenous hemodiafiltration at 35 ml per kilogram of body weight per hour; for patients receiving the less-intensive treatment strategy, the corresponding treatments were provided thrice weekly and at 20 ml per kilogram per hour. RESULTS Baseline characteristics of the 1124 patients in the two groups were similar. The rate of death from any cause by day 60 was 53.6% with intensive therapy and 51.5% with less-intensive therapy (odds ratio, 1.09; 95% confidence interval, 0.86 to 1.40; P = 0.47). There was no significant difference between the two groups in the duration of renalreplacement therapy or the rate of recovery of kidney function or nonrenal organ failure. Hypotension during intermittent dialysis occurred in more patients randomly assigned to receive intensive therapy, although the frequency of hemodialysis sessions complicated by hypotension was similar in the two groups. CONCLUSIONS Intensive renal support in critically ill patients with acute kidney injury did not decrease mortality, improve recovery of kidney function, or reduce the rate of nonrenal organ failure as compared with less-intensive therapy involving a defined dose of intermittent hemodialysis three times per week and continuous renal

  12. Intensive Insulin Therapy in Critically Ill Hospitalized Patients: Making It Safe and Effective

    PubMed Central

    Klonoff, David C

    2011-01-01

    Intensive insulin therapy (IIT) for hyperglycemia in critically ill patients has become a standard practice. Target levels for glycemia have fluctuated since 2000, as evidence initially indicated that tight glycemic control to so-called normoglycemia (80–110 mg/dl) leads to the lowest morbidity and mortality without hypoglycemic complications. Subsequent studies have demonstrated minimal clinical benefit combined with greater hypoglycemic morbidity and mortality with tight glycemic control in this population. The consensus glycemic targets were then liberalized to the mid 100s (mg/dl). Handheld POC blood glucose (BG) monitors have migrated from the outpatient setting to the hospital environment because they save time and money for managing critically ill patients who require IIT. These devices are less accurate than hospital-grade POC blood analyzers or central laboratory analyzers. Three questions must be answered to understand the role of IIT for defined populations of critically ill patients: (1) How safe is IIT, with various glycemic targets, from the risk of hypoglycemia? (2) How tightly must BG be controlled for this approach to be effective? (3) What role does the accuracy of BG measurements play in affecting the safety of this method? For each state of impaired glucose regulation seen in the hospital, such as hyperglycemia, hypoglycemia, or glucose variability, the benefits, risks, and goals of treatment, including IIT, might differ. With improved accuracy of BG monitors, IIT might be rendered even more intensive than at present, because patients will be less likely to receive inadvertent overdosages of insulin. Greater doses of insulin, but with dosing based on more accurate glucose levels, might result in less hypoglycemia, less hyperglycemia, and less glycemic variability. PMID:21722591

  13. Entropy correlates with Richmond Agitation Sedation Scale in mechanically ventilated critically ill patients.

    PubMed

    Sharma, Ankur; Singh, Preet Mohinder; Trikha, Anjan; Rewari, Vimi; Chandralekha

    2014-04-01

    Sedation is routinely used in intensive care units. However due to absence of objective scoring systems like Bispectral Index and entropy our ability to regulate the degree of sedation is limited. This deficiency is further highlighted by the fact that agitation scores used in intensive care units (ICU) have no role in paralyzed patients. The present study compares entropy as a sedation scoring modality with Richmond Agitation Sedation Scale (RASS) in mechanically ventilated, critically ill patients in an ICU. Twenty-seven, mechanically ventilated, critically ill patients of either sex, 16-65 years of age, were studied over a period of 24 h. They received a standard sedation regimen consisting of a bolus dose of propofol 0.5 mg/kg and fentanyl 1 lg/kg followed by infusions of propofol and fentanyl ranging from 1.5 to 5 mg/kg/h and 0.5 to 2.0 lg/kg/h, respectively. Clinically relevant values of RASS for optimal ICU sedation (between 0 and -3) in non-paralyzed patients were compared to corresponding entropy values, to find if any significant correlation exists between the two. These entropy measurements were obtained using the Datex-Ohmeda-M-EntropyTM module. This module is presently not approved by Food and Drug Administration (FDA) for monitoring sedation in ICU. A total of 527 readings were obtained. There was a statistically significant correlation between the state entropy (SE) and RASS [Spearman's rho/rs = 0.334, p\\0.0001]; response entropy (RE) and RASS [Spearman's rho/rs = 0.341, p\\0.0001]). For adequate sedation as judged by a RASS value of 0 to -3, the mean SE was 57.86 ± 16.50 and RE was 67.75 ± 15.65. The present study illustrates that entropy correlates with RASS (between scores 0 and -3) when assessing the level of sedation in mechanically ventilated critically ill patients.

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

    PubMed

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

    2014-12-01

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

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

    PubMed Central

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

    2015-01-01

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

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

    PubMed

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

    2015-10-19

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

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

    PubMed Central

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

    2014-01-01

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

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

    PubMed

    Chlan, Linda L

    2016-07-01

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

  19. Endogenous glutamine production in critically ill patients: the effect of exogenous glutamine supplementation

    PubMed Central

    2014-01-01

    Introduction Glutamine rate of appearance (Ra) may be used as an estimate of endogenous glutamine production. Recently a technique employing a bolus injection of isotopically labeled glutamine was introduced, with the potential to allow for multiple assessments of the glutamine Ra over time in critically ill patients, who may not be as metabolically stable as healthy individuals. Here the technique was used to evaluate the endogenous glutamine production in critically ill patients in the fed state with and without exogenous glutamine supplementation intravenously. Methods Mechanically ventilated patients (n = 11) in the intensive care unit (ICU) were studied on two consecutive days during continuous parenteral feeding. To allow the patients to be used as their own controls, they were randomized for the reference measurement during basal feeding without supplementation, before or after the supplementation period. Glutamine Ra was determined by a bolus injection of 13C-glutamine followed by a period of frequent sampling to establish the decay-curve for the glutamine tracer. Exogenous glutamine supplementation was given by intravenous infusion of a glutamine containing dipeptide, L-alanyl-L-glutamine, 0.28 g/kg during 20 hours. Results A 14% increase of endogenous glutamine Ra was seen at the end of the intravenous supplementation period as compared to the basal measurements (P = 0.009). Conclusions The bolus injection technique to measure glutamine Ra to estimate the endogenous production of glutamine in critically ill patients was demonstrated to be useful for repetitive measurements. The hypothesized attenuation of endogenous glutamine production during L-alanyl-L-glutamine infusion given as a part of full nutrition was not seen. PMID:24731231

  20. Comparison of the RIFLE, AKIN and KDIGO criteria to predict mortality in critically ill patients

    PubMed Central

    Levi, Talita Machado; de Souza, Sérgio Pinto; de Magalhães, Janine Garcia; de Carvalho, Márcia Sampaio; Cunha, André Luiz Barreto; Dantas, João Gabriel Athayde de Oliveira; Cruz, Marília Galvão; Guimarães, Yasmin Laryssa Moura; Cruz, Constança Margarida Sampaio

    2013-01-01

    Objective Acute kidney injury is a common complication in critically ill patients, and the RIFLE, AKIN and KDIGO criteria are used to classify these patients. The present study's aim was to compare these criteria as predictors of mortality in critically ill patients. Methods Prospective cohort study using medical records as the source of data. All patients admitted to the intensive care unit were included. The exclusion criteria were hospitalization for less than 24 hours and death. Patients were followed until discharge or death. Student's t test, chi-squared analysis, a multivariate logistic regression and ROC curves were used for the data analysis. Results The mean patient age was 64 years old, and the majority of patients were women of African descent. According to RIFLE, the mortality rates were 17.74%, 22.58%, 24.19% and 35.48% for patients without acute kidney injury (AKI) in stages of Risk, Injury and Failure, respectively. For AKIN, the mortality rates were 17.74%, 29.03%, 12.90% and 40.32% for patients without AKI and at stage I, stage II and stage III, respectively. For KDIGO 2012, the mortality rates were 17.74%, 29.03%, 11.29% and 41.94% for patients without AKI and at stage I, stage II and stage III, respectively. All three classification systems showed similar ROC curves for mortality. Conclusion The RIFLE, AKIN and KDIGO criteria were good tools for predicting mortality in critically ill patients with no significant difference between them. PMID:24553510

  1. FACTOR VIII MAY PREDICT CATHETER-RELATED THROMBOSIS IN CRITICALLY ILL CHILDREN: A PRELIMINARY STUDY

    PubMed Central

    Faustino, Edward Vincent S.; Li, Simon; Silva, Cicero T.; Pinto, Matthew G.; Qin, Li; Tala, Joana A.; Rinder, Henry M.; Kupfer, Gary M.; Shapiro, Eugene D.

    2015-01-01

    OBJECTIVE If we can identify critically ill children at high risk for central venous catheter-related thrombosis, then we could target them for pharmacologic thromboprophylaxis. We determined whether factor VIII activity or G value was associated with catheter-related thrombosis in critically ill children. DESIGN Prospective cohort study SETTING Two tertiary academic centers PATIENTS We enrolled children <18 years old who were admitted to the pediatric intensive care unit within 24 hours after insertion of a central venous catheter. We excluded children with a recently diagnosed thrombotic event or those anticipated to receive anticoagulation. Children with thrombosis diagnosed with surveillance ultrasonography on the day of enrollment were classified as having prevalent thrombosis. Those who developed catheter-related thrombosis thereafter were classified as having incident thrombosis. INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS We enrolled 85 children in the study. Once enrolled, we measured factor VIII activity with one-stage clotting assay and determined G value with thromboelastography. Of those enrolled, 25 had incident and 12 had prevalent thromboses. The odds ratio for incident thrombosis per standard deviation increase in factor VIII activity was 1.98 (95% confidence interval: 1.10-3.55). The area under the receiver operating characteristic curve was 0.66 (95% confidence interval: 0.52-0.79). At factor VIII activity >100 IU/dL, which was the optimal threshold identified using Youden index, sensitivity and specificity were 92.0% and 41.3%, respectively. The association between factor VIII activity and incident thrombosis remained significant after adjusting for important clinical predictors of thrombosis (odds ratio: 1.93; 95% confidence interval: 1.10-3.39). G value was associated with prevalent but not with incident thrombosis. CONCLUSION Factor VIII activity may be used to stratify critically ill children based on their risk for catheter

  2. Incidence of propofol-related infusion syndrome in critically ill adults: a prospective, multicenter study

    PubMed Central

    2009-01-01

    Introduction While propofol is associated with an infusion syndrome (PRIS) that may cause death, the incidence of PRIS is unknown. Determining the incidence of PRIS and the frequency of PRIS-related clinical manifestations are key steps prior to the completion of any controlled studies investigating PRIS. This prospective, multicenter study sought to determine the incidence of PRIS and PRIS-related clinical manifestations in a large cohort of critically ill adults prescribed propofol. Methods Critically ill adults from 11 academic medical centers administered an infusion of propofol for [>/=] 24 hours were monitored at baseline and then on a daily basis until propofol was discontinued for the presence of 11 different PRIS-associated clinical manifestations and risk factors derived from 83 published case reports of PRIS. Results Among 1017 patients [medical (35%), neurosurgical (25%)], PRIS (defined as metabolic acidosis plus cardiac dysfunction and [>/=] 1 of: rhabdomyolysis, hypertriglyceridemia or renal failure occurring after the start of propofol therapy) developed in 11 (1.1%) patients an average of 3 (1-6) [median (range)] days after the start of propofol. While most (91%) of the patients who developed PRIS were receiving a vasopressor (80% initiated after the start of propofol therapy), few received a propofol dose >83 mcg/kg/min (18%) or died (18%). Compared to the 1006 patients who did not develop PRIS, the APACHE II score (25 +/- 6 vs 20 +/- 7, P = 0.01) was greater in patients with PRIS but both the duration of propofol use (P = 0.43) and ICU length of stay (P = 0.82) were similar. Conclusions Despite using a conservative definition for PRIS, and only considering new-onset PRIS clinical manifestations, the incidence of PRIS slightly exceeds 1%. Future controlled studies focusing on evaluating whether propofol manifests the derangements of critical illness more frequently than other sedatives will need to be large. These studies should also investigate

  3. Physical rehabilitation interventions for adult patients during critical illness: an overview of systematic reviews

    PubMed Central

    Connolly, Bronwen; O'Neill, Brenda; Salisbury, Lisa; Blackwood, Bronagh

    2016-01-01

    Background Physical rehabilitation interventions aim to ameliorate the effects of critical illness-associated muscle dysfunction in survivors. We conducted an overview of systematic reviews (SR) evaluating the effect of these interventions across the continuum of recovery. Methods Six electronic databases (Cochrane Library, CENTRAL, DARE, Medline, Embase, and Cinahl) were searched. Two review authors independently screened articles for eligibility and conducted data extraction and quality appraisal. Reporting quality was assessed and the Grading of Recommendations Assessment, Development and Evaluation approach applied to summarise overall quality of evidence. Results Five eligible SR were included in this overview, of which three included meta-analyses. Reporting quality of the reviews was judged as medium to high. Two reviews reported moderate-to-high quality evidence of the beneficial effects of physical therapy commencing during intensive care unit (ICU) admission in improving critical illness polyneuropathy/myopathy, quality of life, mortality and healthcare utilisation. These interventions included early mobilisation, cycle ergometry and electrical muscle stimulation. Two reviews reported very low to low quality evidence of the beneficial effects of electrical muscle stimulation delivered in the ICU for improving muscle strength, muscle structure and critical illness polyneuropathy/myopathy. One review reported that due to a lack of good quality randomised controlled trials and inconsistency in measuring outcomes, there was insufficient evidence to support beneficial effects from physical rehabilitation delivered post-ICU discharge. Conclusions Patients derive short-term benefits from physical rehabilitation delivered during ICU admission. Further robust trials of electrical muscle stimulation in the ICU and rehabilitation delivered following ICU discharge are needed to determine the long-term impact on patient care. This overview provides recommendations for

  4. Variability of piperacillin concentrations in relation to tazobactam concentrations in critically ill patients.

    PubMed

    Zander, Johannes; Döbbeler, Gundula; Nagel, Dorothea; Scharf, Christina; Huseyn-Zada, Mikayil; Jung, Jette; Frey, Lorenz; Vogeser, Michael; Zoller, Michael

    2016-10-01

    Therapeutic drug monitoring for critically ill patients receiving piperacillin/tazobactam is described as a useful tool. However, the minimum inhibitory concentration of piperacillin depends on a sufficiently high concentration of tazobactam in case of β-lactamase-producing strains. Therefore, the relationship between piperacillin and tazobactam concentrations was assessed in a heterogeneous group of critically ill patients. Sixty patients with severe infections receiving 4.5 g of piperacillin/tazobactam 2-3 times daily by intermittent infusion were included in this prospective observational study (NCT01793012). Over 4 days, multiple serum samples were obtained to determine the total piperacillin and tazobactam concentrations. The target ranges were defined as trough levels >16 mg/L (>22.5 mg/L) and >4 mg/L (>5.7 mg/L) for the calculated unbound concentrations (measured total concentrations) of piperacillin and tazobactam, respectively. Despite a high correlation coefficient (r = 0.93) comparing piperacillin and tazobactam trough levels, the piperacillin/tazobactam quotients varied between ca. 1 and 10. From linear regression analysis of piperacillin versus tazobactam values, it follows that a piperacillin trough level of 22.5 mg/L might be associated with tazobactam trough levels ranging from 1.5 mg/L to 10.1 mg/L. A 70 mg/L threshold for total piperacillin trough levels would be necessary to ensure that tazobactam concentrations are >5.7 mg/L. Because of the observed variability of piperacillin/tazobactam quotients, defining the total piperacillin target range ≥70 mg/L might be useful to ensure that tazobactam concentrations do not fall below 5.7 mg/L. Further studies are necessary to confirm that the used therapeutic ranges are associated with optimal outcomes in critically ill patients. PMID:27476810

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

    PubMed

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

    2015-11-01

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

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

    PubMed

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

    2016-07-01

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

  7. Beta-lactam dosing in critically ill patients with septic shock and continuous renal replacement therapy

    PubMed Central

    2014-01-01

    Although early and appropriate antibiotic therapy remains the most important intervention for successful treatment of septic shock, data guiding optimization of beta-lactam prescription in critically ill patients prescribed with continuous renal replacement therapy (CRRT) are still limited. Being small hydrophilic molecules, beta-lactams are likely to be cleared by CRRT to a significant extent. As a result, additional variability may be introduced to the per se variable antibiotic concentrations in critically ill patients. This article aims to describe the current clinical scenario for beta-lactam dosing in critically ill patients with septic shock and CRRT, to highlight the sources of variability among the different studies that reduce extrapolation to clinical practice, and to identify the opportunities for future research and improvement in this field. Three frequently prescribed beta-lactams (meropenem, piperacillin and ceftriaxone) were chosen for review. Our findings showed that present dosing recommendations are based on studies with drawbacks limiting their applicability in the clinical setting. In general, current antibiotic dosing regimens for CRRT follow a one-size-fits-all fashion despite emerging clinical data suggesting that drug clearance is partially dependent on CRRT modality and intensity. Moreover, some studies pool data from heterogeneous populations with CRRT that may exhibit different pharmacokinetics (for example, admission diagnoses different to septic shock, such as trauma), which also limit their extrapolation to critically ill patients with septic shock. Finally, there is still no consensus regarding the %T>MIC (percentage of dosing interval when concentration of the antibiotic is above the minimum inhibitory concentration of the pathogen) value that should be chosen as the pharmacodynamic target for antibiotic therapy in patients with septic shock and CRRT. For empirically optimized dosing, during the first day a loading dose is required

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

    SciTech Connect

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

    2007-04-15

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

  9. [III Working Meeting SENPE-Baxter: complementary parenteral nutrition in the critically ill patient].

    PubMed

    de Lorenzo, A García; Grau, T; Montejo, J C; Leyba, C Ortiz; Santana, S Ruiz

    2008-01-01

    In the setting of a multidisciplinary debate, and after reviewing the available evidence as well as the experience from experts, the indications and management guidelines for Complementary Parenteral Nutrition (CPN) in the critically ill patient are established. The conclusion refers to the importance of its indication in all the cases where enteral nutrition (EN) is insufficient to cover at least 60% of the caloric-protein target. At least 80% of the patient's caloric requirements should be covered with EN and CPN, with the recommendation of targeting 100% of the demands.

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

    PubMed Central

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

    2016-01-01

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

  11. Programs to Locate Missing and Critically Wandering Elders: A Critical Review and a Call for Multiphasic Evaluation

    PubMed Central

    Petonito, Gina; Muschert, Glenn W.; Carr, Dawn C.; Kinney, Jennifer M.; Robbins, Emily J.; Brown, J. Scott

    2013-01-01

    As America ages, greater numbers of older adults will be living with Alzheimer’s disease or a related dementia, leading to increased incidence of wandering. Currently there are several initiatives to assist older adults who go missing. We describe and critically examine three prominent and widespread programs: Safe Return, Project Lifesaver, and Silver Alert. Despite their emergence, there has been little research on their effectiveness. More fundamentally, the nature and scope of the missing elder problem is understudied. We call for further research into this issue, as well as assessments of how well such programs balance individual liberties with safety concerns. PMID:22565495

  12. Post-traumatic stress disorder in somatic disease: lessons from critically ill patients.

    PubMed

    Schelling, Gustav

    2008-01-01

    Post-traumatic stress disorder (PTSD) is a well-recognized complication of severe illness. PTSD has been described in patients after multiple trauma, burns, or myocardial infarction with a particularly high incidence in survivors of acute pulmonary failure (Acute Respiratory Distress Syndrome) or septic shock. Many patients with evidence of PTSD after critical illness have been treated in intensive care units (ICUs). Studies in long-term survivors of ICU treatment demonstrated a clear and vivid recall of different categories of traumatic memory such as nightmares, anxiety, respiratory distress, or pain with little or no recall of factual events. A high number of these traumatic memories from the ICU has been shown to be a significant risk factor for the later development of PTSD in long-term survivors. In addition, patients in the ICU are often treated with stress hormones like epinephrine, norepinephrine, or cortisol. The number of the above-mentioned categories of traumatic memory increased with the totally administered dosages of catecholamines and cortisol, and the evaluation of these categories at different time points after discharge from the ICU showed better memory consolidation with higher dosages of stress hormones administered. Conversely, the prolonged administration of beta-adrenergic antagonists during the recovery phase after cardiac surgery resulted in a lower number of traumatic memories and a lower incidence of stress symptoms at 6 months after surgery. Findings with regard to the administration of the stress hormone cortisol were more complex, however. Several studies from our group have demonstrated that the administration of stress doses of cortisol to critically ill patients resulted in a significant reduction of PTSD symptoms measured after recovery without influencing the number of categories of traumatic memory. This can possibly be explained by a cortisol-induced temporary impairment in traumatic memory retrieval that has previously been

  13. Vitamin D status and its association with season, hospital and sepsis mortality in critical illness

    PubMed Central

    2014-01-01

    Introduction Vitamin D plays a key role in immune function. Deficiency may aggravate the incidence and outcome of infectious complications in critically ill patients. We aimed to evaluate the prevalence of vitamin D deficiency and the correlation between serum 25-hydroxyvitamin D (25(OH) D) and hospital mortality, sepsis mortality and blood culture positivity. Methods In a single-center retrospective observational study at a tertiary care center in Graz, Austria, 655 surgical and nonsurgical critically ill patients with available 25(OH) D levels hospitalized between September 2008 and May 2010 were included. Cox regression analysis adjusted for age, gender, severity of illness, renal function and inflammatory status was performed. Vitamin D levels were categorized by month-specific tertiles (high, intermediate, low) to reflect seasonal variation of serum 25(OH) D levels. Results Overall, the majority of patients were vitamin D deficient (<20 ng/ml; 60.2%) or insufficient (≥20 and <30 ng/dl; 26.3%), with normal 25(OH) D levels (>30 ng/ml) present in only 13.6%. The prevalence of vitamin D deficiency and mean 25(OH) D levels was significantly different in winter compared to summer months (P <0.001). Hospital mortality was 20.6% (135 of 655 patients). Adjusted hospital mortality was significantly higher in patients in the low (hazard ratio (HR) 2.05, 95% confidence interval (CI) 1.31 to 3.22) and intermediate (HR 1.92, 95% CI 1.21 to 3.06) compared to the high tertile. Sepsis was identified as cause of death in 20 of 135 deceased patients (14.8%). There was no significant association between 25(OH) D and C-reactive protein (CRP), leukocyte count or procalcitonin levels. In a subgroup analysis (n = 244), blood culture positivity rates did not differ between tertiles (23.1% versus 28.2% versus 17.1%, P = 0.361). Conclusions Low 25(OH) D status is significantly associated with mortality in the critically ill. Intervention studies are needed to investigate

  14. Right dose, right now: using big data to optimize antibiotic dosing in the critically ill.

    PubMed

    Elbers, Paul W G; Girbes, Armand; Malbrain, Manu L N G; Bosman, Rob

    2015-01-01

    Antibiotics save lives and are essential for the practice of intensive care medicine. Adequate antibiotic treatment is closely related to outcome. However this is challenging in the critically ill, as their pharmacokinetic profile is markedly altered. Therefore, it is surprising that critical care physicians continue to rely on standard dosing regimens for every patient, regardless of the actual clinical situation. This review outlines the pharmacokinetic and pharmacodynamic principles that underlie the need for individualized and personalized drug dosing. At present, therapeutic drug monitoring may be of help, but has major disadvantages, remains unavailable for most antibiotics and has produced mixed results. We therefore propose the AutoKinetics concept, taking decision support for antibiotic dosing back to the bedside. By direct interaction with electronic patient records, this opens the way for the use of big data for providing the right dose at the right time in each patient.

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

    PubMed

    Puntillo, Kathleen

    2003-07-01

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

  16. Use of a token economy with seriously mentally ill patients: criticisms and misconceptions.

    PubMed

    Corrigan, P W

    1995-12-01

    Although use of a token economy has been shown to have significant impact on adults and children with serious mental illness who participate in inpatient and community treatment programs, the intervention has not been widely adopted. The paper presents common criticisms of token economies, which may explain the infrequent use of this treatment strategy. They include perceptions that token economies are ineffective, that their benefits do not readily generalize to other settings, that token economies do not foster individualized treatment plans, that participating in a token economy is humiliating, that token economies are abusive, that concerns about milieu management are unimportant and irrelevant to treatment delivery in the 1990s, and that effective token economies are impractical. In an effort to rekindle interest in this potent treatment technique, the author shows that many of these criticisms rest on misconceptions and provides rebuttals based on empirical research. He describes three steps in establishing a token economy.

  17. Ethnicity, self-reported illness and use of medical services by the elderly.

    PubMed Central

    Blakemore, K.

    1983-01-01

    Analysis of ethnic differences in disease is complicated by the fact that culture has an effect on whether people identify themselves as ill and how often they use medical services. This paper cities evidence to show that use of selected medical services by older members of ethnic groups appears to be high. Although a relatively high amount of disease among minority ethnic groups partly accounts for this, additional explanations--notably, cultural perceptions of doctors and aspects of the ageing migrant's position in society--are suggested. PMID:6647184

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

    PubMed Central

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

    2016-01-01

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

  19. Early enteral nutrition in critical illness: a full economic analysis using US costs

    PubMed Central

    Doig, Gordon S; Chevrou-Séverac, Hélène; Simpson, Fiona

    2013-01-01

    Purpose Although published meta-analyses demonstrate patient survival may be improved if enteral nutrition (EN) is provided to critically ill patients within 24 hours of injury or admission to the intensive care unit (ICU), these publications did not investigate the impact of early EN on measures of health care resource consumption and total costs. Materials and methods From the perspective of the US acute care hospital system, a cost-effectiveness analysis was undertaken based on a large-scale Monte Carlo simulation (N = 1,000,000 trials) of a 1,000-patient stochastic model, developed using clinical outcomes and measures of resource consumption reported by published meta-analyses combined with cost distributions obtained from the published literature. The mean cost differences between early EN and standard care, along with respective 95% confidence intervals, were obtained using the percentile method. Results and conclusion The provision of early EN to critically ill patients is a dominant technology: Patient survival is significantly improved and total costs of care reduced meaningfully. Under conservative assumptions, the total costs of acute hospital care were reduced by US$14,462 per patient (95% confidence interval US$5,464 to US$23,669). These results were robust, with all sensitivity analyses demonstrating significant savings attributable to the use of early EN, including sensitivity analysis conducted using European cost data. PMID:24003308

  20. The controversy of the treatment of critically ill patients with thyroid hormone.

    PubMed

    Stathatos, N; Levetan, C; Burman, K D; Wartofsky, L

    2001-12-01

    There is currently a vast literature available on the changes in thyroid function tests that occur during non-thyroidal illness. The aetiology of these changes is, however, controversial, especially with respect to whether they play an adaptive role for the organism in order to cope with stress or whether they represent primary pathology of the pituitary-thyroid axis. This is particularly true for critically ill patients, in whom the most significant changes in thyroid function are observed. The changes include low levels of thyroxine and very low levels of tri-iodothyronine, which would, on the surface, appear to indicate hypothyroidism. Therapy with thyroid hormone, as either L-T4 or L-T3, has therefore been suggested because of these low values for thyroid hormones in the blood. It is, however, unclear whether treating these patients with thyroid hormone is beneficial or harmful. Multiple studies have addressed this issue with patients with cardiac disease, sepsis, pulmonary disease (e.g. acute respiratory distress syndrome) or severe infection, or with burn and trauma patients. In spite of a very large number of published studies, it is very difficult to form clear recommendations for treatment with thyroid hormone in the intensive care unit. Instead, we find the evidence far from compelling, and would advise withholding thyroid hormone therapy in the critical care setting in the absence of clear clinical or laboratory evidence for hypothyroidism.

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

    PubMed

    Chen, Jun; Fan, Chaogang

    2016-07-01

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

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

    PubMed

    Porter, C; Cohen, N H

    1996-01-01

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

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

    PubMed

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

    1997-04-01

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

  4. Proton pump inhibitor use is not associated with cardiac arrhythmia in critically ill patients.

    PubMed

    Chen, Kenneth P; Lee, Joon; Mark, Roger G; Feng, Mengling; Celi, Leo A; Malley, Brian E; Danziger, John

    2015-07-01

    Hypomagnesemia can lead to cardiac arrythmias. Recently, observational data have linked chronic proton pump inhibitor (PPI) exposure to hypomagnesemia. Whether PPI exposure increases the risk for arrhythmias has not been well studied. Using a large, single-center inception cohort of critically ill patients, we examined whether PPI exposure was associated with admission electrocardiogram readings of a cardiac arrhythmia in more than 8000 patients. There were 25.4% PPI users, whereas 6% were taking a histamine 2 antagonist. In all, 14.0% had a cardiac arrhythmia. PPI use was associated with an unadjusted risk of arrhythmia of 1.15 (95% CI,1.00-1.32; P =.04) and an adjusted risk of arrhythmia of 0.91 (95% CI, 0.77-1.06; P =.22). Among diuretic users (n = 2476), PPI use was similarly not associated with an increased risk of cardiac arrhythmia. In summary, in a large cohort of critically ill patients, PPI exposure is not associated with an increased risk of cardiac arrhythmia.

  5. Care of critically ill newborns in India. Legal and ethical issues.

    PubMed

    Subramanian, K N; Paul, V K

    1995-06-01

    The nature of neonatal care in India is changing. While the quality of care will most likely improve as the economy grows, the eventual scope of change remains to be seen. Attitudinal and behavioral changes, in addition to better economic conditions, are needed to realize more appropriate interventions in neonatal care. Economic, cultural, religious, social, political, and other considerations may limit or affect neonatal care, especially for ELBW infants or infants with congenital malformations or brain injury. Various protections for critically ill newborns exist under Indian law and the Constitution of India. New laws are being enacted to enhance the level of protection conferred, including laws which ban amniocentesis for sex determination and define brain death in connection with the use of human organs for therapeutic purposes. The applicability of consumer protection laws to medical care is also being addressed. It is noted, however, that India lacks a multidisciplinary bioethics committee. An effort should be made to discuss the legal and ethical issues regarding the care of critically ill newborns, with discussions considering religious, cultural, traditional, and family values. Legal and ethical guidelines should be developed by institutions, medical councils, and society specific to newborn care, and medical, nursing, and other paramedical schools should include these issues as part of the required coursework. Physicians, nurses, philosophers, and attorneys with expertise in law and ethics should develop and teach these courses. Such measures over the long term will ensure that future health care providers are exposed to these issues, ideally with a view toward enhancing patient care.

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

    PubMed

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

    2016-10-01

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

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

    PubMed Central

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

    2015-01-01

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

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

    PubMed

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

    2015-01-01

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

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

    PubMed Central

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

    2016-01-01

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

  10. Sedation and analgesia for critically ill pediatric burn patients: the current state of practice.

    PubMed

    Singleton, Andrew; Preston, Robert J; Cochran, Amalia

    2015-01-01

    The objective of this study was to assess current practice patterns and attitudes toward pediatric sedation and analgesia in United States (US) burn centers for critically ill patients. Survey-based questionnaire was sent to 119 Directors at US burn centers that care for pediatric patients. Forty-one surveys (34%) were analyzed. 48.8% of responding centers mandate pediatric consultation for pediatric burn patients based on factors such as age and burn size. The most common sedation and analgesic agents used were midazolam, fentanyl, morphine, ketamine, and diphenhydramine. Written sedation policies exist at 63.4% of centers. 90.2% of centers employ scoring systems to guide agent titration. 60.9% of respondents practice sedation holidays "always" or "usually." 90.2% of centers perceive the medications they routinely use are "always" or "often" efficacious in pediatric sedation and analgesia. 53.7% of respondents reported the presence of withdrawal signs and symptoms in their patient population. The lack of consensus guidelines for sedation and analgesia delivery to pediatric intensive care unit patients results in practice variation. The majority of centers perceive their sedation and analgesia strategies to be efficacious despite the heavy reliance on propofol and midazolam, both of which have questionable safety profiles in critically ill children.

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

    PubMed Central

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

    2016-01-01

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

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

    PubMed Central

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

    2016-01-01

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

  13. Increased mortality among the critically ill patients admitted on weekends: a global trend.

    PubMed

    Degenhardt, Natalie

    2011-01-01

    Critical illness and injury have no concept of time and do not always occur within regular business hours or at times conducive to optimal hospital function. In fact, it is a global trend that critically ill patients admitted to hospitals on weekends suffer higher mortality rates than those admitted during the week. Using a Canadian nursing lens, it is clear that there are some obvious differences in hospital function on weekends that include decreased hospital staffing, access to diagnostic services, intensivist coverage and the reluctance of patients to seek care on weekends. However, the exact differences contributing to the increased mortality in this patient population on weekends and the solutions remain unclear in the literature, and further research is needed. Possible solutions include moving to a "closed" ICU system, increasing nurse staffing, intensivist coverage and diagnostic accessibility, and creating a true seven-day hospital system. Finally, it is unclear exactly how to solve the nurse staffing portion of this problem, as it appears internally linked to the nursing profession and externally to hospital management, recruiting difficulties and financial restraints, and a problem that will take more than change in nursing management strategy to resolve.

  14. Controversies in the management of the critically ill: the role of probiotics.

    PubMed

    Theodorakopoulou, Maria; Perros, Elias; Giamarellos-Bourboulis, Evangelos J; Dimopoulos, George

    2013-06-01

    Probiotics are commercially available, viable, non-pathogenic micro-organisms that, when ingested in sufficient quantities, exert a health benefit to the host derived through modification of the gut flora, local release of antimicrobial factors, maintenance of integrity of the gut barrier, competition for epithelial adherence, prevention of bacterial translocation, and modulation of the local immune response. In critically ill patients, probiotics appear to lead to decreased susceptibility to antibiotic-associated diarrhoea, Clostridium difficile infections, ventilator-associated pneumonia, necrotising enterocolitis, acute severe pancreatitis, sepsis and multiple organ dysfunction syndrome as well as a shortened duration of infections. Current scientific evidence supporting the use of probiotics is not conclusive and is mainly derived from single-centre, not very well designed trials that are limited by many factors including small sample sizes, heterogeneity in the probiotic strains used, effectiveness of the combined strains, optimum dose regimens, frequency and duration of administration, and certainly incomplete knowledge of the mechanism of action of each strain. Probiotics appear to be well tolerated, whilst adverse events are very rare. The most commonly reported adverse events include bacteraemia, fungaemia and sepsis. At present, based on the available evidence and although helpful and relatively safe for certain disease conditions, routine use of probiotics in the critically ill is not recommended. PMID:23664676

  15. To Trach or Not to Trach: Uncertainty in the Care of the Chronically Critically Ill.

    PubMed

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

    2015-12-01

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

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

    PubMed Central

    Saliski, Mary; Kudchadkar, Sapna R.

    2015-01-01

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

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

    PubMed

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

    2012-07-01

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

  18. The potential role of nano- and micro-technology in the management of critical illnesses.

    PubMed

    Sadikot, Ruxana T

    2014-11-20

    In recent years nanomedicine has become an attractive concept for the targeted delivery of therapeutic and diagnostic compounds to injured or inflamed organs. Nanoscale drug delivery systems have the ability to improve the pharmacokinetics and increase the biodistribution of therapeutic agents to target organs, thereby resulting in improved efficacy and reduced drug toxicity. These systems are exploited for therapeutic purposes to carry the drug in the body in a controlled manner from the site of administration to the therapeutic target. The mortality in many of the critical illnesses such as sepsis and acute respiratory distress syndrome continues to remain high despite of an increased understanding of the molecular pathogenesis of these diseases. Several promising targets that have been identified as potential therapies for these devastating diseases have been limited because of difficulty with delivery systems. In particular, delivery of peptides, proteins, and miRNAs to the lung is an ongoing challenge. Hence, it is an attractive strategy to test potential targets by employing nanotechnology. Here some of the novel nanomedicine approaches that have been proposed and studied in recent years to facilitate the delivery of therapeutic agents in the setting of critical illnesses such as acute respiratory distress syndrome, sepsis and ventilator associated pneumonia are reviewed.

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

    PubMed Central

    Sacristan, Emilio

    2015-01-01

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

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

    PubMed

    Chen, Jun; Fan, Chaogang

    2016-07-01

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

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

    PubMed

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

    2011-01-01

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

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

    PubMed Central

    2013-01-01

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

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

    PubMed

    Overgaard-Steensen, Christian; Ring, Troels

    2013-01-01

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

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

    PubMed Central

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

    2014-01-01

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

  5. Effects of Systematic Oral Care in Critically Ill Patients: A Multicenter Study

    PubMed Central

    Ames, Nancy J.; Sulima, Pawel; Yates, Jan M.; McCullagh, Linda; Gollins, Sherri L.; Soeken, Karen; Wallen, Gwenyth R.

    2012-01-01

    Background No standard oral assessment tools are available for determining frequency of oral care in critical care patients, and the method of providing oral care is controversial. Objectives To examine the effects of a systematic program of oral care on oral assessment scores in critically ill intubated and nonintubated, patients. Methods Clinical data were collected 3 times during critical care admissions before and after institution of a systematic program of oral care in 3 different medical centers. The oral care education program consisted of instruction from a dentist or dental hygienist and a clear procedure outlining systematic oral care. The Beck Oral Assessment Scale and the mucosal-plaque score were used to assess the oral cavity. Data were analyzed by using linear mixed modeling with controls for severity of illness. Results Scores on the Beck Scale differed significantly (F = 4.79, P = .01) in the pattern of scores across the 3 days and between the control group (before oral education) and the systematic oral care group. Unlike the control group, the treatment group had decreasing scores on the Beck Scale from day 1 to day 5. The mucosal-plaque score and the Beck Scale scores had strong correlations throughout the study; the highest correlation was on day 5 (r = 0.798, P < .001, n = 43). Conclusions Oral assessment scores improved after nurses implemented a protocol for systematic oral care. Use of the Beck Scale and the mucosal-plaque score could standardize oral assessment and guide nurses in providing oral interventions. PMID:21885453

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

    PubMed

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

    2013-01-01

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

  7. Short- and Long-Term Mortality after an Acute Illness for Elderly Whites and Blacks

    PubMed Central

    Polsky, Daniel; Jha, Ashish K; Lave, Judith; Pauly, Mark V; Cen, Liyi; Klusaritz, Heather; Chen, Zhen; Volpp, Kevin G

    2008-01-01

    Objective To estimate racial differences in mortality at 30 days and up to 2 years following a hospital admission for the elderly with common medical conditions. Data Sources The Medicare Provider Analysis and Review File and the VA Patient Treatment File from 1998 to 2002 were used to extract patients 65 or older admitted with a principal diagnosis of acute myocardial infarction, stroke, hip fracture, gastrointestinal bleeding, congestive heart failure, or pneumonia. Study Design A retrospective analysis of risk-adjusted mortality after hospital admission for blacks and whites by medical condition and in different hospital settings. Principal Findings Black Medicare patients had consistently lower adjusted 30-day mortality than white Medicare patients, but the initial survival advantage observed among blacks dissipated beyond 30 days and reversed by 2 years. For VA hospitalizations similar patterns were observed, but the initial survival advantage for blacks dissipated at a slower rate. Conclusions Racial disparities in health are more likely to be generated in the posthospital phase of the process of care delivery rather than during the hospital stay. The slower rate of increase in relative mortality among black VA patients suggests an integrated health care delivery system like the VA may attenuate racial disparities in health. PMID:18355259

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

    PubMed

    Beaudeau, Pascal; Schwartz, Joel; Levin, Ronnie

    2014-04-01

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

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

    PubMed Central

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

    2016-01-01

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

  10. Association of Hyperchloremia with Hospital Mortality in Critically Ill Septic Patients

    PubMed Central

    Neyra, Javier A.; Canepa-Escaro, Fabrizio; Li, Xilong; Manllo, John; Adams-Huet, Beverley; Yee, Jerry; Yessayan, Lenar

    2015-01-01

    Objective Hyperchloremia is frequently observed in critically ill patients in the intensive care unit (ICU). Our study aimed to examine the association of serum chloride (Cl) levels with hospital mortality in septic ICU patients. Design Retrospective cohort study. Setting Urban academic medical center ICU. Patients ICU adult patients with severe sepsis or septic shock who had Cl measured on ICU admission were included. Those with baseline estimated glomerular filtration rate < 15 ml/min/1.73 m2 or chronic dialysis were excluded. Intervention: None. Measurements and Main Results Of 1940 patients included in the study, 615 (31.7%) had hyperchloremia (Cl ≥ 110 mEq/L) on ICU admission. All-cause hospital mortality was the dependent variable. Cl on ICU admission (Cl0), Cl at 72 h (Cl72), and delta Cl (ΔCl = Cl72 – Cl0) were the independent variables. Those with Cl0 ≥ 110 mEq/L were older and had higher cumulative fluid balance, base deficit, and sequential organ failure assessment scores. Multivariate analysis showed that higher Cl72 but not Cl0 was independently associated with hospital mortality in the subgroup of patients with hyperchloremia on ICU admission [adjusted odds ratio (OR) for Cl72 per 5 mEq/L increase = 1.27, 95% CI (1.02–1.59), P = 0.03]. For those who were hyperchloremic on ICU admission, every within-subject 5 mEq/L increment in Cl72 was independently associated with hospital mortality [adjusted OR for ΔCl 5 mEq/L = 1.37, 95% CI [1.11–1.69], P = 0.003]. Conclusions In critically ill septic patients manifesting hyperchloremia (Cl ≥110 mEq/L) on ICU admission, higher Cl levels and within-subject worsening hyperchloremia at 72 h of ICU stay were associated with all-cause hospital mortality. These associations were independent of base deficit, cumulative fluid balance, acute kidney injury, and other critical illness parameters. PMID:26154934

  11. Assessment of candidemia-attributable mortality in critically ill patients using propensity score matching analysis

    PubMed Central

    2012-01-01

    Introduction Candidemia in critically ill patients is usually a severe and life-threatening condition with a high crude mortality. Very few studies have focused on the impact of candidemia on ICU patient outcome and attributable mortality still remains controversial. This study was carried out to determine the attributable mortality of ICU-acquired candidemia in critically ill patients using propensity score matching analysis. Methods A prospective observational study was conducted of all consecutive non-neutropenic adult patients admitted for at least seven days to 36 ICUs in Spain, France, and Argentina between April 2006 and June 2007. The probability of developing candidemia was estimated using a multivariate logistic regression model. Each patient with ICU-acquired candidemia was matched with two control patients with the nearest available Mahalanobis metric matching within the calipers defined by the propensity score. Standardized differences tests (SDT) for each variable before and after matching were calculated. Attributable mortality was determined by a modified Poisson regression model adjusted by those variables that still presented certain misalignments defined as a SDT > 10%. Results Thirty-eight candidemias were diagnosed in 1,107 patients (34.3 episodes/1,000 ICU patients). Patients with and without candidemia had an ICU crude mortality of 52.6% versus 20.6% (P < 0.001) and a crude hospital mortality of 55.3% versus 29.6% (P = 0.01), respectively. In the propensity matched analysis, the corresponding figures were 51.4% versus 37.1% (P = 0.222) and 54.3% versus 50% (P = 0.680). After controlling residual confusion by the Poisson regression model, the relative risk (RR) of ICU- and hospital-attributable mortality from candidemia was RR 1.298 (95% confidence interval (CI) 0.88 to 1.98) and RR 1.096 (95% CI 0.68 to 1.69), respectively. Conclusions ICU-acquired candidemia in critically ill patients is not associated with an increase in either ICU or

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

    PubMed Central

    2013-01-01

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

  13. The Effect of Neighborhood and Individual Characteristics on Pediatric Critical Illness

    PubMed Central

    Reibel, Michael; Unger, Jennifer B.; Cockburn, Myles; Escobedo, Loraine A.; Kale, David C.; Chang, Jennifer C.; Gold, Jeffrey I.

    2014-01-01

    The relationship between neighborhood/individual characteristics and pediatric intensive care unit (PICU) outcomes is largely unexplored. We hypothesized that individual- level racial/ethnic minority status and neighborhood-level low socioeconomic status and minority concentration would adversely affect children’s severity of illness on admission to the PICU. Retrospective analyses (1/1/2007–5/ 23/2011) of clinical, geographic, and demographic data were conducted at an academic, tertiary children’s hospital PICU. Clinical data included age, diagnosis, insurance, race/ethnicity, Pediatric Index of Mortality 2 score on presentation to the PICU (PIM2), and mortality. Residential addresses were geocoded and linked with 2010 US Census tract data using geographic information systems geocoding techniques. Repeated measures models to predict PIM2 and mortality were constructed using three successive models with theorized covariates including the patient’s race/ethnicity, the predominant neighborhood racial/ethnic group, interactions between patient race/ethnicity and neighborhood race/ethnicity, neighborhood socioeconomic status, and insurance type. Of the 5,390 children, 57.8 %were Latino and 70.1 %possessed government insurance. Latino children (β = 0.31; p < 0.01), especially Latino children living in a Latino ethnic enclave (β = 1.13; p < 0.05), had higher PIM2 scores compared with non-Latinos. Children with government insurance (β = 0.29; p < 0.01) had higher PIM2 scores compared to children with other payment types and median neighborhood income was inversely associated with PIM2 scores (β = −0.04 per $10,000/year of income; p < 0.05). Lower median neighborhood income, Latino ethnicity, Latino children living in a predominantly Latino neighborhood, and children possessing government insurance were associated with a higher severity of illness on PICU admission. The reasons why these factors affect critical illness severity require further exploration

  14. The effect of neighborhood and individual characteristics on pediatric critical illness.

    PubMed

    Epstein, David; Reibel, Michael; Unger, Jennifer B; Cockburn, Myles; Escobedo, Loraine A; Kale, David C; Chang, Jennifer C; Gold, Jeffrey I

    2014-08-01

    The relationship between neighborhood/individual characteristics and pediatric intensive care unit (PICU) outcomes is largely unexplored. We hypothesized that individual-level racial/ethnic minority status and neighborhood-level low socioeconomic status and minority concentration would adversely affect children's severity of illness on admission to the PICU. Retrospective analyses (1/1/2007-5/23/2011) of clinical, geographic, and demographic data were conducted at an academic, tertiary children's hospital PICU. Clinical data included age, diagnosis, insurance, race/ethnicity, Pediatric Index of Mortality 2 score on presentation to the PICU (PIM2), and mortality. Residential addresses were geocoded and linked with 2010 US Census tract data using geographic information systems geocoding techniques. Repeated measures models to predict PIM2 and mortality were constructed using three successive models with theorized covariates including the patient's race/ethnicity, the predominant neighborhood racial/ethnic group, interactions between patient race/ethnicity and neighborhood race/ethnicity, neighborhood socioeconomic status, and insurance type. Of the 5,390 children, 57.8% were Latino and 70.1% possessed government insurance. Latino children (β = 0.31; p < 0.01), especially Latino children living in a Latino ethnic enclave (β = 1.13; p < 0.05), had higher PIM2 scores compared with non-Latinos. Children with government insurance (β = 0.29; p < 0.01) had higher PIM2 scores compared to children with other payment types and median neighborhood income was inversely associated with PIM2 scores (β = -0.04 per $10,000/year of income; p < 0.05). Lower median neighborhood income, Latino ethnicity, Latino children living in a predominantly Latino neighborhood, and children possessing government insurance were associated with a higher severity of illness on PICU admission. The reasons why these factors affect critical illness severity require further exploration. PMID:24488647

  15. Assessment of calcium homeostasis in the critically ill surgical patient. The diagnostic pitfalls of the McLean-Hastings nomogram.

    PubMed Central

    Zaloga, G P; Chernow, B; Cook, D; Snyder, R; Clapper, M; O'Brian, J T

    1985-01-01

    Hypocalcemia is a common problem in critically ill surgical patients. We prospectively evaluated whether measurement of the total serum calcium (Ca) concentration or calculation of the serum ionized Ca level (by the McLean-Hastings nomogram) accurately reflects the measured serum ionized Ca level. Although 71% and 58% of 156 predominantly surgical intensive care unit (ICU) patients were hypocalcemic by the total serum Ca or calculated ionized Ca level, respectively, only 12% were hypocalcemic by directly measured serum ionized Ca measurement. The total serum Ca and calculated ionized Ca concentrations were sensitive (95% and 89%, respectively) but lacked specificity (32% and 46%, respectively) in predicting ionized hypocalcemia. Analyses of Ca binding to albumin in the serum of surgical ICU patients and normal subjects suggested that there is a circulating factor in critically ill patients that increases the binding of Ca to albumin. These observations may explain why the McLean-Hastings nomogram underestimates the protein-induced changes in serum Ca in critically ill surgical subjects. We conclude that: total serum Ca and calculated ionized Ca concentrations are poor indicators of the true serum ionized Ca status in critically ill surgical patients, and we recommend direct measurement of serum ionized Ca levels in these patients; and variability in the affinity of Ca for binding proteins in critical illness may explain the poor correlation between serum total and ionized Ca measurements. PMID:4051606

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

    PubMed

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

    2016-01-01

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

  17. Pilot study with a glutamine-supplemented enteral formula in critically ill infants.

    PubMed

    Barbosa, E; Moreira, E A; Goes, J E; Faintuch, J

    1999-01-01

    Seriously ill infants often display protein-calorie malnutrition due to the metabolic demands of sepsis and respiratory failure. Glutamine has been classified as a conditionally essential amino acid, with special usefulness in critical patients. Immunomodulation, gut protection, and prevention of protein depletion are mentioned among its positive effects in such circumstances. With the intent of evaluating the tolerance and clinical impact of a glutamine supplement in seriously ill infants, a prospective randomized study was done with nine patients. Anthropometric and biochemical determinations were made, and length of stay in the intensive care unit (ICU), in the hospital, and under artificial ventilation, and septic morbidity and mortality were tabulated. Infants in the treatment group (n = 5) were enterally administered 0.3 g/kg of glutamine, whereas controls received 0.3 g/kg of casein during a standard period of five days. Septic complications occurred in 75% of the controls (3/4) versus 20% of the glutamine-treated group (1/5, p < or = 0.10), and two patients in the control group died of bacterial infections (50% vs. 0%, p < or = 0.10). Days in the ICU, in the hospital, and with ventilation numerically favored glutamine therapy, although without statistical significance. The supplements were usually well tolerated, and no patient required discontinuation of the program. The conclusion was that glutamine supplementation was safe and tended to be associated with less infectious morbidity and mortality in this high-risk population.

  18. Antimicrobial treatment and outcomes of critically ill patients with OXA-48like carbapenemase-producing Enterobacteriaceae infections.

    PubMed

    Lowman, Warren; Schleicher, Gunter

    2015-02-01

    We report on the clinical characteristics, antimicrobial therapy, and outcomes of 20 critically ill patients with severe OXA-48like infections. Carbapenem-based therapy demonstrated improved survival (odds ratio = 5.0) as compared with non-carbapenem therapy. Risk factors for mortality included Acute Physiology and Chronic Health Evaluation III score and length of stay, highlighting the significant influence of comorbidities and severity of underlying illness on outcomes.

  19. Adolescent mothers of critically ill newborns: addressing the rights of parent and child.

    PubMed

    Mercurio, Mark R

    2011-08-01

    Despite recent declines, the teen birth rate in the United States remains markedly higher than in other developed countries. Infants born to teen mothers are more likely to be preterm than those born to adult mothers and thus more likely to end up in the newborn intensive care unit (NICU). Critically ill newborns are not infrequently born to teen mothers, including those in early adolescence. The focus of this chapter is the mechanism of decision-making on behalf of those newborns and the role of the early adolescent mother as surrogate decision-maker. It is argued that the current standard in many US hospitals, and likely elsewhere, is suboptimal and inadequately addresses the rights and needs of both mother and newborn.

  20. [Effect of exercise training on rehabilitation of the chronic critical illness patients].

    PubMed

    Gu, Guosheng; Ren, Jianan

    2016-07-01

    Over the past decades, the evolution of the techniques used in the intensive care has led on one side to better survival rates in ICU patients. On the other side, it has resulted in a growing number of patients who survive an acute event to chronic condition, and who then become dependent on one or more life support treatments. Such patients are called chronic critical illness(CCI) patients. Even these patients can dismiss from intensive care unit (ICU) or transfer to specialized rehabilitation care settings, the mortality of these patients is still very high. Therefore, how to promote the rehabilitation of CCI patients is one of the most important research points of epidemiology, public health and social economics. Exercise training can promote rehabilitation, improve quality of life and independent functional status in these patients, which should be used as one of the standard treatment protocols for CCI patients. PMID:27452749

  1. Music therapy, a review of the potential therapeutic benefits for the critically ill.

    PubMed

    Mofredj, A; Alaya, S; Tassaioust, K; Bahloul, H; Mrabet, A

    2016-10-01

    Intensive care units are a stressful milieu for patients, particularly when under mechanical ventilation which they refer to as inhumane and anxiety producing. Anxiety can impose harmful effects on the course of recovery and overall well-being of the patient. Resulting adverse effects may prolong weaning and recovery time. Music listening, widely used for stress release in all areas of medicine, tends to be a reliable and efficacious treatment for those critically ill patients. It can abate the stress response, decrease anxiety during mechanical ventilation, and induce an overall relaxation response without the use of medication. This relaxation response can lower cardiac workload and oxygen consumption resulting in more effective ventilation. Music may also improve sleep quality and reduce patient's pain with a subsequent decrease in sedative exposure leading to an accelerated ventilator weaning process and a speedier recovery. PMID:27481759

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

    PubMed Central

    CHLAN, LINDA; HEIDERSCHEIT, ANNIE

    2010-01-01

    Music is an ideal intervention to reduce anxiety and promote relaxation in critically ill patients. This article reviews the research studies on music-listening interventions to manage distressful symptoms in this population, and describes the development and implementation of the Music Assessment Tool (MAT) to assist professionals in ascertaining patients’ music preferences in the challenging, dynamic clinical environment of the intensive care unit (ICU). The MAT is easy to use with these patients who experience profound communication challenges due to fatigue and inability to speak because of endotracheal tube placement. The music therapist and ICU nursing staff are encouraged to work collaboratively to implement music in a personalized manner to ensure the greatest benefit for mechanically ventilated patients. PMID:24489432

  3. [Hepatotoxicity in the critically ill patient. The liver under an acute severe insult].

    PubMed

    García de Lorenzo y Mateos, A; Rodríguez Montes, J A

    2008-05-01

    The liver plays an essential role in the metabolism of most of the nutrients since it is a mainly metabolic organ carrying out a series of physiological and metabolic processes related with protein and energy metabolism. The intestinal tract is considered a key element in the development of Multiorgan Dysfunction (MOD) or failure by loosing its barrier function (impaired permeability) against toxins, bio-products and occasionally intraluminal bacteria secondary to hypoxia, one of the main pathophysiogenic mechanisms being the insufficient blood flow to splacnic organs. Liver dysfunction and/or impairment of liver function test are a common event in critically ill patients. They may be due to previous liver cirrhosis or to more immediate causes of liver failure such as sepsis, drugs, liver transplant or any of the multiple etiologies for hepatitis. PMID:18714407

  4. Disturbances of sodium in critically ill adult neurologic patients: a clinical review.

    PubMed

    Tisdall, Martin; Crocker, Matthew; Watkiss, Jonathan; Smith, Martin

    2006-01-01

    Disorders of sodium and water balance are common in critically ill adult neurologic patients. Normal aspects of sodium and water regulation are reviewed. The etiology of possible causes of sodium disturbance is discussed in both the general inpatient and the neurologic populations. Areas of importance are highlighted with regard to the differential diagnosis of sodium disturbance in neurologic patients, and management strategies are discussed. Specific discussions of the etiology, diagnosis, and management of cerebral salt wasting syndrome, the syndrome of inappropriate antidiuretic hormone secretion, and central diabetes insipidus are presented, as well as the problems of overtreatment. The importance of diagnosis at an early stage of these diseases is stressed, with a recommendation for conservative management of milder cases.

  5. The intestinal microbiota and host immune interactions in the critically ill.

    PubMed

    Schuijt, Tim J; van der Poll, Tom; de Vos, Willem M; Wiersinga, W Joost

    2013-05-01

    The gastrointestinal tract harbors a complex population of microbes that play a fundamental role in the development of the immune system and human health. Besides an important local contribution in the host defense against infections, it has become increasingly clear that intestinal bacteria also modulate immune responses at systemic sites. These new insights can be of profound clinical relevance especially for intensive care medicine where the majority of patients are treated with antibiotics, which have pervasive and long-term effects on the intestinal microbiota. Moreover, considerable progress has been made in defining the role of the intestinal microbiota in both health and disease. In this review, we highlight these aspects and focus on recent key findings addressing the role of intestinal microbiota in antimicrobial defense mechanisms and its impact on intestinal homeostasis in the critically ill.

  6. Complications during intrahospital transport of critically ill patients: Focus on risk identification and prevention

    PubMed Central

    Knight, Patrick H; Maheshwari, Neelabh; Hussain, Jafar; Scholl, Michael; Hughes, Michael; Papadimos, Thomas J; Guo, Weidun Alan; Cipolla, James; Stawicki, Stanislaw P; Latchana, Nicholas

    2015-01-01

    Intrahospital transportation of critically ill patients is associated with significant complications. In order to reduce overall risk to the patient, such transports should well organized, efficient, and accompanied by the proper monitoring, equipment, and personnel. Protocols and guidelines for patient transfers should be utilized universally across all healthcare facilities. Care delivered during transport and at the site of diagnostic testing or procedure should be equivalent to the level of care provided in the originating environment. Here we review the most common problems encountered during transport in the hospital setting, including various associated adverse outcomes. Our objective is to make medical practitioners, nurses, and ancillary health care personnel more aware of the potential for various complications that may occur during patient movement from the intensive care unit to other locations within a healthcare facility, focusing on risk reduction and preventive strategies. PMID:26807395

  7. [Enteral access and intestinal function assessment in the critically ill patient].

    PubMed

    Mesejo, A; Juan, M; García-Simón, M

    2007-05-01

    The use of enteral nutrition (EN) in the critically-ill patient makes necessary to evaluate its effectiveness and impact on achieving the target requirements. Gastrically administered EN has a high complication rate, especially increased residue that leads to hyponutrition. The use of the small bowel (jejunum) may achieve greater administered volume, although there are three aspects that directly influence on its use: intestinal access route, motility and absorptive capability, and barrier function. The selection of the access route to the digestive tube has to be done after evaluating the underlying disease and predicted duration of EN. If it is greater than 4-6 weeks a definitive access will be performed through an invasive technique of ostomy (radiologic, endoscopic or surgical jejunostomy) and if it is shorter than 4-6 weeks, an endoscopic, fluoroscopic or ultrasonographic non-invasive or transnasal technique (naso-duodenal, or nasojejunal) will be used. By protocoling procedures and experiences, it has been shown that jejunal nutrition may achieve an increase in the amount of requirements administerd to critically-ill patients with mechanical ventilation as compared to gastric feeding, although the benefits with regards to reducing the number of infectious complications, hospital stay and mortality are not so clear-cut, so that it should be left to those cases in which gastric feeding has been clearly documented. By using the manometrich technique or the acetaminophen absorption tests it has been shown that 50% of critically-ill patients with mechanical ventilation have gastric antral hypomotility with decreased migratory motor complexes and gastric voiding, which considerably hampers nutrition. Under normal circumstances, during fasting, there are regular motor contractions, or an inter-digestive migratory motor complex which pattern prevents nutrient absorption because of being highly propulsive, so that during the nutrient phase, this pattern changes into

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

    PubMed

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

    2008-08-01

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

  9. Respiratory muscle dysfunction: a multicausal entity in the critically ill patient undergoing mechanical ventilation.

    PubMed

    Díaz, Magda C; Ospina-Tascón, Gustavo A; Salazar C, Blanca C

    2014-02-01

    Respiratory muscle dysfunction, particularly of the diaphragm, may play a key role in the pathophysiological mechanisms that lead to difficulty in weaning patients from mechanical ventilation. The limited mobility of critically ill patients, and of the diaphragm in particular when prolonged mechanical ventilation support is required, promotes the early onset of respiratory muscle dysfunction, but this can also be caused or exacerbated by other factors that are common in these patients, such as sepsis, malnutrition, advanced age, duration and type of ventilation, and use of certain medications, such as steroids and neuromuscular blocking agents. In this review we will study in depth this multicausal origin, in which a common mechanism is altered protein metabolism, according to the findings reported in various models. The understanding of this multicausality produced by the same pathophysiological mechanism could facilitate the management and monitoring of patients undergoing mechanical ventilation.

  10. [Update on invasive candidiasis in non-neutropenic critically ill adult patients].

    PubMed

    Zaragoza, Rafael; Ramírez, Paula; Borges, Marcio; Pemán, Javier

    2016-01-01

    Invasive candidiasis in non-neutropenic critically ill patients remains a challenge for clinicians due to its association with high morbidity and mortality rates, increased incidence, and health-care costs. It is well known that early diagnosis and treatment are associated with a better prognosis. For these reasons a thorough update has been performed in this setting focused on recent Spanish epidemiology, new predictive scores and microbiological tests such as mannan antigen, mannan antibodies, Candida albicans germ-tube antibodies or (1→3)-β-D-glucan detection, molecular techniques for the detection of fungal-specific DNA, advances in antifungal treatment and educational programs in Spain. An early diagnostic and therapeutic algorithm is proposed based on the combination of scores and microbiological test. The aim of this review is to provide physicians with the best information available in order to improve the prognosis of these patients.

  11. Octreotide in a Critically Ill Extremely Preterm Infant With Perforated Necrotizing Enterocolitis.

    PubMed

    Martini, Silvia; Aceti, Arianna; Lima, Mario; Maffi, Michela; Faldella, Giacomo; Corvaglia, Luigi

    2016-08-01

    Necrotizing enterocolitis (NEC) is the most severe gastrointestinal complication of prematurity. Surgery, either peritoneal drainage placement or laparotomy with resection of the intestinal necrotic tracts, is the definitive treatment of perforated NEC; however, when clinical conditions contraindicate surgical approaches, little is known about medical treatments adjuvant or alternative to surgery. Octreotide is a synthetic somatostatin analog that inhibits pancreatic secretion and leads to splanchnic vasoconstriction. In preterm neonates, it is mainly used off-label for chylothorax and congenital hyperinsulinism, whereas gastrointestinal indications are limited. We describe the case of a critically ill extremely low birth weight infant with perforated NEC, who had unsuccessfully undergone peritoneal drainage placement and laparotomy. Her unstable condition contraindicated a further laparotomy, thus off-label treatment with octreotide was attempted. No adverse events occurred. The infant's condition gradually improved and progressive reduction of peritoneal outputs and successful resolution of pneumoperitoneum were achieved, with no relapse after octreotide discontinuation. PMID:27405769

  12. Evaluation of the pressure ulcers risk scales with critically ill patients: a prospective cohort study 1

    PubMed Central

    Borghardt, Andressa Tomazini; do Prado, Thiago Nascimento; de Araújo, Thiago Moura; Rogenski, Noemi Marisa Brunet; Bringuente, Maria Edla de Oliveira

    2015-01-01

    AIMS: to evaluate the accuracy of the Braden and Waterlow risk assessment scales in critically ill inpatients. METHOD: this prospective cohort study, with 55 patients in intensive care units, was performed through evaluation of sociodemographic and clinical variables, through the application of the scales (Braden and Waterlow) upon admission and every 48 hours; and through the evaluation and classification of the ulcers into categories. RESULTS: the pressure ulcer incidence was 30.9%, with the Braden and Waterlow scales presenting high sensitivity (41% and 71%) and low specificity (21% and 47%) respectively in the three evaluations. The cut off scores found in the first, second and third evaluations were 12, 12 and 11 in the Braden scale, and 16, 15 and 14 in the Waterlow scale. CONCLUSION: the Braden scale was shown to be a good screening instrument, and the Waterlow scale proved to have better predictive power. PMID:25806628

  13. Should We Aim for Full Enteral Feeding in the First Week of Critical Illness?

    PubMed

    McClave, Stephen A; Codner, Panna; Patel, Jayshil; Hurt, Ryan T; Allen, Karen; Martindale, Robert G

    2016-08-01

    Recent clinical trials have challenged the concept that aggressive full feeding as close to goal requirements as possible is necessary in the first week following admission to the intensive care unit. While the data suggesting that permissive underfeeding is better than full feeds are methodologically flawed, other data do indicate that in certain well-defined patient populations, outcomes may be similar. The most important issues for clinicians in determining optimal nutrition therapy for critically ill patients are to carefully determine nutrition risk and differentiate nutrition from nonnutrition benefits of early enteral feeding. Management decisions in the first week of hospitalization should be made in the context of both short- and long-term outcomes. Patients at highest nutrition risk may require advancement to goal feeds as soon as tolerated to maximize benefit from nutrition therapy. PMID:27317613

  14. [Update on invasive candidiasis in non-neutropenic critically ill adult patients].

    PubMed

    Zaragoza, Rafael; Ramírez, Paula; Borges, Marcio; Pemán, Javier

    2016-01-01

    Invasive candidiasis in non-neutropenic critically ill patients remains a challenge for clinicians due to its association with high morbidity and mortality rates, increased incidence, and health-care costs. It is well known that early diagnosis and treatment are associated with a better prognosis. For these reasons a thorough update has been performed in this setting focused on recent Spanish epidemiology, new predictive scores and microbiological tests such as mannan antigen, mannan antibodies, Candida albicans germ-tube antibodies or (1→3)-β-D-glucan detection, molecular techniques for the detection of fungal-specific DNA, advances in antifungal treatment and educational programs in Spain. An early diagnostic and therapeutic algorithm is proposed based on the combination of scores and microbiological test. The aim of this review is to provide physicians with the best information available in order to improve the prognosis of these patients. PMID:27395022

  15. Intensify, resuscitate or palliate: decision making in the critically ill patient with haematological malignancy.

    PubMed

    Hill, Quentin A

    2010-01-01

    The survival prospects of critically ill patients with haematological malignancy (HM) are reviewed, as are the variables which might influence decisions about the limitation of life sustaining therapies (LLST). Approximately 40% of patients with HM admitted to ICU survive to hospital discharge and a broad admission policy is warranted. Short term survival is predicted by the severity of the underlying physiological disturbance rather than cancer specific characteristics, although the prognostic importance of neutropenia and prior stem cell transplantation remains to be clarified. Survival to hospital discharge in cancer patients following cardio-pulmonary resuscitation (CPR) is only 6-8%. Poor performance status and progressive deterioration despite ICU support appear to predict worse outcome. Patients should be provided with realistic information in order to make an informed decision about CPR. Decisions about LLST must be individualised. Consideration should be given to the patient's wishes and prognosis, the immediate clinical circumstances and their potential reversibility. PMID:19913962

  16. Respiratory muscle dysfunction: a multicausal entity in the critically ill patient undergoing mechanical ventilation.

    PubMed

    Díaz, Magda C; Ospina-Tascón, Gustavo A; Salazar C, Blanca C

    2014-02-01

    Respiratory muscle dysfunction, particularly of the diaphragm, may play a key role in the pathophysiological mechanisms that lead to difficulty in weaning patients from mechanical ventilation. The limited mobility of critically ill patients, and of the diaphragm in particular when prolonged mechanical ventilation support is required, promotes the early onset of respiratory muscle dysfunction, but this can also be caused or exacerbated by other factors that are common in these patients, such as sepsis, malnutrition, advanced age, duration and type of ventilation, and use of certain medications, such as steroids and neuromuscular blocking agents. In this review we will study in depth this multicausal origin, in which a common mechanism is altered protein metabolism, according to the findings reported in various models. The understanding of this multicausality produced by the same pathophysiological mechanism could facilitate the management and monitoring of patients undergoing mechanical ventilation. PMID:23669061

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

    PubMed Central

    Verbruggen, Sascha; Sy, Jama; Gordon, William E.; Hsu, Jean; Wu, Manhong; Chacko, Shaji; Zurakowski, David; Burrin, Douglas

    2009-01-01

    To determine the rates of methionine splanchnic uptake and utilization in critically ill pediatric patients we used two kinetic models: the plasma methionine enrichment and the “intracellular” homocysteine enrichment. Twenty four patients, eight infants, eight children, and eight adolescents, were studied. They received simultaneous, primed, constant, intravenous infusions of l-[2H3]methylmethionine and enteral l-[1-13C]methionine. The ratio of [13C]homocysteine to [13C]methionine enrichment was 1.0 ± 0.15, 0.80 ± 0.20, and 0.66 ± 0.10, respectively, for the infants, children, and adolescents, and it was different between the infants and adolescents (P < 0.01). Methionine splanchnic uptake was 63, 45, and 36%, respectively, in the infants, children, and adolescents, and it was higher (P < 0.01) in the infants compared with the adolescents. The infants utilized 73% of methionine flux for nonoxidative disposal, while 27% was used for transulfuration (P < 0.001). Conversely, in the adolescents, 40% was utilized for nonoxidative disposal, while 60% was used for transulfuration. There is ontogeny on the rates of methionine splanchnic uptake and on the fate of methionine utilization in critically ill children, with greater methionine utilization for synthesis of proteins and methionine-derived compounds (P < 0.01) and decreased transulfuration rates in the infants (P < 0.01), while the opposite was observed in the adolescents. The plasma model underestimated methionine kinetics in children and adolescents but not in the infants, suggesting lesser dilution and greater compartmentation of methionine metabolism in the infant population. All patients were in negative methionine balance, indicating that the current enteral nutritional support is inadequate in these patients. PMID:19724018

  18. Ultrasound-guided internal jugular vein catheterization in critically ill pediatric patients

    PubMed Central

    Yang, Eu Jeen; Ha, Hyeong Seok; Kong, Young Hwa

    2015-01-01

    Purpose Continuous intravenous access is imperative in emergency situations. Ultrasound-guided internal jugular vein (IJV) catheterization was investigated in critically ill pediatric patients to assess the feasibility of the procedure. Methods Patients admitted to the pediatric intensive care unit between February 2011 and September 2012 were enrolled in this study. All patients received a central venous catheter from attending house staff under ultrasound guidance. Outcome measures included successful insertion of the catheter, cannulation time, number of cannulation attempts, and number and type of resulting complications. Results Forty-one central venous catheters (93.2%) were successfully inserted into 44 patients (21 males and 23 females; mean age, 6.54±1.06 years). Thirty-three patients (75.0%) had neurological disorders. The right IJV was used for catheter insertion in 34 cases (82.9%). The mean number of cannulation attempts and the mean cannulation time was 1.57±0.34 and 14.07±1.91 minutes, respectively, the mean catheter dwell time was 14.73±2.5 days. Accidental catheter removal was observed in 9 patients (22.0%). Six patients (13.6%) reported complications, the most serious being catheter-related sepsis, which affected 1 patient (2.3%). Other complications included 2 reported cases of catheter malposition (4.6%), and 1 case each of arterial puncture (2.3%), pneumothorax (2.3%), and skin infection (2.3%). Conclusion The results suggest that ultrasound-guided IJV catheterization can be performed easily and without any serious complications in pediatric patients, even when performed by visiting house staff. Therefore, ultrasound-guided IJV catheterization is strongly recommended for critically ill pediatric patients. PMID:25932035

  19. The Effect of Nutritional Status in the Pathogenesis of Critical Illness Myopathy (CIM)

    PubMed Central

    Ogilvie, Hannah; Larsson, Lars

    2014-01-01

    The muscle wasting and loss of specific force associated with Critical Illness Myopathy (CIM) is, at least in part, due to a preferential loss of the molecular motor protein myosin. This acquired myopathy is common in critically ill immobilized and mechanically ventilated intensive care patients (ICU). There is a growing understanding of the mechanisms underlying CIM, but the role of nutritional factors triggering this serious complication of modern intensive care remains unknown. This study aims at establishing the effect of nutritional status in the pathogenesis of CIM. An experimental ICU model was used where animals are mechanically ventilated, pharmacologically paralysed post-synaptically and extensively monitored for up to 14 days. Due to the complexity of the experimental model, the number of animals included is small. After exposure to this ICU condition, animals develop a phenotype similar to patients with CIM. The results from this study show that the preferential myosin loss, decline in specific force and muscle fiber atrophy did not differ between low vs. eucaloric animals. In both experimental groups, passive mechanical loading had a sparing effect of muscle weight independent on nutritional status. Thus, this study confirms the strong impact of the mechanical silencing associated with the ICU condition in triggering CIM, overriding any potential effects of caloric intake in triggering CIM. In addition, the positive effects of passive mechanical loading on muscle fiber size and force generating capacity was not affected by the nutritional status in this study. However, due to the small sample size these pilot results need to be validated in a larger cohort. PMID:24887774

  20. Care of critically ill newborns in India. Legal and ethical issues.

    PubMed

    Subramanian, K N; Paul, V K

    1995-06-01

    The nature of neonatal care in India is changing. While the quality of care will most likely improve as the economy grows, the eventual scope of change remains to be seen. Attitudinal and behavioral changes, in addition to better economic conditions, are needed to realize more appropriate interventions in neonatal care. Economic, cultural, religious, social, political, and other considerations may limit or affect neonatal care, especially for ELBW infants or infants with congenital malformations or brain injury. Various protections for critically ill newborns exist under Indian law and the Constitution of India. New laws are being enacted to enhance the level of protection conferred, including laws which ban amniocentesis for sex determination and define brain death in connection with the use of human organs for therapeutic purposes. The applicability of consumer protection laws to medical care is also being addressed. It is noted, however, that India lacks a multidisciplinary bioethics committee. An effort should be made to discuss the legal and ethical issues regarding the care of critically ill newborns, with discussions considering religious, cultural, traditional, and family values. Legal and ethical guidelines should be developed by institutions, medical councils, and society specific to newborn care, and medical, nursing, and other paramedical schools should include these issues as part of the required coursework. Physicians, nurses, philosophers, and attorneys with expertise in law and ethics should develop and teach these courses. Such measures over the long term will ensure that future health care providers are exposed to these issues, ideally with a view toward enhancing patient care. PMID:7636406

  1. Complications of continuous renal replacement therapy in critically ill children: a prospective observational evaluation study

    PubMed Central

    2009-01-01

    Introduction Continuous renal replacement therapy (CRRT) frequently gives rise to complications in critically ill children. However, no studies have analyzed these complications prospectively. The purpose of this study was to analyze the complications of CRRT in children and to study the associated risk factors. Methods A prospective, single-centre, observational study was performed in all critically ill children treated using CRRT in order to determine the incidence of complications related to the technique (problems of catheterization, hypotension at the time of connection to the CRRT, hemorrhage, electrolyte disturbances) and their relationship with patient characteristics, clinical severity, need for vasoactive drugs and mechanical ventilation, and the characteristics of the filtration techniques. Results Of 174 children treated with CRRT, 13 (7.4%) presented problems of venous catheterization; this complication was significantly more common in children under 12 months of age and in those weighing less than 10 kg. Hypotension on connection to CRRT was detected in 53 patients (30.4%). Hypotension was not associated with any patient or CRRT characteristics. Clinically significant hemorrhage occurred in 18 patients (10.3%); this complication was not related to any of the variables studied. The sodium, chloride, and phosphate levels fell during the first 72 hours of CRRT; the changes in electrolyte levels during the course of treatment were not found to be related to any of the variables analyzed, nor were they associated with mortality. Conclusions CRRT-related complications are common in children and some are potentially serious. The most common are hypotension at the time of connection and electrolyte disturbances. Strict control and continuous monitoring of the technique are therefore necessary in children on CRRT. PMID:19925648

  2. Accuracy of a Novel Noninvasive Transdermal Continuous Glucose Monitor in Critically Ill Patients

    PubMed Central

    Saur, Nicole M.; England, Michael R.; Menzie, Wayne; Melanson, Ann Marie; Trieu, My-Quyen; Berlin, Jason; Hurley, James; Krystyniak, Keith; Kongable, Gail L.

    2014-01-01

    Stress hyperglycemia and hypoglycemia are associated with increased morbidity and mortality in the critically ill. Intermittent, random blood glucose (BG) measurements can miss episodes of hyper- and hypoglycemia. The purpose of this study was to determine the accuracy of the Symphony® continuous glucose monitor (CGM) in critically ill cardiac surgery patients. Fifteen adult cardiac surgery patients were evaluated immediately postoperatively in the intensive care unit. Prelude® SkinPrep prepared the skin and a sensor was applied to 2 test sites on each subject to monitor interstitial fluid glucose. Reference BG was sampled at 30- to 60-minute intervals. The skin at the test sites was inspected for adverse effects. Accuracy of the retrospectively analyzed CGM data relative to reference BG values was determined using continuous glucose-error grid analysis (CG-EGA) and mean absolute relative difference (MARD). Using 570 Symphony CGM glucose readings paired with reference BG measurements, CG-EGA showed that 99.6% of the readings were within zones A and B. BG measurements ranged from 73 to 251 mg/dL. The MARD was 12.3%. No adverse device effects were reported. The Symphony CGM system is able to safely, continuously, and noninvasively monitor glucose in the transdermal interstitial fluid of cardiac surgery intensive care unit patients with accuracy similar to that reported with other CGM systems. Future versions of the system will need real-time data analysis, fast warm-up, and less frequent calibrations to be used in the clinical setting. PMID:24876448

  3. Acute Kidney Injury Classified by Serum Creatinine and Urine Output in Critically Ill Cancer Patients

    PubMed Central

    Herrera-Gómez, Ángel

    2016-01-01

    Acute kidney injury (AKI) is common in critically ill patients and is associated with higher mortality. Cancer patients are at an increased risk of AKI. Our objective was to determine the incidence of AKI in our critically ill cancer patients, using the criteria of serum creatinine (SCr) and urine output (UO) proposed by the Kidney Disease: Improving Global Outcomes (KDIGO). Methods. We performed a retrospective cohort analysis of a prospectively collected database at the intensive care unit (ICU) of the Instituto Nacional de Cancerología from January 2013 to March 2015. Results. We classified AKI according to the KDIGO definition. We included 389 patients; using the SCr criterion, 192 (49.4%) had AKI; using the UO criterion, 219 (56.3%) had AKI. Using both criteria, we diagnosed AKI in 69.4% of patients. All stages were independently associated with six-month mortality; stage 1 HR was 2.04 (95% CI 1.14–3.68, p = 0.017), stage 2 HR was 2.73 (95% CI 1.53–4.88, p = 0.001), and stage 3 HR was 4.5 (95% CI 2.25–8.02, p < 0.001). Patients who fulfilled both criteria had a higher mortality compared with patients who fulfilled just one criterion (HR 3.56, 95% CI 2.03–6.24, p < 0.001). Conclusion. We diagnosed AKI in 69.4% of patients. All AKI stages were associated with higher risk of death at six months, even for patients who fulfilled just one AKI criterion. PMID:27803928

  4. Challenge for higher colistin dosage in critically ill patients receiving continuous venovenous haemodiafiltration.

    PubMed

    Karaiskos, Ilias; Friberg, Lena E; Galani, Lambrini; Ioannidis, Konstantinos; Katsouda, Emmanouela; Athanassa, Zoe; Paskalis, Harris; Giamarellou, Helen

    2016-09-01

    Traditionally, reduced daily doses of colistin methanesulphonate (CMS) in critically ill patients receiving continuous venovenous haemodiafiltration (CVVHDF) have resulted in suboptimal colistin concentrations. The necessity of a loading dose (LD) at treatment initiation has been proposed. A LD of 9 million IU (MU) [ca. 270 mg of colistin base activity (CBA)] was administrated with a maintenance dose of 4.5 MU (ca. 140 mg CBA) every 12 h (q12h) to eight critically ill patients receiving renal replacement therapy. Blood samples were collected immediately before and at different time intervals after the LD and the fourth dose, whilst pre-filter and post-filter blood samples were also collected. CMS and colistin concentrations were determined using an LC-MS/MS assay. Median maximum observed concentrations after the LD were 22.1 mg/L for CMS and 1.55 mg/L for colistin, whereas during maintenance dosing the corresponding values were 12.6 mg/L and 1.72 mg/L, respectively. CVVHDF clearance was determined as 2.98 L/h for colistin, equivalent to 62% of total apparent colistin clearance in CVVHDF patients. Both CMS and colistin were cleared by CVVHDF. Application of a LD of 9 MU CMS resulted in more rapid achievement of the target colistin concentration. Following implementation of a predicted pharmacokinetic model on plasma CMS/colistin concentrations, a LD of 12 MU CMS appears more appropriate, whilst a CMS maintenance dosage of at least 6.5-7.5 MU q12h is suggested in patients undergoing CVVHDF. However, further clinical studies are warranted to assess the safety of a LD of 12 MU CMS in patients receiving CVVHDF. PMID:27474468

  5. Innate immunity gene expression changes in critically ill patients with sepsis and disease-related malnutrition

    PubMed Central

    Sarnecka, Agnieszka; Dąbrowska, Aleksandra; Kosałka, Katarzyna; Wachowska, Ewelina; Bałan, Barbara J.; Jankowska, Marta; Korta, Teresa; Niewiński, Grzegorz; Kański, Andrzej; Mikaszewska-Sokolewicz, Małgorzata; Omidi, Mohammad; Majewska, Krystyna; Słotwińska, Sylwia M.

    2015-01-01

    The aim of this study was an attempt to determine whether the expression of genes involved in innate antibacterial response (TL R2, NOD 1, TRAF6, HMGB 1 and Hsp70) in peripheral blood leukocytes in critically ill patients, may undergo significant changes depending on the severity of the infection and the degree of malnutrition. The study was performed in a group of 128 patients with infections treated in the intensive care and surgical ward. In 103/80.5% of patients, infections had a severe course (sepsis, severe sepsis, septic shock, mechanical ventilation of the lungs). Clinical monitoring included diagnosis of severe infection (according to the criteria of the ACC P/SCC M), assessment of severity of the patient condition and risk of death (APACHE II and SAPS II), nutritional assessment (NRS 2002 and SGA scales) and the observation of the early results of treatment. Gene expression at the mRNA level was analyzed by real-time PCR. The results of the present study indicate that in critically ill patients treated in the IC U there are significant disturbances in the expression of genes associated with innate antimicrobial immunity, which may have a significant impact on the clinical outcome. The expression of these genes varies depending on the severity of the patient condition, severity of infection and nutritional status. Expression disorders of genes belonging to innate antimicrobial immunity should be diagnosed as early as possible, monitored during the treatment and taken into account during early therapeutic treatment (including early nutrition to support the functions of immune cells). PMID:26648775

  6. Furosemide is associated with acute kidney injury in critically ill patients

    PubMed Central

    Levi, T.M.; Rocha, M.S.; Almeida, D.N.; Martins, R.T.C.; Silva, M.G.C.; Santana, N.C.P.; Sanjuan, I.T.; Cruz, C.M.S.

    2012-01-01

    Acute kidney injury (AKI) is common in critically ill patients. Diuretics are used without any evidence demonstrating a beneficial effect on renal function. The objective of the present study is to determine the incidence of AKI in an intensive care unit (ICU) and if there is an association between the use of furosemide and the development of AKI. The study involved a hospital cohort in which 344 patients were consecutively enrolled from January 2010 to January 2011. A total of 132 patients (75 females and 57 males, average age 64 years) remained for analysis. Most exclusions were related to ICU discharge in the first 24 h. Laboratory, sociodemographic and clinical data were collected until the development of AKI, medical discharge or patient death. The incidence of AKI was 55% (95%CI = 46-64). The predictors of AKI found by univariate analysis were septic shock: OR = 3.12, 95%CI = 1.36-7.14; use of furosemide: OR = 3.27, 95%CI = 1.57-6.80, and age: OR = 1.02, 95%CI = 1.00-1.04. Analysis of the subgroup of patients with septic shock showed that the odds ratio of furosemide was 5.5 (95%CI = 1.16-26.02) for development of AKI. Age, use of furosemide, and septic shock were predictors of AKI in critically ill patients. Use of furosemide in the subgroup of patients with sepsis/septic shock increased (68.4%) the chance of development of AKI when compared to the sample as a whole (43.9%) PMID:22641414

  7. Hyperproteic hypocaloric enteral nutrition in the critically ill patient: A randomized controlled clinical trial

    PubMed Central

    Rugeles, Saúl-Javier; Rueda, Juan-David; Díaz, Carlos-Eduardo; Rosselli, Diego

    2013-01-01

    Introduction: Our aim was to evaluate the impact of hyperproteic hypocaloric enteral feeding on clinical outcomes in critically ill patients, particularly on severity of organic failure measured with the Sequential Organ Failure Assessment (SOFA). Materials and Methods: In a double blind clinical trial, 80 critically ill adult patients were randomized to hyperproteic hypocaloric or to isocaloric enteral nutrition; all patients completed follow-up of at least 4 days. Prescribed caloric intake was: Hyperproteic hypocaloric enteral nutrition (15 kcal/kg with 1.7 g/kg of protein) or isocaloric enteral nutrition (25 kcal/kg with 20% of the calories as protein). The main outcome was the differences in delta SOFA at 48 h. Secondary outcomes were intensive care unit (ICU) length of stay, days on ventilator, hyperglycemic events, and insulin requirements. Results: There were no differences in SOFA score at baseline (7.5 (standard deviation (SD) 2.9) vs 6.7 (SD 2.5) P = 0.17). The total amount of calories delivered was similarly low in both groups (12 kcal/kg in intervention group vs 14 kcal/kg in controls), but proteic delivery was significantly different (1.4 vs 0.76 g/kg, respectively P ≤ 0.0001). The intervention group showed an improvement in SOFA score at 48 h (delta SOFA 1.7 (SD 1.9) vs 0.7 (SD 2.8) P = 0.04) and less hyperglycemic episodes per day (1.0 (SD 1.3) vs 1.7 (SD 2.5) P = 0.017). Discussion: Enteral hyperproteic hypocaloric nutrition therapy could be associated with a decrease in multiple organ failure measured with SOFA score. We also found decreased hyperglycemia and a trend towards less mechanical ventilation days and ICU length of stay. PMID:24501485

  8. Clinical associations of host genetic variations in the genes of cytokines in critically ill patients

    PubMed Central

    Belopolskaya, O B; Smelaya, T V; Moroz, V V; Golubev, A M; Salnikova, L E

    2015-01-01

    Host genetic variations may influence a changing profile of biochemical markers and outcome in patients with trauma/injury. The objective of this study was to assess clinical associations of single nucleotide polymorphisms (SNPs) in the genes of cytokines in critically ill patients. A total of 430 patients were genotyped for SNPs in the genes of pro- (IL1B, IL6, IL8) and anti-inflammatory (IL4, IL10, IL13) cytokines. The main end-points were sepsis, mortality and adult respiratory distress syndrome (ARDS). We evaluated the dynamic levels of bilirubin, blood urea nitrogen, creatine kinase, creatinine and lactate dehydrogenase in five points of measurements (between 1 and 14 days after admission) and correlated them with SNPs. High-producing alleles of proinflammatory cytokines protected patients against sepsis (IL1B −511A and IL8 —251A) and mortality (IL1B −511A). High-producing alleles of anti-inflammatory cytokines IL4 —589T and IL13 431A (144Gln) were less frequent in ARDS patients. The carriers of IL6 —174C/C genotypes were prone to the increased levels of biochemical markers and acute kidney and liver insufficiency. Genotype-dependent differences in the levels of biochemical indicators gradually increased to a maximal value on the 14th day after admission. These findings suggest that genetic variability in pro- and anti-inflammatory cytokines may contribute to different clinical phenotypes in patients at high risk of critical illness. PMID:25619315

  9. The distinct clinical profile of chronically critically ill patients: a cohort study

    PubMed Central

    Estenssoro, Elisa; Reina, Rosa; Canales, Héctor S; Saenz, María Gabriela; Gonzalez, Francisco E; Aprea, María M; Laffaire, Enrique; Gola, Victor; Dubin, Arnaldo

    2006-01-01

    Introduction Our goal was to describe the epidemiology, clinical profiles, outcomes, and factors that might predict progression of critically ill patients to chronically critically ill (CCI) patients, a still poorly characterized subgroup. Methods We prospectively studied all patients admitted to a university-affiliated hospital intensive care unit (ICU) between 1 July 2002 and 30 June 2005. On admission, we recorded epidemiological data, the presence of organ failure (multiorgan dysfunction syndrome (MODS)), underlying diseases (McCabe score), acute respiratory distress syndrome (ARDS) and shock. Daily, we recorded MODS, ARDS, shock, mechanical ventilation use, lengths of ICU and hospital stay (LOS), and outcome. CCI patients were defined as those having a tracheotomy placed for continued ventilation. Clinical complications and time to tracheal decannulation were registered. Predictors of progression to CCI were identified by logistic regression. Results Ninety-five patients (12%) fulfilled the CCI definition and, compared with the remaining 690 patients, these CCI patients were sicker (APACHE II, 21 ± 7 versus 18 ± 9 for non-CCI patients, p = 0.005); had more organ dysfunctions (SOFA 7 ± 3 versus 6 ± 4, p < 0.003); received more interventions (TISS 32 ± 10 versus 26 ± 8, p < 0.0001); and had less underlying diseases and had undergone emergency surgery more frequently (43 versus 24%, p = 0.001). ARDS and shock were present in 84% and 83% of CCI patients, respectively, versus 44% and 48% in the other patients (p < 0.0001 for both). CCI patients had higher expected mortality (38% versus 32%, p = 0.003), but observed mortality was similar (32% versus 35%, p = 0.59). Independent predictors of progression to CCI were ARDS on admission, APACHE II and McCabe scores (odds ratio (OR) 2.26, p < 0.001; OR 1.03, p < 0.01; and OR 0.34, p < 0.0001, respectively). Lengths of mechanical ventilation, ICU and hospital stay were 33 (24 to 50), 39 (29 to 55) and 55 (37 to 84

  10. [Peripheral circulation in critically ill patients: non-invasive methods for the assessment of the peripheral perfusion].

    PubMed

    van Genderen, Michel E; Lima, Alexandre; Bakker, Jan; van Bommel, Jasper

    2013-01-01

    Peripheral tissues, such as skin and muscles, are sensitive to alterations in perfusion. During circulatory shock, these tissues are the first to receive less blood and the last to recover after treatment. By monitoring peripheral circulation, disturbance of the systemic circulation can be detected at an early stage. Peripheral perfusion is often disturbed in critically ill patients. Peripheral perfusion may remain disturbed, even if conventional hemodynamic parameters such as blood pressure and heart frequency normalize after treatment. Persistent abnormal peripheral perfusion is related to a poorer clinical course. With current non-invasive methods, peripheral circulation in critically ill patients can easily be assessed at the bedside. Interventions that improve peripheral circulation may speed up recovery in critically ill patients.

  11. Can We Protect the Gut in Critical Illness: The Role of Growth Factors and Other Novel Approaches

    PubMed Central

    Dominguez, Jessica A.; Coopersmith, Craig M.

    2010-01-01

    Synopsis The intestine plays a central role in the pathophysiology of critical illness and is frequently called the “motor” of the systemic inflammatory response. Perturbations to the intestinal barrier can lead to distant organ damage and multiple organ failure. Therefore, identifying ways to preserve intestinal integrity may be of paramount importance. Growth factors and other peptides have emerged as potential tools for modulation of intestinal inflammation and repair due to their roles in cellular proliferation, differentiation, migration, and survival. In this review, we will examine the involvement of growth factors and other peptides in intestinal epithelial repair during critical illness and their potential use as therapeutic targets. PMID:20643306

  12. Exercise training can improve spatial characteristics of time-critical obstacle avoidance in elderly people.

    PubMed

    Weerdesteyn, Vivian; Nienhuis, Bart; Duysens, Jacques

    2008-10-01

    Fall prevention programs have rarely been evaluated by quantitative movement analysis methods. Quantitative movement analyses could provide insight into the mechanisms underlying the effects of training. A treadmill obstacle avoidance task under time pressure has recently been used to evaluate a fall prevention exercise program for community-dwelling elderly people and it showed that participants improved their obstacle avoidance success rates. The mechanism, by which the increased success rates were achieved, however, remained to be determined. Participants were elderly who had fallen at least once in the year prior to participation. They were assigned to either the exercise or the control group. The control group did not receive any specific treatment. The exercise group was administered a five week exercise program, which consisted of exercises on a functionally oriented obstacle course, walking exercises, and practice of fall techniques. Pre- and post-intervention laboratory obstacle avoidance tests were conducted. Three possible determinants of success were investigated, namely avoidance reaction times, the distribution of avoidance strategies, and three spatial parameters (toe distance, foot clearance and heel distance). Analysis yielded significant TimexGroup interactions in heel distances. The exercise group increased heel distance, while the control group did not. Increased heel distance may result in reduced risk of heel contact with the obstacle and, consequently, larger success rates. The remaining parameters showed no effect of training. In conclusion, the training program was effective in improving time-critical obstacle avoidance skills. In every day life, these effects of training may contribute to less obstacle-related fall incidents in elderly. In addition, these findings could indicate that the execution of other time-critical events, like an actual fall, could also be improved by training.

  13. Prognosis of alcohol-associated lactic acidosis in critically ill patients: an 8-year study

    PubMed Central

    Yang, Chun-Chieh; Chan, Khee-Siang; Tseng, Kuei-Ling; Weng, Shih-Feng

    2016-01-01

    Lactic acidosis is common in critical care; by contrast, a subtype called alcohol-associated lactic acidosis (AALA) is rarely encountered. The primary purpose of this study was to determine the prognosis of AALA in critically ill patients and the second aim was to determine whether the survival was associated to the peak blood lactate concentration. An 8-year retrospective analysis of adult patients admitted to the intensive care unit (ICU) with AALA between January 2007 and December 2014 was considered in a tertiary care hospital. In total, 23 patients were analyzed and the median peak blood lactate level was 15.9 mmol/L. Only 2 patients (8.7%) presented peak blood lactate levels <10 mmol/L. In this study, 21 patients survived from ICU and hospital, the mortality rate was 8.7%. The result indicted the survival of AALA was not associated with peak blood lactate concentration although survivors still had a better lactate clearance rate per hour than non-survivors. Moreover, AALA patients with coexisting sepsis presenting higher lactate clearance rate and shorter lactate clearance time than those of AALA patients with solely sepsis-related lactic acidosis. PMID:27748410

  14. Introduction and executive summary: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.

    PubMed

    Christian, Michael D; Devereaux, Asha V; Dichter, Jeffrey R; Rubinson, Lewis; Kissoon, Niranjan

    2014-10-01

    Natural disasters, industrial accidents, terrorism attacks, and pandemics all have the capacity to result in large numbers of critically ill or injured patients. This supplement provides suggestions for all of those involved in a disaster or pandemic with multiple critically ill patients, including front-line clinicians, hospital administrators, professional societies, and public health or government officials. The current Task Force included a total of 100 participants from nine countries, comprised of clinicians and experts from a wide variety of disciplines. Comprehensive literature searches were conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert-opinion-based suggestions that are presented in this supplement using a modified Delphi process. The ultimate aim of the supplement is to expand the focus beyond the walls of ICUs to provide recommendations for the management of all critically ill or injured adults and children resulting from a pandemic or disaster wherever that care may be provided. Considerations for the management of critically ill patients include clinical priorities and logistics (supplies, evacuation, and triage) as well as the key enablers (systems planning, business continuity, legal framework, and ethical considerations) that facilitate the provision of this care. The supplement also aims to illustrate how the concepts of mass critical care are integrated across the spectrum of surge events from conventional through contingency to crisis standards of care. PMID:25144202

  15. Stratification of the severity of critically ill patients with classification trees

    PubMed Central

    2009-01-01

    Background Development of three classification trees (CT) based on the CART (Classification and Regression Trees), CHAID (Chi-Square Automatic Interaction Detection) and C4.5 methodologies for the calculation of probability of hospital mortality; the comparison of the results with the APACHE II, SAPS II and MPM II-24 scores, and with a model based on multiple logistic regression (LR). Methods Retrospective study of 2864 patients. Random partition (70:30) into a Development Set (DS) n = 1808 and Validation Set (VS) n = 808. Their properties of discrimination are compared with the ROC curve (AUC CI 95%), Percent of correct classification (PCC CI 95%); and the calibration with the Calibration Curve and the Standardized Mortality Ratio (SMR CI 95%). Results CTs are produced with a different selection of variables and decision rules: CART (5 variables and 8 decision rules), CHAID (7 variables and 15 rules) and C4.5 (6 variables and 10 rules). The common variables were: inotropic therapy, Glasgow, age, (A-a)O2 gradient and antecedent of chronic illness. In VS: all the models achieved acceptable discrimination with AUC above 0.7. CT: CART (0.75(0.71-0.81)), CHAID (0.76(0.72-0.79)) and C4.5 (0.76(0.73-0.80)). PCC: CART (72(69-75)), CHAID (72(69-75)) and C4.5 (76(73-79)). Calibration (SMR) better in the CT: CART (1.04(0.95-1.31)), CHAID (1.06(0.97-1.15) and C4.5 (1.08(0.98-1.16)). Conclusion With different methodologies of CTs, trees are generated with different selection of variables and decision rules. The CTs are easy to interpret, and they stratify the risk of hospital mortality. The CTs should be taken into account for the classification of the prognosis of critically ill patients. PMID:20003229

  16. Methylprednisolone exacerbates acute critical illness-related corticosteroid insufficiency associated with traumatic brain injury in rats.

    PubMed

    Chen, Xin; Zhang, Bin; Chai, Yan; Dong, Bo; Lei, Ping; Jiang, Rongcai; Zhang, Jianning

    2011-03-25

    Emerging evidence demonstrates that severe illness could induce critical illness-related corticosteroid insufficiency (CIRCI) and cause poor prognosis. The purpose of this study was to test the hypothesis that methylprednisolone (MP), a synthetic glucocorticoid, promotes post-traumatic apoptosis in both the hypothalamus and pituitary, resulting in acute CIRCI and increased mortality in the acute phase of traumatic brain injury (TBI). We tested this hypothesis by measuring acute CIRCI in rats subjected to fluid percussion injury (FPI) and treated with MP (5-30mg/kg). The corticosteroid response to TBI was evaluated using the corticosterone increase index (CII), where values less than 2.5 were considered indicative of acute CIRCI. The CII of MP treated rats was comparable to that of saline treated control rats before injury but was significantly decreased in injured rats receiving high-dose MP on post-injury day 7. Similarly, the incidence of acute CIRCI was significantly higher in the high-dose MP group on post-injury day 7. Furthermore, the CII of rats that did not survive post-injury was significantly lower compared to that of survival and was indicative of acute CIRCI. We also examined apoptosis in the paraventricular nucleus (PVN) of the hypothalamus and the adenohypophysis of the pituitary, using a TUNEL assay and transmission electron microscopy (TEM). The number of TUNEL-positive cells was significantly higher in injured rats treated with high-dose MP. No TUNEL-positive cells were detected in the adenohypophysis across experimental groups at either 7 or 14days after TBI. However, autopsies performed on rats that did not survive post-injury revealed obvious apoptotic cells in the adenohypophysis. Moreover, TEM revealed morphological changes characteristic of apoptosis in both the PVN and adenohypophysis of high-dose MP treated rats. These data suggest that MP therapy for TBI could increase neuronal apoptosis in both the hypothalamus and pituitary and

  17. Role of the microbiome, probiotics, and ‘dysbiosis therapy’ in critical illness

    PubMed Central

    Wischmeyer, Paul E.; McDonald, Daniel; Knight, Rob

    2016-01-01

    Purpose of review Loss of ‘health-promoting’ microbes and overgrowth of pathogenic bacteria (dysbiosis) in ICU is believed to contribute to nosocomial infections, sepsis, and organ failure (multiple organ dysfunction syndrome). This review discusses new understanding of ICU dysbiosis, new data for probiotics and fecal transplantation in ICU, and new data characterizing the ICU microbiome. Recent findings ICU dysbiosis results from many factors, including ubiquitous antibiotic use and overuse. Despite advances in antibiotic therapy, infections and mortality from often multidrug-resistant organisms (i.e., Clostridium difficile) are increasing. This raises the question of whether restoration of a healthy microbiome via probiotics or other ‘dysbiosis therapies’ would be an optimal alternative, or parallel treatment option, to antibiotics. Recent clinical data demonstrate probiotics can reduce ICU infections and probiotics or fecal microbial transplant (FMT) can treat Clostridium difficile. This contributes to recommendations that probiotics should be considered to prevent infection in ICU. Unfortunately, significant clinical variability limits the strength of current recommendations and further large clinical trials of probiotics and FMT are needed. Before larger trials of ‘dysbiosis therapy’ can be thoughtfully undertaken, further characterization of ICU dysbiosis is needed. To addressing this, we conducted an initial analysis demonstrating a rapid and marked change from a ‘healthy’ microbiome to an often pathogen-dominant microbiota (dysbiosis) in a broad ICU population. Summary A growing body of evidence suggests critical illness and ubiquitous antibiotic use leads to ICU dysbiosis that is associated with increased ICU infection, sepsis, and multiple organ dysfunction syndrome. Probiotics and FMT show promise as ICU therapies for infection. We hope future-targeted therapies using microbiome signatures can be developed to correct ‘illness

  18. 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

  19. Fungal Peritonitis: Underestimated Disease in Critically Ill Patients with Liver Cirrhosis and Spontaneous Peritonitis

    PubMed Central

    Lahmer, Tobias; Brandl, Andreas; Rasch, Sebastian; Schmid, Roland M.; Huber, Wolfgang

    2016-01-01

    Introduction Spontaneous peritonitis, especially spontaneous fungal peritonitis (SFP), is an important and potentially fatal complication in patients with endstage liver disaese. We evaluated potential risk factors, microbiological findings, and outcome of patients with SFP compared to spontaneous bacterial peritonitis (SBP) in critically ill patients. Methods Retrospective analyses of critically ill patients with suspected spontaneous peritonitis. Results Out of 205 patients, 20 (10%) had SFP, 28 (14%) had SBP, 48 (24%) had peritonitis without microbiological findings (SP) and 109 (52%) had no-peritonitis (NP). APACHE II and SOFA score were significantly higher in patients with SFP (26; 22–28; p<0.004 and 16; 14–18; p<0.002), SBP (26; 22–28; p<0.004 and 16; 14–18; p<0.002) and SP (24; 18–30; p<0.045 and 14; 10–18; p<0.044) as compared to NP (22; 16–24 and 12; 10–14). CHILD Pugh classification was mainly CHILD C and MELD Score was in patients with SFP (34; 18–40; p<0.001), SBP (32;12–40 p<0.002) and SP (29; 14–40 p<0.003) significantly higher as compared to NP (25;8–40). Nosocomial peritonitis could be significantly more often found in patients with SFP (65%; p<0.023) and SBP (62%, p<0.030) as compared to SP (51 p = 0.243) and NP (45%). Antibiotic pretreatment last 3 month prior peritonitis was significantly more often in patients with SFP (85%; p<0.002), SBP (71%, p<0.033), and SP (56; p<0.040) as compared to NP (33%). Candida albicans (60%; 12/20) was the most common isolated fungus, followed by Candida glabrata (13%) and Candida krusei (13%). Mortality rate was significantly higher in patients with SFP (90%, p<0.001), followed by SBP (75%; p<0.001) and SP (69%; p<0.001) as compared to NP (45%). Conclusion SFP is not a rare complication in end stage liver disease which is associated with increased mortality. Physicians should be aware of SFP in patients with CHILD C liver cirrhosis, elevated MELD score, antibiotic pretreatment and

  20. Coagulation Disorders and Bleedings in Critically Ill Patients With Hemophagocytic Lymphohistiocytosis.

    PubMed

    Valade, Sandrine; Azoulay, Elie; Galicier, Lionel; Boutboul, David; Zafrani, Lara; Stepanian, Alain; Canet, Emmanuel; Lemiale, Virginie; Venot, Marion; Veyradier, Agnès; Mariotte, Eric

    2015-10-01

    Reactive hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition related to a cytokine storm leading to multiorgan dysfunction. A better understanding of coagulation disorders, frequently reported in HLH patients, may improve outcomes. Critically ill HLH patients managed in a multidisciplinary national reference center were retrospectively included. Relationships between coagulation disorders, severe bleedings, and outcomes were assessed. One hundred and seventeen patients fulfilled the HLH 2004 criteria. The most common HLH etiology was hematologic conditions (73%), followed by infectious diseases (20%), systemic rheumatic diseases (5%), and undetermined HLH etiology (3%). All patients exerted thrombocytopenia. Coagulation disorders were diagnosed in 79 (68%) patients (61 had hypofibrinogenemia < 1.5 g/L, 51 had prothrombin time [PT]  <  0%). The worst median value throughout ICU stay was 52% (38-65) for PT with a factor V level of 35% (27-43), 1.59 (1.30-2.09) for the activated partial thromboplastin time (APTT) ratio, and 2.33 g/L (1.13-3.86) for the fibrinogen level. Disseminated intravascular coagulation (DIC) was found in 50% of patients. Coagulation disorders were more frequent in immunocompromised patients, those with histological/cytological feature of hemophagocytosis, those with the highest ferritin concentrations, and in patients with HLH not related to infection. These patients were more prone to receive mechanical ventilation, vasopressors, or renal replacement therapy. Twenty-six (22%) patients presented severe bleeding complications, including 5 patients dying from hemorrhagic shock. Strikingly, the only coagulation parameter significantly associated with severe bleeding was low fibrinogen with a cutoff value of 2 g/L (P = 0.03). Overall, 33 (28%) patients died in the ICU and hospital mortality was 44%. Coagulation disorders were associated with higher mortality, especially fibrinogen < 2 g/L (P = 0.04) and PT value (P = 0

  1. The efficacy and safety of colloid resuscitation in the critically ill.

    PubMed

    Hartog, Christiane S; Bauer, Michael; Reinhart, Konrad

    2011-01-01

    Despite evidence from clinical studies and meta-analyses that resuscitation with colloids or crystalloids is equally effective in critically ill patients, and despite reports from high-quality clinical trials and meta-analyses regarding nephrotoxic effects, increased risk of bleeding, and a trend toward higher mortality in these patients after the use of hydroxyethyl starch (HES) solutions, colloids remain popular and the use of HES solutions is increasing worldwide. We investigated the major rationales for colloid use, namely that colloids are more effective plasma expanders than crystalloids, that synthetic colloids are as safe as albumin, that HES solutions have the best risk/benefit profile among the synthetic colloids, and that the third-generation HES 130/0.4 has fewer adverse effects than older starches. Evidence from clinical studies shows that comparable resuscitation is achieved with considerably less crystalloid volumes than frequently suggested, namely, <2-fold the volume of colloids. Albumin is safe in intensive care unit patients except in patients with closed head injury. All synthetic colloids, namely, dextran, gelatin, and HES have dose-related side effects, which are coagulopathy, renal failure, and tissue storage. In patients with severe sepsis, higher doses of HES may be associated with excess mortality. The assumption that third-generation HES 130/0.4 has fewer adverse effects is yet unproven. Clinical trials on HES 130/0.4 have notable shortcomings. Mostly, they were not performed in intensive care unit or emergency department patients, had short observation periods of 24 to 48 hours, used cumulative doses below 1 daily dose limit (50 mL/kg), and used unsuitable control fluids such as other HES solutions or gelatins. In conclusion, the preferred use of colloidal solutions for resuscitation of patients with acute hypovolemia is based on rationales that are not supported by clinical evidence. Synthetic colloids are not superior in critically ill

  2. Critical Illness Outcome Study: An Observational Study on Protocols and Mortality in Intensive Care Units

    PubMed Central

    Ali, Naeem A.; Gutteridge, David; Shahul, Sajid; Checkley, William; Sevransky, Jonathan; Martin, Greg S.

    2014-01-01

    Introduction Many individual Intensive Care Unit (ICU) characteristics have been associated with patient outcomes, including staffing, expertise, continuity and team structure. Separately, many aspects of clinical care in ICUs have been operationalized through the development of complex treatment protocols. The United State Critical Illness and Injury Trials Group-Critical Illness Outcomes Study (USCIITG-CIOS) was designed to determine whether the extent of protocol availability and use in ICUs is associated with hospital survival in a large cohort of United States ICUs. Here, we describe the study protocol and analysis plan approved by the USCIITG-CIOS Steering Committee. Methods USCIITG-CIOS is a prospective, observational, ecological multi-centered “cohort” study of mixed ICUs in the U.S. The data collected include organizational information for the ICU (e.g., protocol availability and utilization, multi-disciplinary staffing assessment) and patient level information (e.g. demographics, acute and chronic medical conditions). The primary outcome is all-cause hospital mortality, with the objective being to determine whether there is an association between protocol number and hospital mortality for ICU patients. USCIITG-CIOS is powered to detect a 3% difference in crude hospital mortality between high and low protocol use ICUs, dichotomized according to protocol number at the median. The analysis will utilize regression modeling to adjust for outcome clustering by ICU, with secondary linear analysis of protocol number and mortality and a variety of a priori planned ancillary studies. There are presently 60 ICUs participating in USCIITG-CIOS to enroll approximately 6,000 study subjects. Conclusions USCIITG-CIOS is a large multicentric study examining the effect of ICU protocol use on patient outcomes. The primary results of this study will inform our understanding of the relationship between protocol availability, use, and patient outcomes in the ICU. Moreover

  3. Acute fluid shifts influence the assessment of serum vitamin D status in critically ill patients

    PubMed Central

    2010-01-01

    Introduction Recent reports have highlighted the prevalence of vitamin D deficiency and suggested an association with excess mortality in critically ill patients. Serum vitamin D concentrations in these studies were measured following resuscitation. It is unclear whether aggressive fluid resuscitation independently influences serum vitamin D. Methods Nineteen patients undergoing cardiopulmonary bypass were studied. Serum 25(OH)D3, 1α,25(OH)2D3, parathyroid hormone, C-reactive protein (CRP), and ionised calcium were measured at five defined timepoints: T1 - baseline, T2 - 5 minutes after onset of cardiopulmonary bypass (CPB) (time of maximal fluid effect), T3 - on return to the intensive care unit, T4 - 24 hrs after surgery and T5 - 5 days after surgery. Linear mixed models were used to compare measures at T2-T5 with baseline measures. Results Acute fluid loading resulted in a 35% reduction in 25(OH)D3 (59 ± 16 to 38 ± 14 nmol/L, P < 0.0001) and a 45% reduction in 1α,25(OH)2D3 (99 ± 40 to 54 ± 22 pmol/L P < 0.0001) and i(Ca) (P < 0.01), with elevation in parathyroid hormone (P < 0.0001). Serum 25(OH)D3 returned to baseline only at T5 while 1α,25(OH)2D3 demonstrated an overshoot above baseline at T5 (P < 0.0001). There was a delayed rise in CRP at T4 and T5; this was not associated with a reduction in vitamin D levels at these time points. Conclusions Hemodilution significantly lowers serum 25(OH)D3 and 1α,25(OH)2D3, which may take up to 24 hours to resolve. Moreover, delayed overshoot of 1α,25(OH)2D3 needs consideration. We urge caution in interpreting serum vitamin D in critically ill patients in the context of major resuscitation, and would advocate repeating the measurement once the effects of the resuscitation have abated. PMID:21110839

  4. [The impact of a better coordination between emergency and intensive care units in the care of critically ill patients].

    PubMed

    Lara, Bárbara A; Cataldo, Alejandro; Castro, Ricardo; Aguilera, Pablo R; Ruiz, Carolina; Andresen, Max

    2016-07-01

    The need for critical care services is increasing in Chile. Critical care beds and specialists in this area are scarce. In this article we discuss some aspects that hamper the care of critically ill patients from their arrival to the emergency department to their transfer to the ICU. Special emphasis is given to system saturation and its multiple causes. The benefits of an integrative approach between emergency medicine and critical care specialists are highlighted and some solutions are proposed to strengthen this partnership. PMID:27661556

  5. [Elder].

    PubMed

    Arroyo, Pedro; Gutiérrez-Robledo, Luis Miguel

    2016-09-01

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

  6. 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

  7. Clinical review: critical care in the global context--disparities in burden of illness, access, and economics.

    PubMed

    Fowler, Robert A; Adhikari, Neill K J; 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.

  8. Posttraumatic stress disorder among survivors of critical illness: creation of a conceptual model addressing identification, prevention, and management.

    PubMed

    Long, Ann C; Kross, Erin K; Davydow, Dimitry S; Curtis, J Randall

    2014-06-01

    Quality of life is frequently impaired among survivors of critical illness, and psychiatric morbidity is an important element contributing to poor quality of life in these patients. Among potential manifestations of psychiatric morbidity following critical illness, symptoms of posttraumatic stress are prevalent and intricately linked to the significant stressors present in the intensive care unit (ICU). As our understanding of the epidemiology of post-ICU posttraumatic stress disorder improves, so must our ability to identify those at highest risk for symptoms in the period of time following critical illness and our ability to implement strategies to prevent symptom development. In addition, a focus on strategies to address clinically apparent psychiatric morbidity will be essential. Much remains to be understood about the identification, prevention, and management of this significant public health problem. This article addresses the importance of uniformity in future epidemiologic studies, proposes framing of risk factors into those likely to be modifiable versus non-modifiable, and provides an assessment of modifiable risk factors in the context of a novel conceptual model that offers insight into potential strategies to attenuate symptoms of posttraumatic stress among survivors of critical illness.

  9. 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

  10. Relatives to Critically Ill Patients Have No Sense of Coherence: A Quality Improvement Article Using Mixed Methods

    PubMed Central

    2016-01-01

    Aims and Objective. To investigate the relatives' satisfaction and involvement on a general surgery ward regarding the critically ill patient. Introduction. Relatives to critically ill patients are affected both physically and mentally during the hospitalization of a family member. Research has shown that relatives do not always receive the attention they need from health professionals. There is a lack of studies that focus on relatives' satisfaction and involvement during their family members' hospitalization. Design. A mixed methods design was chosen. Methods. A quantitative study was conducted with 27 relatives to critically ill patients. All participated in a questionnaire and out of the 27 relatives, six participated in qualitative in-depth interviews. Results. The questionnaire revealed that relatives were dissatisfied with care and involvement. For further exploration of the dissatisfaction, a qualitative approach was used and the in-depth interviews revealed three themes: lack of continuity and structure, responsibility of coordination, and relatives feeling left on their own with no guiding and support. Conclusion. Health professionals' key role in relation to relatives must be guidance and support. Thereby, relatives can gain a sense of coherence during the hospitalization of a critically ill patient, which can lead to a greater satisfaction and thereby better support for the patient. PMID:27703810

  11. The epidemiology and prognostic factors of mortality in critically ill children with acute kidney injury in Taiwan.

    PubMed

    Chang, Jei-Wen; Jeng, Mei-Jy; Yang, Ling-Yu; Chen, Tzeng-Ji; Chiang, Shu-Chiung; Soong, Wen-Jue; Wu, Keh-Gong; Lee, Yu-Sheng; Wang, Hsin-Hui; Yang, Chia-Feng; Tsai, Hsin-Lin

    2015-03-01

    The incidence of acute kidney injury (AKI) in critically ill children varies among countries. Here we used claims data from the Taiwanese National Health Insurance program from 2006 to 2010 to investigate the epidemiological features and identify factors that predispose individuals to developing AKI and mortality in critically ill children with AKI. Of 60,338 children in this nationwide cohort, AKI was identified in 850, yielding an average incidence rate of 1.4%. Significant independent risk factors for AKI were the use of extracorporeal membrane oxygenation, mechanical ventilation or vasopressors, intrinsic renal diseases, sepsis, and age more than 1 year. Overall, of the AKI cases, 46.5% were due to sepsis, 36.1% underwent renal replacement therapy, and the mortality rate was 44.2%. Multivariate analysis showed that the use of vasopressors, mechanical ventilation, and hemato-oncological disorders were independent predictors of mortality in AKI patients. Thirty-two of the 474 patients who survived had progression to chronic kidney disease or end-stage renal disease. Thus, although not common, AKI in critically ill children still has a high mortality rate associated with a variety of factors. Long-term close follow-up to prevent progressive chronic kidney disease in survivors of critical illnesses with AKI is mandatory. PMID:25252027

  12. Resistance Training Exercise Program for Intervention to Enhance Gait Function in Elderly Chronically Ill Patients: Multivariate Multiscale Entropy for Center of Pressure Signal Analysis

    PubMed Central

    Jiang, Bernard C.

    2014-01-01

    Falls are unpredictable accidents, and the resulting injuries can be serious in the elderly, particularly those with chronic diseases. Regular exercise is recommended to prevent and treat hypertension and other chronic diseases by reducing clinical blood pressure. The “complexity index” (CI), based on multiscale entropy (MSE) algorithm, has been applied in recent studies to show a person's adaptability to intrinsic and external perturbations and widely used measure of postural sway or stability. The multivariate multiscale entropy (MMSE) was advanced algorithm used to calculate the complexity index (CI) values of the center of pressure (COP) data. In this study, we applied the MSE & MMSE to analyze gait function of 24 elderly, chronically ill patients (44% female; 56% male; mean age, 67.56 ± 10.70 years) with either cardiovascular disease, diabetes mellitus, or osteoporosis. After a 12-week training program, postural stability measurements showed significant improvements. Our results showed beneficial effects of resistance training, which can be used to improve postural stability in the elderly and indicated that MMSE algorithms to calculate CI of the COP data were superior to the multiscale entropy (MSE) algorithm to identify the sense of balance in the elderly. PMID:25295070

  13. Functional Status of Elderly Adults Before and After Interventions for Critical Limb Ischemia

    PubMed Central

    Vogel, Todd R.; Petroski, Gregory F.; Kruse, Robin L.

    2014-01-01

    Objective The impact of interventions for Critical Limb Ischemia (CLI) on functional status in the elderly remains unclear. Open and endovascular procedures were evaluated. Methods Medicare inpatient claims were linked with nursing home assessment data to identify elective admissions for lower extremity procedures for CLI. A functional impairment score (0-28; higher scores indicating greater impairment) based on residents' need for assistance with self-care activities, walking, and locomotion was calculated before and after interventions. Hierarchical modeling determined the effect of the surgery on residents' function, controlling for comorbidity, cognition, and pre-hospital function. Results 352 and 350 patients underwent open and endovascular procedures, respectively (rest pain: 84; ulceration: 351; and gangrene: 267). Hospitalization was associated with a significant worsening in function following both procedures. Disease severity was associated with the amount of initial decline but not with the rate of recovery (p>.35). Residents who received open surgery improved more quickly following hospital discharge (p=.011). Conclusions In the frail elderly, open and endovascular procedures for CLI were associated with similar initial declines in functional status, suggesting that compared with open procedures, less invasive endovascular procedures were not associated with maintaining baseline function. In this select population, endovascular procedures for CLI were not associated with improved functional status over time compared to open. Six months post-hospital, patients who received traditional open bypass had significantly better functional status than those who received endovascular procedures for all CLI diagnoses. Further analysis is required to assist stakeholders in performing procedures most likely to preserve functional status in the frail elderly and nursing home population. PMID:24139567

  14. Vancomycin Therapeutic Targets and Nephrotoxicity in Critically Ill Children With Cancer.

    PubMed

    Seixas, Glaucia T F; Araujo, Orlei R; Silva, Dafne C B; Arduini, Rodrigo G; Petrilli, Antonio S

    2016-03-01

    To obtain pharmacokinetic and pharmacodynamic data for vancomycin in a cohort of critically ill pediatric oncology patients, we analyzed 256 measurements of vancomycin concentrations in 94 patients. Variables were tested as possible risk factors for vancomycin-related nephrotoxicity or death for 28 days. We found the following: mean vancomycin trough serum concentration, 15.6 ± 12.4 μg/mL; mean vancomycin clearance, 0.16 ± 0.098 L/h/kg; and mean vancomycin distribution volume, 1.04 ± 0.11 L/kg. Only 13.6% of serum trough level measurements were between 15 and 20 μg/mL. The trough levels showed a strong correlation with the AUC (area under the curve of serum concentrations vs. time over 24 h to the minimum inhibitory concentration ratio), with a 94% positive predictive value for AUC/MIC ≥ 400, but only for MIC=1. The doses that are currently used (60 mg/kg/d) attained the therapeutic target (AUC/MIC ≥ 400) in only 56% of measurements, considering MIC=1. A serum trough level of ≥ 20 μg/mL was an independent risk for nephrotoxicity (P = 0.0008; odds ratio = 17.83). Vancomycin-related nephrotoxicity was a predictor of death for up to 28 days (P = 0.003, odds ratio = 7.68). Currently administered doses of vancomycin do not reach the therapeutic target for critical cancer patients, particularly if staphylococci isolates have a MIC>1.

  15. Glycemic targets and approaches to management of the patient with critical illness.

    PubMed

    Mesotten, Dieter; Van den Berghe, Greet

    2012-02-01

    Hyperglycemia during critical illness is associated with adverse outcome. The proof-of-concept Leuven studies assessed causality, and revealed that targeting strict normoglycemia (80-110 mg/dL) with insulin improved outcome compared with tolerating hyperglycemia to the renal threshold (215 mg/dL). A large multicenter trial (NICE-SUGAR [Normoglycaemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation]) found an intermediate blood glucose target (140-180 mg/dL) safer than targeting normoglycemia. Differences in design and in execution of glycemic control at the bedside may have contributed to these results. In NICE-SUGAR (Normoglycaemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation), the blood-glucose target range in the control group was lower, there were problems to reach and maintain normoglycemia in the intervention group, and inaccurate handheld blood glucose meters and variable blood sampling sites were allowed. Inaccurate tools led to insulin-dosing errors with consequently (undetected) hypoglycemia and unacceptable blood glucose variability. Also, the studies were done superimposed upon different nutritional strategies. Thus, such differences do not allow simple, evidence-based recommendations for daily practice, but an intermediate blood glucose target may be preferable while awaiting better tools to facilitate safely reaching normoglycemia.

  16. Elevation of procalcitonin after implantation of an interventional lung assist device in critically ill patients.

    PubMed

    Kott, Matthias; Bewig, Burkhard; Zick, Günther; Schaedler, Dirk; Becher, Tobias; Frerichs, Inéz; Weiler, Norbert

    2014-01-01

    A pumpless interventional arteriovenous lung assist device (iLA) facilitates the removal of carbon dioxide from the blood and is used as part of the lung-protective ventilation strategy in patients with acute respiratory distress syndrome (ARDS). In case of bacterial infection, delayed antimicrobial therapy increases the mortality in this group of high-risk critically ill patients, whereas overtreatment promotes bacterial resistance and leads to increased drug toxicity and costs. Besides clinical signs and symptoms, antimicrobial treatment is based on the kinetics of biomarkers such as procalcitonin (PCT). We hereby report an up to 10-fold increase in PCT serum concentrations in four mechanically ventilated patients with ARDS detected within 12-20 hours after iLA implantation in the absence of any infection. Procalcitonin concentrations returned to nearly baseline values in all patients on the fourth day after iLA implantation. We discuss the possible mechanisms of PCT induction in this specific patient population and recommend the onset of antibiotics administration after iLA implantation to be carefully considered in the context of other clinical findings and not solely based on the PCT kinetics. Repeated PCT measurements in short time intervals should be performed in these patients.

  17. Clinical comparison of CR and screen film for imaging the critically ill neonate

    NASA Astrophysics Data System (ADS)

    Andriole, Katherine P.; Brasch, Robert C.; Gooding, Charles A.; Gould, Robert G.; Cohen, Pierre A.; Rencken, Ingo R.; Huang, H. K.

    1996-05-01

    A clinical comparison of computed radiography (CR) versus screen-film for imaging the critically-ill neonate is performed, utilizing a modified (hybrid) film cassette containing a CR (standard ST-V) imaging plate, a conventional screen and film, allowing simultaneous acquisition of perfectly matched CR and plain film images. For 100 portable neonatal chest and abdominal projection radiographs, plain film was subjectively compared to CR hardcopy. Three pediatric radiologists graded overall image quality on a scale of one (poor) to five (excellent), as well as visualization of various anatomic structures (i.e., lung parenchyma, pulmonary vasculature, tubes/lines) and pathological findings (i.e., pulmonary interstitial emphysema, pleural effusion, pneumothorax). Results analyzed using a combined kappa statistic of the differences between scores from each matched set, combined over the three readers showed no statistically significant difference in overall image quality between screen- film and CR (p equals 0.19). Similarly, no statistically significant difference was seen between screen-film and CR for anatomic structure visualization and for visualization of pathological findings. These results indicate that the image quality of CR is comparable to plain film, and that CR may be a suitable alternative to screen-film imaging for portable neonatal chest and abdominal examinations.

  18. Microfluidic Leukocyte Isolation for Gene Expression Analysis in Critically Ill Hospitalized Patients

    PubMed Central

    Russom, Aman; Sethu, Palaniappan; Irimia, Daniel; Mindrinos, Michael N.; Calvano, Steve E.; Garcia, Iris; Finnerty, Celeste; Tannahill, Cynthia; Abouhamze, Amer; Wilhelmy, Julie; López, M. Cecilia; Baker, Henry V.; Herndon, David N.; Lowry, Stephen F.; Maier, Ronald V.; Davis, Ronald W.; Moldawer, Lyle L.; Tompkins, Ronald G.; Toner, Mehmet

    2014-01-01

    BACKGROUND Microarray technology is becoming a powerful tool for diagnostic, therapeutic, and prognostic applications. There is at present no consensus regarding the optimal technique to isolate nucleic acids from blood leukocyte populations for subsequent expression analyses. Current collection and processing techniques pose significant challenges in the clinical setting. Here, we report the clinical validation of a novel microfluidic leukocyte nucleic acid isolation technique for gene expression analysis from critically ill, hospitalized patients that can be readily used on small volumes of blood. METHODS We processed whole blood from hospitalized patients after burn injury and severe blunt trauma according to the microfluidic and standard macroscale leukocyte isolation protocol. Side-by-side comparison of RNA quantity, quality, and genome-wide expression patterns was used to clinically validate the microfluidic technique. RESULTS When the microfluidic protocol was used for processing, sufficient amounts of total RNA were obtained for genome-wide expression analysis from 0.5 mL whole blood. We found that the leukocyte expression patterns from samples processed using the 2 protocols were concordant, and there was less variability introduced as a result of harvesting method than there existed between individuals. CONCLUSIONS The novel microfluidic approach achieves leukocyte isolation in <25 min, and the quality of nucleic acids and genome expression analysis is equivalent to or surpasses that obtained from macroscale approaches. Microfluidics can significantly improve the isolation of blood leukocytes for genomic analyses in the clinical setting. PMID:18375483

  19. 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.

  20. Branched-chain amino acid supplementation: impact on signaling and relevance to critical illness.

    PubMed

    Mattick, John S A; Kamisoglu, Kubra; Ierapetritou, Marianthi G; Androulakis, Ioannis P; Berthiaume, Francois

    2013-01-01

    The changes that occur in mammalian systems following trauma and sepsis, termed systemic inflammatory response syndrome, elicit major changes in carbohydrate, protein, and energy metabolism. When these events persist for too long they result in a severe depletion of lean body mass, multiple organ dysfunction, and eventually death. Nutritional supplementation has been investigated to offset the severe loss of protein, and recent evidence suggests that diets enriched in branched-chain amino acids (BCAAs) may be especially beneficial. BCAAs are metabolized in two major steps that are differentially expressed in muscle and liver. In muscle, BCAAs are reversibly transaminated to the corresponding α-keto acids. For the complete degradation of BCAAs, the α-keto acids must travel to the liver to undergo oxidation. The liver, in contrast to muscle, does not significantly express the branched-chain aminotransferase. Thus, BCAA degradation is under the joint control of both liver and muscle. Recent evidence suggests that in liver, BCAAs may perform signaling functions, more specifically via activation of mTOR (mammalian target of rapamycin) signaling pathway, influencing a wide variety of metabolic and synthetic functions, including protein translation, insulin signaling, and oxidative stress following severe injury and infection. However, understanding of the system-wide effects of BCAAs that integrate both metabolic and signaling aspects is currently lacking. Further investigation in this respect will help rationalize the design and optimization of nutritional supplements containing BCAAs for critically ill patients. PMID:23554299

  1. Cystatin C Falsely Underestimated GFR in a Critically Ill Patient with a New Diagnosis of AIDS

    PubMed Central

    Brown, Caitlin S.; Kashani, Kianoush B.; Clain, Jeremy M.

    2016-01-01

    Cystatin C has been suggested to be a more accurate glomerular filtration rate (GFR) surrogate than creatinine in patients with acquired immunodeficiency syndrome (AIDS) because it is unaffected by skeletal muscle mass and dietary influences. However, little is known about the utility of this marker for monitoring medications in the critically ill. We describe the case of a 64-year-old female with opportunistic infections associated with a new diagnosis of AIDS. During her course, she experienced neurologic, cardiac, and respiratory failure; yet her renal function remained preserved as indicated by an eGFR ≥ 120 mL/min and a urine output > 1 mL/kg/hr without diuresis. The patient was treated with nephrotoxic agents; therefore cystatin C was assessed to determine if cachexia was resulting in a falsely low serum creatinine. Cystatin C measured 1.50 mg/L which corresponded to an eGFR of 36 mL/min. Given the >60 mL/min discrepancy, serial 8-hour urine samples were collected and a GFR > 120 mL/min was confirmed. It is unclear why cystatin C was falsely elevated, but we hypothesize that it relates to the proinflammatory state with AIDS, opportunistic infections, and corticosteroids. More research is needed before routine use of cystatin C in this setting can be recommended. PMID:27293926

  2. Heparin induced thrombocytopenia in critically ill: Diagnostic dilemmas and management conundrums

    PubMed Central

    Gupta, Sachin; Tiruvoipati, Ravindranath; Green, Cameron; Botha, John; Tran, Huy

    2015-01-01

    Thrombocytopenia is often noted in critically ill patients. While there are many reasons for thrombocytopenia, the use of heparin and its derivatives is increasingly noted to be associated with thrombocytopenia. Heparin induced thrombocytopenia syndrome (HITS) is a distinct entity that is characterised by the occurrence of thrombocytopenia in conjunction with thrombotic manifestations after exposure to unfractionated heparin or low molecular weight heparin. HITS is an immunologic disorder mediated by antibodies to heparin-platelet factor 4 (PF4) complex. HITS is an uncommon cause of thrombocytopenia. Reported incidence of HITS in patients exposed to heparin varies from 0.2% to up to 5%. HITS is rare in ICU populations, with estimates varying from 0.39%-0.48%. It is a complex problem which may cause diagnostic dilemmas and management conundrum. The diagnosis of HITS centers around detection of antibodies against PF4-heparin complexes. Immunoassays performed by most pathology laboratories detect the presence of antibodies, but do not reveal whether the antibodies are pathological. Platelet activation assays demonstrate the presence of clinically relevant antibodies, but only a minority of laboratories conduct them. Several anticoagulants are used in management of HITS. In this review we discuss the incidence, pathogenesis, diagnosis and management of HITS. PMID:26261772

  3. Perceptions and practices regarding delirium, sedation and analgesia in critically ill patients: a narrative review.

    PubMed

    Shinotsuka, Cassia Righy; Salluh, Jorge Ibrain Figueira

    2013-01-01

    A significant number of landmark studies have been published in the last decade that increase the current knowledge on sedation for critically ill patients. Therefore, many practices that were considered standard of care are now outdated. Oversedation has been shown to be hazardous, and light sedation and no-sedation protocols are associated with better patient outcomes. Delirium is increasingly recognized as a major form of acute brain dysfunction that is associated with higher mortality, longer duration of mechanical ventilation and longer lengths of stay in the intensive care unit and hospital. Despite all the available evidence, translating research into bedside care is a daunting task. International surveys have shown that practices such as sedation interruption and titration are performed only in the minority of cases. Implementing best practices is a major challenge that must also be addressed in the new guidelines. In this review, we summarize the findings of sedation and delirium research over the last years. We also discuss the gap between evidence and clinical practice and highlight ways to implement best practices at the bedside. PMID:23917981

  4. The Spleen: The Forgotten Organ in Acute Kidney Injury of Critical Illness

    PubMed Central

    Gigliotti, Joseph C.; Okusa, Mark D.

    2016-01-01

    Acute kidney injury (AKI) is an increasing medical burden and is independently associated with mortality. AKI is a common comorbidity in the intensive care unit (ICU), with sepsis-associated AKI seen in almost a quarter of all ICU patients. Due to the high mortality seen in these patients, improved therapeutic options are needed. Data from experimental studies in animals support observations in humans that the host immune response to sepsis and trauma contributes to multiorgan failure and the high morbidity and mortality seen in critically ill patients. The spleen, a major component of the reticuloendothelial system, appears to be a key player in the ‘cytokine storm’ that develops after infection and trauma, and the resultant systemic inflammation is regulated by the autonomic nervous system. Over the past decade, evidence has suggested that controlling the splenic cytokine response improves tissue function and mortality in sepsis and other inflammatory-mediated diseases. One pathway that controls the response of the spleen to sepsis and trauma is the cholinergic anti-inflammatory pathway, and it may provide a key target for therapeutic intervention. Here, we review this concept and highlight the potential use of ultrasound to stimulate the cholinergic anti-inflammatory pathway and reduce systemic inflammation and disease severity. PMID:25343841

  5. [Persistent inflammation immunosuppression catabolism syndrome: a special type of chronic critical illness].

    PubMed

    Ding, Renyu; Ma, Xiaochun

    2016-07-01

    After the concept of "chronic critical illness (CCI)" was proposed, the new concept persistent inflammation immunosuppression catabolism syndrome (PICS) is present recently. Patients with PICS are manifested by fast decreasing body weight, poor nutritional status, long-term immunosuppression and repeated nosocomial infections. These patients are faced with great challenges of persistent inflammation, acquired immunosuppression and high catabolism, which finally results in repeated nosocomial infections, prolonged hospital stay and increased mortality. At present, main problems of PICS diagnosis standard include varying length of ICU stay, difference in normal C reactive protein value, poor value of nutrition indexes, absence of clinical verification. Though associated pathophysiology mechanism is not clear, PICS is preventable and magageable with certain therapy, including early comprehensive prevention and treatment focused on infection control for CCI patients to stop the progression of PICS, application of immune modulator to improve immune function and prognosis of patients, and reasonable nutritional support and treatment. Besides, through the analysis of the association between PICS and CCI, authors draw a conclusion that PICS is a new phenotype of CCI, and immune paralysis is its main feature. PMID:27452746

  6. Comparison of hemodynamic and oxygen transport effects of dopamine and dobutamine in critically ill surgical patients.

    PubMed

    Shoemaker, W C; Appel, P L; Kram, H B; Duarte, D; Harrier, H D; Ocampo, H A

    1989-07-01

    Hemodynamic and oxygen transport effects of dopamine and dobutamine were studied in a series of 25 critically ill postoperative general surgical patients by a prospective, randomized crossover design after maximal response to fluids had been obtained. Dopamine increased MAP, HR, CI, PvO2, DO2, and Qsp while decreasing PaO2. Dobutamine increased HR, CI, SI, stroke work, DO2, VO2, and Qsp while decreasing PAWP and SVRI and PVRI. In general, the effects of the two drugs were greater in patients in the first 72 hours after surgery. The effects of dobutamine on flow and oxygen transport were greater than those of dopamine, especially in the early postoperative period. The effects were smaller and not significant in patients more than three days after surgery, as well as in those with sepsis, respiratory failure, renal failure, age over 65 years, and hyperdynamic states, in part because of the small number of patients in each group. These data are consistent with the hypothesis that the beta 2-adrenergic action of dobutamine vasodilates the previously constricted peripheral circulation, enhances tissue perfusion by improving micro-circulatory flow distribution, and improves DO2 and VO2.

  7. Community-acquired pneumonia and survival of critically ill acute exacerbation of COPD patients in respiratory intensive care units

    PubMed Central

    Lu, Zhiwei; Cheng, Yusheng; Tu, Xiongwen; Chen, Liang; Chen, Hu; Yang, Jian; Wang, Jinyan; Zhang, Liqin

    2016-01-01

    Purpose The aim of this study was to appraise the effect of community-acquired pneumonia (CAP) on inhospital mortality in critically ill acute exacerbation of COPD (AECOPD) patients admitted to a respiratory intensive care unit. Patients and methods A retrospective observational study was performed. Consecutive critically ill AECOPD patients receiving treatment in a respiratory intensive care unit were reviewed from September 1, 2012, to August 31, 2015. Categorical variables were analyzed using chi-square tests, and continuous variables were analyzed by Mann–Whitney U-test. Kaplan–Meier analysis was used to assess the association of CAP with survival of critically ill AECOPD patients for univariate analysis. Cox’s proportional hazards regression model was performed to identify risk factors for multivariate analysis. Results A total of 80 consecutive eligible individuals were reviewed. These included 38 patients with CAP and 42 patients without CAP. Patients with CAP had a higher inhospital rate of mortality than patients without CAP (42% vs 33.3%, P<0.05). Kaplan–Meier survival analysis showed that patients with CAP had a worse survival rate than patients without CAP (P<0.05). Clinical characteristics, including Acute Physiology and Chronic Health Evaluation II (APACHE II) score, C-reactive protein, and CAP, were found to be closely associated with survival of AECOPD individuals. Further multivariate Cox regression analysis confirmed that CAP and APACHE II were independent risk factors for inhospital mortality in critically ill AECOPD patients (CAP: hazard ratio, 5.29; 95% CI, 1.50–18.47, P<0.01 and APACHE II: hazard ratio, 1.20; 95% CI, 1.06–1.37, P<0.01). Conclusion CAP may be an independent risk factor for higher inhospital mortality in critically ill AECOPD patients. PMID:27563239

  8. 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

  9. Optimal Management of the Critically Ill: Anaesthesia, Monitoring, Data Capture, and Point-of-Care Technological Practices in Ovine Models of Critical Care

    PubMed Central

    Shekar, Kiran; Tung, John-Paul; Dunster, Kimble R.; Platts, David; Watts, Ryan P.; Gregory, Shaun D.; Simonova, Gabriela; McDonald, Charles; Hayes, Rylan; Bellpart, Judith; Timms, Daniel; Fung, Yoke L.; Toon, Michael; Maybauer, Marc O.; Fraser, John F.

    2014-01-01

    Animal models of critical illness are vital in biomedical research. They provide possibilities for the investigation of pathophysiological processes that may not otherwise be possible in humans. In order to be clinically applicable, the model should simulate the critical care situation realistically, including anaesthesia, monitoring, sampling, utilising appropriate personnel skill mix, and therapeutic interventions. There are limited data documenting the constitution of ideal technologically advanced large animal critical care practices and all the processes of the animal model. In this paper, we describe the procedure of animal preparation, anaesthesia induction and maintenance, physiologic monitoring, data capture, point-of-care technology, and animal aftercare that has been successfully used to study several novel ovine models of critical illness. The relevant investigations are on respiratory failure due to smoke inhalation, transfusion related acute lung injury, endotoxin-induced proteogenomic alterations, haemorrhagic shock, septic shock, brain death, cerebral microcirculation, and artificial heart studies. We have demonstrated the functionality of monitoring practices during anaesthesia required to provide a platform for undertaking systematic investigations in complex ovine models of critical illness. PMID:24783206

  10. Association of Fluid Accumulation with Clinical Outcomes in Critically Ill Children with Severe Sepsis

    PubMed Central

    Chen, Jiao; Li, Xiaozhong; Bai, Zhenjiang; Fang, Fang; Hua, Jun; Li, Ying; Pan, Jian; Wang, Jian; Feng, Xing; Li, Yanhong

    2016-01-01

    Objective To evaluate whether early and acquired daily fluid overload (FO), as well as fluctuations in fluid accumulation, were associated with adverse outcomes in critically ill children with severe sepsis. Methods This study enrolled 202 children in a pediatric intensive care unit (PICU) with severe sepsis. Early fluid overload was defined as ≥5% fluid accumulation occurring in the first 24 hours of PICU admission. The maximum daily fluid accumulation ≥5% occurring during the next 6 days in patients with at least 48 hours of PICU stay was defined as PICU-acquired daily fluid overload. The fluctuation in fluid accumulation was calculated as the difference between the maximum and the minimum daily fluid accumulation obtained during the first 7 days after admission. Results Of the 202 patients, 61 (30.2%) died during PICU stay. Among all patients, 41 (20.3%) experienced early fluid overload, including 9 with a FO ≥10%. Among patients with at least 48 hours of PICU stay (n = 154), 36 (23.4%) developed PICU-acquired daily fluid overload, including 2 with a FO ≥10%. Both early fluid overload (AOR = 1.20; 95% CI 1.08–1.33; P = 0.001; n = 202) and PICU-acquired daily fluid overload (AOR = 5.47 per log increase; 95% CI 1.15–25.96; P = 0.032; n = 154) were independent risk factors associated with mortality after adjusting for age, illness severity, etc. However, fluctuations in fluid accumulation were not associated with mortality after adjustment. Length of PICU stay increased with greater fluctuations in fluid accumulation in all patients with at least 48 hours of PICU stay (FO <5%, 5%-10% vs. ≥10%: 4 [3–8], 7 [4–11] vs. 10 [6–16] days; P <0.001; n = 154) and in survivors (4 [3–8], 7 [5–11] vs. 10 [5–15] days; P <0.001; n = 121). Early fluid overload achieved an area under-the-receiver-operating-characteristic curve of 0.74 (95% CI 0.65–0.82; P <0.001; n = 202) for predicting mortality in patients with severe sepsis, with a sensitivity of 67

  11. Thromboprophylaxis patterns and determinants in critically ill patients: a multicenter audit

    PubMed Central

    2014-01-01

    Introduction Heparin is safe and prevents venous thromboembolism in critical illness. We aimed to determine the guideline concordance for thromboprophylaxis in critically ill patients and its predictors, and to analyze factors associated with the use of low molecular weight heparin (LMWH), as it may be associated with a lower risk of pulmonary embolism and heparin-induced thrombocytopenia without increasing the bleeding risk. Methods We performed a retrospective audit in 28 North American intensive care units (ICUs), including all consecutive medical-surgical patients admitted in November 2011. We documented ICU thromboprophylaxis and reasons for omission. Guideline concordance was determined by adding days in which patients without contraindications received thromboprophylaxis to days in which patients with contraindications did not receive it, divided by the total number of patient-days. We used multilevel logistic regression including time-varying, center and patient-level covariates to determine the predictors of guideline concordance and use of LMWH. Results We enrolled 1,935 patients (62.3 ± 16.7 years, Acute Physiology and Chronic Health Evaluation [APACHE] II score 19.1 ± 8.3). Patients received thromboprophylaxis with unfractionated heparin (UFH) (54.0%) or LMWH (27.6%). Guideline concordance occurred for 95.5% patient-days and was more likely in patients who were sicker (odds ratio (OR) 1.49, 95% confidence interval (CI) 1.17, 1.75 per 10-point increase in APACHE II), heavier (OR 1.32, 95% CI 1.05, 1.65 per 10-m/kg2 increase in body mass index), had cancer (OR 3.22, 95% CI 1.81, 5.72), previous venous thromboembolism (OR 3.94, 95% CI 1.46,10.66), and received mechanical ventilation (OR 1.83, 95% CI 1.32,2.52). Reasons for not receiving thromboprophylaxis were high risk of bleeding (44.5%), current bleeding (16.3%), no reason (12.9%), recent or upcoming invasive procedure (10.2%), nighttime admission or discharge (9.7%), and life

  12. Accuracy of Point-of-Care Blood Glucose Measurements in Critically Ill Patients in Shock

    PubMed Central

    Buenaluz-Sedurante, Myrna; Jimeno, Cecilia Alegado

    2014-01-01

    A widely used method in monitoring glycemic status of ICU patients is point-of-care (POC) monitoring devices. A possible limitation to this method is altered peripheral blood flow in patients in shock, which may result in over/underestimations of their true glycemic status. This study aims to determine the accuracy of blood glucose measurements with a POC meter compared to laboratory methods in critically ill patients in shock. POC blood glucose was measured with a glucose-1-dehydrogenase-based reflectometric meter. The reference method was venous plasma glucose measured by a clinical chemistry analyzer (glucose oxidase-based). Outcomes assessed were concordance to ISO 15197:2003 minimum accuracy criteria for glucose meters, bias in glucose measurements obtained by the 2 methods using Bland–Altman analysis, and clinical accuracy through modified error grid analysis. A total of 186 paired glucose measurements were obtained. ISO 2003 accuracy criteria were met in 95.7% and 79.8% of POC glucose values in the normotensive and hypotensive group, respectively. Mean bias for the normotensive group was –12.4 mg/dL, while mean bias in the hypotensive group was –34.9 mg/dL. POC glucose measurements within the target zone for clinical accuracy were 90.2% and 79.8% for the normotensive and hypotensive group, respectively. POC blood glucose measurements were significantly less accurate in the hypotensive subgroup of ICU patients compared to the normotensive group. We recommend a lower threshold in confirming POC blood glucose with a central laboratory method if clinically incompatible. In light of recently updated accuracy standards, we also recommend alternative methods of glucose monitoring for the ICU population as a whole regardless of blood pressure status. PMID:25172876

  13. Chronic Complications After Femoral Central Venous Catheter-related Thrombosis in Critically Ill Children.

    PubMed

    Sol, Jeanine J; Knoester, Hennie; de Neef, Marjorie; Smets, Anne M J B; Betlem, Aukje; van Ommen, C Heleen

    2015-08-01

    Prescription of thromboprophylaxis is not a common practice in pediatric intensive care units. Most thrombi are catheter-related and asymptomatic, without causing acute complications. However, chronic complications of these (a)symptomatic catheter-related thrombi, that is, postthrombotic syndrome (PTS) and residual thrombosis have not been studied. To investigate these complications, critically ill children of 1 tertiary center with percutaneous inserted femoral central venous catheters (FCVCs) were prospectively followed. Symptomatic FCVC-thrombosis occurred in 10 of the 134 children (7.5%; 95% confidence interval [CI], 2.4-9.5). Only FCVC-infection appeared to be independently associated (P=0.001) with FCVC-thrombosis. At follow-up 2 of the 5 survivors diagnosed with symptomatic thrombosis developed mild PTS; one of them had an occluded vein on ultrasonography. A survivor without PTS had a partial occluded vein at follow-up. Asymptomatic FCVC-thrombosis occurred in 3 of the 42 children (7.1%; 95% CI, 0.0-16.7) screened by ultrasonography within 72 hours after catheter removal. At follow-up, mild PTS was present in 6 of the 33 (18.2%; 95% CI, 6.1-30.3) screened children. Partial and total vein occlusion was present in 1 (3%) and 4 (12%) children, respectively. In conclusion, children on pediatric intensive care units are at risk for (a)symptomatic FCVC-thrombosis, especially children with FCVC-infection. Chronic complications of FCVC-thrombosis are common. Therefore, thromboprophylaxis guidelines are warranted in pediatric intensive care units to minimize morbidity as a result of FCVC-thrombosis.

  14. Diagnosis of overt disseminated intravascular coagulation in critically Ill adults by Sonoclot coagulation analysis.

    PubMed

    Wan, Peng; Tong, Hua-Sheng; Zhang, Xing-Qin; Duan, Peng-Kai; Tang, You-Qing; Su, Lei

    2014-08-01

    Disseminated intravascular coagulation (DIC) diagnosis is hampered by the limited availability of reliable clinical or laboratory tests. Currently available tests are time consuming and expensive. We investigated whether coagulation and platelet function analyses using the Sonoclot system were suitable for overt DIC diagnosis in critically ill adults. This was an observational diagnostic study performed in 498 patients presenting with an underlying disorder associated with DIC. Overt DIC patients were identified according to an International Society on Thrombosis and Hemostasis (ISTH) score of >5. Coagulation and platelet parameters were analyzed using the Sonoclot system, and compared with ISTH as the gold standard. Receiver operating characteristic curves and area under the curves were used to evaluate the value of the Sonoclot parameters. There were no differences for age or gender between the groups. Significant correlations were observed between activated clotting time (ACT) and ISTH score (r = 0.7; P < 0.001), clot rate (CR) and ISTH score (r = 0.5; P < 0.001), platelet function (PF) and ISTH score (r = -0.6; P < 0.001), and PF and platelet count (r = 0.5; P < 0.001). An ACT cut-off value of 213.5 s alone or combined with CR presented good sensitivity (76.7 and 86.8 %, respectively) and specificity (96.2 and 93.3 %, respectively). Sonoclot analysis can be performed using a point-of-care device that effectively discriminates low and high ISTH scores, and that effectively predicts coagulation dysfunction in patients with overt DIC.

  15. Functional evolution of critically ill patients undergoing an early rehabilitation protocol

    PubMed Central

    Murakami, Fernanda Murata; Yamaguti, Wellington Pereira; Onoue, Mirian Akemi; Mendes, Juliana Mesti; Pedrosa, Renata Santos; Maida, Ana Lígia Vasconcellos; Kondo, Cláudia Seiko; de Salles, Isabel Chateaubriand Diniz; de Brito, Christina May Moran; Rodrigues, Miguel Koite

    2015-01-01

    Objective Evaluation of the functional outcomes of patients undergoing an early rehabilitation protocol for critically ill patients from admission to discharge from the intensive care unit. Methods A retrospective cross-sectional study was conducted that included 463 adult patients with clinical and/or surgical diagnosis undergoing an early rehabilitation protocol. The overall muscle strength was evaluated at admission to the intensive care unit using the Medical Research Council scale. Patients were allocated to one of four intervention plans according to the Medical Research Council score, the suitability of the plan’s parameters, and the increasing scale of the plan expressing improved functional status. Uncooperative patients were allocated to intervention plans based on their functional status. The overall muscle strength and/or functional status were reevaluated upon discharge from the intensive care unit by comparison between the Intervention Plans upon admission (Planinitial) and discharge (Planfinal). Patients were classified into three groups according to the improvement of their functional status or not: responsive 1 (Planfinal > Planinitial), responsive 2 (Planfinal = Planinitial) and unresponsive (Planfinal < Planinitial). Results In total, 432 (93.3%) of 463 patients undergoing the protocol responded positively to the intervention strategy, showing maintenance and/or improvement of the initial functional status. Clinical patients classified as unresponsive were older (74.3 ± 15.1 years of age; p = 0.03) and had longer lengths of intensive care unit (11.6 ± 14.2 days; p = 0.047) and hospital (34.5 ± 34.1 days; p = 0.002) stays. Conclusion The maintenance and/or improvement of the admission functional status were associated with shorter lengths of intensive care unit and hospital stays. The results suggest that the type of diagnosis, clinical or surgical, fails to define the positive response to an early rehabilitation protocol. PMID:26340157

  16. Prediction scores do not correlate with clinically adjudicated categories of pulmonary embolism in critically ill patients

    PubMed Central

    Katsios, CM; Donadini, M; Meade, M; Mehta, S; Hall, R; Granton, J; Kutsiogiannis, J; Dodek, P; Heels-Ansdell, D; McIntyre, L; Vlahakis, N; Muscedere, J; Friedrich, J; Fowler, R; Skrobik, Y; Albert, M; Cox, M; Klinger, J; Nates, J; Bersten, A; Doig, C; Zytaruk, N; Crowther, M; Cook, DJ

    2014-01-01

    BACKGROUND: Prediction scores for pretest probability of pulmonary embolism (PE) validated in outpatient settings are occasionally used in the intensive care unit (ICU). OBJECTIVE: To evaluate the correlation of Geneva and Wells scores with adjudicated categories of PE in ICU patients. METHODS: In a randomized trial of thromboprophylaxis, patients with suspected PE were adjudicated as possible, probable or definite PE. Data were then retrospectively abstracted for the Geneva Diagnostic PE score, Wells, Modified Wells and Simplified Wells Diagnostic scores. The chance-corrected agreement between adjudicated categories and each score was calculated. ANOVA was used to compare values across the three adjudicated PE categories. RESULTS: Among 70 patients with suspected PE, agreement was poor between adjudicated categories and Geneva pretest probabilities (kappa 0.01 [95% CI −0.0643 to 0.0941]) or Wells pretest probabilities (kappa −0.03 [95% CI −0.1462 to 0.0914]). Among four possible, 16 probable and 50 definite PEs, there were no significant differences in Geneva scores (possible = 4.0, probable = 4.7, definite = 4.5; P=0.90), Wells scores (possible = 2.8, probable = 4.9, definite = 4.1; P=0.37), Modified Wells (possible = 2.0, probable = 3.4, definite = 2.9; P=0.34) or Simplified Wells (possible = 1.8, probable = 2.8, definite = 2.4; P=0.30). CONCLUSIONS: Pretest probability scores developed outside the ICU do not correlate with adjudicated PE categories in critically ill patients. Research is needed to develop prediction scores for this population. PMID:24083302

  17. Measurement of endotoxin activity in critically ill patients using whole blood neutrophil dependent chemiluminescence

    PubMed Central

    Marshall, John C; Walker, Paul M; Foster, Debra M; Harris, David; Ribeiro, Melanie; Paice, Jeff; Romaschin, Alexander D; Derzko, Anastasia N

    2002-01-01

    Background Lipopolysaccharide (endotoxin) from the cell wall of Gram-negative bacteria is a potent trigger for the release of host-derived inflammatory mediators. The relationship between endotoxaemia, Gram-negative infection and the clinical syndrome of sepsis has been difficult to establish, in part because of the limitations of available endotoxin assays. Methods We performed an observational cohort study in critically ill patients in the medical/surgical intensive care unit (ICU) of a tertiary care hospital. Whole blood endotoxin levels on the day of ICU admission were measured using a novel chemiluminescent assay – the endotoxin activity assay (EAA) – and the chromogenic modification of the limulus amoebocyte lysate (LAL) assay. Results We studied 74 consecutive admissions. Endotoxin levels were higher in patients with a diagnosis of sepsis (470 ± 57 pg/ml) than in patients admitted with a diagnosis other than sepsis (157 ± 140 pg/ml; P < 0.001). Endotoxaemia was significantly associated with Gram-negative infection (P < 0.05); no patient with a Gram-negative infection had an endotoxin level below 50 pg/ml. White blood cell counts of patients with EAA-detected endotoxaemia were significantly higher (15.7 ± 9.1 × 109 cells/l for endotoxaemic patients versus 10.8 ± 6.2 × 109 cells/l for patients without endotoxaemia; P < 0.05). Conclusion Endotoxaemia is associated with Gram-negative infection from any source, and with a diagnosis of sepsis and leukocytosis. These correlations were not apparent using the LAL method. The EAA may be a useful diagnostic tool for the investigation of invasive Gram-negative infection and incipient sepsis. PMID:12225611

  18. Pharmacokinetics and pharmacodynamics of famotidine and ranitidine in critically ill children.

    PubMed

    Madani, Shailender; Kauffman, Ralph; Simpson, Pippa; Lehr, Victoria Tutag; Lai, Mary Lieh; Sarniak, Ashok; Tolia, Vasundhara

    2014-02-01

    To characterize and compare acid suppression (pharmacodynamics) and pharmacokinetics of IV famotidine and ranitidine in critically ill children at risk for stress gastritis. Single-blind, randomized study in PICU patients 6 months to 18 years requiring mechanical ventilation with continuous gastric pH monitoring, randomized to IV famotidine 12 mg/m(2) or ranitidine 60 mg/m(2) when gastric pH < 4.0 >1 hour with serial blood sampling following first dose. Twenty-four children randomized to either famotidine (n = 12) or ranitidine (n = 12). Sixteen out of twenty-four completed both PK and PD study arms (7/12 famotidine; 4.7 ± 3.4 years; 9/12 ranitidine; 6.6 ± 4.7 years; p = 0.38). Time to gastric pH 4.0 and total time pH above 4.0 similar with no difference in pH at 6 and 12 hours (p > 0.2). No difference between drugs in clearance, volume of distribution and half-life (p > 0.05). Ratio of AUC pH to AUC drug concentration 0-12 hours after first dose was significantly greater for famotidine (0.06849 ± 0.01460 SD) than ranitidine (0.02453 ± 0.01448; p < 0.001) demonstrating greater potency of famotidine. pH lowering efficacy of both drugs is similar. Greater potency of famotidine may offer clinical advantage due to lower drug exposure and less frequent dosing to achieve same pH lowering effect.

  19. Discontinuation of prolonged infusions of dexmedetomidine in critically ill children with heart disease

    PubMed Central

    Burbano, Nelson H.; Otero, Andrea V.; Berry, Donald E.; Orr, Richard A.; Munoz, Ricardo A.

    2013-01-01

    Purpose To describe changes in hemodynamic variables, sedation and pain score after discontinuation of prolonged infusions of dexmedetomidine in a pediatric population of critically ill cardiac patients. Methods Retrospective case series of patients who received continuous infusions of dexmedetomidine for longer than 3 days in a pediatric cardiac intensive care unit from 2008 to 2010. Results Sixty-two patients, age 5.2 months (range 0.3 months – 17 years) and weight 5.1 kg (range 2.2–84 kg), were included. Thirty-nine patients (63%) were <1 year of age. Median duration of dexmedetomidine infusion was 5.8 days (range 4–26 days) and median infusion dose was 0.71 μg/kg/hr (range 0.2–2.1 μg/kg/hr). Median weaning time and dose at discontinuation were 43 hours (range 0–189 hours) and 0.2 μg/kg/hr (range 0.1–1.3 μg/kg/hr). Tachycardia, transient hypertension and agitation were observed in 27%, 35% and 27% of patients. Episodes of tachycardia were more frequent in children >1 year of age (61% vs. 8%, p < .001), patients who received dexmedetomidine for 4 days when compared to those who received 5 days or longer (48% vs. 17%, p = .011) and patients whose infusion was discontinued abruptly (42% vs. 14%, p = .045). Tachyarrhythmias were seen in 9 patients (15%) after discontinuation of the dexmedetomidine infusion. Adequate sedation and analgesia scores at the moment of infusion discontinuation were seen in 90% and 88%, of patients respectively. Conclusions Our study suggests that tachycardia, transient hypertension and agitation are frequently observed in pediatric cardiac intensive care unit patients after discontinuing prolonged dexmedetomidine infusions. PMID:22160200

  20. Critical Illness in Pregnancy: Part II: Common Medical Conditions Complicating Pregnancy and Puerperium.

    PubMed

    Guntupalli, Kalpalatha K; Karnad, Dilip R; Bandi, Venkata; Hall, Nicole; Belfort, Michael

    2015-11-01

    The first of this two-part series on critical illness in pregnancy dealt with obstetric disorders. In Part II, medical conditions that commonly affect pregnant women or worsen during pregnancy are discussed. ARDS occurs more frequently in pregnancy. Strategies commonly used in nonpregnant patients, including permissive hypercapnia, limits for plateau pressure, and prone positioning, may not be acceptable, especially in late pregnancy. Genital tract infections unique to pregnancy include chorioamnionitis, group A streptococcal infection causing toxic shock syndrome, and polymicrobial infection with streptococci, staphylococci, and Clostridium perfringens causing necrotizing vulvitis or fasciitis. Pregnancy predisposes to VTE; D-dimer levels have low specificity in pregnancy. A ventilation-perfusion scan is preferred over CT pulmonary angiography in some situations to reduce radiation to the mother's breasts. Low-molecular-weight or unfractionated heparins form the mainstay of treatment; vitamin K antagonists, oral factor Xa inhibitors, and direct thrombin inhibitors are not recommended in pregnancy. The physiologic hyperdynamic circulation in pregnancy worsens many cardiovascular disorders. It increases risk of pulmonary edema or arrhythmias in mitral stenosis, heart failure in pulmonary hypertension or aortic stenosis, aortic dissection in Marfan syndrome, or valve thrombosis in mechanical heart valves. Common neurologic problems in pregnancy include seizures, altered mental status, visual symptoms, and strokes. Other common conditions discussed are aspiration of gastric contents, OSA, thyroid disorders, diabetic ketoacidosis, and cardiopulmonary arrest in pregnancy. Studies confined to pregnant women are available for only a few of these conditions. We have, therefore, reviewed pregnancy-specific adjustments in the management of these disorders. PMID:26020727

  1. Urinary L-FABP predicts poor outcomes in critically ill patients with early acute kidney injury.

    PubMed

    Parr, Sharidan K; Clark, Amanda J; Bian, Aihua; Shintani, Ayumi K; Wickersham, Nancy E; Ware, Lorraine B; Ikizler, T Alp; Siew, Edward D

    2015-03-01

    Biomarker studies for early detection of acute kidney injury (AKI) have been limited by nonselective testing and uncertainties in using small changes in serum creatinine as a reference standard. Here we examine the ability of urine L-type fatty acid-binding protein (L-FABP), neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18 (IL-18), and kidney injury molecule-1 (KIM-1) to predict injury progression, dialysis, or death within 7 days in critically ill adults with early AKI. Of 152 patients with known baseline creatinine examined, 36 experienced the composite outcome. Urine L-FABP demonstrated an area under the receiver-operating characteristic curve (AUC-ROC) of 0.79 (95% confidence interval 0.70-0.86), which improved to 0.82 (95% confidence interval 0.75-0.90) when added to the clinical model (AUC-ROC of 0.74). Urine NGAL, IL-18, and KIM-1 had AUC-ROCs of 0.65, 0.64, and 0.62, respectively, but did not significantly improve discrimination of the clinical model. The category-free net reclassification index improved with urine L-FABP (total net reclassification index for nonevents 31.0%) and urine NGAL (total net reclassification index for events 33.3%). However, only urine L-FABP significantly improved the integrated discrimination index. Thus, modest early changes in serum creatinine can help target biomarker measurement for determining prognosis with urine L-FABP, providing independent and additive prognostic information when combined with clinical predictors.

  2. Clinical review: Helmet and non-invasive mechanical ventilation in critically ill patients

    PubMed Central

    2013-01-01

    Non-invasive mechanical ventilation (NIV) has proved to be an excellent technique in selected critically ill patients with different forms of acute respiratory failure. However, NIV can fail on account of the severity of the disease and technical problems, particularly at the interface. The helmet could be an alternative interface compared to face mask to improve NIV success. We performed a clinical review to investigate the main physiological and clinical studies assessing the efficacy and related issues of NIV delivered with a helmet. A computerized search strategy of MEDLINE/PubMed (January 2000 to May 2012) and EMBASE (January 2000 to May 2012) was conducted limiting the search to retrospective, prospective, nonrandomized and randomized trials. We analyzed 152 studies from which 33 were selected, 12 physiological and 21 clinical (879 patients). The physiological studies showed that NIV with helmet could predispose to CO2 rebreathing and increase the patients' ventilator asynchrony. The main indications for NIV were acute cardiogenic pulmonary edema, hypoxemic acute respiratory failure (community-acquired pneumonia, postoperative and immunocompromised patients) and hypercapnic acute respiratory failure. In 9 of the 21 studies the helmet was compared to a face mask during either continous positive airway pressure or pressure support ventilation. In eight studies oxygenation was similar in the two groups, while the intubation rate was similar in four and lower in three studies for the helmet group compared to face mask group. The outcome was similar in six studies. The tolerance was better with the helmet in six of the studies. Although these data are limited, NIV delivered by helmet could be a safe alternative to the face mask in patients with acute respiratory failure. PMID:23680299

  3. Understanding critically ill patients hemodynamic response to mobilization: using the evidence to make it safe and feasible.

    PubMed

    Vollman, Kathleen M

    2013-01-01

    In today's critical care environment, we face a difficult but essential task. We must provide comprehensive, compassionate, complex, technological care without causing harm to our patients. To foster a patient-safe environment, we must examine care practices and processes to reduce the chance of error. Successful early mobilization of critically ill patients can reduce several complications including atelectasis and ventilator-associated pneumonia and shorten ventilator time along with cognitive and functional limitations that linger 1 to 5 years after discharge from the intensive care unit. A long-standing challenge to successful mobilization of critically ill patients is the safety concern of hemodynamic instability. An in-depth exploration of what happens to a critically ill patient physiology during mobilization was done to foster a better understanding of strategies that promote adaptation. The article examines the evidence supporting the need to assess readiness for mobilization to reduce the risk of adverse events. Evidence-based tools and techniques to help clinicians prevent hemodynamic instability before, during, and after in-bed or out-of-bed mobilization are discussed. With safety serving as the overriding goal, we can overcome the barriers and succeed in creating and sustaining a culture of early progressive mobility programs within the intensive care unit.

  4. 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

  5. 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.

  6. 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

  7. A Novel Urinary Biomarker Profile to Identify Acute Kidney Injury (AKI) in Critically Ill Neonates - A Pilot Study

    PubMed Central

    Hoffman, Suma Bhat; Massaro, An N.; Soler-García, Ángel A.; Perazzo, Sofia; Ray, Patricio E.

    2014-01-01

    Background The goal of this study was to assess the value of a urinary biomarker profile comprised of Neutrophil Gelatinase-associated Lipocalin (NGAL), Fibroblast Growth Factor-2 (FGF-2), and Epidermal Growth Factor (EGF), to detect acute kidney injury (AKI) in critically ill neonates. Methods We conducted a prospective cohort pilot study of at-risk neonates treated in a level IIIC neonatal intensive care unit (NICU) with therapeutic hypothermia (HT) (n = 25) or extracorporeal membrane oxygenation (ECMO) (n=10). Urine was collected at baseline, 48 hours of illness, and > 24 hours post recovery of their corresponding treatments. Control samples were collected from 27 healthy newborns. The data were expressed as urinary concentrations and values normalized for urinary creatinine. AKI was defined as the presence of oliguria >24 hours and/or elevated serum creatinine (SCr), or the failure to improve the estimated creatinine clearance (eCCL) by >50% post recovery. Non-parametric statistical tests and ROC analyses were used to interpret the data. Results Fifteen at risk newborns had AKI. In the first 48 hours of illness, the urinary levels of NGAL and FGF-2 had high sensitivity but poor specificity to identify neonates with AKI. At recovery, low urinary EGF levels identified neonates with AKI with a sensitivity of 74% and specificity of 84%. Overall, in the early stages of a critical illness, the urinary levels of NGAL and FGF-2 were sensitive, but not specific, to identify neonates at risk of AKI. Low EGF levels post-recovery, identified critically ill neonates with AKI. Conclusions These findings require validation in larger prospective studies. PMID:23783654

  8. Obesity and Serious Mental Ill Health: A Critical Review of the Literature

    PubMed Central

    Bradshaw, Tim; Mairs, Hilary

    2014-01-01

    Individuals who experience serious mental ill health such as schizophrenia are more likely to be overweight or obese than others in the general population. This high prevalence of obesity and other associated metabolic disturbances, such as type 2 diabetes and cardiovascular disease, contribute to a reduced life expectancy of up to 25 years. Several reasons have been proposed for high levels of obesity including a shared biological vulnerability between serious mental ill health and abnormal metabolic processes, potentially compounded by unhealthy lifestyles. However, emerging evidence suggests that the most significant cause of weight gain is the metabolic side effects of antipsychotic medication, usual treatment for people with serious mental ill health. In this paper we review the prevalence of obesity in people with serious mental ill health, explore the contribution that antipsychotic medication may make to weight gain and discuss the implications of this data for future research and the practice of mental health and other professionals. PMID:27429268

  9. Pseudallescheria boydii with Aspergillus fumigatus and Aspergillus terreus in a Critically Ill Hematopoietic Stem Cell Recipient with ARDS.

    PubMed

    Lahmer, Tobias; Messer, Marlena; Ehmer, Ursula; Eser, Stefan; Beitz, Analena; Fekecs, Lisa; Schmid, Roland M; Huber, Wolfgang

    2016-04-01

    Pseudallescheria boydii is a fungal organism known to affect immunocompromised patients. This organism is known to cause, in severe cases, invasive infection of various organs such as the central nervous, cardiovascular, and respiratory systems. We report an unusual case of pulmonary P. boydii pneumonia in an immunocompromised critically ill patient with a co-infection of Aspergillus fumigatus and Aspergillus terreus with ARDS. This case highlights the importance of a high index of suspicion for superimposed fungal infections in patients who are critically ill and immunocompromised. Uncommon fungal pathogens should be considered in the differential diagnosis of respiratory failure, especially if diagnostic markers such as galactomannan (from BAL and serum) or 1,3-beta-D-glucan are elevated. Further diagnostic interventions are warranted when insufficient clinical improvement is observed to prevent treatment failure and adverse outcomes. PMID:26455910

  10. Why a second look might be worth it: immuno-modulatory therapies in the critically ill patient

    PubMed Central

    Siegler, Benedikt H.; Brenner, Thorsten; Uhle, Florian; Weiterer, Sebastian; Weigand, Markus A.

    2016-01-01

    Sepsis and septic shock are associated with high mortality rates and remain a serious menace for the critically ill patient. Concurrent activation of pro- and anti-inflammatory pathways and an excessive cytokine release represent initial key features in the deregulation of the humoral and cellular antimicrobial defense. Research of the last decades addressed both the ebullient inflammation as well as the resulting long-term failure of the host immunity. While the reestablishment of an adequate immune-competence is still under investigation, many promising experimental trials to limit the inflammatory response during sepsis were challenged by missing beneficial effects in clinical studies. Nevertheless, due to advanced knowledge about the complex regulation of inflammatory mediators and their overlapping involvement in other potentially life-threatening diseases, further evaluation of these approaches in relevant subgroups could help to identify critically ill patients with potential benefit from anti-inflammatory therapies. PMID:27293871

  11. Results of distal revascularization in elderly patients for critical ischemia of the lower limbs.

    PubMed

    Illuminati, G; Calio, F G; Bertagni, A; Piermattei, A; Vietri, F; Martinelli, V

    1999-04-01

    Thirty eight patients over 75 years of age were operated upon of 40 distal arterial revascularizations for critical ischaemia of the lower limbs. Arterial reconstruction was proposed to ambulatory, self sufficient patients, with a patent artery of the leg or the foot in continuity with pedal arch, at arteriography. The revascularized artery was the peroneal in 14 cases, the anterior tibial in 11, the posterior tibial in 9, the dorsalis pedis in 5, and the external plantar artery in 1 case. Postoperative mortality was 2.6%. No postoperative arterial occlusion occurred and no postoperative amputation needed to be performed. The mean follow-up of 37 patients surviving operation was 21 months (ext. 2-52 months). At 36 months interval, patients' survival was 43%, primary patency rate was 57%, and limb salvage rate was 76%, at life-table analysis. Distal revascularization enables a good number of elderly patients in critical ischaemia of the lower limb, to enjoy an active, independent life, with a viable limb.

  12. 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

  13. 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.

  14. Relationship between energy expenditure, nutritional status and clinical severity before starting enteral nutrition in critically ill children.

    PubMed

    Botrán, Marta; López-Herce, Jesús; Mencía, Santiago; Urbano, Javier; Solana, Maria José; García, Ana; Carrillo, Angel

    2011-03-01

    The objective of the present study was to investigate the relationship between energy expenditure (EE), biochemical and anthropometric nutritional status and severity scales in critically ill children. We performed a prospective observational study in forty-six critically ill children. The following variables were recorded before starting nutrition: age, sex, diagnosis, weight, height, risk of mortality according to the Paediatric Risk Score of Mortality (PRISM), the Revised Paediatric Index of Mortality (PIM2) and the Paediatric Logistic Organ Dysfunction (PELOD) scales, laboratory parameters (albumin, total proteins, prealbumin, transferrin, retinol-binding protein, cholesterol and TAG, and nitrogen balance) and EE measured by indirect calorimetry. The results showed that there was no relationship between EE and clinical severity evaluated using the PRISM, PIM2 and PELOD scales or with the anthropometric nutritional status or biochemical alterations. Finally, it was concluded that neither nutritional status nor clinical severity is related to EE. Therefore, EE must be measured individually in each critically ill child using indirect calorimetry.

  15. Influence of Daily Fluid Balance prior to Continuous Renal Replacement Therapy on Outcomes in Critically Ill Patients.

    PubMed

    Han, Min Jee; Park, Ki Hyun; Shin, Jung-Ho; Kim, Su Hyun

    2016-08-01

    Positive fluid balance is a risk factor for mortality in critically ill patients, especially those requiring continuous renal replacement therapy (CRRT). However, the association between daily fluid balance and various organ impairments remains unclear. This study investigated the impacts of daily fluid balance prior to CRRT on organ dysfunction, as well as mortality in critically ill patients. We identified daily fluid balance between intensive care unit (ICU) admission and CRRT initiation. According to daily fluid balance, the time to CRRT initiation and the rate of organ failure based on the sequential organ failure assessment (SOFA) score were assessed. We recruited 100 patients who experienced CRRT for acute kidney injury. CRRT was initiated within 2 [0, 4] days. The time to CRRT initiation was shortened in proportion to daily fluid balance, even after the adjustment for the renal SOFA score at ICU admission (HR 1.14, P = 0.007). Based on the SOFA score, positive daily fluid balance was associated with respiratory, cardiovascular, nervous, and coagulation failure, independent of each initial SOFA score at ICU admission (HR 1.36, 1.26, 1.24 and 2.26, all P < 0.05). Ultimately, we found that positive fluid balance was related with an increase in the rate of 28-day mortality (HR 1.14, P = 0.012). Positive daily fluid balance may accelerate the requirement for CRRT, moreover, it can be associated with an increased risk of multiple organ failure in critically ill patients.

  16. Echinocandin to fluconazole step-down therapy in critically ill patients with invasive, susceptible Candida albicans infections.

    PubMed

    van der Geest, Patrick J; Rijnders, Bart J A; Vonk, Alieke G; Groeneveld, A B Johan

    2016-03-01

    Invasive Candida spp. infections are increasingly diagnosed in critically ill patients. For initial treatment, an echinocandin is recommended with a possible step-down to fluconazole when the patients' condition is improving and the isolate appears susceptible, but there are no data to support such policy. We studied the safety and efficacy of step-down therapy in critically ill patients with culture proven deep seated or bloodstream infections by C. albicans susceptible to fluconazole. All patients admitted into the intensive care unit from January 2010 to December 2014, who had a culture proven invasive C. albicans infection and received initial treatment with an echinocandin for at least 4 days were included. Data on patient characteristics, treatment and vital outcomes were assessed. Of the 56 patients, 32 received step-down fluconazole therapy, at median day 5, whereas the echinocandin was continued in the other 24. No differences where seen in baseline characteristics or risk factors for invasive C. albicans infection between the two groups. Response rates were similar and no difference where seen in 28-day or 90-day mortality between the groups. Step-down therapy to fluconazole may be safe and effective in critically ill patients with invasive infections by C. albicans, susceptible to fluconazole, who have clinically improved as early as 4 days after start of treatment with an echinocandin.

  17. 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.

  18. 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.

  19. Meanings of Being Critically Ill in a Sound-Intensive ICU Patient Room - A Phenomenological Hermeneutical Study

    PubMed Central

    Johansson, Lotta; Bergbom, Ingegerd; Lindahl, Berit

    2012-01-01

    The aim of this study was to illuminate the meanings of being critically ill in a sound-intensive ICU patient room, as disclosed through patients’ narratives. Patient rooms in ICUs are filled with loud activity and studies have revealed sound levels comparable to those of a busy road above the patient’s head. There is a risk that the sound or noise is disturbing and at worst a major problem for the patient, but there is a lack of knowledge concerning the patients’ own experiences. Thirteen patients were asked to narrate their experiences of the sound environment in ICU patient rooms. The interviews were analyzed using a phenomenological- hermeneutical method inspired by the philosophy of Ricoeur. Six themes emerged from the analysis. Conclusion: The meanings of being a patient in a sound- intensive environment were interpreted as never knowing what to expect next regarding noise, but also of being situated in the middle of an uncontrollable barrage of noise, unable to take cover or disappear. This condition is not to be seen as static; for some patients there is movement and change over time. The meanings indicate that the unpredictable shifts between silence and disturbing sounds stress the critically ill patient and impede sleep and recovery. Our findings indicate the need to reduce disturbing and unexpected sounds and noise around critically ill patients in high-tech environments in order to facilitate wellbeing, sleep and recovery. Nurses have a vital role in developing such an environment. PMID:22977654

  20. Hemodynamic effects of dexmedetomidine in critically ill neonates and infants with heart disease.

    PubMed

    Lam, Francis; Bhutta, Adnan T; Tobias, Joseph D; Gossett, Jeffrey M; Morales, Laura; Gupta, Punkaj

    2012-10-01

    The primary objective of this study was to evaluate the hemodynamic effects of dexmedetomidine (DEX) infusion on critically ill neonates and infants with congenital heart disease (CHD). The secondary objective of the study was to evaluate the safety and efficacy profile of the drug in this patient population. A retrospective observational study was conducted in the cardiovascular intensive care unit (CVICU) of a single tertiary care university children's hospital. The charts of all neonates and infants who received DEX in the authors' pediatric CVICU between August 2009 and June 2010 were retrospectively reviewed. The demographic data collected included age, weight, sex, diagnosis, and Risk Adjustment in Congenital Heart Surgery (RACHS-1) score. To evaluate the hemodynamic effects of DEX, physiologic data were collected including heart rate, mean arterial pressure (MAP), inotrope score, near-infrared spectroscopy, and central venous pressure (CVP). To assess the efficacy of DEX, the amount and duration of concomitant sedation and analgesic infusions over a period of 24 h were examined together with the number of rescue boluses. The potential side effects evaluated in this study included nausea, vomiting, abdominal distension, dysrhythmias, neurologic abnormalities, seizures, and signs and symptoms of withdrawal. During the study period, 50 neonates and infants received DEX for a median period of 78 h (range, 40-290 h). These patients had an average age of 3.53 ± 2.64 months and a weight of 4.85 ± 1.67 kg. Whereas 34 patients (68%) received DEX after surgery for CHD, 15 patients (30%) received DEX after heart transplantation. Of these 50 infants, 10 (20%) had a single-ventricle anatomy, whereas 13 (26%) had a risk adjustment score (RACHS-1) in the category of 4-6. The median CVICU stay was 29 days (range, 8-69 days). Despite a significant decrease in heart rate, MAP, inotrope score, and CVP, all the patients remained hemodynamically stable during DEX infusion

  1. Single baseline serum creatinine measurements predict mortality in critically ill patients hospitalized for acute heart failure

    PubMed Central

    Schefold, Joerg C.; Hodoscek, Lea Majc; Blöchlinger, Stefan; Doehner, Wolfram; von Haehling, Stephan

    2015-01-01

    Abstract Background Acute heart failure (AHF) is a leading cause of death in critically ill patients and is often accompanied by significant renal dysfunction. Few data exist on the predictive value of measures of renal dysfunction in large cohorts of patients hospitalized for AHF. Methods Six hundred and eighteen patients hospitalized for AHF (300 male, aged 73.3 ± 10.3 years, 73% New York Heart Association Class 4, mean hospital length of stay 12.9 ± 7.7 days, 97% non‐ischaemic AHF) were included in a retrospective single‐centre data analysis. Echocardiographic data, serum creatinine/urea levels, estimated glomerular filtration rate (eGFR), and clinical/laboratory markers were recorded. Mean follow‐up time was 2.9 ± 2.1 years. All‐cause mortality was recorded, and univariate/multivariate analyses were performed. Results Normal renal function defined as eGFR > 90 mL/min/1.73 m2 was noted in only 3% of AHF patients at baseline. A significant correlation of left ventricular ejection fraction with serum creatinine levels and eGFR (all P < 0.002) was noted. All‐cause mortality rates were 12% (90 days) and 40% (at 2 years), respectively. In a multivariate model, increased age, higher New York Heart Association class at admission, higher total cholesterol levels, and lower eGFR independently predicted death. Patients with baseline eGFR < 30 mL/min/1.73 m2 had an exceptionally high risk of death (odds ratio 2.80, 95% confidence interval 1.52–5.15, P = 0.001). Conclusions In a large cohort of patients with mostly non‐ischaemic AHF, enhanced serum creatinine levels and reduced eGFR independently predict death. It appears that patients with eGFR < 30 mL/min/1.73 m2 have poorest survival rates. Our data add to mounting data indicating that impaired renal function is an important risk factor for non‐survival in patients hospitalized for AHF.

  2. Physical rehabilitation for critical illness myopathy and neuropathy: an abridged version of Cochrane Systematic Review.

    PubMed

    Mehrholz, J; Pohl, M; Kugler, J; Burridge, J; Mückel, S; Elsner, B

    2015-10-01

    Intensive care unit (ICU) acquired or generalised weakness due to critical illness myopathy (CIM) and polyneuropathy (CIP) are major causes of chronically impaired motor function that can affect activities of daily living and quality of life. Physical rehabilitation of those affected might help to improve activities of daily living. Our primary objective was to assess the effects of physical rehabilitation therapies and interventions for people with CIP and CIM in improving activities of daily living such as walking, bathing, dressing and eating. Secondary objectives were to assess effects on muscle strength and quality of life, and to assess adverse effects of physical rehabilitation. On 16 July 2014 we searched the Cochrane Neuromuscular Disease Group Specialized Register and on 14 July 2014 we searched CENTRAL, MEDLINE, EMBASE and CINAHL Plus. In July 2014, we searched the Physiotherapy Evidence Database (PEDro) and three trials registries for ongoing trials and further data about included studies with no language restrictions. We also handsearched relevant conference proceedings and screened reference lists to identify further trials. We planned to include randomised controlled trials (RCTs), quasi-RCTs and randomised controlled cross-over trials of any rehabilitation intervention in people with acquired weakness syndrome due to CIP/CIM. We would have extracted data, assessed the risk of bias and classified the quality of evidence for outcomes in duplicate, according to the standard procedures of The Cochrane Collaboration. Outcome data collection would have been for activities of daily living (for example, mobility, walking, transfers and self care). Secondary outcomes included muscle strength, quality of life and adverse events. The search strategy retrieved 3587 references. After examination of titles and abstracts, we retrieved the full text of 24 potentially relevant studies. None of these studies met the inclusion criteria of our review. No data were

  3. Septic versus non-septic acute kidney injury in critically ill patients: characteristics and clinical outcomes

    PubMed Central

    Cruz, Marília Galvão; Dantas, João Gabriel Athayde de Oliveira; Levi, Talita Machado; Rocha, Mário de Seixas; de Souza, Sérgio Pinto; Boa-Sorte, Ney; de Moura, Carlos Geraldo Guerreiro; Cruz, Constança Margarida Sampaio

    2014-01-01

    Objective This study aimed to describe and compare the characteristics and clinical outcomes of patients with septic and non-septic acute kidney injury. Methods This study evaluated an open cohort of 117 critically ill patients with acute kidney injury who were consecutively admitted to an intensive care unit, excluding patients with a history of advanced-stage chronic kidney disease, kidney transplantation, hospitalization or death in a period shorter than 24 hours. The presence of sepsis and in-hospital death were the exposure and primary variables in this study, respectively. A confounding analysis was performed using logistic regression. Results No significant differences were found between the mean ages of the groups with septic and non-septic acute kidney injury [65.30±21.27 years versus 66.35±12.82 years, respectively; p=0.75]. In the septic and non-septic acute kidney injury groups, a predominance of females (57.4% versus 52.4%, respectively; p=0.49) and Afro-descendants (81.5% versus 76.2%, respectively; p=0.49) was observed. Compared with the non-septic patients, the patients with sepsis had a higher mean Acute Physiology and Chronic Health Evaluation II score [21.73±7.26 versus 15.75±5.98; p<0.001)] and a higher mean water balance (p=0.001). Arterial hypertension (p=0.01) and heart failure (p<0.001) were more common in the non-septic patients. Septic acute kidney injury was associated with a greater number of patients who required dialysis (p=0.001) and a greater number of deaths (p<0.001); however, renal function recovery was more common in this group (p=0.01). Sepsis (OR: 3.88; 95%CI: 1.51-10.00) and an Acute Physiology and Chronic Health Evaluation II score >18.5 (OR: 9.77; 95%CI: 3.73-25.58) were associated with death in the multivariate analysis. Conclusion Sepsis was an independent predictor of death. Significant differences were found between the characteristics and clinical outcomes of patients with septic versus non-septic acute kidney

  4. Use of Methadone for Prevention of Opioid Withdrawal in Critically Ill Children

    PubMed Central

    Jeffries, Sonia A; McGloin, Rumi; Pitfield, Alexander F; Carr, Roxane R

    2012-01-01

    Background Opioids are commonly administered to critically ill children for analgesia and sedation, but many patients experience opioid withdrawal upon discontinuation. The authors’ institution developed a protocol for using methadone to prevent opioid withdrawal in children who have received morphine by continuous IV infusion for 5 days or longer in the pediatric intensive care unit (PICU). Objectives The primary objectives were to determine if opioids were tapered according to the protocol and to determine the conversion ratio for IV morphine to oral methadone that was used. Secondary objectives were to describe the methadone dosage used and the clinical outcomes, to evaluate adjustments to methadone dosing, and to report the incidence of adverse effects. Methods A retrospective analysis of charts was conducted for pediatric patients who had received morphine by continuous IV infusion for 5 days or longer followed by methadone in the PICU between May 2008 and August 2009. Validated scoring systems (the Withdrawal Assessment Tool and the State Behavioral Scale) were used to assess symptoms of withdrawal and degree of sedation, respectively. Results Forty-three patients were included in the study, with median age of 8 months (range 0.25–201 months). For 31 patients (72%), the protocol was not used, and there were no patients for whom the protocol was followed to completion. The median duration of weaning was 10 days (range 0–91 days). The conversion ratio for IV morphine to oral methadone was 1:0.78 for anticipated 5-day weaning and 1:0.98 for anticipated 10-day weaning. During the first 10 days of weaning, 18 patients (42%) experienced withdrawal symptoms. The methadone dose was increased for 11 (26%) of the 43 patients. Patients were sedated for a median of 1 day (range 0–9 days), were comfortable for a median of 6.5 days (range 1–64 days), and were agitated for a median of 2.5 days (range 0–23 days). Naloxone was required for 2 patients. Conclusions

  5. Has Stewart approach improved our ability to diagnose acid-base disorders in critically ill patients?

    PubMed

    Masevicius, Fabio D; Dubin, Arnaldo

    2015-02-01

    conventional methods. Although the introduction of the Stewart approach was a new insight into acid-base physiology, the method has not significantly improved our ability to understand, diagnose, and treat acid-base alterations in critically ill patients.

  6. High dose tigecycline in critically ill patients with severe infections due to multidrug-resistant bacteria

    PubMed Central

    2014-01-01

    Introduction The high incidence of multidrug-resistant (MDR) bacteria among patients admitted to ICUs has determined an increase of tigecycline (TGC) use for the treatment of severe infections. Many concerns have been raised about the efficacy of this molecule and increased dosages have been proposed. Our purpose is to investigate TGC safety and efficacy at higher than standard doses. Methods We conducted a retrospective study of prospectively collected data in the ICU of a teaching hospital in Rome. Data from all patients treated with TGC for a microbiologically confirmed infection were analyzed. The safety profile and efficacy of high dosing regimen use were investigated. Results Over the study period, 54 patients (pts) received TGC at a standard dose (SD group: 50 mg every 12 hours) and 46 at a high dose (HD group: 100 mg every 12 hours). Carbapenem-resistant Acinetobacter.baumannii (blaOXA-58 and blaOXA-23 genes) and Klebsiella pneumoniae (blaKPC-3 gene) were the main isolated pathogens (n = 79). There were no patients requiring TGC discontinuation or dose reduction because of adverse events. In the ventilation-associated pneumonia population (VAP) subgroup (63 patients: 30 received SD and 33 HD), the only independent predictor of clinical cure was the use of high tigecycline dose (odds ratio (OR) 6.25; 95% confidence interval (CI) 1.59 to 24.57; P = 0.009) whilst initial inadequate antimicrobial treatment (IIAT) (OR 0.18; 95% CI 0.05 to 0.68; P = 0.01) and higher Sequential Organ Failure Assessment (SOFA) score (OR 0.66; 95% CI 0.51 to 0.87; P = 0.003) were independently associated with clinical failure. Conclusions TGC was well tolerated at a higher than standard dose in a cohort of critically ill patients with severe infections. In the VAP subgroup the high-dose regimen was associated with better outcomes than conventional administration due to Gram-negative MDR bacteria. PMID:24887101

  7. Soluble CD73 in Critically Ill Septic Patients – Data from the Prospective FINNAKI Study

    PubMed Central

    Vaara, Suvi T.; Hollmén, Maija; Korhonen, Anna-Maija; Maksimow, Mikael; Ala-Kokko, Tero; Salmi, Marko; Jalkanen, Sirpa; Pettilä, Ville

    2016-01-01

    Background CD73 dephosphorylates adenosine monophosphate to adenosine that is an anti-inflammatory molecule inhibiting immune activation and vascular leakage. Therefore, CD73 could be an interesting mediator both in sepsis and acute kidney injury (AKI). We aimed to explore the soluble CD73 (sCD73) levels and their evolution in critically ill patients with severe sepsis and, second, to scrutinize the potential association of sCD73 levels with AKI and 90-day mortality. Methods This was a post-hoc laboratory analysis of the prospective, observational FINNAKI study conducted in 17 Finnish ICU during 5 months in 2011–2012. Plasma samples of 588 patients admitted with severe sepsis/shock or with developing severe sepsis were analyzed at 0h (ICU admission) and 24h, and additionally, on day 3 or day 5 from a subset of the patients. Results The median [IQR] sCD73 levels at 0h were 5.11 [3.29–8.28] ng/mL and they decreased significantly from 0h to 4.14 [2.88–7.11] ng/mL at 24h, P<0.001. From 24h to Day 3 (n = 132) the sCD73 levels rose to 5.18 [2.98–8.83] ng/mL (P = 0.373) and from 24h to Day 5 (n = 224) to 5.52 [3.57–8.90] ng/mL (P<0.001). Patients with AKI had higher sCD73 values at 0h and at 24h compared to those without AKI. Non-survivors with severe sepsis, but not with septic shock, had higher CD73 levels at each time-point compared to survivors. After multivariable adjustments, sCD73 levels at 0h associated independently neither with the development of AKI nor 90-day mortality. Conclusions Compared to normal population, the sCD73 levels were generally low at 0h, showed a decrease to 24h, and later an increase by day 5. The sCD73 levels do not seem useful in predicting the development of AKI or 90-day mortality among patients with severe sepsis or shock. PMID:27732656

  8. Population Pharmacokinetics and Pharmacodynamics of Extended-Infusion Piperacillin and Tazobactam in Critically Ill Children

    PubMed Central

    Chung, Eun Kyoung; Knoderer, Chad A.; Buenger, Lauren E.; Healy, Daniel P.; Dees, Jennifer; Crumby, Ashley S.; Kays, Michael B.

    2015-01-01

    The study objective was to evaluate the population pharmacokinetics and pharmacodynamics of extended-infusion piperacillin-tazobactam in children hospitalized in an intensive care unit. Seventy-two serum samples were collected at steady state from 12 patients who received piperacillin-tazobactam at 100/12.5 mg/kg of body weight every 8 h infused over 4 h. Population pharmacokinetic analyses were performed using NONMEM, and Monte Carlo simulations were performed to estimate the piperacillin pharmacokinetic profiles for dosing regimens of 80 to 100 mg/kg of the piperacillin component given every 6 to 8 h and infused over 0.5, 3, or 4 h. The probability of target attainment (PTA) for a cumulative percentage of the dosing interval that the drug concentration exceeds the MIC under steady-state pharmacokinetic conditions (TMIC) of ≥50% was calculated at MICs ranging from 0.25 to 64 mg/liter. The mean ± standard deviation (SD) age, weight, and estimated glomerular filtration rate were 5 ± 3 years, 17 ± 6.2 kg, and 118 ± 41 ml/min/1.73 m2, respectively. A one-compart