2656 articles - 10.09.10
1: Crit Care Med. 2010 Sep;38(9 Suppl):S478-82.
King DR, Velmahos GC.
Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA. dking3@partners.org
Managing patients who are morbidly obese in the intensive care unit is associated with a variety of problems uncommonly experienced with the those who are not morbidly obese. Clinicians experience a myriad of unique problems and circumstances, from the need for special beds and lifts to unusual and unknown volumes of distribution resulting in unclear drug dosing. This review examines several issues including sedation, invasive monitoring, venous thromboembolism prophylaxis, surgical infections, nutritional support, and other complications that may be of particular importance to the critically ill patient who is morbidly obese. In many cases, care is altered based on the complicating issues surrounding morbid obesity. In other cases, the presence of obesity suggests no alterations in our routine critical care delivery. A comprehensive review of the literature is undertaken, data are critically considered, and overall opinion is rendered based on the available peer-reviewed literature. In many cases, data are not available that address the specific patient population in question, so related papers (like gastric bypass data) are considered. Many issues do not have definitive answers based on randomized controlled trials, and much is left to treating clinician opinion and local practice patterns. Where good data exist, however, one should consider carefully and individually deviation from the evidence-based approach.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20724881&dopt=ExternalLink
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PMID: 20724881 [PubMed - in process]2: Am J Respir Crit Care Med. 2010 Aug 23; [Epub ahead of print]
Khemani RG, Newth CJ.
Childrenas Hospital Los Angeles, University of Southern California, Keck School of Medicine, Los Angeles, United States.
Pediatric practitioners face unique challenges when attempting to translate or adapt adult derived evidence regarding ventilation practices for Acute Lung Injury or Acute Respiratory Distress Syndrome into pediatric practice. Fortunately or unfortunately, there appears to be selective adoption of adult practices for pediatric mechanical ventilationamany of which pose considerable challenges or uncertainty when translated to pediatrics. These differences, combined with heterogeneous management strategies within pediatric critical care, can complicate clinical practice and make designing robust clinical trials in pediatric acute respiratory failure particularly difficult. These issues surround the lack of explicit ventilator protocols in pediatrics, either computer or paper based; differences in modes of conventional ventilation and perceived marked differences in the approach to high frequency oscillatory ventilation; challenges with patient recruitment; the shortcomings of the definition of ALI and ARDS; the more reliable yet still somewhat unpredictable relationship between lung injury severity and outcome; and the reliance upon potentially biased surrogate outcome measures like ventilator free days for all pediatric trials. The purpose of this review will be to highlight these challenges, discuss pertinent work which has begun to address them, and propose potential solutions or future investigations which may help facilitate comprehensive trials on pediatric mechanical ventilation and define clinical practice standards.
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PMID: 20732987 [PubMed - as supplied by publisher]3: Crit Care Med. 2010 Aug 19; [Epub ahead of print]
Kopterides P, Siempos II, Tsangaris I, Tsantes A, Armaganidis A.
From the Second Critical Care Department (PK, IIS, IT, AA), "Attiko" University Hospital, University of Athens Medical School, Athens, Greece; and the Laboratory of Hematology & Blood Bank Unit (AT), "Attiko" University Hospital, University of Athens Medical School, Athens, Greece.
OBJECTIVE:: There is increasing interest for strategies that could curtail antibiotic resistance in the critical care setting. We sought to determine the effectiveness and safety of procalcitonin-guided algorithms in the management of septic patients in the intensive care unit. DATA SOURCES:: MEDLINE, Scopus, Cochrane Central Register of Controlled Trials (through February 2010), reference lists of retrieved publications, and queries of corresponding authors. No language restrictions were applied. STUDY SELECTION:: We included only randomized controlled studies reporting on antibiotic use and clinical outcomes of intensive care unit patients managed with a procalcitonin-guided algorithm or according to routine practice. DATA EXTRACTION:: Data on study characteristics, interventions, and outcomes were retrieved by two independent reviewers. Pooled odds ratios, weighted mean differences, and 95% confidence intervals were calculated by implementing both the Mantel-Haenszel fixed effect model and the DerSimonian-Laird random effects model. DATA SYNTHESIS:: Seven randomized controlled studies involving 1131 intensive care unit patients (adults = 1010; neonates = 121) were included. In comparison with routine practice, the implementation of procalcitonin-guided algorithms decreased the duration of antibiotic therapy for the first episode of infection by approximately 2 days (weighted mean difference = -2.36 days; 95% confidence interval, -3.11 to -1.61) and the total duration of antibiotic treatment by 4 days (fixed effect model: weighted mean difference: -4.19 days; 95% confidence interval, -4.98 to -3.39). The comparison between the procalcitonin and the routine practice group was not associated with any apparent adverse clinical outcome: 28-day mortality (fixed effect model: odds ratio = 0.93; 95% confidence interval, 0.69 to 1.26), intensive care unit length of stay (fixed effect model: pooled weighted mean difference = -0.49 days, 95% confidence interval, -1.55 to 0.57), and relapsed/persistent infection rate (fixed effect model: odds ratio = 0.97; 95% confidence interval, 0.56 to 1.69). CONCLUSIONS:: The implementation of a procalcitonin-based algorithm may reduce antibiotic exposure in critically ill, septic patients without compromising clinical outcomes, but further research is necessary before the wide adoption of this strategy.
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PMID: 20729729 [PubMed - as supplied by publisher]4: Crit Care Med. 2010 Aug 12; [Epub ahead of print]
Marik PE, Vasu T, Hirani A, Pachinburavan M.
From the Division of Pulmonary and Critical Care Medicine (PEM); Eastern Virginia Medical School, Norfolk, VA; Division of Pulmonary and Critical Care Medicine (TV, AH, MP), Thomas Jefferson University, Philadelphia, PA.
BACKGROUND:: Recent observational studies suggest that bleeding from stress ulceration is extremely uncommon in intensive care unit patients. Furthermore, the risk of bleeding may not be altered by the use of acid suppressive therapy. Early enteral tube feeding (initiated within 48 hrs of intensive care unit admission) may account for this observation. Stress ulcer prophylaxis may, however, increase the risk of hospital-acquired pneumonia and Clostridia difficile infection. OBJECTIVE:: A systematic review of the literature to determine the benefit and risks of stress ulcer prophylaxis and the moderating effect of enteral nutrition. DATA SOURCES:: MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles. STUDY SELECTION:: Randomized, controlled studies that evaluated the association between stress ulcer prophylaxis and gastrointestinal bleeding. We included only those studies that compared a histamine-2 receptor blocker with a placebo. DATA EXTRACTION:: Data were abstracted on study design, study size, study setting, patient population, the histamine-2 receptor blocker and dosage used, the incidence of clinically significant gastrointestinal bleeding, hospital-acquired pneumonia, mortality, and the use of enteral nutrition. DATA SYNTHESIS:: Seventeen studies (which enrolled 1836 patients) met the inclusion criteria. Patients received adequate enteral nutrition in three of the studies. Overall, stress ulcer prophylaxis with a histamine-2 receptor blocker reduced the risk of gastrointestinal bleeding (odds ratio 0.47; 95% confidence interval, 0.29-0.76; p < .002; I =. 44%); however, the treatment effect was noted only in the subgroup of patients who did not receive enteral nutrition. In those patients who were fed enterally, stress ulcer prophylaxis did not alter the risk of gastrointestinal bleeding (odds ratio 1.26; 95% confidence interval, 0.43-3.7). Overall histamine-2 receptor blockers did not increase the risk of hospital-acquired pneumonia (odds ratio 1.53; 95% confidence interval, 0.89-2.61; p = .12; I =. 41%); however, this complication was increased in the subgroup of patients who were fed enterally (odds ratio 2.81; 95% confidence interval, 1.20-6.56; p = .02; I = 0%). Overall, stress ulcer prophylaxis had no effect on hospital mortality (odds ratio 1.03; 95% confidence interval, 0.78-1.37; p = .82). The hospital mortality was, however, higher in those studies (n =. 2) in which patients were fed enterally and received a histamine-2 receptor blocker (odds ratio 1.89; 95% confidence interval, 1.04-3.44; p = .04, I =. 0%). Sensitivity analysis and meta-regression demonstrated no relationship between the treatment effect (risk of gastrointestinal bleeding) and the classification used to define gastrointestinal bleeding; neither the Jadad quality score nor the year of the study was reported. CONCLUSIONS:: The results of this meta-analysis suggest that, in those patients receiving enteral nutrition, stress ulcer prophylaxis may not be required and, indeed, such therapy may increase the risk of pneumonia and death. However, because no clinical study has prospectively tested the influence of enteral nutrition on the risk of stress ulcer prophylaxis, our findings should be considered exploratory and interpreted with some caution.
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PMID: 20711074 [PubMed - as supplied by publisher]5: Crit Care Med. 2010 Aug 12; [Epub ahead of print]
Noah MA, Dawrant M, Faulkner GM, Hill AM, Harvey C, Hussain A, Jenkins DR, Nichani S, Peek GJ, Sosnowski AW, Firmin RK.
From The Heart Link ECMO Unit, Glenfield General Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK.
OBJECTIVE:: Panton-Valentine leukocidin expressing Staphylococcus aureus pneumonia, an infection that affects predominantly young people, has a mortality rate of >70% despite aggressive conventional management. Little information is available on the management of patients with Panton-Valentine leukocidin expressing S. aureus pneumonia with extracorporeal membrane oxygenation support. As a large extracorporeal membrane oxygenation center, we reviewed our experience and outcomes with Panton-Valentine Leukocidin expressing S. aureus pneumonia. DATA SOURCES:: Locally held register of all extracorporeal membrane oxygenation patients at Glenfield Hospital. STUDY SELECTION:: Retrospective study including all patients with sputum-positive Panton-Valentine leukocidin expressing S. aureus pneumonia managed with extracorporeal membrane oxygenation support at a single extracorporeal membrane oxygenation center. DATA SYNTHESIS:: On review of our database held from September 1989 until date, there were four patients with sputum-confirmed Panton-Valentine leukocidin expressing S. aureus pneumonia managed with extracorporeal membrane oxygenation. Refractory hypoxemia and/or uncompensated hypercapnia despite optimal conventional management were the indications for extracorporeal membrane oxygenation. After varying periods on extracorporeal membrane oxygenation with appropriate antibiotic and ancillary care, all four patients were discharged home. CONCLUSIONS:: Panton-Valentine leukocidin expressing S. aureus pneumonia can cause severe, necrotizing pneumonia associated with acute respiratory distress syndrome, which can be particularly challenging to manage. Extracorporeal membrane oxygenation support permits low pressure lung ventilation, avoiding barotrauma to lungs made friable by Panton-Valentine leukocidin expressing S. aureus infection. Although this is a small number of patients, the results are encouraging.
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PMID: 20711071 [PubMed - as supplied by publisher]6: Crit Care Med. 2010 Aug;38(8 Suppl):S282-91.
Gurses AP, Marsteller JA, Ozok AA, Xiao Y, Owens S, Pronovost PJ.
Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. agurses1@jhmi.edu
OBJECTIVE: Our objective was to identify factors that affect clinicians' compliance with the evidence-based guidelines using an interdisciplinary approach and develop a conceptual framework that can provide a comprehensive and practical guide for designing effective interventions. DESIGN: A literature review and a brainstorming session with 11 researchers from a variety of scientific disciplines were used to identify theoretical and conceptual models describing clinicians' guideline compliance. MEDLINE, EMBASE, CINAHL, and the bibliographies of the papers identified were used as data sources for identifying the relevant theoretical and conceptual models. RESULTS: Thirteen different models that originated from various disciplines including medicine, rural sociology, psychology, human factors and systems engineering, organizational management, marketing, and health education were identified. Four main categories of factors that affect compliance emerged from our analysis: clinician characteristics, guideline characteristics, system characteristics, and implementation characteristics. Based on these findings, we developed an interdisciplinary conceptual framework that specifies the expected interrelationships among these four categories of factors and their impact on clinicians' compliance. CONCLUSIONS: An interdisciplinary approach is needed to improve clinicians' compliance with evidence-based guidelines. The conceptual framework from this research can provide a comprehensive and systematic guide to identify barriers to guideline compliance and design effective interventions to improve patient safety.
Publication Types: Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't Research Support, U.S. Gov't, Non-P.H.S. Review
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PMID: 20647785 [PubMed - indexed for MEDLINE]7: Crit Care Med. 2010 Aug;38(8 Suppl):S265-8.
Patterson JE, Malani PN, Maragakis LL.
University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System, San Antonio, TX, USA. pattersonj@uthscsa.edu
Attention to the improvement of safety in healthcare lately has focused on healthcare-associated infections, including many that occur in the intensive care unit, such as catheter-related bloodstream infections and ventilator-associated pneumonias. Great strides have been made in decreasing the rates of intensive care unit hospital-acquired infections in the past decade. This is attributable to a number of factors, including standardization of care, technological advances, provider payment reform, and consumer activism. Teamwork and communication remain the most important facets in patient safety. The papers in this supplement examine the roles of human factors and process engineering, survey a spectrum of infection control and safety challenges encountered by critical care practitioners, and assess the future challenges for continued improvement in our systems of care.
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PMID: 20647783 [PubMed - indexed for MEDLINE]8: Crit Care Med. 2010 Sep;38(9):1882-9.
Sevransky JE, Checkley W, Martin GS.
Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA. jsevran1@jhmi.edu
OBJECTIVE: Better understanding of the pathophysiology of critical illness has led to an increase in clinical trials designed to improve the clinical care and outcomes of patients with life-threatening illness. Knowledge of basic principles of clinical trial design and interpretation will assist the clinician in better applying the results of these studies into clinical practice. DATA SOURCES: We review selected clinical trials to highlight important design features that will improve understanding of the results of critical care clinical trials designed to improve clinical care of the critically ill. RESULTS: Trial design features such as patient selection, bias, sample size calculation, selection of subjects and controls, and primary outcome measure may influence the results of a critical care clinical trial designed to test a therapy targeting improved clinical care. In conjunction with trial design knowledge, understanding the size of the anticipated treatment effect, the importance of any clinical end point achieved, and whether patients in the trial are representative of typical patients with the illness will assist the reader in determining whether the results should be applied to specific patients or usual clinical practice. CONCLUSIONS: Better understanding of important aspects of trial design and interpretation, such as whether patients enrolled in both intervention arms were comparable and whether the primary outcome of the trial is clinically important, will assist the bedside clinician in determining whether to apply the findings from the clinical study into clinical practice.
Publication Types: Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't
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PMID: 20639755 [PubMed - in process]9: Crit Care Med. 2010 Sep;38(9):1802-8.
Kalil AC, Murthy MH, Hermsen ED, Neto FK, Sun J, Rupp ME.
University of Nebraska Medical Center, Omaha, NE, USA. akalil@unmc.edu
INTRODUCTION: Compared with glycopeptides, linezolid achieves higher lung epithelial lining fluid concentrations, which may correlate with improved efficacy in the treatment of nosocomial pneumonia. However, clinical superiority has not been demonstrated. OBJECTIVE: To test the hypothesis that linezolid may be superior to glycopeptides. METHODS: Prospective randomized trials that tested linezolid vs. vancomycin or teicoplanin for treatment of nosocomial pneumonia were included. Heterogeneity was analyzed by I(2) and Q statistics. Meta-analysis relative risks were based on fixed and random-effects models. Outcomes evaluated consisted of clinical cure, microbiological eradication, and side effects. RESULTS: Nine linezolid trials (vancomycin [7]; teicoplanin [2]) were included (n = 2329). The linezolid vs. glycopeptide analysis shows clinical cure relative risk of 1.01 (95% confidence interval, 0.93-1.10; p = .83; I(2) = 0%) and microbiological eradication relative risk of 1.10 (95% confidence interval, 0.98 -1.22; p = .10; I(2) = 0%). Methicillin-resistant Staphylococcus aureus subgroup analysis yielded a microbiological eradication relative risk of 1.10 (95% confidence interval, 0.87-1.38; p = .44; I(2) = 16%). If linezolid is compared with vancomycin only, then clinical cure relative risk is 1.00 (95% confidence interval, 0.90-1.12), microbiological eradication and methicillin-resistant Staphylococcus aureus relative risks are 1.07 (95% confidence interval, 0.90-1.26; p = .45) and 1.05 (95% confidence interval, 0.82-1.33; p = .71). The risks of thrombocytopenia (relative risk, 1.93; 95% confidence interval, 1.30-2.87; p = .001) and gastrointestinal events (relative risk, 2.02; 95% confidence interval, 1.10-3.70; p = .02) are higher with linezolid, but no differences are seen for renal dysfunction (relative risk, 0.89; 95% confidence interval, 0.56-1.43; p = .64) or all-cause mortality (relative risk, 0.95; 95% confidence interval, 0.76-1.18; p = .63). CONCLUSIONS: Our study does not demonstrate clinical superiority of linezolid vs. glycopeptides for the treatment of nosocomial pneumonia despite a statistical power of 95%. Linezolid shows a significant two-fold increase in the risk of thrombocytopenia and gastrointestinal events. Vancomycin and teicoplanin are not associated with more renal dysfunction than linezolid.
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PMID: 20639754 [PubMed - in process]10: Crit Care Med. 2010 Jul 15; [Epub ahead of print]
Chung KK, Wolf SE, Renz EM, Allan PF, Aden JK, Merrill GA, Shelhamer MC, King BT, White CE, Bell DG, Schwacha MG, Wanek SM, Wade CE, Holcomb JB, Blackbourne LH, Cancio LC.
From the US Army Institute of Surgical Research (KKC, SEW, EMR, JKA, BTK, CEW, CEW, LHB, LCC), Fort Sam Houston, TX; the University of Texas Health Science Center at San Antonio (KKC, SEW, EMR, CEW, MGS, CEW, LCC), San Antonio, TX; Landstuhl Regional Medical Center (PFA, SMW), Landstuhl, Germany; San Antonio Military Medical Center (GAM, MCS, DGB), Fort Sam Houston, TX; the University of Texas Health Science Center at Houston (JBH), Houston, TX; and Uniformed Services University of the Health Sciences (EMR), Bethesda, MD.
OBJECTIVES:: In select burn intensive care units, high-frequency percussive ventilation is preferentially used to provide mechanical ventilation in support of patients with acute lung injury, acute respiratory distress syndrome, and inhalation injury. However, we found an absence of prospective studies comparing high-frequency percussive ventilation with contemporary low-tidal volume ventilation strategies. The purpose of this study was to prospectively compare the two ventilator modalities in a burn intensive care unit setting. DESIGN:: Single-center, prospective, randomized, controlled clinical trial, comparing high-frequency percussive ventilation with low-tidal volume ventilation in patients admitted to our burn intensive care unit with respiratory failure. SETTING:: A 16-bed burn intensive care unit at a tertiary military teaching hospital. PATIENTS:: Adult patients >/=18 yrs of age requiring prolonged (>24 hrs) mechanical ventilation were admitted to the burn intensive care unit. The study was conducted over a 3-yr period between April 2006 and May 2009. This trial was registered with ClinicalTrials.gov as NCT00351741. INTERVENTIONS:: Subjects were randomly assigned to receive mechanical ventilation through a high-frequency percussive ventilation-based strategy (n = 31) or a low-tidal volume ventilation-based strategy (n = 31). MEASUREMENTS AND MAIN RESULTS:: At baseline, both the high-frequency percussive ventilation group and the low-tidal volume ventilation group had similar demographics to include median age (interquartile range) (28 yrs [23-45] vs. 33 yrs [24-46], p = nonsignificant), percentage of total body surface area burn (34 [20-52] vs. 34 [23-50], p = nonsignificant), and clinical diagnosis of inhalation injury (39% vs. 35%, p = nonsignificant). The primary outcome was ventilator-free days in the first 28 days after randomization. Intent-to-treat analysis revealed no significant difference between the high-frequency percussive ventilation and the low-tidal volume ventilation groups in mean (+/- sd) ventilator-free days (12 +/- 9 vs. 11 +/- 9, p = nonsignificant). No significant difference was detected between groups for any of the secondary outcome measures to include mortality except the need for "rescue" mode application (p = .02). Nine (29%) in the low-tidal volume ventilation arm did not meet predetermined oxygenation or ventilation goals and required transition to a rescue mode. By contrast, two in the high-frequency percussive ventilation arm (6%) required rescue. CONCLUSIONS:: A high-frequency percussive ventilation-based strategy resulted in similar clinical outcomes when compared with a low-tidal volume ventilation-based strategy in burn patients with respiratory failure. However, the low-tidal volume ventilation strategy failed to achieve ventilation and oxygenation goals in a higher percentage necessitating rescue ventilation.
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PMID: 20639746 [PubMed - as supplied by publisher]11: Am J Respir Crit Care Med. 2010 Jul 9; [Epub ahead of print]
Davis SD, Rosenfeld M, Kerby GS, Brumback L, Kloster MH, Acton JD, Colin AA, Conrad CK, Hart MA, Hiatt PW, Mogayzel PJ, Johnson RC, Wilcox SL, Castile RG.
Department of Pediatrics; Division of Pediatric Pulmonology; North Carolina Children's Hospital, University University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States.
RATIONALE: The conduct of clinical trials in infants with cystic fibrosis (CF) has been hindered by lack of sensitive outcome measures. OBJECTIVES: To evaluate safety, feasibility, and ability to detect abnormalities in lung function of serial pulmonary function tests (PFTs) in infants with CF. METHODS: Multicenter observational study utilizing a commercial device, rigorous training, ongoing quality control, and over-reading of data by an independent panel. Raised volume rapid thoracoabdominal compression technique and plethysmography were performed at enrollment, 6 and 12 months, with an additional 1-month reproducibility visit. MEASUREMENTS AND MAIN RESULTS: 342 procedures were performed in 100 infants with CF at 10 centers. FRC measurements were acceptable at a higher proportion of study visits (89%) than raised volume (72%) or fractional lung volume (68%) measurements. Average z-scores for many parameters differed significantly from historical control values. Mean (95% CI) z scores were -0.52 (-.78, -.25) for forced expiratory flow at 75% of FVC (FEF75); 1.92 (1.39, 2.45) for FRC; 1.22 (0.68, 1.76) for RV; 0.87 (0.60, 1.13) for FRC/TLC and 0.66 (0.27, 1.06) for RV/TLC. For future multicenter clinical trials utilizing infant PFTs as primary endpoints, minimum detectable treatment effects are presented for several sample sizes. CONCLUSIONS: In this 10-center study, key PFT measures were significantly different in CF infants than in historical controls. However, infant PFTs do not yet appear ready as primary efficacy endpoints for multicenter clinical trials, particularly at inexperienced sites, based on acceptability rates, variability, and potentially large sample sizes required to detect reasonable treatment effects.
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PMID: 20622043 [PubMed - as supplied by publisher]12: Crit Care Med. 2010 Aug;38(8):1644-50.
Diaz JV, Brower R, Calfee CS, Matthay MA.
University of California, San Francisco, San Francisco, CA, USA. diazj@who.int
OBJECTIVE: In the management of patients with severe acute lung injury and acute respiratory distress syndrome, clinicians are sometimes challenged to maintain acceptable gas exchange while avoiding harmful mechanical ventilation practices. In some of these patients, physicians may consider the use of "rescue therapies" to sustain life. Our goal is to provide a practical, evidence-based review to assist critical care physicians' care for patients with severe acute lung injury and acute respiratory distress syndrome. DATA SOURCES: We searched the PubMed database for clinical trials that examined the use of the following therapies in severe acute lung injury and acute respiratory distress syndrome: recruitment maneuvers, high positive end-expiratory pressure, prone position, high-frequency oscillatory ventilation, glucocorticoids, inhaled nitric oxide, buffer therapy, and extracorporeal life support. STUDY SELECTION: All clinical trials that included patients with severe acute lung injury and acute respiratory distress syndrome were included in the review. DATA SYNTHESIS: The primary author reviewed the aforementioned trials in depth and then disputed findings and conclusions with the other authors until consensus was achieved. CONCLUSIONS: This article is designed to provide clinicians with a simple bedside definition for the diagnosis of severe acute respiratory distress syndrome; to describe several therapies that can be used for severe acute respiratory distress syndrome with an emphasis on the potential risks and the indications and benefits; and to offer practical guidelines for implementation of these therapies.
Publication Types: Research Support, Non-U.S. Gov't Review
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20562704&dopt=ExternalLink
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PMID: 20562704 [PubMed - indexed for MEDLINE]13: Crit Care Med. 2010 Sep;38(9):1765-72.
Nelson JE, Bassett R, Boss RD, Brasel KJ, Campbell ML, Cortez TB, Curtis JR, Lustbader DR, Mulkerin C, Puntillo KA, Ray DE, Weissman DE; Improve Palliative Care in the Intensive Care Unit Project.
Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine and Hertzberg Palliative Care Institute, Mount Sinai School of Medicine, New York, NY, USA. Judith.nelson@mssm.edu
OBJECTIVE: To describe models used in successful clinical initiatives to improve the quality of palliative care in critical care settings. DATA SOURCES: We searched the MEDLINE database from inception to April 2010 for all English language articles using the terms "intensive care," "critical care," or "ICU" and "palliative care"; we also hand-searched reference lists and author files. Based on review and synthesis of these data and the experiences of our interdisciplinary expert Advisory Board, we prepared this consensus report. DATA EXTRACTION AND SYNTHESIS: We critically reviewed the existing data with a focus on models that have been used to structure clinical initiatives to enhance palliative care for critically ill patients in intensive care units and their families. CONCLUSIONS: There are two main models for intensive care unit-palliative care integration: 1) the "consultative model," which focuses on increasing the involvement and effectiveness of palliative care consultants in the care of intensive care unit patients and their families, particularly those patients identified as at highest risk for poor outcomes; and 2) the "integrative model," which seeks to embed palliative care principles and interventions into daily practice by the intensive care unit team for all patients and families facing critical illness. These models are not mutually exclusive but rather represent the ends of a spectrum of approaches. Choosing an overall approach from among these models should be one of the earliest steps in planning an intensive care unit-palliative care initiative. This process entails a careful and realistic assessment of available resources, attitudes of key stakeholders, structural aspects of intensive care unit care, and patterns of local practice in the intensive care unit and hospital. A well-structured intensive care unit-palliative care initiative can provide important benefits for patients, families, and providers.
Publication Types: Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20562699&dopt=ExternalLink
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PMID: 20562699 [PubMed - in process]14: Crit Care Med. 2010 Sep;38(9):1890-8.
Kanji S, Lam J, Johanson C, Singh A, Goddard R, Fairbairn J, Lloyd T, Monsour D, Kakal J.
Department of Pharmacy, The Ottawa Hospital, Ontario, Canada. skanji@ottawahospital.on.ca
OBJECTIVE: To quantify the physical and chemical stability data published for commonly used continuously infused medications in the intensive care unit and to evaluate the quality of the studies providing these data. DATA SOURCES AND STUDY SELECTION: We conducted a systematic electronic literature search of MEDLINE, EMBASE, and International Pharmaceutical Abstracts as well as the references of electronic drug compatibility textbooks for all English and French language research publications evaluating the physical compatibility or chemical stability of the 820 possible two-drug combinations of 41 commonly used drugs in an adult intensive care unit. DATA EXTRACTION AND SYNTHESIS: A total of 93 studies comprised of 86 (92%) studies evaluating physical compatibility and 35 (38%) studies evaluating chemical compatibility of at least one drug combination of interest were included. Physical and/or chemical compatibility data exist for only 441 of the possible 820 two-drug combinations (54%), whereas chemical compatibility data exist for only 75 (9%) of the possible combinations. Of the 441 combinations for which compatibility data are available, 67 (15%) represent incompatible combinations and 39 (9%) had conflicting data in which both compatible and incompatible data were identified. CONCLUSIONS: Physical compatibility studies that provide the basis for y-site compatibility are lacking for commonly used medications in intensive care unit patients and may contribute to unsafe medication practices. Furthermore, the heterogeneity in the methodology of these studies likely contributes to the common finding of conflicting data for specific combinations of drugs. Future studies should apply similar methodologic and reporting principles to be able to reproduce and compare outcomes both clinically and in the laboratory.
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PMID: 20562698 [PubMed - in process]15: Crit Care Med. 2010 Aug;38(8):1651-64.
Kumar A, Safdar N, Kethireddy S, Chateau D.
Medical Microbiology and Pharmacology/Therapeutics, University of Manitoba, Winnipeg, Manitoba, Canada. akumar61@yahoo.com
OBJECTIVE: To assess whether a potential benefit with combination antibiotic therapy is restricted to the most critically ill subset of patients, particularly those with septic shock. DATA SOURCES: OVID MEDLINE (1950-October 2009), EMBASE (1980-October 2009), the Cochrane Central Register of Controlled Trials (to third quarter 2009), the ClinicalTrial.gov database, and the SCOPUS database. STUDY SELECTION: Randomized or observational studies of antimicrobial therapy of serious bacterial infections potentially associated with sepsis or septic shock. Fifty studies met entry criteria. DATA EXTRACTION: Study design, mortality/clinical response, and other variables were extracted independently by two reviewers. When possible, study datasets were split into mutually exclusive groups with and without shock or critical illness. DATA SYNTHESIS: Although a pooled odds ratio indicated no overall mortality/clinical response benefit with combination therapy (odds ratio, 0.856; 95% confidence interval, 0.71-1.03; p = .0943; I = 45.1%), stratification of datasets by monotherapy mortality risk demonstrated substantial benefit in the most severely ill subset (monotherapy risk of death >25%; odds ratio of death, 0.51; 95% confidence interval, 0.41-0.64; I = 8.6%). Of those datasets that could be stratified by the presence of shock/critical illness, the more severely ill group consistently demonstrated increased efficacy of a combination therapy strategy (odds ratio, 0.49; 95% confidence interval, 0.35-0.70; p < .0001; I = 0%). An increased risk of death was found in low-risk patients (risk of death <or=15% in the monotherapy arm) exposed to combination therapy (odds ratio, 1.53; 95% confidence interval, 1.16-2.03; p = .003; I = 8.2%). Meta-regression indicated that efficacy of combination therapy was dependent only on the risk of death in the monotherapy group. CONCLUSION: Combination antibiotic therapy improves survival and clinical response of high-risk, life-threatening infections, particularly those associated with septic shock but may be detrimental to low-risk patients.
Publication Types: Comparative Study Meta-Analysis Review
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20562695&dopt=ExternalLink
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PMID: 20562695 [PubMed - indexed for MEDLINE]16: Am J Respir Crit Care Med. 2010 Jun 10; [Epub ahead of print]
Prevots DR, Shaw PA, Strickland D, Jackson LA, Raebel MA, Blosky MA, Montes de Oca R, Shea YR, Seitz AE, Holland SM, Olivier KN.
Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, United States.
RATIONALE: Single-site clinic-based studies suggest an increasing prevalence of pulmonary nontuberculous mycobacteria (NTM) disease but systematic data are lacking. OBJECTIVES: To describe prevalence and trends for NTM lung disease at four geographically-diverse integrated heathcare delivery systems in the United States. METHODS: We abstracted mycobacterial culture results from electronic laboratory databases and linked to other datasets containing clinical and demographic information. Possible cases were defined as a single positive NTM pulmonary isolate, and definite cases were defined as two positive sputum cultures, or one positive culture from a bronchoalveolar lavage or lung biopsy. Annual prevalence was calculated using US census data; average annual prevalence is presented for 2004-2006. Poisson regression models were used to estimate the annual percent change in prevalence. MEASUREMENTS AND MAIN RESULTS: 28,697 samples from 7940 patients were included in the analysis. Of these, 3988 (50%) were defined as possible cases, and 1865 (47%) of these were defined as definite cases. Average annual (2004-2006) site-specific prevalence ranged from 1.4 to 6.6 per 100,000. Prevalence was 1.l to 1.6 fold higher among women relative to men across sites. The prevalence of NTM lung disease was increasing significantly at the two sites where trends were studied, by 2.6% per year among women and 2.9% per year among men. Among persons aged >60 years, annual prevalence increased from 19.6 / 100,000 during 1994-1996 to 26.7/100,000 during 2004-2006. CONCLUSIONS: The epidemiology of nontuberculous mycobacterial lung disease is changing, with a predominance of women and increasing prevalence at the sites studied.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20538958&dopt=ExternalLink
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PMID: 20538958 [PubMed - as supplied by publisher]17: Crit Care Med. 2010 Aug;38(8):1630-6.
Akech SO, Jemutai J, Timbwa M, Kivaya E, Boga M, Fegan G, Maitland K.
KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya.
OBJECTIVES: A previous meta-analysis has shown a consistent survival benefit in children with severe malaria receiving human albumin solution compared to other resuscitation fluids. Human albumin solution is expensive and not readily available in Africa. We examined the safety and efficacy of the fluid resuscitation with two synthetic colloids, Dextran 70 and hydroxyethyl starch, to inform future trial design. DESIGN: An open-label randomized, controlled, phase II safety and efficacy trial. SETTING: High-dependency unit, Kilifi District Hospital, Kenya. PATIENTS: Children aged >6 months with severe falciparum malaria and acidosis (base deficit >8 mmol). INTERVENTIONS: Boluses (20-40 mL/kg) of 6% Dextran 70 and 6% hydroxyethyl starch (130/0.4). MEASUREMENTS AND MAIN RESULTS: Primary end point: resolution of shock over 8 hrs. Secondary end points include resolution of acidosis, in-hospital mortality, and adverse events (allergic reactions, pulmonary edema, and neurologic sequelae). A total of 79 children were enrolled: 39 received Dextran 70 and 40 received hydroxyethyl starch. No significant difference was observed in Dextran 70 and hydroxyethyl starch groups for shock resolution at 8 hrs: 23/37 (62%) and 25/39 (64%), respectively (p = .99). Acidosis resolution and respiratory distress were marginally superior in the hydroxyethyl starch group: 3/39 (8%) remained acidotic at 8 hrs versus 10/37 (27%) in the Dextran 70 arm (p = .05). There were four deaths (5%): two per arm, including three deaths in the coma subgroup (3/39, 8%). No other new adverse event was reported. CONCLUSIONS: Correction of shock by volume expansion with either Dextran 70 or hydroxyethyl starch in children with severe malaria acidosis is safe with low mortality, including the highest risk cases admitted in coma. Both solutions present an attractive and practical option for consideration in future volume resuscitation trials in severe malaria.
Publication Types: Clinical Trial, Phase II Randomized Controlled Trial Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20526196&dopt=ExternalLink
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PMID: 20526196 [PubMed - indexed for MEDLINE]18: Am J Respir Crit Care Med. 2010 Jun 3; [Epub ahead of print]
Lacherade JC, De Jonghe B, Guezennec P, Debbat K, Hayon J, Monsel A, Fangio P, Appere De Vecchi C, Ramaut C, Outin H, Bastuji-Garin S.
Medico-surgical ICU (site of Poissy), Poissy Saint-Germain Hospital, Poissy, France.
RATIONALE: Ventilator-associated pneumonia (VAP) causes substantial morbidity and mortality. The influence of subglottic secretions drainage (SSD) in preventing VAP remains controversial. OBJECTIVE: To determine whether SSD reduces the overall incidence of microbiologically-confirmed VAP. METHODS: Randomized controlled clinical trial conducted at 4 French centers. A total of 333 adult patients intubated with a tracheal tube allowing drainage of subglottic secretions and expected to require mechanical ventilation for >/=48 hours were included. Patients were randomly assigned to undergo intermittent SSD (n=169) or not (n=164). MEASUREMENTS: Primary outcome was the overall incidence of VAP based on quantitative culture of distal pulmonary samplings performed after each clinical suspicion. Other outcomes included incidence of early- and late-onset VAP, duration of mechanical ventilation, ICU mortality. RESULTS: Microbiologically-confirmed VAP occurred in 67 patients, 25/169 (14.8%) in the SSD group and 42/164 (25.6%) in the control group (P=.02) yielding a relative risk reduction of 42.2% (95% confidential interval, 10.4%-63.1%). Using the day 5 threshold, the beneficial effect of SSD in reducing VAP was observed in both earlyonset VAP (2/169 [1.2%] SSD patients vs 10/164 [6.1%] control patients, P=.02) and late-onset VAP (23/126 [18.6%] SSD patients vs 32/97 [33.0%] control patients, P=.01). VAP was clinically suspected at least once in 51/169 (30.2%) SSD patients and 60/164 (36.6%) control patients (P=.25). No significant between-group differences were observed in duration of mechanical ventilation and ICU mortality. CONCLUSIONS: Subglottic secretions drainage during mechanical ventilation results in a significant reduction in VAP, including late-onset VAP. Clinical Trials Registry Information: ID#NCT00219661 registered at www.clinicaltrials.gov.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20522796&dopt=ExternalLink
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PMID: 20522796 [PubMed - as supplied by publisher]19: Crit Care Med. 2010 Jun;38(6 Suppl):S90-6.
Scanlon MC, Karsh BT.
Department of Pediatrics, Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA. mscanlon@mcw.edu
Conventional wisdom suggests that the "human factor" in critical care environments is reason for inadequate medication and patient safety. "Human factors" (or human factors engineering) is also a scientific discipline and practice of improving human performance. Using decades of human factors research, this paper evaluates a range of common beliefs about patient safety through a human factors lens. This evaluation demonstrates that human factors provides a framework for understanding safety failures in critical care settings, offers insights into how to improve medication and patient safety, and reminds us that the "human factor" in critical care units is what allows these time-pressured, information-intense, mentally challenging, interruption-laden, and life-or-death environments to function so safely so much of the time.
Publication Types: Research Support, N.I.H., Extramural
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20502180&dopt=ExternalLink
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PMID: 20502180 [PubMed - indexed for MEDLINE]20: Crit Care Med. 2010 Jun;38(6 Suppl):S106-16.
Empey PE.
Department of Pharmacy and Therapeutics and Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA. pempey@pitt.edu
Adverse drug reactions are a significant public health problem that leads to mortality, hospital admissions, an increased length of stay, increasing healthcare costs, and withdrawal of drugs from market. Intensive care unit patients are particularly vulnerable and are at an elevated risk. Critical care practitioners, regulatory agencies, and the pharmaceutical industry aggressively seek biomarkers to mitigate patient risk. The rapidly expanding field of pharmacogenomics focuses on the genetic contributions to the variability in drug response. Polymorphisms may explain why some groups of patients have the expected response to pharmacotherapy whereas others experience adverse drug reactions. Historically, genetic association studies have focused on characterizing the effects of variation in drug metabolizing enzymes on pharmacokinetics. Recent work has investigated drug transporters and the variants of genes encoding drug targets, both intended and unintended, that comprise pharmacodynamics. This has led to an appreciation of the role that genetics plays in adverse drug reactions that are either predictable extensions of a drug's known therapeutic effect or idiosyncratic.This review presents the evidence for a genetic predisposition to adverse drug reactions, focusing on gene variants producing alterations in drug pharmacokinetics and pharmacodynamics in intensive care unit patients. Genetic biomarkers with the strongest associations to adverse drug reaction risk in the intensive care unit are presented along with the medications involved. Variant genotypes and phenotypes, allelic frequencies in different populations, and clinical studies are discussed. The article also presents the current recommendations for pharmacogenetic testing in clinical practice and explores the drug, patient, research study design, regulatory, and practical issues that presently limit more widespread implementation.
Publication Types: Review
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20502164&dopt=ExternalLink
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PMID: 20502164 [PubMed - indexed for MEDLINE]