Non-invasive pressure support ventilation and CPAP in cardiogenic pulmonary edema: a multicenter randomized study in the emergency department

Introduction

Noninvasive pressure support ventilation (NIPSV) and continuous positive airway pressure (CPAP) are both advocated in the treatment of cardiogenic pulmonary edema (CPE); however, the superiority of one technique over the other has not been clearly demonstrated. With regard to its physiological effects, we hypothesized that NIPSV would be better than CPAP in terms of clinical benefit.

Methods

In a prospective, randomized, controlled study performed in four emergency departments, 200 patients were assigned to CPAP (n?=?101) or NIPSV (n?=?99). Primary outcome was combined events of hospital death and tracheal intubation. Secondary outcomes included resolution time, myocardial infarction rate, and length of hospital stay. Separate analysis was performed in patients with hypercapnia and those with high B-type natriuretic peptide (>500?pg/ml).

Results

Hospital death occurred in 5 (5.0%) patients receiving NIPSV and 3 (2.9%) patients receiving CPAP (p?=?0.56). The need for intubation was observed in 6 (6%) patients in the NIPSV group and 4 (3.9%) patients in the CPAP group (p?=?0.46). Combined events were similar in both groups. NIPSV was associated to a shorter resolution time compared to CPAP (159?±?54 vs. 210?±?73?min; p?Conclusions During CPE, NIPSV accelerates the improvement of respiratory failure compared to CPAP but does not affect primary clinical outcome either in overall population or in subgroups of patients with hypercapnia or those with high B-type natriuretic peptide.     

Early CPAP prevents evolution of acute lung injury in patients with hematologic malignancy

Purpose

Although chemotherapy and transplantation improve outcome of patients with hematological malignancy, complications of these therapies are responsible for a 20–50% mortality rate that increases when respiratory symptoms evolve into acute lung injury (ALI). The aim of this study is to determine the effectiveness of early continuous positive airway pressure (CPAP) delivered in the ward to prevent occurrence of ALI requiring intensive care unit (ICU) admission for mechanical ventilation.

Methods

Patients with hematological malignancy presenting in the hematological ward with early changes in respiratory variables were randomized to receive oxygen (N = 20) or oxygen plus CPAP (N = 20). Primary outcome variables were need of mechanical ventilation requiring ICU admission, and intubation rate among those patients who required ICU admission.

Results

At randomization, arterial-to-inspiratory O₂ ratio in control and CPAP group was 282 ± 41 and 256 ± 52, respectively. Patients who received CPAP had less need of ICU admission for mechanical ventilation (4 versus 16 patients; P = 0.0002). CPAP reduced the relative risk for developing need of ventilatory support to 0.25 (95% confidence interval: 0.10–0.62). Among patients admitted to ICU, intubation rate was lower in the CPAP than in the control group (2 versus 14 patients; P = 0.0001). CPAP reduced the relative risk for intubation to 0.46 (95% confidence interval: 0.27–0.78).

Conclusions

This study suggests that early use of CPAP on the hematological ward in patients with early changes in respiratory variables prevents evolution to acute lung injury requiring mechanical ventilation and ICU admission.     

Helmet CPAP vs. oxygen therapy in severe hypoxemic respiratory failure due to pneumonia

Purpose

The efficacy of noninvasive continuous positive airway pressure (CPAP) to improve outcomes in severe hypoxemic acute respiratory failure (hARF) due to pneumonia has not been clearly established. The aim of this study was to compare CPAP vs. oxygen therapy to reduce the risk of meeting criteria for endotracheal intubation (ETI).

Methods

In a multicenter randomized controlled trial conducted in four Italian centers patients with severe hARF due to pneumonia were randomized to receive helmet CPAP (CPAP group) or oxygen delivered with a Venturi mask (control group). The primary endpoint was the percentage of patients meeting criteria for ETI, including either one or more major criteria (respiratory arrest, respiratory pauses with unconsciousness, severe hemodynamic instability, intolerance) or at least two minor criteria (reduction of at least 30 % of basal PaO₂/FiO₂ ratio, increase of 20 % of PaCO₂, worsening of alertness, respiratory distress, SpO₂ less than 90 %, exhaustion).

Results

Between February 2010 and 2013, 40 patients were randomized to CPAP and 41 to Venturi mask. The proportion of patients meeting ETI criteria in the CPAP group was significantly lower compared to those in the control group (6/40 = 15 % vs. 26/41 = 63 %, respectively, p < 0.001; relative risk 0.24, 95 % CI 0.11–0.51; number needed to treat, 2) two patients were intubated in the CPAP group and one in the control group. The CPAP group showed a faster and greater improvement in oxygenation in comparison to controls (p < 0.001). In either study group, no relevant adverse events were detected.

Conclusions

Helmet CPAP reduces the risk of meeting ETI criteria compared to oxygen therapy in patients with severe hARF due to pneumonia.     

Elevation of creatine kinase is associated with worse outcomes in 2009 pH1N1 influenza?A infection

Background

Current medical knowledge lacks specific information regarding creatine kinase (CK) elevation in influenza?A pH1N1 (2009) infection.

Objectives

Primary endpoints were correlation between CK at intensive care unit (ICU) admission and ICU mortality. Secondary endpoints were ICU length of stay (LOS), mechanical ventilation (MV), and requirement of renal replacement techniques (RRT).

Materials and methods

A prospective multicenter register included all adults admitted for severe acute respiratory insufficiency (SARI) with confirmed pH1N1 in 148 ICUs. Clinical data including demographics, comorbidities, laboratory information, organ involvement, and prognostic data were registered. Post?hoc classification of subjects was determined according to CK level. Data are expressed as median (interquartile range).

Results

Five hundred and five (505) patients were evaluable. Global ICU mortality was 17.8?% without documented differences between breakpoints. CK ≥500?UI/L was documented in 23.8?% of ICU admissions, being associated with greater renal dysfunction: acute kidney injury (AKI) was more frequent (26.1 versus 17.1?%, p?p?p?p?=?0.07) and duration of mechanical ventilation (median 15?days versus 11?days, p?Conclusions CK is a biomarker of severity in pH1N1 infection. Elevation of CK was associated with more complications and increased ICU LOS and healthcare resources.     

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

Introduction

Endotracheal intubation in the ICU is a challenging procedure and is frequently associated with life-threatening complications. The aim of this study was to investigate the effect of the C-MAC^? video laryngoscope on laryngeal view and intubation success compared with direct laryngoscopy.

Methods

In a single-center, prospective, comparative before-after study in an anesthetist-lead surgical ICU of a tertiary university hospital, predictors of potentially difficult tracheal intubation, number of intubation attempts, success rate and glottic view were evaluated during a 2-year study period (first year, Macintosh laryngoscopy (ML); second year, C-MAC^?).

Results

A total of 274 critically ill patients requiring endotracheal intubation were included; 113 intubations using ML and 117 intubations using the C-MAC^? were assessed. In patients with at least one predictor for difficult intubation, the C-MAC^? resulted in more successful intubations on first attempt compared with ML (34/43, 79% vs. 21/38, 55%; P = 0.03). The visualization of the glottis with ML using Cormack and Lehane (C&L) grading was more frequently rated as difficult (20%, C&L grade 3 and 4) compared with the C-MAC^? (7%, C&L grade 3 and 4) (P < 0.0001).

Conclusion

Use of the C-MAC^? video laryngoscope improved laryngeal imaging and improved the intubating success rate on the first attempt in patients with predictors for difficult intubation in the ICU setting. Video laryngoscopy seems to be a useful tool in the ICU where potentially difficult endotracheal intubations regularly occur.     

Increased nonbeneficial care in patients spending their birthday in the ICU

Objective

End-of-life decisions are based on objective and subjective criteria. Previous studies identified substantial subjective biases during end-of-life decision-making. We evaluated whether in-ICU patient’s birthday influenced management decisions.

Design

We used a case–control design in which patients spending their birthday in the ICU (cases) were matched to controls on center, gender, age, severity, type of admission, and length of ICU stay before birthday.

Setting

12 ICUs in French hospitals.

Patients

The cases and controls were patients with ICU admissions >48?h over a 10-year period.

Interventions

None.

Measurements and main results

Compared with the 1,042 controls, the 223 cases were more often trauma patients and received a larger number and longer durations of life-sustaining interventions. This increased intensity of life support occurred after, but not before, the birthday. The cases had longer ICU stay lengths. ICU and hospital mortality were not different between the two groups. End-of-life decisions were made in 22% and 24% of cases and controls, respectively. However, these decisions were made later in the cases than in the controls (18 [5–33] versus 9 [3–19]?days).

Conclusions

Our finding that patients who spent their birthday in the ICU received a higher intensity of life-sustaining care and had longer ICU stays but did not have significantly different mortality rates compared with the controls suggests the use of nonbeneficial interventions. Staff members caring for patients whose birthdays fall during the ICU stay should be aware that this feature can bias end-of-life decisions, leading to an inappropriate level of care.     

Prospective validation of the vasoactive-inotropic score and correlation to short-term outcomes in neonates and infants after cardiothoracic surgery

Purpose

Prospective validation of the vasoactive-inotropic score (VIS) and inotrope score (IS) in infants after cardiovascular surgery.

Methods

Prospective observational study of 70 infants (≤90?days of age) undergoing cardiothoracic surgery. VIS and IS were assessed at 24 (VIS24, IS24), 48 (VIS48, IS48), and 72 (VIS72, IS72)?h after surgery. Maximum VIS and IS scores in the first 48?h were also calculated (VIS48max and IS48max). The primary outcome was length of intubation. Additional outcomes included length of intensive care (ICU) stay and hospitalization, cardiac arrest, mortality, time to negative fluid balance, peak lactate, and change in creatinine.

Results

Based on receiver-operating characteristic (ROC) analysis, the area under the curve (AUC) was highest for VIS48 to identify prolonged intubation time. AUC for the primary outcome was higher for VIS than IS at all time points assessed. On multivariate analysis VIS48 was independently associated with prolonged intubation (OR 22.3, p?=?0.002), prolonged ICU stay (OR 8.1, p?=?0.017), and prolonged hospitalization (OR 11.3, p?=?0.011). VIS48max, IS48max, and IS48 were also associated with prolonged intubation, but not prolonged ICU or hospital stay. None of the scores were associated with time to negative fluid balance, peak lactate, or change in creatinine.

Conclusion

In neonates and infants, a higher VIS at 48?h after cardiothoracic surgery is strongly associated with increased length of ventilation, and prolonged ICU and total hospital stay. At all time points assessed, VIS is more predictive of poor short-term outcome than IS. VIS may be useful as an independent predictor of outcomes.     

Implementation of a combo videolaryngoscope for intubation in critically ill patients: a before–after comparative study

Purpose

Airway management in intensive care unit (ICU) patients is challenging. The main objective of this study was to compare the incidence of difficult laryngoscopy and/or difficult intubation between a combo videolaryngoscope and the standard Macintosh laryngoscope in critically ill patients.

Methods

In the context of the implementation of a quality-improvement process for airway management, we performed a prospective interventional monocenter before–after study which evaluated a new combo videolaryngoscope. The primary outcome was the incidence of difficult laryngoscopy (defined by Cormack grade 3–4) and/or difficult intubation (more than two attempts). The secondary outcomes were the severe life-threatening complications related to intubation in ICU and the rate of difficult intubation in cases of predicted difficult intubation evaluated by a specific score (MACOCHA score ≥3).

Results

Two hundred and ten non-selected consecutive intubation procedures were included, 140 in the standard laryngoscope group and 70 in the combo videolaryngoscope group. The incidence of difficult laryngoscopy and/or difficult intubation was 16 % in the laryngoscope group vs. 4 % in the combo videolaryngoscope group (p = 0.01). The severe life-threatening complications related to intubation did not differ between groups (16 vs. 14 %, p = 0.79). Among the 32 patients with a MACOCHA score ≥3, there were significantly more patients with difficult intubation in the standard laryngoscope group in comparison to the combo videolaryngoscope group [12/23 (57 %) vs. 0/9 (0 %), p < 0.01].

Conclusions

The systematic use of a combo videolaryngoscope in ICU was associated with a decreased incidence of difficult laryngoscopy and/or difficult intubation.     

Assessment of the Addition of Prehospital Continuous Positive Airway Pressure (CPAP) to an Urban Emergency Medical Services (EMS) System in Persons with Severe Respiratory Distress

Background

The use of continuous positive airway pressure (CPAP)-assisted ventilation in the prehospital setting has not been well studied.

Objectives

The purpose of this study was to measure the efficacy of adding prehospital CPAP to an urban emergency medical services (EMS) respiratory distress protocol for persons with respiratory distress.

Methods

An historical cohort analysis of consecutive EMS patients presenting during the years 2005–2010. Groups were matched for severity of respiratory distress. Physiologic variables were the primary outcomes obtained from first responders and upon triage in the Emergency Department. Additional outcomes included endotracheal intubation rate, hospital mortality, overall hospital length of stay (LOS), intensive care unit (ICU) admission, and ICU LOS.

Results

There were a total of 410 consecutive patients with predetermined criteria for severe respiratory distress, 235 historical controls matched with 175 post-implementation patients, entered in the study. The average age was 67 years; 54% were men. There were significant median differences in heart and respiratory rates favoring the historical cohort (all p < 0.05). There were no significant differences in intubation rate, overall hospital LOS, ICU admission rate, ICU LOS, or hospital mortality (all p > 0.05). Patients who were continued on non-invasive ventilatory assistance had a significantly improved rate of intubation and ICU LOS (all p < 0.05).

Conclusion

The addition of CPAP to an EMS prehospital respiratory distress protocol resulted in improved heart and respiratory rates. Though not statistically significant, decrease in overall and ICU LOS were observed. Patients with continued ventilatory assistance seemed to have improved rates of intubation and ICU LOS.     

Small increases in serum creatinine are associated with prolonged ICU stay and increased hospital mortality in critically ill patients with cancer

Purpose

Declining kidney function has been associated with adverse hospital outcome in cancer patients. ICU literature suggests that small changes in serum creatinine are associated with poor outcome. We hypothesized that reductions in renal function previously considered trivial would predict a poor outcome in critically ill patients with malignant disease. We evaluated the effects on hospital mortality and ICU length of stay of small changes in creatinine following admission to the intensive care unit.

Methods

We conducted a retrospective cohort study utilizing clinical, laboratory and pharmacy data collected from 3,795 patients admitted to the University of Texas M.D. Anderson Cancer Center's Intensive Care Unit. We conducted univariate and multivariate regression analysis to determine those factors associated with adverse ICU and hospital outcome.

Results

Increases in creatinine as small as 10% (0.2?mg/dl) were associated with prolonged ICU stay (5?days vs 6.6?days, p?<?0.001) and increased mortality (14.6% vs 25.5%, p?<?0.0001). Patients with a 25% rise in creatinine during the first 72?h of ICU admission were twice as likely to die in the hospital (14.3% vs 30.1%, p?<?0.001). RIFLE criteria were accurate predictors of outcome, though they missed much of the risk of even smaller increases in creatinine.

Conclusions

Even small rises in serum creatinine following admission to the ICU are associated with increased morbidity and mortality in oncologic patients. The poor outcome in those with rising creatinine could not be explained by severity of illness or other risk factors. These small changes in creatinine may not be trivial, and should be regarded as evidence of a decline in an individual patient's condition.     

Statistics review 14: Logistic regression

Introduction

Tracheostomy is frequently performed in critically ill patients for prolonged intubation. However, the optimal timing of tracheostomy, and its impact on weaning from mechanical ventilation and outcomes in critically ill patients who require mechanical ventilation remain controversial.

Methods

The medical records of patients who underwent tracheostomy in the medical intensive care unit (ICU) of a tertiary medical centre from July 1998 to June 2001 were reviewed. Clinical characteristics, length of stay in the ICU, rates of post-tracheostomy pneumonia, weaning from mechanical ventilation and mortality rates were analyzed.

Results

A total of 163 patients (93 men and 70 women) were included; their mean age was 70 years. Patients were classified into two groups: successful weaning (n = 78) and failure to wean (n = 85). Shorter intubation periods (P = 0.02), length of ICU stay (P = 0.001) and post-tracheostomy ICU stay (P = 0.005) were noted in patients in the successful weaning group. Patients who underwent tracheostomy more than 3 weeks after intubation had higher ICU mortality rates and rates of weaning failure. The length of intubation correlated with the length of ICU stay in the successful weaning group (r = 0.70; P < 0.001). Multivariate analysis revealed that tracheostomy after 3 weeks of intubation, poor oxygenation before tracheostomy (arterial oxygen tension/fractional inspired oxygen ratio <250) and occurrence of nosocomial pneumonia after tracheostomy were independent predictors of weaning failure.

Conclusion

The study suggests that tracheostomy after 21 days of intubation is associated with a higher rate of failure to wean from mechanical ventilation, longer ICU stay and higher ICU mortality.     

Clinical impact and risk factors for colonization with extended-spectrum β-lactamase-producing bacteria in the intensive care unit

Purpose

The changed epidemiology of extended spectrum beta-lactamases (ESBL), the spread to the community and the need for prudent use of carbapenems require updated knowledge of risk factors for colonization with ESBL-producing enterobacteriaceae (ESBL-PE).

Methods

An 8-month prospective study in the medical ICU of an 850-bed general and university-affiliated hospital.

Results

Of 610 patients admitted, 531 (87?%) had a rectal swab obtained at admission, showing a 15?% (82 patients) ESBL-PE carriage rate, mostly of E. coli (n?=?51, 62?%); ESBL-PE caused 9 (3?%) infections on admission. By multivariable analysis, transfer from another ICU (OR?=?2.56 [1, 22]), hospital admission in another country [OR?=?5.28 (1.56–17.8)], surgery within the past year [OR?=?2.28 (1.34–3.86)], prior neurologic disease [OR?=?2.09 (1.1–4.0)], and prior administration of third generation cephalosporin (within 3–12?months before ICU admission) [OR?=?3.05 (1.21–7.68)] were independent predictive factors of colonization by ESBL-PE upon ICU admission. Twenty-eight patients (13?% of those staying for more than 5?days) acquired ESBL carriage in ICU, mostly with E. cloacae (n?=?13, 46?%) and K. pneumoniae (n?=?10, 36?%). In carriers, ESBL-PE caused 10 and 27?% of first and second episodes of ICU-acquired infections, respectively.

Conclusion

We found a high prevalence of ESBLE-PE colonization on admission to our ICU, even in the subgroup admitted from the community, but few first infections. Identifying risk factors for ESBL-PE colonization may help identifying which patients may warrant empiric ESBL-targeted antimicrobial drug therapy as a means to limit carbapenem use.     

Mild therapeutic hypothermia shortens intensive care unit stay of survivors after out-of-hospital cardiac arrest compared to historical controls

Introduction

Persistent coma is a common finding after cardiac arrest and has profound ethical and economic implications. Evidence suggests that therapeutic hypothermia improves neurological outcome in these patients. In this analysis, we investigate whether therapeutic hypothermia influences the length of intensive care unit (ICU) stay and ventilator time in patients surviving out-of-hospital cardiac arrest.

Methods

A prospective observational study with historical controls was conducted at our medical ICU. Fifty-two consecutive patients (median age 62.6 years, 43 males, 34 ventricular fibrillation) submitted to therapeutic hypothermia after out-of-hospital cardiac arrest were included. They were compared with a historical cohort (n = 74, median age 63.8 years, 53 males, 43 ventricular fibrillation) treated in the era prior to hypothermia treatment. All patients received the same standard of care. Neurological outcome was assessed using the Pittsburgh cerebral performance category (CPC) score. Univariate analyses and multiple regression models were used.

Results

In survivors, therapeutic hypothermia and baseline disease severity (Acute Physiology and Chronic Health Evaluation II [APACHE II] score) were both found to significantly influence ICU stay and ventilator time (all P < 0.01). ICU stay was shorter in survivors receiving therapeutic hypothermia (median 14 days [interquartile range (IQR) 8 to 26] versus 21 days [IQR 15 to 30] in the control group; P = 0.017). ICU length of stay and time on ventilator were prolonged in patients with CPC 3 or 4 compared with patients with CPC 1 or 2 (P = 0.003 and P = 0.034, respectively). Kaplan-Meier analysis showed improved probability for 1-year survival in the hypothermia group compared with the controls (log-rank test P = 0.013).

Conclusion

Therapeutic hypothermia was found to significantly shorten ICU stay and time of mechanical ventilation in survivors after out-of-hospital cardiac arrest. Moreover, profound improvements in both neurological outcome and 1-year survival were observed.     

Safety of performing fiberoptic bronchoscopy in critically ill hypoxemic patients with acute respiratory failure

Background

The safety of fiberoptic bronchoscopy (FOB) in nonintubated critically ill patients with acute respiratory failure has not been extensively evaluated. We aimed to measure the incidence of intubation and the need to increase ventilatory support following FOB and to identify predictive factors for this event.

Methods

A prospective multicenter observational study was carried out in eight French adult intensive care units. The study included 169 FOB performed in patients with a PaO₂/FiO₂ ratio ??300. The main end-point was intubation rate. The secondary end-point was rate of increased ventilatory support defined as an increase in oxygen requirement >50?%, the need to start noninvasive positive pressure ventilation (NI-PPV) or increase NI-PPV support.

Results

Within 24?h, an increase in ventilatory support was required following 59 bronchoscopies (35?%), of which 25 (15?%) led to endotracheal intubation. The existence of chronic obstructive pulmonary disease (COPD; OR 5.2, 95?% CI 1.6?C17.8; p?=?0.007) or immunosuppression (OR 5.4, 95?% CI 1.7?C17.2; p?=?0.004] were significantly associated with the need for intubation in the multivariable analysis. None of the baseline physiological parameters including the PaO₂/FiO₂ ratio was associated with intubation.

Conclusions

Bronchoscopy is often followed by an increase in ventilatory support in hypoxemic critically ill patients, but less frequently by the need for intubation. COPD and immunosuppression are associated with the need for invasive ventilation in the 24?h following bronchoscopy.     

Measuring the nursing workload per shift in the ICU

Purpose

In the intensive care unit (ICU) different strategies and workload measurement tools exist to indicate the number of nurses needed. The gathered information is always focused on manpower needed per 24?h. However, a day consists of several shifts, which may be unequal in nursing workload. The aim of this study was to evaluate if differences in nursing workload between consecutive shifts can be identified by a nursing workload measurement tool.

Methods

The nursing activities score (NAS) was registered per patient for every shift during a 4-week period in a prospective, observational research project in the surgical-pediatric ICU (SICU-PICU) and medical ICU (MICU) of an academic hospital.

Results

The NAS was influenced by the patient characteristics and the type of shift. Furthermore, the scores were lower during night shifts, in weekends and in MICU patients. Overall, the mean NAS per nurse per shift was 85.5?%, and the NAS per 24?h was 54.7?%.

Conclusion

This study has shown that the nursing workload can be measured per working shift. In the ICU, the NAS differentiates the nursing workload between shifts, patients and units.     

Prehospital use of continuous positive airway pressure for acute severe congestive heart failure

Background

The utility of continuous positive airway pressure (CPAP) in the in-hospital treatment of congestive heart failure (CHF) is well established. Its exact role is less clear in the prehospital arena.

Objective

To describe the prehospital use of CPAP for patients presenting with acute severe heart failure in a large Emergency Medical Services system in New Jersey.

Methods

Retrospective review of prehospital charts from January 1, 2005 to December 31, 2006 of patients treated for acute CHF. Inclusion criteria for eligibility for CPAP mask use were: respiratory rate > 25 breaths/min, labored and shallow breathing, bilateral rales, history of CHF, intact mental status, and prehospital clinical diagnosis of CHF. Data collected included demographics, vital signs, oxygen saturation (SaO₂), need for endotracheal intubation (ETI), and complications.

Results

There were 1306 charts reviewed; 387 patients met inclusion criteria. Of the 387, 149 patients had placement of CPAP (38.5%). The prehospital treatment times were (CPAP = 30 min; non-CPAP = 31 min; p < 0.01). The increase in SaO₂ for the CPAP group (9%) vs. the non-CPAP group (5%) was statistically significant (p < 0.01). Systolic blood pressure (BP) reduction (CPAP [27.1 mm Hg], non-CPAP [19.9 mm Hg], p < 0.01), diastolic BP reduction (CPAP [14.1 mm Hg], non-CPAP [7.4 mm Hg], p < 0.01), heart rate reduction (CPAP [17.2 beats/min], non-CPAP [9.6 beats/min], p < 0.01), respiratory rate reduction (CPAP [5.63], non-CPAP [4.09], p < 0.01), and ETI reduction (CPAP [2.6%], non-CPAP [5.46%], p < 0.01), all were statistically significant. Adjunctive CHF treatments were similar between the groups.

Conclusion

The use of CPAP for eligible patients with acute severe CHF seems to be feasible and beneficial. Large-scale randomized prospective prehospital studies are needed to validate these results.     

Acute kidney injury in critically ill patients with 2009 influenza A (H1N1) viral pneumonia: an observational study

Objective

To describe the incidence, risk factors, and impact on mortality of acute kidney injury (AKI) in patients with 2009 influenza?A (H1N1) viral pneumonia requiring mechanical ventilation.

Design

Observational cohort study.

Patients and methods

AKI was defined as risk, injury or failure, according to the RIFLE classification. Early and late AKI were defined as AKI occurring on intensive care unit (ICU) day?2 or before, or after ICU day?2, respectively. Demographic data and information on organ dysfunction were collected daily.

Results

Of 84 patients, AKI developed in 43 patients (51%). Twenty (24%) needed renal replacement therapy. Early and late AKI were found in 28 (33%) and 15 (18%) patients, respectively. Patients with AKI, as compared with patients without AKI, had higher Acute Physiology and Chronic Health Evaluation (APACHE)?II score and ICU mortality (72% versus 39%, p?<?0.01) and presented on admission more marked cardiovascular, respiratory, and hematological dysfunction. Patients with early but not late AKI presented on admission higher APACHE?II score and more marked organ dysfunction, as compared with patients without AKI. ICU mortality was higher in late versus early AKI (93% versus 61%, p?<?0.001). On multivariate analysis, only APACHE?II score and late but not early AKI [odds ratio (OR) 1.1 (95% confidence interval 1.0?C1.1) and 15.1 (1.8?C130.7), respectively] were associated with mortality.

Conclusions

AKI is a frequent complication of 2009 influenza?A (H1N1) viral pneumonia. AKI developing after 2?days in ICU appears to be associated with different risk factors than early AKI, and is related to a higher mortality rate.     

Alternative lipid emulsions in the critically ill: a systematic review of the evidence

Purpose

Parenteral lipid emulsions (LEs) are commonly rich in long-chain triglycerides derived from soybean oil (SO). SO-containing emulsions may promote systemic inflammation and therefore may adversely affect clinical outcomes. We hypothesized that alternative oil-based LEs (SO-sparing strategies) may improve clinical outcomes in critically ill adult patients compared to products containing SO emulsion only. The purpose of this systematic review was to evaluate the effect of parenteral SO-sparing strategies on clinical outcomes in intensive care unit (ICU) patients.

Methods

We searched computerized databases from 1980 to 2013. We included randomized controlled trials (RCTs) conducted in critically ill adult patients that evaluated SO-sparing strategies versus SO-based LEs in the context of parenteral nutrition.

Results

A total of 12 RCTs met the inclusion criteria. When the results of these RCTs were statistically aggregated, SO-sparing strategies were associated with clinically important reductions in mortality (risk ratio, RR 0.83; 95 % confidence intervals, CI 0.62, 1.11; P = 0.20), in duration of ventilation (weighted mean difference, WMD ?2.57; 95 % CI ?5.51, 0.37; P = 0.09), and in ICU length of stay (LOS) (WMD ?2.31; 95 % CI ?5.28, 0.66; P = 0.13) but none of these differences were statistically significant. SO-sparing strategies had no effect on infectious complications (RR 1.13; 95 % CI 0.87, 1.46; P = 0.35).

Conclusion

Alternative oil-based LEs may be associated with clinically important reductions in mortality, duration of ventilation, and ICU LOS but lack of statistical precision precludes any clinical recommendations at this time. Further research is warranted to confirm these potential positive treatment effects.     

End-of-life decisions in an Indian intensive care unit

Background

There is a paucity of data on end-of-life decisions (EOLD) for patients in Indian intensive care units (ICUs).

Objective

To document the end-of-life and full-support (FS) decisions among patients dying in an ICU, to compare the respective patient characteristics and to describe the process of decision-making.

Design

Retrospective, observational.

Patients

Consecutive patients admitted to a 12-bed closed medical-surgical ICU.

Exclusions

Patients with EOLD discharged home or transferred to another hospital.

Measurements and results

Demographic profile, APACHE IV at 24 h, ICU outcome, type of limitation, disease category, pre-admission functional status, reasons for EOLD, interventions and therapies within 3 days of death, time to EOLD, time to death after EOLD and ICU length of stay. Out of 88 deaths among 830 admissions, 49% were preceded by EOLD. Of these 58% had withholding of treatment, 35% had do-not-resuscitate orders (DNR) and 7% had a withdrawal decision. Mean age and APACHE IV scores were similar between EOLD and FS groups. Functional dependence before hospitalization favored EOLD. Patients receiving EOLD as opposed to FS had longer stays. Fifty-three percent of limitations were decided during the first week of ICU stay well before the time of death. Escalation of therapy within 3 days of death was less frequent in the EOLD group.

Conclusions

Despite societal and legal barriers, half the patients dying in the ICU received a decision to limit therapy mostly as withholding or DNR orders. These decisions evolved early in the course of stay and resulted in significant reduction of therapeutic burdens.