Resuscitation Practices Research Articles

Early outcomes following trauma related to sex: A matched analysis of military service members in the department of defense trauma registry.

Several studies have identified sex as a factor influencing early outcomes after trauma. With the increased representation of women in combat roles, there is a need for improved understanding of the pathophysiology of traumatic injury in women. The purpose of this study was to define sex-based differences in early combat trauma outcomes amongst military service members. A retrospective review of the Department of Defense Trauma Registry between 2008 and 2016 was performed. A 2:1 case control match was performed to match for Injury Severity Score, mechanism of injury, and age. The primary outcome of the study was mortality. A total of 4,625 patients were included in the study, 2.2% of whom were women. Women were less significantly injured than men (Injury Severity Score, 7.7 vs. 11, p = 0.003) and more likely to sustain blunt trauma (81% vs. 62.5%, p = 0.01). After case-control matching, 202 men and 101 women were evaluated. There was no statistical difference in the primary outcome of mortality. There was no statistical difference in Glasgow Coma Scale score, crystalloid or colloid administration, Packed Red Blood Cells (PRBC), platelet, cryoprecipitate, or plasma usage between men and women. Contrary to the civilian trauma literature, our study demonstrated no significant difference in early mortality between male and female combat casualties in a matched cohort. This finding may represent a difference in injury patterns, resuscitation practices, or lifesaving interventions in a deployed setting as compared with civilian setting. As the proportion of women involved in combat operations continues to increase, prospective studies should be performed to better define injury patterns, as well as early and late outcomes related to military trauma in the female population. Retrospective, Level IV.

Resuscitation - practical implementation of guidelines and standards in the hospital

Out of hospital cardiac arrest (OHCA) requiring cardio-pulmonary resuscitation (CPR) remains a mojor public health concern. OHCA affects nearly 275 000 people in Europe annualy with more than 70 000 of those in Germany alone. It represents of the major causes of death in Europe.In 40 % of patients CPR is successful and leads to a return of spontaneous circulation (ROSC). Due to the relevance of OHCA and CPR detailed guidelines with sound scientific foundation exist. However, even after successful CPR, mortality and morbidity remain high due to the severity of underlying diseases and sequelae of OHCA and CPR itself. Thus, optimization of the initial CPR treatment with reducing overall no-flow time (time from collaps with cardiac arrest to start of CPR) and optimization and streamlining of treatment algorithms and quality in hospitals receiving patients after cardiac arrest have been a strong focus to improve overall survival. Current guidelines suggest creation of Cardiac Arrest Centers as specialized hospitals who focus on high quality of post-resuscitation care with standardized processes and interdisciplinary treatment of patients after OHCA to establish fast, secure and effective treatment that is widely available in all regions.This article will address the relevant items to be considered in daily practice of resuscitation and post-resuscitation care for cardiac arrest.

Resuscitation Fluid Use in a Single Surgical Intensive Care Unit

Purpose The aim of this study was to analyze the temporal change of resuscitation fluid use based on all fluids administered in a surgical intensive care unit (ICU). Methods The administration of resuscitation fluid to all patients admitted to a surgical ICU of a tertiary referral hospital was investigated from 2008 to 2015. The types and volumes of fluid, and laboratory data taken within 7 days after ICU admission were evaluated. Resuscitation fluids were defined as fluids infused according to stat orders, rather than routine orders. Results There were a total of 8,885 admissions to the ICU for 7,886 patients. The volumetric proportion of crystalloid to total resuscitation fluids increased significantly over the study period (p < 0.001; 79.6% in 2008; 93.7% in 2015). Although the proportion of 0.9% saline to crystalloids decreased, that of balanced solutions increased (p < 0.001; 29.5% in 2008; 55.6% in 2015). The use of colloids decreased from 20.4% in 2008, to 6.3% in 2015 (p < 0.001). Proportions calculated using the number of individual fluids administered revealed trends similar to those calculated using volumetric data. The amount of infused 0.9% saline was weakly correlated with the lowest blood pH and the highest serum chloride levels (ρ = -0.26 and 0.19, respectively). Conclusion Changes in the trends of fluid resuscitation practice were noted in a single surgical ICU over the 8-year study period. Crystalloid use increased owing to a rise in the utilization of balanced solutions with a downward trend in colloid use. Keywords: colloids, crystalloid solutions, fluid therapy, intensive care units

2019 Year in Review: Neonatal Respiratory Support.

Respiratory support of the critically ill neonate has steadily shifted from invasive to noninvasive forms of support. There have recently been a number of important advances in our understanding of the changes to neonatal resuscitation practices as they pertain to clinically important outcomes, mechanisms of gas exchange for high-flow nasal cannula, and best use of noninvasive ventilation and predicting response. Although the proportion of infants requiring intubation and mechanical ventilation has decreased, the most severely ill often still require intubation and ventilation. Recently, volume-targeted ventilation, high-frequency ventilation, and different methods of assessing weaning and extubation have been investigated. This review summarizes a number of important advances that have been made in the management of prematurity and neonatal respiratory distress syndrome.

705 Evaluation of Burn Resuscitation Practices at a Large Burn Center

Abstract Introduction Large burns cause a systemic inflammatory response in the entire body leading to profound capillary leak, tissue edema and hemodynamic instability, a condition known as burn shock. If not managed appropriately, the patient can go into cardiac collapse and multi-organ failure. Adequate and timely burn resuscitation is a cornerstone in burn care. Different formulas have been studied to estimate fluid needs during the first 24hrs. The purpose of this study was to retrospectively evaluate burn resuscitation practices of large burns (20% TBSA and greater) and their associated outcomes at a large urban burn center. Methods This was a retrospective chart review of adult patients admitted to the burn center with burns of 20% TBSA or greater who survived the first 48hrs of admission. Primary outcome was evaluating the percentage of patients who received resuscitation according to predetermined volume ranges (&amp;lt; or equal to 4ml/kg/% TBSA vs &amp;gt;4ml/kg/%TBSA). Secondary outcomes included the use of adjuncts (colloids and ascorbic acid), markers of over- and under-resuscitation, the use of perfusion markers to guide resuscitation, and ICU and hospital length of stay. Results One hundred and fifty one adults with burns of 30–50% TBSA were included. Fifty nine per cent of them received a median of 2.9ml/kg/%TBSA (low volume- LV group) compared to 41% that received 5.1ml/kg/%TBSA (high volume-HV group). The HV group received more adjuncts in form of colloids (73% vs 61%) and ascorbic acid infusion (55% vs 37% of patients). Majority of patients in both groups had an adequate urine output and showed an improved base deficit at 24hrs from admission which were used as resuscitation markers; lactate levels were trended infrequently. The most common over-resuscitation complication was pulmonary edema, found in both groups in ~ 30% of patients. Only 6% of patients in both groups required renal replacement therapy initiation at 96hrs from admission. Patients in the LV group had a shorter ICU and hospital length of stay (16 vs 36 days, and 27 vs 39 days, respectively, p value &amp;lt; 0.05). Conclusions Patients who received median resuscitation volumes of ~ 3ml/kg/%TBSA had better outcomes compared to patients who received higher volumes. Protocolized monitoring of resuscitation markers is key to tailoring resuscitation efforts to patient’s individual response. The effect of the different adjunct therapies (colloids, ascorbic acid) should be further investigated. Applicability of Research to Practice Burn resuscitation is a cornerstone of specialized critical burn care. Additional data regarding the amount and type of resuscitation volume used and its associated outcomes can advance practice to guide successful resuscitation and decrease early set backs that may further complicate the patient’s clinical course.

Health System Factors Influencing Practice of Neonatal Resuscitation Among Nurses in Machakos Level 5 Hospital

Health System Factors Influencing Practice of Neonatal Resuscitation Among Nurses in Machakos Level 5 Hospital

The Australasian Resuscitation In Sepsis Evaluation: Fluids or vasopressors in emergency department sepsis (ARISE FLUIDS), a multi‐centre observational study describing current practice in Australia and New Zealand

ObjectivesTo describe haemodynamic resuscitation practices in ED patients with suspected sepsis and hypotension.MethodsThis was a prospective, multicentre, observational study conducted in 70 hospitals in Australia and New Zealand between September 2018 and January 2019. Consecutive adults presenting to the ED during a 30‐day period at each site, with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation, were eligible. Data included baseline demographics, clinical and laboratory variables and intravenous fluid volume administered, vasopressor administration at baseline and 6‐ and 24‐h post‐enrolment, time to antimicrobial administration, intensive care admission, organ support and in‐hospital mortality.ResultsA total of 4477 patients were screened and 591 were included with a mean (standard deviation) age of 62 (19) years, Acute Physiology and Chronic Health Evaluation II score 15.2 (6.6) and a median (interquartile range) systolic blood pressure of 94 mmHg (87–100). Median time to first intravenous antimicrobials was 77 min (42–148). A vasopressor infusion was commenced within 24 h in 177 (30.2%) patients, with noradrenaline the most frequently used (n = 138, 78%). A median of 2000 mL (1500–3000) of intravenous fluids was administered prior to commencing vasopressors. The total volume of fluid administered from pre‐enrolment to 24 h was 4200 mL (3000–5661), with a range from 1000 to 12 200 mL. Two hundred and eighteen patients (37.1%) were admitted to an intensive care unit. Overall in‐hospital mortality was 6.2% (95% confidence interval 4.4–8.5%).ConclusionCurrent resuscitation practice in patients with sepsis and hypotension varies widely and occupies the spectrum between a restricted volume/earlier vasopressor and liberal fluid/later vasopressor strategy.

Role of action-oriented teaching combined with scene simulation teaching in the teaching of cardiopulmonary resuscitation

Objective To investigate the role and signification of action-oriented teaching combined with scene simulation teaching in the clinical teaching of cardiopulmonary resuscitation. Methods A total of 120 undergraduates received cardiopulmonary resuscitation clinical practice were divided into two groups: the experimental group (n=60) and the control group (n=60). Undergraduates in the experimental group were taught by action-oriented teaching combined with scene simulation teaching method, while in the control group were taught by traditional teaching method. After teaching, theoretical examination and cardiopulmonary resuscitation practice examination were used for assessing the teaching efficacy and the efficacy of the two teaching methods was compared. Simultaneously, evaluations including teaching satisfaction, theoretical knowledge comprehension and practical improvement were carried out among students. SPSS 22.0 was used to conduct t-test and R×C chi square test. Results The scores of the theoretical examination in the experimental group and the control group were (92.50±10.71) and (86.35±9.02), respectively; the scores of the cardiopulmonary resuscitation practice examination in the experimental group the control group were (85.90±9.72) and (80.15±11.76), respectively. The scores of theoretical examination and practice examination were both higher than those in the control group, with statistical significance (P<0.01, P=0.002). The constituent ratios of the evaluations showed there was a statistical difference between the experimental group and the control group (P=0.035, P=0.025, P=0.019). The ratios of high satisfaction, theoretical knowledge comprehension and practical ability improvement in the experiment group were higher than those in the control group, with statistical significance (P=0.005, P=0.003, P=0.001). Conclusion Action-oriented teaching method combined with scene simulation teaching plays a positive role in the teaching of cardiopulmonary resuscitation, and should be further studied and applied in clinical teaching practice. Key words: Action-oriented teaching method; Scene simulation teaching method; Cardiopulmonary resuscitation

Blowing Smoke Up Your Arse: Drowning, Resuscitation, and Public Health in Eighteenth-Century Venice.

This article examines resuscitation practices in the second half of the eighteenth century, especially the new use of tobacco smoke enema machines on people who had been extracted from water with no signs of life. Drownings accounted for a small number and proportion of urban deaths, yet governments promoted resuscitation techniques at considerable expense in order to prevent such deaths. The visibility of drowning in religious, urban, and civic life encouraged engagement with new approaches. Analyzing the deployment of resuscitation practices illuminates three key features of premodern public health interventions: the focus of governments on the logistics of these interventions, the participation of physicians and surgeons at all levels of the professional hierarchy, and the importance of communication.

Evaluating the effectiveness of cardiac arrest resuscitation short course (CARS) for rural physicians of Asia: The Rural Emergency Care Training for Physicians (RECTIFY) project.

Background:Physicians from resource-constrained rural areas being lone lifesavers pose a unique challenge in resuscitating emergencies like cardiac arrest. Rural Emergency Care Training for Physicians (RECTIFY) was devised as a short course training to equip them to deal with occasional emergencies using minimal gadgets. This study was conceived to assess the effectiveness of the RECTIFY-Cardiac Arrest Resuscitation Short course (CARS) module in improving current knowledge and practice of cardiopulmonary resuscitation (CPR) among interested rural physicians of Asia.Methods:A three-tier observational study was conducted to assess current CPR knowledge with a pretested structured questionnaire and skills using a checklist, followed by a 3-h hands-on training and posttest evaluation using the same study instruments. Data were entered into Microsoft Excel and analyzed using SPSS 13.0.Results:Out of 622 participants, most of the participants (603; 96.9%) were willing to provide CPR despite poor knowledge and skills. Pretest scores averaged 1.5 ± 0.99 and 0.1 ± 0.3 for CPR knowledge and skills, respectively. Posttest scores for CPR knowledge (10.5 ± 1.5) and skills (2.8 ± 1.6) improved significantly (both P = 0.001). Whereas a majority improved upon chest compression skills, appropriate use of sophisticated gadgets like automated external defibrillators (AED) was low (2.4%) despite training.Conclusion:The level of knowledge and skill among participants was poor despite the enthusiasm and positive intent. The impact of RECTIFY-CARS on knowledge and skills among participant physicians was significant and is recommended for implementation by health policymakers in resource-poor rural settings. However, essential gadgets like AED were not impactful which necessitates the use of simpler rural alternatives.

Study on knowledge, attitude and practice of cardiac resuscitation among nursing professionals at dessie referal Hospital, North East Ethiopia

Study on knowledge, attitude and practice of cardiac resuscitation among nursing professionals at dessie referal Hospital, North East Ethiopia

Is There an Improvement in Patient Survival/Code Blue Activation after Training Based on Simulation (Basic Life Support—BLS) Based Practice of Cardiopulmonary Resuscitation?

Background and Aim: The only way to survive a sudden cardiac arrest is when the CPR is performed immediately after the arrest. The focus of the present research study is to assess the effectiveness of a pre- and post-simulation-based BLS training (BLS) and the outcome was measured on the basis of patient survival after the cardiac arrest. Study Design: This pre- and post-training BLS/CPR training study enrolled all nursing staff, all hospital residents, internees, throughout the hospital in a simulation-based BLS training as per the standards of American Heart Association (AHA), to make them respond to immediate resuscitation and code blue activation during the cardiac arrest within the hospital premises including ED, wards, ICUs, MRI, CT and all miscellaneous areas. The providers completed self-efficacy questionnaires as per the AHA protocol before being certified and were evaluated during the emergency in hospital cardiopulmonary arrest. Results: 296 nursing staff, 206 non-healthcare professionals, 143 residents, 212 internees, and 98 medical staff grade doctors completed the BLS training (total 955 hospital staff—providers) were graded for the response by pre- and post-training testing. In the course of pre-BLS training period out of the 250 cardiac arrest patients, 68 patients (27.2%) had ROSC, while after instituting the BLS training period, 143 individuals (40.86%) of the 350 patients who had cardiac arrest had ROSC (p 0.05). Conclusion: A simulation-based CPR and BLS training curriculum greatly improves patient outcome by reducing mortality and morbidity with improved subjectivity, self-efficiency along with the objective assessment of the performance scores during acute cardiac arrest in Emergency Cardiovascular Care (ECC).

Emergency nurses’ experience of adult basic and advanced life support workstations as a support strategy for clinical practice in the emergency department

BackgroundStandards endorsed by the Australian Resuscitation Council in 2014 recommend that healthcare providers trained in cardiopulmonary resuscitation should have their skills refreshed at least annually and for those who infrequently perform resuscitation, more frequent refresher training is advised. Emergency nurses were given the opportunity to attend workstations to refresh their knowledge and skills essential to resuscitation practice. The aim of this manuscript was to report the perception of the nurses’ experience following attendance at the workstations. MethodsLesson plans were developed for six workstations. Consented participants were invited to complete an on-line evaluation survey of their experience following programme participation and at 6-months following programme attendance. Thematic analysis and descriptive statistics were used to report outcomes ResultsA total of 143 nurses working in the Emergency Department consented to participate. Following attendance at the workstations, most reported increased knowledge and skills (93.7 %), increased confidence (91.9 %) and that they practiced skills (91.9 %) during workstation participation. At 6-months follow-up the majority of nurses (97.1 %) found the programme to be beneficial and 82 (80.4 %) reported using the knowledge and skills gained from the programme in their clinical practice. ConclusionsEmergency nurses felt more confident in delivering patient care following attendance at the resuscitation workstations. Ongoing education was highly regarded by emergency nurses.

Vitamin C in surgical sepsis.

The current review discusses the supplemental use of vitamin C as an adjunct in the management of sepsis and septic shock. The antioxidant properties of vitamin C are touted to be useful in modulating the inflammatory response, decreasing vasopressor requirements, and improving resuscitation. Current resuscitation practices are focused on addressing the hemodynamic instability and ensuring adequate oxygen delivery to tissues. The conceptual framework of the use of vitamin C during a resuscitation is to modulate in a beneficial fashion the inflammatory response to sepsis while concomitantly resuscitating and treating the infection. While there is promising animal and burn-related data on improved fluid resuscitation with the use of vitamin C as an adjunct, the most recent meta-analyses of the available data fail to show a survival benefit in sepsis, and concerns regarding nephrotoxicity remain. Although there are large number of animal studies, only a few small prospective and retrospective studies in humans address the use of vitamin C to treat sepsis. Further research in a controlled and randomized fashion is needed to determine if vitamin C is effective in this role. While there is a promise of ascorbate's addition to the sepsis bundle as an adjunct to resuscitation, the evidence is not conclusive.

Data-driven Development of ROTEM and TEG Algorithms for the Management of Trauma Hemorrhage: A Prospective Observational Multicenter Study.

Developing pragmatic data-driven algorithms for management of trauma induced coagulopathy (TIC) during trauma hemorrhage for viscoelastic hemostatic assays (VHAs). Admission data from conventional coagulation tests (CCT), rotational thrombelastometry (ROTEM) and thrombelastography (TEG) were collected prospectively at 6 European trauma centers during 2008 to 2013. To identify significant VHA parameters capable of detecting TIC (defined as INR > 1.2), hypofibrinogenemia (< 2.0 g/L), and thrombocytopenia (< 100 x10/L), univariate regression models were constructed. Area under the curve (AUC) was calculated, and threshold values for TEG and ROTEM parameters with 70% sensitivity were included in the algorithms. A total of, 2287 adult trauma patients (ROTEM: 2019 and TEG: 968) were enrolled. FIBTEM clot amplitude at 5 minutes (CA5) had the largest AUC and 10 mm detected hypofibrinogenemia with 70% sensitivity. The corresponding value for functional fibrinogen (FF) TEG maximum amplitude (MA) was 19 mm. Thrombocytopenia was similarly detected using the calculated threshold EXTEM-FIBTEM CA5 30 mm. The corresponding rTEG-FF TEG MA was 46 mm. TIC was identified by EXTEM CA5 41 mm, rTEG MA 64 mm (80% sensitivity). For hyperfibrinolysis, we examined the relationship between viscoelastic lysis parameters and clinical outcomes, with resulting threshold values of 85% for EXTEM Li30 and 10% for rTEG Ly30.Based on these analyses, we constructed algorithms for ROTEM, TEG, and CCTs to be used in addition to ratio driven transfusion and tranexamic acid. We describe a systematic approach to define threshold parameters for ROTEM and TEG. These parameters were incorporated into algorithms to support data-driven adjustments of resuscitation with therapeutics, to optimize damage control resuscitation practice in trauma.

Abstract 245: Role of the Resuscitation Champion on Survival Outcomes for In-Hospital Cardiac Arrest

Background: Hospitals vary markedly in survival rates for their patients with in-hospital cardiac arrest (IHCA). Although many sites have resuscitation champions, whether a resuscitation champion’s clinical background and intensity of engagement distinguishes sites with higher cardiac arrest survival rates remains unknown. Methods: We conducted a nationwide survey of adult hospitals participating in GWTG-Resuscitation to elicit detailed information on resuscitation practices, including of their resuscitation champion. Risk-standardized survival rates for IHCA for 2016-2017 were calculated for each hospital, and these were then used to categorize hospitals into quintiles of performance. The association between a resuscitation champion’s clinical background and intensity of engagement (categorized as very active non-physician champion, very active physician champion, and all others) and quintiles of survival was evaluated using multivariable hierarchical proportional odds logistic regression models. Results: Overall, 200 of 218 eligible adult hospitals (91.7%) completed the study survey and 190 facilities with &gt; 10 cases comprised the final study cohort. Risk-standardized survival rates after IHCA varied substantially (median: 24.7%; range: 9.2% to 37.5%). One-third (63/190 [33.2%]) of hospitals had a very active non-physician champion, 29 (15.3%) had a very active physician champion, and the remaining 98 (51.2%) had a resuscitation champion not perceived to be very active or had no champion. Compared to sites with very active non-physician champions, those with a very active physician champion had 5-fold higher odds (adjusted OR, 5.15 [95% CI: 2.13-12.5]) of being in a higher survival quintile category, whereas there was no difference in survival outcomes between sites with less active or no resuscitation champions and very active non-physician champions (adjusted OR, 0.94 [95% CI: 0.52-1.77]) . Conclusions: Although most hospitals have resuscitation champions, the background and engagement level of a resuscitation champion is a critical factor in a hospital’s survival outcomes for IHCA. Hospitals with the highest survival rates for IHCA are more likely to have very active physician resuscitation champions.

Abstract 370: Delivery of CPR in Patients With Single and Biventricular Cardiac Disease

Introduction: Diminished survival after cardiopulmonary resuscitation (CPR) has been shown in patients with congenital heart disease (CHD) and single ventricle (SV) anatomy compared to biventricular anatomy (BV). The role guideline-compliant CPR plays in SV outcomes is unknown. Hypothesis: During pediatric in-hospital cardiac arrest (IHCA), there will be a difference in CPR delivery and outcomes of patients with SV compared to BV anatomy. Methods: Prospective observational cohort from 12 pediRES-Q sites of IHCA in children ≤ 18 years with CPR quality metric data (chest compression (CC) rate, depth, and fraction (CCF)) (Zoll R-Series, Chelmsford, MA). We compared 60-sec CC epoch compliance with 2015 American Heart Association guideline targets defined as: CC rate 100-120/min; depth ≥4.0 cm in &lt;1 yo, ≥5 to ≤6 cm in 1-&lt;18 yo; and CCF ≥0.80. Total guideline compliance was defined as a CC event with ≥ 60% epochs meeting all targets. Metric summaries were reported as median [IQR] and compliance as frequency (%). Differences were assessed using Wilcoxon rank-sum and Fishers exact tests, respectively. Logistic regression assessed for associations with outcomes, including anatomy and proportion of guideline-compliant CPR. Results: From 10/2015 to 3/2019, we analyzed 82 events (&gt; 5 epochs) in patients with CHD. Thirty-seven percent had SV anatomy and more SV patients were post-operative (70% vs 2%). There were no differences in time to first epinephrine dose (1 vs 2 min), shockable rhythm (7% vs 6%), or need for ECMO (27% vs 23%). Total guideline compliance across all ages was not different (SV 10.0% vs BV 5.8%, P=0.67) and not associated with ROSC or survival to hospital discharge (SHD). There was a 75% lower adjusted odds of SHD in 1-&lt;8 yo vs &lt;1 yo. Conclusion: There were no meaningful differences in resuscitative practice or delivery of guideline-compliant CPR in those with SV versus BV anatomy. Guideline-compliant CPR was not associated with outcomes regardless of cardiac anatomy.

System for syndrome monitoring of critical conditions based on cognitive graphics

The authors propose to consider one of the debatable topics of general pathology — the conventionality of the concept of ‘syndrome’ from the pragmatic positions of a resuscitator. At the same time, an important point is emphasized: the meaning of the concepts of ‘syndrome’ in resuscitation and general therapeutic practice is fundamentally different, the contradictions in this matter are due to the fact that when analyzing a critical condition, various authors operate with different levels of integration of body parameters that determine the degree of pathological disorders. Nevertheless, the use of one of the integral parameters — the syndrome — provides a real opportunity to move from cumbersome parametric monitoring to more visual syndrome monitoring based on computer cognitive graphics.

Multiple organ dysfunction after trauma.

BackgroundThe nature of multiple organ dysfunction syndrome (MODS) after traumatic injury is evolving as resuscitation practices advance and more patients survive their injuries to reach critical care. The aim of this study was to characterize contemporary MODS subtypes in trauma critical care at a population level.MethodsAdult patients admitted to major trauma centre critical care units were enrolled in this 4‐week point‐prevalence study. MODS was defined by a daily total Sequential Organ Failure Assessment (SOFA) score of more than 5. Hierarchical clustering of SOFA scores over time was used to identify MODS subtypes.ResultsSome 440 patients were enrolled, of whom 245 (55·7 per cent) developed MODS. MODS carried a high mortality rate (22·0 per cent versus 0·5 per cent in those without MODS; P < 0·001) and 24·0 per cent of deaths occurred within the first 48 h after injury. Three patterns of MODS were identified, all present on admission. Cluster 1 MODS resolved early with a median time to recovery of 4 days and a mortality rate of 14·4 per cent. Cluster 2 had a delayed recovery (median 13 days) and a mortality rate of 35 per cent. Cluster 3 had a prolonged recovery (median 25 days) and high associated mortality rate of 46 per cent. Multivariable analysis revealed distinct clinical associations for each form of MODS; 24‐hour crystalloid administration was associated strongly with cluster 1 (P = 0·009), traumatic brain injury with cluster 2 (P = 0·002) and admission shock severity with cluster 3 (P = 0·003).ConclusionContemporary MODS has at least three distinct types based on patterns of severity and recovery. Further characterization of MODS subtypes and their underlying pathophysiology may lead to future opportunities for early stratification and targeted interventions.

Precision and consistency of the passive leg raising maneuver for determining fluid responsiveness with bioreactance non-invasive cardiac output monitoring in critically ill patients and healthy volunteers.

ObjectiveThe passive leg raising (PLR) maneuver has become standard practice in fluid resuscitation. We aim to investigate the precision and consistency of the PLR for determining fluid responsiveness in critically ill patients and healthy volunteers using bioreactance non-invasive cardiac output monitoring (NiCOM™, Cheetah Medical, Inc., Newton Center, Massachusetts, USA).MethodsThis study is prospective, single-center, observational cohort with repeated measures in critically ill patients admitted to the medical intensive care unit and healthy volunteers at a tertiary academic medical center. Three cycles of PLR were performed, each at 20–30 minutes apart. Fluid responsiveness was defined as a change in stroke volume index (ΔSVI) > 10% with each PLR as determined by NiCOM™. Precision was the variability in ΔSVI after the 3 PLR’s, and determined by range, average deviation and standard deviation. Consistency was the same fluid responsiveness determination of “Yes” (ΔSVI > 10%) or “No” (ΔSVI ≤ 10%) for all 3 PLR’s.ResultsSeventy-five patients and 25 volunteers were enrolled. In patients, the precision was range of 17.2±13.3%, average deviation 6.5±4.0% and standard deviation 9.0±5.2%; and for volunteers, 17.4±10.3%, 6.6±3.8% and 9.0±6.7%, respectively. There was no statistical difference in the precision measurements between patients and volunteers. Forty-nine (65.3%) patients vs. twenty-four (96.0%) volunteers had consistent results, p < 0.01. Among those with consistent results, twenty-four (49.0%) patients and 24 (100%) volunteers were fluid responsive.ConclusionsThe precision and consistency of determining ΔSVI with NiCOM™ after PLR may have clinical implication if ΔSVI > 10% is the absolute cutoff to determine fluid responsiveness.