Single Intensive Care Unit Research Articles

Predictors and outcomes of sepsis-induced cardiomyopathy in critically ill patients.

BackgroundSepsis-induced cardiomyopathy (SIC) occurs frequently in critically ill patients, but the clinical features and prognostic impact of SIC on sepsis outcome remain controversial. Here, we investigated the predictors and outcomes of SIC.MethodsPatients admitted to a single medical intensive care unit from June 2016 to September 2017 were retrospectively reviewed. SIC was diagnosed by ejection fraction (EF) <50% and ≥10% decrease in baseline EF that recovered within 2 weeks.ResultsIn total, 342 patients with sepsis met the inclusion criteria, and 49 patients (14.3%) were diagnosed with SIC; the latter were compared with 259 patients whose EF was not deteriorated by sepsis (non-SIC). Low systolic blood pressure and increased left ventricular end-diastolic diameter (LVEDD) were identified as predictors of SIC. SIC and non-SIC patients did not differ significantly in terms of 28-day all-cause mortality (24.5% vs. 26.3%, P=0.936). Acute Physiology and Chronic Health Evaluation II (APACHE II; hazard ratio [HR], 1.10; 95% confidential interval [CI], 1.02 to 1.18; P=0.009) and delta neutrophil index (DNI; HR, 1.02; 95% CI, 1.00 to 1.08; P=0.026) were independent risk factors for 28-day mortality with SIC. DNI, APACHE II, and lactate were identified as risk factors for 28-day mortality in sepsis patients as a whole.ConclusionsSIC was not associated with increased mortality compared to non-SIC. Low systolic blood pressure and increased LVEDD were predictors of SIC. High APACHE II score and elevated DNI, which reflect sepsis severity, predict 28-day all-cause mortality.

A retrospective observational study of sarcopenia and outcomes in critically ill patients.

Frailty assessment in patients admitted to intensive care is often limited using traditional clinical frailty assessment tools. Opportunistic use of contemporary computed tomography (CT) can provide an objective estimate of low skeletal muscle mass (sarcopenia) as a proxy for frailty. The aim of this study was to establish the prevalence of sarcopenia in an Australian intensive care unit (ICU) population and to examine the relationship between sarcopenia and clinical outcomes. We undertook a single centre retrospective study of 1085 adult patients admitted to a single ICU over 12months. Patients with a contemporary CT scan including the L3 vertebral body were included. Patients were categorised as sarcopenic or non-sarcopenic using previously published data. A total of 279 patients with a mean age of 67 years had an eligible CT scan; 163 (58%) were male. Higher 30-day mortality was associated with the use of CRRT (continuous renal replacement therapy) during the ICU admission (OR 6.84, P < 0.001) and also associated with lower cross-sectional muscle area (odds ratio (OR) 0.98, P = 0.004). Sarcopenia was found to be highly prevalent in this particular Australian ICU population (68%) and associated with older age (68 versus 55years, P < 0.001), lower body mass index (27 versus 32 kg m-2, P < 0.001), more comorbidities (3 versus 2, P = 0.009), and longer stays in hospital (279 versus 223h, P = 0.043). As a continuous predictor, lumbar muscle mass was associated with 30-day mortality with and without adjusting for other covariates.

Azithromycin Treatment vs Placebo in Children With Respiratory Syncytial Virus–Induced Respiratory Failure

Despite a high disease burden, there is no effective treatment for respiratory syncytial virus (RSV) infection. To determine whether administration of azithromycin (AZM) to children with RSV-induced respiratory failure is safe and to define the effect of AZM therapy on nasal matrix metalloproteinase 9 (MMP-9) levels. This randomized, double-blind, placebo-controlled phase 2 trial was conducted at a single tertiary pediatric intensive care unit from February 2016 to February 2019. The study included children with RSV infection who were admitted to the pediatric intensive care unit and required respiratory support via positive pressure ventilation (invasive and noninvasive). A total of 147 children were screened; 90 were excluded for not meeting inclusion criteria, having an absent legal guardian, lacking pharmacy support, or having a language barrier and 9 declined participation, resulting in 48 patients enrolled in the study. Receipt of standard dose AZM (10 mg/kg/d), high-dose AZM (20 mg/kg/d), or a matching placebo of normal saline intravenously for 3 days. Nasal and endotracheal samples were collected at baseline as well as at 24 hours and 48 hours after start of treatment. The secondary outcome was to determine treatment effect on clinical outcome measures, including days of positive pressure ventilation and length of hospital stay. A total of 48 patients were enrolled in the trial, with a median (range) age at randomization of 12 (1 to 125) months; 36 participants (75.0%) were younger than 2 years. Overall, 26 participants (54.2%) were boys, and 29 (60.4%) had a comorbidity. A total of 16 patients were randomized into each trial group (ie, placebo, standard-dose AZM, and high-dose AZM). Baseline demographic characteristics were comparable among the 3 groups. Both doses of AZM were safe, with no adverse events observed. No difference in nasal MMP-9 levels were observed between treatment groups. Among those who required mechanical ventilation and received high-dose AZM, endotracheal active and total MMP-9 levels were lower on day 3. Compared with baseline, active and total MMP-9 levels in endotracheal aspirates were 1.0 log lower in the high-dose AZM group (active MMP-9: 99.8% CI, -1.28 to -0.64; P < .001; total MMP-9: 99.8% CI, -1.37 to -0.57; P < .001). Patients who received high-dose AZM had fewer median (interquartile range) hospital days compared with those receiving the placebo (8 [6-14] days vs 11 [8-20] days; mean ratio estimate, 0.57; 95% CI, 0.38-0.87; P = .01). In this phase 2 randomized clinical trial, both doses of AZM were safe. While nasal MMP-9 levels were unchanged among treatment groups, endotracheal MMP-9 levels were lower among those who received high-dose AZM. The positive secondary clinical outcome, while exploratory, provides insight for end points in a multicenter randomized trial. ClinicalTrials.gov Identifier: NCT02707523.

Effects of Quality Control Targets (SpO2≠100%, PaCO2/10 cmH2O) on Outcomes in Patients in the ICU.

Objectives: A series of quality control (QC) targets (SpO2≠100%, PaCO2≮40 mmHg, Pmean≯10 cmH2O) was put forward and widely used in a single intensive care unit (ICU) setting. The aim of this study was to assess whether these QC targets could improve the outcomes of critically ill patients.Methods: The real-time clinical data of patients undergoing mechanical ventilation at ICU admission between May 2013 and May 2017 in the Department of Critical Care Medicine of Peking Union Medical College Hospital were collected and analyzed.Results: A total of 7,670 patients [mean age, 58 years; 3,943 (51.5%) male] were divided into the before QC (n = 3,936) and after QC (n = 3,734) groups. QC targets (SpO2, PaCO2, and Pmean) and respiratory parameters (FiO2%, PaO2, PEEP, tidal volume, and respiratory rate) within 72 h of ICU admission, primary outcomes (ICU mortality, 28-, 60-, and 90-day mortality) and secondary outcomes (discharge against medical advice, ICU admission days, mechanical ventilation times, and central venous pressure) were measured and compared between the before and after QC groups. The 72 h average of the Pmean, FiO2%, PaO2, and VT were significantly lower and PaCO2 was higher in the after QC than in the before QC group (P < 0.05). A lower 90-day mortality rate, less discharge against medical advice, fewer ICU admission days, and reduced mechanical ventilation times were found in the after QC group compared with the before QC group (P < 0.05). Interestingly, CVP was significantly lower in the after QC group than in the before QC group (P < 0.05).Conclusions: The QC targets (SpO2≠100%, PaCO2≮40 mmHg, Pmean≯10 cmH2O) contributed to avoiding high oxygen level hazards, protecting against lung injury, and improving circulatory function, which resulted in a better prognosis of critically ill patients.

The Evolution and Devolution of Hospital Care

The Evolution and Devolution of Hospital Care

Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019 in Shanghai, China.

Severe cases of coronavirus disease 2019 (COVID-19) cannot be adequately managed with mechanical ventilation alone. The role and outcome of extracorporeal membrane oxygenation (ECMO) in the management of COVID-19 is currently unclear. Eight COVID-19 patients have received ECMO support in Shanghai with seven with venovenous (VV) ECMO support and one veno arterial (VA) ECMO during cardiopulmonary resuscitation. As of March 25, 2020, four patients died (50% mortality), three patients (37.5%) were successfully weaned off ECMO after 22, 40, and 47 days support, respectively, but remain on mechanical ventilation. One patient is still on VV ECMO with mechanical ventilation. The partial pressure of oxygen/fractional of inspired oxygen ratio before ECMO initiation was between 54 and 76, and all were well below 100. The duration of mechanical ventilation before ECMO ranged from 4 to 21 days. Except the one emergent VA ECMO during cardiopulmonary resuscitation, other patients were on ECMO support for between 18 and 47 days. In conclusion, ensuring effective, timely, and safe ECMO support in COVID-19 is key to improving clinical outcomes. Extracorporeal membrane oxygenation support might be an integral part of the critical care provided for COVID-19 patients in centers with advanced ECMO expertise.

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

Preventing Catheter-Associated Urinary Tract Infections in the Pediatric Intensive Care Unit.

Catheter-associated urinary tract infections are common health care-associated infections and have been associated with increased mortality, morbidity, length of stay, and cost. Prevention strategies are grouped into bundles focused on reducing unnecessary catheter use and promptly removing urinary catheters. Before intervention in the study institution, no urinary catheters were unnecessarily used and compliance with the catheter-associated urinary tract infection bundle was 84%. To increase bundle compliance by using targeted rounds specifically focused on eliminating dependent loops in drainage tubing and ensuring appropriate catheter use to reduce the incidence of catheter-associated urinary tract infections. A multidisciplinary team was formed to identify misperceptions, highlight best practices, and eliminate barriers to success over 1 year in a single pediatric intensive care unit. The team completed a quality improvement project of daily targeted rounding for patients with an indwelling urinary catheter. The goals were to assess appropriateness of catheterization, increase bundle compliance, and decrease catheter-associated urinary tract infection risk. Targeted rounds were conducted in addition to the medical team rounds. Bundle compliance supported by targeted rounding increased from 84% to 93% and helped reduce the overall catheter-associated urinary tract infection rate from 2.7 infections per 1000 catheter-days at baseline to 0. This change was sustained for 1 year. Targeted rounding for pediatric patients with an indwelling urinary catheter is an effective and sustainable strategy to reduce catheter-associated urinary tract infections. The ease of implementation for this intervention lends itself to generalizability to other patient populations.

Effect of Pacifier Design on Nonnutritive Suck Maturation and Weight Gain in Preterm Infants: A Pilot Study

BackgroundPacifiers are effective in promoting oral feeding by increasing the maturation of nonnutritive sucking to nutritive suck in preterm neonates. It is unclear whether pacifier design can influence suck dynamics and weight loss during the first week of life.ObjectivesThis pilot study examined the feasibility of studying the effect of pacifier design on suck maturation and weight loss in preterm neonates.MethodsTwenty-five preterm neonates (mean [SD] birth weight 1791 [344.9] grams, mean [SD] gestational age 33.1 [1.2] weeks) were studied in a single newborn intensive care unit. Neonates were assigned to either an orthodontic pacifier (n = 13) or a bulb-shaped pacifier (n = 12) immediately after birth. Suck dynamics (cycles per minute, total compressions per minute, cycle bursts, and amplitude) were assessed with an NTrainer (Innara Health, Olathe, Kansas). Weight was recorded during the first week of life on day 1.2 (±2.5 days) and day 6.0 (±2.1 days). Descriptive statistics were applied to analyze data.ResultsNo significant differences were seen between groups with respect to birth weight and gestational age. Reproducible nonnutritive sucking measurements could be obtained with the NTrainer, with both types of pacifiers. No differences were detected in nonnutritive sucking dynamics or weight loss over time within each group or between groups.ConclusionsData indicate that it is feasible to measure nonnutritive sucking dynamics and associated weight loss in relation to pacifier design in preterm neonates. Larger trials over longer time periods are needed to determine whether pacifier design influences suck dynamics and maturation, oromotor function, feeding/weight loss, and dental formation in preterm neonates. (Curr Ther Res Clin Exp. 2020; 81:XXX–XXX)

Mechanical ventilation withdrawal as a palliative procedure in a Brazilian intensive care unit.

ObjectiveTo describe the characteristics and outcomes of patients undergoing mechanical ventilation withdrawal and to compare them to mechanically ventilated patients with limitations (withhold or withdrawal) of life-sustaining therapies but who did not undergo mechanical ventilation withdrawal.MethodsThis was a retrospective cohort study from January 2014 to December 2018 of mechanically ventilated patients with any organ support limitation admitted to a single intensive care unit. We compared patients who underwent mechanical ventilation withdrawal and those who did not regarding intensive care unit and hospital mortality and length of stay in both an unadjusted analysis and a propensity score matched subsample. We also analyzed the time from mechanical ventilation withdrawal to death.ResultsOut of 282 patients with life-sustaining therapy limitations, 31 (11%) underwent mechanical ventilation withdrawal. There was no baseline difference between groups. Intensive care unit and hospital mortality rates were 71% versus 57% and 93% versus 80%, respectively, among patients who underwent mechanical ventilation withdrawal and those who did not. The median intensive care unit length of stay was 7 versus 8 days (p = 0.6), and the hospital length of stay was 9 versus 15 days (p = 0.015). Hospital mortality was not significantly different (25/31; 81% versus 29/31; 93%; p = 0.26) after matching. The median time from mechanical ventilation withdrawal until death was 2 days [0 - 5], and 10/31 (32%) patients died within 24 hours after mechanical ventilation withdrawal.ConclusionIn this Brazilian report, mechanical ventilation withdrawal represented 11% of all patients with treatment limitations and was not associated with increased hospital mortality after propensity score matching on relevant covariates.

The occurrence of adverse events is associated with increased morbidity and mortality in children admitted to a single pediatric intensive care unit.

Healthcare can cause harm. The goal of this study is to evaluate the association between the occurrence of adverse events (AEs) and morbidity-mortality in critically ill children. A prospective cohort study was designed. All children admitted to the Pediatric Intensive Care Unit (PICU) between August 2016 and July 2017 were followed. An AE was considered any harm associated with a healthcare-related incident. AEs were identified in two steps: first, adverse clinical incidents (ACI) were recognized through direct observation and active surveillance by PICU physicians, and then the patient safety committee evaluated every ACI to define which would be considered an AE. The outcome was hospital morbidity-mortality. There were 467 ACI registered, 249 (53.31%) were considered AEs and the rate was 4.27/100 patient days. From the 842 children included, 142 (16.86%) suffered AEs, 39 (4.63%) experienced morbidity-mortality: 33 (3.92%) died, and 6 (0.71%) had morbidity. Multivariate analysis revealed that the occurrence of AEs was significantly associated with morbidity-mortality, OR 5.70 (CI95% 2.58-12.58, p = 0.001). This association was independent of age and severity of illness score.Conclusion: Experiencing AEs significantly increased the risk of morbidity-mortality in this cohort of PICU children.What is Known:• Many children suffer healthcare-associated harm during pediatric intensive care hospitalization.What is New:• This prospective cohort study shows that experiencing adverse events during pediatric intensive care hospitalization significantly increases the risk of morbidity and mortality independent of age and severity of illness at admission.

A predictive factor for patients with acute respiratory distress syndrome: CT lung volumetry of the well-aerated region as an automated method

PurposeAcute respiratory distress syndrome (ARDS) is an acute inflammatory lung injury that frequently shows fatal outcomes. As radiographic predictive factors, some reports have focused on the region of ill-aerated lung, but none have focused on well-aerated lung. Our objective was to evaluate the relationship between computed tomography (CT) volume of the well-aerated lung region and prognosis in patients with ARDS. MethodThis retrospective observational study of a single intensive care unit (ICU) included patients with ARDS treated between April 2011 and May 2013. We identified 42 patients with ARDS for whom adequate helical CT scans were available. CT images were analyzed for 3-dimensional reconstruction, and lung region volumes were measured using automated volumetry methods. Lung regions were identified by CT attenuation in Hounsfield units (HU). ResultsOf the 42 patients, 35 (83.3 %) survived 28 days and 32 (76.2 %) survived to ICU discharge. CT lung volumetry was performed within 144.5 ± 76.6 s, and inter-rater reliability of CT lung volumetry for lung regions below −500 HU (well-aerated lung region) were near-perfect. Well-aerated lung region showed a positive correlation with 28-day survival (P = 0.020), and lung volumes below −900 HU correlated positively with 28-day survival and ICU survival, respectively (P = 0.028, 0.017). Survival outcome was better for percentage of well-aerated lung region/predicted total lung capacity ≥40 % than for <40 % (P = 0.039). ConclusionsCT lung volumetry of the well-aerated lung region using an automated method allows fast, reliable quantitative CT analysis and potentially prediction of the clinical course in patients with ARDS.

Non-surgical Risk Factors for the Development of Chylothorax in Children after Cardiac Surgery-Does Fluid Matter?

We hypothesize that there are post-operative, non-surgical risk factors that could be modified to prevent the occurrence of chylothorax, and we seek to determine those factors. Retrospective chart review of 285 consecutive patients < 18years who underwent cardiac surgery from 2015 to 2017 at a single institution pediatric intensive care unit. Data was collected on patient demographics, cardiac lesion, surgical and post-operative characteristics. Primary outcome was development of chylothorax. Of 285 patients, median age was 189days, median weight was 6.6kg, 48% were female, and 10% had trisomy 21. 3.5% of patients developed upper extremity DVTs, and 8% developed chylothorax. At 24h following surgery, a majority were in the 0-10% fluid overload category or had a negative fluid balance (63% and 34%, respectively), and a positive fluid balance was rare at 72h (16%). In univariate analysis, age, weight, bypass time, DVT, arrhythmia, and trisomy 21 were significantly associated with chylothorax and adjusted for in logistic regression. Presence of an upper extremity DVT (OR 49.8, p < 0.001) and trisomy 21 (OR 5.8, p < 0.001) remained associated with chylothorax on regression modeling. The presence of an upper extremity DVT and trisomy 21 were associated with the development of chylothorax. Fluid overload was rare in our population. The presence of positive fluid balance, fluid overload, elevated central venous pressure, and early initiation of fat containing feeds were not associated with chylothorax.

2271. Bacteremia Due to Multi-Drug-Resistant Organisms Is an Independent Risk Factor for Death Among Patients Supported by Extracorporeal Membrane Oxygenation (ECMO)

BackgroundECMO is a type of life-support for patients with refractory respiratory and/or cardiac failure. Our objective was to determine the incidence, resistance patterns and risk factors for development of blood stream infections (BSI) in patients receiving ECMO therapy.MethodsThis was a retrospective cohort study of a single intensive care unit. All patients receiving ECMO therapy between 7/1/13 and 4/28/18 were evaluated. Multidrug-resistant (MDR) pathogens were defined as non-susceptible to ≥1 agent in ≥3 antimicrobial classes, and vancomycin-resistant Enterococcus (VRE).Results471 patients received ECMO, accounting for 4,739 ECMO days. Thirty-six patients (7.6%) had ≥1 episode of BSI; 47 episodes occurred, resulting in 10 events per 1,000 ECMO days. The most common organisms were Enterobacteriaceae (26%), 33% of which were MDR. Staphylococcus aureus (17%), coagulase-negative Staphylococcus (17%), Enterococcus faecium (11%) and Candida spp. (6%) were also identified. Overall, 20% of BSI were due to MDR bacteria. Median duration of BSI was significantly longer for infections due to VRE (8.5 days), than other organisms (1 day; P = 0.0006). Duration of ECMO (P < 0.0001), continuous renal replacement therapy (P = 0.01), units of blood transfused (P = 0.0001) and end-stage lung disease (ESLD) awaiting transplant (P = 0.004) were risk factors for BSI. Duration of ECMO, units of blood transfused and ESLD were independent risk factors for BSI. VV vs. VA-ECMO or central vs. peripheral cannulation were not significant risk factors. By logistic regression, MDR bacterial BSI was associated with longer duration of ECMO (P = 0.001) and number of units of blood transfused (P = 0.01). 1-year mortality after initiation of ECMO was 48%. Independent risk factors for 1-year mortality were age (P < 0.0001) and BSI due to MDR bacteria (P = 0.049).ConclusionThe rate of BSIs during ECMO is relatively low, but these infections are commonly caused by MDR bacteria and associated with high 1-year mortality. Clinicians should consider empiric antibiotic coverage for MDR bacteria in patients with BSI on prolonged ECMO, and in patients on ECMO who received multiple blood transfusions. Since MDR bacterial BSI is an independent risk factor for mortality, future research on preventive strategies are warranted in high-risk ECMO cohorts.Disclosures All authors: No reported disclosures.

Prevalence of risk-drinking in critically ill patients, screened with carbohydrate-deficient transferrin and AUDIT-C score: A retrospective study.

Background Studies demonstrate that up to one-third of intensive care unit (ICU) admissions are directly or indirectly related to alcohol. Screening for alcohol use is not routine. This study examined the prevalence of elevated %CDT (carbohydrate-deficient transferrin) and above risk-level AUDIT-C (Alcohol Use Disorders Identification Test, Consumption) in patients admitted to ICU. Methods We conducted a retrospective analysis of clinical and laboratory data from a single ICU where %CDT and AUDIT-C were included in routine assessment. After excluding readmissions, 2532 adult patients from a 21-month period were included. Admission values of %CDT were available for 2049 patients, and AUDIT-C was available for 1617 patients. The association of %CDT and AUDIT-C with short- and long-term outcome was studied by using univariate and multivariate logistic regression analysis. Results %CDT was above the reference value in 23.7% (486/2048) of patients with available %CDT. Of patients with available AUDIT-C, 33% (544/1617) had a risk-level AUDIT-C score. Patients with a risk-level AUDIT-C score were significantly younger than those with a lower score (51 vs 64years, P<.0001). Increased %CDT was associated with higher severity of illness. AUDIT-C was associated independently with increased risk of long-term mortality in multivariate analysis (P=.007). Conclusion One in three of ICU patients are risk-level alcohol users as measured with AUDIT-C score, and one in four are analysed with %CDT. The prevalence varies according to the method used and any method alone may be insufficient to detect risk-level consumption reliably. Editorial Comment Alcohol overconsumption is associated with need for ICU admission and with less favorable outcomes. Diagnosis of alcohol overconsumption though is problematic due to low sensitivity in screening. In a pilot study, a biomarker and a screening tool are compared. The finding is that multiple tools are needed to achieve an adequate sensitivity for detection.

Changes in Stroke Volume Variation Induced by Passive Leg Raising to Predict Fluid Responsiveness in Cardiac Surgical Patients With Protective Ventilation

Stroke volume variation (SVV) has been used to predict fluid responsiveness. The authors hypothesized the changes in SVV induced by passive leg raising (PLR) might be an indicator of fluid responsiveness in patients with protective ventilation after cardiac surgery. A prospective single-center observational study. A single cardiac surgery intensive care unit at a tertiary hospital. A total of 123 patients undergoing cardiac surgery with hemodynamic instability. Tidal volume was set between 6 and 8 mL/kg of ideal body weight. PLR maneuver, fluid challenge. SVV was continuously recorded using pulse contour analysis before and immediately after a PLR test and after fluid challenge (500 mL of colloid given over 30 min). Sixty-three (51.22%) patients responded to fluid challenge, in which PLR and fluid challenge significantly increased the SV and decreased the SVV. The decrease in SVV induced by PLR was correlated with the SV changes induced by fluid challenge. A 4% decrease in the SVV induced by PLR-discriminated responders to fluid challenge with an area under the curve of 0.90. The gray zone identified a range of SVV changes induced by PLR (between -3.94% and -2.91%) for which fluid responsiveness could not be predicted reliably. The gray zone included 15.45% of the patients. The SVV at baseline predicted fluid responsiveness with an area under the curve of 0.72. Changes in the SVV induced by PLR predicted fluid responsiveness in cardiac surgical patients with protective ventilation.

Acute dizziness with potential life-threatening event: A case series from single ICU

Whether the acute dizziness would be associated with potentially life-threatening event, which was previously unknown. Between Jan 2014 and Dec 2016, We performed a retrospective survey to investigate the clinical data of patients with acute dizziness from an intensive care unit (ICU) in China. Inclusion criteria for all cases were presented with acute dizziness at onset, and then with a potentially life-threatening event. Baseline data and 30-days outcomes were collected. Approximately 1.0% of ICU patients had an acute dizziness with potentially life-threatening events. The median age of patients was 60 years (range 23 to 81 years), male: female ratio was 1.8:1. The causes of acute dizziness included focal cerebral hemorrhage in 15 cases (60%), shock in 7cases (28%), and cerebral infarction in 3 cases (12%). The most frequent potentially life-threatening event was acute brain failure (24/25), and the most common cause leading to brain failure was the lesion enlarged (54.2%, including hematoma enlargement in 8 cases, large area infarction or new infarction in 3 cases, and intraventricular hemorrhage in 2 cases). The second potentially life-threatening event was septic shock/secondary sepsis (45.8%). The fatality rate for all life- threatening events was in 64%. Compared with the survival group, the patients with lesion enlarged (56.3% vs. 11.1%, p < 0.05), acute respiratory failure (93.8% vs. 55.6% p < 0.05), lactate level (5.3 mmol/l vs. 1.3 mmol/l, p < 0.05), and Sequential Organ Failure Assessment (SOFA) score (6.9 vs. 3.4, p < 0.0001) in the non-survival group were significantly higher, while late mean arterial blood pressure (84.6 mmHg vs.124 mmHg, p < 0.0001), GCS score (5.0 score vs. 15 score, p < 0.0001) in the non-survival group were significantly lower. Acute dizziness with potentially life-threatening events accounts for about 1% of adult ICU patients. Acute dizziness in ICU patients is associated with a high risk of death within 30 days of onset.

Endoscopic Insertion of Nasojejunal Feeding Tube at Bedside for Critically Ill Patients: Relationship between Tube Position and Intragastric Countercurrent of Contrast Medium

Background and Oblectives: We evaluated the success rate of endoscopically positioned nasojejunal feeding tubes and the intragastric countercurrent of contrast medium thereafter. Method: This retrospective observational study investigated patients who were admitted to a single intensive care unit and required endoscopic placement of a post-pyloric feeding tube between January 2010 and June 2016. The feeding tube was grasped with forceps via a transoral endoscope and inserted into the duodenum or jejunum. Thereafter, we assessed the position of the tube and the intragastric countercurrent using abdominal radiography with contrast medium. Results: The tube tip was inserted at the jejunum and the duodenal fourth portion in 55.8 and 33.6% of patients, respectively. The tip of the inserted tube had moved into the jejunum of 71.7% of patients by the following day. The countercurrent rate was significantly lower among patients with a tube inserted into the duodenal fourth portion or more distal than among those with tubes inserted more proximally (8.4 vs. 45.4%, p = 0.0022). Conclusions: The endoscopic insertion and positioning of a nasojejunal feeding tube seemed effective because the rate of tube insertion into the duodenal fourth portion or more distal was about 90%. The findings of intragastric countercurrents indicated that feeding tubes should be inserted into the duodenal fourth portion or beyond to prevent vomiting and the aspiration of enteral nutrients.

Exploring Incontinence-Associated Dermatitis in a Single Center Intensive Care Unit: A Longitudinal Point Prevalence Survey.

The purpose of this study was to provide longitudinal prevalence rates of incontinence-associated dermatitis (IAD) in patients in an intensive care unit (ICU) and to identify patient characteristics associated with IAD development. Prospective observational. The sample comprised 351 patients aged 18 years and older in a major metropolitan public hospital ICU in Queensland, Australia. All consenting, eligible participants at risk of developing IAD underwent weekly skin inspections to determine the presence of IAD. Data were collected weekly for 52 consecutive weeks. Descriptive statistics described the study sample and logistic regression analysis was used to identify patient characteristics associated with development of IAD. The weekly IAD prevalence ranged between 0% and 70%, with IAD developing in 17% (n = 59/351) of ICU patients. The odds of IAD developing increased statistically significantly with increasing age (odds ratio [OR]: 1.029, 95% confidence interval [CI]: 1.005-1.054, P = .016), time in the ICU (OR = 1.104; 95% CI: 1.063-1.147, P < .001), and Bristol Stool chart score (OR = 4.363, 95% CI: 2.091-9.106, P < .001). Patients with respiratory (OR = 3.657, 95% CI: 1.399-9.563, P = .008) and sepsis (OR = 3.230, 95% CI: 1.281-8.146, P = .013) diagnoses had increased odds of developing IAD. These data show the high variability of IAD prevalence over a 1-year period. Characteristics associated with the development of IAD in patients in the ICU included older age, longer lengths of ICU stay, incontinent of liquid feces, and having respiratory or sepsis diagnoses.

Detection of Brain Activation in Unresponsive Patients with Acute Brain Injury

BackgroundBrain activation in response to spoken motor commands can be detected by electroencephalography (EEG) in clinically unresponsive patients. The prevalence and prognostic importance of a dissociation between commanded motor behavior and brain activation in the first few days after brain injury are not well understood.MethodsWe studied a prospective, consecutive series of patients in a single intensive care unit who had acute brain injury from a variety of causes and who were unresponsive to spoken commands, including some patients with the ability to localize painful stimuli or to fixate on or track visual stimuli. Machine learning was applied to EEG recordings to detect brain activation in response to commands that patients move their hands. The functional outcome at 12 months was determined with the Glasgow Outcome Scale–Extended (GOS-E; levels range from 1 to 8, with higher levels indicating better outcomes).ResultsA total of 16 of 104 unresponsive patients (15%) had brain activation detected by EEG at a median of 4 days after injury. The condition in 8 of these 16 patients (50%) and in 23 of 88 patients (26%) without brain activation improved such that they were able to follow commands before discharge. At 12 months, 7 of 16 patients (44%) with brain activation and 12 of 84 patients (14%) without brain activation had a GOS-E level of 4 or higher, denoting the ability to function independently for 8 hours (odds ratio, 4.6; 95% confidence interval, 1.2 to 17.1).ConclusionsA dissociation between the absence of behavioral responses to motor commands and the evidence of brain activation in response to these commands in EEG recordings was found in 15% of patients in a consecutive series of patients with acute brain injury. (Supported by the Dana Foundation and the James S. McDonnell Foundation.)