Critical Care Support Research Articles

Etiology and Outcome of Patients with HIV Infection and Respiratory Failure Admitted to the Intensive Care Unit

Background. Although access to HAART has prolonged survival and improved quality of life, HIV-infected patients with severe immunosuppression or comorbidities may develop complications that require critical care support. Our objective is to evaluate the etiology of respiratory failure in patients with HIV infection admitted to the ICU, its relationship with the T-lymphocytes cell count as well as the use of HAART, and its impact on outcome. Methods. A single-center, prospective, and observational study among all patients with HIV-infection and respiratory failure admitted to the ICU from December 1, 2011, to February 28, 2013, was conducted. Results. A total of 42 patients were admitted during the study period. Their median CD4 cell count was 123 cells/μL (mean 205.7, range 2.0–694.0), with a median HIV viral load of 203.5 copies/mL (mean 58,676, range <20–367,649). At the time of admission, 23 patients (54.8%) were receiving HAART. Use of antiretroviral therapy at ICU admission was not associated with survival, but it was associated with higher CD4 cell counts and lower HIV viral loads. Twenty-five patients (59.5%) had respiratory failure secondary to non-HIV-related diseases. Mechanical ventilation was required in 36 patients (85.1%). Thirteen patients (31.0%) died. Conclusions. Noninfectious etiologies of respiratory failure account for majority of HIV-infected patients admitted to ICU. Increased mortality was observed among patients with sepsis as etiology of respiratory failure (HIV related and non-AIDS related), in those receiving mechanical ventilation, and in patients with decreased CD4 cell count. Survival was not associated with the use of HAART. Complementary studies are warranted to address the impact of HAART on outcomes of HIV-infected patients with respiratory failure admitted to ICU.

Organisation and planning of anaesthesia for emergency surgery

Patients presenting for emergency surgery represent a category at high risk of complications, with substantial morbidity and mortality, whose management may be extremely challenging. In this first of two articles we consider the identification and evaluation of high risk emergency patients, the provision of critical care support, the management of sepsis, common postoperative complications and in-theatre death.

Pre-operative nutrition support in patients undergoing gastrointestinal surgery.

Post-operative management in gastrointestinal (GI) surgery is becoming well established with 'Enhanced Recovery After Surgery' protocols starting 24 hours prior to surgery with carbohydrate loading and early oral or enteral feeding given to patients the first day following surgery. However, whether or not nutritional intervention should be initiated earlier in the preoperative period remains unclear. Poor pre-operative nutritional status has been linked consistently to an increase in post-operative complications and poorer surgical outcome. To review the literature on preoperative nutritional support in patients undergoing gastrointestinal surgery (GI). The searches were initially run in March 2011 and subsequently updated in February 2012. Databases including all EBM Reviews (Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA and NHSEED) MEDLINE, EMBASE, AMED, British Nursing Index Archive using OvidSP were included and a search was run on each database separately after which duplicates were excluded. The inclusion criteria were randomised controlled trials that evaluated pre-operative nutritional support in GI surgical participants using a nutritional formula delivered by a parenteral, enteral or oral route. The primary outcomes included post-operative complications and length of hospital stay. Two observers screened the abstracts for inclusion in the review and performed data extraction. Bias was assessed for each of the included studies using the bias assessment tables in the Cochrane Software Review Manager (version 5.1, Cochrane Collaboration). The trials were analysed using risk ratios with Mantel-Haenszel in fixed effects methods displayed with heterogeneity. Meta-analyses were undertaken on trials evaluating immune enhancing (IE) nutrition, standard oral supplements, enteral and parenteral nutrition (PN) which were administered pre-operatively.Study characteristics were summarised in tables. Dichotomous and ratio data were entered into meta-analyses for the primary outcomes. These were then summarised in tables with assumed and corresponding risk with relative effect giving 95% confidence intervals. The searches identified 9900 titles and, after excluding duplicates, 6433 titles were initially screened. After the initial title screen, 6266 were excluded. Abstracts were screened for 167 studies and 33 articles were identified as meeting the inclusion criteria, of which 13 were included in the review after an assessment of the complete manuscripts.Seven trials evaluating IE nutrition were included in the review, of which 6 were combined in a meta-analysis. These studies showed a low to moderate level of heterogeneity and significantly reduced total post-operative complications (risk ratio (RR) 0.67 CI 0.53 to 0.84). Three trials evaluating PN were included in a meta-analysis and a significant reduction in post-operative complications was demonstrated (RR 0.64 95% CI 0.46 to 0.87) with low heterogeneity, in predominantly malnourished participants. Two trials evaluating enteral nutrition (RR 0.79, 95% CI 0.56 to 1.10) and 3 trials evaluating standard oral supplements (RR 1.01 95% CI 0.56 to 1.10) were included, neither of which showed any difference in the primary outcomes. There have been significant benefits demonstrated with pre-operative administration of IE nutrition in some high quality trials. However, bias was identified which may limit the generalizability of these results to all GI surgical candidates and the data needs to be placed in context with other recent innovations in surgical management (eg-ERAS). Some unwanted effects have also been reported with components of IE nutrition in critical care patients and it is unknown whether there would be detrimental effects by administering IE nutrition to patients who could require critical care support after their surgery. The studies evaluating PN demonstrated that the provision of PN to predominantly malnourished surgical candidates reduced post-operative complications; however, these data may not be applicable to current clinical practice, not least because they have involved a high degree of 'hyperalimentation'. Trials evaluating enteral or oral nutrition were inconclusive and further studies are required to select GI surgical patients for these nutritional interventions.

Management of the critically ill obstetric patient

From 2006 to 2008, 261 women in the United Kingdom died either as a direct or indirect result of pregnancy. More than half of these received critical care input. The support required varied from observation and supportive management to multi-organ support. In many women death occurred despite optimal care, but in a number substandard care was identified when the cases were reviewed as part of the Confidential Enquiry into Maternal Deaths. An understanding of the different types of organ support and treatment that are available in a critical care setting and when these are indicated is therefore crucial for medical professionals caring for these unwell obstetric patients.Described here are the technical aspects of organ support that can be utilized in a critical care setting and the alterations in physiology that occur in pregnancy which influence the use of each treatment modality. Also highlighted in more detail are conditions that are common or life threatening in pregnancy and key points about management of these conditions when they mandate critical care support.

Management of necrotizing skin and soft tissue infections

Although rare, necrotizing skin and soft tissue infections can be devastating infections that are difficult to diagnose and challenging to manage. Clinical presentation is often insidious, and a low index of suspicion is critical. Various diagnostic tools, such as scoring systems or imaging techniques, have been introduced, but none is convincingly superior to sound clinical judgment. Early diagnosis allows early adequate therapy that includes antibiotic therapy, critical care support, specific interventions such as intravenous immunoglobulin in selected patients and, most importantly, early source control. Empirical antibiotic therapy should cover a broad range of both Gram-negative and Gram-positive aerobic and anaerobic microorganisms, and clindamycin is recommended when group A Streptococcus is a suspected pathogen.

Maintaining quality of care 24/7 in a nontrauma surgical intensive care unit

Most surgical critical care literature reflects practices at trauma centers and tertiary hospitals. Surgical critical care needs and practices may be quite different at nontrauma center teaching hospitals. As acute care surgery develops as a component of surgical critical care and trauma, the opportunities and challenges of the nontrauma centers should be considered. In 2001, a new surgical critical care service was created for an 800-bed urban teaching hospital with a 12-bed surgical intensive care unit (SICU). Consults, daily rounds, daily notes, and adherence to best practices were standardized over the next 9 years for a team of postgraduate year-1 and -2 surgical residents, physician assistants and surgical intensivists. The Fundamentals of Critical Care Support course was given as basic introduction, and published guidelines for ventilators, hemodynamics, cardiac, infections, and nutrition management were implemented. A "beyond FCCS" curriculum was repeated every resident rotation. A 12-bed stepdown unit was developed for the more stable patients, mostly run by SICU physician assistants with SICU attending coverage. The first 5 years, night coverage was by the daytime intensivist from home. The last 4 years, night coverage was in-unit surgical intensivists or cardiac surgeons. Data for 13,020 patients drawn from 152,154 operations over 9 years is reported. Surgery grew 89% to 24,000 cases/year in 2010. Half the patients were general, gastrointestinal oncology, or vascular surgery. Ninety-two percent were perioperative. The 8% nonoperative patients were mostly gastrointestinal bleeding, abdominal pain, or pancreatitis. In the first year, annual SICU mortality decreased from an average of 4.5% the 5 previous years to 1.96% (2002) and remained 1.75% (2003), 2.1% (2004), 1.9% (2005), 1.5% (2006), 1.5% (2007), 2.2% (2008), 2.4% (2009), and 2.1% (2010). Annual mortality immediately improved at a busy nontrauma hospital with rapid, structured consultation by the SICU team, comprehensive daily rounds guided by critical care best practices, and daytime in-unit surgical intensivists. Low mortality was maintained over 9 years as surgery volume nearly doubled but did not improve further with 24/7 in-unit coverage by surgical intensivists and cardiac surgeons. The process of care in an SICU may be more important than 24 hour a day, 7 days a week intensivists. Therapeutic study, level II.

Chemical Terrorism for the Intensivist

The use of chemical agents for terrorist attacks or military warfare is a major concern at the present time. Chemical agents can cause significant morbidity, are relatively inexpensive, and are easy to store and use. Weaponization of chemical agents is only limited by the physicochemical properties of some agents. Recent incidents involving toxic industrial chemicals and chemical terrorist attacks indicate that critical care services are frequently utilized. For obvious reasons, the critical care literature on chemical terrorism is scarce. This article reviews the clinical aspects of diagnosing and treating victims of chemical terrorism while emphasizing the critical care management. The intensivist needs to be familiar with the chemical agents that could be used in a terrorist attack. The military classification divides agents into lung agents, blood agents, vesicants, and nerve agents. Supportive critical care is the cornerstone of treatment for most casualties, and dramatic recovery can occur in many cases. Specific antidotes are available for some agents, but even without the antidote, aggressive intensive care support can lead to favorable outcome in many cases. Critical care and emergency services can be overwhelmed by a terrorist attack as many exposed but not ill will seek care.

Status Dystonicus Following Deep Brain Stimulation Surgery in DYT1 Dystonia Patients (P01.227)

Objective: We describe a case series of patients who experienced status dystonicus (SD), also known as dystonic storm, following deep brain stimulation (DBS) surgery to implant or remove electrodes in the globus pallidus pars interna (GPi). Background SD is a rare complication of primary and secondary dystonia characterized by acute and severe worsening of dystonic movements, often to the point where it is considered a life-threatening emergency. Of approximately 50 cases described in the literature, 14 used DBS as an acute treatment, whereas one case reported SD arising after lead explantation. To our knowledge, SD following DBS implantation has not yet been described. Design/Methods: Medical records of DBS surgeries for dystonia were reviewed, with criteria being 1) clear documentation of SD event and 2) level of severity requiring critical-care support or the presence of end organ involvement. Demographic data collected included age, ethnicity, duration of disease, DYT1 status and BFMDRS scores. The severity and course of each episode were tracked by the duration of ICU admission, IV sedation requirements, mechanical ventilation, as well as abnormal CK, liver, or renal failure. Results: We found six episodes of SD across 3 patients. Presumed causes included: 1) surgical stress from the DBS lead implantation (n=3); 2) sudden cessation of stimulation (n=2) or baclofen pump function (n=1). The duration of these episodes ranged from 3 to 29 days in the ICU with a similar duration of continuous IV sedation requirements. All patients recovered to their baseline dystonia severity, with early initiation of pallidal stimulation in 4 of 6 episodes. Conclusions: These cases suggest that stereotactic implantation or sudden removal of DBS electrodes may trigger SD. While early DBS activation may improve and expedite SD outcomes, it is important to closely monitor patients post-operatively for unexpected deterioration of symptoms, including SD in extreme cases. Supported by: Dr. Cheung has received travel support from Dystonia Coalition grant #NS067501. Disclosure: Dr. Cheung has received research support from Medtronic, Inc. Dr. Flatow has nothing to disclose. Dr. Ben-Haim has nothing to disclose. Dr. Osborn has nothing to disclose. Dr. Cho has nothing to disclose. Dr. Tagliati has received personal compensation for activities with Medtronic Ipsen, Merz and St.Jude as a speaker, consultant and participant on an advisory board. Dr. Alterman received personal compensation for activities with Medtronic, Inc. Dr. Alterman has received research support from Ceregene, Inc and ANS.

Predictors of critical care-related complications in colectomy patients using the National Surgical Quality Improvement Program

Colectomy patients experience a broad set of adverse outcomes. Complications requiring critical care support are common in this group. We hypothesized that as frailty increases, the risk of Clavien class IV and V complications will increase in colectomy patients. Using the National Surgical Quality Improvement Program (NSQIP) participant use files for 2005-2009, we identified patients who underwent laparoscopic and open colectomies by Current Procedural Terminology code. Using the Clavien classification for postoperative complications, we identified NSQIP data points most consistent with Clavien class IV requiring intensive care unit (ICU) care or class V complications (death). We used a modified frailty index with 11 variables based on mapping the Canadian Study of Health and Aging Frailty Index and existing NSQIP variables. Logistic regression was performed to acuity adjust the findings. A total of 58,448 colectomies were identified. As frailty index increased from 0 to 0.55, the proportion of those experiencing Clavien class IV or V complications increased from 3.2% at baseline to 56.3%. Variables found to be significant by logistic regression (odds ratio) were frailty index (14.4; p = 0.001), open procedure (2.35; p < 0.001), and American Society of Anesthesiologists class 4 (3.2; p = 0.038) or 5 (7.1; p = 0.001) while emergency operation and wound classification 3 or 4 were not. Complications requiring ICU care represent a significant morbidity in the colectomy patient population. Frailty index seems to be an important predictor of ICU-level complications and death, and laparoscopy seems to be protective.

Two case reports of neuroinvasive west nile virus infection in the critical care unit.

We describe the clinical course of two cases of neuroinvasive West Nile Virus (WNV) infection in the critical care unit. The first case is a 70-year-old man who presented during summer with mental status changes. Cerebrospinal fluid (CSF) analysis revealed pleocytosis with lymphocyte predominance. WNV serology was positive in the CSF. His condition worsened with development of left-sided weakness and deterioration of mental status requiring intensive care. The patient gradually improved and was discharged with residual left-sided weakness and near-complete improvement in his mental status. The second case is an 81-year-old man who presented with mental status changes, fever, lower extremity weakness, and difficulty in walking. CSF analysis showed pleocytosis with neutrophil predominance. WNV serology was also positive in CSF. During the hospital stay his mentation worsened, eventually requiring intubation for airway protection and critical care support. The patient gradually improved and was discharged with residual upper and lower extremity paresis. Neuroinvasive WNV infection can lead to significant morbidity, especially in the elderly. These cases should be suspected in patients with antecedent outdoor activities during summer. It is important for critical care providers to be aware of and maintain a high clinical suspicion of this disease process.

Formal ventilation patient education for ALS predicts real-life choices

Our objective was to evaluate a single-session, hands-on education programme on mechanical ventilation for ALS patients and caregivers in terms of knowledge, change in affect and to determine whether ventilator decisions made after the education sessions predict those made later in life. Questionnaires were administered to 26 patients and 26 caregivers on four separate occasions. The questionnaires assessed knowledge of ventilatory support, feedback on the nature of the education programme, as well as self-reported emotional well-being. All patients were followed until their death or until initiation of invasive ventilation. Both groups demonstrated significant improvements in knowledge as a result of the education session which was retained after one month. There was no change in patient or caregiver reports' self-reported emotional well-being. The choices of ventilatory support expressed at one month (T4) accurately predicted the real-life clinical choices made by 76% of patients. Any difference resulted from choosing palliative care. Hands-on patient and caregiver education results in improved knowledge, assists in decision-making with respect to ventilatory support, and is not associated with a worsening of affect. It also provides for an accurate prediction of real-life choices and avoids undesired life support interventions and critical care admissions.

The Clinical Outcome of UK Military Personnel Who Received a Massive Transfusion in Afghanistan During 2009

Objectives The UK Defence Medical Services has developed a Massive Transfusion Protocol (MTP) that forms part of the initial Damage Control Resuscitation process for severely injured combat casualties. The key...

Medical Residents and Nutrition Support in Critical Care

Medical Residents and Nutrition Support in Critical Care

Emergency Management of Perforated Colon Cancers: How Aggressive Should We Be?

BackgroundEmergency treatment of perforated colon cancer has traditionally been linked with dismal outcomes due to the double jeopardy of a septic insult combined with a malignant disease, leaving unclear how aggressive emergency surgical procedures should be. We aimed to define short- and long-term outcomes in the current era of critical care support and oncologic advances, to provide updated data for decision making. Study DesignPatients with perforations associated with a primary colon cancer were identified. Peri-operative and long-term survival were compared among free (FP; n = 41) and contained perforations (CP; n = 45) and to age-, stage-, and resection status case-matched, non-perforated (NP; n = 85), controls. ResultsTumors were completely resected in 67% of FP but fewer lymph nodes were harvested (median, 11 vs. 11 and 16 in CP and NP; p = 0.21 and p < 0.001). Peri-operative mortality was highest in FP: 19% vs. 0% and 5% in CP and NP (p = 0.038), respectively. After adjusting for peri-operative mortality, 5-year overall survival was comparable: 55%, 59%, and 54% for FP, CP, and NP, respectively. Advanced age, higher ASA class, presence of residual disease, and advanced stage, but not perforation, were independent predictors of poorer long-term overall survival. ConclusionsPatients with malignant colonic perforation face high risk of peri-operative death, making septic source control the priority in the acute setting. Pursuit of an oncologically oriented resection and long-term cancer-directed treatments, however, may lead to improved long-term outcomes.

Intra-Arterial Nicardipine for the Treatment of Cerebral Vasospasm in Postpartum Cerebral Angiopathy: A Case Study and Review of Literature

ABSTRACTIntroduction: Postpartum cerebral angiopathy is one of the many neurological complications seen during pregnancy and the postpartum period. Management of these patients consists of optimal blood pressure control, and general supportive critical care. We present a case of diffuse cerebral vasospasm, which improved with intra-arterial nicardipine. This brief report addresses the utility of interventional management in cases of postpartum cerebral angiopathy. Case report: A 28-year-old female presented 1 week after cesarean delivery with altered mental status, endotracheal intubation for airway protection, thrombocytopenia, and hypofibrinogenemia. Cerebral angiogram revealed anterior and posterior circulation vasospasm, which responded to repeated selective intra-arterial injections of nicardipine. This treatment coupled with optimal blood pressure control resulted in complete recovery. Discussion: Our case report highlights the importance of cerebral angiography for the diagnosis and treatment of patients with postpartum cerebral angiopathy. Although nicardipine is used in patients with aneurysmal subarachnoid hemorrhage for the treatment of cerebral vasospasm, this agent has the potential to be used in patients with cerebral vasospasm due to other etiologies. Summary: Intra-arterial nicardipine is one of the therapeutic measures available to physicians in the management of patients with cerebral vasospasm. In patients with postpartum cerebral angiopathy, early cerebral angiography should be considered to quantify and treat cerebral vasospasm with either angioplasty or selective intra-arterial injections of nicardipine.

Intensive Care Unit Admission of Decompensated Cirrhotic Patients: Prognostic Scoring Systems

Cirrhotic patients who need critical care support show high morbidity and mortality rates compared with other critically ill patients. Their prognosis is, in fact, influenced by both the severity of the underlying hepatic disease and the worsening of extrahepatic organ function. Clinicians and investigators have been persistently looking for objective scoring systems capable of providing accurate information on disease severity and short-term prognosis. Risk stratification helps differentiate patients who would not benefit from admission to the intensive care unit (ICU) from those who could achieve better outcomes once aggressively treated. The most common scores, ie, multiple organ dysfunction score, sequential organ failure assessment, and acute physiology and chronic health evaluation, developed in general ICUs to evaluate illness severity, have also been validated to predict the prognosis of cirrhotic patients admitted to the ICU. However, their absolute predictive value has been questioned. A weakness of common prediction models consists in not recognizing the continuum of physiological changes in critically ill decompensated cirrhotic patients. In addition, the predictive power to stratify individual risk is relatively low due to the great variability of liver dysfunction stages, the severity of related manifestations, and the number of nonfunctioning organs on admission. Probability models are not capable of predicting whether a patient will live or die with 100% accuracy, nor can they deny or confirm the indications for mechanical ventilation, vasopressor support or renal replacement therapy, or help to decide when to withhold or withdraw support. Because there are no absolute criteria to predict which cirrhotic decompensated patients will improve with normalization of organ function or deteriorate progressively, a scoring system should be regarded as an adjunct rather than a substitute for clinical judgment in the decision process concerning whether a patient should be admitted to the ICU.

Evolving a Successful Acute Care Surgical/Surgical Critical Care Group at a Nontrauma Hospital

A large acute care but nontrauma teaching hospital in Manhattan, New York performing 24 000 operations/year has evolved a Surgical Intensive Care Unit (SICU) Service with 3 attendings and 5 physician assistants over 9 years. The division follows nationally recognized, published best practices in shock, sepsis, ventilator management, nutrition, and antibiotic use and has maintained a total mortality of 1.9% (varying between 1.5% and 2.1%) for 9 years. Although PGY-1 and PGY-2 residents rotate through SICU, the division relies heavily on experienced, Fundamentals of Critical Care Support–trained physician assistants for organized consultation and ensuring adherence to best practices in daily patient care. For the past 4 years, the division has provided 24/7 in-house attending coverage in collaboration with the Division of Cardiac Surgery. In-house attending intensivist/cardiac surgeon coverage did not improve mortality. The division also provides approximately one third of the institution’s acute care surgery in rotation/collaboration with general surgeons. The practicalities of the division’s evolution and recommendations are discussed.

Acute-on-chronic liver failure: concept, natural history, and prognosis

A population of patients with previously compensated cirrhosis will develop acute deterioration resulting in multiorgan failure and high short-term mortality. Complications of cirrhosis frequently culminate in admissions to the ICU. This review advances the concept of acute-on-chronic liver failure as a distinct clinical entity. Recently, the American Association for the Study of Liver Disease and the European Association for the Study of the Liver created a research consortium to advance the state of the science of acute-on-chronic liver failure. The goal of this consortium is aimed at improving outcomes, identification of a subset of patients with cirrhosis at high risk for deterioration, and the inciting events that lead to this deterioration. Liver transplant remains the only curative option for advanced cirrhosis; however, the limited number of available organs necessitates innovations in the care of advanced liver disease. Liver replacement therapies have not as yet demonstrated reduction in mortality, but have demonstrated improvements in other measures. Large-scale prospective studies of cirrhosis are required. Acute-on-chronic liver failure may be a distinct clinical entity with a potential for reversibility when identified early and managed with aggressive critical care support.

Availability and utilisation of physician-based pre-hospital critical care support to the NHS ambulance service in England, Wales and Northern Ireland

BackgroundEvery day throughout the UK, ambulance services seek medical assistance in providing critically ill or injured patients with pre-hospital care.ObjectiveTo identify the current availability and utilisation of physician-based pre-hospital critical...

Oseltamivir‐resistant 2009 H1N1 influenza pneumonia during therapy in a renal transplant recipient

The emergence of oseltamivir-resistant 2009 H1N1 influenza virus (conferred by the H275Y substitution in NA) during therapy or prophylaxis in immunocompromised patients is a serious concern. The optimal therapy for immunosuppressed patients with oseltamivir-resistant 2009 H1N1 influenza virus is unknown and few options exist. We report a 10-yr-old recipient of kidney transplant who was hospitalized with oseltamivir-resistant 2009 H1N1 influenza pneumonia complicated by severe respiratory failure, ARDS, and renal failure requiring institution of ECMO and CRRT. On presentation, treatment with oseltamivir (second course) and broad-spectrum antibiotics was initiated. Immunosuppressive agents were stopped on hospital day (d) 2. On hospital d 7, given his critical status, immunocompromised state, and difficulty in obtaining intravenous zanamivir, after obtaining ethical approval and parental consent, he was treated with intravenous peramivir (through an Emergency Investigational New Drug Application) for two wk. He tolerated the regimen well and his clinical status improved gradually. Several factors may have contributed to virus clearance and survival including recovery of the immune system, aggressive critical care support, and administration of peramivir. Ongoing surveillance is essential to monitor how oseltamivir-resistant H275Y mutant viruses may evolve in the future.