Intensive Care Medicine

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidencebased guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

Phase angle as measured by bioelectrical impedance analysis reflects fat-free mass. Fat-free mass loss relates to worse prognosis in chronic diseases. Primary aim of this study was: to determine the association between fat-free mass at intensive care unit admission and 28-day mortality. Ten centres in nine countries participated in this multicentre prospective observational study. The inclusion criteria were age >18 years; expected length of stay >48 h; absence of pacemaker, heart defibrillator implant, pregnancy and lactation. Fat-free mass was assessed by measurement of the 50-kHz phase angle at admission. The primary endpoint was 28-day mortality. The area under the receiver operating characteristic curve (AUC) was used to assess prediction of 28-day mortality by fat-free mass at ICU admission. The variables associated with 28-day mortality were analysed by means of multivariable logistic regression. Of the 3605 patients screened, 931 were analysed: age 61 ± 16 years, male ...

Fujitani S, Yu VL. Diagnosis of ventilator-associated pneumonia: focus on nonbronchoscopic techniques (nonbronchoscopic bronchoalveolar lavage, including mini-BAL, blinded protected specimen brush, and blinded bronchial sampling) and endotracheal aspirates.

Objective To examine the effects of positive end-expiratory pressure (PEEP) on extravascular lung water (EVLW), lung tissue, and lung volume. Design and setting Experimental animal study at a university research facility. Subjects Fifteen adult sheep. Interventions All animals were studied before and after saline washout-induced lung injury while ventilated with sequentially increasing PEEP (0, 7, 14, or 21 cmH2O). Measurements and results Lung volume was determined by computed tomography and EVLW by the thermal dye dilution technique. Saline washout significantly increased lung tissue volume (21±3 to 37±5 ml/kg) and EVLW (9±2 to 36±9 ml/kg). While increasing levels of PEEP reduced EVLW (30±7, 24±8, and 18±4 ml/kg), lung tissue volume remained constant. Total lung volume significantly increased (50±8 ml/kg at PEEP 0 to 77±12 ml/kg at PEEP 21). Nonaerated lung volume significantly decreased and was closely correlated with the changes in EVLW (r=0.67). In addition, a highly significant correlation was found between PEEP-induced decrease in nonaerated lung volume and decrease in transpulmonary shunt (r=0.83). Conclusions The main findings are as follows: (a) PEEP effectively decreases EVLW. (b) The decrease in EVLW is closely correlated with the PEEP-induced decrease in nonaerated lung volume, making EVLW a valuable bedside parameter indicating alveolar recruitment, similar to measurements of transpulmonary shunt. (c) As excess tissue volume remained constant, however, EVLW may not be suitable to reflect overall severity of lung disease

Background For decades, vitamin K antagonists and specifically warfarin, have been the sole agents used orally to manage thromboembolic conditions, including stroke and venous thromboembolism (VTE). Several factors lead to warfarin dose variability, including genetic and non-genetic factors which made warfarin management challenging especially at the initiation phase. To overcome the challenges with warfarin dosing at initiation, strategies other than conventional or fixed dosing were introduced and explored. Aim In this narrative review, we aim to discuss and critique the different dosing strategies for warfarin at initiation with more focus on genotype-guided warfarin dosing and the most recent supporting evidence for and against its use. Method Medline database was searched from 1965 to July 2021. Articles addressing different warfarin dosing methods were screened for inclusion. Results A number of methods exist for warfarin initiation. Studies comparing different dosing methods ...

Objective: Sleep loss and sleep disruption are common in critically ill patients and may adversely affect clinical outcomes. Although polysomnography remains the most accurate and reliable way to measure sleep, it is costly and impractical for regular use in the intensive care unit. This study evaluates the accuracy of two other methods currently used for measuring sleep, actigraphy (monitoring of gross motor activity) and behavioural assessment by the bedside nurse, by comparing them to overnight polysomnography in critically ill patients. Design: Observational study with simultaneous polysomnography, actigraphy and behavioural assessment of sleep. Setting: Medical-surgical intensive care unit. Patients and participants: Twelve stable, critically ill, mechanically ventilated patients [68 (13) years, Glasgow coma scale 11 (0)]. Interventions: None. Measurements and results: Sleep was severely disrupted, reflected by decreased total sleep time and sleep efficiency, high frequency of arousals and awakenings and abnormal sleep architecture. Actigraphy overestimated total sleep time and sleep efficiency. The overall agreement between actigraphy and polysomnography was \65%. Nurse assessment underestimated the number of awakenings from sleep. Estimated total sleep time, sleep efficiency and number of awakenings by nurse assessment did not correlate with polysomnographic findings. Conclusions: Actigraphy and behavioural assessment by the bedside nurse are inaccurate and unreliable methods to monitor sleep in critically ill patients.

O câncer é um termo que envolve os tipos de doenças malignas que têm em comum o crescimento desordenado de células, que podem invadir tecidos adjacentes ou órgãos a distância podendo se dividir rapidamente, essas células pode ser incontroláveis e agressivas, acarretando a formação de tumores, que podem espalhar-se para outras regiões do corpo. O câncer de mama é classificado como uma doença que sua causa principal é pela multiplicação desordenada de células anormais da mama, formando um tumor com capacidade de invadir outros órgãos. No Brasil, as taxas de mortalidade por câncer de mama continuam em crescimento, certamente porque a doença ainda é diagnosticada em estágios avançados. O objetivo desse trabalho foi avaliar a importância da fisioterapia na prevenção de sequelas de mulheres que realizaram pós-mastectomia. O presente trabalho consistiu em uma pesquisa de campo quali-quantitativa e a aplicação de um questionário de 17 perguntas fechadas realizado pela plataforma Google Forms, aplicado para 20 mulheres que tiveram câncer de mama. Como resultados obtidos pode ser observado das 20 mulheres entrevistadas que a faixa etária predominante foi de 30 a 49 anos, 45% encontrou o nódulo na mama pela mamografia de rotina, 90% das mulheres não teve complicações pós-operatório e que dessas complicações apenas 20% apresentou a presença de linfedema, das 20 mulheres 90% recebeu orientações sobre os cuidados e 50% realizou a fisioterapia, 65% teve a mobilidade articular diminuída e a importância da fisioterapia foi avaliada em 90% das mulheres com nota 10. Pode se concluir com base na pesquisa que o câncer de mama é o mais comum entre as mulheres, mas, que se for identificado no começo a chance de óbito é menor. Pode se observar que a fisioterapia é bem avaliada para todas as pacientes que realizaram a mastectomia, sendo de extrema importância no pós-operatório, evitando complicações como linfedema e na diminuição da amplitude de movimento.

Objective: We propose that higher airway occlusion pressure (P0.1) responses to hypercapnic challenge (HC) indicate less severe injury. The study aim was to determine whether P0.1 responses to HC were associated with successful weaning after prolonged mechanical ventilation (PMV) in patients with brainstem lesions and to determine a reference value for clinical use. Design and setting: Forty-two patients with brainstem lesions on PMV were recruited. Breathing parameters and P0.1 were measured before HC. Three-minute HC challenges with increasing CO 2 concentrations were initiated and P0.1, respiratory rate, minute ventilation (V e), tidal volume (V t) and end tidal CO 2 were measured. Measurements and results: Patients were classified into high (group I) and low (group II) response groups on the basis of P0.1 responses to HC. Increases in V e and V t after HC were significantly greater in group I patients (12.22 ± 8.22 vs. 3.08 ± 4.84 L/min, P \ 0.001 and 399.11 ± 278.18 vs. 110.54 ± 18.275 ml, P \ 0.001). P0.1 levels were significantly higher in group I compared to group II before HC (2.69 ± 1.81 vs. 1.28 ± 1.04 cmH 2 O, P = 0.003). The increase in P0.1 following HC was significantly greater in group I compared to group II patients (11.05 ± 4.06 vs. 2.90 ± 2.53 cmH 2 O, P \ 0.001). Weaning success was significantly higher in group I compared to group II patients (72.2% vs. 33.3%, P = 0.02). A P0.1 increase of [6 cmH 2 O following HC was significantly associated with successful weaning. Conclusions: Assessing the P.01 response to serial increases in the level of HC may be a safe means to ascertain whether patients with brainstem lesions are ready for ventilator weaning.

Objective The evaluation of oxygen consumption (VO2) and oxygen delivery (DO2) has gained increasing importance in the monitoring of critically ill patients. They can be obtained from either direct measurements or by indirect calculations based on the Fick principle. However the choice between these two approaches remains controversial. The aim of the study was to investigate whether these 2 methods provide similar results, and if not, to define the best one in terms of reproducibility. Design Oxygen delivery and oxygen consumption were prospectively analyzed in 171 consecutive critically ill patients. Metabolic data were obtained simultaneously. Setting The study was completed in the intensive care unit as part of the management of the patients studied. Patients A first “group” of 279 evaluations was carried out in 73 consecutive critically ill patients. The results were subsequently validated by 423 observations performed in the 98 following patients. Interventions Before and during each evaluation, the patients were kept in stable hemodynamic and metabolic conditions. All were mechanically ventilated. Measurements and results VO2 was evaluated by calculation (Fick principle) and direct measurement using indirect calorimetry. Cardiac output was both measured by the thermodilution technique and calculated (Fick principle) and the data were used for the evaluation of the directly measured and indirectly calculated DO2. For both VO2 and DO2 the agreement between direct and indirect evaluations was not satisfactory. Differences as great as 55 ml/min·m2 and 267 ml/min·m2 between simultaneously measured and calculated VO2 and DO2 respectively may be expected. Finally, the indirect calculated methods were less reproducible than the measured ones. These observations resulted mainly from the cumulative effects of the random errors in the metabolic data entering into the calculation of VO2 and DO2. Conclusions Our data suggested that the indirect calculation (Fick equation) and the direct measurement (indirect calorimetry, thermodilution) of both VO2 and DO2 did not provide similar results. Direct measurements are more reproducible methods and must be preferred.

Objectives: To evaluate of the oxygenation effects of 12-h prone positioning (PP) in ARDS patients and to assess the safety of such a procedure. Design and setting: Prospective observational study in a medical intensive care unit (12 beds) of a university hospital. Patients: 51 consecutive ARDS patients. Intervention: PP for at least 12 h daily until recovery or death. Measurements and results: Arterial blood gases were collected before and during PP and 1 h after return to supine. Turning adverse events, cutaneous bedsores, and enteral nutrition intolerance were specifically monitored and collected daily by a referring physician. In total 224 PP sessions were performed. Oxygenation improved 1 h after the turn and continued improving over the 12-h period 4 . The beneficial effect persisted 1 h after return to supine 01 . We considered 96% patients responders: 45% as early responders and 53% persistent responders (persistent benefit after return to supine). Four significant adverse events occurred during the 448 turning maneuvers (0.9%). Stage III ulceration and stage IV necrosis cutaneous bedsores occurred in ten patients (20%). Enteral nutrition intolerance was reported in 25% but without inability to meet patient's caloric requirement. Conclusions: Twelvehour PP is a safe procedure and allows a continuous oxygenation improvement throughout the entire session.

Objective: Although quantitative microbiological cultures of samples obtained by bronchoscopy are considered the most specific tool for diagnosing ventilator-associated pneumonia, this labor-intensive invasive technique is not widely used. The Clinical Pulmonary Infection Score (CPIS), a diagnostic algorithm that relies on easily available clinical, radiographic, and microbiological criteria, could be an attractive alternative for diagnosing ventilatorassociated pneumonia. Initially, the CPIS scoring system was validated upon 40 quantitative cultures of bronchoalveolar lavage fluid from 28 patients, and only few other studies have evaluated this scoring system since then. Therefore, little is known about the accuracy of this score. Design: We compared the scores of a slightly adjusted CPIS with results from quantitative cultures of bronchoalveolar lavage fluid in 99 consecutive patients with suspicion of ventilator-associated pneumonia, using growth of ≥10 4 cfu/ml in bronchoalveolar lavage fluid as a cut-off for diagnosing ventilator-associated pneumonia. In addition, the CPIS were calculated for 52 patients by two different intensivists to determine the inter-observer variability. Results: Ventilator-associated pneumonia was diagnosed in 69 (69.6%) patients. When using a CPIS >5 as diagnostic cutoff, the sensitivity of the score was 83% and its specificity was 17%. The area under the Receiver Operating Characteristic curve was 0.55. The level of agreement for prospectively measured Clinical Pulmonary Infection Score (£6 and >6) was poor (kappa =0.16). Conclusions: When compared to quantitative cultures of bronchoalveolar lavage fluid, the CPIS has a low sensitivity and specificity for diagnosing ventilator-associated pneumonia with considerable inter-observer variability.

Central venous catheters are being increasingly used in both intensive care units and general wards. Their use is associated with both mechanical and infectious complications. This review will focus on short-and medium-term mechanical complications of catheter placement; infectious complications will be discussed in a separate article. The most important risk factors are patient characteristics (morbidity, underlying disease and local anatomy), the expertise of the doctor performing the procedure, and nursing care. Placement aids, such as ultrasoundguided catheter insertion, are also discussed.

Objective: To determine the steady-state plasma and epithelial lining fluid (ELF) concentrations of piperacillin/tazobactam (P/T) administered to critically ill patients with severe bacterial pneumonia. Design: Prospective, open-label study. Setting: An intensive care unit and research ward in a university hospital. Patients: Ten adult patients with severe nosocomial bacterial pneumonia on mechanical ventilation. Interventions: All subjects received a 30-min intravenous infusion of P/T 4 g/0.5 g every 8 h. The steady-state plasma and ELF concentrations of P/T were determined by high-performance liquid chromatography. Measurements and main results: The mean€SD steady-state plasma trough, peak, and intermediate concentrations were 8.5€4.6 g/ml, 55.9€21.6 g/ml, and 24.0€13.8 g/ml for piperacillin, and 2.1€1.0 g/ml, 4.8€2.1 g/ml, and 2.4€1.2 g/ml for tazobactam, respectively. The mean€SD steady-state intermediate ELF concentrations were 13.6€9.4 g/ml for piperacillin and 2.1€1.1 g/ml for tazobactam, respectively, showing a mean percentage penetration of piperacillin and tazobactam into ELF of 56.8% and 91.3 %, respectively, with a P/T ratio of 6.5:1. Conclusion: Our results show that during the treatment of severe nosocomial pneumonia, a regimen of P/T 4 g/ 0.5 g every 8 h might provide insufficient concentrations into lung tissue to exceed the MIC of many causative pathogens. This suggests that higher doses of P/T should be administered in order to maximize the antibiotic concentration at the site of infection, or that a second antimicrobial agent should be used in association.

Purpose: To determine the epidemiology, in-hospital mortality, trends, patient characteristics and predictors of intensive care unit (ICU) readmission in Australia. Methods: A retrospective longitudinal study of data for 38 Australian ICUs extracted from the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS-ADP) for the years 2000-2007. Demographic, diagnostic, physiological and outcome data were analysed. A multivariate model was constructed to identify risk factors for ICU readmission. Outcomes examined included observed and risk-adjusted in-hospital mortality. Results: A total of 247,103 patients were discharged alive from their first ICU admission; 13,598 (5.5%) were readmitted at least once. Variables associated with an odds ratio greater than 1.05 for readmission (p \ 0.001) were an initial ICU admission source other than elective surgery, any chronic health variable on severity scoring, tertiary hospital ICU and discharge between 6 p.m. and 6 a.m. Five initial diagnoses were associated with an odds ratio (OR) greater than 2 for readmission (p \ 0.001). In-hospital mortality in readmitted patients was 20.7% compared with 4.4% in those not readmitted. Readmission rates have not changed over the study period. After adjustment for illness severity and readmission propensity, ICU readmission remained significantly associated with in-hospital mortality (OR 5.4, 95%, confidence interval (CI) 5.1-5.7). Conclusions: Many risk factors for increased ICU readmission were identified in this study including ICU discharge between 6 p.m. and 6 a.m. This was the only modifiable variable studied. Prospective studies are required to identify other factors and to determine whether interventions may reduce ICU readmission and its high associated in-hospital mortality.

The relative merits of immediate extubation versus terminal weaning for mechanical ventilation withdrawal are controversial, particularly regarding the experience of patients and relatives. This prospective observational multicentre study (ARREVE) was done in 43 French ICUs to compare terminal weaning and immediate extubation, as chosen by the ICU team. Terminal weaning was a gradual decrease in the amount of ventilatory assistance and immediate extubation was extubation without any previous decrease in ventilatory assistance. The primary outcome was posttraumatic stress symptoms (Impact of Event Scale Revised, IES-R) in relatives 3 months after the death. Secondary outcomes were complicated grief, anxiety, and depression symptoms in relatives; comfort of patients during the dying process; and job strain in staff. Results: We enrolled 212 (85.5%) relatives of 248 patients with terminal weaning and 190 relatives (90.5%) of 210 patients with immediate extubation. Immediate extubation was associated with airway obstruction and a higher

Practice guidelines on weaning should be based on the results of several well-designed randomized studies performed over the last decade. One of those studies demonstrated that immediate extubation after successful trials of spontaneous breathing expedites weaning and reduces the duration of mechanical ventilation as compared with a more gradual discontinuation of ventilatory support. Two other studies showed that the ability to breathe spontaneously can be adequately tested by performing a trial with either T-tube or pressure support of 7 cmH 2 O lasting either 30 or 120 min. In patients with unsuccessful weaning trials, a gradual withdrawal for mechanical ventilation can be attempted while factors responsible for the ventilatory dependence are corrected. Two randomized studies found that, in difficult-to-wean patients, synchronized intermittent mandatory ventilation (SIMV) is the most effective method of weaning.

Critical illness polyneuromypathy has not previously been reported as a complication of diabetic coma. We describe a patient with hyperosmolar non-ketotic coma (HONK) complicating gram-negative sepsis in whom persistent coma and profound tetraplegia caused considerable concern. Although, initially, it was feared that the patient had suffered a central neurological complication such as stroke or cerebral oedema, a diagnosis of critical illness motor syndrome (CIMS) was subsequently confirmed neurophysiologically. Profound limb weakness associated with HONK is not necessarily due to a catastrophic cerebral event, rather it may be a result of CIMS, which has an excellent prognosis for full neurological recovery.

IMPORTANCE Survivors of critical illness demonstrate skeletal muscle wasting with associated functional impairment. OBJECTIVE To perform a comprehensive prospective characterization of skeletal muscle wasting, defining the pathogenic roles of altered protein synthesis and breakdown. DESIGN, SETTING, AND PARTICIPANTS Sixty-three critically ill patients (59% male; mean age: 54.7 years [95% CI, 50.0-59.6 years]) with an Acute Physiology and Chronic Health Evaluation II score of 23.5 (95% CI, 21.9-25.2) were prospectively recruited within 24 hours following intensive care unit (ICU) admission from August 2009 to April 2011 at a university teaching and a community hospital in England. Patients were recruited if older than 18 years and were anticipated to be intubated for longer than 48 hours, to spend more than 7 days in critical care, and to survive ICU stay.

Purpose: To assess the value of serum procalcitonin (PCT) for the differentiation between patients with and without neonatal sepsis. Methods: We systematically searched PubMed, Scopus, and the Cochrane Library for studies evaluating PCT in neonatal sepsis. PCT had to be measured in neonatal blood samples, at the initial presentation of patients with suspected sepsis, before the administration of antibiotics. We performed a bivariate meta-analysis of sensitivity and specificity, and constructed a hierarchical summary receiver-operating characteristic (HSROC) curve. Results: Overall, 29 studies eligible for inclusion were identified. We analyzed the 16 studies (involving 1,959 neonates) that evaluated PCT in neonates with cultureproven or clinically diagnosed sepsis in comparison with ill neonates with other conditions. The pooled (95% confidence interval) sensitivity and specificity were 81% (74-87%) and 79% (69-87%), respectively. The area under the HSROC curve (AUC) was 0.87. The diagnostic accuracy of PCT seemed higher for neonates with late-onset sepsis ([72 h of life) than for those with early onset sepsis; the AUC for these analyses was 0.95 and 0.78, respectively. However, fewer data were available for late-onset sepsis. High statistical heterogeneity was observed for all analyses. Conclusion: Our findings suggest that serum PCT at presentation has very good diagnostic accuracy (AUC = 0.87) for the diagnosis of neonatal sepsis. However, in view of the marked observed statistical heterogeneity, along with the lack of a uniform definition for neonatal sepsis, the interpretation of these findings should be done with appropriate caution.

Background: Management algorithms for adult severe traumatic brain injury (sTBI) were omitted in later editions of the Brain Trauma Foundation's sTBI Management Guidelines, as they were not evidence-based. Methods: We used a Delphi-method-based consensus approach to address management of sTBI patients undergoing intracranial pressure (ICP) monitoring. Forty-two experienced, clinically active sTBI specialists from six continents comprised the panel. Eight surveys iterated queries and comments. An in-person meeting included whole-and small-group discussions and blinded voting. Consensus required 80% agreement. We developed heatmaps based on a traffic-light model where panelists' decision tendencies were the focus of recommendations. Results: We provide comprehensive algorithms for ICP-monitor-based adult sTBI management. Consensus established 18 interventions as fundamental and ten treatments not to be used. We provide a three-tier algorithm for treating elevated ICP. Treatments within a tier are considered empirically equivalent. Higher tiers involve higher risk therapies. Tiers 1, 2, and 3 include 10, 4, and 3 interventions, respectively. We include inter-tier considerations, and recommendations for critical neuroworsening to assist the recognition and treatment of declining patients. Novel elements include guidance for autoregulation-based ICP treatment based on MAP Challenge results, and two heatmaps to guide (1) ICP-monitor removal and (2) consideration of sedation holidays for neurological examination. Conclusions: Our modern and comprehensive sTBI-management protocol is designed to assist clinicians managing sTBI patients monitored with ICP-monitors alone. Consensus-based (class III evidence), it provides management

To evaluate efficacy and safety of aggressive correction of hypophosphatemia with intravenous potassium phosphate in the ICU. Design and setting: Randomized interventional prospective study in the medical and surgical ICU of a tertiary university hospital. Patients: Critically ill patients with hypophosphatemia between June and November 1998. Measurements and results: Patients with moderate hypophosphatemia (<0.65 and >0.40 mmol/l; n=37) were randomized into two groups: group 1 received 30 mmol potassium phosphate intravenously in 50 ml saline over 2 h, and group 2 received 30 mmol potassium phosphate in 100 ml saline over 4 h. Patients with severe hypophosphatemia (<0.40 mmol/l; n=10) were also randomized into two groups: group 3 received 45 mmol potassium phosphate intravenously in 100 ml saline over 3 h, and group 4 received

Septic thrombophlebitis (STP) is a complex, cross-disciplinary clinical condition that combines a localized infection with a neighboring venous thrombosis. STP can occur at several possible anatomic sites, such as dural sinuses, jugular vein (Lemierre syndrome), portal vein (pylephlebitis), and pelvic veins. Its high mortality in the preantibiotic era improved considerably with the introduction of modern antibiotics. However, little evidence exists to date to guide its clinical management. The incidence of STP or its risk factors may be increasing, and its mortality may still be considerable. These trends would have far-reaching implications, especially in the setting of increasing resistance to antimicrobial agents. No clinical assessment tools exist to support patient screening or guide treatment in STP. Few interventional studies exist on the efficacy and safety of anticoagulation. Recommendations on its indications, duration, and the agents of choice are mostly based on evidence derived from small observational studies. While all forms of STP pose similar challenges, future research may benefit from the distinction between bacteria-associated, virus-associated, and mycosis-associated thrombophlebitis. Addressing these gaps in evidence would enhance our ability to diagnose this condition and treat patients effectively.

Objectives To analyse 1-year mortality and functional disability outcomes and resource use in critical stroke patients admitted to ICU. Design and setting Multi-centre, prospective, observational study in 28 Spanish hospitals. Patients Patients admitted for acute stroke from March–August 1999. Intervention Collection of data on: severity by Apache III and Glasgow Coma Score; neurological lesion, hospital and 1-year mortality; functional disability at 1 year by Barthel Index and Glasgow Outcome Scale; ICU length of stay, life support techniques, and neurosurgical interventions. Measurement and results We studied 132 patients: 21% with subarachnoid haemorrhage (SAH), 58% intracerebral haemorrhage (ICH), 20% ischaemic stroke (ISC); Apache III 63±29 ICU stay 13±12 days; 74% required mechanical ventilation. Hospital and 1-year mortality was 33% (22%:ISC, 32%:SAH, 37%:ICH) and 53.8% (66%:ISC, 39%:SAH, 54%:ICH), respectively. Age, APACHE III, and diagnosis defined hospital mortality. Age, APACHE III, and Glasgow Coma Score defined 1-year mortality. Barthel Index score improved (PBarthel Index scores were related to functional outcome at 1 year. Conclusions Critical stroke patients are characterized by high severity of illness, elevated resource consumption, and poor outcomes that are mainly influenced by severity and age. Glasgow Coma Score-measured neurological severity is the main determinant of future functional capacity, which is greater at 1 year.

Objective: To estimate the usefulness of 2-h creatinine clearance (CrCl) in the ICU and define variables that may reduce agreement. Design: Prospective study. Setting: Polyvalent ICU of a university hospital. Patients: 359 patients. Interventions: We compared 24-h CrCl (CrCl-24h), as the standard measure, with 2-h CrCl (CrCl-2h) (at the start of the period) and the Cockroft-Gault equation (Ck-G). Measurements and results:

Objective: To compare in intubated patients manually ventilated in order to mirror the ventilator, the respiratory and hemodynamic effects induced by a bag device equipped with an inspiratory gas flow-limiting valve (Smart Bag, 0-Two Medical Technologies Inc., Mississauga, ON, Canada) and a Standard bag. Design: Non-randomized crossover study comparing 13 respiratory and eight hemodynamically paired parameters. Eight intubated patients were manually ventilated, each by three different intensive care workers yielding 24 sets of data for comparison. Data were collected during two sessions of manual ventilation, first with the Standard bag and then with the Smart Bag. Between each session, the patient was reconnected to the ventilator until return to the baseline. Patients, included after coronary surgery, were sedated and paralyzed. Setting: Intensive Care Unit, university hospital. Results: Compared with Standard bag, the Smart Bag ® provided a decrease of inspiratory flow (23 ± 4.7 vs. 47.3 ± 16.5 l/min) with a decrease

Objective External validation of the paediatric logistic organ dysfunction (PELOD) score in two paediatric intensive care units (PICU) in South America. Methods Prospective observational cohort study including all PICU admissions from July 2003 to December 2004 in Porto Alegre, Brazil, and from January 2004 to December 2004 in Buenos Aires, Argentina. The data collected included demographic variables, diagnosis, need for mechanical ventilation, length of PICU stay and mortality, and the 12 variables in the PELOD score. For each PELOD score variable, the worst daily value and the worst value of the whole PICU stay were used for the daily PELOD (dPELOD) and PELOD scores, respectively. Results A total of 1,476 admissions (51.3% from Argentina and 48.7% from Brazil) were analysed. Observed and predicted mortality were, respectively, 4.7% and 6.6%, with a standardized mortality ratio of 0.72. The score showed excellent discrimination capacity, with an area under the receiver operator characteristic (ROC) curve of 0.93 (0.88–0.98). The dPELOD score on days 1–5 also showed good discrimination capacities, with areas under the ROC curve >0.85. However, PELOD and dPELOD scores showed poor calibration with the Hosmer–Lemeshow test (chi-square 72.3, p  Conclusions The PELOD score is reproducible, has excellent discrimination, but over-predicts mortality and has poor calibration. Although the lack of calibration may not invalidate the score, the PELOD score is a discontinuous variable and we advise careful consideration when using it as a surrogate endpoint in clinical trials.

Inhaled nitric oxide (NO) is used as a therapy of pulmonary hypertension in children after cardiac surgery. Hemoglobin binds to NO with great affinity and forms methemoglobin by oxidation in the erythrocyte. Once produced, methemoglobin is unable to transport and unload oxygen in the tissues. The amount of available hemoglobin in the body for oxygen transport is thereby reduced. Anemia, acidosis, respiratory compromise and cardiac disease may render patients more susceptible than expected for a given methemoglobin level. The goal of the present study was to review the cumulative effect of inhaled NO on methemoglobin formation in critically ill children. We therefore looked for methemoglobin levels in children with congenital heart disease after cardiac surgery who were treated with inhaled NO in a range of 5-40 ppm. We retrospectively reviewed the medical charts of 38 children with congenital heart disease after cardiac surgery. We extracted demographic data and physiological measur...

Purpose: A prospective multicentre cohort study was conducted to determine the prevalence of hypovitaminosis D in adult critically ill patients, to characterize alterations in the parathyroid hormone (PTH)vitamin D-calcium axis and to explore associations between hypovitaminosis D and adverse clinical outcomes. Methods: Demographic, disease severity scores and clinical outcome data were collected in 100 consecutive patients with expected intensive care unit (ICU) admission of at least 2 days. Levels of 25-hydroxyvitamin D (25-OH-D), 1,25dihydroxyvitamin D (1,25-(OH) 2 -D), PTH and ionized calcium were measured on days 1, 3 and on day 7 or ICU discharge. Results: The prevalence of vitamin D insufficiency (25 nmol/L B 25-OH-D B 50 nmol/ L) and deficiency (25-OH-D \ 25 nmol/L) were 54 and 24 %, respectively, and levels did not recover during ICU stay. Admission 25-OH-D levels correlated with 1,25-(OH) 2 -D (R = 0.61, p = 0.001), Simplified Acute Physiology Score (SAPS-II) (R = -0.3, p = 0.01), Acute Physiology and Chronic Health Evaluation (APACHE-II) scores (R = -0.2, p = 0.05), but not calcium (R = 0.16, p = 0.11) or PTH (R = -0.11, p = 0.31) levels. Vitamin D deficiency was associated with fewer hospital-free days, OR 3.15 (1.18-8.43) in univariate analysis. Secondary hyperparathyroidism (PTH [ 7 pmol/L) was observed in 37.5 % of hypocalcaemic and 32.5 % of vitamin D insufficient/deficient patients, and was associated with higher SAPS-II [43 (31.3-60) vs. 36 (30-43), p = 0.03]. Conclusions: Hypovitaminosis D and secondary hyperparathyroidism are highly prevalent in critically ill patients. Low vitamin D status persists during ICU stay and is associated with worse disease severity and fewer hospital-free days.

Objective: To evaluate changes in serum and urinary zinc, cobalt, copper, iron, and calcium concentrations in critically ill patients receiving propofol containing disodium edetate (disodium ethylenediaminetetraacetic acid [EDTA]) versus sedative agents without EDTA. Design: This was a randomised, open-label, parallel-group study with randomisation stratified by baseline Acute Physiology and Chronic Health Evaluation (APACHE II) scores. Setting: Intensive care units (ICU) in 23 medical centres. Patients: Medical, surgical, or trauma ICU patients 17 years of age or older who required mechanical ventilator support and sedation.

Acute kidney injury (AKI) is associated with significantly increased morbidity and mortality. To provide a uniformly accepted definition, the RIFLE classification was introduced by the Acute Dialysis Quality Initiative, recently modified by the Acute Kidney Injury Network (AKIN), suggesting staging of AKI based on dynamic changes within 48 h. This study compares these two classification systems with regard to outcome. Cohort analysis of SAPS 3 database. Sixteen thousand seven hundred and eighty-four ICU patients from 303 ICUs were analysed. Classification was performed according to RIFLE (Risk, Injury, Failure) or according to AKIN (stage 1, 2, 3) without including a requirement of renal replacement therapy in the analysis. Changes of serum creatinine as well as urinary output were assessed for both AKIN and RIFLE during the first 48 h of ICU admission. Primary endpoint was hospital mortality. Incidence of AKI in our population of critically ill patients was found to range between 28.5 and 35.5% when applying AKIN and RIFLE criteria, respectively, associated with increased hospital mortality averaging 36.4%. Observed-to-expected mortality ratios revealed excess mortality conferred by any degree of AKI increasing from 0.81 for patients classified as non-AKI up to 1.31 and 1.23 with AKIN stage 3 or RIFLE Failure, respectively. AKIN misclassified 1,504 patients as non-AKI compared to RIFLE which misclassified 504 patients. Acute kidney injury classified by either RIFLE or AKIN is associated with increased hospital mortality. Despite presumed increased sensitivity by the AKIN classification, RIFLE shows better robustness and a higher detection rate of AKI during the first 48 h of ICU admission.

Purpose: To validate an adaptation of the Behavioral Pain Scale (BPS) for its use in non-intubated intensive care unit (ICU) patients unable to self-report their pain because of the occurrence of delirium. The ''vocalization'' domain was inserted to construct the BPS-non intubated (BPS-NI) scale, ranging from 3 (no pain) to 12 (most pain). Design: Prospective psychometric study in a medical-surgical ICU. Methods: The same physician and one bedside nurse rated pain in nonintubated patients unable to selfreport their pain during four conditions: before and after a catheter dressing change (non-nociceptive procedure) and before and after turning the patient (nociceptive procedure). Delirium was assessed by the Confusion Assessment Method for the ICU (CAM-ICU). Results: A total of 120 paired evaluations were performed in 30 consecutive adult patients, 84% with delirium (CAM-ICU positive). BPS-NI scores were higher during painful procedures than at rest [6.0 (5.0-8.0) vs. 3.0 (3.0-3.8); P \ 0.001], while no changes in BPS-NI scores were found during non-nociceptive procedures (discriminative validity). The BPS-NI had good internal consistency (standardized Cronbach a = 0.79), and each domain reflected the pain expression factor in a balanced way (coefficients between 0.57 and 0.59). The BPS-NI had a good inter-rater reliability (weighted kappa coefficient = 0.89 for the four conditions and 0.82 during nociceptive procedures) and a good responsiveness, with an effect size ranging from 1.5 to 3.6. Conclusions: Pain during procedures is perceived even in non-intubated ICU patients with delirium. In those patients, pain level can be assessed with the BPS-NI scale since this instrument exhibited good psychometric properties.

INTRODUCTION: Ventilator-associated pneumonia (VAP) is the most common nosocomial infection among intensive care unit (ICU) patients. OBJECTIVE: Prospectively identify the factors associated with development of VAP and examine the incidence of VAP. SUBJECTS: Over a 6-month period we had 175 patients who required mechanical ventilation for longer than 24 hours. RESULTS: VAP occurred in 56 patients (32%). Stepwise logistic regression analysis identified 5 factors independently associated with VAP (p < 0.05): bronchoscopy (adjusted odds ratio [AOR] ‫؍‬ 2.95; 95% confidence interval [CI], 1.1-8.3; p ‫؍‬ 0.036); tube thoracostomy (AOR ‫؍‬ 2.78; 95% CI, 1.1-6.6; p ‫؍‬ 0.023); tracheostomy (AOR ‫؍‬ 3.56; 95% CI, 1.7-8.4; p ‫؍‬ 0.002); Acute Physiology and Chronic Health Evaluation (APACHE II) score > 18 (AOR ‫؍‬ 2.33; 95% CI, 1.1-5.1; p ‫؍‬ 0.033); and enteral feeding (AOR ‫؍‬ 2.89; 95% CI, 1.3-7.7; p ‫؍‬ 0.026). The duration of mechanical ventilation was longer among patients who developed VAP (p < 0.001). VAP was not associated with the cause of ICU admission. CONCLUSIONS: VAP is a common infection and certain interventions might affect the incidence of VAP. ICU clinicians should be aware of the risk factors for VAP, which could prove useful in identifying patients at high risk for VAP and modifying patient care to minimize the risk of VAP, such as avoiding unnecessary bronchoscopy or modulating enteral feeding.