Apr 192015
 

The administration of dextrose during in-hospital cardiac arrest is associated with increased mortality and neurologic morbidity.

Crit Care. 2015 Apr 10;19(1):160

Authors: Peng TJ, Andersen LW, Saindon BZ, Giberson TA, Kim WY, Berg K, Novack V, Donnino MW, American Heart Association’s Get With The Guidelines® - Resuscitation Investigators

Abstract
INTRODUCTION: Dextrose may be used during cardiac arrest resuscitation to prevent or reverse hypoglycemia. However, the incidence of dextrose administration during cardiac arrest and the association of dextrose administration with survival and other outcomes are unknown.
METHODS: We utilized the Get With the Guidelines - Resuscitation national registry to identify adult patients with an in-hospital cardiac arrest between the years 2000 and 2010. To assess the adjusted effects of dextrose administration on survival, we used multivariable regression models with adjustment for multiple patient, event and hospital characteristics. We performed additional analyses to examine the effects of dextrose on neurological outcome and return of spontaneous circulation.
RESULTS: Among the 100,029 patients included in our study, 4,189 (4.2%) received dextrose during cardiac arrest resuscitation. The rate of dextrose administration increased during the study period (odds ratio: 1.11 [1.09 - 1.12] per year, p < 0.001). Patients who received dextrose during resuscitation had lower rates of survival compared to patients who did not receive dextrose (relative risk: 0.88 [0.80 - 0.98], p = 0.02). Administration of dextrose was associated with worse neurological outcome (relative risk: 0.88 [0.79 - 0.99], p = 0.03) but an increased chance of return of spontaneous circulation (relative risk: 1.07 [1.04 - 1.10], p < 0.001).
CONCLUSIONS: In this dataset, the administration of dextrose during resuscitation in patients with in-hospital cardiac arrest was found to be associated with a significantly decreased chance of survival and decreased chance of good neurological outcome.

PMID: 25887120 [PubMed - as supplied by publisher]

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Apr 192015
 

Acute kidney injury after cardiac arrest.

Crit Care. 2015 Apr 17;19(1):169

Authors: Tujjar O, Mineo G, Dell'Anna A, Poyatos-Robles B, Donadello K, Scolletta S, Vincent JL, Taccone FS

Abstract
INTRODUCTION: To evaluate the incidence and determinants of AKI in a large cohort of cardiac arrest patients.
METHODS: We reviewed all patients admitted, for at least 48 hours, to our Dept. of Intensive Care after CA between January 2008 and October 2012. AKI was defined as oligo-anuria (daily urine output <0.5 ml/kg/h) and/or an increase in serum creatinine (≥0.3 mg/dl from admission value within 48 hours or a 1.5 time from baseline level). Demographics, comorbidities, CA details, and ICU interventions were recorded. Neurological outcome was assessed at 3 months using the Cerebral Performance Category scale (CPC 1-2 = favorable outcome; 3-5 = poor outcome).
RESULTS: A total of 199 patients were included, 85 (43%) of whom developed AKI during the ICU stay. Independent predictors of AKI development were older age, chronic renal disease, higher dose of epinephrine, in-hospital CA, presence of shock during the ICU stay, a low creatinine clearance (CrCl) on admission and a high cumulative fluid balance at 48 hours. Patients with AKI had higher hospital mortality (55/85 vs. 57/114, p = 0.04), but AKI was not an independent predictor of poor 3-month neurological outcome.
CONCLUSIONS: AKI occurred in more than 40% of patients after CA. These patients had more severe hemodynamic impairment and needed more aggressive ICU therapy; however the development of AKI did not influence neurological recovery.

PMID: 25887258 [PubMed - as supplied by publisher]

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Apr 192015
 

Systolic blood pressure and short-term mortality in the emergency department and prehospital setting: a hospital-based cohort study.

Crit Care. 2015 Apr 9;19(1):158

Authors: Kristensen AK, Holler JG, Mikkelsen S, Hallas J, Lassen A

Abstract
INTRODUCTION: Systolic blood pressure is a widely used tool to assess circulatory function in acutely ill patients. The systolic blood pressure limit where a given patient should be considered hypotensive is the subject of debate and recent studies have advocated higher systolic blood pressure thresholds than the traditional 90 mmHg. The aim of this study was to identify the best performing systolic blood pressure thresholds with regards to predicting 7-day mortality and to evaluate the applicability of these in the emergency department as well as in the prehospital setting.
METHODS: A retrospective, hospital-based cohort study was performed at Odense University Hospital which included all adult patients in the emergency department between 1995 and 2011, all patients transported to the emergency department in ambulances in the period 2012-2013, and all patients serviced by the physician staffed mobile emergency care unit in Odense between 2007 and 2013. We used the first recorded systolic blood pressure and the main outcome was 7-day mortality. Best performing thresholds were identified with methods based on receiver operating characteristics (ROC) and multivariate regression. The performance of systolic blood pressure thresholds was evaluated with standard summary statistics for diagnostic tests.
RESULTS: 7-day mortality rates varied from 1.8 % (95 % CI [1.7, 1.9]) of 112,727 patients in the emergency department to 2.2 % (95 % CI [2.0, 2.5]) of 15,862 patients in the ambulance and 5.7 % (95 % CI [5.3, 6.2]) of 12,270 patients in the mobile emergency care units. Best performing thresholds ranged from 95 to 119 mmHg in the emergency department, 103-120 mmHg in the ambulance, and 101-115 mmHg in the MECU but area under the ROC curve indicated poor overall discriminatory performance of SBP thresholds in all cohorts.
CONCLUSIONS: Systolic blood pressure alone is not sufficient to identify patients at risk regardless of the defined threshold for hypotension. If, however, a threshold is to be defined, a systolic blood pressure threshold of 100-110 mmHg is probably more relevant than the traditional 90 mmHg.

PMID: 25888035 [PubMed - as supplied by publisher]

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Apr 192015
 

A simple prognostic index based on admission vital signs data among patients with sepsis in a resource-limited setting.

Crit Care. 2015;19(1):86

Authors: Asiimwe SB, Abdallah A, Ssekitoleko R

Abstract
INTRODUCTION: In sub-Saharan Africa, vital signs are a feasible option for monitoring critically ill patients. We assessed how admission vital signs data predict in-hospital mortality among patients with sepsis. In particular, we assessed whether vital signs data can be incorporated into a prognostic index with reduced segmentation in the values of included variables.
METHODS: Subjects were patients with sepsis hospitalized in Uganda, who participated in two cohort studies. Using restricted cubic splines of admission vital signs data, we predicted probability of in-hospital death in the development cohort and used this information to construct a simple prognostic index. We assessed the performance of the index in a validation cohort and compared its performance to that of the Modified Early Warning Score (MEWS).
RESULTS: We included 317 patients (167 in the development cohort and 150 in the validation cohort). Based on how vital signs predicted mortality, we created a prognostic index giving a score of 1 for: respiratory rates ≥30 cycles/minute; pulse rates ≥100 beats/minute; mean arterial pressures ≥110/<70 mmHg; temperatures ≥38.6/<35.6°C; and presence of altered mental state defined as Glasgow coma score ≤14; 0 for all other values. The proposed index (maximum score = 5) predicted mortality comparably to MEWS. Patients scoring ≥3 on the index were 3.4-fold (95% confidence interval (CI) 1.6 to 7.3, P = 0.001) and 2.3-fold (95% CI 1.1 to 4.7, P = 0.031) as likely to die in hospital as those scoring 0 to 2 in the development and validation cohorts respectively; those scoring ≥5 on MEWS were 2.5-fold (95% CI 1.2 to 5.3, P = 0.017) and 1.8-fold (95% CI 0.74 to 4.2, P = 0.204) as likely to die as those scoring 0 to 4 in the development and validation cohorts respectively.
CONCLUSION: Among patients with sepsis, a prognostic index incorporating admission vital signs data with reduced segmentation in the values of included variables adequately predicted mortality. Such an index may be more easily implemented when triaging acutely-ill patients. Future studies using a similar approach may develop indexes that can be used to monitor treatment among acutely-ill patients, especially in resource-limited settings.

PMID: 25888322 [PubMed - as supplied by publisher]

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Apr 192015
 

A systematic review of implementation strategies for assessment, prevention, and management of ICU delirium and their effect on clinical outcomes.

Crit Care. 2015 Apr 9;19(1):157

Authors: Trogrlić Z, van der Jagt M, Bakker J, Balas MC, Ely EW, van der Voort PH, Ista E

Abstract
INTRODUCTION: Despite recommendations from professional societies and patient safety organizations, the majority of ICU patients worldwide are not routinely monitored for delirium, thus preventing timely prevention and management. The purpose of this systematic review is to summarize what types of implementation strategies have been tested to improve ICU clinicians' ability to effectively assess, prevent and treat delirium and to evaluate the effect of these strategies on clinical outcomes.
METHOD: We searched PubMed, Embase, PsychINFO, Cochrane and CINAHL (January 2000 and April 2014) for studies on implementation strategies that included delirium-oriented interventions in adult ICU patients. Studies were suitable for inclusion if implementation strategies' efficacy, in terms of a clinical outcome, or process outcome was described.
RESULTS: We included 21 studies, all including process measures, while 9 reported both process measures and clinical outcomes. Some individual strategies such as "audit and feedback" and "tailored interventions" may be important to establish clinical outcome improvements, but otherwise robust data on effectiveness of specific implementation strategies were scarce. Successful implementation interventions were frequently reported to change process measures, such as improvements in adherence to delirium screening with up to 92%, but relating process measures to outcome changes was generally not possible. In meta-analyses, reduced mortality and ICU length of stay reduction were statistically more likely with implementation programs that employed more (six or more) rather than less implementation strategies and when a framework was used that either integrated current evidence on pain, agitation and delirium management (PAD) or when a strategy of early awakening, breathing, delirium screening and early exercise (ABCDE bundle) was employed. Using implementation strategies aimed at organizational change, next to behavioural change ,was also associated with reduced mortality.
CONCLUSION: Our findings may indicate that multi-component implementation programs with a higher number of strategies targeting ICU delirium assessment, prevention and treatment and integrated within PAD or ABCDE bundle have the potential to improve clinical outcomes. However, prospective confirmation of these findings is needed to inform the most effective implementation practice with regard to integrated delirium management and such research should clearly delineate effective practice change from improvements in clinical outcomes.

PMID: 25888230 [PubMed - as supplied by publisher]

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Apr 192015
 

Prognostic value of procalcitonin in respiratory tract infections across clinical settings.

Crit Care. 2015;19(1):74

Authors: Kutz A, Briel M, Christ-Crain M, Stolz D, Bouadma L, Wolff M, Kristoffersen KB, Wei L, Burkhardt O, Welte T, Schroeder S, Nobre V, Tamm M, Bhatnagar N, Bucher HC, Luyt CE, Chastre J, Tubach F, Mueller B, Schuetz P

Abstract
INTRODUCTION: Whether the inflammatory biomarker procalcitonin provides prognostic information across clinical settings and different acute respiratory tract infections (ARIs) is poorly understood. In the present study, we investigated the prognostic value of admission procalcitonin levels to predict adverse clinical outcome in a large ARI population.
METHODS: We analysed data from 14 trials and 4,211 ARI patients to study associations of admission procalcitonin levels and setting specific treatment failure and mortality alone at 30 days. We used multivariable hierarchical logistic regression and conducted sensitivity analyses stratified by clinical settings and ARI diagnoses to assess the results' consistency.
RESULTS: Overall, 864 patients (20.5%) experienced treatment failure and 252 (6.0%) died. The ability of procalcitonin to differentiate patients with from those without treatment failure was highest in the emergency department setting (treatment failure area under the curve (AUC): 0.64 (95% confidence interval (CI): 0.61, 0.67), adjusted odds ratio (OR): 1.85 (95% CI: 1.61, 2.12), P <0.001; and mortality AUC: 0.67 (95% CI: 0.63, 0.71), adjusted OR: 1.82 (95% CI: 1.45, 2.29), P <0.001). In lower respiratory tract infections, procalcitonin was a good predictor of identifying patients at risk for mortality (AUC: 0.71 (95% CI: 0.68, 0.74), adjusted OR: 2.13 (95% CI: 1.82, 2.49), P <0.001). In primary care and intensive care unit patients, no significant association of initial procalcitonin levels and outcome was found.
CONCLUSIONS: Admission procalcitonin levels are associated with setting specific treatment failure and provide the most prognostic information regarding ARI in the emergency department setting.

PMID: 25887979 [PubMed - as supplied by publisher]

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