Related Articles

Anemia and blood transfusion and outcome on the intensive care unit.

Crit Care. 2010 May 25;14(1):438

Authors: Müller MC, Juffermans NP

ABSTRACT: The observation of Sakr and colleagues that transfusion may be beneficial in certain subgroups of intensive care unit (ICU) patients 1 is interesting, since large observational studies demonstrate that transfusion is independently associated with an increased risk of death 2. Also, a systematic review showed that the benefits of transfusion in the ICU do not outweigh the risks 3. Sakr and colleagues ascribe their discrepant results to the fact that transfused blood was leukoreduced. Of the 17 randomized controlled trials on the association of nonleukoreduced blood with mortality, however, a benefit of leukoreduction was found only in cardiac surgery patients 4. A meta-analysis confirmed that available evidence does not justify universal leukoreduction 5.Given the increased risk of nosocomial infection, multiple organ failure and acute respiratory distress syndrome, an explanation of a beneficial effect from transfusion in anemic critically ill patients is tempting. We propose that the results of this study may be related to the indication of transfusion, this being active bleeding and not correction of anemia associated with critical illness. Hereby, transfusion may have prevented adverse events due to postoperative bleeding, explaining the survival benefit. The fact that 76% of patients were referred from the operating/recovery room and that the median length of ICU stay was only 1 day may support this hypothesis. Based on numerous reports on the association of transfusion with adverse outcome, a liberal transfusion strategy in critically ill anemic patients in the absence of acute bleeding should not be advocated.

PMID: 20804562 [PubMed - as supplied by publisher]

[Read more →]

Related Articles

Corticosteroids for sepsis: registry versus Cochrane systematic review!

Crit Care. 2010 Jul 30;14(4):185

Authors: Annane D

ABSTRACT: A recent report from the PROGRESS registry highlighted that low dose corticosteroids are widely used in patients with sepsis around the world. In this report, corticosteroids may be associated with increased morbidity and mortality. However, these findings should be viewed with caution given that this study has several inherent flaws because of its retrospective nature and the lack of controlled use of corticosteroids. In this commentary, these findings are contrasted with those of a recent Cochrane systematic review.

PMID: 20727225 [PubMed - as supplied by publisher]

[Read more →]

Related Articles

Bench to bedside: A role for erythropoietin in sepsis.

Crit Care. 2010 Aug 6;14(4):227

Authors: Walden AP, Young JD, Sharples E

ABSTRACT: Sepsis is the systemic inflammatory response to infection and can result in multiple organ dysfunction syndrome with associated high mortality, morbidity and health costs. Erythropoietin is a well-established treatment for the anaemia of renal failure due to its anti-apoptotic effects on red blood cells and their precursors. The extra-haemopoietic actions of erythropoietin include vasopressor, anti-apoptotic, cytoprotective and immunomodulating actions, all of which could prove beneficial in sepsis. Attenuation of organ dysfunction has been shown in several animal models and its vasopressor effects have been well characterised in laboratory and clinical settings. Clinical trials of erythropoietin in single organ disorders have suggested promising cytoprotective effects, and while no randomised trials have been performed in patients with sepsis, good quality data exist from studies on anaemia in critically ill patients, giving useful information of its pharmacokinetics and potential for harm. An observational cohort study examining the microvascular effects of erythropoietin is underway and the evidence would support further phase II and III clinical trials examining this molecule as an adjunctive treatment in sepsis.

PMID: 20727227 [PubMed - as supplied by publisher]

[Read more →]

The interpretation of brain natriuretic peptide in critical care patients; will it ever be useful?

Crit Care. 2010 Aug 6;14(4):184

Authors: Dixon J, Philips B

ABSTRACT: The measurement of B-type natriuretic peptide (BNP) is recommended for the diagnosis of decompensated heart failure, the prognosis of chronic heart failure is worse if BNP is increased and studies suggest that BNP is useful to guide therapy. A study by Di Somma and colleagues adds to the body of evidence showing that patients with a marked decrease in BNP concentrations during their hospital admission are less likely to be readmitted with a further adverse cardiac event than patients in whom BNP fails to decrease. However, the wider interpretation of BNP concentrations in critically ill patients with other conditions remains uncertain.

PMID: 20712913 [PubMed - as supplied by publisher]

[Read more →]

Organ failure and tight glycemic control in the SPRINT study.

Crit Care. 2010 Aug 12;14(4):R154

Authors: Chase JG, Pretty CG, Pfeifer L, Shaw GM, Preiser JC, Le Compte AJ, Lin J, Hewett D, Moorhead KT, Desaive T

ABSTRACT: INTRODUCTION: Intensive care unit mortality is strongly associated with organ failure rate and severity. The sequential organ failure assessment (SOFA) score is used to evaluate the impact of a successful tight glycemic control (TGC) intervention (SPRINT) on organ failure, morbidity, and thus mortality. METHODS: A retrospective analysis of 371 patients (3356 days) on SPRINT (August 2005 – April 2007) and 413 retrospective patients (3211 days) from 2 years prior, matched by Acute Physiology And Chronic Health Evaluation (APACHE) III. SOFA is calculated daily for each patient. The effect of the SPRINT TGC intervention is assessed by comparing the percentage of patients with SOFA[less than or equal to]5 each day and its trends over time and cohort/group. Organ-failure free days (all SOFA components [less than or equal to] 2) and number of organ failures (SOFA components > 2) are also compared. Cumulative time in 4.0-7.0 mmol/L band (cTIB) was evaluated daily to link tightness and consistency of TGC (cTIB[greater than or equal to]0.5) to SOFA[less than or equal to]5 using conditional and joint probabilities. RESULTS: Admission and maximum SOFA scores were similar (p=0.20; p=0.76), with similar time to maximum (median: 1 day; IQR: [1, 3] days; p=0.99). Median length of stay was similar (4.1 days SPRINT and 3.8 days Pre-SPRINT; p=0.94). The percentage of patients with SOFA[less than or equal to]5 is different over the first 14 days (p=0.016), rising to ~75% for Pre-SPRINT and ~85% for SPRINT, with clear separation after 2 days. Organ failure free days were different (SPRINT=41.6%; Pre-SPRINT=36.5%; p<0.0001) as were the percent of total possible organ failures (SPRINT=16.0%; Pre-SPRINT=19.0%; p<0.0001). By day 3 over 90% of SPRINT patients had cTIB[greater than or equal to]0.5 (37% Pre-SPRINT) reaching 100% by day 7 (50% Pre-SPRINT). Conditional and joint probabilities indicate tighter, more consistent TGC under SPRINT (cTIB[greater than or equal to]0.5) increased the likelihood SOFA[less than or equal to]5. CONCLUSIONS: SPRINT TGC resolved organ failure faster, and for more patients, from similar admission and maximum SOFA scores, than conventional control. These reductions mirror the reduced mortality with SPRINT. The cTIB[greater than or equal to]0.5 metric provides a first benchmark linking TGC quality to organ failure. These results support other physiological and clinical results indicating the role tight, consistent TGC can play in reducing organ failure, morbidity and mortality, and should be validated on data from randomised trials.

PMID: 20704712 [PubMed - as supplied by publisher]

[Read more →]

Treatment of hypophosphatemia in the intensive care unit: a review.

Crit Care. 2010 Aug 3;14(4):R147

Authors: Geerse DA, Bindels AJ, Kuiper MA, Roos AN, Spronk PE, Schultz MJ

ABSTRACT: INTRODUCTION: There is currently no evidence-based guideline for the approach to hypophosphatemia in critically ill patients. METHODS: We performed a narrative review of the medical literature to identify the incidence, symptoms, and treatment of hypophosphatemia in critically ill patients. Specifically, we searched for answers to the questions whether correction of hypophosphatemia is associated with improved outcome, and whether a certain treatment strategy is superior. RESULTS: Incidence: hypophosphatemia is frequently encountered in the intensive care unit; critically ill patients are at increased risk for developing hypophosphatemia due to the presence of multiple causal factors. Symptoms: hypophosphatemia may lead to a multitude of symptoms, including cardiac and respiratory failure. Treatment: hypophosphatemia is generally corrected when it is symptomatic or severe. However, although multiple studies confirm the efficacy and safety of intravenous phosphate administration, it remains uncertain when and how to correct hypophosphatemia. Outcome: in some studies hypophosphatemia was associated with higher mortality; there is a paucity of randomized controlled evidence for whether correction of hypophosphatemia improves outcome in critically ill patients. CONCLUSIONS: Additional studies addressing the current approach to hypophosphatemia in critically ill patients are required. Studies should focus on the association between hypophosphatemia and morbidity and/or mortality, as well as the effect of correction of this electrolyte disorder.

PMID: 20682049 [PubMed - as supplied by publisher]

[Read more →]

Macrolides and community-acquired pneumonia: is quorum sensing the key?

Crit Care. 2010 Jul 20;14(4):181

Authors: Wise MP, Williams DW, Lewis MA, Frost PJ

ABSTRACT: Combination therapy with two antimicrobial agents is superior to monotherapy in severe community-acquired pneumonia, and recent data suggest that addition of a macrolide as the second antibiotic might be superior to other combinations. This observation requires confirmation in a randomised control trial, but this group of antibiotics have pleiotropic effects that extend beyond bacterial killing. Macrolides inhibit bacterial cell-to-cell communication or quorum sensing, which not only might be an important mechanism of action for these drugs in severe infections but may also provide a novel target for the development of new anti-infective drugs.

PMID: 20663182 [PubMed - as supplied by publisher]

[Read more →]

Proven infection-related sepsis induces a differential stress response early after ICU admission.

Crit Care. 2010 Jul 9;14(4):R131

Authors: Lesur O, Roussy JF, Chagnon F, Gallo-Payet N, Dumaine R, Sarret P, Chraibi A, Chouinard L, Hogue B

ABSTRACT: INTRODUCTION: Neuropeptides arginine-vasopressin (AVP), apelin (APL), and stromal-derived factor-1alpha (SDF-1alpha) are involved in the dysfunction of the corticotropic axis observed in septic ICU patients. Study aims were: (i) to portray a distinctive stress-related neuro-corticotropic systemic profile of early sepsis, (ii) to propose a combination data score, for aiding ICU physicians in diagnosing sepsis on admission. METHODS: This prospective one-center observational study was carried out in a medical intensive care unit (MICU), tertiary teaching hospital. Seventy-four out of 112 critically ill patients exhibiting systemic inflammatory response syndrome (SIRS) were divided into two groups: proven sepsis and "non sepsis", based on post hoc analysis of microbiological criteria and final diagnosis, and compared to healthy volunteers (n=14). A single blood sampling was performed on admission for measurements of AVP, copeptin, APL, SDF-1alpha, adrenocorticotropic hormone (ACTH), cortisol baseline and post-stimulation, and procalcitonin (PCT). RESULTS: Blood baseline ACTH/cortisol ratio was lower and copeptin higher in septic vs. nonseptic patients. SDF-1alpha was further increased in septic patients vs. normal patients. Cortisol baseline, ACTH, PCT, Apache II and sepsis scores, and shock on admission, were independent predictors of sepsis diagnosis upon admission. Using the three first aforementioned categorical bio-parameters, a probability score for predicting sepsis yielded an area under the ROC curves better than sepsis score or PCT alone (0.903 vs 0.727 and 0.726: P=0.005 and P<0.04, respectively). CONCLUSIONS: The stress response of early admitted ICU patients is different in septic vs. non-septic conditions. A proposed combination of variable score analyses will tentatively help in refining bedside diagnostic tools to efficiently diagnose sepsis after further validation.

PMID: 20615266 [PubMed - as supplied by publisher]

[Read more →]

Bench-to-bedside review: The role of beta-lactamases in antibiotic-resistant Gram-negative infections.

Crit Care. 2010 Jun 29;14(3):224

Authors: Bush K

ABSTRACT: Multidrug resistance has been increasing among Gram-negative bacteria and is strongly associated with the production of both chromosomal- and plasmid-encoded beta-lactamases, whose number now exceeds 890. Many of the newer enzymes exhibit broad-spectrum hydrolytic activity against most classes of beta-lactams. The most important plasmid-encoded beta-lactamases include (a) AmpC cephalosporinases produced in high quantities, (b) the expanding families of extended-spectrum beta-lactamases such as the CTX-M enzymes that can hydrolyze the advanced-spectrum cephalosporins and monobactams, and (c) carbapenemases from multiple molecular classes that are responsible for resistance to almost all beta-lactams, including the carbapenems. Important plasmid-encoded carbapenemases include (a) the KPC beta-lactamases originating in Klebsiella pneumoniae isolates and now appearing worldwide in pan-resistant Gram-negative pathogens and (b) metallo-beta-lactamases that are produced in organisms with other deleterious beta-lactamases, causing resistance to all beta-lactams except aztreonam. beta-Lactamase genes encoding these enzymes are often carried on plasmids that bear additional resistance determinants for other antibiotic classes. As a result, some infections caused by Gram-negative pathogens can now be treated with only a limited number, if any, antibiotics. Because multidrug resistance in Gram-negative bacteria is observed in both nosocomial and community isolates, eradication of these resistant strains is becoming more difficult.

PMID: 20594363 [PubMed - as supplied by publisher]

[Read more →]

Echocardiography: a help in the weaning process.

Crit Care. 2010 Jun 22;14(3):R120

Authors: Caille V, Amiel JB, Charron C, Belliard G, Vieillard-Baron A, Vignon P

ABSTRACT: INTRODUCTION: To evaluate the ability of transthoracic echocardiography (TTE) to detect the effects of spontaneous breathing trial (SBT) on central hemodynamics and to identify indices predictive of cardiac-related weaning failure. METHODS: TTE was performed just before and at the end of a 30-min SBT in 117 patients fulfilling weaning criteria. Maximal velocities of mitral E and A waves, deceleration time of E wave (DTE), maximal velocity of E' wave (tissue Doppler at the lateral mitral annulus), and left ventricular (LV) stroke volume were measured. Values of TTE parameters were compared between baseline (pressure support ventilation) and SBT in all patients and according to LV ejection fraction (EF): >50% (n=58), 35% to 50% (n=30), and <35% (n=29). Baseline TTE indices were also compared between patients who were weaned (n=94) and those who failed (n=23). RESULTS: Weaning failure was of cardiac origin in 20/23 patients (87%). SBT resulted in a significant increase in cardiac output and E/A, and a shortened DTE. At baseline, DTE was significantly shorter in patients with LVEF <35% when compared to other subgroups (median [25th-75th percentiles]: 119 ms [90-153] vs. 187 ms [144-224] vs. 174 ms [152-193]; P<0.01) and E/E' was greater (7.9 [5.4-9.1] vs. 6.0 [5.3-9.0] vs. 5.2 [4.7-6.0]; P<0.01). When compared to patients who were successfully weaned, those patients who failed exhibited at baseline a significantly lower LVEF (36% [27-55] vs. 51% [43-55]: P=0.04) and higher E/E' (7.0 [5.0-9.2] vs. 5.6 [5.2-6.3]: P=0.04). CONCLUSIONS: TTE detects SBT-induced changes in central hemodynamics. When performed by an experienced operator prior to SBT, TTE helps in identifying patients at high risk of cardiac-related weaning failure when documenting a depressed LVEF, shortened DTE and increased E/E'. Further studies are needed to evaluate the impact of this screening strategy on the weaning process and patient outcome.

PMID: 20569504 [PubMed - as supplied by publisher]

[Read more →]

Incidence and prognostic impact of new onset atrial fibrillation in patients with septic shock: a prospective observational study.

Crit Care. 2010 Jun 10;14(3):R108

Authors: Meierhenrich R, Steinhilber E, Eggermann C, Weiss M, Voglic S, Bogelein D, Gauss A, Georgieff M, Stahl W

ABSTRACT: INTRODUCTION: Since data regarding new onset atrial fibrillation (AF) in septic shock patients are scarce, the purpose of the present study was to evaluate the incidence and prognostic impact of new onset AF in this patient group. METHODS: We prospectively studied all patients with new onset AF and all patients suffering from septic shock in a non-cardiac surgical intensive care unit (ICU) during a 13 month period. RESULTS: During the study period, 687 patients were admitted to the ICU, of which 58 patients were excluded from further analysis due to pre-existing chronic or intermittent AF. In 49 out of the remaining 629 patients (7.8%) new onset AF occurred and 50 out of the 629 patients suffered from septic shock. 23 out of the 50 patients with septic shock (46%) developed new onset AF. There was a steady, significant increase in C-reactive protein (CRP) levels before onset of AF in septic shock patients. ICU mortality in septic shock patients with new onset AF was 10/23 (44%) compared with 6/27 (22%) in septic shock patients with maintained sinus rhythm (SR) (P=0.14). During a 2-year follow-up there was a trend towards an increased mortality in septic shock patients with new onset AF, but the difference did not reach statistical significance (P=0.075). The median length of ICU stay among surviving patients was longer in patients with new onset AF compared to those with maintained SR (30 versus 17 days, P=0.017). The success rate to restore SR was 86%. Failure to restore SR was associated with increased ICU mortality (71.4 % versus 21.4%, P=0.015). CONCLUSIONS: AF is a common complication in septic shock patients and is associated with an increased length of ICU stay among surviving patients. The increase in CRP levels before onset of AF may support the hypothesis that systemic inflammation is an important trigger for AF.

PMID: 20537138 [PubMed - as supplied by publisher]

[Read more →]

Another step for noninvasive ventilation in chronic obstructive pulmonary disease patients!

Crit Care. 2010 Jun 9;14(3):163

Authors: Jaber S, Chanques G

ABSTRACT: The use of noninvasive positive pressure ventilation (NPPV) in chronic obstructive pulmonary disease (COPD) patients who are not eligible for the technique because of their incapability to spontaneously eliminate accumulated secretions associated with hypercapnic encephalopathy is not recommended and is often considered a contraindication. In a case-control study, an experienced team reported the feasibility and safety of the use of NPPV with early fibreoptic bronchoscopy in selected acutely decompensated COPD patients with hypercapnic encephalopathy, and reported the patients’ inability to spontaneously clear copious secretions. The reported data suggest that this innovative therapeutic may be considered as a potential alternative to endotracheal intubation.

PMID: 20537199 [PubMed - as supplied by publisher]

[Read more →]

In-hospital percentage BNP reduction is highly predictive for adverse events in patients admitted for acute heart failure: the Italian RED Study.

Crit Care. 2010 Jun 15;14(3):R116

Authors: Di Somma S, Magrini L, Pittoni V, Marino R, Mastrantuono A, Ferri E, Ballarino P, Semplicini A, Bertazzoni G, Carpinteri G, Mule P, Pazzaglia M, Shah K, Maisel A, Clopton P

ABSTRACT: INTRODUCTION: Our aim was to evaluate the role of B-type natriuretic peptide (BNP) percentage variations at 24 hours and at discharge compared to its value at admission in order to demonstrate its predictive value for outcomes in patients with acute decompensated heart failure (ADHF). METHODS: This was a multicenter Italian (8 centers) observational study (Italian Research Emergency Department: RED). 287 patients with ADHF were studied through physical exams, lab tests, chest X Ray, electrocardiograms (ECGs) and BNP measurements, performed at admission, at 24 hours, and at discharge. Follow up was performed 180 days after hospital discharge. Logistic regression analysis was used to estimate odds ratios (OR) for the various subgroups created. For all comparisons, a P value < 0.05 was considered statistically significant. RESULTS: BNP median (interquartile range (IQR)) value at admission was 822 (412 – 1390) pg\mL; at 24 hours was 593 (270 – 1953) and at discharge was 325 (160 – 725). A BNP reduction of >46% at discharge had an area under curve (AUC) of 0.70 (P <0.001) for predicting future adverse events. There were 78 events through follow up and in 58 of these patients the BNP level at discharge was >300 pg/mL. A BNP reduction of 25.9% after 24 hours had an AUC at ROC curve of 0.64 for predicting adverse events (P <0.001). The odds ratio of the patients whose BNP level at discharge was <300pg/mL and whose percentage decrease at discharge was <46% compared to the group whose BNP level at discharge was <300pg/mL and whose percentage decrease at discharge was >46% was 4.775 (95% confidence interval (CI) 1.76 – 12.83, P <0.002). The odds ratio of the patients whose BNP level at discharge was >300pg/mL and whose percentage decrease at discharge was <46% compared to the group whose BNP level at discharge was <300pg/mL and whose percentage decrease at discharge was >46% was 9.614 (CI 4.51 – 20.47, P <0.001). CONCLUSIONS: A reduction of BNP >46% at hospital discharge compared to the admission levels coupled with a BNP absolute value <300 pg/mL seems to be a very powerful negative prognostic value for future cardiovascular outcomes in patients hospitalized with ADHF.

PMID: 20550660 [PubMed - as supplied by publisher]

[Read more →]

Model of end stage liver disease (MELD) score greater than 23 predicts length of stay in the ICU but not mortality in liver transplant recipients.

Crit Care. 2010 Jun 15;14(3):R117

Authors: Oberkofler CE, Duttkowski P, Stocker R, Stover JF, Schuepbach RA, Clavien PA, Bechir M

ABSTRACT: INTRODUCTION: The impact of model of end stage liver disease (MELD) score on postoperative morbidity and mortality is still elusive, especially for high MELD. There are reports of poorer patient outcome in transplant candidates with high MELD score, others though report no influence of MELD score on outcome and survival. METHODS: We retrospectively analyzed data of 144 consecutive liver transplant recipients over a 72-month period in our transplant unit, from January 2003 until December 2008 and performed uni- and multivariate analysis for morbidity and mortality, in particular to define the influence of MELD to these parameters. RESULTS: This study identified MELD score greater than 23 as an independent risk factor of morbidity represented by intensive care unit (ICU) stay longer than 10 days (odds ratio 7.0) but in contrast had no negative impact on mortality. Furthermore, we identified transfusion of more than 7 units of red blood cells as independent risk factor for mortality (hazard ratio 7.6) and for prolonged ICU stay (odds ratio [OR] 7.8) together with transfusion of more than 10 units of fresh frozen plasma (OR 11.6). Postoperative renal failure is a strong predictor of morbidity (OR 7.9) and postoperative renal replacement therapy was highly associated with increased mortality (hazard ratio 6.8), as was hepato renal syndrome prior to transplantation (hazard ratio 13.2). CONCLUSIONS: This study identified MELD score greater than 23 as an independent risk factor of morbidity represented by ICU stay longer than 10 days but in contrast had no negative impact on mortality. This finding supports the transplantation of patients with high MELD score but only with knowledge of increased morbidity.

PMID: 20550662 [PubMed - as supplied by publisher]

[Read more →]

Clinical review: Strict or loose glycemic control in critically ill patients – implementing best available evidence from randomized controlled trials.

Crit Care. 2010 Jun 7;14(3):223

Authors: Schultz MJ, Harmsen RE, Spronk PE

ABSTRACT: Glycemic control aiming at normoglycemia, frequently referred to as ’strict glycemic control’ (SGC), decreased mortality and morbidity of adult critically ill patients in two randomized controlled trials (RCTs). Five successive RCTs, however, failed to show benefit of SGC with one trial even reporting an unexpected higher mortality. Consequently, enthusiasm for the implementation of SGC has declined, hampering translation of SGC into daily ICU practice. In this manuscript we attempt to explain the variances in outcomes of the RCTs of SGC, and point out other limitations of the current literature on glycemic control in ICU patients. There are several alternative explanations for why the five negative RCTs showed no beneficial effects of SGC, apart from the possibility that SGC may indeed not benefit ICU patients. These include, but are not restricted to, variability in the performance of SGC, differences among trial designs, changes in standard of care, differences in timing (that is, initiation) of SGC, and the convergence between the intervention groups and control groups with respect to achieved blood glucose levels in the successive RCTs. Additional factors that may hamper translation of SGC into daily ICU practice include the feared risk of severe hypoglycemia, additional labor associated with SGC, and uncertainties about who the primarily responsible caregiver should be for the implementation of SGC.

PMID: 20550725 [PubMed - as supplied by publisher]

[Read more →]