Tag Archives: research

Antibiotic Timing and Mortality in Sepsis

The current standard of care for sepsis is the early administration of antibiotics. However, efforts to shorten time to antibiotic administration may also cause harm because more patients may receive unnecessary antibiotics. Liu et al  evaluated the association between antibiotic timing and mortality among patients with sepsis receiving antibiotics within 6 hours of emergency department registration.

They found that hourly delays in antibiotic administration for patients with sepsis were associated with increased odds of hospital mortality, even among patients who received antibiotics within 6 hours.

Read the full Concise Critical Appraisal by logging in to the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

Outcomes of Mandated Sepsis Bundles

It is a requirement in some hospitals to follow protocols for the early identification and treatment of sepsis. However, there is controversy about whether more rapid treatment of sepsis improves outcomes in patients. Therefore, Seymour et al set out to determine the association between the time until completion of the 3-hour bundle and risk-adjusted mortality.

They found that more rapid completion of the 3-hour bundle of sepsis care and rapid antibiotics, but not rapid completion of an initial bolus of intravenous fluids, were associated with lower risk-adjusted in-hospital mortality.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

Examining Out-of-Hospital Cardiac Arrest

Out-of-hospital cardiac arrest is a major public health problem affecting over 300,000 persons in the United States each year. Therefore, Wang et al set out to determine if arterial oxygen and carbon dioxide abnormalities in the first 24 hours after return of spontaneous circulation are associated with increased mortality in adult out-of-hospital cardiac arrest.

They found that in the first 24 hours after return of spontaneous circulation, post-arrest
oxygen and carbon dioxide tension abnormalities are associated with increased out-of-hospital cardiac arrest mortality.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

Optimal Position for Intubation

Hypoxemia is the most common complication during endotracheal intubation of critically ill adults. Intubation in the ramped position has been hypothesized to prevent hypoxemia by increasing functional residual capacity and decreasing the duration of intubation, but has never been studied outside of the operating room. Therefore, Semler et al conducted a multicenter, randomized trial comparing the ramped position with the sniffing position among 260 adults undergoing endotracheal intubation by pulmonary and critical care medicine fellows in four intensive care units between July 22, 2015, and July 19, 2016.

They found that the ramped position did not improve oxygenation during endotracheal intubation of critically ill adults compared with the sniffing position.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

mRNA Expression of CD74 and IL10

Intensive care unit-acquired infections (IAIs) result in increased hospital and intensive care unit stay, costs and mortality. To date, no biomarker has shown sufficient evidence and ease of application in clinical routine for the identification of patients at risk of IAI. Therefore, Peronnet et al evaluated the association of the systemic mRNA expression of two host response biomarkers, CD74 and IL10, with IAI occurrence in a large cohort of intensive care unit patients.

Their results suggest that two immune biomarkers, CD74 and IL10, could be relevant tools for the identification of IAI risk in intensive care unit patients.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

Examining Stress Ulcer Prophylaxis

A decreased frequency of upper gastrointestinal bleeding and a possible association of proton pump inhibitor use with Clostridium difficile and ventilator-associated pneumonia have raised concerns recently. The Reevaluating the Inhibition of Stress Erosions (REVISE) Pilot Trial determined the feasibility of undertaking a larger trial investigating the efficacy and safety of withholding proton pump inhibitors in critically ill patients.

The results support the feasibility of a larger trial to evaluate the safety of withholding stress ulcer prophylaxis.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

Podcast Discusses PANGEA Study

In the newly available iCritical Care podcast SCCM Pod-345 International Survey of Critically Ill Children with Acute Neurological Insults, Margaret Parker, MD, MCCM, speaks with Ericka L. Fink, MD, MS, about the Prevalence of Acute Critical Neurological Disease in Children: A Global Epidemiological Assessment (PANGEA) study.

Published in the April 2017 issue of Pediatric Critical Care Medicine (PCCM), this study offers a worldwide snapshot of acute neurologic conditions among critically ill children.

Overall, 16.2% of children in the reporting ICUs had acute neurologic conditions. Many children had preexisting medical conditions, but 61% had normal neurologic status before their current hospitalizations.

Cardiac arrest, resulting in lack of blood flow to the brain, was the most common overall cause of acute neurologic conditions (23%). Other causes included traumatic brain injury (19%), central nervous system infection or inflammation (16%), and stroke or a mass, such as a brain tumor (9% each).

The study found that regions differed in terms of most common condition reported. Infection/inflammation was the most common cause in Asia, South America, and the sole African hospital contributing to the study. In all other regions, cardiac arrest was the main cause.

Ericka L. Fink, MD, MS, and coauthors believe that the PANGEA data “suggest a vital need for resources to assist in the challenge of improving outcomes for these children throughout the span of the periods of emergency care through to rehabilitation.”

Society of Critical Care Medicine members who are also part of the Pediatrics Section can access the full content of PCCM online by logging into MySCCM.

Examining Chest Compressions

Mechanical chest compression (CC) during cardiopulmonary resuscitation (CPR) with AutoPulse or LUCAS devices has not improved survival from cardiac arrest. Cohort studies suggest risk of excess damage. Therefore, Koster et al studied the safety of mechanical CC compared with manual CC, as pertains to excess damage in patients with in-hospital cardiac arrest or with out-of-hospital cardiac arrest arriving with manual CPR at the emergency department.

They found that LUCAS does not cause significantly more serious or life-threatening visceral damage than manual CC. For AutoPulse, significantly more serious or life-threatening visceral damage than manual CC cannot be excluded.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

Examining Angiotensin II

Vasodilatory shock that does not respond to high-dose vasopressors is associated with high mortality. Khanna et al therefore investigated the effectiveness of angiotensin II for the treatment of patients with this condition.

They found that angiotensin II effectively increased blood pressure in patients with vasodilatory shock that did not respond to high doses of conventional vasopressors.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

Evaluating Transfusion Strategies

Cancer patients are at increased risk of septic shock. Therefore, Bergamin et al set out to assess whether a restrictive strategy of red blood cell (RBC) transfusion reduces 28-day mortality when compared with a liberal strategy in cancer patients with septic shock.

They observed a survival trend favoring a liberal transfusion strategy in cancer patients with septic shock when compared with the restrictive strategy.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

Sepsis and Therapeutic Interventions

The global burden of sepsis is substantial. Therefore, in a retrospective before-after clinical study, Marik et al compared the outcome and clinical course of consecutive septic patients treated with intravenous vitamin C, hydrocortisone and thiamine during a seven-month period (treatment group) at an intensive care unit (ICU) at Sentara Norfolk General Hospital compared to a control group treated (without intravenous vitamin C or thiamine) during the preceding seven months at the same ICU. The primary outcome was hospital survival.

The study’s results suggest that the early use of intravenous vitamin C, together with corticosteroids and thiamine, may prove to be effective in preventing progressive organ dysfunction and in reducing the mortality of patients with severe sepsis and septic shock.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

Sevoflurane for Sedation

Sevoflurane improves gas exchange, and reduces alveolar edema and inflammation in preclinical studies of lung injury, but its therapeutic effects have never been investigated in acute respiratory distress syndrome (ARDS). Jabaudon et al set out to assess whether sevoflurane would improve gas exchange and inflammation in ARDS.

They found that in patients with ARDS, use of inhaled sevoflurane improved oxygenation and decreased levels of a marker of epithelial injury and of some inflammatory markers, compared with midazolam.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

Molecular Detection of Pathogens

Microbiological diagnosis of infections remains insufficient. The resulting empirical antimicrobial therapy leads to multidrug resistance and inappropriate treatments. Cambau et al therefore evaluated the cost-effectiveness of direct molecular detection of pathogens in blood for patients with severe sepsis, febrile neutropenia, and suspected infective endocarditis.

They found that the addition of molecular detection to standard care improves microbiological diagnosis and thus efficiency of healthcare resource usage in patients with severe sepsis.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

Examining Tracheal Intubation

Tracheal intubation is common during adult in-hospital cardiac arrest, but little is known about the association between tracheal intubation and survival in this setting. Andersen et al set out to determine whether tracheal intubation during adult in-hospital cardiac arrest is associated with survival to hospital discharge.

They found that among adult patients with in-hospital cardiac arrest, initiation of tracheal intubation within any given minute during the first 15 minutes of resuscitation, compared with no intubation during that minute, was associated with decreased survival to hospital discharge.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

Prognostic Accuracy of Sepsis-3

Does the quick Sequential Organ Failure Assessment (qSOFA) score more accurately predict in-hospital mortality than the systemic inflammatory response syndrome (SIRS) or severe sepsis criteria among emergency department patients with suspected infection? Freund et al set out to answer this question.

They found that among patients presenting to the emergency department setting with suspected infection, the use of qSOFA resulted in greater prognostic accuracy for in-hospital mortality than either SIRS or severe sepsis.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.