Journal of Intensive Care Medicine

BACKGROUND: Intensive care unit (ICU) environment disrupts the circadian rhythms due to environmental and other nonphotic synchronizers. The main purpose of this article is to establish whether critically patients have desynchronization at the molecular level after 1 week of stay in the ICU. METHODS: The rhythm of Clock, Bmal1, Cry1, and Per2 genes in neuro-ICU patients (n = 11) on the first day after admission in the unit (1 day) and 1 week later (1 week) was studied, 4 time points throughout the day, at 6, 12, 18, and 24 hours...

Resuscitation after out-of-hospital cardiac arrest can be one of the most challenging scenarios in acute-care medicine. The devastating effects of postcardiac arrest syndrome carry a substantial morbidity and mortality that persist long after return of spontaneous circulation. Management of these patients requires the clinician to simultaneously address multiple emergent priorities including the resuscitation of the patient and the efficient diagnosis and management of the underlying etiology. This review provides a concise evidence-based overview of the core concepts involved in the early postcardiac arrest resuscitation...

PURPOSE: Catecholamines are first-line vasopressors for hemodynamic support in distributive shock but are associated with adverse effects, which may be mitigated with noncatecholamine vasopressors. Angiotensin II (ATII) is a noncatecholamine vasopressor recently approved for the management of distributive shock, but limited data support its clinical utility. The purpose of this study was to describe our institution's usage of ATII including patient outcomes (eg, response to therapy, safety profile)...

OBJECTIVE: Red blood cell exchange (RBCE) is the standard of care for patients with sickle cell disease (SCD) who present with severe vaso-occlusive crisis (VOC). However, subsets of these critically ill patients have progressive multiorgan failure (MOF) despite RBCE therapy. The purpose of this case series is to describe the use of plasma exchange (PLEX) for the treatment of SCD-related MOF that is refractory to RBCE. METHODS: A retrospective case review of patients with severe MOF from sickle cell crisis unresponsive to RBCE who underwent PLEX in a 14-bed adult medical intensive care unit (ICU) at a tertiary care university hospital over a 4-year time period...

BACKGROUND: Outcome prediction after out-of-hospital cardiac arrest (OHCA) is difficult. We hypothesized that lactate and need for vasopressors would predict outcome, and that addition of a mitochondrial biomarker would enhance performance of the tool. METHODS: Prospective observational study of OHCA patients presenting to an academic medical center September 2008 to April 2016. We conducted univariate and multivariate logistic regressions. RESULTS: Patients were divided based on 2 variables: vasopressor status and initial lactate (<5 mmol/L, 5-10, ≥10)...

OBJECTIVES: To determine whether, similar to adults, early tracheostomy in pediatric patients with severe traumatic brain injury (TBI) improves inhospital outcomes including ventilator days, intensive care unit (ICU) length of stay (LOS), and total hospital LOS when compared to late tracheostomy. DESIGN: Retrospective cohort analysis. SETTING: The Pediatric Trauma Quality Improvement Program (TQIP) database. PATIENTS: One hundred twenty-seven pediatric patients <16 years old with severe (>3) abbreviated injury scale TBI who underwent early (days 1-6) or late (day ≥7) tracheostomy between 2014 and 2016...

Multiple organ dysfunction syndrome (MODS) is one of the most common syndromes of critical illness and the leading cause of mortality among critically ill patients. Multiple organ dysfunction syndrome is the clinical consequence of a dysregulated inflammatory response, triggered by clinically diverse factors with the main pillar of management being invasive organ support. During the last years, the advances in the clarification of the molecular pathways that trigger, mitigate, and determine the outcome of MODS have led to the increasing recognition of MODS as a distinct disease entity with distinct etiology, pathophysiology, and potential future therapeutic interventions...

Decision-making for the hospitalized dying and critically ill is often characterized by an understanding of autonomy that leads to clinical care and outcomes that are antithetical to patients' preferences around suffering and quality of life. A better understanding of autonomy will facilitate the ultimate goal of a patient-centered approach and ensure compassionate, high-quality care that respects our patients' values. We reviewed the medical literature and our experiences through the ethics service, palliative care service, and critical care service of a large community teaching hospital...

OBJECTIVES: Adequate postoperative pain management is crucial in pediatric patients undergoing cardiac surgery because pain can lead to devastating short- and long-term consequences. This review discusses the limitations of current postoperative pain assessment and management in children after cardiac surgery, the obstacles to providing optimal treatment, and concepts to consider that may overcome these barriers. DATA SOURCE: MEDLINE and PubMed. CONCLUSIONS: Effective pain management in infants and young children undergoing cardiac surgery continues to evolve with innovative methods of both assessment and therapy using newer drugs or novel routes of administration...

PURPOSE: International clinical practice guidelines call for initial volume resuscitation of at least 30 mL/kg body weight for patients with sepsis-induced hypotension or shock. Although not considered in the guidelines, preexisting cardiac dysfunction may be an important factor clinicians weigh in deciding the quantity of volume resuscitation for patients with septic shock. METHODS: We conducted a multicenter survey of clinicians who routinely treat patients with sepsis to evaluate their beliefs, behaviors, knowledge, and perceived structural barriers regarding initial volume resuscitation for patients with sepsis and concomitant heart failure with reduced ejection fraction (HFrEF) <40%...

BACKGROUND: Advanced critical care echocardiography (CCE) involves comprehensive assessment of cardiac structure and function for frontline critical care applications. This study reports the effectiveness of a 3-day course in advanced CCE. METHODS: We studied the outcome of 5 consecutive advanced CCE courses delivered between 2013 and 2017. A total number of 239 learners were studied. The course included didactic lectures, image interpretation sessions, and hands-on training with normal individuals as models...

OBJECTIVE: To examine the hospital-level variation in intensive care unit (ICU) utilization and quantify the relative contribution of patient and hospital characteristics versus individual hospital factors to the variation in ICU admission rates among pediatric hospitalizations with diabetic ketoacidosis (DKA). METHODS: The Texas Inpatient Public Use Data File was used to identify hospitalizations of state residents aged 1 month to 19 years with a primary diagnosis of DKA between 2005 and 2014...

Ultrasound-guided central line placement has been shown to decrease the number of needle puncture attempts, complication, and failure rates. In order to obtain successful central access, it is important to have adequate cognitive knowledge, workflow understanding, and manual dexterity to safely execute this invasive procedure. The operator should also be familiar with the anatomical variations, equipment operations, and potential complications and their prevention. In this article, we present a detailed review of ultrasound-guided central venous access...

BACKGROUND: Atrial fibrillation (AF) portends poor prognoses in intensive care unit patients with sepsis. However, AF research is challenging: Previous studies demonstrate that International Classification of Disease ( ICD ) codes may underestimate the incidence of AF, but chart review is expensive and often not feasible. We aim to examine the accuracy of nurse-charted AF and its temporal precision in critical care patients with sepsis. METHODS: Patients with sepsis with continuous electrocardiogram (ECG) waveforms were identified from the Medical Information Mart for Intensive Care (MIMIC-III) database, a de-identified, single-center intensive care unit electronic health record (EHR) source...

OBJECTIVE: Hyperchloremia is associated with worsened outcomes in various clinical situations; however, data are limited in patients with diabetic ketoacidosis (DKA). The purpose of this study was to determine the effect of hyperchloremia on time to DKA resolution. METHODS: We conducted a retrospective cohort study of adult patients admitted with incident DKA from January 2013 through October 2017 and stratified by the development of hyperchloremia versus maintaining normochloremia...

OBJECTIVE: In the intensive care unit (ICU), prolonged inactivity is common, increasing patients' risk for adverse outcomes, including ICU-acquired weakness. Hence, interventions to minimize inactivity are gaining popularity, highlighting actigraphy, a measure of activity involving a wristwatch-like accelerometer, as a method to inform these efforts. Therefore, we performed a systematic review of studies that used actigraphy to measure patient activity in the ICU setting. DATA SOURCES: We searched PubMed, EMBASE, CINAHL, Cochrane Library, and ProQuest from inception until December 2016...

INTRODUCTION: We aimed to study the use of ascorbic acid, thiamine, and steroids (ATS) in patients with septic shock (SS). METHODS: Data on 62 patients with SS were collected from Acute Physiologic and Chronic Health Evaluation (APACHE) Outcome database and medical records. The ATS group received full doses of intravenous (IV) ATS (ascorbic acid [1.5 g every 6 hours for 4 days], hydrocortisone [50 mg every 6 hours for 7 days], and thiamine [200 mg every 12 hours for 4 days])...

INTRODUCTION: Previous studies have evaluated procalcitonin clearance (PCTc) as a marker of sepsis severity but at different time points and cutoffs. We aimed to assess the predictive performance of PCTc at different time points of sepsis management in patients with cancer. METHODS: This retrospective cohort study included patients with cancer admitted to an intensive care unit between 2013 and 2016. We calculated PCTc at 24, 48, 72, and 96 hours after admission...

BACKGROUND: Midkine has been reported to play a crucial role in inflammatory, hypoxia, and tissue injury processes. We aimed to investigate plasma midkine in septic patients and its association with 28-day mortality and organ function. METHODS: Septic patients admitted to the Department of Critical Care Medicine, Zhongda Hospital, a tertiary hospital, from November 2017 to March 2018 were enrolled in the study. The baseline characteristics of the septic patients were recorded at admission...

BACKGROUND: The management of refractory septic shock remains a major challenge in critical care and its early indicators are not fully understood. We hypothesized that the maximum norepinephrine dosage within 24 hours of intensive care unit (ICU) admission may be a useful indicator of early mortality in patients with septic shock. METHODS: In this retrospective single-center observational study, patients with septic shock admitted to the emergency ICU of an academic medical center between April 2011 and March 2017 were included...