Critical care

OBJECTIVE: Twice/day dosing of insulin glargine has been used to treat hyperglycemia in clinical practice; however, data supporting its use in the critically ill population are lacking. This study was designed to evaluate the safety and efficacy of twice/day insulin glargine in critically ill patients. METHODS: A retrospective study was conducted in adult patients admitted to the intensive care units between February 2013 and June 2017 who received insulin glargine twice/day or 40 units or more once/day for 48 hours or longer...

The risks, measurements of severity, and management of severe acute pancreatitis and its complications have evolved rapidly over the past decade. Evidence suggests that initial goal directed therapy, nutritional support, and vigilance for pancreatic complications are best practice. Patients can develop pancreatic fluid collections including acute pancreatic fluid collections, pancreatic pseudocysts, acute necrotic collections, and walled-off necrosis. Several randomized controlled trials and cohort studies have recently highlighted the advantage of managing these conditions with a progressive approach, with initial draining for infection followed by less invasive techniques...

PURPOSE OF REVIEW: Most clinical trials of lung-protective ventilation have tested one-size-fits-all strategies with mixed results. Data are lacking on how best to tailor mechanical ventilation to patient-specific risk of lung injury. RECENT FINDINGS: Risk of ventilation-induced lung injury is determined by biological predisposition to biophysical lung injury and physical mechanical perturbations that concentrate stress and strain regionally within the lung. Recent investigations have identified molecular subphenotypes classified as hyperinflammatory and hypoinflammatory acute respiratory distress syndrome (ARDS), which may have dissimilar risk for ventilation-induced lung injury...

Classically, mitochondria have largely been believed to influence the development of illness by modulating cell metabolism and determining the rate of production of high-energy phosphate compounds (eg, adenosine triphosphate). It is now recognized that this view is simplistic and that mitochondria play key roles in many other processes, including cell signaling, regulating gene expression, modulating cellular calcium levels, and influencing the activation of cell death pathways (eg, caspase activation). Moreover, these multiple mitochondrial functional characteristics are now known to influence the evolution of cellular and organ function in many disease states, including sepsis, ICU-acquired skeletal muscle dysfunction, acute lung injury, acute renal failure, and critical illness-related immune function dysregulation...

Renal replacement therapy (RRT) is frequently required to manage critically ill patients with acute kidney injury (AKI). There is limited evidence to support the current practice of RRT in intensive care units (ICUs). Recently published randomized control trials (RCTs) have further questioned our understanding of RRT in critical care. The optimal timing and dosing continues to be debatable; however, current evidence suggests delayed strategy with less intensive dosing when utilising RRT. Various modes of RRT are complementary to each other with no definite benefits to mortality or renal function preservation...

OBJECTIVES: Lung ultrasound has shown increasing diagnostic value in many lung diseases and has become an efficient tool in the management of dyspnea. In the present case report, we describe a new ultrasound feature of potential interest. DATA SOURCES: Clinical observation of a patient. STUDY SELECTION: Case report. DATA EXTRACTION: Data were extracted from medical records, after obtaining consent from the patient's family...

PURPOSE OF REVIEW: Overview of influenza infection, focusing on outcome and complications in critically ill patients. We also discuss relevant elements in immunopathogenesis and their role as predictors of severity. RECENT FINDINGS: Pandemic influenza A (H1N1) virus circulates seasonally and remains the predominant subtype among intensive care patients. Mortality in acute respiratory failure (ARF) is around 20%, independent of influenza subtypes. During severe infection, the imbalance between pro-inflammatory and anti-inflammatory molecules, such as Th1 and Th17 cytokines, is associated with complicated infections and mortality...

PURPOSE OF REVIEW: To review the current management of walled-off pancreatic necrosis (WOPN). RECENT FINDINGS: The management of WOPN has evolved. Many collections do not require intervention and may resolve over time. Nutritional support and treatment of infection are two critical components of medical management. For collections requiring drainage, minimally invasive endoscopic therapies now play a primary role. Endoscopic transmural puncture with stent placement may provide access for drainage and decompression...

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INTRODUCTION: Early empirical broad-spectrum antimicrobial therapy is recommended for patients with severe infections, including sepsis. β-lactam/β-lactamase inhibitor combinations or carbapenems are often used to ensure coverage of likely pathogens. Piperacillin/tazobactam is proposed as a carbapenem-sparing agent to reduce the incidence of multidrug-resistant bacteria and superinfections. In the recently published MERINO trial, increased mortality from piperacillin/tazobactam was suggested in patients with bacteraemia with resistant Escherichia coli or Klebsiella species...

PURPOSE: This study compared anti-Xa activity in critically ill patients receiving UFH for VTE prophylaxis between two weight groups (<100 kg vs ≥100 kg). METHODS: This prospective, observational study included critically ill patients on UFH 5000 or 7500 units every 8 h. A peak and trough anti-Xa activity assay was ordered for each patient at steady state. Goal peak anti-Xa activity was 0.1-0.3 units/mL. RESULTS: From March 2017 to June 2018, 75 patients were enrolled with 44 in the <100 kg group and 31 in the ≥100 kg group...

Ventilator-free days (VFDs) are a commonly reported composite outcome measure in acute respiratory distress syndrome trials. VFDs combine survival and duration of ventilation in a manner that summarizes the "net effect" of an intervention on these two outcomes. However, this combining of outcome measures makes VFDs difficult to understand and analyze, which contributes to imprecise interpretations. We discuss the strengths and limitations of VFDs and other "failure-free day" composites, and we provide a framework for when and how to use these outcome measures...

BACKGROUND: Patient ventilator asynchrony (PVA) occurs frequently, but little is known about the types and frequency of PVA. Asynchrony is associated with significant patient discomfort, distress and poor clinical outcomes (duration of mechanical ventilation, intensive care unit and hospital stay). METHODS: Pressure-time and flow-time waveform data were collected on 27 ICU patients using the Noninvasive Cardiac Output monitor for up to 90 min per subject and blinded waveform analysis was performed...

PURPOSE OF REVIEW: The purpose of the review is to alert clinicians to the prevalent and frequently underrecognized problem of asynchrony in mechanically ventilated patients. To provide a mechanistic model of patient-ventilator asynchrony to help personnel understand how different asynchronies develop. To provide practical advice on how to recognize and solve different asynchronies in different contexts. RECENT FINDINGS: Patient-ventilator asynchrony is a serious problem that is associated with prolonged mechanical ventilation, prolonged ICU and hospital stays, and increased mortality...

PURPOSE: To describe the meanings of the lived experiences of grieving of Thai Buddhist husbands who had lost their wives from critical illnesses. DESIGN: Hermeneutic phenomenological approach using van Manen's concepts. Seven husbands from southern Thailand who met the inclusion criteria participated in the study. METHODS: Individual in-depth interviews were conducted and recorded on tape, while the interview data were transcribed and analyzed following van Manen's phenomenological approach...

BACKGROUND: In-hospital cardiac arrest (IHCA) portends a poor prognosis and survival to discharge rate. Prognostic markers such as interleukin-6, S-100 protein and high sensitivity C reactive protein have been studied as predictors of adverse outcomes after return of spontaneous circulation (ROSC); however; these variables are not routine laboratory tests and incur additional cost making them difficult to incorporate and less attractive in assessing patient's prognosis. The neutrophil-lymphocyte ratio (NLR) is a marker of adverse prognosis for many cardiovascular conditions and certain types of cancers and sepsis...

Acute kidney injury (AKI) affects many ICU patients and is responsible for increased morbidity and mortality. Although lifesaving in many situations, renal replacement therapy (RRT) may be associated with complications, and the appropriate timing of its initiation is still the subject of intense debate. An early initiation strategy can prevent some metabolic complications, whereas a delayed one may allow for renal function recovery in some patients without need for this costly and potentially dangerous technique...

BACKGROUND: Vasopressors are commonly applied to restore and maintain blood pressure in patients with sepsis. We aimed to evaluate the current practice and therapeutic goals regarding vasopressor use in septic shock as a basis for future studies and to provide some recommendations on their use. METHODS: From November 2016 to April 2017, an anonymous web-based survey on the use of vasoactive drugs was accessible to members of the European Society of Intensive Care Medicine (ESICM)...

INTRODUCTION: Patient-ventilator asynchrony is considered a major clinical problem for mechanically ventilated patients. It occurs during partial ventilatory support, when the respiratory muscles and the ventilator interact to contribute generating the volume output. In this review article, we consider all studies published on patient-ventilator asynchrony in the last 25 years. EVIDENCE ACQUISITION: We selected 62 studies. The different forms of asynchrony are first defined and classified...

BACKGROUND: Pathophysiological changes often result in altered pharmacokinetics of ciprofloxacin in critically ill patients. Although ciprofloxacin clearance (CLCIP) substantially depends on kidney function in healthy volunteers, its relationship to measured creatinine clearance (CLCRM) is weak in critically ill patients. OBJECTIVES: To assess the need for dose reductions in isolated or combined kidney and liver dysfunction in critically ill patients and to re-evaluate relationships between kidney parameters, demographics and ciprofloxacin pharmacokinetics...