http://ccforum.com/ The most accessed research articles published by Critical Care 2012-05-04T00:00:00Z Monitoring plays an important role in the current management of patients with acute respiratory failure but sometimes lacks definition regarding which 'signals' and 'derived variables' should be prioritized as well as specifics related to timing (continuous versus intermittent) and modality (static versus dynamic). Many new techniques of respiratory monitoring have been made available for clinical use recently, but their place is not always well defined. Appropriate use of available monitoring techniques and correct interpretation of the data provided can help improve our understanding of the disease processes involved and the effects of clinical interventions. In this consensus paper, we provide an overview of the important parameters that can and should be monitored in the critically ill patient with respiratory failure and discuss how the data provided can impact on clinical management. http://ccforum.com/content/16/2/219 Laurent Brochard Greg Martin Lluis Blanch Paolo Pelosi F Belda Amal Jubran Luciano Gattinoni Jordi Mancebo V Ranieri Jean-Christophe Richard Diederik Gommers Antoine Vieillard-Baron Antonio Pesenti Samir Jaber Ola Stenqvist Jean-Louis Vincent Critical Care 2012, null:219 2012-04-26T00:00:00Z doi:10.1186/cc11146 /content/figures/cc11146-toc.gif Critical Care 1364-8535 ${item.volume} 219 2012-04-26T00:00:00Z XML IntroductionThis study hypothesised that a reduction of sound during the night using earplugs could be beneficial in the prevention of intensive care delirium. Two research questions were formulated. First, does the use of earplugs during the night reduce the onset of delirium or confusion in the ICU? Second, does the use of earplugs during the night improve the quality of sleep in the ICU? Methods: A randomized clinical trial included adult intensive care patients in an intervention group of 69 patients sleeping with earplugs during the night and a control group of 67 patients sleeping without earplugs during the night. The researchers were blinded during data collection. Assignment was performed by an independent nurse researcher using a computer program. Eligible patients had an expected length of stay in the ICU of more than 24 hours, were Dutch- or English-speaking and scored a minimum Glasgow Coma Scale of 10. Delirium was assessed using the validated NEECHAM scale, sleep perception was reported by the patient in response to five questions. Results: The use of earplugs during the night lowered the incidence of confusion in the studied intensive care patients. A vast improvement was shown by a Hazard Ratio of 0.47 (95% confidence interval (CI) 0.27 to 0.82). Also, patients sleeping with earplugs developed confusion later than the patients sleeping without earplugs. After the first night in the ICU, patients sleeping with earplugs reported a better sleep perception. Conclusions: Earplugs may be a useful instrument in the prevention of confusion or delirium. The beneficial effects seem to be strongest within 48 hours after admission. The relation between sleep, sound and delirium, however, needs further research.Trial registrationCurrent Controlled Trials ISRCTN36198138 http://ccforum.com/content/16/3/R73 Bart Van Rompaey Monique Elseviers Wim Van Drom Veronique Fromont Philippe Jorens Critical Care 2012, null:R73 2012-05-04T00:00:00Z doi:10.1186/cc11330 Preventing delirium with earplugs The use of earplugs in the ICU can lead to a better night's sleep for patients, lower the incidence of confusion, and delay the onset of cognitive disturbances. /content/figures/cc11330-toc.gif Critical Care 1364-8535 ${item.volume} R73 2012-05-04T00:00:00Z XML IntroductionCritical illness is characterized by oxidative stress which is a major promoter of systemic inflammation and organ failure due to excessive free radicals production, depletion of antioxidant defenses, or both. We hypothesized that exogenous supplementation of trace elements and vitamins could restore antioxidant status improving clinical outcomes. Methods: We searched computerized databases, reference lists of pertinent articles, and personal files from 1980 to 2011. We included randomized controlled trials (RCTs) conducted in critically ill adults patients that evaluated relevant clinical outcomes with antioxidants micronutrients (vitamins and trace elements) supplementation versus placebo. Results: A total of 21 RCTs met inclusion criteria. When the results of these studies were statistically aggregated (n= 20), combined antioxidants were associated with a significant reduction in mortality (risk ratio [RR]= 0.82, 95% confidence interval [CI] 0.72-0.93, P= 0.002); a significant reduction in duration of mechanical ventilation (weighed mean difference in days = -0.67, 95% CI -1.22,-0.13, P= 0.02); a trend towards a reduction in infections (RR= 0.88, 95% CI 0.76,1.02, P= 0.08); and no overall effect on ICU or hospital length of stay (LOS). Furthermore, antioxidants were associated with a significant reduction in overall mortality among patients with higher risk of death (> 10% mortality in control group) (RR 0.79, 95 % CI 0.68, 0.92, P = 0.003) whereas there was no significant effect observed for trials of patients with a lower mortality in the control group (RR = 1.14, 95% 0.72, 1.82, P=0.57). Trials using more than 500g per day of selenium showed a trend towards a lower mortality (RR= 0.80, 95% CI 0.63-1.02, P= 0.07) whereas trials using doses lower than 500g had no effect on mortality (RR 0.94, 95% CI 0.67-1.33, P= 0.75). Conclusions: Supplementation with high dose trace elements and vitamins may improve outcomes of critically ill patients, particularly those at high risk of death. http://ccforum.com/content/16/2/R66 William Manzanares Rupinder Dhaliwal Xuran Jiang Lauren Murch Daren Heyland Critical Care 2012, null:R66 2012-04-25T00:00:00Z doi:10.1186/cc11316 /content/figures/cc11316-toc.gif Critical Care 1364-8535 ${item.volume} R66 2012-04-25T00:00:00Z PDF The Surviving Sepsis Campaign (SSC) is an international effort to reduce mortality in severe sepsis and septic shock. The campaign included the creation of evidence-based guidelines sponsored and endorsed by 11 international organizations. From these guidelines, sepsis change bundles for initial resuscitation (6 hours) and management (24 hours) were created as a performance improvement tool. In this issue of Critical Care, Gao et al. have evaluated performance at their institution by using a close adaptation of the two SSC bundle sets and demonstrated an association between 100% compliance with the bundle elements and clinical outcome. The next step will be to demonstrate that the use of education and feedback for performance improvement will increase compliance and decrease mortality in the patient population in general. http://ccforum.com/content/9/6/653 Critical Care 2005, null:653 2005-11-25T00:00:00Z doi:10.1186/cc3952 /content/figures/cc3952-toc.gif Critical Care 1364-8535 ${item.volume} 653 2005-11-25T00:00:00Z XML IntroductionChest x-rays (CXRs) are the most frequent radiological tests performed in the intensive care unit (ICU). However, the utility of performing daily routine CXRs is unclear. Methods: We searched Medline and Embase (1948 to March 2011) for randomized and quasi-randomized controlled trials (RCTs) and before-after observational studies comparing a strategy of routine CXRs to a more restrictive approach with CXRs performed to investigate clinical changes among critically ill adults or children. In duplicate, we extracted data on the CXR strategy, study quality and clinical outcomes (ICU and hospital mortality; duration of mechanical ventilation and ICU and hospital stay). Results: Nine studies (39358 CXRs, 9611 patients) were included in the meta-analysis. Three trials (N=870) of moderate to good quality provided information on the safety of a restrictive routine CXR strategy; only 1 trial systematically assessed for missed findings. Pooled data from trials showed no evidence of effect of a restrictive approach on ICU mortality (risk ratio [RR] 1.04, 95% CI 0.84 to 1.28, P=0.72; 2 trials, N=776), hospital mortality (RR 0.98, 95% CI 0.68 to 1.41, P=0.91; 2 trials, N=259), ICU length of stay (weighted mean difference [WMD] -0.86 days, 95% CI -2.38 to 0.66 days, P=0.27; 3 trials, N=870), hospital length of stay (WMD -2.50 days, 95% CI -6.62 to 1.61 days, P=0.23; 2 trials, N= 259), or duration of mechanical ventilation (WMD -0.30 days, 95% CI -1.48 to 0.89 days, P=0.62; 3 trials, N=705). Adding data from 6 observational studies, 1 of which systematically screened for missed findings, gave similar results. Conclusions: This meta-analysis did not detect any harm associated with a restrictive chest radiograph strategy. However, confidence intervals were wide and harm was not rigorously assessed. Therefore, the safety of abandoning routine CXRs in patients admitted to the ICU remains uncertain. http://ccforum.com/content/16/2/R68 Anu Ganapathy Neill Adhikari Jamie Spiegelman Damon Scales Critical Care 2012, null:R68 2012-04-27T00:00:00Z doi:10.1186/cc11321 /content/figures/cc11321-toc.gif Critical Care 1364-8535 ${item.volume} R68 2012-04-27T00:00:00Z PDF IntroductionVentilator-associated pneumonia (VAP) may contribute to the mortality associated with acute respiratory distress syndrome (ARDS). We aimed to determine the incidence, outcome, and risk factors of bacterial VAP complicating severe ARDS in patients ventilated by using a strictly standardized lung-protective strategy. Methods: This prospective epidemiologic study was done in all the 339 patients with severe ARDS included in a multicenter randomized, placebo-controlled double-blind trial of cisatracurium besylate in severe ARDS patients. Patients with suspected VAP underwent bronchoalveolar lavage to confirm the diagnosis. Results: Ninety-eight (28.9%) patients had at least one episode of microbiologically documented bacterial VAP, including 41 (41.8%) who died in the ICU, compared with 74 (30.7%) of the 241 patients without VAP (P = 0.05). After adjustment, age and severity at baseline, but not VAP, were associated with ICU death. Cisatracurium besylate therapy within 2 days of ARDS onset decreased the risk of ICU death. Factors independently associated with an increased risk to develop a VAP were male sex and worse admission Glasgow Coma Scale score. Tracheostomy, enteral nutrition, and the use of a subglottic secretion-drainage device were protective. Conclusions: In patients with severe ARDS receiving lung-protective ventilation, VAP was associated with an increased crude ICU mortality which did not remain significant after adjustment. http://ccforum.com/content/16/2/R65 Jean-Marie Forel Francois Voillet Daniel Pulina Arnaud Gacouin Gilles Perrin Karine Barrau Samir Jaber Jean-Michel Arnal Mohamed Fathallah Pascal Auquier Antoine Roch Elie Azoulay Laurent Papazian Critical Care 2012, null:R65 2012-04-18T00:00:00Z doi:10.1186/cc11312 /content/figures/cc11312-toc.gif Critical Care 1364-8535 ${item.volume} R65 2012-04-18T00:00:00Z XML IntroductionThere is no consensus definition of acute renal failure (ARF) in critically ill patients. More than 30 different definitions have been used in the literature, creating much confusion and making comparisons difficult. Similarly, strong debate exists on the validity and clinical relevance of animal models of ARF; on choices of fluid management and of end-points for trials of new interventions in this field; and on how information technology can be used to assist this process. Accordingly, we sought to review the available evidence, make recommendations and delineate key questions for future studies. Methods: We undertook a systematic review of the literature using Medline and PubMed searches. We determined a list of key questions and convened a 2-day consensus conference to develop summary statements via a series of alternating breakout and plenary sessions. In these sessions, we identified supporting evidence and generated recommendations and/or directions for future research. Results: We found sufficient consensus on 47 questions to allow the development of recommendations. Importantly, we were able to develop a consensus definition for ARF. In some cases it was also possible to issue useful consensus recommendations for future investigations. We present a summary of the findings. (Full versions of the six workgroups' findings are available on the internet at http://www.ADQI.net) Conclusion: Despite limited data, broad areas of consensus exist for the physiological and clinical principles needed to guide the development of consensus recommendations for defining ARF, selection of animal models, methods of monitoring fluid therapy, choice of physiological and clinical end-points for trials, and the possible role of information technology. http://ccforum.com/content/8/4/R204 Rinaldo Bellomo Claudio Ronco John Kellum Ravindra Mehta Paul Palevski Critical Care 2004, null:R204 2004-05-24T00:00:00Z doi:10.1186/cc2872 /content/figures/cc2872-toc.gif Critical Care 1364-8535 ${item.volume} R204 2004-05-24T00:00:00Z XML IntroductionWhile propofol is associated with an infusion syndrome (PRIS) that may cause death, the incidence of PRIS is unknown. Determining the incidence of PRIS and the frequency of PRIS-related clinical manifestations are key steps prior to the completion of any controlled studies investigating PRIS. This prospective, multicenter study sought to determine the incidence of PRIS and PRIS-related clinical manifestations in a large cohort of critically ill adults prescribed propofol. Methods: Critically ill adults from 11 academic medical centers administered an infusion of propofol for [>/=] 24 hours were monitored at baseline and then on a daily basis until propofol was discontinued for the presence of 11 different PRIS-associated clinical manifestations and risk factors derived from 83 published case reports of PRIS. Results: Among 1017 patients [medical (35%), neurosurgical (25%)], PRIS (defined as metabolic acidosis plus cardiac dysfunction and [>/=] 1 of: rhabdomyolysis, hypertriglyceridemia or renal failure occurring after the start of propofol therapy) developed in 11 (1.1%) patients an average of 3 (1-6) [median (range)] days after the start of propofol. While most (91%) of the patients who developed PRIS were receiving a vasopressor (80% initiated after the start of propofol therapy), few received a propofol dose >83 mcg/kg/min (18%) or died (18%). Compared to the 1006 patients who did not develop PRIS, the APACHE II score (25 +/- 6 vs 20 +/- 7, P = 0.01) was greater in patients with PRIS but both the duration of propofol use (P = 0.43) and ICU length of stay (P = 0.82) were similar. Conclusions: Despite using a conservative definition for PRIS, and only considering new-onset PRIS clinical manifestations, the incidence of PRIS slightly exceeds 1%. Future controlled studies focusing on evaluating whether propofol manifests the derangements of critical illness more frequently than other sedatives will need to be large. These studies should also investigate the mechanism(s) and risk factors for PRIS. http://ccforum.com/content/13/5/R169 Russel Roberts Jeffrey Barletta Jeffrey Fong Greg Schumaker Philip Kuper Stella Papadopoulos Dinesh Yogaratnam Elise Kendall Renee Xamplas Anthony Gerlach Paul Szumita Kevin Anger Paul Arpino Stacey Voils Philip Grgurich Robin Ruthazer John Devlin Critical Care 2009, null:R169 2009-10-29T00:00:00Z doi:10.1186/cc8145 /content/figures/cc8145-toc.gif Critical Care 1364-8535 ${item.volume} R169 2009-10-29T00:00:00Z XML {no abstract} http://ccforum.com/content/16/2/210 Andrea Coppadoro Edward Bittner Lorenzo Berra Critical Care 2012, null:210 2012-03-20T00:00:00Z doi:10.1186/cc11225 /content/figures/cc11225-toc.gif Critical Care 1364-8535 ${item.volume} 210 2012-03-20T00:00:00Z XML The translation of knowledge into rational care is as essential and pressing a task as the development of new diagnostic or therapeutic devices, and is arguably more important. The emerging science of health care delivery has identified the central role of human factor ergonomics in the prevention of medical error, omission, and waste. Novel informatics and systems engineering strategies provide an excellent opportunity to improve the design of acute care delivery. In this article, future hospitals are envisioned as organizations built around smart environments that facilitate consistent delivery of effective, equitable, and error-free care focused on patient-centered rather than provider-centered outcomes. http://ccforum.com/content/16/2/220 Brian Pickering John Litell Vitaly Herasevich Ognjen Gajic Critical Care 2012, null:220 2012-04-26T00:00:00Z doi:10.1186/cc11142 /content/figures/cc11142-toc.gif Critical Care 1364-8535 ${item.volume} 220 2012-04-26T00:00:00Z XML