Open lung ventilation strategies have been recommended in patients with acute respiratory distress syndrome (ARDS).
To determine whether a maximal lung recruitment strategy reduces ventilator-free ...days in patients with ARDS.
A phase II, multicenter randomized controlled trial in adults with moderate to severe ARDS. Patients received maximal lung recruitment, titrated positive end expiratory pressure and further Vt limitation, or control "protective" ventilation.
The primary outcome was ventilator-free days at Day 28. Secondary outcomes included mortality, barotrauma, new use of hypoxemic adjuvant therapies, and ICU and hospital stay. Enrollment halted October 2, 2017, after publication of ART (Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial), when 115 of a planned 340 patients had been randomized (57% male; mean age, 53.6 yr). At 28 days after randomization, there was no difference between the maximal lung recruitment and control ventilation strategies in ventilator-free days (median, 16 d interquartile range (IQR), 0-21 d,
= 57, vs. 14.5 d IQR, 0-21.5 d,
= 56;
= 0.95), mortality (24.6%
= 14/56 vs. 26.8%
= 15/56;
= 0.79), or the rate of barotrauma (5.2%
= 3/57 vs. 10.7%
= 6/56;
= 0.32). However, the intervention group showed reduced use of new hypoxemic adjuvant therapies (i.e., inhaled nitric oxide, extracorporeal membrane oxygenation, prone; median change from baseline 0 IQR, 0-1 vs. 1 IQR, 0-1;
= 0.004) and increased rates of new cardiac arrhythmia (
= 17 29% vs.
= 7 13%;
= 0.03).
Compared with control ventilation, maximal lung recruitment did not reduce the duration of ventilation-free days or mortality and was associated with increased cardiovascular adverse events but lower use of hypoxemic adjuvant therapies.Clinical trial registered with www.clinicaltrials.gov (NCT01667146).
- Albumin is the most abundant and perhaps most important protein in human blood. Research has identified many of albumin's possible roles in modulating acid-base balance, modifying inflammation, ...maintaining vascular endothelial integrity, and binding endogenous and exogenous compounds.
- Albumin plays a key role in the homeostasis of vascular endothelium, offering protection from inflammation and damage to the glycocalyx.
- Albumin binds a diverse range of compounds. It transports, delivers and clears drugs, plus it helps with uptake, storage and disposal of potentially harmful biological products.
- The biological effects of albumin in critical illness are incompletely understood, but may enhance its clinical role beyond use as an intravenous fluid. In this article, we summarise the evidence surrounding albumin's biological and physiological effects beyond its use for plasma volume expansion, and explore potential mechanistic effects of albumin as a disease modifier in patients with critical illness.
The prevalence of Hospital Acquired Complications (HACs) within major hospitals and intensive care units (ICUs) is often used as an indication of care quality. We performed a retrospective cohort ...study of acute care separations from four adult public hospitals in the state of South Australia, Australia. Data were derived from the Integrated South Australian Activity Collection (ISAAC) database, subdivided into those admitted to ICU or non-ICU (Ward) in tertiary referral or (other major) metropolitan hospitals. During the five-year study period (1 July 2013 to 30 June 2018), there were 471,934 adult separations with 65,133 HAC events reported in 43,987 (9.32%) at a mean rate of 13.8 (95% confidence interval (CI) 13.7 to 13.9) HAC events per 100 separations and 18.5 (95% CI 18.4 to 18.7) per 1000 bed days. The Ward cohort accounted for the majority (430,583 (91.2%)) of separations, in-hospital deaths (6928 (66.4%)) and HAC events (29,826 (67.8%)). The smaller ICU cohort (41,351 (8.76%)) had a higher mortality rate (8.46% versus 1.61%; P < 0.001), longer length of stay (median 10.0 (interquartile range (IQR) 6.0-18.0) days versus 4.0 (IQR 3.0-8.0) days P < 0.001), and higher HAC prevalence (62.1 (95% CI 61.3 to 62.9) versus 9.16 (95% CI 9.07 to 9.25) per 100 separations P < 0.001). Both ICU and Ward HAC prevalence rates were higher in tertiary referral than major metropolitan hospitals (P < 0.001). In conclusion, higher HAC prevalence rates in the ICU and tertiary referral cohorts may be due to high-risk patient cohorts, variable provision of care, or both, and warrants urgent clinical investigation and further research.
Community-acquired pneumonia (CAP) poses a significant global health challenge, prompting exploration of innovative treatments. This systematic review and meta-analysis aimed to evaluate the efficacy ...and safety of vitamin C supplementation in adults undergoing treatment for CAP. A comprehensive search of the MEDLINE, Embase, CINAHL, the Cochrane Central Register of Controlled Trials, and Clinical Trials.gov databases from inception to 17 November 2023 identified six randomized-controlled-trials (RCTs) meeting inclusion criteria. The primary outcome analysis revealed a non-significant trend towards reduced overall mortality in the vitamin C group compared to controls (RR 0.51; 95% CI 0.24 to 1.09; p = 0.052; I
= 0; p = 0.65). Sensitivity analysis, excluding corona-virus-disease 2019 (COVID-19) studies and considering the route of vitamin C administration, confirmed this trend. Secondary outcomes, including hospital length-of-stay (LOS), intensive-care-unit (ICU) LOS, and mechanical ventilation, exhibited mixed results. Notably, heterogeneity and publication bias were observed in hospital LOS analysis, necessitating cautious interpretation. Adverse effects were minimal, with isolated incidents of nausea, vomiting, hypotension, and tachycardia reported. This meta-analysis suggests potential benefits of vitamin C supplementation in CAP treatment. However, inconclusive findings and methodological limitations warrants cautious interpretation, emphasising the urgency for high-quality trials to elucidate the true impact of vitamin C supplementation in CAP management.
Purpose
Bolus intravenous administration of 0.9% saline has been associated with the development of pulmonary edema, and increased mortality. An animal model has previously demonstrated that rapid ...intravenous administration of 0.9% saline was associated with non-hydrostatic lung injury with increased lung lavage protein. We hypothesized that this non-hydrostatic effect would also occur in human volunteers.
Methods
In a randomized, cross-over study of 14 healthy male subjects, the lung lavage protein concentration and cardiorespiratory effects of an intervention with rapid intravenous administration of 30 mL/kg of 0.9% saline were compared with sham intervention. Bronchoalveolar lavage (BAL) was performed after fluid administration. Doppler echocardiography, lung ultrasound, pulmonary function tests, and blood sampling were performed before and after each intervention.
Results
The BAL total protein concentration was greater after 0.9% saline administration than with sham (196.1 µg/mL (SD 87.6) versus 129.8 µg/mL (SD 55.4), respectively (
p
= 0.020). Plasma angiopoietin-2 concentration was also increased to 2.26 ng/mL (SD 0.87) after 0.9% saline administration compared with sham 1.53 ng/mL (SD 0.69) (
p
< 0.001). There were small increases in stroke volume (from 58 mL (IQR 51–74) to 66 mL (IQR 58–74),
p
= 0.045) and Doppler echocardiography left ventricle E/e’ ratio (from 5.0 (IQR 4.5–6.0) to 5.7 (IQR 5.3–6.3),
p
= 0.007), but no changes to right ventricular function.
Conclusion
Rapid intravenous administration of 0.9% saline leads to interstitial permeability pulmonary edema in healthy human volunteers. Further research is now warranted to understand these effects in critically ill patients.
Comprehensive data on the burden of severe acute pancreatitis (SAP) in global intensive care units (ICUs) and trends over time are lacking. Our objective was to compare trends in hospital and ICU ...mortality, in-hospital and ICU length of stay, and costs related to ICU admission in Australia and New Zealand (ANZ) for SAP.
We performed a retrospective, observational, cohort study of ICU admissions reported to the ANZ Intensive Care Society Adult Patient Database over three consecutive six-year time periods from 2003 to 2020.
12,635 patients with SAP from 189 ICUs in ANZ were analysed. No difference in adjusted hospital mortality (11.4% vs 11.5% vs 11.0%, p = 0.85) and ICU mortality rates (7.5% vs 8.0% vs 8.1%, p = 0.73) were noted over the study period. Median length of hospital admission reduced over time (13.9 days in 2003-08, 13.1 days in 2009-14 and 12.5 days in 2015-20; p < 0.01). No difference in length of ICU stay was noted over the study period (p = 0.13). The cost of managing SAP in ANZ ICUs remained constant over the three time periods.
In critically-ill SAP patients in ANZ, no change in mortality has been noted over nearly two decades. There was a slight reduction in hospital stay (1 day), while the length of ICU stay remained unchanged. Given the significant costs related to care of patients with SAP in ICU, these findings highlight the need to prioritise resource allocation for healthcare delivery and targeted clinical research to identify treatments aimed at reducing mortality.
Stress induced hyperglycemia occurs in critically ill patients who have normal glucose tolerance following resolution of their acute illness. The objective was to evaluate the association between ...stress induced hyperglycemia and incident diabetes in survivors of critical illness.
Retrospective cohort study.
All adult patients surviving admission to a public hospital intensive care unit (ICU) in South Australia between 2004 and 2011.
Stress induced hyperglycemia was defined as a blood glucose ≥ 11.1 mmol/L (200 mg/dL) within 24 hours of ICU admission. Prevalent diabetes was identified through ICD-10 coding or prior registration with the Australian National Diabetes Service Scheme (NDSS). Incident diabetes was identified as NDSS registration beyond 30 days after hospital discharge until July 2015. The predicted risk of developing diabetes was described as sub-hazard ratios using competing risk regression. Survival was assessed using Cox proportional hazards regression.
Stress induced hyperglycemia was identified in 2,883 (17%) of 17,074 patients without diabetes. The incidence of type 2 diabetes following critical illness was 4.8% (821 of 17,074). The risk of diabetes in patients with stress induced hyperglycemia was approximately double that of those without (HR 1.91 (95% CI 1.62, 2.26), p<0.001) and was sustained regardless of age or severity of illness.
Stress induced hyperglycemia identifies patients at subsequent risk of incident diabetes.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Sleep disturbance is a frequently overlooked complication of intensive care unit (ICU) stay.
To evaluate sleep quality among patients admitted to ICU and investigate environmental and ...non-environmental factors that affect sleep quality in ICU.
Over a 22-month period, we consecutively recruited patients who spent ≥ 2 nights post-endotracheal extubation in ICU and who were orientated to time, place, and person on the day of discharge. Self-reported sleep quality, according to a modified Freedman questionnaire, which provided data on self-reported ICU sleep quality in ICU and environmental factors affecting sleep quality in the ICU, were collected. We also investigated non-environmental factors, such as severity of illness, ICU interventions, and medications that can affect sleep quality.
Fifty males and 50 females were recruited with a mean (± SD) age of 65.1 ± 15.2 years. APACHE II score at admission to ICU was 18.1 ± 7.5 with duration of stay 6.7 ± 6.5days. Self-reported sleep quality score at home (1 = worst; 10 = best) was 7.0 ± 2.2; this decreased to 4.0 ± 1.7 during their stay in ICU (p < 0.001). In multivariate analysis with APACHE III as severity of illness (R(2) = 0.25), factors exp(b)(95% CI), p value which significantly affected sleep in ICU were sex 0.37(0.19-0.72), p < 0.01, age and sex interaction 1.02(1.01-1.03), p < 0.01, bedside phone 0.92(0.87-0.97), p < 0.01, prior quality of sleep at home 1.30(1.05-1.62), p = 0.02, and use of steroids 0.82(0.69-0.98), p = 0.03 during the stay in ICU.
Reduced sleep quality is a common problem in ICU with a multifactorial etiology.
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