Intensive Care Medicine

Diagnostic yield of lumbar puncture in adult patients with purpura fulminans

Continual hemodynamic monitoring with a single-use transesophageal echocardiography probe in critically ill patients with shock: a randomized controlled clinical trial Abstract Purpose Mortality in circulatory shock is high. Enhanced resolution of shock may improve outcomes. We aim to determine whether adding hemodynamic monitoring with continual transesophageal echocardiography (hTEE) to usual care accelerates resolution of hemodynamic instability. Methods 550 patients with circulatory shock were randomly assigned to four groups stratified using hTEE (hTEE vs usual care) and assessment frequency (minimum every 4 h vs 8 h). Primary outcome was time to resolution of hemodynamic instability, analyzed as intention-to-treat (ITT) analysis at day 6 and in a predefined secondary analysis at days 3 and 28. Results Of 550 randomized patients, 271 with hTEE and 274 patients with usual care were eligible and included in the ITT analysis. Time to resolution of hemodynamic instability did not differ within the first 6 days [hTEE vs usual care adjusted sub-hazard ratio (SHR) 1.20, 95% confidence interval (CI) 0.98–1.46, p = 0.067]. Time to resolution of hemodynamic instability during the 72 h of hTEE monitoring was shorter in patients with TEE (hTEE vs usual care SHR 1.26, 95% CI 1.02–1.55, p = 0.034). Assessment frequency had no influence. Time to resolution of clinical signs of hypoperfusion, duration of organ support, length of stay and mortality in the intensive care unit and hospital, and mortality at 28 days did not differ between groups. Conclusions In critically ill patients with shock, hTEE monitoring or hemodynamic assessment frequency did not influence resolution of hemodynamic instability or mortality within the first 6 days. Trial registration and statistical analysis plan ClinicalTrials.gov Identifier: NCT02048566.

Causal inference in secondary analysis of a randomized controlled trial

Intensive care unit length of stay is reduced by protocolized family support intervention: a systematic review and meta-analysis Abstract Purpose This study aimed to elucidate the impact of protocolized family support intervention on length of stay (LOS) in the intensive care unit (ICU) through a systematic review and meta-analysis. Methods Medline, EMBASE, the Cochrane Central Register of Controlled Trials, and other web-based databases were referenced since inception until November 26, 2018. We included randomized-controlled trials wherein protocolized family support interventions were conducted for enhanced communication and shared medical decision-making. LOS (in days) and mortality were evaluated using a random-effects model, and adjusted LOS was estimated using a mixed-effects model. Results We included seven randomized-controlled trials with 3477 patients. Protocolized family support interventions were found to significantly reduce the ICU LOS {mean difference = − 0.89 [95% confidence interval (CI) = − 1.50 to − 0.27]} and hospital LOS [mean difference = − 3.78 (95% CI = − 5.26 to − 2.29)]; the results of the mixed-effect model showed that they significantly reduced ICU LOS after adjusting for the therapeutic goal [mean difference = − 1.30 (95% CI = − 2.35 to − 0.26)], methods of measurement [mean difference = − 0.89 (95% CI = − 1.55 to − 0.22)], and timing of intervention [mean difference = − 1.05 (95% CI = − 2.05 to − 0.05)]. Similar results were found after adjusting for patients' disease severity [mean difference = − 1.21 (95% CI = − 2.03 to − 0.39)] and the trim-and-fill method [mean difference = − 0.86 (95% CI = − 1.44 to − 0.28)]. There was no difference in mortality rate in ICU and hospital between the protocolized intervention and control groups. Conclusions Protocolized family support intervention for enhanced communication and shared decision-making with the family reduced ICU LOS in critically ill patients without impacting mortality.

Epidemiology of childhood death in Australian and New Zealand intensive care units Abstract Purpose Data on childhood intensive care unit (ICU) deaths are needed to identify changing patterns of intensive care resource utilization. We sought to determine the epidemiology and mode of pediatric ICU deaths in Australia and New Zealand (ANZ). Methods This was a retrospective, descriptive study of multicenter data from pediatric and mixed ICUs reported to the ANZ Pediatric Intensive Care Registry and binational Government census. All patients < 16 years admitted to an ICU between 1 January 2006 and 31 December 2016 were included. Primary outcome was ICU mortality. Subject characteristics and trends over time were evaluated. Results Of 103,367 ICU admissions, there were 2672 (2.6%) deaths, with 87.6% of deaths occurring in specialized pediatric ICUs. The proportion of ANZ childhood deaths occurring in ICU was 12%, increasing by 43% over the study period. Unadjusted (0.1% per year, 95% CI 0.096–0.104; p < 0.001) and risk-adjusted (0.1%/year, 95% CI 0.07–0.13; p < 0.001) ICU mortality rates fell. Across all admission sources and diagnostic groups, mortality declined except following pre-ICU cardiopulmonary arrest where increased mortality was observed. Half of the deaths followed withdrawal of life-sustaining therapy (51%), remaining constant throughout the study. Deaths despite maximal resuscitation declined (0.92%/year, 95% CI 0.89–0.95%; p < 0.001) and brain death diagnoses increased (0.72%/year, 95% CI 0.69–0.75%; p = 0.001). Conclusions Unadjusted and risk-adjusted mortality for children admitted to ANZ ICUs is declining. Half of pediatric ICU deaths follow withdrawal of life-sustaining therapy. Epidemiology and mode of pediatric ICU death are changing. Further investigation at an international level will inform benchmarking, resource allocation and training requirements for pediatric critical care.

Point-of-care ultrasound in the critically ill pregnant or postpartum patient: what every intensivist should know

Epidemiology of post-influenza bacterial pneumonia due to Panton–Valentine leucocidin positive Staphylococcus aureus in intensive care units: a retrospective nationwide study

Focus on ethics of admission and discharge policies and conflicts of interest

Focus on sepsis

Shaking and tremors in thyroid storm

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com