An investigation into the effects of commencing haemodialysis in the critically ill

<b>Introduction:</b> We have aimed to describe haemodynamic changes when haemodialysis is instituted in the critically ill. 3 hypotheses are tested: 1)The initial session is associated with cardiovascular instability, 2)The initial session is associated with more cardiovascular instability compared to subsequent sessions, and 3)Looking at unstable sessions alone, there will be a greater proportion of potentially harmful changes in the initial sessions compared to subsequent ones. <b>Methods:</b> Data was collected for 209 patients, identifying 1605 dialysis sessions. Analysis was performed on hourly records, classifying sessions as stable/unstable by a cutoff of >+/-20% change in baseline physiology (HR/MAP). Data from 3 hours prior, and 4 hours after dialysis was included, and average and minimum values derived. 3 time comparisons were made (pre-HD:during, during HD:post, pre-HD:post). Initial sessions were analysed separately from subsequent sessions to derive 2 groups. If a session was identified as being unstable, then the nature of instability was examined by recording whether changes crossed defined physiological ranges. The changes seen in unstable sessions could be described as to their effects: being harmful/potentially harmful, or beneficial/potentially beneficial. <b>Results:</b> Discarding incomplete data, 181 initial and 1382 subsequent sessions were analysed. A session was deemed to be stable if there was no significant change (>+/-20%) in the time-averaged or minimum MAP/HR across time comparisons. By this definition 85/181 initial sessions were unstable (47%, 95% CI SEM 39.8-54.2). Therefore Hypothesis 1 is accepted. This compares to 44% of subsequent sessions (95% CI 41.1-46.3). Comparing these proportions and their respective CI gives a 95% CI for the standard error of the difference of -4% to 10%. Therefore Hypothesis 2 is rejected. In initial sessions there were 92/1020 harmful changes. This gives a proportion of 9.0% (95% CI SEM 7.4-10.9). In the subsequent sessions there were 712/7248 harmful changes. This gives a proportion of 9.8% (95% CI SEM 9.1-10.5). Comparing the two unpaired proportions gives a difference of -0.08% with a 95% CI of the SE of the difference of -2.5 to +1.2. Hypothesis 3 is rejected. Fisher’s exact test gives a result of p=0.68, reinforcing the lack of significant variance. <b>Conclusions:</b> Our results reject the claims that using haemodialysis is an inherently unstable choice of therapy. Although proportionally more of the initial sessions are classed as unstable, the majority of MAP and HR changes are beneficial in nature

Sepsis and septic shock in patients with malignancies : a Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique study

Objectives: Cancer affects up to 20% of critically ill patients, and sepsis is one of the leading reasons for ICU admission in this setting. Early signals suggested that survival might be increasing in this population. However, confirmation studies have been lacking. The goal of this study was to assess trends in survival rates over time in cancer patients admitted to the ICU for sepsis or septic shock over the last 2 decades. Data Source: Seven European ICUs. Study Selection: A hierarchical model taking into account the year of admission and the source dataset as random variables was used to identify risk factors for day 30 mortality. Data Extraction: Data from cancer patients admitted to ICUs for sepsis or septic shock were extracted from the Groupe de Recherche Respiratoire en Reanimation Onco-Hematologique database (1994-2015). Data Synthesis: Overall, 2,062 patients (62% men, median [interquartile range] age 59 yr [48-67 yr]) were included in the study. Underlying malignancies were solid tumors (n = 362; 17.6%) or hematologic malignancies (n = 1,700; 82.4%), including acute leukemia (n = 591; 28.7%), non-Hodgkin lymphoma (n = 461; 22.3%), and myeloma (n = 244; 11.8%). Two-hundred fifty patients (12%) underwent allogeneic hematopoietic stem cell transplantation and 640 (31.0%) were neutropenic at ICU admission. Day 30 mortality was 39.9% (823 deaths). The year of ICU admission was associated with significant decrease in day 30 mortality over time (odds ratio, 0.96; 95% CI, 0.93-0.98; p = 0.001). Mechanical ventilation (odds ratio, 3.25; 95% CI, 2.52-4.19; p < 0.01) and vasopressors use (odds ratio, 1.42; 95% CI, 1.10-1.83; p < 0.01) were independently associated with day 30 mortality, whereas underlying malignancy, allogeneic hematopoietic stem cell transplantation, and neutropenia were not. Conclusions: Survival in critically ill oncology and hematology patients with sepsis improved significantly over time. As outcomes improve, clinicians should consider updating admission policies and goals of care in this population

ESC core curriculum for the general cardiologist (2013)

[No abstract available

Acute lung injury in paediatric intensive care: course and outcome

Introduction: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) carry a high morbidity and mortality (10-90%). ALI is characterised by non-cardiogenic pulmonary oedema and refractory hypoxaemia of multifactorial aetiology [1]. There is limited data about outcome particularly in children. Methods This retrospective cohort study of 85 randomly selected patients with respiratory failure recruited from a prospectively collected database represents 7.1% of 1187 admissions. They include those treated with High Frequency Oscillation Ventilation (HFOV). The patients were admitted between 1 November 1998 and 31 October 2000. Results: Of the 85, 49 developed acute lung injury and 47 had ARDS. There were 26 males and 23 females with a median age and weight of 7.7 months (range 1 day-12.8 years) and 8 kg (range 0.8-40 kg). There were 7 deaths giving a crude mortality of 14.3%, all of which fulfilled the Consensus I [1] criteria for ARDS. Pulmonary occlusion pressures were not routinely measured. The A-a gradient and PaO2/FiO2 ratio (median + [95% CI]) were 37.46 [31.82-43.1] kPa and 19.12 [15.26-22.98] kPa respectively. The non-survivors had a significantly lower PaO2/FiO2 ratio (13 [6.07-19.93] kPa) compared to survivors (23.85 [19.57-28.13] kPa) (P = 0.03) and had a higher A-a gradient (51.05 [35.68-66.42] kPa) compared to survivors (36.07 [30.2-41.94]) kPa though not significant (P = 0.06). Twenty-nine patients (59.2%) were oscillated (Sensormedics 3100A) including all 7 non-survivors. There was no difference in ventilation requirements for CMV prior to oscillation. Seventeen of the 49 (34.7%) were treated with Nitric Oxide including 5 out of 7 non-survivors (71.4%). The median (95% CI) number of failed organs was 3 (1.96-4.04) for non-survivors compared to 1 (0.62-1.62) for survivors (P = 0.03). There were 27 patients with isolated respiratory failure all of whom survived. Six (85.7%) of the non-survivors also required cardiovascular support.Conclusion: A crude mortality of 14.3% compares favourably to published data. The A-a gradient and PaO2/FiO2 ratio may be of help in morbidity scoring in paediatric ARDS. Use of Nitric Oxide and HFOV is associated with increased mortality, which probably relates to the severity of disease. Multiple organ failure particularly respiratory and cardiac disease is associated with increased mortality. ARDS with isolated respiratory failure carries a good prognosis in children

Defining The Difficult-To-Sedate Clinical Phenotype In Critically Ill Children

Each year thousands of critically-ill children receive sedation to help them tolerate intensive care therapies. A significant number of these children do not respond as expected to appropriately dosed sedation and remain agitated for some period, leading to iatrogenic injury and increased stress, as well as increased resource use. Children who remain under-sedated despite optimal therapy are considered “difficult-to-sedate”, but, to date, little data have been available to support an accurate description of this group of children. Recent attention to heterogeneity of treatment effect has spurred the development of clinical phenotypes that describe subgroups of patients within a disease process who differ in their clinical attributes and responses to therapy. Defining the difficult-to-sedate clinical phenotype in critically ill children is important because it will allow the use of sedation therapy targeted to the unique clinical, physiological, and developmental characteristics of the child. The three papers developed in this dissertation study explored the concept of the difficult-to-sedate child clinical phenotype. A comprehensive review of the literature identified the lack of an operational definition and identified factors contributing to the clinical phenotype. These factors were used to develop an initial operational definition and to construct a conceptual model. Expert critical care clinicians validated the elements of the operational definition through an assessment of face and content validity and proposed additional factors for inclusion in the model. A refined definition was tested using data from the RESTORE study. Characteristics identified through latent class and classification and regression tree analysis were consistent with the conceptual model proposed. Decreasing the ambiguity that currently exists around the concept of the difficult-to-sedate child clinical phenotype is a major achievement of this study. A clear operational definition of the concept promotes its consistent measurement and facilitates future investigation, and allows useful comparisons across studies. The conceptual model and operational definition require further investigation and refinement, as well as prospective validation by other investigators. This study suggests that a clinically meaningful population of difficult-to-sedate children requiring mechanical ventilation for a critical illness exists. Documentation of this phenotype promotes the development of evidence to support best practices in the care of these children

Evaluation of Various Inspiratory Times and Inflation Pressures During Airway Pressure Release Ventilation

There are few recommendations on how best to apply certain modes of mechanical ventilation. The application of Airway Pressure Release Ventilation (APRV) includes strategic implementation of specific inspiratory times (I-times) and particular mean airway pressures (MAWP) neither of which is standardized. This study utilized a retrospective analysis of archived electronic health record data to evaluate the clinical outcomes of adult patients that had been placed on APRV for at least 8 hours. 68 adult subjects were evaluated as part of a convenient purposive sample. All outcomes of interest (surrogates) for short-term clinical outcomes to include the PaO2/FiO2 (P/F) ratio, Oxygen Index and Oxygen Saturation Index (OI; OSI), and Modified Sequential Organ Failure Assessment (MSOFA) scores showed improvement after at least 8 hours on APRV. Most notably, there was significant improvement in P/F ratio (p = .012) and OSI (p = .000). Results of regression analysis showed P low as a statistically significant negative predictor of pre-APRV P/F ratio with a higher initial P low coinciding with a lower P/F ratio. The regression analysis also showed MAWP as a significant positive predictor of post-APRV OSI and P high and P low as significant negative predictors of post-APRV MSOFA scores. In summary, it was found that settings for P high, Plow, and T low in addition to overall MAWP and Body Mass Index (BMI) had significant correlation to impact at least one of the short-term clinical outcomes measured