Interrater Variability in Identifying Ventilator Associated Pneumonia Using Six Different Definitions

Objective There is no widely accepted standard definition for Ventilator Associated Pneumonia (VAP). The reliability of the current definitions in use remains controversial. Our objective was to assess the reliability of six commonly used VAP definitions: The Loose, The Rigorous, The Modified Clinical Pulmonary Infection Score (CPIS), The Canadian Critical Care Trials Group (CCCTG), The International Sepsis Forum Consensus (ISFC) and The Center for Disease Control and Prevention (CDC). Design We examined the electronic health records of all the consecutively admitted adult patients at our institution who received invasive mechanical ventilation (IMV) for ≥ 48 hours, from January 2006 through December 2006.Patients were excluded if they developed pneumonia within the first 48 hours or if they had a tracheostomy before IMV. Two expert intensivists independently reviewed the following data for each patient: indications and duration of IMV, vital signs, oxygen requirements, frequency of respiratory suctioning, amount, color and consistency of secretion, ventilator settings, leukocyte count, microbiologic and radiographic data. Interreviewer reliability in diagnosing VAP independently were compared using Cohen’s-Kappa statistics. Results A total of 115 patients met the initial inclusion criteria of which 47 patients were excluded (40 had pneumonia on presentation, 6 developed pneumonia within 48 hours and 1 had a tracheostomy on admission). The inter-reviewer agreement Kappa for the Loose, the Rigorous, CPIS, CCCTG, ISFC and CDC definitions for VAP were 0.22, 0.49, 0.33, 0.41, 0.38 and 0.68 respectively. Conclusion The CDC definition of VAP proved to be statistically more reliable than other tested definitions of VAP, as demonstrated by the lowest interrater variability between two independent reviewers

Characterization of Platelet Biologic Markers in the Early Pathogenesis of Postoperative Acute Respiratory Distress Syndrome

IMPORTANCE:. Animal models and limited human studies have suggested a plausible role for platelets in the pathogenesis and resolution of acute respiratory distress syndrome (ARDS). However, there are little data regarding the role of platelets in ARDS development. OBJECTIVES:. The objective of this study was to characterize the role of platelets in a postoperative ARDS model through an analysis of two platelet-specific biologic markers: thromboxane A2 (TxA2) and soluble CD-40-ligand (sCD40L). DESIGN, SETTING, AND PARTICIPANTS:. This was a nested case-control study of ARDS cases matched to non-ARDS controls. Blood samples were collected from a cohort of 500 patients undergoing thoracic, aortic vascular, or cardiac surgery that placed them at high-risk of developing postoperative ARDS. MAIN OUTCOMES AND MEASURES:. TxA2 and sCD40L were analyzed at baseline (prior to surgical incision) as well as 2 hours and 6 hours after the key intraoperative events believed to be associated with increased risk of postoperative ARDS. RESULTS:. Of 500 patients enrolled, 20 ARDS cases were matched 1:2 to non-ARDS controls based on age, sex, surgical procedure, and surgical lung injury prediction score. Those who developed ARDS had longer surgeries, greater fluid administration, and higher peak inspiratory pressures. There were no significant differences in levels of TxA2 or sCD40L at baseline, at 2 hours, or at 6 hours. There was also no difference in the change in biomarker concentration between baseline and 2 hours or baseline and 6 hours. CONCLUSIONS:. Two novel platelet-associated biologic markers (TxA2 and sCD40L) were not elevated in patients who developed ARDS in a postoperative ARDS model. Although limited by the relatively small study size, these results do not support a clear role for platelets in the early pathogenesis of postoperative ARDS

Feasibility of an International Remote Simulation Training Program in Critical Care Delivery: A Pilot Study

Objective: To determine the feasibility and effectiveness of a video-enabled remote simulation training program to teach a systematic, standardized approach to the evaluation and management of the critically ill patients as part of an international quality improvement intervention. Patients and Methods: In this pilot “train-the-trainer” prospective cohort study, we provided a remote simulation-based educational program for practicing clinicians from intensive care units involved in an international quality improvement project (www.icertain.org). Between February 21, 2014, and August 6, 2015, participants completed a self-guided online curriculum and participated in structured simulation training using web conference software with recording capabilities. The performance was assessed using a matched pair analysis at baseline and using standardized scenarios and a validated assessment tool postintervention. Participants rated their satisfaction with the training experience and confidence in implementing these skills in clinical practice. Results: Eighteen local champions from 8 hospitals in 7 countries in Asia, Europe, and South and Central America completed the educational program. Learners exhibited significant improvements in cumulative critical task performance during simulated critical care scenarios with training (60.3%-81.8%; P=.002). Most clinicians (94%) reported that they felt well prepared to manage the common critical care scenarios after training. These local champions have subsequently delivered this educational program to more than 800 international clinicians over a 4-year period. Conclusion: Insufficient training is a major barrier to the delivery of cost-effective critical care in many areas of the world. Video-enabled remote simulation training is a low-cost, feasible, and effective method to disseminate clinical skills to critical care practitioners in diverse international settings

Chemokines in ICU Delirium: An Exploratory Study

OBJECTIVES:. The pathophysiology of delirium is complex and incompletely understood. Inflammation is hypothesized to be integral to its development due to effects on blood brain barrier integrity, facilitation of leukocyte extravasation into brain parenchyma, and propagation of neuroinflammation. Septic shock is the prototypical condition associated with ICU delirium; however, the relative contribution of resultant hypotension and systemic inflammation to the development of delirium is unknown. DESIGN:. This was a prospective exploratory study. SETTING:. A multidisciplinary ICU at an academic medical center in Phoenix, AZ. PATIENTS:. Critically ill patients older than or equal to 18 years old admitted to the ICU. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. Screening for delirium was performed using the Confusion Assessment Method for the ICU tool. The levels of C-C motif ligand 2 (CCL2), C-C motif ligand 3, C-X-C motif chemokine ligand 1, C-X-C motif chemokine ligand 10, and interleukin-8 were measured in serum samples obtained within 12 hours of ICU admission. Univariate and multivariate analyses were performed to assess the association of delirium with patient data pertaining to hospital course, laboratory values, vital signs, medication administration, and levels of the aforementioned chemokines. Forty-one of 119 patients (34.5%) in the study cohort developed ICU delirium. Each chemokine studied was associated with delirium on univariate analyses; however, CCL2 was the only chemokine found to be independently associated with the development of delirium on multivariable analysis. The association of increased CCL2 levels with delirium remained robust in various models controlling for age, presence of shock, Sequential Organ Failure Assessment score, Acute Physiology and Chronic Health Evaluation IV score, mean arterial pressure at presentation, lowest mean arterial pressure, and total opioid, midazolam, propofol, and dexmedetomidine exposure. CONCLUSIONS:. The demonstrated relationship between CCL2 and delirium suggests this chemokine may play a role in the development of delirium and warrants further investigation

Oral Midodrine Administration During the First 24 Hours of Sepsis to Reduce the Need of Vasoactive Agents: Placebo-Controlled Feasibility Clinical Trial

Objectives:. Our preliminary data and observational studies suggested an increasing “off label” use of oral midodrine as a vasopressor sparing agent in various groups of critically ill patients, including those with sepsis. We designed this clinical trial to evaluate the feasibility of use of midodrine hydrochloride in early sepsis to reduce the duration for IV vasopressors and decrease ICU and hospital length of stay. Design:. Pilot, two-center, placebo-controlled, double blinded randomized clinical trial. Setting:. Medical ICUs at Mayo Clinic Rochester and Cleveland Clinic Abu Dhabi were the study sites. Patients and Methods:. Adult patients (≥ 18 yr old) were included within 24 hours of meeting the Sepsis-3 definition if the mean arterial pressure remained less than 70 mm Hg despite receiving timely antibiotics and initial IV fluid bolus of 30 cc/kg. Intervention:. Three doses of 10 mg midodrine versus placebo were administered. Measurements and Main Results:. Total 32 patients were randomized into midodrine (n = 17) and placebo groups (n = 15). There were no major differences in baseline variables between the groups except for higher baseline creatinine in the midodrine group (2.0 ± 0.9 mg/dL) versus placebo group (1.4 ± 0.6 mg /dL), p = 0.03. The median duration of IV vasopressor requirement was 14.5 ± 8.1 hours in midodrine group versus 18.8 ± 7.1 hours in the placebo group, p value equals to 0.19. Patients in the midodrine group needed 729 ± 963 norepinephrine equivalent compared with 983 ± 1,569 norepinephrine equivalent in the placebo group, p value equals to 0.59. ICU length of stay was 2.29 days (interquartile range, 1.65–3.9 d) in the midodrine group, compared with 2.45 days (interquartile range, 1.6–3.2 d) in the placebo group, p value equals to 0.36. No serious adverse events were observed in either group. Conclusions:. Phase II clinical trial powered for clinical outcomes (duration of vasopressor use, need for central venous catheter, and ICU and hospital length of stay) is justified