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Background: The organizational and staffing structure of an ICU influences the outcome of critically ill and injured patients. A change in the ICU staffing structure frequently occurs at nighttime and on weekends (off-hours). We postulated that patients who are admitted to an ICU during off hours may be at an increased risk of death.Methods: We performed a systematic review of the literature to assess whether admission to an ICU during off-hours is associated with an increased mortality. We selected studies that evaluated the association between time of admission to the ICU and mortality, with adjustment for severity of disease. We excluded studies that included pediatric and non-ICU patients. Study characteristics extracted included date of publication, study design, country where study was done, study population, time factor (weekend or night shift), severity adjustment tool, and outcome.Results: Ten cohort studies met our inclusion criteria; eight of these studies evaluated nighttime admissions, whereas six studies evaluated weekend admissions. The pooled analysis demonstrated that nighttime admission was not associated with an increased mortality (odds ratio [OR], 1.0 [95% CI, 0.87-1.17]; P = .956); however, patients admitted over the weekend had a significant increase in the adjusted risk of death (OR, 1.08 [95% CI, 1.04-1.13]; P < .001). Significant heterogeneity was found in the studies that evaluated nighttime admissions.Conclusions: Whereas patients admitted to an ICU over the weekend appear to be at an increased risk of death, nighttime admissions were not associated with an increased mortality. The lower level of staffing and intensity of care provided by many hospitals over the weekend may account for this finding. The heterogeneity noted between studies evaluating nighttime admissions likely reflects the diverse organizational structure of the hospitals and ICUs where these studies were carried out. [ABSTRACT FROM AUTHOR]

Experimental and clinical evidence has demonstrated a strong cause-and-effect relationship between persistence vs reduction in systemic inflammation and progression (unresolving) vs resolution (resolving) of ARDS. In this review, the cellular mechanisms involved in activating and regulating inflammation are contrasted between patients with resolving and unresolving ARDS. At the cellular level, patients with unresolving ARDS have deficient glucocorticoid (GC)-mediated down-regulation of inflammatory cytokine and chemokine transcription despite elevated levels of circulating cortisol, a condition defined as systemic inflammation-associated acquired GC resistance. These patients, contrary to those with resolving ARDS, have persistent elevation in levels of both systemic and BAL fluid inflammatory cytokines and chemokines, markers of alveolar-capillary membrane permeability and fibrogenesis. At the tissue level, the continued production of inflammatory mediators leads to tissue injury, intravascular and extravascular coagulation, and the proliferation of mesenchymal cells, all resulting in maladaptive lung repair and progression of extrapulmonary organ dysfunction. In ARDS, down-regulation of systemic inflammation is essential to restoring homeostasis, decreasing morbidity, and improving survival. Prolonged low-to-moderate dose GC therapy promotes the down-regulation of inflammatory cytokine transcription at the cellular level. Eight controlled studies have consistently reported a significant reduction in markers of systemic inflammation, pulmonary and extrapulmonary organ dysfunction scores, duration of mechanical ventilation, and ICU length of stay. In the aggregate (n = 628), reduction in mortality was substantial for all patients (relative risk [RR], 0.75; 95% CI, 0.63 to 0.89; p < 0.001; I(2), 43%) and for those treated before day 14 (RR, 0.71; 95% CI, 0.59 to 0.85; p < 0.001; I(2), 40%). [ABSTRACT FROM AUTHOR]

The diagnosis of adrenal failure and the indications for corticosteroid therapy in critically ill patients are controversial. This controversy is fueled by the complexity of the issues and the paucity of data from high quality clinical trials. Nevertheless, while the use of high-dose corticosteroids in patients with severe sepsis and ARDS failed to improve outcome and was associated with increased complications, an extended course of stress-dose corticosteroids has been reported to increase the occurrence of ventilator-free days and survival in select groups of ICU patients. These patients typically have an exaggerated proinflammatory response. Until recently the exaggerated proinflammatory response that characterizes critically ill patients with systemic inflammation has focused on suppression of the hypothalamic-pituitary-adrenal axis and adrenal failure. However, experimental and clinical data suggest that glucocorticoid tissue resistance may also play an important role. This complex syndrome is referred to as critical illness-related corticosteroid insufficiency (CIRCI) and is defined as inadequate corticosteroid activity for the severity of the illness of a patient. The paper reviews cortisol physiology, CIRCI, and the role of corticosteroid therapy in critically ill patients. [ABSTRACT FROM AUTHOR]

Ultrasonography has become an invaluable tool in the management of critically ill patients. Its safety and portability allow for use at the bedside to provide rapid, detailed information regarding the cardiovascular system and the function and anatomy of certain internal organs. Echocardiography can noninvasively elucidate cardiac function and structure. This information is vital in the management hemodynamically unstable patients in the ICU. In addition, ultrasonography has particular value for the assessment and safe drainage of pleural and intra-abdominal fluid and the placement of central venous catheters. A new generation of portable, battery-powered, inexpensive, hand-carried ultrasound devices have recently become available; these devices can provide immediate diagnostic information not assessable by physical examination alone and allow for ultrasound-guided thoracocentesis, paracentesis, and central venous cannulation. This two-part article reviews the application of bedside ultrasonography in the ICU. [ABSTRACT FROM AUTHOR]

Anemia and allogenic RBC transfusions are exceedingly common among critically ill patients. Multiple pathologic mechanisms contribute to the genesis of anemia in these patients. Emerging risks associated with allogenic RBC transfusions including the transmission of newer infectious agents and immune modulation predisposing the patient to infections requires reevaluation of current transfusion strategies. Recent data have suggested that a restrictive transfusion practice is associated with reduced morbidity and mortality during critical illness, with the possible exception of acute coronary syndromes. In this article, we review the immune-modulatory role of allogenic RBC transfusions in critically ill patients. [ABSTRACT FROM AUTHOR]

Status epilepticus is a major medical emergency associated with significant morbidity and mortality. Status epilepticus is best defined as a continuous, generalized, convulsive seizure lasting > 5 min, or two or more seizures during which the patient does not return to baseline consciousness. Lorazepam in a dose of 0.1 mg/kg is the drug of first choice for terminating status epilepticus. Patients who continue to have clinical or EEG evidence of seizure activity after treatment with lorazepam should be considered to have refractory status epileptics and should be treated with a continuous infusion of propofol or midazolam. This article reviews current information regarding the management of status epilepticus in adults. [ABSTRACT FROM AUTHOR]

Stress from many sources, including pain, fever, and hypotension, activates the hypothalamic-pituitary-adrenal (HPA) axis with the sustained secretion of corticotropin and cortisol. Increased glucocorticoid action is an essential component of the stress response, and even minor degrees of adrenal insufficiency can be fatal in the stressed host. HPA dysfunction is a common and underdiagnosed disorder in the critically ill. We review the risk factors, pathophysiology, diagnostic approach, and management of HPA dysfunction in the critically ill. [ABSTRACT FROM AUTHOR]

Objective: To compare sublingual PCO(2) (PslCO(2)) measurements with gastric intramucosal PCO(2) (PimCO(2)) as well as with the traditional indexes of tissue oxygenation in hemodynamically unstable ICU patients.Design: A prospective, validation study.Setting: The medical and coronary ICUs of a community teaching hospital.Patients: Consecutive patients with severe sepsis, septic shock, or cardiogenic shock requiring pulmonary artery catheterization for hemodynamic management.Interventions: During the first 24 h of ICU admission, the PslCO(2), PimCO(2), and blood lactate concentrations as well conventional hemodynamic and oxygenation parameters were recorded every 4 to 6 h. The PslCO(2)-PaCO(2) and PimCO(2)-PaCO(2) differences were used as indexes of tissue dysoxia. These variables were correlated with each other as well as with the traditional markers of tissue oxygenation.Results: Seventy-six data sets were obtained on 22 patients. Fifteen patients had severe sepsis/septic shock, and 7 patients did not have sepsis. A patient with ischemic bowel who had a large PimCO(2)-PslCO(2) difference (60.2 mm Hg) was excluded. The initial PslCO(2) and PimCO(2) measurements were 43.5 +/- 10.4 mm Hg and 42.8 +/- 10.9 mm Hg, respectively (correlation coefficient [r] of 0.86; p < 0.001). The mean PslCO(2) and PimCO(2) for the entire data set were 48.0 +/- 13.4 mm Hg and 46.1 +/- 12.3 mm Hg, respectively (r = 0.78; p < 0.001). Ten patients died. The initial PslCO(2)-PaCO(2) difference was 9.2 +/- 5.0 mm Hg in the survivors and 17.8 +/- 11.5 mm Hg in the nonsurvivors (p = 0.04). The initial PimCO(2)-PaCO(2) difference was 8.4 +/- 4.8 mm Hg in the survivors and 16.1 +/- 13.7 mm Hg in the nonsurvivors (p = 0.08, not significant). The initial PslCO(2)-PaCO(2) difference correlated with the initial mixed venous-arterial CO(2) gradient (r = 0.66; p = 0.001), but correlated poorly with the initial blood lactate concentration (r = 0.38), mixed venous PO(2) (r = 0.05), and systemic oxygen delivery (r = - 0.39).Conclusion: In this study, sublingual capnometry yielded measurements that correlated well with those of gastric tonometry. PslCO(2) may serve as a technically simple and noninvasive clinical measurement of tissue dysoxia in critically ill and injured patients. [ABSTRACT FROM AUTHOR]

Objective: To describe the clinical features and complications of patients hospitalized with influenza during the 1999-2000 influenza season.Methods: We reviewed all cases of patients with influenza admitted to a large metropolitan referral hospital during the 1999-2000 season.Results: Thirty-five adult patients (15 men and 20 women) tested positive for influenza A by direct enzyme immunoassay. A fourfold to sevenfold increase in the number of influenza cases was observed over previous years. Most patients had serious comorbid illnesses (88%), such as diabetes and chronic respiratory and heart disease. Seventeen patients developed pneumonia; these patients tended to be older (mean +/- SD, 63 +/- 13 years vs 51 +/- 19 years, respectively; p = 0.04) and had a higher incidence of chronic lung disease (41% vs 6%, respectively; p = 0.02) than the patients without pneumonia. Shortness of breath was the only symptom that distinguished patients with pneumonia from those with an upper respiratory tract illness alone. Antiviral treatment was begun 4 +/- 3 days from initiation of symptoms in patients with pneumonia and consisted of oseltamivir (35.2%), rimantadine (5.8%), or a combination of both (17.6%). Respiratory and/or blood culture results were positive in five patients (29%), Staphylococcus aureus was isolated in five patients, and Streptococcus pneumoniae was isolated in one patient. Ten of the patients with pneumonia (58.8%) were admitted to the ICU, and 5 patients (29%) died. The length of ICU stay and mechanical ventilation were 28 +/- 26 days and 21.5 +/- 20.5 days, respectively. Death in most pneumonia patients was attributed to respiratory failure.Conclusion: The recognized number of hospital admissions for influenza increased fourfold to sevenfold over previous years, most likely due to the implementation of rapid diagnostic tests for influenza. Patients with signs and symptoms of influenza and shortness of breath should undergo chest radiography. Hospitalization of patients with influenza pneumonia occurred in both previously healthy and immunocompromised patients and had a high mortality. S aureus was the most common bacterial isolate in patients with influenza pneumonia. Empiric antibiotics with staphylococcal activity should be used pending culture results in patients with influenza pneumonia. The effectiveness of oseltamivir and rimantadine in treating patients with influenza pneumonia remains to be determined. [ABSTRACT FROM AUTHOR]

Background: Sepsis refers to the dysregulated host immune response elicited by microbial infections resulting in life-threatening organ dysfunction. Sepsis represents a medical challenge, since it is associated with a rate of death as high as 60%. Septic shock is strongly associated with vascular dysfunction and elevated pulmonary capillary permeability. We recently reported that the combination of hydrocortisone (HC), ascorbic acid (vitC), and thiamine dramatically improves outcomes and reduces mortality in patients with sepsis. In the present study, we provide experimental evidence in support of the hypothesis that the combination of HC and vitC enhances endothelial barrier function., Methods: Human lung microvascular endothelial cells were exposed to lipopolysaccharide (LPS) in the absence or presence of HC and vitC., Results: LPS alone induced profound hyperpermeability, as reflected in decreased values of transendothelial electrical resistance. vitC alone did not exhibit barrier enhancement properties nor did it affect the LPS-induced hyperpermeability. Similarly, HC alone exhibited only a minor barrier-enhancing and protective effect. Conversely, the combination of HC and vitC, either as before or after treatment, dramatically reversed the LPS-induced barrier dysfunction. The barrier-protective effects of HC and vitC were associated with reversal of LPS-induced p53 and phosphorylated cofilin downregulation and LPS-induced RhoA activation and myosin light chain phosphorylation., Conclusions: These data provide a novel mechanism of endothelial barrier protection and suggest one possible pathway that may contribute to the therapeutic effects of HC and vitC in patients with sepsis., (Copyright © 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: The global burden of sepsis is estimated as 15 to 19 million cases annually, with a mortality rate approaching 60% in low-income countries., Methods: In this retrospective before-after clinical study, we compared the outcome and clinical course of consecutive septic patients treated with intravenous vitamin C, hydrocortisone, and thiamine during a 7-month period (treatment group) with a control group treated in our ICU during the preceding 7 months. The primary outcome was hospital survival. A propensity score was generated to adjust the primary outcome., Results: There were 47 patients in both treatment and control groups, with no significant differences in baseline characteristics between the two groups. The hospital mortality was 8.5% (4 of 47) in the treatment group compared with 40.4% (19 of 47) in the control group (P < .001). The propensity adjusted odds of mortality in the patients treated with the vitamin C protocol was 0.13 (95% CI, 0.04-0.48; P = .002). The Sepsis-Related Organ Failure Assessment score decreased in all patients in the treatment group, with none developing progressive organ failure. All patients in the treatment group were weaned off vasopressors, a mean of 18.3 ± 9.8 h after starting treatment with the vitamin C protocol. The mean duration of vasopressor use was 54.9 ± 28.4 h in the control group (P < .001)., Conclusions: Our results suggest that the early use of intravenous vitamin C, together with corticosteroids and thiamine, are effective in preventing progressive organ dysfunction, including acute kidney injury, and in reducing the mortality of patients with severe sepsis and septic shock. Additional studies are required to confirm these preliminary findings., (Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Sepsis is among the most common reasons for admission to ICUs throughout the world, and it is believed to be the third most common cause of death in the United States. The pathogenetic mechanism and physiologic changes associated with sepsis are exceedingly complex, but our understanding is evolving rapidly. The major pathophysiologic changes in patients with septic shock include vasoplegic shock (distributive shock), myocardial depression, altered microvascular flow, and a diffuse endothelial injury. These pathophysiologic changes play a central role in the management of sepsis. The early management of patients with severe sepsis and septic shock centers on the administration of antibiotics, IV fluids, and vasoactive agents, followed by source control. However, the specific approach to the resuscitation of patients with septic shock remains highly controversial. This review provides a practical and physiologic-based approach to the early management of sepsis and explores the controversies surrounding the management of this complex condition.

Background: The clinical assessment of intravascular volume status and volume responsiveness is one of the most difficult tasks in critical care medicine. Furthermore, accumulating evidence suggests that both inadequate and overzealous fluid resuscitation are associated with poor outcomes. The objective of this study was to determine the predictive value of passive leg raising (PLR)- induced changes in stroke volume index (SVI) as assessed by bioreactance in predicting volume responsiveness in a heterogenous group of patients in the ICU. A secondary end point was to evaluate the change in carotid Doppler fl ow following the PLR maneuver., Methods: During an 8-month period, we collected clinical, hemodynamic, and carotid Doppler data on hemodynamically unstable patients in the ICU who underwent a PLR maneuver as part of our resuscitation protocol. A patient whose SVI increased by . 10% following a fluid challenge was considered a fluid responder., Results: A complete data set was available for 34 patients. Twenty-two patients (65%) had severe sepsis/septic shock, whereas 21 (62%) required vasopressor support and 19 (56%) required mechanical ventilation. Eighteen patients (53%) were volume responders. The PLR maneuver had a sensitivity of 94% and a specificity of 100% for predicting volume responsiveness (one false negative result). In the 19 patients undergoing mechanical ventilation, the stroke volume variation was 18.0% 5.1% in the responders and 14.8% 3.4% in the nonresponders ( P 5 .15). Carotid blood fl ow increased by 79% 32% after the PLR in the responders compared with 0.1% 14% in the nonresponders ( P , .0001). There was a strong correlation between the percent change in SVI by PLR and the concomitant percent change in carotid blood fl ow ( r 5 0.59, P 5 .0003). Using a threshold increase in carotid Doppler fl ow imaging of 20% for predicting volume responsiveness, there were two false positive results and one false negative result, giving a sensitivity and specificity of 94% and 86%, respectively. We noted a significant increase in the diameter of the common carotid artery in the fluid responders., Conclusions: Monitoring the hemodynamic response to a PLR maneuver using bioreactance provides an accurate method of assessing volume responsiveness in critically ill patients. In addition, the study suggests that changes in carotid blood fl ow following a PLR maneuver may be a useful adjunctive method for determining fluid responsiveness in hemodynamically unstable patients.

Background: Following publication of the Leuven Intensive Insulin Therapy Trial in 2001, tight glycemic control became the standard of care in ICUs around the world. Recent studies suggest that this approach may be flawed. The goal of this systematic review was to determine the benefits and risks of tight glycemic control in ICU patients and to explain the differences in outcomes among reported trials., Methods: Prospective, randomized controlled clinical trials (RCTs) that studied the impact of tight glycemic control (blood glucose 80-110 mg/dL) on mortality in ICU patients were identified through a search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews, and a citation review of relevant primary and review articles. Data were abstracted on study design, study size, and patient characteristics, as well as on the mean (or median) and SD of the ICU blood glucose level, mean daily dose of insulin administered, average daily caloric intake, percentage of calories given intravenously (parenteral nutrition), incidence of hypoglycemia, need for dialysis, and 28-day/hospital mortality. Metaanalytic techniques were used to analyze the data; subgroup analysis and metaregression were used to explain differences in the treatment effect., Results: We identified seven RCT studies that included 11,425 patients. Overall, tight glycemic control did not reduce the 28-day mortality (odds ratio [OR] 0.95; 95% CI, 0.87-1.05), the incidence of blood stream infections (OR 1.04; 95% CI, 0.93-1.17), or the requirement for renal replacement therapy (OR 1.01; 95% CI, 0.89-1.13). The incidence of hypoglycemia was significantly higher in patients randomized to tight glycemic control (OR 7.7; 95% CI, 6.0-9.9; P < .001). Metaregression demonstrated a significant relationship between the treatment effect (28-day mortality) and the proportion of calories provided parenterally (P = .005). This suggests that the difference in outcome between the two Leuven Intensive Insulin Therapy Trials and the subsequent trials could be related to the use of parenteral nutrition. When the two Leuven Intensive Insulin Therapy Trials were excluded from the metaanalysis, mortality was lower in the control patients (OR 0.90; 95% CI, 0.81-0.99; P = .04; I(2) = 0%)., Conclusions: There is no evidence to support the use of intensive insulin therapy in general medical-surgical ICU patients who are fed according to current guidelines. Tight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients not receiving parenteral nutrition.

Background: Central venous pressure (CVP) is used almost universally to guide fluid therapy in hospitalized patients. Both historical and recent data suggest that this approach may be flawed., Objective: A systematic review of the literature to determine the following: (1) the relationship between CVP and blood volume, (2) the ability of CVP to predict fluid responsiveness, and (3) the ability of the change in CVP (DeltaCVP) to predict fluid responsiveness., Data Sources: MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles., Study Selection: Reported clinical trials that evaluated either the relationship between CVP and blood volume or reported the associated between CVP/DeltaCVP and the change in stroke volume/cardiac index following a fluid challenge. From 213 articles screened, 24 studies met our inclusion criteria and were included for data extraction. The studies included human adult subjects, healthy control subjects, and ICU and operating room patients., Data Extraction: Data were abstracted on study design, study size, study setting, patient population, correlation coefficient between CVP and blood volume, correlation coefficient (or receive operator characteristic [ROC]) between CVP/DeltaCVP and change in stroke index/cardiac index, percentage of patients who responded to a fluid challenge, and baseline CVP of the fluid responders and nonresponders. Metaanalytic techniques were used to pool data., Data Synthesis: The 24 studies included 803 patients; 5 studies compared CVP with measured circulating blood volume, while 19 studies determined the relationship between CVP/DeltaCVP and change in cardiac performance following a fluid challenge. The pooled correlation coefficient between CVP and measured blood volume was 0.16 (95% confidence interval [CI], 0.03 to 0.28). Overall, 56+/-16% of the patients included in this review responded to a fluid challenge. The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18 (95% CI, 0.08 to 0.28). The pooled area under the ROC curve was 0.56 (95% CI, 0.51 to 0.61). The pooled correlation between DeltaCVP and change in stroke index/cardiac index was 0.11 (95% CI, 0.015 to 0.21). Baseline CVP was 8.7+/-2.32 mm Hg [mean+/-SD] in the responders as compared to 9.7+/-2.2 mm Hg in nonresponders (not significant)., Conclusions: This systematic review demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/DeltaCVP to predict the hemodynamic response to a fluid challenge. CVP should not be used to make clinical decisions regarding fluid management.

Antineoplastic agent-induced pulmonary toxicity is an important cause of respiratory failure. Although the incidence of antineoplastic agent-induced pulmonary toxicity seems to be low, more cases can be expected, with increasing numbers of patients receiving the new generations of antineoplastic agents. Antineoplastic agents have previously been associated with bronchospasm, hypersensitivity reactions, venous thromboembolism, and pulmonary hemorrhage. Physicians should be aware of the clinical and radiographic presentations of the pulmonary toxicities associated with the newer antineoplastic agents. The approach to diagnosis, risk factors, and possible mechanisms of antineoplastic agent-induced pulmonary toxicity are discussed in this article.

Hypertension affects > 65 million people in the United States and is one of the leading causes of death. One to two percent of patients with hypertension have acute elevations of BP that require urgent medical treatment. Depending on the degree of BP elevation and presence of end-organ damage, severe hypertension can be defined as either a hypertensive emergency or a hypertensive urgency. A hypertensive emergency is associated with acute end-organ damage and requires immediate treatment with a titratable short-acting IV antihypertensive agent. Severe hypertension without acute end-organ damage is referred to as a hypertensive urgency and is usually treated with oral antihypertensive agents. This article reviews definitions, current concepts, common misconceptions, and pitfalls in the diagnosis and management of patients with acutely elevated BP as well as special clinical situations in which BP must be controlled.

This is the second of a two-part review on the application of bedside ultrasonography in the ICU. In this part, the following procedures will be covered: (1) echocardiography and cardiovascular diagnostics (second part); (2) the use of bedside ultrasound to facilitate central-line placement and to aid in the care of patients with pleural effusions and intra-abdominal fluid collections; (3) the role of hand-carried ultrasound in the ICU; and (4) the performance of bedside ultrasound by the intensivist. The safety and utility of bedside ultrasonography performed by adequately trained intensivists has now been well demonstrated. This technology, as a powerful adjunct to the physical examination, will become an indispensable tool in the management of critically ill patients.

Ultrasonography has become an invaluable tool in the management of critically ill patients. Its safety and portability allow for use at the bedside to provide rapid, detailed information regarding the cardiovascular system and the function and anatomy of certain internal organs. Echocardiography can noninvasively elucidate cardiac function and structure. This information is vital in the management hemodynamically unstable patients in the ICU. In addition, ultrasonography has particular value for the assessment and safe drainage of pleural and intra-abdominal fluid and the placement of central venous catheters. A new generation of portable, battery-powered, inexpensive, hand-carried ultrasound devices have recently become available; these devices can provide immediate diagnostic information not assessable by physical examination alone and allow for ultrasound-guided thoracocentesis, paracentesis, and central venous cannulation. This two-part article reviews the application of bedside ultrasonography in the ICU.

Autoimmune hemolytic anemia (AIHA) is the clinical condition in which IgG antibodies bind to RBC surface antigens and initiate RBC destruction via the complement and reticuloendothelial system. AIHA is commonly treated with transfusions, corticosteroids, and splenectomy. We present a case of an adult with life-threatening AIHA secondary to ulcerative colitis emergently managed with neuromuscular paralysis, induced hypothermia, and splenic embolization.

Anemia and allogenic RBC transfusions are exceedingly common among critically ill patients. Multiple pathologic mechanisms contribute to the genesis of anemia in these patients. Emerging risks associated with allogenic RBC transfusions including the transmission of newer infectious agents and immune modulation predisposing the patient to infections requires reevaluation of current transfusion strategies. Recent data have suggested that a restrictive transfusion practice is associated with reduced morbidity and mortality during critical illness, with the possible exception of acute coronary syndromes. In this article, we review the immune-modulatory role of allogenic RBC transfusions in critically ill patients.

Status epilepticus is a major medical emergency associated with significant morbidity and mortality. Status epilepticus is best defined as a continuous, generalized, convulsive seizure lasting > 5 min, or two or more seizures during which the patient does not return to baseline consciousness. Lorazepam in a dose of 0.1 mg/kg is the drug of first choice for terminating status epilepticus. Patients who continue to have clinical or EEG evidence of seizure activity after treatment with lorazepam should be considered to have refractory status epileptics and should be treated with a continuous infusion of propofol or midazolam. This article reviews current information regarding the management of status epilepticus in adults.

Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality in the elderly, and the leading cause of death among residents of nursing homes. Oropharyngeal aspiration is an important etiologic factor leading to pneumonia in the elderly. The incidence of cerebrovascular and degenerative neurologic diseases increase with aging, and these disorders are associated with dysphagia and an impaired cough reflex with the increased likelihood of oropharyngeal aspiration. Elderly patients with clinical signs suggestive of dysphagia and/or who have CAP should be referred for a swallow evaluation. Patients with dysphagia require a multidisciplinary approach to swallowing management. This may include swallow therapy, dietary modification, aggressive oral care, and consideration for treatment with an angiotensin-converting enzyme inhibitor.

Traumatic brain injury (TBI) is a major cause of disability and death in most Western nations and consumes an estimated $100 billion annually in the United States alone. In the last 2 decades, the management of TBI has evolved dramatically, as a result of a more thorough understanding of the physiologic events leading to secondary neuronal injury as well as advances in the care of critically ill patients. However, it is likely that many patients with TBI are not treated according to current treatment principles. This article presents an overview of the current management of patients with TBI.

Severe hypertension is a common clinical problem in the United States, encountered in various clinical settings. Although various terms have been applied to severe hypertension, such as hypertensive crises, emergencies, or urgencies, they are all characterized by acute elevations in BP that may be associated with end-organ damage (hypertensive crisis). The immediate reduction of BP is only required in patients with acute end-organ damage. Hypertension associated with cerebral infarction or intracerebral hemorrhage only rarely requires treatment. While nitroprusside is commonly used to treat severe hypertension, it is an extremely toxic drug that should only be used in rare circumstances. Furthermore, the short-acting calcium channel blocker nifedipine is associated with significant morbidity and should be avoided. Today, a wide range of pharmacologic alternatives are available to the practitioner to control severe hypertension. This article reviews some of the current concepts and common misconceptions in the management of patients with acutely elevated BP.

Fever is a common problem in ICU patients. The presence of fever frequently results in the performance of diagnostic tests and procedures that significantly increase medical costs and expose the patient to unnecessary invasive diagnostic procedures and the inappropriate use of antibiotics. ICU patients frequently have multiple infectious and noninfectious causes of fever, necessitating a systematic and comprehensive diagnostic approach. Pneumonia, sinusitis, and blood stream infection are the most common infectious causes of fever. The urinary tract is unimportant in most ICU patients as a primary source of infection. Fever is a basic evolutionary response to infection, is an important host defense mechanism and, in the majority of patients, does not require treatment in itself. This article reviews the common infectious and noninfectious causes of fever in ICU patients and outlines a rational approach to the management of this problem.

The clinical assessment of cardiac performance and ventricular preload is notoriously unreliable in critically ill patients. Consequently, a number of technologies have been developed to provide the clinician with indexes of cardiovascular function to assist in therapeutic decision making. Foremost among these is the pulmonary artery catheter (PAC). Indeed, the PAC has largely shaped the practice of modern critical care. Yet, the information provided by the PAC is largely misunderstood, and its efficacy is never proven. Recently, continuous esophageal Doppler monitoring has emerged as an alternative to pulmonary artery catheterization. This paper evaluates the clinical utility of the PAC and esophageal Doppler monitoring in assessing the hemodynamic status of ICU patients.